Public Health 101 An Introduction for Stakeholders

A Trainer’s GuideTarrant County Public Health

Public Health Preparedness Division&

Southwest Center for Advanced Public Health Practice

2009

Course Outline

I. Introduction to Public HealthII. Public Health PreparednessIII. Incident Command System (ICS)IV. Public Health Response to EmergenciesV. Strategic National Stockpile (SNS)VI. Introduction to EpidemiologyVII. Isolation and QuarantineVIII. Case Study 1: Hepatitis A outbreakIX. Case Study 2: Avian Influenza outbreakX. Case Study 3: White Powder Incident

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

What is Health?

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

Public Health vs. Medicine

Public Health Medicine

Patient Entire Populations Individuals

InterventionAssess, Policy

Development & Assurance

Medical Treatment

Process System ManagementPatient

Management

Outcome Healthy Community Healing

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

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 servicesThe American Public Health Association http://www.apha.org/ppp/science/10ES.htm

Tarrant CountyPublic 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

Population BasedPublic Health Services

• Environmental Health• Infectious Disease Control and

Investigation• Laboratory Services• Health Education Services

The Public Health System

Federal Agencies

State Agencies

Local Agencies

Public Health’s Many PartnersPublic Health’s Many Partners

MCOs

Home Health

Parks

Economic Development

Mass Transit

Employers

Nursing Homes

Mental Health

Drug Treatment

Civic GroupsCHCs

Laboratory Facilities

Hospitals

EMSCommunity

Centers

Doctors

Health Department

Churches

Philanthropist

Elected Officials

Tribal Health

Schools

Police

Fire

Corrections

Environmental Health

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

What is Public Health Preparedness?

“Plans,procedures, policies, training, and equipmentnecessary tomaximize the ability to prevent,respond and recover from major events.”

(HSPD-21)

Public Health PreparednessBuilds Infrastructure for:

Public Health EmergenciesBioterrorism, pandemics

Everyday health threatsInfectious & foodborne

diseases

Preparedness and Bioterrorism

What is bioterrorism???

-- The use of... Bacteria Viruses Parasites Their by-products

…in a terrorist act.

Preparedness and Bioterrorism

• Possible agents of bioterrorism– Anthrax– Smallpox– Plague– Botulism

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

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

Roles in Preparedness

Examples: – Outbreaks from

contaminated food or water, infectious diseases, etc.

– Natural disasters: hurricanes, floods, fires

Roles in Preparedness

• Planning• Coordination/Collaboration• Training and Exercise• Response• Evaluation and Corrective

Action

Collaboration is critical to success!

Roles in Preparedness

• Examples of public health roles:– Health threats

investigator– Public

service/media– Post-event tracking– Environmental

investigators

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

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

LE/FR Advisory and Alerting Portal

Incident Command System

• Allows a more effective, efficient response to emergencies

• Examples:– HazMat incidents– Terrorist incidents– Natural disasters– Incidents involving

multiple casualties

Incident Command

LHD’s use ICS Command & Control

PH Resources & Personnel

Communicate to partner agencies

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.

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

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

Public Health Responding to Emergencies

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

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

Group Exercise:Crypto OutbreakCryptosporidium

(crypto) is a microscopic parasite caused by fecal contamination in water. It most often manifests in public swimming areas.

Group Exercise:Crypto Outbreak

Lake Sharon a popular public swimming lake is source of a large crypto outbreak.

Group Exercise:Crypto OutbreakBased on the ICS

201… Complete an ICS 202 Write objectives Write safety message Secure perimeter Take into account

environmental hazards

Preparedness Exercise

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

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:

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

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

Local Response to Strategic National Stockpile

• Essential that First Responders and others in contact with exposed civilians are the first to be medicated

Local Response to Strategic National Stockpile

• Must prepare to dispense medicine to a huge number of people in a relatively short time span

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

Local Response to Strategic National Stockpile

• Remember the 5 P’s . . .

Prior Planning Prevents Poor Performance

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

What is Epidemiology?

Study of the spread and causes of diseases or events in specified populations, and the control of health problems.

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

Areas of Epidemiology

• Infectious diseases• Environmental• Behavioral• Forensic• Disaster

• Person

• Place

• Time

Key Elements in Epidemiology

Epidemiology Study Examples(risk or exposure outcome)

• Smoking (exposure) increases the risk of developing Lung Cancer (outcome)

Epidemiology Study Examples(risk or exposure

outcome)

• Eating undercooked hamburger (exposure) increases the risk of infection with the bacteria E. coli (outcome).

• Getting a flu shot (exposure) decreases the risk of becoming ill with the flu (outcome).

Epidemiology Study Examples(risk or exposure

outcome)

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

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

Case Study #1: Hepatitis A outbreak

Scenario: Hepatitis A outbreak in Texas in 1997

Hepatitis A symptoms

• Jaundice (yellowing skin)

• Fatigue • Abdominal pain • Loss of appetite• Nausea • Diarrhea • Fever

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

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

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

Hepatitis A Transmission

• Transmission of Hepatitis A prior to food preparation:– Ex: Contamination

occurs in fields where item is grown and harvested

Hep A Transmission Summary

• Transmission of hepatitis A:– Contaminated food

Infected foodhandler Specific food item

– Contaminated water

Problem has been detected

In this scenario: Hepatitis A cases

have been found among students or staff in four different school districts in Texas

Infectious agent has been verified

The diagnosis of Hepatitis A has been verified (lab confirmed)

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?

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

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.)

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

Gather & Analyze Data

• Investigators gather and analyze data and information from the interviews

Hypothesis about causation

• Investigators determined:– Transmission via

contaminated water was not viable

– Transmission by an infected food handler was not plausible

Hypothesized causal agent

• Interviews did implicate a contaminated food item:

Frozen strawberries from Mexico

Implement Prevention & Control Measures

• Based on the hypothesis, implement prevention/control measures

• GOAL:Prevent additional cases of illness

Prevention & Control Measures

• Administer shots of immune globulin (IG)

• Treatment is effective if given within 2 weeks from the time the strawberries were consumed

Prevention & Control Measures

• Traceback contaminated frozen strawberries to the original source

• Recall any lots still in distribution

Prevention & Control Measures

• US Department of Agriculture (USDA) recommends placing an immediate hold on all unused product from the distributor

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

Isolation and Quarantine Protocol

Tarrant County Public Health

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.

Definitions:

Isolation:• The separation of someone who’s

infected or contaminated from others so that the infection or contamination is not spread

Quarantine• Limitation of freedom of movement

of a well person who’s been exposed to an infectious agent

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

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.

What is Involuntary Detention?• This is what Public Health will pursue if

an individual does not voluntarily comply with an ordered control measure.

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

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)*

Who Can Enforce these Rules?

• Local law enforcement must enforce an order issued by local health authority.

Questions?

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 A Pandemic is a is a World-Wide EpidemicWorld-Wide Epidemic

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

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.

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

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)

Avian Influenza Virus Transmission Concerns

1. Strain efficiently transmitted between birds and humans

2. Strain efficiently transmitted from human to human

Influenza Outbreak Scenario

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

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

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

Influenza Outbreak

• The farm owner wakes up one morning suffering from:– Fever– Sore throat– Coughing– Muscle aches

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.

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

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.

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.

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.

Influenza Outbreak

Influenza Outbreak

Within days after the Tarrant resident returns home, local hospitals see an increase in patients presenting with:

• coughing• fever• muscle aches

Influenza Outbreak

• Local physicians report similar trends in symptoms seen in recent days in their private practices.

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

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.

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)

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

Question 2

• Could this influenza outbreak have been prevented completely?

AnswerHighly 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 . . .

Question 3

• Could the magnitude of this outbreak have been reduced?

AnswerYes – 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

Question 4

• Would a quarantine be required?

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

Question 5

• Why would a non-compliant person be arrested and sent to forced quarantine?

Answer

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

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

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

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 Therefore, we must be prepared for this possibilityprepared for this possibility

Case Study #3 - White Powder Incident

Scenario• It is early Monday

morning at a major law firm in downtown Fort Worth

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

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

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

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

White Powder Incident

• Individuals who may have come in contact with the powder were quarantined and held for decontamination

• The law office was evacuated

White Powder Incident

• Law enforcement requests that HazMat collect a specimen

• HazMat team collects a sample of the white powder from the law office

White Powder Incident

• HazMat turns over the powder specimen to law enforcement to transport to the Texas Department of State Health Services for testing

White Powder Incident

• HazMat also handles decontamination of the woman who opened the letter and had direct exposure to the white powder

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?

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.

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.

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

Question

• What happens next if lab results come back positive?

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

Question

• What happens next if lab results come back negative?

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

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

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

End of Presentation