1. Public Health 101 – An Introduction for Public Health Stakeholders
2009 NACCHO/APC Road Show
Public Health 101 – An Introduction for Public Health Stakeholders
Presented by
Southwest Center for
Advanced Public Health Practice
Tarrant County Public Health, TX
2009

2. Course Objectives
Identify the basic roles and responsibilities of a local public health agency
Discuss the importance of collaboration between public health and its stakeholders 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 several of the main steps in an outbreak investigation
List scenarios where public health and first responders are most likely to interface

3. Course Outline Introduction to Public Health
Public Health Preparedness
Incident Command System (ICS)
Public Health Response to Emergencies
Strategic National Stockpile (SNS)
Introduction to Epidemiology
Isolation and Quarantine
Case Study: Avian Influenza Outbreak

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

5. Public Health vs. Medicine
Patient
Entire Populations
Individuals
Intervention
Assess, Policy Development & Assurance
Medical
Treatment
Process
System Management
Patient Management
Outcome
Healthy Community
Healing

6. 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
… derived from American Public Health Association, Ten Essential Services

7. Typical Menu of 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
BUT…providing direct clinical services is only one part of the mission of a local health department

8. Population Based Public Health Services
Environmental Health
Infectious Disease Control and Investigation
Laboratory Services
Health Education Services
Restaurant permits and inspections,Public swimming pool inspections and water quality testing,Food-borne illness complaints, West Nile virus prevention and control measures, Septic tank permits
Communicable disease and food-borne outbreaks, Bioterrorism surveillance and rapid response
BSL level 3 laboratory testing – biological agents and pandemic influenza,Food and water testing

9. The Public Health System
Federal Agencies
State Agencies
Functions outlined in Tarrant County and City of Fort Worth Emergency Operations Plan (EOP)
Emergency Support Function (ESF) VIII
Local Agencies

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

11. 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

12. 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)

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

14. Preparedness Professionals – Many Voices, One Mission
Physicians
Statisticians
Epidemiologists
Emergency Preparedness Coordinator and Nurse Coordinator
Media Relation Specialists
Support Staff
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15. Preparedness and Bioterrorism
What is bioterrorism???
-- The use of...
Bacteria
Viruses
Parasites
Their by-products
…in a terrorist act.

16. Preparedness and Bioterrorism
The threat and reality of bioterrorism have focused attention on public health preparedness for emergencies
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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. Collaboration is critical to success!
Roles in Preparedness
Planning
Coordination/Collaboration
Training and Exercise
Response
Evaluation and Corrective Action
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Collaboration is critical to success!

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

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

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

23. 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.

24. Public Health Responding to Emergencies
Public health is integrated in local emergency response planning efforts
Local public health responsibility ensures:
Health problems are monitored
(injury & disease surveillance)
Services to correct the problem are available
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25. Public Health Responding to Emergencies
In what type events would you expect Public Health to assume lead role for providing health and medical services ?
Events involving biological agents, catastrophic disease outbreaks, pandemics, or any other covert health threat in which PH is the first notified agency

26. Public Health Responding to Emergencies
Responsibilities include securing, assisting, & supporting other agencies with the following:
Health and medical services
Resources
Personnel
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27. 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

28. Strategic National Stockpile

29. 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

30. 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:

31. 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

32. 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

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

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

35. 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

36. Epidemiology

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

38. 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

39. Areas of Epidemiology Infectious diseases Environmental Behavioral
Forensic
Disaster

40. Key Elements in Epidemiology
Person
Place
Time
Person - Age, Sex, Race or ethnicity Place - Geographic location (epidemic? Pandemic?), Proximity to potential exposure, Clustering Time - Date / time of exposure or onset of illness, Seasonality of infectious diseases, Identifying endemic versus epidemic disease rates

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

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

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

44. Simplified Steps in an Outbreak Investigation
Confirm outbreak and verify diagnosis
Perform field work and complete study
Implement control and prevention measures
Communicate findings
To handout

45. Disease Reporting: Notifiable Diseases
Healthcare providers are required by law to report patients with certain diseases and conditions:
Report immediately (in most states)
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
handout

46. Isolation and Quarantine Protocol

47. 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.

48. Definitions:

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

50. Quarantine
Limitation of freedom of movement of a well person who’s been exposed to an infectious agent
1) For duration of incubation period
Goal is to prevent people who have not been exposed
Emphasize difference between isolation and quarantine

51. 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

52. 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.

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

54. 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)*

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

56. Questions?

57. Case study: 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

58. A Pandemic is a World-Wide Epidemic
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.
The hallmarks of a PANDEMIC are that humans are susceptible to the “new” disease; and since the disease is NEW TO HUMANS. almost NO ONE will have ANY immunity to it, which we expect to would cause a lot of deaths. Of course, it must pass from human to human easily in order to spread quickly; however, many bacteria and virus can live on hard surfaces for a few days, so practicing cleanliness and hygiene are important to control.
Population must be “immunologicially naïve” --- have no immunity to it because it is a “new” disease.

59. 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.
I think this slide could be deleted but I clarified the H5N1 situation here.

60. 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

61. 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)

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

63. I put this in because it breaks up the seriousness, and it usually gets a chuckle or two.

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

65. 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

66. 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

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

68. 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.

69. 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

70. 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.

71. 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.

72. 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.

73. Influenza Outbreak

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

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

76. 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.

77. 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)

78. 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

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

80. 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 . . .

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

82. 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

83. Question 4
Would a quarantine be required?

84. Answer Yes - general quarantine precautions would apply:
An infected patient (with SARS, Avian, TB or even H1N1) 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 isolation or quarantine

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

86. Answer
So the non-compliant patient does not endanger the public or themselves.

87. 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

88. Influenza Outbreak Disclaimer
Currently no sustainable human-to-human transmission of bird flu has 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

89. Conclusions and Questions

90. * - Originating authors
Credits
This course was made possible through the efforts of public health and EMS staff from Dekalb County, GA and Tarrant County, TX:
Darren Collins*, MPH, Dekalb
Jason Craw* Dekalb
Bill Stephens, MS, Tarrant
Kay Sanyal-Mukherji, MPH, Tarrant
Micky Moerbe, MPH, Tarrant
Diana Cervantes, MS, Tarrant
Jennifer Dowdy, MPH, Tarrant
Mark Fulmer, MS, Tarrant
Terry Lafon, RN, Tarrant
Teresa Bates, LVN, Tarrant
Donald Fisher, MS, Tarrant
Reviewed by Dr. Elvin Adams, MD, FACEP, Health Authority, Tarrant
* - Originating authors
This training was produced by the Southwest Center for Advanced Public Health Practice (Center) at Tarrant County Public Health, and was supported by Cooperative Agreement Number U50/CCU from the Centers for Disease Control and Prevention (CDC) to the National Association of County and City Health Officials (NACCHO).  Its contents are solely the responsibility of Center and do not necessarily represent the official views of CDC or NACCHO