preparing for and responding to bioterrorism: information for the public health workforce

Northwest Center for Public Health PracticeUniversity of Washington School of Public Health and Community Medicine

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Preparing for and Responding to Preparing for and Responding to Bioterrorism: Bioterrorism:

Information for the Public Health Information for the Public Health WorkforceWorkforce

UW Northwest Center for Public Health Practice

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Acknowledgements Acknowledgements Acknowledgements Acknowledgements

This presentation, and the accompanying instructor’s manual, were prepared by Jennifer Brennan Braden, MD, MPH, at the Northwest Center for Public Health Practice in Seattle, WA, for thepurpose of educating public health employees in the general aspects of bioterrorism preparedness and response. Instructors are encouragedto freely use all or portions of the material for its intended purpose.

The following people and organizations provided information and/or support in the development of this curriculum. A complete list of resources can be found in the accompanying instructor’s guide.

Patrick O’Carroll, MD, MPH Project Coordinator Centers for Disease Control and Prevention

Judith YarrowDesign and Editing Health Policy and Analysis; University of WA

Washington State Department of Health

Jeff Duchin, MD Jane Koehler, DVM, MPHCommunicable Disease Control, Epidemiology and Immunization Section

Public Health - Seattle and King County

Ed Walker, MD; University of WADepartment of Psychiatry


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Consequence ManagementConsequence Management For Public Health Leaders For Public Health Leaders

Module AModule A

Consequence ManagementConsequence Management For Public Health Leaders For Public Health Leaders

Module AModule A


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Consequence ManagementConsequence ManagementLearning ObjectivesLearning Objectives


Describe the role of public health in Describe the role of public health in consequence management following a public consequence management following a public health emergency and identify laws supporting health emergency and identify laws supporting this rolethis role

Describe the legal basis for quarantine and Describe the legal basis for quarantine and potential adverse consequences and identify potential adverse consequences and identify factors to consider when implementing and factors to consider when implementing and enforcingenforcing quarantine quarantine

Describe the role of public health in Describe the role of public health in consequence management following a public consequence management following a public health emergency and identify laws supporting health emergency and identify laws supporting this rolethis role

Describe the legal basis for quarantine and Describe the legal basis for quarantine and potential adverse consequences and identify potential adverse consequences and identify factors to consider when implementing and factors to consider when implementing and enforcingenforcing quarantine quarantine


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Describe the basic structure and components of Describe the basic structure and components of the National Pharmaceutical Stockpile, the National Pharmaceutical Stockpile, How and when it is employedHow and when it is employed The responsibilities of state and local health The responsibilities of state and local health

officials in accepting and distributing the officials in accepting and distributing the resources providedresources provided

Identify the potential psychological responses, Identify the potential psychological responses, on individual and community levels, following a on individual and community levels, following a BT event, threat, or other public health BT event, threat, or other public health emergencyemergency

Describe the basic structure and components of Describe the basic structure and components of the National Pharmaceutical Stockpile, the National Pharmaceutical Stockpile, How and when it is employedHow and when it is employed The responsibilities of state and local health The responsibilities of state and local health

officials in accepting and distributing the officials in accepting and distributing the resources providedresources provided

Identify the potential psychological responses, Identify the potential psychological responses, on individual and community levels, following a on individual and community levels, following a BT event, threat, or other public health BT event, threat, or other public health emergencyemergency


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Consequence Management Consequence Management Legal Basis for Local EffortsLegal Basis for Local Efforts

Consequence Management Consequence Management Legal Basis for Local EffortsLegal Basis for Local Efforts

State police powers give states the authority to State police powers give states the authority to prescribe within the limits of state and federal prescribe within the limits of state and federal constitutions, reasonable laws necessary to constitutions, reasonable laws necessary to preserve the public order, health, safety, preserve the public order, health, safety, welfare, and morals. welfare, and morals.

RCW 70.05.070 gives the local health officer RCW 70.05.070 gives the local health officer power to “take such measures as he or she power to “take such measures as he or she deems necessary in order to promote the public deems necessary in order to promote the public health.”health.”

State police powers give states the authority to State police powers give states the authority to prescribe within the limits of state and federal prescribe within the limits of state and federal constitutions, reasonable laws necessary to constitutions, reasonable laws necessary to preserve the public order, health, safety, preserve the public order, health, safety, welfare, and morals. welfare, and morals.

RCW 70.05.070 gives the local health officer RCW 70.05.070 gives the local health officer power to “take such measures as he or she power to “take such measures as he or she deems necessary in order to promote the public deems necessary in order to promote the public health.”health.”


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Presidential Decision Directive 39Presidential Decision Directive 39U.S. Policy on CounterterrorismU.S. Policy on Counterterrorism

Presidential Decision Directive 39Presidential Decision Directive 39U.S. Policy on CounterterrorismU.S. Policy on Counterterrorism

Consequence management - response to the Consequence management - response to the disaster, focusing on the alleviation of damage, loss, disaster, focusing on the alleviation of damage, loss, hardship, or sufferinghardship, or suffering Public health, medical, and emergency personnel Public health, medical, and emergency personnel Response and Recovery phasesResponse and Recovery phases State have primary responsibility for responseState have primary responsibility for response Federal agencies provide assistance as neededFederal agencies provide assistance as needed

FEMA has lead roleFEMA has lead role

Consequence management - response to the Consequence management - response to the disaster, focusing on the alleviation of damage, loss, disaster, focusing on the alleviation of damage, loss, hardship, or sufferinghardship, or suffering Public health, medical, and emergency personnel Public health, medical, and emergency personnel Response and Recovery phasesResponse and Recovery phases State have primary responsibility for responseState have primary responsibility for response Federal agencies provide assistance as neededFederal agencies provide assistance as needed

FEMA has lead roleFEMA has lead rolePDD-39

http://www.fas.org/irp/offdocs/pdd39.htm


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Consequence Management Consequence Management Federal SupportFederal Support

Consequence Management Consequence Management Federal SupportFederal Support

Federal Response Plan, Emergency Support Federal Response Plan, Emergency Support Function #8Function #8 Provides “federal assistance to supplement Provides “federal assistance to supplement

state and local resources in response to state and local resources in response to public health and medical needs following a public health and medical needs following a major disaster or emergency, or during a major disaster or emergency, or during a developing potential medical situation”developing potential medical situation”

Directed by DHHS Directed by DHHS CDC lead for protecting health and safetyCDC lead for protecting health and safety

Federal Response Plan, Emergency Support Federal Response Plan, Emergency Support Function #8Function #8 Provides “federal assistance to supplement Provides “federal assistance to supplement

state and local resources in response to state and local resources in response to public health and medical needs following a public health and medical needs following a major disaster or emergency, or during a major disaster or emergency, or during a developing potential medical situation”developing potential medical situation”

Directed by DHHS Directed by DHHS CDC lead for protecting health and safetyCDC lead for protecting health and safety


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Consequence Management Consequence Management Other Emergency Support FunctionsOther Emergency Support FunctionsConsequence Management Consequence Management Other Emergency Support FunctionsOther Emergency Support Functions

ESFESF FunctionFunction Lead AgencyLead Agency

55 Information and Information and planningplanning

FEMAFEMA

66 Mass careMass care American Red American Red CrossCross

1010 Hazardous materialsHazardous materials EPAEPA

1111 FoodFood USDAUSDA


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Consequence ManagementConsequence ManagementNecessary Protocols and ProceduresNecessary Protocols and Procedures


Communication and informational updatesCommunication and informational updates Between staff/agency divisionsBetween staff/agency divisions With other coordinating agenciesWith other coordinating agencies With the media and public With the media and public

Evaluation and referral of phone calls and Evaluation and referral of phone calls and requests for information or services requests for information or services

Mass antibiotic prophylaxis and immunization Mass antibiotic prophylaxis and immunization Quarantine and isolation Quarantine and isolation

Communication and informational updatesCommunication and informational updates Between staff/agency divisionsBetween staff/agency divisions With other coordinating agenciesWith other coordinating agencies With the media and public With the media and public

Evaluation and referral of phone calls and Evaluation and referral of phone calls and requests for information or services requests for information or services

Mass antibiotic prophylaxis and immunization Mass antibiotic prophylaxis and immunization Quarantine and isolation Quarantine and isolation


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Closure of public places/institutions Closure of public places/institutions Evaluating and referring reports of suspicious Evaluating and referring reports of suspicious

packages or substancespackages or substances Surge capacity Surge capacity Use of private resources Use of private resources Use of volunteers and outside aid Use of volunteers and outside aid Requesting state/federal assistanceRequesting state/federal assistance

Closure of public places/institutions Closure of public places/institutions Evaluating and referring reports of suspicious Evaluating and referring reports of suspicious

packages or substancespackages or substances Surge capacity Surge capacity Use of private resources Use of private resources Use of volunteers and outside aid Use of volunteers and outside aid Requesting state/federal assistanceRequesting state/federal assistance


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QuarantineQuarantineQuarantineQuarantine

Comes from Italian Comes from Italian quarantequarante – refers to the 40 – refers to the 40 day sequestration imposed on arriving merchant day sequestration imposed on arriving merchant ships during plague outbreaks of the 13ships during plague outbreaks of the 13 thth century century

Today – broader definition Today – broader definition Restriction of movement of persons, animals, Restriction of movement of persons, animals,

and things that might otherwise spread a and things that might otherwise spread a contagious diseasecontagious disease

Usually refers to population-wide measures Usually refers to population-wide measures Time period not specified Time period not specified

Comes from Italian Comes from Italian quarantequarante – refers to the 40 – refers to the 40 day sequestration imposed on arriving merchant day sequestration imposed on arriving merchant ships during plague outbreaks of the 13ships during plague outbreaks of the 13 thth century century

Today – broader definition Today – broader definition Restriction of movement of persons, animals, Restriction of movement of persons, animals,

and things that might otherwise spread a and things that might otherwise spread a contagious diseasecontagious disease

Usually refers to population-wide measures Usually refers to population-wide measures Time period not specified Time period not specified


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CDC Definition: Quarantine vs. Isolation CDC Definition: Quarantine vs. Isolation CDC Definition: Quarantine vs. Isolation CDC Definition: Quarantine vs. Isolation

Isolation Isolation The separation of a person or group of The separation of a person or group of

persons from other people to prevent the persons from other people to prevent the spread of infection spread of infection

Quarantine Quarantine Restriction of activities or limitation of Restriction of activities or limitation of

freedom of movement of those freedom of movement of those presumed presumed exposedexposed to a communicable disease in such to a communicable disease in such a manner as to prevent effective contact with a manner as to prevent effective contact with those not so exposed those not so exposed

Isolation Isolation The separation of a person or group of The separation of a person or group of

persons from other people to prevent the persons from other people to prevent the spread of infection spread of infection

Quarantine Quarantine Restriction of activities or limitation of Restriction of activities or limitation of

freedom of movement of those freedom of movement of those presumed presumed exposedexposed to a communicable disease in such to a communicable disease in such a manner as to prevent effective contact with a manner as to prevent effective contact with those not so exposed those not so exposed


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CDC Definition: Quarantine vs. Isolation CDC Definition: Quarantine vs. Isolation CDC Definition: Quarantine vs. Isolation CDC Definition: Quarantine vs. Isolation

Quarantine measures may include: Quarantine measures may include:

Suspension of public gatheringsSuspension of public gatherings

Closure of public placesClosure of public places

Restriction of travelRestriction of travel

Cordon sanitaireCordon sanitaire

Quarantine measures may include: Quarantine measures may include:

Suspension of public gatheringsSuspension of public gatherings

Closure of public placesClosure of public places

Restriction of travelRestriction of travel

Cordon sanitaireCordon sanitaire


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QuarantineQuarantineLegal authority – Local LevelLegal authority – Local Level

QuarantineQuarantineLegal authority – Local LevelLegal authority – Local Level

When confined to a specific locale (community, When confined to a specific locale (community, state) – rests with local and/or state health state) – rests with local and/or state health authorities (police power)authorities (police power)

Few states have specific policies/procedures for Few states have specific policies/procedures for deciding whether quarantine is deciding whether quarantine is warranted in a warranted in a specific situationspecific situation

Be familiar with the laws pertaining to Be familiar with the laws pertaining to quarantine or that might be interpreted as quarantine or that might be interpreted as applying to quarantine, existing in your stateapplying to quarantine, existing in your state

When confined to a specific locale (community, When confined to a specific locale (community, state) – rests with local and/or state health state) – rests with local and/or state health authorities (police power)authorities (police power)

Few states have specific policies/procedures for Few states have specific policies/procedures for deciding whether quarantine is deciding whether quarantine is warranted in a warranted in a specific situationspecific situation

Be familiar with the laws pertaining to Be familiar with the laws pertaining to quarantine or that might be interpreted as quarantine or that might be interpreted as applying to quarantine, existing in your stateapplying to quarantine, existing in your state


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Quarantine Quarantine Legal Authority - FederalLegal Authority - Federal

Quarantine Quarantine Legal Authority - FederalLegal Authority - Federal

Section 311 of Public Section 311 of Public Health Service Act Health Service Act Allows for federal Allows for federal

assistance to state and assistance to state and local authorities in local authorities in enforcing quarantine enforcing quarantine and other health and other health regulationsregulations

Section 311 of Public Section 311 of Public Health Service Act Health Service Act Allows for federal Allows for federal

assistance to state and assistance to state and local authorities in local authorities in enforcing quarantine enforcing quarantine and other health and other health regulationsregulations


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Quarantine Quarantine Legal Authority – Federal Legal Authority – Federal

Quarantine Quarantine Legal Authority – Federal Legal Authority – Federal

42 CFR Part 70 - 42 CFR Part 70 - authorizes the apprehension, authorizes the apprehension, detention or conditional release of people to prevent detention or conditional release of people to prevent the spread of specified communicable diseases, the spread of specified communicable diseases, and federal action and federal action if state efforts insufficientif state efforts insufficient

42 CFR Part 71 - 42 CFR Part 71 - authorizes CDC to detain, isolate authorizes CDC to detain, isolate or place under surveillance, or place under surveillance, people arriving in the people arriving in the USUS who are reasonably believed to be infected w/ who are reasonably believed to be infected w/ or been exposed to certain communicable or been exposed to certain communicable diseases, if necessary to prevent the introduction, diseases, if necessary to prevent the introduction, transmission, or spread of those diseasestransmission, or spread of those diseases

42 CFR Part 70 - 42 CFR Part 70 - authorizes the apprehension, authorizes the apprehension, detention or conditional release of people to prevent detention or conditional release of people to prevent the spread of specified communicable diseases, the spread of specified communicable diseases, and federal action and federal action if state efforts insufficientif state efforts insufficient

42 CFR Part 71 - 42 CFR Part 71 - authorizes CDC to detain, isolate authorizes CDC to detain, isolate or place under surveillance, or place under surveillance, people arriving in the people arriving in the USUS who are reasonably believed to be infected w/ who are reasonably believed to be infected w/ or been exposed to certain communicable or been exposed to certain communicable diseases, if necessary to prevent the introduction, diseases, if necessary to prevent the introduction, transmission, or spread of those diseasestransmission, or spread of those diseases


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Quarantine and IsolationQuarantine and IsolationFactors to ConsiderFactors to Consider

Quarantine and IsolationQuarantine and IsolationFactors to ConsiderFactors to Consider

Is there a scientific basis? Is there a scientific basis? Among Category A agents, only smallpox, Among Category A agents, only smallpox,

pneumonic plague, and some VHFs pneumonic plague, and some VHFs transmitted person-to-person transmitted person-to-person

Is it practical and feasible? Is it practical and feasible? Defined geographic area of riskDefined geographic area of risk Resources to enforce and maintain Resources to enforce and maintain Time period required Time period required

Do the potential benefits outweigh the risks?Do the potential benefits outweigh the risks?

Is there a scientific basis? Is there a scientific basis? Among Category A agents, only smallpox, Among Category A agents, only smallpox,

pneumonic plague, and some VHFs pneumonic plague, and some VHFs transmitted person-to-person transmitted person-to-person

Is it practical and feasible? Is it practical and feasible? Defined geographic area of riskDefined geographic area of risk Resources to enforce and maintain Resources to enforce and maintain Time period required Time period required

Do the potential benefits outweigh the risks?Do the potential benefits outweigh the risks?


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Medical Reasons for Isolation or QuarantineMedical Reasons for Isolation or QuarantineMedical Reasons for Isolation or QuarantineMedical Reasons for Isolation or Quarantine

Isolation Isolation Disease transmitted person-to-personDisease transmitted person-to-person

i.e., plague pneumonia, smallpox, viral i.e., plague pneumonia, smallpox, viral hemorrhagic fevers hemorrhagic fevers

Degree of isolation appropriate for mode of Degree of isolation appropriate for mode of transmission transmission (e.g., respiratory vs. direct contact)(e.g., respiratory vs. direct contact)

Quarantine Quarantine Disease may be transmitted by exposed Disease may be transmitted by exposed

persons prior to recognition of symptoms or persons prior to recognition of symptoms or diagnosis diagnosis

Smallpox infectious at rash onset, but rash Smallpox infectious at rash onset, but rash may be overlooked in early stages may be overlooked in early stages

Isolation Isolation Disease transmitted person-to-personDisease transmitted person-to-person

i.e., plague pneumonia, smallpox, viral i.e., plague pneumonia, smallpox, viral hemorrhagic fevers hemorrhagic fevers

Degree of isolation appropriate for mode of Degree of isolation appropriate for mode of transmission transmission (e.g., respiratory vs. direct contact)(e.g., respiratory vs. direct contact)

Quarantine Quarantine Disease may be transmitted by exposed Disease may be transmitted by exposed

persons prior to recognition of symptoms or persons prior to recognition of symptoms or diagnosis diagnosis

Smallpox infectious at rash onset, but rash Smallpox infectious at rash onset, but rash may be overlooked in early stages may be overlooked in early stages


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Quarantine Quarantine Potential Adverse ConsequencesPotential Adverse Consequences

Quarantine Quarantine Potential Adverse ConsequencesPotential Adverse Consequences

Increased risk of disease transmission in Increased risk of disease transmission in quarantined population quarantined population

Mistrust of governmentMistrust of government Civil disobedience Civil disobedience violence violence

Social stigmatization Social stigmatization Economic effects Economic effects

Businesses in quarantined area Businesses in quarantined area Businesses relying on goods and services Businesses relying on goods and services

from quarantined area from quarantined area

Increased risk of disease transmission in Increased risk of disease transmission in quarantined population quarantined population

Mistrust of governmentMistrust of government Civil disobedience Civil disobedience violence violence

Social stigmatization Social stigmatization Economic effects Economic effects

Businesses in quarantined area Businesses in quarantined area Businesses relying on goods and services Businesses relying on goods and services

from quarantined area from quarantined area


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Quarantine and Isolation Quarantine and Isolation Pre-Event PlanningPre-Event Planning

Quarantine and Isolation Quarantine and Isolation Pre-Event PlanningPre-Event Planning

Identify community facilities appropriate for use Identify community facilities appropriate for use as quarantine sites as quarantine sites

Identify non-infected personnel to administer Identify non-infected personnel to administer services at quarantine/isolation site services at quarantine/isolation site Health care providers Health care providers Laundry and waste disposal personnel Laundry and waste disposal personnel Enforcers/access control Enforcers/access control

Identify community facilities appropriate for use Identify community facilities appropriate for use as quarantine sites as quarantine sites

Identify non-infected personnel to administer Identify non-infected personnel to administer services at quarantine/isolation site services at quarantine/isolation site Health care providers Health care providers Laundry and waste disposal personnel Laundry and waste disposal personnel Enforcers/access control Enforcers/access control


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Quarantine and IsolationQuarantine and IsolationPre-Event PlanningPre-Event Planning

Quarantine and IsolationQuarantine and IsolationPre-Event PlanningPre-Event Planning

Identify means of Identify means of food and supply food and supply provision to provision to quarantine/isolation quarantine/isolation site site

Ensure means of Ensure means of communication with communication with outside communityoutside community

Identify means of Identify means of food and supply food and supply provision to provision to quarantine/isolation quarantine/isolation site site

Ensure means of Ensure means of communication with communication with outside communityoutside community


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Quarantine and IsolationQuarantine and IsolationPolicies and ProceduresPolicies and Procedures

Quarantine and IsolationQuarantine and IsolationPolicies and ProceduresPolicies and Procedures

When to institute When to institute Who is allowed access to site Who is allowed access to site Infection control policies Infection control policies

Transportation of people to siteTransportation of people to site Within site Within site

Criteria for entry and departure Criteria for entry and departure When to discontinue When to discontinue

When to institute When to institute Who is allowed access to site Who is allowed access to site Infection control policies Infection control policies

Transportation of people to siteTransportation of people to site Within site Within site

Criteria for entry and departure Criteria for entry and departure When to discontinue When to discontinue


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IsolationIsolationCDC Smallpox Response Plan CDC Smallpox Response Plan

IsolationIsolationCDC Smallpox Response Plan CDC Smallpox Response Plan

Facility Categories Facility Categories

Type C – Contagious Type C – Contagious

Confirmed and probable casesConfirmed and probable cases

Type X – Uncertain diagnosis Type X – Uncertain diagnosis

Vaccinated febrile contacts without rashVaccinated febrile contacts without rash

Type R – AsymptomaticType R – Asymptomatic

Non-febrile contacts Non-febrile contacts

Facility Categories Facility Categories

Type C – Contagious Type C – Contagious

Confirmed and probable casesConfirmed and probable cases

Type X – Uncertain diagnosis Type X – Uncertain diagnosis

Vaccinated febrile contacts without rashVaccinated febrile contacts without rash

Type R – AsymptomaticType R – Asymptomatic

Non-febrile contacts Non-febrile contacts


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Type C FacilitiesType C FacilitiesCDCCDC Smallpox Response PlanSmallpox Response Plan

Type C FacilitiesType C FacilitiesCDCCDC Smallpox Response PlanSmallpox Response Plan

Non-shared heating, air-conditioning, and Non-shared heating, air-conditioning, and ventilation systems ventilation systems

Exhaust all air out through HEPA filter, or at Exhaust all air out through HEPA filter, or at least 100 yds from other occupied areasleast 100 yds from other occupied areas

Adequate water, heating, cooling, and closed Adequate water, heating, cooling, and closed window ventilation window ventilation

Able to provide high-level medical care Able to provide high-level medical care

(incl. vent support and cardiac resuscitation)(incl. vent support and cardiac resuscitation)

Non-shared heating, air-conditioning, and Non-shared heating, air-conditioning, and ventilation systems ventilation systems

Exhaust all air out through HEPA filter, or at Exhaust all air out through HEPA filter, or at least 100 yds from other occupied areasleast 100 yds from other occupied areas

Adequate water, heating, cooling, and closed Adequate water, heating, cooling, and closed window ventilation window ventilation

Able to provide high-level medical care Able to provide high-level medical care

(incl. vent support and cardiac resuscitation)(incl. vent support and cardiac resuscitation)


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Type X FacilitiesType X Facilities CDC Smallpox Response Plan CDC Smallpox Response Plan

Type X FacilitiesType X Facilities CDC Smallpox Response Plan CDC Smallpox Response Plan

Same isolation and Same isolation and general supply general supply requirements as requirements as Type C facility Type C facility

Able to provide basic medical care Able to provide basic medical care (e.g., monitoring vital signs)(e.g., monitoring vital signs)

Same isolation and Same isolation and general supply general supply requirements as requirements as Type C facility Type C facility

Able to provide basic medical care Able to provide basic medical care (e.g., monitoring vital signs)(e.g., monitoring vital signs)


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Type R FacilitiesType R Facilities CDCCDC Smallpox Response Plan Smallpox Response Plan

Type R FacilitiesType R Facilities CDCCDC Smallpox Response Plan Smallpox Response Plan

May be the person’s home May be the person’s home

oror

Hotel/motel if warranted due to logistical or Hotel/motel if warranted due to logistical or other reasons other reasons

May be the person’s home May be the person’s home

oror

Hotel/motel if warranted due to logistical or Hotel/motel if warranted due to logistical or other reasons other reasons

National Pharmaceutical StockpileNational Pharmaceutical StockpilePurposePurpose

National Pharmaceutical StockpileNational Pharmaceutical StockpilePurposePurpose

Provides resources to respond to both biologic Provides resources to respond to both biologic and chemical attacksand chemical attacks

Requested by governorRequested by governor

Managed by Centers for Disease Control Managed by Centers for Disease Control and Prevention and Prevention

Provides resources to respond to both biologic Provides resources to respond to both biologic and chemical attacksand chemical attacks

Requested by governorRequested by governor

Managed by Centers for Disease Control Managed by Centers for Disease Control and Prevention and Prevention

More on NPS... 28

National Pharmaceutical StockpileNational Pharmaceutical StockpilePush PackagesPush Packages


12-hour “Push Packages” in cargo-sized 12-hour “Push Packages” in cargo-sized containers weighing approximately 37 tons eachcontainers weighing approximately 37 tons each

Located around the country at strategic Located around the country at strategic locationslocations

Held in environmentally controlled and secured Held in environmentally controlled and secured warehouseswarehouses

Can reach a destination within 12 hours of Can reach a destination within 12 hours of being requestedbeing requested

12-hour “Push Packages” in cargo-sized 12-hour “Push Packages” in cargo-sized containers weighing approximately 37 tons eachcontainers weighing approximately 37 tons each

Located around the country at strategic Located around the country at strategic locationslocations

Held in environmentally controlled and secured Held in environmentally controlled and secured warehouseswarehouses

Can reach a destination within 12 hours of Can reach a destination within 12 hours of being requestedbeing requested

More on NPS... 29



Contain color-coded inventoryContain color-coded inventory

Pharmaceuticals - stock rotated before Pharmaceuticals - stock rotated before expirationexpiration

IV supplies, airway supplies, ventilatorsIV supplies, airway supplies, ventilators

Bandages and personal protective equipmentBandages and personal protective equipment

Contain color-coded inventoryContain color-coded inventory

Pharmaceuticals - stock rotated before Pharmaceuticals - stock rotated before expirationexpiration

IV supplies, airway supplies, ventilatorsIV supplies, airway supplies, ventilators

Bandages and personal protective equipmentBandages and personal protective equipment

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Materials pre-packaged for immediate Materials pre-packaged for immediate dispensingdispensing

Support staff will accompany the packageSupport staff will accompany the package

Receiving state responsible for logistics of Receiving state responsible for logistics of repackaging and distributionrepackaging and distribution

Materials pre-packaged for immediate Materials pre-packaged for immediate dispensingdispensing

Support staff will accompany the packageSupport staff will accompany the package

Receiving state responsible for logistics of Receiving state responsible for logistics of repackaging and distributionrepackaging and distribution

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National Pharmaceutical StockpileNational Pharmaceutical StockpileVendor-Managed InventoryVendor-Managed Inventory

National Pharmaceutical StockpileNational Pharmaceutical StockpileVendor-Managed InventoryVendor-Managed Inventory

Agreements with pharmaceutical manufacturers Agreements with pharmaceutical manufacturers to make large stocks available on demandto make large stocks available on demand

Shipped to arrive within 24-36 hours after Shipped to arrive within 24-36 hours after requestedrequested

VA hospitals have an agreement with CDC to VA hospitals have an agreement with CDC to assist in the procurement and maintenance of assist in the procurement and maintenance of NPS NPS

Agreements with pharmaceutical manufacturers Agreements with pharmaceutical manufacturers to make large stocks available on demandto make large stocks available on demand

Shipped to arrive within 24-36 hours after Shipped to arrive within 24-36 hours after requestedrequested

VA hospitals have an agreement with CDC to VA hospitals have an agreement with CDC to assist in the procurement and maintenance of assist in the procurement and maintenance of NPS NPS

More on NPS... 32


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Pre-Event PlanningPre-Event PlanningMass Prophylaxis and TreatmentMass Prophylaxis and Treatment

Pre-Event PlanningPre-Event PlanningMass Prophylaxis and TreatmentMass Prophylaxis and Treatment

Identification of sites Identification of sites Coordination with local hospitals, clinics, Coordination with local hospitals, clinics,

pharmacies, and other community facilities pharmacies, and other community facilities Contagiousness of disease may require separate Contagiousness of disease may require separate

site for antibiotic dispensing/immunizations (i.e., site for antibiotic dispensing/immunizations (i.e., smallpox)smallpox)

Infection control precautions Infection control precautions Identification of staff and equipment, in low- and Identification of staff and equipment, in low- and

high-volume situations (surge capacity) high-volume situations (surge capacity) Establishing a record-keeping systemEstablishing a record-keeping system Developing follow-up protocols and proceduresDeveloping follow-up protocols and procedures

Identification of sites Identification of sites Coordination with local hospitals, clinics, Coordination with local hospitals, clinics,

pharmacies, and other community facilities pharmacies, and other community facilities Contagiousness of disease may require separate Contagiousness of disease may require separate

site for antibiotic dispensing/immunizations (i.e., site for antibiotic dispensing/immunizations (i.e., smallpox)smallpox)

Infection control precautions Infection control precautions Identification of staff and equipment, in low- and Identification of staff and equipment, in low- and

high-volume situations (surge capacity) high-volume situations (surge capacity) Establishing a record-keeping systemEstablishing a record-keeping system Developing follow-up protocols and proceduresDeveloping follow-up protocols and procedures


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Psychological Response toPsychological Response toA Public Health EmergencyA Public Health Emergency Psychological Response toPsychological Response toA Public Health EmergencyA Public Health Emergency

Reaction to the event itself Reaction to the event itself Anticipation of future events Anticipation of future events Reaction to public health measures taken to Reaction to public health measures taken to

manage/control disease and injury manage/control disease and injury Quarantine Quarantine Prophylactic measures Prophylactic measures Prioritization/rationing of resources Prioritization/rationing of resources

Reaction to misinformation (e.g., myths, rumors) Reaction to misinformation (e.g., myths, rumors)

Reaction to the event itself Reaction to the event itself Anticipation of future events Anticipation of future events Reaction to public health measures taken to Reaction to public health measures taken to

manage/control disease and injury manage/control disease and injury Quarantine Quarantine Prophylactic measures Prophylactic measures Prioritization/rationing of resources Prioritization/rationing of resources

Reaction to misinformation (e.g., myths, rumors) Reaction to misinformation (e.g., myths, rumors)


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Psychological Aftermath of Crisis: Psychological Aftermath of Crisis: Role of Public HealthRole of Public Health

Psychological Aftermath of Crisis: Psychological Aftermath of Crisis: Role of Public HealthRole of Public Health

Educating and informing clinicians and the Educating and informing clinicians and the public about current risks and protective public about current risks and protective measuresmeasures

Coordination of and referral to medical and Coordination of and referral to medical and social support resources social support resources

Ensuring the needs of populations at-risk for Ensuring the needs of populations at-risk for psychological sequelae are addressedpsychological sequelae are addressed

Educating and informing clinicians and the Educating and informing clinicians and the public about current risks and protective public about current risks and protective measuresmeasures

Coordination of and referral to medical and Coordination of and referral to medical and social support resources social support resources

Ensuring the needs of populations at-risk for Ensuring the needs of populations at-risk for psychological sequelae are addressedpsychological sequelae are addressed


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Key Concepts of Disaster Mental HealthKey Concepts of Disaster Mental HealthKey Concepts of Disaster Mental HealthKey Concepts of Disaster Mental Health

Two types of disaster trauma Two types of disaster trauma IndividualIndividual CommunityCommunity

Most people pull together and function during Most people pull together and function during and after a disaster, but their effectiveness is and after a disaster, but their effectiveness is diminisheddiminished

Social support systems are crucial to recoverySocial support systems are crucial to recovery

Two types of disaster trauma Two types of disaster trauma IndividualIndividual CommunityCommunity

Most people pull together and function during Most people pull together and function during and after a disaster, but their effectiveness is and after a disaster, but their effectiveness is diminisheddiminished

Social support systems are crucial to recoverySocial support systems are crucial to recovery

Source: US DHHS. Key Concepts Of Disaster Mental Health


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Key Concepts of Disaster Mental HealthKey Concepts of Disaster Mental HealthKey Concepts of Disaster Mental HealthKey Concepts of Disaster Mental Health

Disaster stress and grief reactions are normal Disaster stress and grief reactions are normal responses to an abnormal situation.responses to an abnormal situation.

Many emotional reactions of disaster survivors Many emotional reactions of disaster survivors stem from living problems brought about by the stem from living problems brought about by the disaster.disaster.

Most people do not see themselves as needing Most people do not see themselves as needing mental health services following disaster and mental health services following disaster and will not seek such services.will not seek such services.

Disaster stress and grief reactions are normal Disaster stress and grief reactions are normal responses to an abnormal situation.responses to an abnormal situation.

Many emotional reactions of disaster survivors Many emotional reactions of disaster survivors stem from living problems brought about by the stem from living problems brought about by the disaster.disaster.

Most people do not see themselves as needing Most people do not see themselves as needing mental health services following disaster and mental health services following disaster and will not seek such services.will not seek such services.

Source: US DHHS. Key Concepts Of Disaster Mental Health


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Psychological and Behavioral Responses to Psychological and Behavioral Responses to Trauma and DisasterTrauma and Disaster


DepressionDepression Sadness Sadness DemoralizationDemoralization Isolation/withdrawalIsolation/withdrawal Difficulty Difficulty

concentratingconcentrating Sleep and appetite Sleep and appetite

disturbancesdisturbances

DepressionDepression Sadness Sadness DemoralizationDemoralization Isolation/withdrawalIsolation/withdrawal Difficulty Difficulty

concentratingconcentrating Sleep and appetite Sleep and appetite

disturbancesdisturbances

Physical ComplaintsPhysical Complaints FatigueFatigue Aches and painsAches and pains Stomach and Stomach and

intestinal complaintsintestinal complaints HeadacheHeadache Skin rashesSkin rashes

Physical ComplaintsPhysical Complaints FatigueFatigue Aches and painsAches and pains Stomach and Stomach and

intestinal complaintsintestinal complaints HeadacheHeadache Skin rashesSkin rashes


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AnxietyAnxiety Re-experiencingRe-experiencing NumbingNumbing Hyperarousal Hyperarousal

Shock and disbeliefShock and disbelief FearFear PanicPanic AngerAnger IrritabilityIrritability

AnxietyAnxiety Re-experiencingRe-experiencing NumbingNumbing Hyperarousal Hyperarousal

Shock and disbeliefShock and disbelief FearFear PanicPanic AngerAnger IrritabilityIrritability

Behavioral Behavioral ↑↑ substance use substance use

alcohol, caffeine, alcohol, caffeine, tobacco tobacco

Interpersonal Interpersonal conflictconflict

Impaired Impaired work/school work/school performanceperformance

Behavioral Behavioral ↑↑ substance use substance use

alcohol, caffeine, alcohol, caffeine, tobacco tobacco

Interpersonal Interpersonal conflictconflict

Impaired Impaired work/school work/school performanceperformance


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Responses to Trauma - ChildrenResponses to Trauma - ChildrenResponses to Trauma - ChildrenResponses to Trauma - Children

After any disaster, After any disaster, children are most afraid children are most afraid that: that: The event will happen The event will happen

againagain Someone will be injured Someone will be injured

or killedor killed They will be separated They will be separated

from the familyfrom the family They will be left aloneThey will be left alone

After any disaster, After any disaster, children are most afraid children are most afraid that: that: The event will happen The event will happen

againagain Someone will be injured Someone will be injured

or killedor killed They will be separated They will be separated

from the familyfrom the family They will be left aloneThey will be left alone


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Helping Children Cope After TraumaHelping Children Cope After TraumaHelping Children Cope After TraumaHelping Children Cope After Trauma

Assume they know a disaster has occurredAssume they know a disaster has occurred Talk with them calmly and openly at their levelTalk with them calmly and openly at their level Ask what they think has happened, and about Ask what they think has happened, and about

their fearstheir fears Share your own fears and reassureShare your own fears and reassure Emphasize the normal routineEmphasize the normal routine Limit media re-exposureLimit media re-exposure Allow expression in private ways (i.e., drawing)Allow expression in private ways (i.e., drawing)

Assume they know a disaster has occurredAssume they know a disaster has occurred Talk with them calmly and openly at their levelTalk with them calmly and openly at their level Ask what they think has happened, and about Ask what they think has happened, and about

their fearstheir fears Share your own fears and reassureShare your own fears and reassure Emphasize the normal routineEmphasize the normal routine Limit media re-exposureLimit media re-exposure Allow expression in private ways (i.e., drawing)Allow expression in private ways (i.e., drawing)


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Psychological Responses Following a Psychological Responses Following a Biological Terrorist AttackBiological Terrorist Attack

Psychological Responses Following a Psychological Responses Following a Biological Terrorist AttackBiological Terrorist Attack

Magical thinking Magical thinking about microbes and about microbes and virusesviruses

Fear of invisible Fear of invisible agentsagents

Fear of contagionFear of contagion

Magical thinking Magical thinking about microbes and about microbes and virusesviruses

Fear of invisible Fear of invisible agentsagents

Fear of contagionFear of contagion

Attribution of arousal Attribution of arousal symptoms to symptoms to infectioninfection

ScapegoatingScapegoating Panic and paranoiaPanic and paranoia Loss of faith in Loss of faith in

social institutionssocial institutions

Attribution of arousal Attribution of arousal symptoms to symptoms to infectioninfection

ScapegoatingScapegoating Panic and paranoiaPanic and paranoia Loss of faith in Loss of faith in

social institutionssocial institutions

Source: Holloway et al. JAMA 1997;278(5):425-7


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At-risk Populations for Psychiatric Sequelae At-risk Populations for Psychiatric Sequelae Following Traumatic StressFollowing Traumatic Stress


Those exposed to the dead and injuredThose exposed to the dead and injured Eye witnesses and those endangered by Eye witnesses and those endangered by

eventevent Emergency first-respondersEmergency first-responders Medical personnel caring for victims Medical personnel caring for victims

The elderlyThe elderly

The very young The very young

Those exposed to the dead and injuredThose exposed to the dead and injured Eye witnesses and those endangered by Eye witnesses and those endangered by

eventevent Emergency first-respondersEmergency first-responders Medical personnel caring for victims Medical personnel caring for victims

The elderlyThe elderly

The very young The very young Source: Norwood et al. Disaster psychiatry: principles and practice.


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Those with a history of exposure to other Those with a history of exposure to other traumas or with recent or subsequent major traumas or with recent or subsequent major life stressors or emotional strain life stressors or emotional strain

Chronic poverty, homelessness, Chronic poverty, homelessness,

unemployment, or discriminationunemployment, or discrimination

Those with chronic medical or Those with chronic medical or

psychological disorderspsychological disorders

Those with a history of exposure to other Those with a history of exposure to other traumas or with recent or subsequent major traumas or with recent or subsequent major life stressors or emotional strain life stressors or emotional strain

Chronic poverty, homelessness, Chronic poverty, homelessness,

unemployment, or discriminationunemployment, or discrimination

Those with chronic medical or Those with chronic medical or

psychological disorderspsychological disorders

Source:ACOEM Disaster Preparedness web site


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Stress Management for Stress Management for Public Health WorkersPublic Health Workers

Stress Management for Stress Management for Public Health WorkersPublic Health Workers

Take care of yourself: Take care of yourself: Get sufficient sleep Get sufficient sleep Eat regular mealsEat regular meals Keep caffeine and alcohol consumption Keep caffeine and alcohol consumption

moderatemoderate Talk through your feelings with a safe Talk through your feelings with a safe

confidant confidant Family memberFamily member Mental health or other health care provider Mental health or other health care provider

Seek help when feelings overwhelm or Seek help when feelings overwhelm or interfere with your ability to function interfere with your ability to function

Take care of yourself: Take care of yourself: Get sufficient sleep Get sufficient sleep Eat regular mealsEat regular meals Keep caffeine and alcohol consumption Keep caffeine and alcohol consumption

moderatemoderate Talk through your feelings with a safe Talk through your feelings with a safe

confidant confidant Family memberFamily member Mental health or other health care provider Mental health or other health care provider

Seek help when feelings overwhelm or Seek help when feelings overwhelm or interfere with your ability to function interfere with your ability to function


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Stress Management for Public Health Workers: Stress Management for Public Health Workers: Advice for ManagementAdvice for Management

Stress Management for Public Health Workers: Stress Management for Public Health Workers: Advice for ManagementAdvice for Management

Complements can serve as powerful Complements can serve as powerful motivators and stress monitors.motivators and stress monitors.

Ensure regular breaks from tending to duties.Ensure regular breaks from tending to duties. Establish a place for workers to talk and Establish a place for workers to talk and

receive support from colleagues.receive support from colleagues. Encourage contact with loved ones, as well Encourage contact with loved ones, as well

as relaxing activities. as relaxing activities.

Hold department meetings to keep people Hold department meetings to keep people informed of plans and events.informed of plans and events.

Complements can serve as powerful Complements can serve as powerful motivators and stress monitors.motivators and stress monitors.

Ensure regular breaks from tending to duties.Ensure regular breaks from tending to duties. Establish a place for workers to talk and Establish a place for workers to talk and

receive support from colleagues.receive support from colleagues. Encourage contact with loved ones, as well Encourage contact with loved ones, as well

as relaxing activities. as relaxing activities.

Hold department meetings to keep people Hold department meetings to keep people informed of plans and events.informed of plans and events.

Modified from: Center for Traumatic Stress, Uniformed Services University of the Health Sciences, American Psychiatric Association


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Summary of Key Points Summary of Key Points Summary of Key Points Summary of Key Points

The initial and primary response to the The initial and primary response to the consequences of a terrorist event occurs at the consequences of a terrorist event occurs at the local level. local level.

ESF 8 provides for federal assistance to ESF 8 provides for federal assistance to supplement state and local efforts in response supplement state and local efforts in response to a public health emergency.to a public health emergency.

Medical, practical, and feasibility considerations Medical, practical, and feasibility considerations are important in the decision to implement are important in the decision to implement quarantine.quarantine.

The initial and primary response to the The initial and primary response to the consequences of a terrorist event occurs at the consequences of a terrorist event occurs at the local level. local level.

ESF 8 provides for federal assistance to ESF 8 provides for federal assistance to supplement state and local efforts in response supplement state and local efforts in response to a public health emergency.to a public health emergency.

Medical, practical, and feasibility considerations Medical, practical, and feasibility considerations are important in the decision to implement are important in the decision to implement quarantine.quarantine.


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Summary of Key PointsSummary of Key PointsSummary of Key PointsSummary of Key Points

Individual, community, and event-specific Individual, community, and event-specific factors influence the psychological response to factors influence the psychological response to a public health emergency.a public health emergency.

Most individuals will function adequately Most individuals will function adequately following a traumatic event, but a few will need following a traumatic event, but a few will need psychological or medical intervention. psychological or medical intervention.

Many emotional reactions of disaster survivors Many emotional reactions of disaster survivors stem from livingstem from living problemsproblems brought about by brought about by the disaster.the disaster.

Individual, community, and event-specific Individual, community, and event-specific factors influence the psychological response to factors influence the psychological response to a public health emergency.a public health emergency.

Most individuals will function adequately Most individuals will function adequately following a traumatic event, but a few will need following a traumatic event, but a few will need psychological or medical intervention. psychological or medical intervention.

Many emotional reactions of disaster survivors Many emotional reactions of disaster survivors stem from livingstem from living problemsproblems brought about by brought about by the disaster.the disaster.


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Summary of Key PointsSummary of Key PointsSummary of Key PointsSummary of Key Points

Anxiety responses are most likely following a Anxiety responses are most likely following a biological attack, but depression, physical biological attack, but depression, physical symptoms, and substance use may also occur.symptoms, and substance use may also occur.

Anxiety responses are most likely following a Anxiety responses are most likely following a biological attack, but depression, physical biological attack, but depression, physical symptoms, and substance use may also occur.symptoms, and substance use may also occur.


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Resources Resources Resources Resources

Centers for Disease Control and PreventionCenters for Disease Control and Prevention

Barbera J, et al. Large-scale quarantine Barbera J, et al. Large-scale quarantine following biological terrorism in the United following biological terrorism in the United States. States.

Centers for Disease Control and PreventionCenters for Disease Control and Prevention

Barbera J, et al. Large-scale quarantine Barbera J, et al. Large-scale quarantine following biological terrorism in the United following biological terrorism in the United States. States.

http://www.bt.cdc.gov

JAMA. 2001;286:2711-2717


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ResourcesResourcesResourcesResources

American Psychiatric Association American Psychiatric Association

-- info on disaster psychiatry-- info on disaster psychiatry Federal Emergency Management Agency Federal Emergency Management Agency

DHHS/SAMHSA - disaster mental health info and links to publications

American Psychiatric Association American Psychiatric Association

-- info on disaster psychiatry-- info on disaster psychiatry Federal Emergency Management Agency Federal Emergency Management Agency

DHHS/SAMHSA - disaster mental health info and links to publications

http://www.psych.org

http://www.mentalhealth.org/cmhs/EmergencyServices/

http://www.fema.gov

preparing for and responding to bioterrorism: information for the public health workforce

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