Preparing for and Responding to Bioterrorism Information for
Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce Northwest Center for Public Health Practice University of Washington School of Public Health and Community Medicine 1
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 UW Northwest Center for Public Health Practice 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 2
Consequence Management For Public Health Professional Staff Module B UW Northwest Center for Public Health Practice 3
Consequence Management Learning Objectives n Describe the role of local public health in consequence management following a public health emergency n Describe the roles of state and federal health agencies in consequence management UW Northwest Center for Public Health Practice 4
Consequence Management Learning Objectives n Identify factors determining the need for isolation or quarantine and describe the potential adverse consequences n Describe the basic structure and components of the National Pharmaceutical Stockpile and how and when it is employed UW Northwest Center for Public Health Practice 5
Consequence Management Learning Objectives n Recognize the potential psychological responses, on individual and community levels, following a BT event, threat, or other public health emergency n Be able to provide basic disaster counseling and know when to refer for abnormal responses UW Northwest Center for Public Health Practice 6
Consequence Management Legal Basis for Local Efforts n 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. n 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. ” UW Northwest Center for Public Health Practice 7
Consequence Management Federal Support n Federal Response Plan, Emergency Support Function #8 n 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” n Directed by DHHS n CDC lead for protecting health and safety UW Northwest Center for Public Health Practice 8
Consequence Management Role of Public Health n Education and information updates n Between staff/agency divisions With other coordinating agencies n With the media and public n Evaluation and referral of phone calls and requests for information or services n Follow-up of cases/victims and contacts n UW Northwest Center for Public Health Practice 9
Consequence Management Role of Public Health n In cooperation with other agencies: n Mass antibiotic prophylaxis and n immunization n Quarantine and isolation n Closure of public places/institutions when indicated n Evaluating and referring reports of suspicious packages or substances UW Northwest Center for Public Health Practice 10
Consequence Management Protocols and Procedures n Be familiar with your agency’s protocols and procedures in an emergency for: n Triaging calls and clinic patients n Quarantine and isolation Designated quarantine sites n Designated staff n Infection control precautions n Prerequisites or precautions for entering and exiting facilities n UW Northwest Center for Public Health Practice 11
Consequence Management Protocols and Procedures Administering antibiotic prophylaxis or immunizations n Designated sites n Determining eligibility/need and contraindications n Record-keeping n n Infection control precautions Counseling re: adverse effects and risks n Follow-up procedures n UW Northwest Center for Public Health Practice 12
CDC Definition: Quarantine vs. Isolation n Isolation The separation of a person or group of persons from other people to prevent the spread of infection n 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 UW Northwest Center for Public Health Practice 13
CDC Definition: Quarantine vs. Isolation n Quarantine measures may include: n Suspension of public gatherings n Closure of public places n Restriction of travel n Cordon sanitaire UW Northwest Center for Public Health Practice 14
Quarantine Legal authority – Local Level n When confined to a specific locale (community, state) – rests with local and/or state health authorities (police power) n Few states have specific policies/procedures for deciding whether quarantine is warranted in a specific situation n Be familiar with the laws pertaining to quarantine or that might be interpreted as applying to quarantine existing in your state UW Northwest Center for Public Health Practice 15
Medical Reasons for Isolation or Quarantine n Isolation n Disease transmitted person-to-person n i. e. , plague pneumonia, smallpox, viral hemorrhagic fevers n Degree of isolation appropriate for mode of transmission (e. g. , respiratory, direct contact) n Quarantine n Disease may be transmitted by exposed persons, prior to recognition of symptoms or diagnosis n Smallpox infectious at rash onset, but rash may be overlooked in early stages UW Northwest Center for Public Health Practice 16
Quarantine Other Factors to Consider n Is it practical and feasible? n Defined geographic area of risk n Resources to enforce and maintain n Time period required n Do the potential benefits outweigh the risks? UW Northwest Center for Public Health Practice 17
Quarantine Potential Adverse Consequences n n Increased risk of disease transmission in quarantined population Mistrust of government n Civil disobedience violence Social stigmatization Economic effects n Businesses in quarantined area n Businesses relying on goods and services from quarantined area UW Northwest Center for Public Health Practice 18
Isolation CDC Smallpox Response Plan n Facility Categories n Type C – Contagious n Confirmed and probable cases n Type X – Uncertain diagnosis n Vaccinated febrile contacts without rash n Type R – Asymptomatic n Non-febrile UW Northwest Center for Public Health Practice contacts 19
Type C Facilities CDC Smallpox Response Plan n n 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) UW Northwest Center for Public Health Practice 20
Type X Facilities CDC Smallpox Response Plan n Same isolation and general supply requirements as Type C facility n Able to provide basic medical care (e. g. , monitoring vital signs) UW Northwest Center for Public Health Practice 21
Type R Facilities CDC Smallpox Response Plan n May be the person’s home or n Hotel/motel if warranted due to logistical or other reasons UW Northwest Center for Public Health Practice 22
National Pharmaceutical Stockpile Purpose n Provides resources to respond to both biologic and chemical attacks n Requested by governor n Managed by Centers for Disease Control and Prevention More on NPS. . . 23
National Pharmaceutical Stockpile Push Packages n Contain color-coded inventory n Pharmaceuticals - stock rotated before expiration n IV supplies, airway supplies, ventilators n Bandages and personal protective equipment More on NPS. . . 24
National Pharmaceutical Stockpile Vendor-Managed Inventory n Agreements with pharmaceutical manufacturers to make large stocks available on demand n Shipped to arrive within 24 -36 hours after requested n VA hospitals have an agreement with CDC to assist in the procurement and maintenance of NPS More on NPS. . . 25
Psychological Response to A Public Health Emergency Reaction to the event itself n Anticipation of future events n Reaction to public health measures taken to manage/control disease and injury n Isolation and quarantine n Prophylactic measures n Prioritization/rationing of resources n Reaction to misinformation (e. g. , myths, rumors) n UW Northwest Center for Public Health Practice 26
Psychological Aftermath of Crisis Role of Public Health n Educating and informing clinicians and the public about current risks and protective measures n Coordination of and referral to medical and social support resources n Ensuring the needs of populations at-risk for psychological sequelae are addressed UW Northwest Center for Public Health Practice 27
The Psychological Aftermath of Crisis Additional Roles for the Allied Health Professional n n n Active listening and encouragement Basic disaster/crisis counseling Identification and referral of abnormal stress responses Encouragement of re-entry into social roles, when appropriate Discouragement of repeated exposure to trauma (e. g. , TV replays, newspaper articles) Communication of medical risks, as appropriate UW Northwest Center for Public Health Practice 28
Key Concepts of Disaster Mental Health n Two types of disaster trauma n Individual n Community n Most people pull together and function during and after a disaster, but their effectiveness is diminished n Social support systems are crucial to recovery Source: US DHHS. Key Concepts Of Disaster Mental Health UW Northwest Center for Public Health Practice 29
Key Concepts of Disaster Mental Health n Disaster stress and grief reactions are normal responses to an abnormal situation. n Many emotional reactions of disaster survivors stem from living problems brought about by the disaster. n 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 UW Northwest Center for Public Health Practice 30
Psychological and Behavioral Responses to Trauma and Disaster n Depression n Sadness n Demoralization n Isolation/withdrawal n Difficulty concentrating n Sleep and appetite disturbances UW Northwest Center for Public Health Practice n Physical Complaints Fatigue n Aches and pains n Stomach and intestinal complaints n Headache n Skin rashes n 31
Psychological and Behavioral Responses to Trauma and Disaster n Anxiety n Behavioral n Re-experiencing n ↑ substance use n Numbing n alcohol, caffeine, n Hyperarousal tobacco n Shock and disbelief n Interpersonal n Fear conflict n Panic n Impaired n Anger work/school n Irritability performance UW Northwest Center for Public Health Practice 32
Responses to Trauma - Children n After any disaster, children are most afraid that: n The event will happen again n Someone will be injured or killed n They will be separated from the family n They will be left alone UW Northwest Center for Public Health Practice 33
Responses to Trauma - Children n n Influenced by developmental stage May include: n Depressed or irritable mood n Decreased school performance n Increased dependence and clinginess n Changes in appetite - ↑ or ↓ n Sleep disturbances n Physical complaints (e. g. , stomach aches, headache) UW Northwest Center for Public Health Practice 34
Responses to Trauma School-Age Children Preschool-2 nd grade n Separation anxiety n Avoidance n Regressive symptoms n Fear of the dark n 3 rd-6 th graders n Re-enactment through traumatic play n Withdrawal from friends n Aggressive behavior at home or school n Hyperactivity that wasn’t present earlier n UW Northwest Center for Public Health Practice 35
Responses to Trauma Adolescents n n n Increased risk-taking behavior Decline in previous responsible behavior Social withdrawal Apathy Rebellion at home or school UW Northwest Center for Public Health Practice 36
Helping Children Cope After Trauma n n n n 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) UW Northwest Center for Public Health Practice 37
Psychological Responses Following a Biological Terrorist Attack Magical thinking about microbes and viruses n Fear of invisible agents n Fear of contagion n n Attribution of arousal symptoms to infection Scapegoating Panic and paranoia Loss of faith in social institutions Source: Holloway et al. JAMA 1997; 278(5): 425 -7 UW Northwest Center for Public Health Practice 38
Factors Influencing Response to Traumatic Events n n n Degree and nature of exposure Developed coping mechanisms/strategies Available resources and support Ability to understand what occurred/is happening Developmental level Personal meaning of the event UW Northwest Center for Public Health Practice 39
At-risk Populations for Psychiatric Sequelae Following Traumatic Stress n Those exposed to the dead and injured n Eye witnesses and those endangered by event n Emergency first-responders n Medical personnel caring for victims n The elderly n The very young Source: Norwood et al. Disaster psychiatry: principles and practice. UW Northwest Center for Public Health Practice 40
At-risk Populations for Psychiatric Sequelae Following Traumatic Stress n Those with a history of exposure to other traumas or with recent or subsequent major life stressors or emotional strain n Chronic poverty, homelessness, unemployment, or discrimination n Those with chronic medical or psychological disorders Source: ACOEM Disaster Preparedness web site UW Northwest Center for Public Health Practice 41
Disaster Counseling Skills Establishing rapport n Caring eye contact, calm presence, nonjudgmental and empathic listening n Active listening n Allow silence n Attend nonverbally n Paraphrase n Reflect feelings n Allow expressions of emotions n UW Northwest Center for Public Health Practice 42
Disaster Counseling Skills n Problem solving n Identify and define the problem Assess current functioning and coping n Evaluate available resources n n Develop and implement a plan UW Northwest Center for Public Health Practice 43
When to Refer for Mental Health Services n Symptoms are persistent and overwhelm or interfere with the person’s normal functioning n n n Depression Anxiety Repeated thoughts/memories of traumatic event Disorientation n Psychotic symptoms – hallucinations, delusions n Suicidal thoughts or plans n UW Northwest Center for Public Health Practice 44
When to Refer for Mental Health Services n Inability to care for self n Problematic use of alcohol or drugs n n Includes use of illegal, as well as overuse of legal substances Domestic violence/abuse UW Northwest Center for Public Health Practice 45
Stress Management for Public Health Workers n Take care of yourself: n Get sufficient sleep n Eat regular meals n Keep caffeine and alcohol consumption moderate n Talk through your feelings with a safe confident n Family member n Mental health or other health care provider n Seek help when feelings overwhelm or interfere with your ability to function UW Northwest Center for Public Health Practice 46
Summary of Key Points n The initial and primary response to the consequences of a terrorist event occurs at the local level. n ESF 8 provides for federal assistance to supplement state and local efforts in response to a public health emergency. n Medical, practical, and feasibility considerations are important in the decision to implement quarantine. UW Northwest Center for Public Health Practice 47
Summary of Key Points n Individual, community, and event-specific factors influence the psychological response to a public health emergency. n Most individuals will function adequately following a traumatic event, but a few will need psychological or medical intervention. n Many emotional reactions of disaster survivors stem from living problems brought about by the disaster. UW Northwest Center for Public Health Practice 48
Summary of Key Points n The psychological response and long-term effects following a traumatic event are influenced by an individual’s unique combination of health, developmental level, resources, and experiences. n Anxiety responses are most likely following a biological attack, but depression, physical symptoms, and substance use may also occur. UW Northwest Center for Public Health Practice 49
Resources n Centers for Disease Control and Prevention http: //www. bt. cdc. gov n Barbera J, et al. Large-scale quarantine following biological terrorism in the United States. JAMA. 2001; 286: 2711 -2717 UW Northwest Center for Public Health Practice 50
Resources n American Psychiatric Association http: //www. psych. org info on disaster psychiatry n Federal Emergency Management Agency http: //www. fema. gov n DHHS/SAMHSA - disaster mental health info, and links to publications http: //www. mentalhealth. org/cmhs/Emergency. Services/ UW Northwest Center for Public Health Practice 51
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