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 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 UW Northwest Center for Public Health Practice
Consequence Management For Public Health Leaders Module A 3 UW Northwest Center for Public Health Practice
Consequence Management Learning Objectives n Describe the role of public health in consequence management following a public health emergency and identify laws supporting this role n Describe the legal basis for quarantine and potential adverse consequences and identify factors to consider when implementing and enforcing quarantine 4 UW Northwest Center for Public Health Practice
Consequence Management Learning Objectives Describe the basic structure and components of the National Pharmaceutical Stockpile, n How and when it is employed n The responsibilities of state and local health officials in accepting and distributing the resources provided n Identify the potential psychological responses, on individual and community levels, following a BT event, threat, or other public health emergency n 5 UW Northwest Center for Public Health Practice
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. ” 6 UW Northwest Center for Public Health Practice
Presidential Decision Directive 39 U. S. Policy on Counterterrorism n Consequence management - response to the disaster, focusing on the alleviation of damage, loss, hardship, or suffering n Public health, medical, and emergency personnel n Response and Recovery phases n State have primary responsibility for response n Federal agencies provide assistance as needed n FEMA has lead role PDD-39 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 8 UW Northwest Center for Public Health Practice
Consequence Management Other Emergency Support Functions ESF Function Lead Agency 5 FEMA 6 Information and planning Mass care 10 Hazardous materials American Red Cross EPA 11 Food USDA 9 UW Northwest Center for Public Health Practice
Consequence Management Necessary Protocols and Procedures n Communication and informational 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 Mass antibiotic prophylaxis and immunization n Quarantine and isolation n 10 UW Northwest Center for Public Health Practice
Consequence Management Necessary Protocols and Procedures n n n 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 11 UW Northwest Center for Public Health Practice
Quarantine n Comes from Italian quarante – refers to the 40 day sequestration imposed on arriving merchant ships during plague outbreaks of the 13 th century n Today – broader definition n 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 12 UW Northwest Center for Public Health Practice
CDC Definition: Quarantine vs. Isolation n The separation of a person or group of persons from other people to prevent the spread of infection n Quarantine n 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 13 UW Northwest Center for Public Health Practice
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 14 UW Northwest Center for Public Health Practice
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 15 UW Northwest Center for Public Health Practice
Quarantine Legal Authority - Federal n Section 311 of Public Health Service Act n Allows for federal assistance to state and local authorities in enforcing quarantine and other health regulations 16 UW Northwest Center for Public Health Practice
Quarantine Legal Authority – Federal n 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 n 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 17 UW Northwest Center for Public Health Practice
Quarantine and Isolation Factors to Consider n Is there a scientific basis? n Among Category A agents, only smallpox, pneumonic plague, and some VHFs transmitted person-to-person 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? 18 UW Northwest Center for Public Health Practice
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 vs. 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 19 UW Northwest Center for Public Health Practice
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 20 UW Northwest Center for Public Health Practice
Quarantine and Isolation Pre-Event Planning n Identify community facilities appropriate for use as quarantine sites n Identify non-infected personnel to administer services at quarantine/isolation site n Health care providers n Laundry and waste disposal personnel n Enforcers/access control 21 UW Northwest Center for Public Health Practice
Quarantine and Isolation Pre-Event Planning n Identify means of food and supply provision to quarantine/isolation site n Ensure means of communication with outside community 22 UW Northwest Center for Public Health Practice
Quarantine and Isolation Policies and Procedures n n n When to institute Who is allowed access to site Infection control policies n Transportation of people to site n Within site Criteria for entry and departure When to discontinue 23 UW Northwest Center for Public Health Practice
Isolation CDC Smallpox Response Plan n Facility Categories n Type C – Contagious n Confirmed n Type and probable cases X – Uncertain diagnosis n Vaccinated n Type febrile contacts without rash R – Asymptomatic n Non-febrile contacts 24 UW Northwest Center for Public Health Practice
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) 25 UW Northwest Center for Public Health Practice
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) 26 UW Northwest Center for Public Health Practice
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 27 UW Northwest Center for Public Health Practice
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 Prevention and More on NPS. . . 28
National Pharmaceutical Stockpile Push Packages n 12 -hour “Push Packages” in cargo-sized containers weighing approximately 37 tons each n Located around the country at strategic locations n Held in environmentally controlled and secured warehouses n Can reach a destination within 12 hours of being requested More on NPS. . . 29
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. . . 30
National Pharmaceutical Stockpile Push Packages n Materials pre-packaged for immediate dispensing n Support staff will accompany the package n Receiving state responsible for logistics of repackaging and distribution More on NPS. . . 31
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. . . 32
Pre-Event Planning Mass Prophylaxis and Treatment n Identification of sites n n n 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) n Establishing a record-keeping system n Developing follow-up protocols and procedures n 33 UW Northwest Center for Public Health Practice
Psychological Response to A Public Health Emergency n n Reaction to the event itself Anticipation of future events Reaction to public health measures taken to manage/control disease and injury n Quarantine n Prophylactic measures n Prioritization/rationing of resources Reaction to misinformation (e. g. , myths, rumors) 34 UW Northwest Center for Public Health Practice
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 35 UW Northwest Center for Public Health Practice
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 36
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 37
Psychological and Behavioral Responses to Trauma and Disaster n Depression n Physical Complaints n Sadness n Fatigue n Demoralization n Aches and pains n Isolation/withdrawal n Stomach and intestinal complaints n Difficulty concentrating n Headache n Sleep and appetite n Skin rashes disturbances 38 UW Northwest Center for Public Health Practice
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 39 UW Northwest Center for Public Health Practice
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 40 UW Northwest Center for Public Health Practice
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) 41 UW Northwest Center for Public Health Practice
Psychological Responses Following a Biological Terrorist Attack n n n Magical thinking about microbes and viruses Fear of invisible agents 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 42
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 43
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 44
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 confidant n Family member n Mental health or other health care provider n Seek help when feelings overwhelm or interfere with your ability to function 45 UW Northwest Center for Public Health Practice
Stress Management for Public Health Workers: Advice for Management n Complements can serve as powerful motivators and stress monitors. n Ensure regular breaks from tending to duties. n Establish a place for workers to talk and receive support from colleagues. n Encourage contact with loved ones, as well as relaxing activities. n 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 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. 47 UW Northwest Center for Public Health Practice
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. 48 UW Northwest Center for Public Health Practice
Summary of Key Points n Anxiety responses are most likely following a biological attack, but depression, physical symptoms, and substance use may also occur. 49 UW Northwest Center for Public Health Practice
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 50 UW Northwest Center for Public Health Practice
Resources American Psychiatric Association http: //www. psych. org -- info on disaster psychiatry n Federal Emergency Management Agency n http: //www. fema. gov n DHHS/SAMHSA - disaster mental health info and links to publications http: //www. mentalhealth. org/cmhs/Emergency. Services/ 51 UW Northwest Center for Public Health Practice
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