Public Health Measures Mary Kennedy Deputy General Counsel Tennessee Department of Health September 17, 2014 It is the mission of the Tennessee Department of Health to protect, promote and improve the health and prosperity of people in Tennessee

What is Public Health? “Public Health is what we, as a society, do collectively to assure the conditions in which people can be healthy.” Institute of Medicine, The Future of Public Health, 1988 Concerned with the health of the population rather than the individual. Requires the Department to be concerned with the actions or conditions of an individual, entity or premises which may create a threat to others.

Tuberculosis Eighty years ago there were over 1,000 deaths annually from TB; in 2013 Tennessee had a total of 15 deaths from TB.

E-Coli linked to Raw Milk Knox County Outbreak: 9 cases, 5 hospitalized, 3 children with kidney failure; we have 20-25 foodborne outbreaks annually.

Injectable Drug Diversion The risk is that an injectable drug abuser with access to syringes etc., may put used syringes back where they will be re-used. The unwitting infected may then transmit a communicable disease carried by the abuser to sexual partners etc., The diseases of concern are particularly STDs and Hepatitis C

Ebola US Public Health Service stationed at international airports Number of Ebola deaths in Tennessee – ZERO!

Authority of the Health Department Tenn. Code Ann. Title 68 Chapter 1 – General Provisions Tenn. Code Ann. § 68-1-102 Commissioner, Chief Medical Officer Tenn. Code Ann. § 68-1-103 Rules and Regulations Tenn. Code Ann. § 68-1-104 Duties of Commissioner Tenn. Code Ann. § 68-1-201 Power to Quarantine

Quarantine and Isolation Tenn. Code Ann. Title 68, Chapter 1 Part 2 Tenn. Code Ann. § 68-1-201 Power to Quarantine Tenn. Code Ann. § 68-1-202 Quarantine Stations Tenn. Code Ann. § 68-1-203 Violation a misdemeanor

What’s the Distinction? Rule 1200-14-1-.01 Isolation – Separates an infected or suspect individual, or from the community during infectious period; Quarantine – Limits freedom of movement or prevents access to the premises until diagnosis is established or confirmed in order to determine cause and prevent spread of infection Quarantine may include isolation

Local Health Services Tenn.Code Ann. § 68-2-601 et seq. Establishes County Health Department Creates position of County health director Creates position of County health officer Tenn Code Ann. § 68-2-609 Establishes authority of County health officer to issue administrative orders and seek judicial remedies

Disease-Specific Chapters Tuberculosis Tenn. Code Ann. Title 68 Chapter 9 Sexually Transmitted diseases Tenn. Code Ann. Title 68 Chapter 10 Both include the power of the health officer to isolate or quarantine, both specifically give jurisdiction to the General Sessions Courts

DISEASE CONTROL/HEALTH THREAT PROCEDURES: Rule 1200-14-4.01 et seq. Identification of the threat; Directive requiring cooperation with efforts to prevent disease transmission; Petition for Temporary Hold; Petition for Health Measure; Issuance of Health Measure;

Identification of the Threat Rule 1200-14-4-.03 Reporting a Health Threat to Others Any licensed health professional is required to report a person who may be a health threat to others and is acting in a manner which puts others at risk; If a carrier who poses a threat flees the state to avoid treatment, isolation or quarantine, TDH may contact health authorities where the carrier is believed to be. See also Rule 1200-14-1-.02 for reporting of specific diseases to the Health Department

Issuance of the Health Directive Rule 1200-14-4-.04 Health Directive Commissioner or Health Officer may issue directive; Based on clinical and epidemiological findings; Written statement, or oral statement followed in writing; Includes findings and specific requirements to diminish the threat, using least restrictive alternative; If subject refuses testing, presumption shifts to subject; Subject may request review of Chief Medical Officer; Non-Compliance is grounds for seeking health measure.

Temporary Hold in Emergencies Rule 1200-14-4-.05 Health Officer or Commissioner may petition General Sessions Court where person may be found or premises is located for a temporary hold; Petition is filed under seal; Petition must include supporting affidavit; Petition may be heard ex parte; May order examination, isolation, treatment or, in case of premises, prevention or restriction of access; Hold may not exceed 5 business days except by agreement, with outside limit of 15 business days;

Public Health Measure Rule 1200-14-4-.06 Petition for Public Health Measure Commissioner or Health Officer may file petition, under seal, in General Sessions; Must set forth grounds demonstrating threat to others; Must propose least restrictive measure(s); Evidentiary standard is clear and convincing; Must give 5 business days notice and advise respondent of rights at hearing; Respondent may appeal or seek habeas corpus, but order shall remain in force pending conclusion.

Commitment to Custody of the Commissioner Rule 1200-14-4-.07 Must be reviewed by Chief Medical Officer at least every 92 days to determine if still appropriate; Physical commitment must expire after 6 months unless supplemental petition is filed; May be renewed as many times as necessary if clear and evidence that the threat to the public health continues.

Patient Bill of Rights Rule 1200-14-4-.08 Communication with friends, family and counsel; Treatment shall not be forced, however refusal may compel continued action to protect the public health; Isolation only when medically necessary; Patient may enter into contracts, vote, execute instruments, etc., Patient shall be given maximum freedom possible;

Patient Bill of Rights (Cont’d) Rule 1200-14-4-.08 (Cont’d) No mechanical restraints unless medically indicated and prescribed by physician; All records, reports, legal documents confidential; Health directives and public health measures should be written in plain language and include Reasons for the action; Tests or treatments expected; Anticipated duration; and Appeal Rights.