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Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce. Acknowledgements. This presentation, and the accompanying instructor’s manual, were prepared by Jennifer Brennan Braden, MD, MPH, at the

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Preparing for and responding to bioterrorism information for the public health workforce

Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce


This presentation, and the accompanying instructor’s manual,

were prepared by Jennifer Brennan Braden, MD, MPH, at the

Northwest Center for Public Health Practice in Seattle, WA, for the

purpose of educating public health employees in the general aspects of

bioterrorism preparedness and response. Instructors are encouraged

to freely use all or portions of the material for its intended purpose.

The following people and organizations provided information and/or

support in the development of this curriculum. A complete list of

resources can be found in the accompanying instructor’s guide.

Patrick O’Carroll, MD, MPH

Project Coordinator

Centers for Disease Control and Prevention

Judith Yarrow

Design and Editing

Health Policy and Analysis; University of WA

Washington State Department of Health

Jeff Duchin, MD

Jane Koehler, DVM, MPH

Communicable Disease Control,

Epidemiology and Immunization Section

Public Health - Seattle and King County

Ed Walker, MD; University of WA

Department of Psychiatry

Consequence management for public health leaders module a
Consequence Management For Public Health Leaders Module A

Consequence management learning objectives
Consequence ManagementLearning Objectives

  • Describe the role of public health in consequence management following a public health emergency and identify laws supporting this role

  • Describe the legal basis for quarantine and potential adverse consequences and identify factors to consider when implementing and enforcing quarantine

Consequence management learning objectives1
Consequence ManagementLearning Objectives

  • Describe the basic structure and components of the National Pharmaceutical Stockpile,

    • How and when it is employed

    • The responsibilities of state and local health officials in accepting and distributing the resources provided

  • Identify the potential psychological responses, on individual and community levels, following a BT event, threat, or other public health emergency

Consequence management legal basis for local efforts
Consequence Management Legal Basis for Local Efforts

  • State police powers give states the authority to prescribe within the limits of state and federal constitutions, reasonable laws necessary to preserve the public order, health, safety, welfare, and morals.

  • RCW 70.05.070 gives the local health officer power to “take such measures as he or she deems necessary in order to promote the public health.”

Presidential decision directive 39 u s policy on counterterrorism
Presidential Decision Directive 39U.S. Policy on Counterterrorism

  • Consequence management - response to the disaster, focusing on the alleviation of damage, loss, hardship, or suffering

    • Public health, medical, and emergency personnel

    • Response and Recovery phases

    • State have primary responsibility for response

    • Federal agencies provide assistance as needed

      • FEMA has lead role


Consequence management federal support
Consequence Management Federal Support

  • Federal Response Plan, Emergency Support Function #8

    • Provides “federal assistance to supplement state and local resources in response to public health and medical needs following a major disaster or emergency, or during a developing potential medical situation”

    • Directed by DHHS

      • CDC lead for protecting health and safety

Consequence management other emergency support functions
Consequence Management Other Emergency Support Functions

Consequence management necessary protocols and procedures
Consequence ManagementNecessary Protocols and Procedures

  • Communication and informational updates

    • Between staff/agency divisions

    • With other coordinating agencies

    • With the media and public

  • Evaluation and referral of phone calls and requests for information or services

  • Mass antibiotic prophylaxis and immunization

  • Quarantine and isolation

Consequence management necessary protocols and procedures1
Consequence ManagementNecessary Protocols and Procedures

  • Closure of public places/institutions

  • Evaluating and referring reports of suspicious packages or substances

  • Surge capacity

  • Use of private resources

  • Use of volunteers and outside aid

  • Requesting state/federal assistance


  • Comes from Italian quarante – refers to the 40 day sequestration imposed on arriving merchant ships during plague outbreaks of the 13th century

  • Today – broader definition

    • Restriction of movement of persons, animals, and things that might otherwise spread a contagious disease

    • Usually refers to population-wide measures

    • Time period not specified

Cdc definition quarantine vs isolation
CDC Definition: Quarantine vs. Isolation

  • Isolation

    • The separation of a person or group of persons from other people to prevent the spread of infection

  • Quarantine

    • Restriction of activities or limitation of freedom of movement of those presumed exposed to a communicable disease in such a manner as to prevent effective contact with those not so exposed

Cdc definition quarantine vs isolation1
CDC Definition: Quarantine vs. Isolation

  • Quarantine measures may include:

    • Suspension of public gatherings

    • Closure of public places

    • Restriction of travel

    • Cordon sanitaire

Quarantine legal authority local level
QuarantineLegal authority – Local Level

  • When confined to a specific locale (community, state) – rests with local and/or state health authorities (police power)

  • Few states have specific policies/procedures for deciding whether quarantine is warranted in a specific situation

  • Be familiar with the laws pertaining to quarantine or that might be interpreted as applying to quarantine, existing in your state

Quarantine legal authority federal
Quarantine Legal Authority - Federal

  • Section 311 of Public Health Service Act

    • Allows for federal assistance to state and local authorities in enforcing quarantine and other health regulations

Quarantine legal authority federal1
Quarantine Legal Authority – Federal

  • 42 CFR Part 70 - authorizes the apprehension, detention or conditional release of people to prevent the spread of specified communicable diseases, and federal action if state efforts insufficient

  • 42 CFR Part 71 - authorizes CDC to detain, isolate or place under surveillance, people arriving in the US who are reasonably believed to be infected w/ or been exposed to certain communicable diseases, if necessary to prevent the introduction, transmission, or spread of those diseases

Quarantine and isolation factors to consider
Quarantine and IsolationFactors to Consider

  • Is there a scientific basis?

    • Among Category A agents, only smallpox, pneumonic plague, and some VHFs transmitted person-to-person

  • Is it practical and feasible?

    • Defined geographic area of risk

    • Resources to enforce and maintain

    • Time period required

  • Do the potential benefits outweigh the risks?

Medical reasons for isolation or quarantine
Medical Reasons for Isolation or Quarantine

  • Isolation

    • Disease transmitted person-to-person

      • i.e., plague pneumonia, smallpox, viral hemorrhagic fevers

      • Degree of isolation appropriate for mode of transmission (e.g., respiratory vs. direct contact)

  • Quarantine

    • Disease may be transmitted by exposed persons prior to recognition of symptoms or diagnosis

      • Smallpox infectious at rash onset, but rash may be overlooked in early stages

Quarantine potential adverse consequences
Quarantine Potential Adverse Consequences

  • Increased risk of disease transmission in quarantined population

  • Mistrust of government

    • Civil disobedience  violence

  • Social stigmatization

  • Economic effects

    • Businesses in quarantined area

    • Businesses relying on goods and services from quarantined area

Quarantine and isolation pre event planning
Quarantine and Isolation Pre-Event Planning

  • Identify community facilities appropriate for use as quarantine sites

  • Identify non-infected personnel to administer services at quarantine/isolation site

    • Health care providers

    • Laundry and waste disposal personnel

    • Enforcers/access control

Quarantine and isolation pre event planning1
Quarantine and IsolationPre-Event Planning

  • Identify means of food and supply provision to quarantine/isolation site

  • Ensure means of communication with outside community

Quarantine and isolation policies and procedures

When to institute

Who is allowed access to site

Infection control policies

Transportation of people to site

Within site

Criteria for entry and departure

When to discontinue

Quarantine and IsolationPolicies and Procedures

Isolation cdc smallpox response plan
IsolationCDC Smallpox Response Plan

  • Facility Categories

    • Type C – Contagious

      • Confirmed and probable cases

    • Type X – Uncertain diagnosis

      • Vaccinated febrile contacts without rash

    • Type R – Asymptomatic

      • Non-febrile contacts

Type c facilities cdc smallpox response plan
Type C FacilitiesCDCSmallpox Response Plan

  • Non-shared heating, air-conditioning, and ventilation systems

  • Exhaust all air out through HEPA filter, or at least 100 yds from other occupied areas

  • Adequate water, heating, cooling, and closed window ventilation

  • Able to provide high-level medical care

    (incl. vent support and cardiac resuscitation)

Type x facilities cdc smallpox response plan
Type X FacilitiesCDC Smallpox Response Plan

  • Same isolation and

    general supply

    requirements as

    Type C facility

  • Able to provide basic medical care

    (e.g., monitoring vital signs)

Type r facilities cdc smallpox response plan
Type R FacilitiesCDCSmallpox Response Plan

  • May be the person’s home


  • Hotel/motel if warranted due to logistical or other reasons

National pharmaceutical stockpile purpose
National Pharmaceutical StockpilePurpose

  • Provides resources to respond to both biologic and chemical attacks

  • Requested by governor

  • Managed by Centers for Disease Control and Prevention

More on NPS...


National pharmaceutical stockpile push packages
National Pharmaceutical StockpilePush Packages

  • 12-hour “Push Packages” in cargo-sized containers weighing approximately 37 tons each

  • Located around the country at strategic locations

  • Held in environmentally controlled and secured warehouses

  • Can reach a destination within 12 hours of being requested

More on NPS...


National pharmaceutical stockpile push packages1
National Pharmaceutical StockpilePush Packages

  • Contain color-coded inventory

  • Pharmaceuticals - stock rotated before expiration

  • IV supplies, airway supplies, ventilators

  • Bandages and personal protective equipment

More on NPS...


National pharmaceutical stockpile push packages2
National Pharmaceutical StockpilePush Packages

  • Materials pre-packaged for immediate dispensing

  • Support staff will accompany the package

  • Receiving state responsible for logistics of repackaging and distribution

More on NPS...


National pharmaceutical stockpile vendor managed inventory
National Pharmaceutical StockpileVendor-Managed Inventory

  • Agreements with pharmaceutical manufacturers to make large stocks available on demand

  • Shipped to arrive within 24-36 hours after requested

  • VA hospitals have an agreement with CDC to assist in the procurement and maintenance of NPS

More on NPS...


Pre event planning mass prophylaxis and treatment
Pre-Event PlanningMass Prophylaxis and Treatment

  • Identification of sites

    • Coordination with local hospitals, clinics, pharmacies, and other community facilities

    • Contagiousness of disease may require separate site for antibiotic dispensing/immunizations (i.e., smallpox)

    • Infection control precautions

  • Identification of staff and equipment, in low- and high-volume situations (surge capacity)

  • Establishing a record-keeping system

  • Developing follow-up protocols and procedures

Psychological response to a public health emergency
Psychological Response toA Public Health Emergency

  • Reaction to the event itself

  • Anticipation of future events

  • Reaction to public health measures taken to manage/control disease and injury

    • Quarantine

    • Prophylactic measures

    • Prioritization/rationing of resources

  • Reaction to misinformation (e.g., myths, rumors)

Psychological aftermath of crisis role of public health
Psychological Aftermath of Crisis: Role of Public Health

  • Educating and informing clinicians and the public about current risks and protective measures

  • Coordination of and referral to medical and social support resources

  • Ensuring the needs of populations at-risk for psychological sequelae are addressed

Key concepts of disaster mental health
Key Concepts of Disaster Mental Health

  • Two types of disaster trauma

    • Individual

    • Community

  • Most people pull together and function during and after a disaster, but their effectiveness is diminished

  • Social support systems are crucial to recovery

Source: US DHHS. Key Concepts Of Disaster Mental Health

Key concepts of disaster mental health1
Key Concepts of Disaster Mental Health

  • Disaster stress and grief reactions are normal responses to an abnormal situation.

  • Many emotional reactions of disaster survivors stem from living problems brought about by the disaster.

  • Most people do not see themselves as needing mental health services following disaster and will not seek such services.

Source: US DHHS. Key Concepts Of Disaster Mental Health

Psychological and behavioral responses to trauma and disaster





Difficulty concentrating

Sleep and appetite disturbances

Physical Complaints


Aches and pains

Stomach and intestinal complaints


Skin rashes

Psychological and Behavioral Responses to Trauma and Disaster

Psychological and behavioral responses to trauma and disaster1





Shock and disbelief






↑ substance use

alcohol, caffeine, tobacco

Interpersonal conflict

Impaired work/school performance

Psychological and Behavioral Responses to Trauma and Disaster

Responses to trauma children
Responses to Trauma - Children

  • After any disaster, children are most afraid that:

    • The event will happen again

    • Someone will be injured or killed

    • They will be separated from the family

    • They will be left alone

Helping children cope after trauma
Helping Children Cope After Trauma

  • Assume they know a disaster has occurred

  • Talk with them calmly and openly at their level

  • Ask what they think has happened, and about their fears

  • Share your own fears and reassure

  • Emphasize the normal routine

  • Limit media re-exposure

  • Allow expression in private ways (i.e., drawing)

Psychological responses following a biological terrorist attack

Magical thinking about microbes and viruses

Fear of invisible agents

Fear of contagion

Attribution of arousal symptoms to infection


Panic and paranoia

Loss of faith in social institutions

Psychological Responses Following a Biological Terrorist Attack

Source: Holloway et al. JAMA 1997;278(5):425-7

At risk populations for psychiatric sequelae following traumatic stress
At-risk Populations for Psychiatric Sequelae Following Traumatic Stress

  • Those exposed to the dead and injured

    • Eye witnesses and those endangered by event

    • Emergency first-responders

    • Medical personnel caring for victims

  • The elderly

  • The very young

Source: Norwood et al. Disaster psychiatry: principles and practice.

At risk populations for psychiatric sequelae following traumatic stress1
At-risk Populations for Psychiatric Sequelae Following Traumatic Stress

  • Those with a history of exposure to other traumas or with recent or subsequent major life stressors or emotional strain

  • Chronic poverty, homelessness, unemployment, or discrimination

  • Those with chronic medical or

    psychological disorders

Source:ACOEM Disaster Preparedness web site

Stress management for public health workers
Stress Management for Traumatic StressPublic Health Workers

  • Take care of yourself:

    • Get sufficient sleep

    • Eat regular meals

    • Keep caffeine and alcohol consumption moderate

    • Talk through your feelings with a safe confidant

      • Family member

      • Mental health or other health care provider

    • Seek help when feelings overwhelm or interfere with your ability to function

Stress management for public health workers advice for management
Stress Management for Public Health Workers: Advice for Management

  • Complements can serve as powerful motivators and stress monitors.

  • Ensure regular breaks from tending to duties.

    • Establish a place for workers to talk and receive support from colleagues.

    • Encourage contact with loved ones, as well as relaxing activities.

  • Hold department meetings to keep people informed of plans and events.

Modified from: Center for Traumatic Stress, Uniformed Services University of the

Health Sciences, American Psychiatric Association

Summary of key points
Summary of Key Points Management

  • The initial and primary response to the consequences of a terrorist event occurs at the local level.

  • ESF 8 provides for federal assistance to supplement state and local efforts in response to a public health emergency.

  • Medical, practical, and feasibility considerations are important in the decision to implement quarantine.

Summary of key points1
Summary of Key Points Management

  • Individual, community, and event-specific factors influence the psychological response to a public health emergency.

  • Most individuals will function adequately following a traumatic event, but a few will need psychological or medical intervention.

  • Many emotional reactions of disaster survivors stem from livingproblemsbrought about by the disaster.

Summary of key points2
Summary of Key Points Management

  • Anxiety responses are most likely following a biological attack, but depression, physical symptoms, and substance use may also occur.

Resources Management

  • Centers for Disease Control and Prevention

  • Barbera J, et al. Large-scale quarantine following biological terrorism in the United States.

JAMA. 2001;286:2711-2717

Resources Management

  • American Psychiatric Association

    -- info on disaster psychiatry

  • Federal Emergency Management Agency

  • DHHS/SAMHSA - disaster mental health info and links to publications