The Objective of the Tabletop Exercise in Schenectady County Is for the Participating Agencies

Isolation & Quarantine Tabletop Exercise Schenectady County, New York June 8, 2006

Contents Objectives...... 1 Scenario...... 1 “Minimal guidance for responding to outbreaks”...... 3 Glossary...... 4 Additional Study...... 7 Discussion Guide...... 8

Objectives While meeting the state exercise deliverable, we will be successful if we: 1. Practice decision-making to implement the County Public Health Service guidelines for isolation/quarantine in the event of identification of more than one individual or household to be isolated and more than one individual or household to be quarantined during an outbreak of highly infectious influenza. 2. Identify key issues/concerns for subsequent planning, training or other follow-up

University at Albany Center for Public Health Preparedness 1 Scenario A local hospital has 2 hospitalized patients now confirmed as having influenza Q [not real]. Each of these individuals has a household of 3-6 others now being monitored closely as potential cases. All of these individuals should be quarantined.

In the community, due to work and school, each of these is likely to have been in close contact with 3 to 10 individuals in the community (school, co-workers, church colleagues) who should be quarantined until their health is assured, or until they are diagnosed and put into treatment. Two of the co-workers are planning to travel tomorrow; the school attended by one of the family members is hosting the local middle- school music festival this week; one of the contact families is likely undocumented and includes hourly household help and farm workers.

It is 9 AM and you have been assembled at the County Emergency Operations Center. Your first task is to establish an incident management structure for this event.

Having done that, the goal is to determine what should be done in the following areas: 1. Management of isolated (ill) individuals 2. Management of quarantined, not-yet-ill individuals 3. Legal actions 4. Public information 5. Coordination with other agencies/organizations

University at Albany Center for Public Health Preparedness 2 “Minimal guidance for responding to outbreaks”

1. Verify the diagnosis

2. Confirm the existence of an outbreak

3. Identify affected persons and their characteristics

a. Record case histories

b. Identify additional cases

4. Define and investigate population at risk

5. Formulate a hypothesis as to source and spread of the outbreak

6. Contain the outbreak

a. Manage cases TODAY b. Implement control measures to prevent spread

c. Conduct ongoing disease surveillance

d. Prepare a report

Source: Heymann DL. Control of Communicable Diseases Manual. 18th ed. Washington (DC): American Public Health Association; 2004. P xxviii.

University at Albany Center for Public Health Preparedness 3 Glossary

Carrier: A person or animal that harbors a specific infectious agent without Communicable Disease: An illness discernible symptoms of disease and due to a specific infectious agent or its serves as a potential source of infection. toxic products that arises through (1) transmission of that agent or its Case: In epidemiology, a person in the products from an infected person, population or study group identified as animal, or inanimate source to a having the particular disease, health susceptible host; either directly or disorder, or condition under indirectly through an intermediate plant investigation. A variety of criteria may or animal host, vector, or the inanimate be used to identify cases, e.g., individual environment. (1) physicians’ diagnoses, registries and Contact: In regards to communicable notifications, abstracts of clinical diseases, a person or animal that has records, surveys of the general been in such association with an population, population screening, and infected person, animal, or a reporting of defects such as in a dental contaminated environment, resulting in record. The epidemiologic definition of an opportunity to acquire an infection. a case is not necessarily the same as (1) the ordinary clinical definition. (2) Epidemic: The occurrence in a Case Definition: A set of diagnostic community or region of cases of an criteria that must be fulfilled in order to illness, specific health-related behavior, identify a person as a case of a or other health-related events clearly in particular disease. Case definition can excess of normal expectancy. From the be based on clinical, laboratory, or Greek ep (upon), dēmos (people). (2) combined clinical and laboratory criteria, Epidemiology: The study of the or a scoring system with points for each distribution and determinants of disease criterion that matches the features of the frequency in human populations and the disease. (2) application of this study to control health Case History: Information about each problems. (3) confirmed or suspected case must be Incubation Period: The time interval recorded to obtain a complete between initial contact with an infectious understanding of the outbreak. Usually agent and the first appearance of this information includes name, age, symptoms associated with the infection. sex, occupation, place of residence, In a vector, it is the time between recent movements, details of symptoms entrance of an organism into the vector (including dates and time of onset) and and the time when that vector can dates of previous immunization against transmit the infection (extrinsic childhood or other diseases. Other incubation period). The period between details will vary with the differential the time of exposure to an infectious diagnosis. If the incubation period is agent and the time when the agent can known, information on possible source be detected in blood or stool is called contacts may be sought. (4) the pre-patent period. (1)

University at Albany Center for Public Health Preparedness 4 Infected Individual: A person or animal disease, e.g., in a village, town, or that harbors an infectious agent and closed institution. (2) who has either manifest disease or Pandemic: An epidemic occurring unapparent infection. (1) worldwide, or over a very wide area, Infectious Person or Animal: One crossing international boundaries, and from whom the infectious agent can be usually affecting a large number of naturally acquired. (1) people. (2) Infectious Agent: An organism (virus, Period of Communicability / rickettsia, bacteria, fungus, protozoan or Communicable Period: The time helminth) that is capable of producing during which an infectious agent may be infection or infectious disease. (1) transferred directly or indirectly from an Isolation: As applied to patients, infected person to another person, from isolation represents separation, for a an infected animal to humans, or from period at least equal to the period of an infected person to animals including communicability, of infected persons or arthropods. (1) animals from others, in such places and Quarantine: Restriction of activities for under such conditions as to prevent or well persons or animals who have been limit the direct or indirect transmission of exposed (or are considered to be at high the infectious agent from those infected risk of exposure) to a case of to those who are susceptible to infection communicable disease during its period or who may spread the agent to others. of communicability (i.e., contacts) to (1) prevent disease transmission during the Laboratory Response Network (LRN): incubation period if infection should National network of local, state and occur. (1) The two main types of federal public health, food testing, quarantine are: veterinary diagnostic, and environmental Absolute or complete quarantine: The testing laboratories that provide the limitation of freedom of movement of laboratory infrastructure and capacity to those exposed to a communicable respond to biological and chemical disease for a period of time not longer terrorism, and other public health than the longest usual incubation period emergencies. The more than 140 of that disease, in such manner as to laboratories that make up the LRN are prevent effective contact with those not affiliated with federal agencies, military so exposed. installations, international partners, and Modified quarantine: A selective, partial state/local public health departments. limitation of freedom of movement of (CDC) contacts, commonly on the basis of Monitoring: The intermittent known or presumed differences in performance and analysis of routine susceptibility and related measurements, aimed at detecting to the assessed risk of disease changes in the environment or health transmission. Such limitations may be status of populations. Not to be designed to accommodate particular confused with surveillance which is a situations. Examples are exclusion from continuous process. (2) school, exemption of immune persons Outbreak: An epidemic limited to from provisions applicable to susceptible localized increase in the incidence of a persons, or restriction of military populations to post or to quarters.

University at Albany Center for Public Health Preparedness 5 Personal surveillance, one type of to protect uninfected from infected modified quarantine, is the practice of segments of a population. (1) close medical or other supervision of Surveillance: Systematic ongoing contacts to permit prompt recognition of collection, collation, and analysis of data infection or illness but without restriction and the timely dissemination of of movement. Another type of modified information to those who need to know quarantine, segregation, is the so that action can be taken. (World separation of some part of a group of Health Organization cited in (2)) persons or domestic animals from Susceptible: A person or animal not others for special consideration, control, possessing sufficient resistance against or observation; removal of susceptible a particular infectious agent to prevent children to homes of immune persons; contracting infection or disease when or establishment of a sanitary boundary exposed to that agent. (1)

Sources: (1) National Association of County and City Health Officials (NACCHO). “Isolation and Quarantine: Issues to Consider”. Accessed at: http://www.naccho.org/toolbox/Issues%20to%20Consider%20Isolation %20Quarantine.pdf (2) Last JM, editor. A Dictionary of Epidemiology. 4th ed. New York: Oxford UP; 2001. (3) Aschengrau A, Seage GR. Essentials of Epidemiology in Public Health. Sudbury (MA): Jones and Bartlett; 2003. (4) Heymann DL. Control of Communicable Diseases Manual. 18th ed. Washington (DC): American Public Health Association; 2004.

University at Albany Center for Public Health Preparedness 6 Additional Study

Video program: “Isolation and Quarantine: Practice & Law” originally aired November 10, 2005 with Frederic E. Shaw, MD, JD, CDC Public Health Law Program http://www.ualbanycphp.org/GRS/eventpast.cfm? id=46

Short paper: “Isolation and Quarantine: Issues to Consider” by the National Association of County and City Health Officials (NACCHO).. Accessed at: http://www.naccho.org/toolbox/Issues%20to %20Consider%20Isolation%20Quarantine.pdf

Online self-paced course: “Preparedness & Community Response to Pandemics” helps you: . Describe the historical context of influenza. . Describe what a pandemic is and how they occur (antigenic shift and drift). . Outline the epidemiology of influenza. . Explain surveillance activities related to influenza. . Recognize the clinical features of influenza. . Identify control measures to be taken prior/during a pandemic of influenza. . Identify response efforts and partners to a pandemic (both locally and globally). . Describe the unique characteristics of a virus. . Explain how a pandemic unfolds (pandemic phases and periods).

http://www.ualbanycphp.org/learning/registration/d etail_Pandemics.cfm

University at Albany Center for Public Health Preparedness 7 Discussion Guide 1. Incident management structure a. What is the incident management structure for this event? b. Who is in charge? c. We want a rapid, coordinated response for its own sake, but also because the public judges the quality of government and other agencies’ responses by their speed. Lack of coordination may undermine trust, and ultimately impact the public’s health and your own job status. 2. Isolated patients at the hospital a. Are there any issues with the isolated ill individuals at the hospital? Assume they are truly ill and happily not going anywhere. b. See [local plan section on voluntary isolation/quarantine] page [#] c. See [local plan voluntary isolation/quarantine directive] page [#] d. See [local plan entry on isolation and Quarantine notification] page [#] 3. Household contacts: Quarantined and not-yet-ill households a. What needs to happen regarding the quarantined family members who are not yet ill but were definitely exposed to the ill, isolated individuals? This let’s us look at the fundamentals of isolation, quarantine, and disease b. See [local plan entry on initial steps for isolation and quarantine implementation] page [#] c. If they cooperate? i. See [local plan section on voluntary isolation/quarantine] page [#] ii. See [local plan voluntary isolation/quarantine directive] page [#] iii. Where should they stay? 1. See [local plan guidance for human isolation/quarantine site selection] page [#] d. If they do not cooperate? i. See [local plan entry for health order/court ordered involuntary isolation/quarantine] page [#] ii. See [local plan sample order of isolation and confinement in a respondent suspected of having a serious communicable disease] page [#] iii. See [local plan entry on arrangements while in confinement] page [#] iv. Carry out the legal actions. e. Personal needs 4. What happens if the quarantined become ill? a. For example, in one household suppose that everyone has becomes terribly ill and is hospitalized. What are the implications for the disease outbreak investigation, epidemiology, and assumptions about other quarantine households? b. For example, in another household several individuals report symptoms. What should they do? What if their illness does not require hospitalization? c. If they need to be involuntarily isolated?

University at Albany Center for Public Health Preparedness 8 5. Incidental contacts (outside the home of the ill): a. What needs to happen regarding the others in the community that have been exposed to the isolated ill individuals (classmates, co-workers, fellow church-goers, etc)? This is where we really see the potential for a massive outbreak or pandemic, and a massive increase in isolation, quarantine, and disease control measures. b. How will they be identified and contacted? c. What action should they take? i. Two co-workers are planning to travel tomorrow. ii. One family member of an ill person is hosting the local middle school music festival this week. If that family member is in fact ill and infectious, they may have exposed many classmates who may then expose many more at the music festival. This is an immediate example of how an outbreak could explode into an epidemic. 6. Epidemic/Surge: a. Who will carry out all of these actions, especially as the usual public health staff reach their limit? b. See [local plan entry on training] page [#] c. See [local plan entry on isolation site selection for large numbers of individuals] page [#] 7. Public information: a. What depends on providing good and trusted information to the public? i. Preventing spread: get the public to follow advice and report illnesses. ii. Cooperation with authorities iii. Trust iv. If we assume that this outbreak explodes into a full pandemic in a few months, what is the likelihood of recriminations against authorities if the public have not understood what the authorities have been doing; why, how, what processes are in place; therefore you don’t need to be mistrusted, ignored, or replaced. v. Acceptance helps compliance, as individuals who should be isolated or quarantined trust authorities, and as their friends and families trust authorities and help reinforce the importance of cooperating. 8. Coordination with other agencies/organizations a. Schools b. Doctors’ offices c. Other health care providers; coordination to increase doctors offices’ surveillance for illness and what do d. Get call center up and running, have some notice from other parts of country; e. Home care provider info f. New guidance goes to emergency departments and doctors offices, maybe school nurses

University at Albany Center for Public Health Preparedness 9