Legal and Enforcement Issues Panelists

1. Legal and Enforcement Issues Panelists Maggie Moran, KC Board of Health Administrator Jane McKenzie, J.D. KC Senior Deputy Prosecuting Attorney Byron C. Byrne, Regional Emergency Response Coordinator - PHSKC John Miner, Lieutenant, Operations and Support, Redmond Police Department

2. Isolation and Quarantine Legal and Enforcement Issues

3. In order to protect the public health, the State Board of Health shall: (d) Adopt rules for the imposition and use of isolation and quarantine RCW 43.20.050 (2) (d).

4. Washington law grants broad authority to local boards of health [RCW 70.05.060] and local health officers [RCW 70.05.070] to institute emergency control measures.

5. November 2001 - SBOH adopted “Response Capacity During a Public Health Emergency”

6. March 2002 - State Board convened a work group to discuss gaps in existing statutes and administrative law that might impair local response to public health emergency, including bioterrorism event or a major communicable disease outbreak.

7. December 2002 - Rule changes proposed and adopted • Added new sections to chapter 246-100 WAC, Communicable and Certain Other Diseases to establish due process procedures for isolation and quarantine. • Added new section to chapter 246-100 WAC referencing existing statutory legal authority and requirements to enforce the orders of local health officer.

8. January 2003 - Public Health - Seattle and King County begin to develop policies, procedures and tools for carrying out WAC 246-100

9. Chapter 246-100 WAC • 011 Definitions • 036 Responsibilities and duties - local health officers • 040 Procedures for isolation and quarantine • 045 Conditions and principles for isolation and quarantine

10. Chapter 246-100 WAC • 050 Isolation or quarantine premises • 055 Relief from isolation or quarantine • 060 Right to counsel • 065 Consolidation • 070 Enforcement of local health officer orders

11. 011 Definitions “Isolation means the separation, for the period of communicability or contamination, of infected or contaminated persons or animals from others in such places and under such conditions as to prevent or limit the direct or indirect transmission of the infectious agent or contaminant….”

12. 011 Definitions “Quarantine means the limitation of freedom of movement of such well persons or domestic animals as have been exposed to, or are suspected to have been exposed to, an infectious agent, …..in such manner as to prevent effective contact with those so exposed.”

13. 036 Responsibilities and duties - local health officers “Local health officer shall establish, in consultation with local health care providers, health facilities, emergency management personnel, law enforcement agencies, and any other entity he or she deems necessary, plans, policies, and procedures for instituting emergency measures necessary to prevent the spread of communicable disease or contamination.”

14. 040 Procedures for isolation and quarantine • Voluntary Isolation • Emergency Detention Order • Petition to the Superior Court

15. Voluntary Isolation • Individual agrees to stay home • Health Department checks periodically • Health Department and emergency management partners attends to health and other needs

16. Involuntary Detention Health Officer may order immediate involuntary detention: • Must have made reasonable efforts which have been documented - to obtain voluntary compliance OR • Must have determined that seeking voluntary compliance would create a risk of serious harm;

17. Involuntary Detention • Must have reason to believe that person/persons is or is suspected to be, infected with, exposed to or contaminated with communicable disease or chemical, biological, or radiological agent that could spread to others; AND • Must have reason to believe that person(s) would pose a serious and imminent risk to the health and safety of others if not detained.

18. Involuntary Detention • Emergency Detention Order must be issued within 12 hours of detention. • Provide copy to person(s) detained. • Detention pursuant to Emergency Detention Order cannot exceed 10 days under WAC.

19. Required contents of Emergency Detention Order • Identity of person(s) subject to isolation or quarantine; • Premises subject to isolation or quarantine; • Date and time at which isolation and quarantine commences; • Suspected communicable disease or infectious agent

20. Required contents of Emergency Detention Order • Measures taken by health officer to seek voluntary compliance OR basis on which health officer determined that seeking voluntary compliance would create risk of serious harm; • Medical basis on which isolation and quarantine is justified;

21. Required contents of Emergency Detention Order • Notice of right to petition Superior Court for release from isolation, and right to counsel, at government expense, if cannot afford counsel. • Required notice language set forth in WAC 246-100-040(3)(d).

22. Enforcement of Emergency Detention Order Washington law requires that the public comply with orders of boards of health and local health officers made for prevention, suppression, and control of dangerous contagious and infectious diseases. (RCW 70.05.120)

23. Enforcement of Emergency Detention Order Police officers, sheriffs, constables, and all other officers and employees of any political subdivisions within the health department jurisdiction are directed to enforce orders given to effectuate isolation and quarintine. (WAC 246-100-070 and RCW 43.20.050)

24. Petition to the Superior Court Person(s) may petition the court for release from detention ordered by health officer. (WAC 246-100-055)

25. Court Ordered detention • Alternative to health officer ordering involuntary detention • Ex-parte petition to Court must contain much of the same information as Emergency Detention Order. • Detention ordered cannot exceed 10 days • Advantage: Court order, extra protection against due process challenge. • Disadvantage: Extra step

26. Petition to the Superior Court for continued detention. • Seek order for continued involuntary detention. • For period up to 30 day • Hearing to be held within 72 hours (excluding Saturday, Sunday, and holidays). • Prior to expiration of court order - continued involuntary detention • For period up to 30 days

27. Contents of Petition for Continued Detention • Much of the same information as in Emergency Detention Order • Declaration of health officer attesting to facts asserted in petition. • Statement of compliance with conditions and principles for isolation and quarantine.

28. Additional suggested pleadings (not required by WAC) • Motion to Seal Records (health care information) • Motion for Court Appointed Counsel right to counsel pursuant to WAC 246-100-060

29. Coordination with Superior Court and Public Defender • Prepare for logistical problems --court hearings with potentially contagious individuals • Telephonic hearings • Video conferencing • Hearings at detention site.

30. Conditions and principles for isolation and quarantine • Least restrictive means • Isolated person(s) confined separately from quarantined person(s) • Health status monitored regularly • Subsequently infected quarantined individuals to be placed in isolation • Isolated/quarantined person(s) to be released as soon as possible

31. Conditions and principles for isolation and quarantine • Person(s) needs must be addressed to greatest extent possible. • Safe and hygienic premises • Cultural and religious beliefs should be considered • Shall not abridge the right of person(s) to rely exclusively on spiritual means alone through prayer to treat a communicable disease • Person(s) retains right to be isolated or quarantined in private place of his/her choice provided it is approve by health officer.

32. Isolation or quarantine premises • Restricts entry into isolation or quarantine premises as determined by health officer • Those person(s) allowed entry must be provided with infection control training and/or wear PPE and/or be vaccinated; • Requires those person(s) allowed entry to follow rules established by SBOH of orders of local health officer.

33. Managing Quarantine and Isolation Measures in the Community

34. SARS as a Planning Surrogate • Recent real world experience • Lessons learned and shared • CDC guidance • Principles of SARS isolation and quarantine have application to other naturally occurring or man-made biological emergencies • Potential re-occurrence provides motivation

35. SARS Quarantine “The objective is to monitor and evaluate contacts of SARS cases to ensure early identification of illness and rapid institution of infection control precautions to prevent further spread. “ -CDC Guidelines

36. Types of SARS Quarantine Home Quarantine- suitable for most contacts who have a home environment in which their basic needs will be met and where protection of unexposed family members is feasible

37. Types of SARS Quarantine • Contacts who do not have an appropriate home environment for quarantine or contacts who do not wish to be quarantined at home may be quarantined in facilities designated for this purpose. • These will be improvised facilities

38. Types of SARS Quarantine Work quarantine - applies to healthcare workers or other essential personnel who have been exposed to SARS patients and who may need to continue working (with appropriate infection control precautions) but who are quarantined either at home or in a designated facility during off-duty hours.

39. SARS Isolation “The objective is to ensure appropriate separation and confinement of patients with SARS during the period of communicability.”

40. Planning Basics • Current Emergency Response Plan provides starting point and defines basic Incident Command structure • Operational requirements for managing community isolation and quarantine program can be anticipated • Planning requirement can be met by the creation of an Isolation and Quarantine Annex

41. Planning Conditions • Planning must be multi-jurisdictional, multi-disciplinary, and multi-agency • Collaboration and cooperation are critical planning elements • Partnerships are essential to successful development and execution of the plan • Planning must be followed by preparation • Time is of the essence

42. Public Health Role • Public Health will be the lead agency • Public health will be multi-tasking in an outbreak requiring isolation and quarantine measures • Public Health’s resources are finite • Must have assistance of community partners

43. Planning Tasks • Incident Command structure that: • is scaleable to operational needs • includes multiple agencies and partners • can be expanded to incorporate multiple sites • is flexible enough to incorporate additional agencies and partners • is regional in scope - IN WRITING -

44. Planning Tasks • Communication section that: • includes existing systems • increases capability with communication equipment that is simple, reliable, and user friendly • incorporates multiple technologies • provides for management of communications as a regional resource

45. Planning Tasks • Operations section that provides for: • notification, tracking, and monitoring of isolation and quarantine orders • notification of isolation or quarantine orders of patients admitted to health care facilities • enforcement of involuntary detention orders • determination of a home setting as an isolation or quarantine option

46. Planning Tasks • Operations • implementation of community “snow days”, cancellation of public events and other activities to limit social interactions • a comprehensive public information and education program

47. Enforcement of local health officer orders • “An order issued by a local health officer….. must be enforced by all police officers, sheriffs, constables, and all other officers and employees of any political subdivisions within the jurisdiction of the health department” [WAC 246-100-070] • Violations of this chapter and lawful health orders are a misdemeanor

48. The Isolation and Quarantine Project • Meetings…and more meetings • Initially, more questions than answers • But, failure or even failure to act, is not an option on this issue • We, as a group, MUST find a way to deal with this seemingly overwhelming task 1932 Measles Quarantine in Yakima, Washington

49. Isolation and Quarantine Team Purpose: • To identify, train, and support joint public health and law enforcement team members • To obtain, deliver and enforce involuntary detention orders issued out of Superior Court • To operate across jurisdictions within King County • To provide awareness level training to various agencies and intra-agency teams

50. The Initial Team: • Public Health • King County Sheriff’s Department • Seattle Police • Redmond Police • King County Prosecutor’s Office