Public Health 101 – An Introduction for Public Health Stakeholders Southwest Center for Advanced...

Public Health 101 – An Introduction for

Public Health Stakeholders

Southwest Center for Advanced Public Health Practice

Tarrant County Public Health, TX

2009

Presented by

Public Health 101

2009 NACCHO/APC Road Show

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

Course OutlineI. 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: Avian Influenza Outbreak

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. MedicinePublic Health Medicine

Patient Entire Populations Individuals

Intervention

Assess, Policy Development & Assurance

Medical Treatment

Process System Management

Patient Management

Outcome Healthy Community

Healing

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

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

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

Roles in Preparedness

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

Action

Collaboration is critical to success!

Roles in Preparedness

Situation Examples: – Outbreaks from

contaminated food or water, infectious diseases, etc.

– Natural disasters: hurricanes, floods, fires

Roles in Preparedness

• Examples of public health job roles:– Health threats

investigator– Public

service/media– Post-event tracking– Environmental

investigators

Incident Command System

• Allows a more effective, efficient response to emergencies

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

multiple casualties

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.

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

Strategic National Stockpile

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 large 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

Epidemiology

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

• Infectious diseases

• Environmental

• Behavioral

• Forensic

• Disaster

Areas of Epidemiology

• 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

• 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

Isolation and Quarantine Protocol

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.

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?

Case study: Influenza Outbreak

Background on avian influenza:Strains of influenza that infect birdsCirculate among wild water birdsBird-to-bird transmission via:

Fecal material Saliva

Nasal & respiratory secretions

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

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 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

• 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

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

Question 5

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

Answer

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

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 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 Therefore, we must be prepared for this possibilitythis possibility

Conclusions and Questions

CreditsThis 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* DekalbBill Stephens, MS, Tarrant

Kay Sanyal-Mukherji, MPH, TarrantMicky Moerbe, MPH, Tarrant

Diana Cervantes, MS, TarrantJennifer Dowdy, MPH, Tarrant

Mark Fulmer, MS, TarrantTerry Lafon, RN, Tarrant

Teresa Bates, LVN, Tarrant Donald Fisher, MS, Tarrant

Reviewed by Dr. Elvin Adams, MD, FACEP, Health Authority, Tarrant

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/CCU302718 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

* - Originating authors