Planning for PANDEMIC FLU

1. Planning forPANDEMIC FLU Principles of Isolation and Quarantine in the 21st Century Catherine Slemp, MD, MPH WV Bureau for Public Health November 2006

2. Objectives / Overview • Review Targeted and Layered Approach Concept • Review Disease Spread Principles and Goals in Addressing a Pandemic • Brief History of Isolation and Quarantine (I & Q) • 21st Century Principles of I & Q • I & Q Authorities in WV • Activities Underway • Ethical considerations and principles

3. Pandemics vary in severity and Combined approaches seem most effective (from history and modeling) ….therefore

4. A Targeted and Layered Approach

5. Epidemiology Drives Approach(Targeted) SAMPLE

6. A Layered Approach Individual / Household / Agency Hand hygiene Cough etiquette Infection control Living space control Isolation of ill Designated care provider Facemasks where indicated Community Isolation of ill Treatment of ill Quarantine of exposed Prophylaxis of exposed School closure Protective sequestration of children Social distancing - Community - Workplace Liberal leave policies International Containment-at-source Support efforts to reduce transmission Travel advisories Layered screening of travelers Health advisories Limited points of entry

7. Recent Analyses Suggest That Community Actions May Significantly Reduce Illness and Death Before Vaccine is Available When necessary, early and uniform implementation of such measures as: • School closure • Keeping kids and teens at home • Social distancing at work and in the community • Encouraging voluntary home isolation by ill individuals and voluntary home quarantine by their household contacts • Treating the ill and providing targeted antiviral prophylaxis to household contacts • Implementing measures early and in a coordinated way

8. Things to consider in choosing strategies • Disease severity • Information on the disease (e.g., are there high risk subgroups? How effective are antivirals? etc.) • Ability to practically implement the control measure • Public acceptability of the control measure • Secondary impacts of the measure—are we doing more harm than good? • What should be implemented by communities and what centrally? Is a common approach important? • Ethical considerations

9. Understanding Disease Spread

10. Ro = 2 R0 = 1

11. Effect of Increasing Social Distance on Epidemic Dynamics Suppression Exponentiation Ro = 2.0, Progression = 1:2:4:8:16 Ro = 0.67, Progression = 1:2:4:3:2

12. Ways to Increase “Social Distance” • Implement “Community Shielding” recommendations • Close or alter high risk transmission environments e.g. schools, daycare centers if supported by epidemiology • Cancel large public gatherings (concerts, theaters) • Minimize other exposures (markets, churches, public transit) • Encourage ill and exposed persons to stay home (isolation and quarantine) • Encourage telecommuting; other worksite adaptations • Scaling back or altered transportation services (holiday schedule) • Etc. • Other Interventions Supporting / Adding to “Social Distance” Measures • COOP to minimize economic impact, enable worksite adaptations, sustain secondary effects of “social distancing” measures • Infection Control: masks, hand hygiene, cough etiquette, barrier precautions, etc. where applicable.

14. Potential Tools in Our Toolbox • Vaccine: Our best countermeasure; will probably be unavailable during the first wave of a pandemic • Antivirals: • Treatment: If effective against specific virus that emerges, treatment may reduce disease duration / symptoms; will have only modest effects on transmission. • Prophylaxis: If virus susceptible and supply sufficient, may have more substantial effects on reducing transmission • Infection Control and Social Distancing: likely should reduce transmission; Strategies to implement many of these require clarification and significant advance planning.

15. Isolation and Quarantine as one of many means to increase “Social Distance” Isolation and Quarantine in 21st Century Public Health (a different tool than in prior centuries)

16. Definitions • Isolation • Separation of ill persons with contagious diseases • Often in a hospital setting, not always • Applied to individual(s), cohorts, populations • Quarantine • Restriction of persons who are not ill but presumed exposed • Usually in the home or a designated facility • Applied to individual(s), groups, or communities *voluntary vs. compulsory, request vs. legal order

17. 1800’s: “Quarantine” = Torture, exile, and death Death in a sailor’s uniform holding the yellow quarantine flag knocking on the door of NYC during the 1898 yellow fever epidemic Frank Leslie’s Illustrated Newspaper, Sept. 1878

18. 21st Century Quarantine Collective actions for the common good Public good Individual liberties Preventing Disease Spread While Safeguarding The Health of People Infected & Exposed to Highly Dangerous Infectious DiseasesParamount to meet needs of individuals infected and exposed ; avoid stigmatizing the victims

19. 10 Principles of Modern Quarantine • Used when exposed to highly dangerous and contagious disease and when resources available to implement and maintain • Encompasses a wide range of strategies, often used in combination with other interventions • Ensures rapid isolation of contagious persons from exposed • Ensures those in Q/I: access to essential goods services, be among those prioritized to receive interventions • Lasts only as long as necessary, not more than incubation period

20. 10 Principles of Modern Quarantine, cont. • Does not have to be absolute to be effective, therefore favors voluntary over compulsory • Must actively combat stigma and adhere to accepted ethical principles • Requires clear understanding of jurisdictional roles and legal authorities • Requires careful coordination and advance planning with many partners/stakeholders • Requires education, trust and participation of general public as well as strong leadership

21. Q-Ethical Construct 1. Justifiable Harms (necessity) 2. Least restrictive means 3. Reciprocity (support) 4. Due Process (notification & appeal) 5. Fairness * Construct derived from Ross Upshur, Can J PH 2002 (93):101-103

22. DUE PROCESS IN QUARANTINE AND ISOLATION • Flexible concept (procedures may vary) • Courts employ a balancing test • Degree of deprivation; risk of erroneous determination; value of added procedural safeguards • Common elements of due process • Adequate notice (written order) • Opportunity to be heard in meaningful time & manner • Neutral decision-maker • Access to legal counsel

23. Misconceptions • Effectiveness of containment measures requires 100% compliance • Isolation or Quarantine always means using a legal order to restrict someone’s activity • Isolation or Quarantine must be mandatory to be effective

24. Misconceptions • Quarantine only means large geographic “cordon sanitaire” • The public will never accept the use of quarantine as a mitigation strategy

25. I & Q is only one way to Increase “Social Distance” • “Community Shielding” measures • Close or alter high risk transmission environments e.g. schools, daycare centers if supported by epidemiology • Cancel large public gatherings (concerts, theaters) • Minimize other exposures (markets, churches, public transit) • Encourage ill persons to stay home (isolation) • Encourage exposed persons to stay home (quarantine) • Encourage telecommuting; other worksite adaptations • Scaling back or altered transportation services (holiday schedule) • Other interventions supporting / adding to “social distance” measures • COOP to minimize economic impact, enable worksite adaptations, sustain secondary effects of “social distancing” measures • Infection Control: masks, hand hygiene, cough etiquette, barrier precautions, etc. where applicable.

26. Advantages of “Community Shielding” Approaches • Intuitive • Leverages the public’s instinct for self-preservation Cordon sanitaire conflicts with this instinct • Less restrictive approach than geographic quarantine

27. “Quarantine” in Pan Flu • “Cordon Sanitaire”—likely limited to no significant applicability or usefulness. • Short incubation period, early period of communicability, and global nature of today’s world. • If considered at all: • Very early stages (first few cases / potential cases worldwide) • An attempt to prevent pandemic from occurring or significantly slow initial spread (“buying time”). • Other methods of quarantine may be useful—e.g. voluntary, home based quarantine • More practical and effective • Builds on interest and instinct to do what’s right / protect self and others • Undertaken as one of many community shielding measures

28. Lessons Learned from SARS Different disease, but learned in Toronto that… • People followed public health recommendations if • Clearly Communicated What to do and Why • Supported in Accomplishing / made it as Practical as Possible (access to basic necessities, job security, financial stability for period, etc.). Doing this takes more than gov’t alone. • Rarely needed to use legal authority • Was “voluntary” as long as you complied • Had legal authority to enforce if determined necessary. • 30,000+ quarantined in Toronto. Very few legal orders issued (<20). Most all challenges dropped once learned more.

29. Legal Authorities of PH in WV • State: §16-3-1.State director of health authority to quarantine and to enforce regulations; state board of health authority to issue regulations to control infectious or contagious diseases. • Local: §16-3-2. Powers of county and municipal boards of health to establish quarantine; penalty for violation.

30. Public Health Orders • Authorities to issue PH Orders • Local Boards of Health • State Health Commissioner • Don’t require declaration of emergency • In cases of isolation and quarantine, • Can be declared by BPH Commissioner or local Board of Health. • With latter, must be reported to and determined necessary by Commissioner as soon as practical to do so. Commissioner may lift if not deemed necessary.

31. Current Key Activities • Isolation and Quarantine Protocol Development (IDEP-DSDC-BPH) (when applicable for what disease, etc.) • Legal Workgroup: Administrative Processes and Tools

32. Remember: We have a Tool Kit of Control Measures to Use • Community Shielding (many methods) • Hygiene measures • Antivirals (treatment; prevention, if supplies sufficient) • Vaccine • Continuity of Operations Planning

33. Ethical Principles to Consider Alexander Capron, Ethical and Legal Considerations in Mitigating Pandemic Disease, IOM Forum on Emerging Infections, Washington, D.C., September 19-20, 2006

34. Ethical Principles to Consider Alexander Capron, Ethical and Legal Considerations in Mitigating Pandemic Disease, IOM Forum on Emerging Infections, Washington, D.C., September 19-20, 2006

35. Specific Ethical Considerations in Pandemic Flu Planning Alexander Capron, Ethical and Legal Considerations in Mitigating Pandemic Disease, IOM Forum on Emerging Infections, Washington, D.C., September 19-20, 2006

36. Specific Ethical Considerations in Pandemic Flu Planning Alexander Capron, Ethical and Legal Considerations in Mitigating Pandemic Disease, IOM Forum on Emerging Infections, Washington, D.C., September 19-20, 2006

37. Resources / References • “Stand on Guard for Thee: Ethical Considerations in Preparedness Planning for Pandemic Influenza.” November 2005. University of Toronto Joint Center for Bioethics, Influenza Working Group Report. Website reference: http://www.utoronto.ca/jcb/home/documents/pandemic.pdf • Alexander Capron, Ethical and Legal Considerations in Mitigating Pandemic Disease, IOM Forum on Emerging Infections, Washington, D.C., September 19-20, 2006.Website reference:http://www.iom.edu/CMS/3783/3924/35857/37298.aspx

38. Seasonal Influenza Pandemic Influenza All Hazard Preparedness

39. Get Informed, Be Prepared! RESOURCES • WVBPH: Div Threat Prep or DSDC • Your Emergency Management Agency and Local Health Department • http://www.wvflu.org • http://www.pandemicflu.gov • ASTHO (www.astho.org) and NACCHO (www.naccho.org) Websites • CDC website (www.cdc.gov)