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

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

2. Acknowledgements 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

3. Consequence Management For Public Health Leaders Module A

4. 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

5. 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

6. 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.”

7. 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 PDD-39

8. 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

9. Consequence Management Other Emergency Support Functions

10. 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

11. 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

12. Quarantine • 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

13. 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

14. CDC Definition: Quarantine vs. Isolation • Quarantine measures may include: • Suspension of public gatherings • Closure of public places • Restriction of travel • Cordon sanitaire

15. 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

16. 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

17. 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

18. 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?

19. 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

20. 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

21. 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

22. Quarantine and IsolationPre-Event Planning • Identify means of food and supply provision to quarantine/isolation site • Ensure means of communication with outside community

23. 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

24. 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

25. 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)

26. 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)

27. Type R FacilitiesCDCSmallpox Response Plan • May be the person’s home or • Hotel/motel if warranted due to logistical or other reasons

28. 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... 28

29. 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... 29

30. 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... 30

31. 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... 31

32. 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... 32

33. 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

34. 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)

35. 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

36. 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

37. 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

38. Depression Sadness Demoralization Isolation/withdrawal Difficulty concentrating Sleep and appetite disturbances Physical Complaints Fatigue Aches and pains Stomach and intestinal complaints Headache Skin rashes Psychological and Behavioral Responses to Trauma and Disaster

39. Anxiety Re-experiencing Numbing Hyperarousal Shock and disbelief Fear Panic Anger Irritability Behavioral ↑ substance use alcohol, caffeine, tobacco Interpersonal conflict Impaired work/school performance Psychological and Behavioral Responses to Trauma and Disaster

40. 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

41. 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)

42. Magical thinking about microbes and viruses Fear of invisible agents Fear of contagion Attribution of arousal symptoms to infection Scapegoating 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

43. 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.

44. 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

45. Stress Management for Public 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

46. 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

47. Summary of Key Points • 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.

48. Summary of Key Points • 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.

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

50. Resources • Centers for Disease Control and Prevention • Barbera J, et al. Large-scale quarantine following biological terrorism in the United States. http://www.bt.cdc.gov JAMA. 2001;286:2711-2717