Facilitating An Effective Public Health Response To Pandemic Flu

1. Facilitating An Effective Public Health Response To Pandemic Flu Tony Iton, M.D., J.D., MPH - Alameda County Health Officer Legal Preparedness for Pandemic Flu. The Clarion Hotel 4-26- 2006

2. What is Local Public Health? The Structure and Function of a Local Public Health Department

3. US Public Health System Infrastructure

4. Basic Structure of an LHD • Communicable Disease Control • Disaster Preparedness • Environmental Health • Chronic Disease Prevention • Maternal & Child Health • (Mish-mash of Direct Medical & Case Management Services) $$$$$$ $$$$$$ $$$$$$

5. Generic Health Department Structure

6. Generic Health Department Structure Smallpox Anthrax SARS Pandemic Flu West Nile

7. Local Public Health Legal Authority

8. CA Local Health Officers • Each health officer knowing or having reason to believe that any case of the diseases made reportable by regulation of the department, or any other contagious, infectious or communicable disease exists, or has recently existed, within the territory under his or her jurisdiction, shall take measures as may be necessary to prevent the spread of the disease or occurrence of additional cases. –California Health & Safety Code Section 120175

9. Local Public Health Legal Authority • The historical basis of local public health legal authority is the prevention and control of communicable diseases. • The latter part of the 20th century saw a waning in the incidence and health significance of communicable diseases (in developed countries) in favor of chronic disease. • As a consequence, public health’s emphasis on legal authority decreased.

10. Then Came 9/11….

13. Images of the new coronavirus Electron microscopic (EM) images of the new coronavirus attached to the cell surface. Source: Department of MicrobiologyThe University of Hong KongHong Kong SAR China

15. American Bioterrorism Attacks • 1984: Dalles, OR; Rajneeshee Salmonella food poisoning • 750 ill; 60 visited ER; 21 hospitalized; 0 deaths • 1991: Minnesota; Patriot’s Council ricin toxin • Plot undermined; 0 ill; 0 hospitalized; 0 deaths • 1995: Arkansas; ricin toxin • Plot undermined; 0 ill; 0 hospitalized; 0 deaths • 1995: Ohio; plague • Plot undermined; 0 ill; 0 hospitalized; 0 deaths • 1996: Dallas, TX; shigella • Poisoned donuts; 13 ill; 13 hospitalized; 0 deaths • 1998: Las Vegas, NV; anthrax • Plot undermined; 0 ill; 0 hospitalized; 0 deaths • 2000: Irvine, CA; many agents • Plot undermined; 0 ill; 0 hospitalized; 0 deaths • 2001: FL, NY, NJ, DC, CT; anthrax mailings • ~Millions of doses mailed; 33,000 people on antibiotics; 22 cases; 5 deaths

16. New Legal Challenges Posed • Quarantine & isolation of individuals, families, & large groups • Compulsory prophylaxis or vaccination • Travel bans, prohibiting large gatherings • Evacuation • Condemnation of property

17. Role of PH Agency During Infectious Disease Emergency • Surveillance • Control • Coordination • Communication

18. Role of PH Agency During Infectious Disease Emergency • Surveillance • What Is It? • How Widespread? • How Is It Transmitted? • Who Is At Risk?

19. Role of PH Agency During Infectious Disease Emergency • Surveillance • Control • How To Interrupt Cycle of Transmission? • Pharmaceutical measures (eg. vaccines, drugs) • Physical measures (e.g. quarantine, isolation) • Environmental measures (e.g. insecticides) • Behavioral measures (e.g. condoms, needles)

20. Role of PH Agency During Infectious Disease Emergency • Surveillance • Control • Coordination • Ensuring appropriate resource availability • Security • Transportation, cold storage • Medical equipment (e.g. ventilators, staffing) • Body bags, etc.

21. Role of PH Agency During Infectious Disease Emergency • Surveillance • Control • Coordination • Communication • Politicians/Policymakers message • Physician/Provider message • Public message

22. Role of PH Agency During Infectious Disease Emergency • Surveillance • Control • Coordination • Communication The efficient exercise of each of these functions during an infectious disease emergency may require various legal tools.

23. Role of PH Agency During Infectious Disease Emergency • Surveillance • Control • Coordination • Communication

24. Role of PH Agency During Infectious Disease Emergency • Surveillance • What Is It? • How Widespread? • How Is It Transmitted? • Who Is At Risk?

25. Definition of Disease Surveillance Ongoing, systematic collection, collation, analysis and interpretation of data and the dissemination of information to those that need to know in order that action may be taken. • Passive, • Enhanced passive, • Active.

26. Passive Surveillance • Medical providers report notifiable diseases on a case-by-case basis to the local or state health agency, based upon a published list of conditions

28. Passive Disease Reporting Health Care providers must report communicable diseases: • It shall be the duty of every health care provider, knowing of or in attendance on a case or suspected case of any of the diseases or conditions listed in subsection (j) of this section, to report to the local health officer for the jurisdiction where the patient resides as required in subsection (h) of this section. –17 CCR § 2500 Hospitals and Clinics must have procedures in place for reporting: • The administrator of each health facility, clinic or other setting where more than one health care provider may know of a case, a suspected case or an outbreak of disease within the facility shall establish and be responsible for administrative procedures to assure that reports are made to the local health officer. –17 CCR § 2500 Reports must include identifying information: • name of the disease or condition being reported; the date of onset; the date of diagnosis; the name, address, telephone number, occupation, race/ethnic group, Social Security number, sex, age, and date of birth for the case or suspected case; the date of death if death has occurred; and the name, address and telephone number of the person making the report. –17 CCR § 2500

30. Active Surveillance • Health officials actively contact providers to ascertain the existence of certain types of diseases, syndromes or presenting symptoms. • Essentially medical detective work • May require more open-ended review of medical records, particularly when pursuing contact investigations. • May include inspection of records, property, and examination of persons.

31. Active Surveillance - Example • We would like to review the medical records of all patients who presented to your ER between Monday, April 24 and Friday, April 28, who complained of cough, fever, headache or rash, and lived or worked in the cities of San Francisco, San Rafael, or Sausalito. • (Is this a search subject to 4th Amendment constraints?) • Cal Civil Code 56.10 (medical records privacy) might be read to preclude hospitals from making such disclosures.

32. Role of PH Agency During Infectious Disease Emergency • Surveillance • Control • How To Interrupt Cycle of Transmission? • Pharmaceutical measures (eg. vaccines, drugs) • Physical measures (e.g. quarantine, isolation) • Environmental measures (e.g. insecticides) • Behavioral measures (e.g. condoms, needles)

33. Disease Control Measures • Isolation and quarantine • Measures of social distancing • Canceling large gatherings • Canceling school • Restricting certain kinds of commerce (e.g. live poultry markets) • Mass screening and prophylaxis • Decontamination and destruction of property

34. Quarantine vs. Isolation

35. Quarantine • Quarantine is the physical separation and confinement of an individual or groups of individuals, who are or may have been exposed to a contagious or possibly contagious disease and who do not show signs or symptoms of a contagious disease, from non-quarantined individuals, to prevent or limit the transmission of the disease to non-quarantined individuals. –Model State Emergency Health Powers Act, Center for Law and the Public’s Health 12/21/01

36. Isolation • Isolation is the physical separation and confinement of an individual or groups of individuals who are infected or reasonably believed to be infectedwith a contagious or possibly contagious disease from non-isolated individuals, to prevent or limit the transmission of the disease to non-isolated individuals. –Model State Emergency Health Powers Act, Center for Law and the Public’s Health 12/21/01

37. Local Quarantine Authority-CA • Quarantine is defined as the limitation of freedom of movement of persons or animals that have been exposed to a communicable disease for a period of time equal to the longest usual incubation period of the disease, in such manner as to prevent effective contact with those not so exposed. If the disease is one requiring quarantine of the contacts in addition to isolation of the case, the local health officer shall determine the contacts who are subject to quarantine, specify the place to which they shall be quarantined, and issue instructions accordingly. He shall insure that provisions are made for the medical observation of such contacts as frequently as necessary during the quarantine period.-CA Code of Regulations Title 17 Section §2520

38. Role of PH Agency During Infectious Disease Emergency • Surveillance • Control • Coordination • Ensuring appropriate resource availability • Security • Transportation, cold storage • Medical equipment (e.g. ventilators, staffing) • Body bags, etc.

39. Resource Coordination • Works primarily through an organized and practiced process ICS/SEMS/NIMS, coordinated through state OES, but this mechanism would likely not work as well during an 6-8 week influenza outbreak with all jurisdictions afflicted and competing for resources. • May need to inventory public and private supplies of critical medical equipment and supplies ( “proprietary” info?) • May need to commandeer property (e.g. trucks, storage facilities, medical equipment, medical facilities). Conscription of staff?

40. Role of PH Agency During Infectious Disease Emergency • Surveillance • Control • Coordination • Communication • Politicians/Policymakers message • Physician/Provider message • Public message

41. Communication • May need to withhold certain information to protect confidentiality. (May not be able to tell employer the name of their employee who may be a source of influenza within the workplace.) • May need to disclose certain information that might affect proprietary business interests. (May need to name a company or business where the public may have faced or continue to face certain risks of infection. E.g. market, opera house, theater, airline, or hotel.)

42. Role of PH Agency During Infectious Disease Emergency • Surveillance • Control • Coordination • Communication An understanding of the logic and tools employed by public health departments to reduce and hopefully prevent the impact of communicable disease, is essential for attorneys who might be called upon to both prepare their clients for pandemic flu and respond to requests made of their clients by the public health and other government officials.

43. Questions?