Transcript Pan Flu Videoconference 11-28-06

Planning for
PANDEMIC FLU
Principles of Isolation and Quarantine
in the 21st Century
Catherine Slemp, MD, MPH
WV Bureau for Public Health
November 2006
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
Pandemics vary in severity
and
Combined approaches seem
most effective
(from history and modeling)
….therefore
A Targeted and Layered
Approach
Epidemiology Drives Approach
(Targeted)
Mild
Moderate
Severe
Case Fatality Rate
≤ 0.1%
0.1 - 0.5%
≥ 0.5%
Isolation
Yes
Yes
Yes
Treatment
Yes
Yes
Yes
Quarantine
No
???
Yes
Prophylaxis
High-risk individuals
High-risk individuals
Yes
School Closure
Reactive
Punctuated ???
Proactive
Protective sequestration High-risk individuals
High-risk individuals
Children
Community social
distancing
High-risk individuals
Encouraged
Encouraged +
selective closures
Workplace protections
Encourage good
hygiene
Social distancing
Aggressive social
distancing
Liberal leave policies
Confirmed influenza
Influenza-like illness
ILI and/or sick family
members
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
International
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
Containment-at-source
Support efforts to
reduce transmission
Travel advisories
Layered screening of
travelers
Health advisories
Limited points of entry
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
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
Understanding Disease
Spread
Ro
R0 = 12
Effect of Increasing Social Distance
on Epidemic Dynamics
Exponentiation
Suppression
Ro = 2.0,
Ro = 0.67,
Progression = 1:2:4:8:16
Progression = 1:2:4:3:2
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.
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.
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)
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
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
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 Diseases
Paramount to meet needs of individuals infected and exposed ;
avoid stigmatizing the victims
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
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
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
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
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
Misconceptions
• Quarantine only means large
geographic “cordon sanitaire”
• The public will never accept the use
of quarantine as a mitigation strategy
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.
Advantages of “Community
Shielding” Approaches
• Intuitive
• Leverages the public’s instinct for selfpreservation
Cordon sanitaire conflicts with this instinct
• Less restrictive approach than
geographic quarantine
“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
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.
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.
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.
Current Key Activities
• Isolation and Quarantine Protocol
Development (IDEP-DSDC-BPH) (when
applicable for what disease, etc.)
• Legal Workgroup: Administrative
Processes and Tools
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
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
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
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
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
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
Seasonal Influenza
Pandemic Influenza
All Hazard
Preparedness
Get Informed,
Be Prepared!
RESOURCES


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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)