Facilitating An Effective Public Facilitating An Effective Public Health Response To Pandemic FluHealth 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

What is Local What is Local Public Health?Public Health?

The Structure and Function of a Local Public Health Department

US Public Health System US Public Health System InfrastructureInfrastructure

Community Clinics

Hospitals

Local Physicians Nursing Homes

School Based Health Services

Pharmacies

Community Based Organizations

CDC

State Health Department

Local Health Department

FEDERAL LEVEL

STATE LEVEL

LOCAL LEVEL

Department of Health & Human Services

Basic Structure of an LHDBasic Structure of an LHD

1. Communicable Disease Control

2. Disaster Preparedness

3. Environmental Health

4. Chronic Disease Prevention

5. Maternal & Child Health• (Mish-mash of Direct Medical & Case

Management Services)$$$$$$

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Generic Health Department StructureGeneric Health Department Structure

D isaste r P repa redness C om m un icab le D iseaseC ontro l

E nv ironm en ta l Hea lth C h ron ic D iseaseP revention

M a terna l & C hild H ea lth

H ealth O fficer

EM S AG E N C Y

D isaste r P re pa redne ss

T B C o n tro l

ST D C o n tro l

C om m un icab le D ise a seC ontro l

Ve cto r C o n to l

F o o d/R esta ura n ts

W a ter

En viro n m e n ta l He a lth

D ia be tes P re ven tion

Asth m a P re ve n tion

T o b acco C on tro l

C h ron ic D isea sePreve ntion

In fa n t M o rta lity

T e en P re gnan cy

M a tern a l & C hild H e a lth

H ealth O fficer

AnthraxSmallpox

SARSPandemic Flu West Nile

Generic Health Department StructureGeneric Health Department Structure

Local Public Health Local Public Health Legal AuthorityLegal Authority

CA Local Health OfficersCA 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 shall take measures as may be necessary to prevent the spread of the necessary to prevent the spread of the disease or occurrence of additional casesdisease or occurrence of additional cases. –California Health & Safety Code Section 120175

Local Public Health Legal Local Public Health Legal AuthorityAuthority 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.

Then Came 9/11….Then Came 9/11….

Images of the new Images of the new coronaviruscoronavirus

                                                                                                   

Electron microscopic (EM) images of the new coronavirus attached to the cell surface.

Source: Department of MicrobiologyThe University of Hong KongHong Kong SAR China

American Bioterrorism AttacksAmerican Bioterrorism Attacks

1984: Dalles, OR; Rajneeshee Salmonella food poisoning750 ill; 60 visited ER; 21 hospitalized; 0 deaths

1991: Minnesota; Patriot’s Council ricin toxinPlot undermined; 0 ill; 0 hospitalized; 0 deaths

1995: Arkansas; ricin toxinPlot undermined; 0 ill; 0 hospitalized; 0 deaths

1995: Ohio; plaguePlot undermined; 0 ill; 0 hospitalized; 0 deaths

1996: Dallas, TX; shigellaPoisoned donuts; 13 ill; 13 hospitalized; 0 deaths

1998: Las Vegas, NV; anthraxPlot undermined; 0 ill; 0 hospitalized; 0 deaths

2000: Irvine, CA; many agentsPlot 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

New Legal Challenges PosedNew Legal Challenges Posed

1. Quarantine & isolation of individuals, families, & large groups

2. Compulsory prophylaxis or vaccination

3. Travel bans, prohibiting large gatherings

4. Evacuation

5. Condemnation of property

Role of PH Agency During Role of PH Agency During Infectious Disease EmergencyInfectious Disease Emergency Surveillance Control Coordination Communication

Role of PH Agency During Role of PH Agency During Infectious Disease EmergencyInfectious Disease Emergency Surveillance

– What Is It?– How Widespread?– How Is It Transmitted?– Who Is At Risk?

Role of PH Agency During Role of PH Agency During Infectious Disease EmergencyInfectious 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)

Role of PH Agency During Role of PH Agency During Infectious Disease EmergencyInfectious Disease Emergency Surveillance Control Coordination

– Ensuring appropriate resource availability• Security• Transportation, cold storage• Medical equipment (e.g. ventilators, staffing)• Body bags, etc.

Role of PH Agency During Role of PH Agency During Infectious Disease EmergencyInfectious Disease Emergency Surveillance Control Coordination Communication

– Politicians/Policymakers message – Physician/Provider message – Public message

Role of PH Agency During Role of PH Agency During Infectious Disease EmergencyInfectious Disease Emergency Surveillance Control Coordination Communication

The efficient exercise of each of these functions during an infectious disease emergency may require various legal tools.

Role of PH Agency During Role of PH Agency During Infectious Disease EmergencyInfectious Disease Emergency Surveillance Control Coordination Communication

Role of PH Agency During Role of PH Agency During Infectious Disease EmergencyInfectious Disease Emergency Surveillance

– What Is It?– How Widespread?– How Is It Transmitted?– Who Is At Risk?

Definition of Disease SurveillanceDefinition 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.

Passive SurveillancePassive 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

Passive Disease ReportingPassive 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

Active SurveillanceActive 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.

Active Surveillance - ExampleActive 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.

Role of PH Agency During Role of PH Agency During Infectious Disease EmergencyInfectious 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)

Disease Control MeasuresDisease 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

Quarantine vs. Quarantine vs. IsolationIsolation

QuarantineQuarantine

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

IsolationIsolation

Isolation is the physical separation and confinement of an individual or groups of individuals who are infected or reasonably believed to be infected with 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

Local Quarantine Authority-CALocal 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

Role of PH Agency During Role of PH Agency During Infectious Disease EmergencyInfectious Disease Emergency Surveillance Control Coordination

– Ensuring appropriate resource availability• Security• Transportation, cold storage• Medical equipment (e.g. ventilators, staffing)• Body bags, etc.

Resource CoordinationResource 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?

Role of PH Agency During Role of PH Agency During Infectious Disease EmergencyInfectious Disease Emergency Surveillance Control Coordination Communication

– Politicians/Policymakers message – Physician/Provider message – Public message

CommunicationCommunication

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.)

Role of PH Agency During Role of PH Agency During Infectious Disease EmergencyInfectious 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.

Questions?