2. Public Health 101 An Introduction for Stakeholders A Trainer’s Guide Tarrant County Public Health Public Health Preparedness Division & Southwest Center for Advanced Public Health Practice 2009

3. Course Outline I.Introduction to Public Health II.Public Health Preparedness III.Incident Command System (ICS) IV.Public Health Response to Emergencies V.Strategic National Stockpile (SNS) VI.Introduction to Epidemiology VII.Isolation and Quarantine VIII.Case Study 1: Hepatitis A outbreak IX.Case Study 2: Avian Influenza outbreak X.Case Study 3: White Powder Incident

4. Course Objectives Identify the basic roles and responsibilities of a local public health agency Discuss the importance of collaboration between public health and first responders in the event of an emergency Provide examples of events that are within the scope of public health preparedness Explain and demonstrate how public health utilizes ICS during emergencies Describe functions of public health surveillance and alerting system for law enforcement/first responders Describe several of the main steps in an outbreak investigation List scenarios where public health and first responders are most likely to interface

5. What is Health? Health is a state of complete physical, mental and social well- being and not merely the absence of disease or infirmity.

6. Public Health vs. Medicine Public HealthMedicine Patient Entire PopulationsIndividuals Intervention Assess, Policy Development & Assurance Medical Treatment Process System Management Patient Management Outcome Healthy CommunityHealing

7. Tarrant County Public Health’s Vision & Mission Vision: The Tarrant County Public Health Department assures, protects and promotes the overall health and well-being of our residents Mission: Safeguarding Our Community’s Health

8. Public Health Objectives Prevent epidemics and the spread of disease Protect against environmental hazards Prevent injuries Promote and encourage healthy behaviors Respond to disasters and assist communities in recovery Assure the quality and accessibility of health services The American Public Health Association http://www.apha.org/ppp/science/10ES.htm

9. Tarrant County Public Health Services Personal Health Services (clinical services) –Immunizations –STD/HIV testing and counseling –Chronic disease counseling –Tuberculosis services –Family planning and maternal & child health services –Travel health services Providing direct clinical services is only one part of the mission of a local health department

10. Population Based Public Health Services Environmental Health Infectious Disease Control and Investigation Laboratory Services Health Education Services

11. The Public Health System Federal Agencies State Agencies Local Agencies

12. Public Health’s Many Partners Public Health’s Many Partners MCOs Home Health Parks Economic Development Mass Transit Employers Nursing Homes Mental Health Drug Treatment Civic Groups CHCs Laboratory Facilities Hospitals EMS Community Centers Doctors Health Department Churches Philanthropist Elected Officials Tribal Health Schools Police Fire Corrections Environmental Health

13. Which level of government is responsible for protecting public health? 10th Amendment to the U.S. Constitution: –All powers not delegated to the Federal government shall be reserved for the state governments States are responsible for protecting public health

14. What is Public Health Preparedness? “Plans, procedures, policies, training, and equipment necessary to maximize the ability to prevent, respond and recover from major events.” (HSPD-21)

15. Public Health Preparedness Builds Infrastructure for: Public Health Emergencies Bioterrorism, pandemics Everyday health threats Infectious & foodborne diseases

16. Preparedness and Bioterrorism What is bioterrorism??? -- The use of...  Bacteria  Viruses  Parasites  Their by-products …in a terrorist act.

17. Preparedness and Bioterrorism Possible agents of bioterrorism –Anthrax –Smallpox –Plague –Botulism

18. Preparedness and Bioterrorism What might an attack of bioterrorism look like? –Not necessarily explosions or plumes of smoke –May not be readily apparent and detectable –Sick people arrive at hospitals or doctors’ offices –Delayed recognition and diagnosis –Population panic

19. Why is Public Health a Responder? Public health has been involved with preparedness issues long before 9/11/2001 Public health preparedness involves more than just bioterrorism

20. Roles in Preparedness Examples: –Outbreaks from contaminated food or water, infectious diseases, etc. –Natural disasters: hurricanes, floods, fires

21. Roles in Preparedness Planning Coordination/Collaboration Training and Exercise Response Evaluation and Corrective Action Collaboration is critical to success!

22. Roles in Preparedness Examples of public health roles: –Health threats investigator –Public service/media –Post-event tracking –Environmental investigators

23. Early Detection of Health Threats PRIMARY SURVEILLANCE TARGET: Covert Health Threats KEY GOAL: protecting community assets and reducing illness and death HSPD-21 defines key directive for state and local biosurveillance Collaboration on detection response critical to achieving key goal Initial detection and response is LOCAL

24. Public Health Biosurveillance Systems Automated collection from 56 hospitals in NC Texas, 16 ISDs and pharmacies 24/7/365 Automated alerting Local initial response Special secure web-based communication system

25. LE/FR Advisory and Alerting Portal

26. Incident Command System Allows a more effective, efficient response to emergencies Examples: –HazMat incidents –Terrorist incidents –Natural disasters –Incidents involving multiple casualties

27. Incident Command LHD’s use ICSCommand & Control PH Resources & Personnel Communicate to partner agencies

28. Incident Command & Public Health In the event of a public health emergency the public health director will interact with the local EOC or incident command post. The public health Department of Operations Center (DOC) may be activated to facilitate tactical communications.

29. Notifying Public Health Public health is a valuable & relevant partner Public health is available 24/7 System in place to triage calls during business & non- business hours

30. Notifying Public Health (24 Hour Hotline) If you need their help in an emergency call, 817-994-3708 Public health can’t respond if you don’t call them Public health will always respond in a timely manner

31. Public Health Responding to Emergencies In what type events would you expect Public Health to assume lead role for providing health and medical services ?

32. Public Health Preparedness Summary Build public health infrastructure to respond to threats from: –Bioterrorism –Natural disasters & disease outbreaks Requires collaboration between agencies: –Planning –Training & exercises –Response –Communication –Management of resources

33. Group Exercise: Crypto Outbreak Cryptosporidium (crypto) is a microscopic parasite caused by fecal contamination in water. It most often manifests in public swimming areas.

34. Group Exercise: Crypto Outbreak Lake Sharon a popular public swimming lake is source of a large crypto outbreak.

35. Group Exercise: Crypto Outbreak Based on the ICS 201… Complete an ICS 202 Write objectives Write safety message Secure perimeter Take into account environmental hazards

36. Preparedness Exercise

37. Strategic National Stockpile (SNS) A national stockpile available in the event of a major terrorist attack against the civilian US population National repository consisting of: –Pharmaceuticals (i.e., antibiotics and vaccines) –Antidotes and antitoxins –Medical and surgical supplies

38. Strategic National Stockpile SNS is a federal asset deployed locally after a major disaster –The governor of the affected state requests deployment of SNS from:

39. Strategic National Stockpile Delivered within 12 hours of federal decision to deploy SNS assets –12-hour “Push Package” –Push packages are warehoused in strategically- positioned locations around the US

40. Local Response to Strategic National Stockpile SNS deployment is a large-scale event requiring adequate: Security Pre–determined Points of Distribution Crowd control Traffic control

41. Local Response to Strategic National Stockpile Essential that First Responders and others in contact with exposed civilians are the first to be medicated

42. Local Response to Strategic National Stockpile Must prepare to dispense medicine to a huge number of people in a relatively short time span

43. Local Response to Strategic National Stockpile Expect to work with Public Health: Work collaboratively Implement emergency response according to prior planning Have conducted prior training and exercises Interagency Cross-Training

44. Local Response to Strategic National Stockpile Remember the 5 P’s... Prior Planning Prevents Poor Performance

45. And What Type Of A Planner Are You Going To Be?

49. What is Epidemiology? Study of the spread and causes of diseases or events in specified populations, and the control of health problems.

50. Epidemiology concerned with OUTBREAKS An adverse health event involving an unusual increase in cases among a certain population of individuals, within a certain period of time, in a certain location

51. Areas of Epidemiology Infectious diseases Environmental Behavioral Forensic Disaster

52. Person Place Time Key Elements in Epidemiology

53. Epidemiology Study Examples (risk or exposure outcome) Smoking (exposure) increases the risk of developing Lung Cancer (outcome)

54. Epidemiology Study Examples (risk or exposure outcome) Eating undercooked hamburger (exposure) increases the risk of infection with the bacteria E. coli (outcome).

55. Getting a flu shot (exposure) decreases the risk of becoming ill with the flu (outcome). Epidemiology Study Examples (risk or exposure outcome)

56. Simplified Steps in an Outbreak Investigation 1.Confirm outbreak and verify diagnosis 2.Perform field work and complete study 3.Implement control and prevention measures 4.Communicate findings

57. Disease Reporting: Notifiable Diseases Texas healthcare providers are required by law to report patients with certain diseases and conditions: –Report immediately Potential BT agents (anthrax, smallpox, plague) Botulism (foodborne) Viral hemorrhagic fever, including Ebola Other selected contagious serious diseases that may affect children and immune compromised or un-protected victims

58. Case Study #1: Hepatitis A outbreak Scenario: Hepatitis A outbreak in Texas in 1997

59. Hepatitis A symptoms Jaundice (yellowing skin) Fatigue Abdominal pain Loss of appetite Nausea Diarrhea Fever

60. Hepatitis A Background Information Hepatitis A virus is found in the stool (feces) of persons infected w/ hepatitis A Virus found in food or water contaminated by the infected individual

61. Hepatitis A Transmission 1.Direct person-to-person spread: –Putting something in the mouth that has been contaminated by the stool of a person with hepatitis A (households, day care centers) –Contaminated blood or blood products 2. Ingestion of contaminated food or water –Infected food handlers during preparation –Prior to food preparation: When item is grown, harvested, processed, or distributed

62. Hepatitis A Transmission Transmission of hepatitis A during food preparation: –Ex: infected food- handler fails to wash hands thoroughly between using the restroom and preparing food

63. Hepatitis A Transmission Transmission of Hepatitis A prior to food preparation: –Ex: Contamination occurs in fields where item is grown and harvested

64. Hep A Transmission Summary Transmission of hepatitis A: –Contaminated food  Infected foodhandler  Specific food item –Contaminated water

65. Problem has been detected In this scenario:  Hepatitis A cases have been found among students or staff in four different school districts in Texas

66. Infectious agent has been verified The diagnosis of Hepatitis A has been verified (lab confirmed)

67. Determined Magnitude Epidemic ** Unusually high number of cases among: school-aged children Within school districts in the same county Similar time period What do you do next?

68. Next Steps Identify those who are ill (cases) and determine what exposures they have in common Identify those who are NOT ill (controls) and ask about the same exposures as with the cases

69. Exposure History Interviews How do we do this? –Obtain contact information –Interview for common exposures (specific food item/ water source, ate at same restaurant, etc.)

70. Seek additional cases of illness –Notify private MDs, Emergency Departments, Labs, etc. to look for and report additional cases of Hep A to the health department

71. Gather & Analyze Data Investigators gather and analyze data and information from the interviews

72. Hypothesis about causation Investigators determined: –Transmission via contaminated water was not viable –Transmission by an infected food handler was not plausible

73. Hypothesized causal agent Interviews did implicate a contaminated food item:  Frozen strawberries from Mexico

74. Implement Prevention & Control Measures Based on the hypothesis, implement prevention/control measures GOAL: Prevent additional cases of illness

75. Prevention & Control Measures Administer shots of immune globulin (IG) Treatment is effective if given within 2 weeks from the time the strawberries were consumed

76. Prevention & Control Measures Traceback contaminated frozen strawberries to the original source Recall any lots still in distribution

77. Prevention & Control Measures US Department of Agriculture (USDA) recommends placing an immediate hold on all unused product from the distributor

78. Hepatitis A Outbreak Summary Wrap-Up Outbreak investigation involves:  Detecting a problem  Confirming the diagnosis  Identifying infected individuals  Determining how people are getting ill  Implementing control measures to prevent further spread of illness

79. Isolation and Quarantine Protocol Tarrant County Public Health

80. History of Quarantine In the fourteenth century, to protect cities from plague epidemics, ships arriving in Venice from infected ports had to sit at anchor for forty days before landing. “Quarantine” is derived from the Latin word quaresma, meaning forty.

81. Definitions:

82. Isolation: The separation of someone who’s infected or contaminated from others so that the infection or contamination is not spread

83. Quarantine Limitation of freedom of movement of a well person who’s been exposed to an infectious agent

84. What Does it Mean to be Isolated or Quarantined? No contact with any new people Can not leave home or place of containment For evaluation and verification purposes patient needs to check in with Public Health every day

85. What is Voluntary Compliance? Voluntary compliance with isolation, quarantine or other control measures means a patient cooperates and complies with Public Health’s instructions to comply with the recommended control measures in order to prevent the spread of disease.

86. What is Involuntary Detention? This is what Public Health will pursue if an individual does not voluntarily comply with an ordered control measure.

87. What is the Health and Safety Code? This is the law of the State of Texas regarding various “control measures.” This is codified as Chapter 81

88. To What or Who Can “Control Measures” be Imposed? Person (s) Groups (5 or more individuals) Area (city block, ZIP code, county) –Buildings (hospital, hotel, business)* –Common Carrier (plane, bus, train)*

89. Who Can Enforce these Rules? Local law enforcement must enforce an order issued by local health authority.

90. Questions?

91. A new bacteria or virus that can infect humans Nearly all people have no immunity to the new organism High mortality rate Easily spread from person to person. A Pandemic is a World-Wide Epidemic

92. Case study #2: Influenza Outbreak Background on avian influenza: –Strains of influenza that infect birds –Circulate among wild water birds –Bird-to-bird transmission via: Fecal material Saliva Nasal & respiratory secretions

93. Background – Avian Influenza –Varying severity and infectiousness among birds –The highly pathological avian influenza (HPAI) is the virus that is a pandemic among migrating water fowl. –Potential to combine with human flu virus to produce a “new” influenza transmissible to humans that could be lethal.

94. Viral reassortment Mixing of viral genes from two different animal species simultaneously Example: Human infected with human and avian influenza virus at the same time

95. Influenza Virus Transmission Influenza viruses have the potential to mutate rapidly and gain the ability to spread from: Birds to farm animals (i.e., pigs) Animals to humans Birds to humans (directly)

96. Avian Influenza Virus Transmission Concerns 1.Strain efficiently transmitted between birds and humans 2.Strain efficiently transmitted from human to human

98. Influenza Outbreak Scenario Scenario: A highly infectious form of avian influenza begins to circulate among poultry at a farm in Hong Kong.

99. Influenza Outbreak The owner of the farm also has several pig pens The pig pens are located right next to the bird cages The feed troughs for both the pigs and poultry are often interchanged

100. Influenza Outbreak The avian flu virus mutates and infects several of the pigs. The virus mutates again and is transmitted from one of the pigs to the farm owner. Bird → Pig → Human

101. Influenza Outbreak The farm owner wakes up one morning suffering from: –Fever –Sore throat –Coughing –Muscle aches

102. Influenza Outbreak In the afternoon, he travels into the crowded capital city to sell his poultry at the local market. He is in extremely close contact with customers for several hours.

103. Influenza Outbreak A couple days later, several of the customers from the market begin to show symptoms of flu- like illness: –Coughing –Fever –Sore throat –Muscle aches

104. Influenza Outbreak Several of them work in the kitchen of a nearby hotel restaurant The restaurant is popular among Americans on business trips in Hong Kong.

105. Influenza Outbreak A Tarrant County resident traveling in Hong Kong on a business trip stays at the hotel. He eats at the hotel restaurant on an evening in which one of the infected workers is preparing food.

106. Influenza Outbreak The businessman is infected with flu. Within a few days of eating at the restaurant, he exhibits flu-like symptoms. The following day, he flies home to DFW.

107. Influenza Outbreak

108. Within days after the Tarrant resident returns home, local hospitals see an increase in patients presenting with: coughing fever muscle aches

109. Influenza Outbreak Local physicians report similar trends in symptoms seen in recent days in their private practices.

110. Influenza Outbreak Additionally, FWFD & Medstar report increased calls for transporting individuals with flu- like illness. Tarrant County biosurveillance system showing unusual increase in flu-like symptoms in both ED and outpatient. Alerts issued to LE/FR

111. Influenza Outbreak Over the next couple days, several EMS workers who’ve been transporting ill patients, call in sick to work complaining of flu-like symptoms. The work-force loses capacity because so many employees have fallen ill.

112. Question 1 What factors might be contributing to EMS staff contracting influenza? (Hint: prior influenza vaccination likely would NOT be effective in preventing infection from an avian flu virus)

113. Answer Staff were not taking appropriate protective measures around infected persons: – Not regularly washing hands after contact with sick individuals – Failing to wear personal protective equipment (masks and gloves) – Failing to disinfect contaminated surfaces and medical equipment after transporting patients

114. Question 2 Could this influenza outbreak have been prevented completely?

115. Answer Highly unlikely : –Population has little to no immunity against a new avian flu virus strain –Prior influenza vaccination not protective against avian flu virus strain –Minimum of 6 months needed to develop a new flu vaccine However...

116. Question 3 Could the magnitude of this outbreak have been reduced?

117. Answer Yes – it is likely the magnitude of the outbreak could have been reduced by: –Earlier attention to health alerts –Regular hand washing after contact with patients –Wearing personal protective equipment (masks, gloves, gowns) –Regularly disinfecting surfaces and medical equipment

118. Question 4 Would a quarantine be required?

119. Answer Yes - general quarantine precautions would apply: –An infected patient (with SARS, Avian, TB or Panflu) on an international flight CAN be detained at the airport terminal –CDC, airport and local public health authorities can request flight manifests and have passengers undergo medical screening for their safety –A non-compliant patient can be arrested and sent to forced quarantine

120. Question 5 Why would a non-compliant person be arrested and sent to forced quarantine?

121. Answer This is so a non-compliant patient does not endanger the public or themselves.

122. Importance of Yearly Influenza Vaccination Reduce chances of dual infection with avian and human flu viruses Dual infection could result in a highly virulent and transmissible strain

123. Influenza Outbreak Summary BE RESPONSIBLE!! It is especially important... –Wash hands or use sanitizers regularly –Practice good respiratory hygiene and cough etiquette –Don’t come to work when you are sick –Get a flu shot each year

124. Influenza Outbreak Disclaimer Disclaimer:  Currently no sustainable human-to- human transmission of bird flu have been reported  However, cases of human-to-human transmission continue to occur and the virus continues to mutate Therefore, we must be prepared for this possibility

125. Case Study #3 - White Powder Incident Scenario It is early Monday morning at a major law firm in downtown Fort Worth

126. White Powder Incident An office secretary is opening mail delivered over the weekend She sees a suspicious looking letter with an unusual return address and excessive tape on the outside

127. White Powder Incident She opens the letter and white powder falls out of the envelope She leaves the envelope on her desk and notifies a co- worker, who calls 911

128. White Powder Incident Local law enforcement and HazMat teams are notified Law enforcement arrives first at the scene Law enforcement implements ICS Maintains chain of command and control

129. White Powder Incident Law enforcement determines that the credibility of the threat is legitimate The area of the law office where the powder was found was immediately isolated

130. White Powder Incident Individuals who may have come in contact with the powder were quarantined and held for decontamination The law office was evacuated

131. White Powder Incident Law enforcement requests that HazMat collect a specimen HazMat team collects a sample of the white powder from the law office

132. White Powder Incident HazMat turns over the powder specimen to law enforcement to transport to the Texas Department of State Health Services for testing

133. White Powder Incident HazMat also handles decontamination of the woman who opened the letter and had direct exposure to the white powder

134. Questions 1.Should public health be notified about this white powder incident? 2.Who should call public health? 3.Why should public health be notified?

135. White Powder Incident YES, law enforcement should notify public health immediately Public health will:  Send nurses and epidemiologists to interview those potentially exposed to the white powder (including first responders)  Determine the exposure risk and appropriate preventive and treatment measures  Follow up with the lab results at the Texas Department of State Health Services.

136. White Powder Incident Once all crime scene investigation and public health investigation is complete... Public health collaborates w/ law enforcement and Fire/HazMat to determine when the building can be re- entered.

137. White Powder Incident Public health officials will start planning for post-exposure prophylaxis before test results come back Test results will be confirmed within 24 hours

138. Question What happens next if lab results come back positive?

139. White Powder Incident If lab results are positive for a biological agent: –Local public health officials notified immediately –Law enforcement notified –Begin post-exposure prophylaxis of those potentially exposed –SNS may be requested if medical resources are insufficient

140. Question What happens next if lab results come back negative?

141. White Powder Incident If lab results are negative for biological agent: –Law enforcement will be notified –Local public health notified to inform those exposed of the test results

142. White Powder Incident Scenario Resolution Test results came back negative for anthrax and other biological agents Tests determined the white powder was derived from an aspirin product

143. White Powder Incident Take Home Messages Every white powder incident is different Involves collaboration among: –Law enforcement –Fire & EMS, HazMat –Local public health officials Efficient management requires: –Mutual understanding of roles and responsibilities –Collaborative efforts –Good intra-agency and inter-agency communication

144. End of Presentation