Planning forPANDEMIC 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 SevereCase 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

SAMPLE

A Layered Approach

Individual / Household / Agency

Hand hygieneCough etiquetteInfection controlLiving space controlIsolation of illDesignated care providerFacemasks where indicated

Community

Isolation of illTreatment of illQuarantine of exposedProphylaxis of exposedSchool closureProtective sequestration of childrenSocial distancing

- Community- Workplace

Liberal leave policies

International

Containment-at-sourceSupport efforts to reduce transmissionTravel advisoriesLayered screening of travelersHealth advisoriesLimited 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 = 2R0 = 1

Suppression

Ro = 0.67,

Progression = 1:2:4:3:2

Exponentiation

Ro = 2.0,

Progression = 1:2:4:8:16

Effect of Increasing Social Distance on Epidemic Dynamics

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

Frank Leslie’s Illustrated Newspaper, Sept. 1878

Death in a sailor’s uniform holding the yellow quarantine flag knocking on the door of NYC during the 1898 yellow fever epidemic

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 self-preservationCordon 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

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

Ethical Principles to Consider

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

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)