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May 2, 2006

San Mateo County Health Department Pandemic Influenza Plan

Table of Contents

I. Introduction Overview The Need for Planning Purpose Pandemic Planning Assumptions Plan Maintenance Acknowledgements II. Concept of Operations Rationale Goals Overview Participating Agencies and Response Roles Planning and Response Phases Pandemic Phase Matrix III. Continuity of Government and Business Rationale Goals Overview Specific Communication Strategies IV. Surveillance Outpatient Surveillance CMR/AVSS Nurses’ Database Sentinel Provider Network/Flu Surveillance Syndromic Surveillance Emergency Department Surveillance ED Census First Watch

Hospital Surveillance Hospital/Infection Control Site Visit CMR/AVSS ED Census Nurses’ Database Syndromic Surveillance Mortality Surveillance CMR/AVSS Nurses’ Database Pediatric Death Reporting

San Mateo County Pandemic Influenza Plan 1

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122 Cities Death Reporting Community Surveillance School Absenteeism Outbreak Reporting Pharmaceutical/Over-the-Counter Medication Sales Laboratory Staff Surveillance Veterinary Surveillance CD/DCP Unit Communications Airport-Based Surveillance Appendix 1: Ed Census Appendix 2: First Watch Appendix 3: 122 City Death Reporting Appendix 4: School Absenteeism Appendix 5: National Retail Data Monitor Appendix 6: Veterinary Surveillance V. Laboratory Diagnostics Interpandemic and Pandemic Alert Periods Role of Public Health Laboratory Pandemic Period Role of Public Health Laboratory Rationale Overview Laboratory Testing for Novel Influenza Subtypes Testing for Human Cases of Avian Influenza Recommendations on Laboratory Testing for Human Cases of Avian Influenza Testing for Human Influenza Strains with Pandemic Potential Recommendations for the Pandemic Period Use of Diagnostic Assays During an Influenza Pandemic Virus Isolation RT-PCR Subtyping Status of San Mateo County Public Health Laboratory Appendix 1: Influenza Diagnostic Assays Appendix 2: Reference Testing Guidelines for Potential Pandemic Strains of Influenza Appendix 3: Laboratory Biosafety Guidelines for Handling and Processing Specimens or Isolates of Novel Influenza Strains Appendix 4: Guidelines for Collecting and Shipping Specimens for Influenza Diagnostics VI. Healthcare Planning

Overview Essential Hospital Surge Strategies


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Alert Levels Trigger for the Standardized Emergency Management System/National Incident Management System Element 1. Staffing — “Umbrella Plan” Considerations Strategies Element 2. Bed Capacity Considerations Strategies Element 3. Consumable and Durable Supplies Considerations Element 4. Continuation of Essential Medical Services VII. Infection Control Strategies VIII. Clinical Guidelines and the Role of Public Health

Rationale Overview Summary of Public Health Roles

Interpandemic and Pandemic Alert Periods Pandemic Periods

Clinical Guidelines for the Interpandemic and Pandemic Alert Periods Clinical Guidelines for the Pandemic Period

Appendix 1: Clinical Presentation and Complications to Seasonal Influenza Appendix 2: Clinical Presentation and Complications of Illnesses Associated with Avian Influenza A (H5N1) and Previous Pandemic Influenza Viruses Appendix 3: Guidelines for Management of Community-Acquired Pneumonia, Including Post-Influenza Community-Acquired Pneumonia IX. Vaccine and Antiviral Distribution and Use Purpose Overview Health Department Organization During Mass Prophylaxis

NETVAC ICS Structure NETVAC Patient Flow Chart NETVAC Position Description Job Action Checklist: Operations Section Chief Job Action Checklist: NETVAC Zone Director Job Action Checklist: NETVAC Area Supervisor Job Action Checklist: NETCVAC Unit Leader Job Action Checklist: NETVAC Administrative Assistant Job Action Checklist: Facility Liaison Job Action Checklist: Mental Health Specialist Job Action Checklist: NETVAC Logistics Lead Job Action Checklist: NETVAC Generic Function


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Personnel Phone Tree Physical Requirements and Logistical Considerations NETVAC Sites Enteric Go Kit Contents Respiratory Go Kit Contents Minimal Clinic Equipment/Supplies Children’s Antiviral Medication Dosages Assumptions to Set Up a NETVAC X. Community Disease Control and Prevention—Legal Aspects Introduction General Authority of the Health Officer Health Officer Defined Sources of Health Officer Authority Health Officer Authority to Investigate and Report Disease Health Officer Authority to Prevent and Control Communicable Disease

Health Officer’s Jurisdictional Territory and Enforcement of Health Officer Orders Health Officer Powers, Duties and Responsibilities are Circumscribed by Constitutional Limitations

Health Officer Authority to Declare a Local Emergency Constitutional Parameters impacting the Authority of the Health Officer

Protecting Public Health is an Exercise of Police Power Health Officer Actions Must Be Consistent with Constitutional Requirements Other Constitutional Considerations

Enforcement of Health Officer Authority The Authority to Enforce Health Officer Orders Derives from the Statutory

Duties and Powers of the Health Officer Enforcement of Health Officer Orders Must Meet Constitutional Due

Process Requirements Preliminary Steps to Enforcement Enforcement Methods in the Event of Non-Compliance with Health Officer

Orders Enforcement of Court Orders Preparedness Points Interjurisdictional Coordination and Cooperation State Department of Health Services United States Public Health Service Director of Centers for Disease Control and Prevention Health Officer Jurisdiction within Federal Enclaves Law Enforcement Other Local Jurisdictions Native American Tribes University of California Facilities Preparedness Pointers


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Confidentiality of Health Information The Release of Patient Information is Restricted by Both Federal and

California Law Using Health Information for Public Health Activities Responding to Public Records Requests Media Resources and Management Releasing General Non-Medical Information to the Media Release of Patient Health Information to the Media Preparedness Points Limiting the Movement of Individuals and Groups Isolation and Quarantine in Non-Tuberculosis Context Temporary Closures of Public Gatherings Evacuation Curfews Preparedness Points Involuntary Investigation, Examination, Decontamination, Treatment, and

Vaccination Involuntary Investigation, Examination, and Diagnostic Testing Involuntary Decontamination, Disinfection, and Treatment Vaccination and Immunization Preparedness Points Inspection, Seizure, Decontamination, Disinfection, and Destruction of Real and

Personal Property Inspection and Seizure Decontamination, Disinfection, and Destruction Owner Compensation Rationing of Resources Authority for Health Officers to Order Rationing Content of Rationing Orders Preparedness Points Commandeering Commandeering Real or personal Property Authority to Commandeer Real or Personal Property Content of Commandeering Orders Preparedness Points Conscription Conscription Authority to Conscript Preparedness Points Table of Authorities XI. Travel-Related Risk of Disease Transmission XII. Public Health Communication Influenza Pandemic Preparedness Activities


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Interpandemic and Pandemic Alert Periods Pandemic Period

Messages and Audience XIII. Psychosocial Workforce Support Services Rationale Responsibilities in Workforce Support Interpandemic and Pandemic Alert Periods Institutionalizing Psychosocial Support Services Preparing Workforce Support Materials Developing Workforce Resilience Programs Pandemic Period Delivering Psychosocial Support Services Services for Families Implementing Workforce Resilience Programs Appendix 1: San Mateo County Mental Health Interventions in Flu Pandemic XIV. Coroner’s Office Rationale Goals Overview Mitigation of Surge Investigation Storage Transportation Equipment Statistics and Reporting Safety


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Overview The San Mateo County Health Department has overall responsibility for protecting the population of the county on a day-to-day basis and in a public health emergency—either natural or human-made. Since 2001, several events have changed the focus of public health and the need for emergency preparedness and response planning: bioterrorism and the intentional release of anthrax, emerging infections such as SARS, natural disasters, and the real threat of pandemic influenza. An influenza pandemic has the potential to cause more death and illness than any other public health threat. The “Spanish Flu” of 1918, considered to be one of the worst natural disasters of modern times, caused 20 million deaths worldwide, including over 500,000 in the United States. If a pandemic influenza virus with similar virulence to the 1918 strain emerged today, in the absence of intervention, it is estimated that 1.9 million Americans could die and almost 10 million could be hospitalized over the course of the pandemic—which may evolve over a year or more. Although the timing, nature, and severity of the next pandemic cannot be predicted with any certainty, preparedness planning is imperative to lessen the impact.1 Influenza is a highly contagious viral disease. People may be immune to some strains of the influenza virus either because they have had a particular strain of influenza in the past or because they have recently received an influenza vaccine. Sometimes the influenza virus changes so dramatically that no one has previous immunity and the vaccine available does not protect against it. This can 1 November 2005, U.S. Department of Health and Human Services Pandemic Influenza Plan, Executive Summary.

I. INTRODUCTION


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result in an influenza pandemic with serious health consequences for the population. An influenza pandemic occurs when a new influenza virus subtype appears, against which no one is immune. This may result in several simultaneous epidemics worldwide with high numbers of cases and deaths. With the increase in global transport and urbanization, epidemics caused by the new influenza virus are likely to occur rapidly around the world. The Centers for Disease Control and Prevention has developed estimates of the impact pandemic influenza can have on a population. The following table applies these estimates to the population of California and San Mateo County to quantify the impact pandemic influenza may have.

CDC Estimates of Percent of Population Affected by the Next

Pandemic (Avian Flu Rates)

Rate

California

San Mateo

County Population 33,000,000 750,000 Influenza Infection Rate 35% 11,550,000 262,500 Patients Requiring Hospitalization 3.8% 440,000 10,000 Mortality Rate 50% 220,000 5,000

The Need for Planning As a result of the widespread emergence and spread of the H5N1 virus among birds, public health experts are escalating and intensifying their pandemic preparedness planning. Uncertainty about the magnitude of the next pandemic mandates planning for a severe pandemic influenza occurrence. Adequate planning for a pandemic also requires the involvement of every level of our nation and indeed, the world. The ubiquitous nature of an influenza pandemic compels governments, communities, schools, businesses, families, and individuals to learn about, prepare for, and collaborate in efforts to slow, respond to, mitigate, and recover from a potential pandemic. The development, refinement, and exercise of a pandemic influenza plan by all stakeholders are critical components of preparedness. Purpose The purpose of this plan is to direct and coordinate actions by the San Mateo County Health Department and other county partners in preparing for and responding to pandemic Influenza. The plan serves as a blue print for all pandemic influenza preparedness planning and response activities within the county. While it is new, the plan incorporates several existing Department


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influenza response elements; e.g., mass vaccination, and is consistent with the November 2005 Federal Health and Human Services Pandemic Influenza Plan. The plan describes the emergency management concepts and structures under which the county will operate and the roles and responsibilities of the county government staff. The pandemic influenza plan should be thoroughly understood by relevant county personnel prior to its use. Pandemic Planning Assumptions Some of the characteristics of an influenza pandemic that were considered in this plan include:

• The ability of the virus to spread rapidly worldwide; • The fact that people may be asymptomatic while infectious; • Simultaneous or near-simultaneous outbreaks in communities across the

country, thereby limiting the ability of any jurisdiction to provide support and assistance to other areas;

• Enormous demands on the healthcare system; • Delays and shortages in the availability of vaccines and antiviral drugs; • Potential disruption of national and community infrastructure including

transportation, commerce, utilities, and public safety to widespread illness and death among workers and their families and concern about ongoing exposure to the virus.2

Plan Maintenance Because all plans should remain living documents, they should be updated periodically in the time before, during, and after a pandemic. They should also be exercised to identify weaknesses and promote effective implementation.3 This plan will be updated periodically to reflect new developments in the future understanding of the influenza virus, its spread, prevention, and treatment. The plan will also incorporate changes in response roles and improvements in response capability developed through ongoing planning efforts. Acknowledgements The development of the Pandemic Influenza Plan included the following partners: Hospital Consortium of San Mateo County, Sheriff’s Department, Office of Emergency Services, County Manager, Coroner’s Office, Infectious Disease Medical Community, County Counsel, and the staff of the Health Department.

2 November 2005 U.S. Department of Health and Human Services Pandemic Influenza Plan, Executive Summary. 3 November 2005 U.S. Department Health and Human Services Pandemic Influenza Plan, Preface.


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II. CONCEPT OF OPERATIONS

Rationale This section defines the phases of a pandemic influenza outbreak, what organizations are to respond and their duties and responsibilities, how communications will be maintained, and the command structure. Goals

• Introduce and emphasize the operating principle of “self-sufficiency” into planning efforts.

• Assist the general public in becoming more self-sufficient. • Ensure cross-departmental coordination in the planning for and

responding to an outbreak of pandemic influenza. • Ensure all involved departments know their roles and responsibilities. • Outline the command structure in accordance with SEMS/NIMS. • Provide a plan for cities to coordinate their response with that of San

Mateo County’s. • Ensure the San Mateo County does not progress from Red to Black in the

color-coded response scheme. • If San Mateo County does progress to Black, ensure the majority of

residents are able to care for themselves. Overview Most scientists believe it is a question of when, not if, the next pandemic will occur. After the “Spanish Flu” of 1918-19, 1957 and 1968 marked two more pandemics, killing 90,000 and 34,000 people in the U.S., respectively. During inter-pandemic years, influenza kills approximately 20,000 people in the U.S. annually, including 200 in California. Widespread illness throughout the county and state poses not only severe health risks, it is a major threat to the human


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infrastructure staffing critical facilities and can have severe economic and social consequences. Experts believe that in the U.S. alone, an influenza pandemic could cause as many as 207,000 deaths and have an economic impact of up to $166 billion in losses, not including disruptions to commerce. The timeframe for a pandemic outbreak could range from several months to more than a year. The pandemic is likely to occur as several “waves” of waxing and waning infections. An effective vaccine may take up to six months to create, produce, and distribute. This Pandemic Influenza Response Plan outlines the local disease containment strategies that must be in place and prepared to deploy. Participating Agencies and Response Roles Covered by This CONOPS plan Public Health Department Division (PHD): Prepare and activate countywide Pandemic Influenza Response Plan. Communicate with local, state, and federal partners, and oversee public health response activities. Emergency Medical Services (EMS): Facilitate and coordinate planning activities and response efforts of the hospital community and the first responder community. Epidemiology Unit (EU): Plan for and implement new and existing methods of community surveillance through data gathering and interpretation. Surveillance may include, but is not limited to, sentinel schools, clinics, hotels, day care/pre-schools, skilled nursing facilities, and coordination with San Francisco International Airport agencies. Tools used may include geographical and demographical mapping, statistical inference, and others. Public Health Laboratory (PHL): Work with federal or state partners to enhance laboratory-based monitoring of seasonal influenza virus subtypes. Conduct testing for novel subtypes of influenza viruses when BSL-3 biocontainment conditions with enhancements are available. Institute surveillance for ILI among laboratory personnel. Coordinate and communicate with clinical laboratories regarding procedures, specimen gathering and transportation, and novel strain identification. Office of Emergency Services (OES): Activates/operates the County Emergency Operations Center (EOC), coordinates responding agencies, ensures availability of adequate resources, and requests additional outside resources in the event of a major disaster within the Operational Area. Sheriff’s Department (Sheriff): Coordinates law enforcement resources. Coordinates force protection for involved agencies and facilities. Coroner’s Office (Coroner): Plan for and scale up to a surge in county morbidity rate. Secure additional personnel and equipment resources.


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Coordinate with local funeral homes and mortuaries to ensure plans are in place and mutual aid is agreed upon. Public Information Officer (PIO): Inform the public and media about the state of emergency, mitigation steps, locations, and procedures for receiving vaccinations and/or anti-viral medications. Mental Health (MH): Provide psychosocial support to employees as they respond to and work within the stressful environment of an outbreak of pandemic influenza. Planning Assumptions

• A pandemic influenza outbreak event can be divided into the four local phases listed below. Actions should be based on these four local phases.

• The Health Officer determines the phase in response to local conditions in San Mateo County.

o It is difficult to determine actual trigger events prior to an actual pandemic because triggers will need to be based on the level of preparedness, the unique characteristics of the pandemic virus (lethality, ease of transmission), and the availability of counter-measures (i.e., vaccine, antivirals) among other considerations. Triggers will be related to real-time determinations of how the pandemic is progressing locally. A change in phase will be communicated widely.

• Public Health should be focusing on containment o Social distancing (keeping people apart) is a key strategy in

preventing transmission. • Organizations should be focusing on continuity of operations

o Organizations should anticipate on absenteeism rates exceeding 50% in key personnel.

o Organizations should anticipate that essential supplies, not already on hand, will not be available.

• The timeframe for a pandemic outbreak could range from several months to more than a year.

Phases of Pandemic Flu in San Mateo County

1. Green-little or no transmission 2. Yellow-limited to moderate transmission 3. Red-extensive transmission 4. Black-uncontrolled transmission and uncontrollable transmission


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Pandemic Phase Matrix

Phase Agency/Organization Action

Green-little or no human transmission

All Agencies and Organizations (Local government, Businesses, Schools, Hospitals)

• Preparation phase represented by: • Review and update existing plans and

procedures • Ensure essential services are identified • Ensure essential supplies necessary to

provide essential services are available (stockpile)

• Identify how essential services will be delivered with when there are shortages of key personnel and essential supplies

PHD • Monitor status worldwide • Monitor status locally • Establish 24/7 capability • Assist other agencies and organizations in

preparedness activities • Develop communication mechanisms with

partners • Regularly update partners about situation • Assist general public to become self-

sufficient • Establish close working relationship with

SFO and neighboring counties • Train staff on SEMS and their role in an

emergency • Issue PPE to selected staff

EU • Expand surveillance by utilizing existing data gathering and integration tools and explore new technology and techniques

• Establish baselines by geography and community

• Establish 24/7 capability • Cross train staff on epi investigation and

analysis


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PHL • Establish 24/7 capability • Upgrade lab’s technological capability

emphasizing molecular lab techniques to identify pandemic strain

• Pursue upgrade of PHL to level B • Ensure staff are trained in the collection,

handling, and transportation of specimens • Issue PPE to all personnel • Ensure specimen collection and shipping

materials are available OES • Evaluate and test EOC equipment

• Develop EOC staffing patterns • Design and exercise drills

EMS • Ensure staff is familiar with plan and notification process

• Coordinate hospital planning process • Facilitate planning between hospitals and

emergency responders • Identify NETVAC responders from

emergency responders list Sheriff • Support OES in planning efforts

• Participate in exercises Coroner • Prepare procedural plans

• Estimate staffing • Determine storage capacity and alternative

sites • Establish MOUs with alternative storage

sites • Pre-order body bags

Mental Health • Ensure plans exist for providing psychosocial support for responders


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PIO • Establish phased communications strategy for pandemic influenza

• Plan and test capacity for meeting expected information demands for diverse audiences

• Establish networks among key response stakeholders, including risk communications, non-health government departments, and professional and technical groups

• Familiarize news media with plans, preparedness activities, and decision-making related to seasonal and pandemic influenza

• Identify target groups for delivery of key messages; develop appropriate materials, formats, and language options

• Work with partners, especially fellow PIOs, to ensure consistent messages are delivered

• Review and update information materials for news media, general public, health workers, and policy makers

• Review communications systems and facilities to ensure that they are functioning optimally, and that contact lists are up-to-date

Yellow-limited to moderate human transmission

All Agencies • Cooperate with PHD instructions • Implement phase yellow actions as needed

to continue essential operations • Prepare to perform essential services only • Increase use of telecommuting and social

distancing strategies • Deploy PPE (masks) to assigned personnel • Ensure staff understand self-protection

strategies


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PHD • Communicate change in status to all partners

• Open the DOC, meet at least one time per day

• Implement phased public health legal strategies-Individually based isolation/quarantine orders, selected school and business closures, limitation of public gatherings

• Encourage use of surgical masks, basic respiratory hygiene strategies, and social distancing

• Continue to monitor status locally and worldwide

• Provide weekly to biweekly updates to partners about situation

• Begin distribution of vaccine/antivirals according to availability. This may include limited opening of NETVACs

• Increase surveillance at SFO • Directly place a staff member at SFO

operations EU • Expand surveillance to include additional

indicators such as school, institutions, and business absenteeism or infection rates

• Begin monitoring hospital bed capacity • Update DSAT twice daily • Provide HO detailed daily information on

transmission characteristics locally • Coordinate with regional jurisdictions

PHL • Increase throughput of influenza specimens by suspending lower priority testing

• Monitor and implement WHO and/or HHS guidelines for specimen handling

OES • Open the ECC • Consult with HO • Facilitate delivery of supplies to NETVACs

and RSS EMS • Facilitate communication between hospitals

and emergency responders and the ECC and the DOC

• Ensure hospital plans are in place • Facilitate data gathering and reporting to EU


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Sheriff • Assist with law enforcement support for public health orders

• Assist city police in supporting public health orders

• Support the EOC • Provide security at RSS • Coordinate security at NETVACs

Coroner • Test procedural plans • Ensure availability alternative storage sites • Store body bags and update plan with

location and procedures for retrieval Mental Health • Provide support to responders PIO • Provide detailed communication to the

general public, through the media, on actions that they should be taking.

• Encourage use of surgical masks, basic respiratory hygiene messages, and social distancing

• Coordinate with fellow PIOs • Keep news media, public, professional

partners and other stakeholders informed about progress of pandemic in affected areas; prepare audiences for imminent onset of severe pandemic activity.

• Utilize last “window of opportunity” to refine communications strategies and systems in anticipation of imminent pandemic

• Inform public about interventions that may be modified or implemented during a pandemic; e.g., prioritization of healthcare services and supplies, travel restrictions, shortages of basic commodities, etc.

Red extensive human transmission

All Agencies • Perform essential services only • Follow PHD guidance • Maximize telecommuting option • Deploy PPE to assigned personnel • Respond to NETVACs or RSS as requested • Ensure staff understand self-protection

strategies


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PHD • Communicate change in status to all partners

• Staff the DOC 24/7 • Continue to monitor status locally and

worldwide • Provide daily updates to partners about

situation • Augment use of public health legal

strategies-Individually and geographically based isolation/quarantine orders, extensive school and business closures, discontinue all public gatherings

• Encourage use of surgical masks, basic respiratory hygiene strategies, and social distancing

• Issue PPE to all personnel • Through PIO, communicate reason and

importance of public health interventions to partners and the general public

• Open NETVACs to distribute vaccine/antivirals according to availability and priority scheme.

• Interact with SFO as needed EU • Continue expanded surveillance

• Continue monitoring hospital bed capacity in conjunction with EMS

• Provide HO continuous and detailed information on transmission characteristics locally

• Coordinate with regional jurisdictions PHL • Focus all lab efforts on the needs of the

DOC to control transmission • Monitor and implement WHO and/or HHS

guidelines for specimen handling OES • Open the EOC

• Manage EOC and expand as situation requires (open to Level 3)

• Anticipate civil unrest and forward deploy resources

• Consult with HO • Prepare cities for crisis; ensure NETVAC

sites are available • Facilitate delivery of supplies to NETVACs

and RSS


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EMS • Provide staff for EOC • Facilitate communication between the EOC

and the DOC • Facilitate communication between hospitals

and the DOC Sheriff • Assist with law enforcement support for

public health orders • Assist city police in supporting public health

orders • Support the EOC • Work with local agencies to ensure traffic

control and security at NETVACs • Provide security at RSS • Consider mass OR jail release • Limit contacts at jails

Coroner • Estimate staffing with latest estimated mortality rates

• Confirm vendor for storage • Monitor coroner issues in responding

jurisdictions • Ensure source for stretchers; prepare for

surge Mental Health • Provide support to responders PIO • Keep news media, public, professional

partners and other stakeholders informed about progress of pandemic in affected areas

• Redefine key messages; set reasonable public expectations; emphasize need to comply with public health measures despite their possible limitations.

• Encourage use of surgical masks, basic respiratory hygiene messages, and social distancing

• Continue to inform public about interventions that may be modified or implemented during a pandemic; e.g., prioritization of healthcare services and supplies, travel restrictions, shortages of basic commodities, etc.


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Black- uncontrolled and uncontrollable human transmission

-Minimal, if any, government service. --People are, for the most part, on their own and should not expect any outside assistance.

-Only austere medical care is rendered

All Agencies • Perform essential services, if possible • Follow PHD guidance • Maximize telecommuting option • Ensure staff understand self-protection

strategies PHD • Communicate change in status to all

partners • Staff the DOC 24/7, if possible • Continue to monitor status locally and

worldwide • Provide daily updates to partners about

situation • Maximize use public health legal strategies-

Individually and geographically based isolation/quarantine orders, extensive school and business closures, discontinue all public gatherings, if possible

• Through PIO, communicate message of you’re mostly on your own

EU • Provide surveillance, as possible • Provide HO continuous and detailed

information on transmission characteristics locally

• Coordinate with regional jurisdictions PHL • No activity OES • Keep open the EOC at level 3, if possible

• Anticipate civil unrest and forward deploy resources

• Consult with HO EMS • Provide staff for EOC, if possible

• Facilitate communication between the EOC and the DOC, if possible

• Facilitate communication between hospitals and the DOC, if possible


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Sheriff • Assist with law enforcement support for public health orders and maintaining order

• Consider mass OR jail release • Limit contacts at jails

Coroner • Transport and store bodies en masse • Coordinate response with mortuaries • Implement HO rules regarding disposition

and disposal of bodies Mental Health • Provide support to responders PIO • Communicate lack of outside help available

and that you must take care of yourself • Reinforce and intensify key messages on

prevention of human-to-human spread • Provide instruction in self-protection • Encourage use of surgical masks, basic

respiratory hygiene messages, and social distancing

• Re-emphasize infection-control measures in the community, healthcare settings, and long-term care facilities.

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NETVACUnit Leader

OperationsTeam

PlanningTeam

Logistics(City)Team

FinanceTeam

City Liaison

TransportationInventorySafetySecurityFacilitiesCommunicationsPersonnelTrainingTraffic

Vaccine Administration


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III. CONTINUITY OF GOVERNMENT AND BUSINESS

Rationale During a pandemic it is necessary to continue to provide local government services, even though employees may not be able to report to their place of work. Continuity of government will require coordination activities as well as the ability for County staff to work and communicate with other County staff from home.

Goals The goal is to ensure operations of County government by providing a communications strategy to coordinate activities and to provide a near-immediate ability for County employees to work remotely, most likely from their own homes.

Overview It is necessary to have adequate capacity to provide services whether at fixed sites or remotely. There may be a need to simultaneously plan to upgrade the capacity to provide services and to then be able to provide that service remotely. When considering a set of communication strategies we chose to have ones that provide sequential alternatives.

Specific Communication Strategies Call Center: Currently there are 28 stations for this critical function of taking calls to inform the public. It has been established that the number of stations should be increased to


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65 and that the call center should be operated remotely. To increase the number of agents to 65 to staff the stations, with the ability to scale up to 105 agents, a new call routing and statistical system will be installed in the Public Health Automated Call Distribution (ACD) Call Center. Additional SBC phone lines will be required to complement the additional stations and telephones in the Call Center. Two additional T1 lines, providing 23 lines each, will be installed, increasing the amount of SBC lines available in the Public Health Call Center to 74. LAN Fax: It is necessary to upgrade the capacity for simultaneous faxing to eight from the current three lines. Five additional phone lines will be installed and the LAN Fax software as well as the hardware platform will be upgraded to accommodate the required eight lines. Remote Access: The goal is that county employees will be able to work while away from the office due to imposed limitations on travel. The county’s current remote access method relies on SBC facilities and the public Internet. In the event of a pandemic, the Department anticipates that SBC facilities will be overly taxed, resulting in unpredictable access to the Internet. In response to the concern about availability, ISD is pursuing a second ISP relationship with Comcast Cable. The plan is to identify 30-50 county staff who members of a Virtual Command Group (VCG) and who must have remote access abilities into the county. These 30-50 County staff would be outfitted with cable modems using static IP addresses and would access the county infrastructure though a secondary Internet connection. In addition, the amount of county staff currently able to access the county infrastructure through SBC facilities would be increased from 300 to 1,000. This increase would be based on “mission critical” positions as identified by county leadership.

Call forwarding: The goal is that county employees will be able to work while away from the office due to imposed limitations on travel. This requires a mechanism to allow employees to answer their work phones from home. ISD is able to forward county extensions to other county extensions (or ACD queues) or to outside lines. This call forwarding can be done by ISD staff and will not require extensions owners to forward their lines. Working from a list of lines to forward compiled by county leadership, ISD will have a system in place to forward county extensions when requested to do so by the county’s Health Officer.


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Media Server on the Internet: The goal is to allow a finite number of sites (about 50) access to training and information with full motion video. To avoid bandwidth competition between remote access users and media server users, the media server will be co-located. The co-location site will be selected based on criteria that includes location, network redundancy, and availability guarantees.

ISD Staff in Health Disaster Worker Roles: The need is to assure that some staff from the Information Services Department be assigned primarily to the Health Department to provide IT assistance in the event of a pandemic. In the next version of the ISD disaster recover plan, due in draft form first quarter 2006, there will be provision that staff report to the San Mateo campus and be available to assist in the set up of the Health Emergency Operations Center. Redundancy in Communication: The need is to assure a backup for voice communications in the event of a failure of traditional telecommunications lines (landlines). In anticipation of unpredictable availability of traditional telephone service, commercially available phone services should be tried in the following order: (1) First try traditional landlines. (2) If landline dial tone is unavailable, next try cell phones. (3) Finally, the VCG should use county-issued microwave radios if they have been made available as these are the most reliable communication modality; however, they are limited in number. It is planned that county microwave radios would be staged and in the possession of VCG members. Satellite phones were once considered a viable option, but the New Orleans experience following Hurricane Katrina indicates that there are capacity-related weaknesses with this method. Moreover, there are a very limited number of satellite phones in San Mateo County.


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IV. SURVEILLANCE

Outpatient Surveillance

During a pandemic, outpatient surveillance data will be needed on a frequent basis to monitor disease severity and determine the most severely affected population groups within San Mateo County (SMC).

The San Mateo County Public Health Department (SMCHD) receives outpatient surveillance data through several mechanisms that are described in this section of the Plan including Confidential Morbidity Reports (CMR), the Automated Vital Statistics Systems (AVSS), the Nurses’ Database, Sentinel Provider Network/Flu Surveillance, Syndromic Surveillance, and Emergency Department Surveillance such as ED Census and FirstWatch.

CMR/AVSS

• Description: The Confidential Morbidity Report (CMR) is mandated by Title 17, California Code of Regulations (CCR), §2500, §2593, §§2641-2643, and §§2800-2812: Reportable Diseases and Conditions. Healthcare providers, laboratories, and schools that have knowledge of a case of one of a list of reportable diseases are required to report this to the health officer at the jurisdiction of the case’s residence. Cases are reported by phone or fax. In addition to the list of reportable diseases for California, several conditions and diseases are reportable in San Mateo County. Influenza is not a reportable disease in California; however, outbreaks of


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any disease are reportable, especially in an institution and/or in the community.

The Automated Vital Statistics System (AVSS) is a statewide automated information system for public health records. Counties routinely enter information on reportable diseases and vital statistics into AVSS. This data is readily accessible to the California Department of Health Services, and subsequently to the Centers for Disease Control and Prevention (CDC).

• Routine Use: CMRs are routinely managed and routed by administrative

staff. Diseases of particular concern or those that require further investigation are routed to public health nurses. If needed, additional case reporting forms are completed, which include demographic information, exposure history, and clinical description. Weekly reports from AVSS are used to summarize disease activity in the county. Outbreaks of influenza should be reported to the health department and entered into AVSS (see Outbreak Reporting). CMR and AVSS data can be analyzed to identify gaps in disease reporting. Relationships with providers and hospitals who report consistently can be reinforced while relationships with those that do not report consistently can be strengthened.

• Enhanced Use: During a pandemic, it is likely that influenza could be

added to the list of reportable diseases. CMRs would be used to monitor and collect data on all cases in the county. Epidemiologic investigation and contact tracing for known cases could be used to identify additional cases.

Nurses’ Database

• Description: The public health nurses in the SMCHD Disease Control and Prevention Unit maintain the Nurses’ Database. This is a database of all communicable disease cases currently under investigation, including cases associated with an outbreak. This database is used to assign cases to investigators, monitor progress, and analyze disease occurrence.

• Routine Use: Public health nurses enter information on cases that need

to be investigated. Entered information includes the source of the report, assigned investigator, dates and times associated with the investigation, and demographic information about the case. Epidemiologists review cases by disease type to identify potential clusters among existing cases. Categories that are examined by epidemiologists include travel history, food history, whether or not the case is in a sensitive occupation or situation, and attendance at large events. Summary reports are generated


May 2, 2006

weekly giving the frequency of reports by disease for the preceding week and month.

• Enhanced Use: During a pandemic, influenza cases and outbreaks that

are identified and under investigation will be entered into the Nurses’ Database. More extensive contact tracing and epidemiologic investigation will be collected to identify additional cases or outbreaks. As case volume increases, summary reports will be generated more frequently and include analyses of patient demographics and timeliness of reporting by providers.

Sentinel Provider Network/Flu Surveillance

• Description: Surveillance for outpatient visits for influenza-like illness (ILI) is conducted via the Sentinel Provider Network (SPN), a collaboration between state health departments, local healthcare providers, and CDC. ILI is defined as a fever >100°F or 37.8°C along with sore throat and/or cough, in the absence of a known cause other than influenza. State health departments recruit and maintain a local network of healthcare providers who have agreed to report the total number of patient visits and number of patients with ILI each week. SPN members may also send specimens from a subset of patients with ILI to the state public health Viral and Rickettsial Diseases Laboratory (VRDL) for diagnostic testing at no cost. CDC develops and maintains reporting materials and systems, serves as a data repository, and provides feedback to the states. Each state is asked to have at least one sentinel provider per 250,000 people. Reporting is year-round.

For local health departments, the SPN: o Serves as an early warning system to increases of ILI in the

community o Tracks trends in influenza activity and identifies populations that are

most severely affected o Monitors the infection’s impact on health

• Routine Use: Based on our population of about 700,000 people and the

desired ratio of one sentinel provider per 250,000 people, SMC has three sentinel providers. As required, these providers report ILI information directly to the state health department. We aid the state in ensuring that sentinel providers in our county report weekly, regardless of the time of year.

• Enhanced Use: The applicability of the SPN to pandemic situations would

occur mostly in the alerting phase. An increase in either the total number of patient visits or number of patients with ILI, especially at a time of year


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with normally low influenza activity, would alert us to closely evaluate similar patterns and indicators in other surveillance systems. We also have direct contact information for the SMC sentinel providers and could request further details from them about the overall increase or specific cases.

Syndromic Surveillance

• Description: SMC is a participant in a multi-site national demonstration project for syndromic surveillance systems. Kaiser Permanente Northern California provides line-listings on clusters of patients that fall into a number of syndrome categories, including respiratory and ILI. These listings are provided when the number and geographic distribution of cases exceeds a certain threshold for alerting. Patients are categorized based on ICD-9 code. If needed, epidemiologists respond to alerts and obtain more detailed clinical information on cases of concern.

• Routine Use: Data from Kaiser Permanente are analyzed daily and alerts

generated as needed. Coordinators for this demonstration project generate the alerts.

• Enhanced Use: In the event of a pandemic, alerts will still be generated

based on the same thresholds. Epidemiologists may change the threshold for identifying cases that may require further investigation. If needed, epidemiologists and disease investigators will contact infectious disease practitioners to identify possible cases of pandemic influenza.

Emergency Department Surveillance (Subset of Outpatient) During a pandemic, emergency department (ED) surveillance data will be needed on a frequent basis in the county to monitor disease severity and determine the most severely affected population groups. The SMCHD receives ED surveillance data through several mechanisms that are described below including ED Census and FirstWatch.

ED Census

• Description: Hospital Allocation Resource Tracking (HART) provides computerized hospital ED status and hospital bed availability status


May 2, 2006

throughout SMC via the Internet. The hospital bed availability status collects patient census information on the following bed types: o Medical/surgical o Critical care/intensive care unit o Pediatric o Obstetrics o Other types (psychiatric, skilled nursing facility, etc.) o ED Daily information on occupied patient beds is reported as the census count of admitted patients by bed type. Each facility enters the number of occupied beds in the ED as well as the facility as a whole. Additionally, the information below is reported individually by bed type for all of the above listed bed types (with the exception of ED beds): o Estimated number of patients the facility can admit at the current time

based on current staffing levels o Estimated number of additional patients the facility can admit within

two hours based on staffing levels Information is entered into the HART system daily at midnight by eight SMC hospitals, two hospitals in Alameda County, and one hospital in San Francisco County. Each hospital also selects their current facility status, which is displayed as a color code on the HART main page. These color codes may indicate that patients should be diverted to another area facility. Facility status options include: o Green = Facility is able to carry out normal operational functions o Yellow = Some reduction in patient services, but overall facility is able

to carry out normal operational functions o Orange = Trauma center use only. Limited trauma services available o Red = Significant reductions in patient services. Emergency services

only being provided o Black = Facility has been severely affected. Unable to continue any

services

When a HART status change is received, it is automatically sent to the Emergency Medical Services dispatchers. Information from the HART system can be obtained from any computer having Internet access, granted the user has a valid username and password (see Appendix 1 – ED Census).

• Routine Use: The Epidemiology Unit uses the HART system to monitor daily hospital patient volume by reviewing the ED census for each facility. ED Census information from six SMC hospitals is entered into a database and graphed. This line graph displays the total ED Census number for the hospitals over the last month with an additional trend line. Information on the previous three-day trend is also graphed (see Appendix 1 – ED


May 2, 2006

Census). Facilities reporting an ED census greater than 20% above their average census are noted. A cumulative ED census for all facilities totaling greater than 500 indicates that area hospitals are experiencing a patient volume that may be stretching their care capacities. When ED census is noted to be greater than 500, the Health Officer is notified.

Enhanced Use: During a pandemic, the Epidemiology Unit will be requesting that area hospitals participating in HART report not only at midnight, but also at noon daily. The Epidemiology Unit will monitor the ED census twice daily and will be able to detect large fluctuations in the ED patient volume.

First Watch • Description: FirstWatch is syndromic surveillance software utilized by

SMCHD to monitor health conditions in the community. FirstWatch imports information from the County’s Public Safety Communications’ computer-aided dispatch (CAD) database at the conclusion of each 911 medical event. The reason for medical calls to 911 are identified and categorized into 64 specific determinants grouped into the following illness condition categories: breathing problems, cardiac or respiratory arrest, chest pain, sick person, or unconscious/fainting episode. The FirstWatch database establishes a baseline of requests by determinant within the same day of the week over the past 52 weeks. The number of calls for that determinant, the ratio of determinant requests to all requests of any type, and the cumulative summary (CUSUM) statistic is calculated for each running 12-hour period. FirstWatch uses tabular, graphic, and spatial data displays to optimize evaluation and analysis of alert information (see Appendix 2 - FirstWatch). When each of these three measures exceeds two and a half standard deviations (2.5 sigma) above the mean for a determinant, an email and/or text page message is sent to various personnel within the Public Health and Emergency Medical Services (EMS) divisions. The Health Officer, EMS Administrator, epidemiologist, or public health nurse then investigates the cause of the alert to determine if an outbreak or other threat is imminent.

• Routine Use: FirstWatch generates email and/or text alert messages

when an illness condition surpasses its threshold. Many SMCHD staff, including the Epidemiology Unit, receive these alerts. The Epidemiology Unit reviews data in the FirstWatch system to determine if an investigation is warranted.

• Enhanced Use: During a pandemic, FirstWatch may be generating more

alert messages in all of the illness condition categories. It will be important for FirstWatch data to be reviewed for each alert to determine if any preventative measures can be targeted to certain geographic or demographic cohorts in the county.


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Hospital Surveillance During a pandemic, hospitalization data will be needed on a frequent basis in the county to monitor disease severity and determine the most severely affected demographic groups. The SMCHD receives surveillance data through several mechanisms that are described below including Confidential Morbidity Reports (CMR), the Automated Vital Statistics System (AVSS), ED Census, the Nurses’ Database, and syndromic surveillance.

Hospital/Infection Control Site Visit • Description: In order to develop relationships and provide mutual

information updates, SMCHD Disease Control and Prevention and the Epidemiology Unit attended meetings with six major hospitals in SMC. Present at these meeting were public health nurses, public health epidemiologists, infection control nurses, infectious disease doctors, quality management personnel, laboratory directors, microbiologists, virologists, and phlebotomists. At these meetings, the SMC Avian Influenza Algorithm was shared and thoroughly reviewed. Procedures for proper specimen collection and transportation of specimens to the SMC Public Health Laboratory (PHL) were also reviewed. Information was collected from each facility on the number of available isolation (negative pressure) rooms, testing protocols for monitoring ventilation in isolation rooms, and availability of respiratory pathogen diagnostic testing in the facility laboratory (i.e., rapid test).

• Routine Use: Not Applicable.

• Enhanced Use: During a pandemic, SMCHD may contact hospital

personnel to collect information on facility patient volume, laboratory results and capabilities, infection control practices, follow-up of suspect cases, employee cases, issuing of isolation orders, and contact investigations.

CMR/AVSS (see Outpatient Surveillance, above)

ED Census (see ED Surveillance, above)

Nurses’ Database (see Outpatient Surveillance, above)

Syndromic Surveillance (see Outpatient Surveillance, above)


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Mortality Surveillance During a pandemic, policy makers and public health officials will likely ask local health departments to provide mortality data to guide decision-making on control and response measures. The collection of mortality data can help health departments monitor the severity of a pandemic and determine which subgroups of the population (e.g., age, region, occupation) are most affected.

CMR/AVSS (see Outpatient Surveillance, above)

Nurses’ Database (see Outpatient Surveillance, above

Pediatric Death Reporting

• Description: Information related to pediatric deaths is monitored through the National Notifiable Disease Surveillance System (NNDSS). Participating state health departments (including California) report to CDC all deaths associated with laboratory-confirmed influenza among children younger than 18 years old. CDC receives electronic, patient-level data on each of these deaths.

• Routine Use: Although county health departments are not directly

involved in the transmission of this information, we receive summaries of the information each week via the CD Brief – an electronic bulletin distributed by the California Department of Health and Human Services.

• Enhanced Use: During a pandemic, we would monitor pediatric deaths

more closely. We would also work with county vital statistics to notify us, in addition to the state, when they receive a pediatric death report. This would alert us to individual events more quickly. At this point, we would also assess key epidemiologic characteristics for each case (e.g., demographics, symptoms, region of the county) and potentially initiate follow-up to look for contacts of the deceased.

122 Cities Death Reporting

• Description: Through the 122 Cities Mortality Reporting System, municipal vital records offices in 122 cities transmit weekly data to CDC on the total number of death certificates filed, as well as the number of deaths with pneumonia and/or influenza (P&I) listed anywhere on the death


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certificate. Reporting is done by age group and throughout the year. Although no San Mateo County cities are included, the 122 cities cover between one-fourth and one-third of the U.S. population. Bay area cities included in this system are Berkeley, Fresno, Sacramento, San Francisco, San Jose, and Santa Cruz (for a complete list and further information, see http://www.cdc.gov/epo/dphsi/121hist.htm). The average lag from death to report to CDC is 15 days, thus providing a more timely assessment of influenza deaths than mortality statistics collected by the National Center for Health Statistics (NCHS).

Once reported to the CDC, weekly mortality data from the 122 cities are compared to a seasonal baseline calculated using a robust regression procedure run on the previous five years of data. If the proportion of P&I deaths for a given week exceeds the baseline value for that week by a statistically significant amount, P&I deaths are said to be above the epidemic threshold. Data can be analyzed by age group and geographic region, but interpretation of the data require the development of a separate baseline for each data subset.

• Daily Use: Each week, the reports received through the 122 Cities

Mortality Reporting System are published as Table 3: Notifiable Diseases/Deaths in Selected Cities Weekly Information, of the CDC’s Morbidity and Mortality Weekly Report (MMWR). This is available online at http://www.cdc.gov/mmwr/weekcvol.html. An example is attached (Appendix 3 - 122 City Death Reports Table).

• Enhanced Use: In a pandemic situation, we will regularly monitor the

“Pneumonia and Influenza Total” (last column of the table) for the Pacific Region in order to be updated on regional trends and age groups most affected.

Community Surveillance Because influenza is not a reportable disease and because most individuals who are infected with influenza may not seek medical care or have diagnostic testing performed, other community-level surveillance activities are crucial. During a pandemic, data on the impact of influenza in a community may provide an earlier indication of virus activity. SMCHD receives data for school absenteeism, outbreaks, pharmaceutical and over-the-counter drug sales, laboratory staff illness, and surveillance for zoonotic diseases. To provide for broader Bay Area regional information, surveillance items are discussed and exchanged within the SMCHD CD Unit and with neighboring counties.


http://www.cdc.gov/epo/dphsi/121hist.htm

http://www.cdc.gov/mmwr/weekcvol.html

May 2, 2006

School Absenteeism

• Description: Because younger children are often disproportionately affected by influenza early in an outbreak, monitoring rates of absenteeism in schools, especially elementary schools, can help detect influenza activity more quickly than ED census numbers and influenza case reports.

• Daily Use: Each school day, school districts report the number of students

absent from each of their schools. Using the total number of students enrolled (also provided by the district), absentee rates are computed for each school and graphs are produced for each district. An example is attached (Appendix 4 - School Absenteeism Graph). These graphs are distributed to health officers, CD team, and epidemiologists, as well as incorporated into the Daily Situational Awareness Tool (DSAT). Absenteeism rates are compared to baseline data, calculated from the 2004-2005 rates.

Retrospective data about school absenteeism for the 2004-2005 school year will be provided by the SMC Office of Education. These data will include the number of students in attendance each day for every public school in SMC. Baseline absentee rates will be calculated as the average of absences for periods before and after the influenza season. Variation in baseline attendance will be controlled for based on day of the week, proximity to holidays, parent-teacher conferences, standardized exams, or partial school days.

• Enhanced Use: An absentee rate of 10% has been established in the

literatures as “worrisome” and warranting further investigation. If the absentee rates go above this, we can evaluate other data sources (e.g., ED Census and NRDM) or directly contact the implicated school(s).

Collaborating with each school district through this project also gives us the potential to increase and/or enhance surveillance in a (potential or confirmed) pandemic situation. Schools can be asked to provide additional information about absent students, including demographics, grade level, and specific reasons for absence.

Outbreak Reporting

• Description: The Epidemiology Unit routinely conducts passive surveillance for outbreaks. Reports of potential outbreaks or disease


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clusters are reported to SMCHD by the general public, healthcare providers, schools, community agencies and employers, and congregate settings such as nursing homes, group homes, and correctional facilities. These reports are relayed to the Epidemiology Unit and Disease Control and Prevention for investigation.

• Routine Use: The Epidemiology Unit routinely conducts passive

surveillance for outbreaks.

• Enhanced Use: During a pandemic, information to be collected on cases and contacts of those with ILI during a pandemic period include, but are not limited to, the following: o Demographic information

• Full legal name, date of birth, gender, home address, telephone contact, alternate contact person and their telephone number, race/ethnicity, occupation, employer, country of origin

o Illness onset date and symptomology o Vaccination or antiviral prophylaxis status o Pneumococcal vaccination status o Healthcare provider o Hospitalization status o Pneumonia status and illness outcome o Number of contacts per identified case o Information on each contact:

• Relationship to the case • Nature and time of exposure • Whether the contact was vaccinated or on antiviral prophylaxis • Underlying medical conditions

o Number of contacts (including any in quarantine) that become ill o Number of days between onset of symptoms and reporting to SMCHD

Contact investigations of cases with ILI will be utilized for source and additional case finding. Information collected from contact investigations may be utilized for quarantine and isolation orders. Additionally, the SMCHD may send an alert message to medical providers, schools, and congregate settings requesting reporting to SMCHD of any potential outbreaks or clusters of ILI.

Pharmaceutical/Over-the-Counter Medication Sales

• Description: Pharmaceutical and over-the-counter (OTC) medication sales are monitored through the National Retail Data Monitor (NRDM). Begun in December 2002, the NRDM is a public health surveillance tool that collects and analyzes daily over-the-counter data to rapidly identify


May 2, 2006

disease outbreaks. The NRDM was built by the Real-time Outbreak and Disease Surveillance (RODS) Laboratory at the University of Pittsburgh, in collaboration with the food and drug retail industry, state and local health departments, and CDC.

As of August 2004, there were 12 major food, drug, and mass merchandise chains representing more than 20,000 stores that participate across the nation. Access to the system is through a secure web-based user interface.

The system looks at sales of OTC healthcare products in the following categories: o Antidiarrheal o Baby/child electrolytes o Cold relief pediatric liquid o Cold relief pediatric tablets o Cough/cold o Thermometers

All are analyzed for anomalies indicative of a disease outbreak. The output is available to public health officials via a secure extranet that displays time series charts and maps for public health surveillance. An example is attached (Appendix 5 - NRDM Screen).

• Daily Use: Sales of OTC healthcare products are of great interest to early-

warning surveillance. When people become ill, they often purchase OTC products before visiting a healthcare provider. By analyzing multiple years of market data across many cities and states, researchers have been able to correlate certain disease outbreaks with significant OTC sales increases. In some cases, it is possible to identify an outbreak up to two weeks earlier with OTC sales than by monitoring clinical data.

SMC epidemiologists monitor the NRDM website daily, and a summary is incorporated into the DSAT.

• Enhanced Use: If anything out of the ordinary were observed in the

NRDM, other sources of similar types of information would be checked (e.g., ED Census and school absenteeism) to see if similar trends were being noted. In a pandemic situation, we would also specifically monitor the cough/cold and thermometer categories.


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Laboratory Staff Surveillance

• Description: Surveillance of the SMC PHL personnel ensures that lab workers who are at risk of exposure to influenza-like viruses (including avian influenza A or novel influenza viruses) receive appropriate education, monitoring, evaluation, and treatment.

• Routine Use: Baseline serum samples will be taken in the event that SMC

PHL workers are working with influenza-like viruses. If an occupational exposure to influenza-like viruses occurs, the SMC PHL will notify SMC Disease Control and Prevention. Additionally, the laboratory workers will report any fever or lower respiratory symptoms to their supervisor and/or the PHL Director. Additionally, they will be monitored for early symptoms including: sore throat, rhinorrhea, chills, rigors, myalgia, headache, and diarrhea. Exposed or symptomatic workers will be isolated, counseled about the risk of transmission to others, and considered for oseltamivir prophylaxis.

In the event that a laboratory worker reports symptoms associated with ILI, if they are at work, they will be isolated and asked to give a respiratory specimen for a real time PCR test. In some cases of a symptomatic worker, an oseltamivir prophylaxis will be considered. If they are at home, they should still notify the PHL Director and then seek care at their healthcare provider.

• Enhanced Use: During a pandemic, laboratory workers will continue to be counseled about the risk of occupational exposure to influenza-like viruses and monitored for early symptoms of ILI. Additionally, they will be fit-tested for personal protective equipment such as N-95 masks that they will be required to wear at all times in the PHL.

Again, in the event that a laboratory worker reports symptoms associated with ILI, if they are at work, they will be isolated and given a respiratory specimen for viral culture. In some cases, an oseltamivir prophylaxis will be considered. If they are at home, they should still notify the PHL Director and then seek care at their healthcare provider. If the worker is not sick enough to be admitted to the hospital, they should remain isolated at their home pending results from a viral culture. If they test positive, they should remain home until their symptoms subside and they can resume their normal activities.


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Veterinary Surveillance

• Description: Surveillance of zoonotic diseases is important in the case of animal-to-human transmission. Epidemiologic surveillance includes measures to ensure zoonotic disease events in humans are detected and appropriate infection control measures are implemented to reduce the risk of disease spread.

• Routine Use: Existing communication plans are in place for zoonotic

diseases (see Appendix 6 – Veterinary Surveillance). Human cases of zoonotic diseases are investigated as part of routine communicable disease case investigation. In this case, both the California Department of Health Services (CDHS) Veterinary Public Health Branch and the SMCHD Environmental Health Vector Control Program would provide consultation and support to do animal contact tracing and/or identify other exposed individuals.

For animal cases of zoonotic diseases, the Peninsula Humane Society and local veterinarians communicate directly with the regional veterinarian of the California Department of Food and Agriculture (CDFA). CDFA would be in charge of animal investigations and SMCHD (including the Epidemiology Unit, the Agricultural Commissioner, and the Vector Control Program) is available for support and consultation. In some cases, the Epidemiology Unit communicates with local veterinarians and the Peninsula Humane Society via the Veterinary LanFax and county medical care providers through a physicians’ LanFax. This allows the distribution of outreach materials and public health advisories regarding specific public health threats of zoonotic diseases.

• Enhanced Use: During a pandemic, there would be increased

communication between the Epidemiology Unit and the CDHS Veterinary Public Health Branch, CDFA, and SMCHD’s Environmental Health Vector Control Program. For increased communication with local vets, the Epidemiology Unit would utilize the Veterinary LanFax and medical care provider LanFax to establish an email distribution list.

County hospitals will be asked to submit daily or weekly line listings for recently diagnosed zoonotic diseases that are potentially related to ILI. Additionally, the Peninsula Humane Society, commercial veterinary testing labs, and the CDFA may also be asked to submit line listings for zoonotic cases with the potential of animal-to-human transmission.


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CD/DCP Unit Communications

• Description: Communication about communicable disease (CD) in the county, including ILI, occurs through the weekly CD team meetings. Regional communication mechanisms include the California Health Alert Network (CAHAN), the Bay Area CD exchange, and the CD Brief.

• Routine Use: The CD team meeting occurs weekly and is attended by

public health nurses, epidemiologists, and infectious disease physicians to discuss current communicable disease activity in the county. This includes a review of current CD case investigations, presentation of unusual cases, and updates on disease-specific surveillance.

CAHAN is a public health alerting system used throughout California by state and local public health practitioners and accessible to SMC public health employees. Employees use their log on and password to access the CAHAN site (http://login.cahan.ca.gov/vaSSOLogin/caLogin.aspx). The site consists of three main features: a directory of other CAHAN users throughout the state, a documents library that allows document sharing among users, and the public health alerts. Users establish an alerts profile that indicates where they prefer to receive alerts based on the alert’s priority (high, medium, and low). Locations include work email and telephone, alternate email and telephone, and pager. The Bay Area CD Exchange is a bi-monthly informal meeting of CD controllers and other CD staff to highlight interesting and unusual cases in Bay Area counties. Notes from each meeting are then circulated to DCP staff. The state’s Infectious Diseases Branch produces the CD Brief weekly based on their weekly staff meetings. The brief is then sent to CD Controllers throughout the state for them to share with staff. Both the Bay Area CD Exchange and CD Brief are informal mechanisms that help facilitate information sharing and communication among public health workers throughout the state.

• Enhanced Use: During enhanced surveillance, neither the Bay Area CD

Exchange nor CD Brief would be the primary mode of communication during periods of enhanced surveillance for ILI. However, the CD team meetings may occur more frequently than one time per week to facilitate increased communication. CAHAN could also be used more in terms of sending more frequent alerts and sharing disease information with other public health workers.


http://login.cahan.ca.gov/vaSSOLogin/caLogin.aspx

May 2, 2006

Airport-Based Surveillance

• Description: San Francisco International Airport’s (SFIA) International Terminal contains both the CDC Quarantine Station and the SFIA Medical Clinic. The station is comprised of three officers whose purpose is to monitor any international passenger who may carry disease. In the event that a passenger is found with a contagious disease, they may be quarantined to prevent the further spread of illness. The CDC Quarantine Station works with each airline, the SFIA Medical Clinic, and the Health Officer on-call for cases of reportable disease. The telephone number for the station is (650) 876-2872. The SFIA Medical Clinic provides onsite medical services for passengers with medical issues, in addition to any passengers the CDC Quarantine Station refers to them. Together with the CDC Quarantine Station, they assess and address disease transmission. The SFIA Medical Clinic is not open in the evening. Any passengers requiring medical assistance are referred to area hospitals. The telephone number for the clinic is (650) 821-5601. A surveillance plan for hotels in the area of SFO is still under discussion.

• Routine Use: Epidemiology has arranged with the CDC Quarantine Station to receive daily quarantine updates. The station produces a daily log of activity that is completed between 5:00-6:00 pm each day. Due to a majority of international flights arriving between 2:00-4:00 pm the update is most relevant after that time period.

In addition to daily contact with the CDC Quarantine Station, the station has been directed to use the after-hours number for the Health Officer on-call, for any events occurring on the weekend or after 5:00pm.

• Enhanced Use: During enhanced surveillance, Public Health would need

to track any quarantined passengers who had cleared Customs. When a passenger has left the Custom’s portion of the International Terminal they are in San Mateo County’s jurisdiction. Quarantine might occur in the CDC Quarantine Station, or in surrounding hospitals or hotels. The OD list would be notified of any quarantine situations, in addition to area physicians through the LanFax if it was deemed necessary.


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Appendix 1: ED Census Below is the screen that opens first upon login to the HART system. The participating facilities and organizations are abbreviated in three-letter acronyms with a facility status color. By selecting a facility, one can view more detailed facility information.


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Detailed view of facility information. By selecting Hospital Bed Availability, one can view more detailed information about the type of occupied beds as well as total facility census and ED census.


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Hospital Bed Availability Form. Data are entered into this form at midnight daily by each of the participating facilities. Data from this form are used by the Epidemiology Unit to monitor daily hospital patient volume (ED Census).


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The Epidemiology Unit using the ED Census reported from six area hospitals produces this graph daily. The total ED Census for all facilities is graphed in dark blue. When the ED Census is greater than 550, the Health Officer is notified as an ED Census greater than 550 indicates a patient volume that may be stretching hospital care capacities.


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Appendix 2: First Watch

Below is the screen that opens first upon login to the FirstWatch system. The illness condition categories are displayed along with real-time data. By selecting an illness condition, one can view more detailed information.


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Detailed view of graphical FirstWatch information displayed by illness condition.


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Detailed tabular FirstWatch information displayed by illness condition.


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Detailed spatial FirstWatch information displayed by illness condition.


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Appendix 3: 122 City Death Reporting Source: MMWR. December 9, 2005. Vol. 54, No. 48 (available at: http://www.cdc.gov/mmwr/weekcvol.html)


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Appendix 4: School Absenteeism

San Mateo County Health DepartmentSchool Absenteeism Tracking Project

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

12/1 12/2 12/5 12/6 12/7 12/8 12/9 12/12 12/13 12/14 12/15 12/16

Date

Belmont-Redwood Shores Elementary School DistrictSt. Matthew's School (San Mateo)Cabrillo Unified School DistrictRavenswood City Elementary School DistrictSo. San FranciscoParkside Elementary


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Appendix 5: National Retail Data Monitor


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Appendix 6: Veterinary Surveillance

Veterinary Surveillance Information Flow: Animal-to-Human Disease Transmission

California Department of Food & Agriculture (CDFA)

Department of Health Services Veterinary Public Health

San Mateo County Health Department (CD Controller on behalf of Health Officer)

Commercial Animal Health Labs/CDFA Lab

Peninsula Humane Society and Local Vets


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Veterinary Surveillance Information Flow: Animal-to-Animal Disease Transmission

California Department of Food & Agriculture (CDFA)

SMC Division of Agriculture, Weights, & Measures

San Mateo County Health Department (CD Controller on behalf of Health Officer)

Commercial Animal Health Labs/CDFA Lab

Peninsula Humane Society and Local Vets


May 2, 2006


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V. LABORATORY DIAGNOSTICS

INTERPANDEMIC AND PANDEMIC ALERT PERIODS Role of the Public Health Laboratory: • Work with federal partners to enhance laboratory-based monitoring of

seasonal influenza virus subtypes. • Conduct testing for novel subtypes of influenza viruses using RT-PCR. • Institute surveillance for ILI among laboratory personnel. • Conduct preparedness planning to support the response to an influenza

pandemic. PANDEMIC PERIOD Role of Public Health Laboratory: Scale up to manage increased numbers of requests for influenza testing. Work with federal partners to provide healthcare providers and clinical

laboratories with guidelines on all aspects of specimen management and diagnostic testing.

Work with federal partners to monitor the pandemic virus. RATIONALE The goals of diagnostic testing during a pandemic are to: • Identify the earliest San Mateo County cases of pandemic influenza.


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• Support disease surveillance to monitor the pandemic’s geographic spread and impact of interventions.

• Facilitate clinical treatment by distinguishing patients with influenza from those with other respiratory illnesses.

• Monitor circulating viruses for antiviral resistance. Diagnostic testing for pandemic influenza virus may involve a range of laboratory assays, including rapid antigen tests, reverse-transcription polymerase chain reaction (RT-PCR), virus isolation, and immunofluorescence antibody (IFA) assays (see Box 1 and Appendix 1). During the earliest stages of a pandemic, the public health laboratory will receive a large and potentially overwhelming volume of clinical specimens. Pre-pandemic planning is therefore essential to ensure the timeliness of diagnostic testing and the availability of diagnostic supplies and reagents, address staffing issues, and disseminate protocols for safe handling and shipping of specimens. Once a pandemic is underway, the need for laboratory confirmation of clinical diagnoses may decrease as the virus becomes widespread. OVERVIEW Laboratory Testing for Novel Influenza Subtypes The public health laboratory should be prepared to process and, in some instances, test—if they have the capability (see below)—specimens from suspected cases of infection with: • Avian influenza A (H5N1) and other avian influenza viruses • Other animal influenza viruses (e.g., swine influenza viruses) • New or re-emergent human influenza viruses (e.g., H2) with pandemic

potential Clinicians should contact the San Mateo County Public Health Department if they suspect a human case of infection with any novel influenza A virus. State and local health departments, in turn, should contact CDC via the CDC Emergency Response Hotline: (770) 488-7100. Guidelines about when to send specimens or isolates of suspected novel avian or human strains to CDC for reference testing are provided in Appendix 2. Testing for Human Cases of Avian Influenza Currently, avian influenza strains implicated in human disease (in addition to influenza A [H5N1]) include the highly pathogenic avian influenza (HPAI) strain H7N7 and the low pathogenic avian influenza (LPAI) strains H9N2, H7N2, and H7N3. As of October 2005, no laboratory-confirmed cases of human infection with influenza A (H5N1) had been reported in the U.S. However, CDC has


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confirmed two non-fatal cases of avian A (H7N2) influenza in Virginia and New York. As new U.S. cases of human infection with avian influenza viruses are reported, they will be posted at www.aphis.usda.gov/vs/birdbiosecurity/hpai.html and at www.cdc.gov/flu. Recommendations on Laboratory Testing for Human Cases of Avian Influenza Local or state public health laboratories may conduct testing to identify suspected subtypes of avian influenza, including H5 and H7, if appropriate laboratory capacity and biocontainment equipment are available. Because of the danger that HPAI strains present to the U.S. agricultural industry, U.S. Department of Agriculture (USDA) regulations require that HPAI strains such as H5N1 (which are classified as select agents) must be cultured using BSL-3 biocontainment conditions with enhancements (see Appendix 3). Public health laboratories that lack BSL-3 facilities may use RT-PCR with BSL-2 containment to test clinical specimens from suspected human cases of avian influenza to identify and subtype influenza A viruses (e.g., H1, H3, H5, and H7; see S2-III.C). Or, they may send specimens to CDC, using the collection, handling, and shipping procedures described in Appendix 4. During the Pandemic Alert Period, specimens from suspected cases of human infection with novel influenza viruses should be sent for testing to public health laboratories with proper biocontainment facilities: RT-PCR – BSL-2 Virus isolation – BSL-3 with enhancements. The American Society for Microbiology maintains a list of emergency contacts in state public health laboratories, which is available at www.asm.org/ASM/files/0000000527/labemergencycontacts[1].PDF. If an avian influenza strain, or a human virus variant that evolves from it, causes an influenza pandemic, it might become necessary to re-evaluate biocontainment requirements and select agent registration requirements for laboratory testing. CDC and the Laboratory Response Network (LRN) will assist the USDA, as requested, in making such a decision. Testing for Human Influenza Strains with Pandemic Potential During the Pandemic Alert Period, the SMCPH Lab should be on the alert for new human subtypes of influenza that might have pandemic potential. Recommendations are as follows: State and local public health laboratories that can detect human and avian influenza subtypes by RT-PCR should report all unusual subtypes to CDC via the Emergency Response Hotline at (770) 488-7100.


http://www.cdc.gov/flu

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Public health laboratories that can detect human (but not avian) influenza subtypes by IFA staining or RT-PCR should send influenza A isolates that cannot be subtyped to the state. (If an avian strain is suspected, virus isolation and IFA should be performed under BSL-3 conditions with enhancements.) Public health laboratories should send specimens to the state if a patient meets the clinical and epidemiologic criteria for infection with a novel influenza virus and: (a) tests positive for influenza A by RT-PCR or by rapid diagnostic testing, or (b) tests negative for influenza A by rapid diagnostic testing and/or RT-PCR testing for influenza is not available. RECOMMENDATIONS FOR THE PANDEMIC PERIOD 1. Laboratory support for disease surveillance The Public Health Laboratory will support surveillance for pandemic influenza through the same mechanisms that support laboratory-based surveillance for seasonal influenza. As soon as a pandemic strain has been identified, CDC’s Influenza Laboratory will develop, produce, and disseminate RT-PCR and IFA reagents, as needed. As necessary, CDC and APHL will also update the RT-PCR protocol currently available to public health laboratories through the APHL website. As the pandemic continues, CDC will advise states on when confirmatory testing (i.e., subtyping) is required. Although confirmatory testing will be required when the pandemic begins, the level of testing will decrease as the virus becomes widespread. CDC will advise states on the percentage of isolates per week or month that they should send to CDC as part of efforts to monitor changes in the antigenicity and antiviral susceptibility of the pandemic virus. Throughout the pandemic, CDC will provide updated instructions on the collection of clinical and epidemiologic data that should accompany isolates. CDC could ask some state public health laboratories to perform virus isolation or RT-PCR subtyping before sending specimens to CDC.


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2. Laboratory support for clinicians When a pandemic begins, the public health laboratory will scale up to manage increased numbers of requests for influenza testing. As part of this effort, CDC will work with state and local public health laboratories and the LRN to provide clinical laboratories with guidelines for safe handling, processing, and rapid diagnostic testing of clinical specimens from patients who meet the case definition for pandemic influenza. These tests may be used by physicians to supplement clinical diagnoses of pandemic influenza. Because the sensitivity of rapid diagnostic kits might not be optimal, physicians should take their positive and negative predictive values into consideration when interpreting test results. 3. Biocontainment procedures During an influenza pandemic, laboratory procedures should be conducted under appropriate biosafety conditions:

• Commercial antigen detection testing for influenza should be conducted using BSL-2 work practices.

• The Public Health Laboratory will conduct RT-PCR testing using BSL-2 work practices and virus isolation using BSL-3 practices with enhancements.

Additional information on laboratory biocontainment is provided in Appendix 3. USE OF DIAGNOSTIC ASSAYS DURING AN INFLUENZA PANDEMIC The Public Health Laboratory will use different types of diagnostic tests for influenza at different stages of a pandemic. Each of the tests discussed below is described in detail in Appendix 1. Virus Isolation Virus isolation—growing the viral strain in cell culture—is the “gold standard” for influenza diagnostics because it confirms that the virus is infectious. During a pandemic, virus isolation followed by antigenic and genetic (sequencing) analysis will be used to characterize the earliest pandemic isolates, as well as to monitor their evolution during the pandemic. Laboratories that participate in the WHO Global Influenza Surveillance Network typically use virus isolation followed by hemagglutination inhibition (HAI), IFA staining, or RT-PCR to monitor circulating seasonal strains of influenza. If clinical and epidemiologic data suggest that a human case of influenza might be due to infection with avian influenza A (H5N1) or another highly pathogenic avian influenza strain (see Box 3), the virus should not be cultured except under BSL-3 conditions with enhancements. Laboratories


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that lack BSL-3 enhanced facilities may either perform RT-PCR subtyping using BSL-2 containment procedures or send the specimen to CDC for isolation and characterization. RT-PCR Subtyping Influenza specimens may also be typed and subtyped using RT-PCR, which does not require in vitro growth or isolation of virus. As of October 2005, CDC has trained scientists from 48 states to use RT-PCR subtyping to identify human and avian HA subtypes of public health concern. APHL members can access protocols and sequences of primers and probes that can be used for typing and subtyping on the APHL website. STATUS OF SAN MATEO COUNTY PUBLIC HEALTH LABORATORY The San Mateo County Public Health Laboratory is a CLIA certified laboratory with 10 FTE operating under Biological Safety Level 2 standards. The laboratory does not have sufficient security or containment measures in place to meet Federal Select Agent standards. Despite these limitations the laboratory is planning to support the Health Department’s seasonal influenza surveillance efforts by participating in the California Influenza Rapid Test Surveillance Program. In order to comply with security and containment measures and to increase laboratory capacity to handle the anticipated volume of samples from an influenza pandemic or other naturally occurring outbreak involving dozens of victims (or more), a new laboratory facility is needed. Plans for designing such a facility are in progress. Until a new lab facility is available, routine testing will have to be suspended and all available space and resources directed toward the pandemic/outbreak. Perhaps additional personnel can be mobilized by training recently retired microbiologists to work as extra-help employees. San Mateo County Public Health Laboratory (PHL) participates in the California Influenza Rapid Test Surveillance Program and can perform in-house testing using viral isolation and identification procedures (R-Mix) for the identification of certain common respiratory viruses, including Influenza A and B, Adenovirus, Respiratory Syncytial virus and Parainfluenza viruses 1-3. In addition, the laboratory is developing the ability to perform Real Time Polymerase Chain Reaction (RT-PCR) tests for Influenza A and B and for Influenza A subtypes H1, H3, and H5. Any positive rapid influenza test or any patient(s) with warranted symptoms will be sent to PHL for either confirmation testing of the initial rapid (positive) result or


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for initial screening and identification. All isolates testing positive for Influenza A or Influenza B will be sent to the state Viral and Rickettsial Disease Laboratory (VRDL) for subtyping. Any viral isolates or patient samples that cannot be identified through screening and detection method performed at PHL will be sent to the state VRDL for further identification. All clinical samples and viral isolates will be packaged and shipped following the International Air Transport Association (IATA) Dangerous Goods Regulations for infectious substances. Courier services will be utilized for transport to the state VRDL.


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APPENDIX 1. INFLUENZA DIAGNOSTIC ASSAYS Among the several types of assays used to detect influenza, rapid antigen tests, reverse-transcription polymerase chain reaction (RT-PCR), viral isolation, immunofluorescence assays (IFA), and serology are the most commonly used. The sensitivity and specificity of any test for influenza will vary by the laboratory that performs the test, the type of test used, and the type of specimen tested. A chart that lists influenza diagnostic procedures and commercially available rapid diagnostic tests follows more detailed descriptions provided below. Virus Isolation Biocontainment level: Interpandemic and Pandemic Alert Periods – BSL-3 with enhancements; Pandemic Period – BSL-2 Highly pathogenic avian influenza (HPAI) viruses are BSL-3 agents. During the Interpandemic and Pandemic Alert Periods, laboratories should attempt to culture HPAI viruses—as well as other influenza viruses with pandemic potential— only under BSL-3 conditions with enhancements in order to optimally reduce the risk of a novel influenza virus subtype spreading to persons or animals. During the Pandemic Period, biocontainment of BSL-2 is appropriate to prevent laboratory-acquired infection and the virus will already be widespread. In recent years, the use of cell lines has surpassed the use of embryonated eggs for culturing of influenza viruses, although only viruses grown in embryonated eggs are used as seed viruses for vaccine production. Because standard isolation procedures require several days to yield results, they should be used in combination with the spin-amplification shell-vial method. The results of these assays can be obtained in 24–72 hours, compared to an average of 4.5 days using standard culture techniques. Spin-amplification should not be performed using 24-well plates because of increased risk of cross-contamination. The most effective combination of cell lines recommended for public health laboratories is primary rhesus monkey for standard culture; along with Madin Darby Canine Kidney (MDCK) in shell vial. The use of these two cell lines in combination has demonstrated maximum sensitivity over time for recovery of evolving influenza strains. Some clinical laboratories have recently reported good isolation rates using commercially available cell-line mixed-cell combinations; however, data are lacking on the performance of these mixed cells with new subtypes of Influenza A viruses. Appropriate clinical specimens for virus isolation include nasal washes, nasopharyngeal aspirates, nasopharyngeal and throat swabs, tracheal aspirates, and bronchoalveolar lavage. Ideally, specimens should be collected within 72 hours of the onset of illness. Immunofluorescence Assays Biocontainment level: BSL-2 when performed directly on clinical specimens; if used on cultures for earlier detection of virus, biocontainment recommendations for viral culture apply


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Direct (DFA) or indirect (IFA) immunofluorescence antibody staining of virus-infected cells is a rapid and sensitive method for diagnosis of influenza and other viral infections. DFA and IFA can also be used to type and subtype influenza viruses using commercially available monoclonal antibodies specific for the influenza virus HA. The sensitivity of these methods is greatly influenced by the quality of the isolate, the specificity of the reagents used, and the experience of the person(s) performing, reading, and interpreting the test. Although IFA can be used to stain smears of clinical specimens directly, when rapid diagnosis is needed it is preferable to first increase the amount of virus through growth in cell culture. For HPAI isolates, attempts to culture the virus should be made only under BSL-3 conditions with enhancements. Reverse-Transcription Polymerase Chain Reaction (RT-PCR) Biocontainment level: BSL-2 PCR can be used for rapid detection and subtyping of influenza viruses in respiratory specimens. Because the influenza genome consists of single-stranded RNA, a complementary DNA (cDNA) copy of the viral RNA must be synthesized using the reverse-transcriptase (RT) enzyme prior to the PCR reaction. Laboratories can obtain CDC protocols and sequences of primers and probes for rapid RT-PCR detection of human and avian HA subtypes of current concern at the APHL website (available for members only). These protocols use real-time RT-PCR methods with fluorescent-labeled primers that allow automatic, semi-quantitative estimation of the input template. The RT-PCR results are analyzed and archived electronically, without the need for gel electrophoresis and photographic recording. A large number of samples may be analyzed at the same time, reducing the risk of carry-over contamination. As with all PCR assays, interpretation of real-time RT-PCR tests must account for the possibility of false-negative and false-positive results. False-negative results can arise from poor sample collection or degradation of the viral RNA during shipping or storage. Application of appropriate assay controls that identify poor-quality samples (e.g., an extraction control and, if possible, an inhibition control) can help avoid most false-negative results. Serologic Tests Hemagglutination Inhibition (HAI) Biocontainment level: BSL-2 Serologic testing can be used to identify recent infections with influenza viruses. It can be used when the direct identification of influenza viruses is not feasible or possible (e.g., because clinical specimens for virus isolation cannot be obtained, cases are identified after shedding of virus has stopped, or the laboratory does not have the resources or staff to perform virus isolation).


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Since most human sera contain antibodies to influenza viruses, serologic diagnosis requires demonstration of a four-fold or greater rise in antibody titer using paired acute and convalescent serum samples. HAI is the preferred diagnostic test for determining antibody rises. In general, acute-phase sera should be collected within one week of illness onset, and convalescent sera should be collected 2–3 weeks later. There are two exceptions in which the collection of single serum samples can be helpful in the diagnosis of influenza. In investigations of outbreaks due to novel viruses, testing of single serum samples has been used to identify antibody to the novel virus. In other outbreak investigations, antibody test results from single specimens collected from persons in the convalescent phase of illness have been compared with results either from age-matched persons in the acute phase of illness or from non-ill controls. In such situations, the geometric mean titers between the two groups to a single influenza virus type or subtype can be compared. In general, these approaches are not optimal, and paired sera should be collected whenever possible. Because HAI titers of antibodies in humans infected with avian influenza viruses are usually very low or even undetectable, more sensitive serologic tests, such as microneutralization, may be needed. 3 Enzyme-linked immunoassay (EIA) is not included on this list because of non-specificity issues. Complement fixation is not included because it is currently out of use. Microneutralization Assay Biocontainment level: Interpandemic and Pandemic Alert Periods – BSL-3 with enhancements; Pandemic Period – BSL-2 The virus neutralization test is a highly sensitive and specific assay for detecting virus-specific antibody in animals and humans. The neutralization test is performed in two steps: 1) a virus-antibody reaction step, in which the virus is mixed with antibody reagents, and 2) an inoculation step, in which the mixture is inoculated into a host system (e.g., cell cultures, embryonated eggs, or animals). The absence of infectivity constitutes a positive neutralization reaction and indicates the presence of virus-specific antibodies in human or animal sera. The virus neutralization test gives the most precise answer to the question of whether or not a person has antibodies that can neutralize the infectivity of a given virus strain. The neutralization test has several additional advantages for detecting antibody to influenza virus. First, the assay primarily detects antibodies to the influenza virus HA and thus can identify functional, strain-specific antibodies in animal and human serum. Second, since infectious virus is used,


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the assay can be developed quickly upon recognition of a novel virus and before suitable purified viral proteins become available for use in other assays. The microneutralization test is a sensitive and specific assay for detecting virus-specific antibody to avian influenza A (H5N1) in human serum and potentially for detecting antibody to other avian subtypes. Microneutralization can detect H5-specific antibody in human serum at titers that cannot be detected by HAI. Because antibody to avian influenza subtypes is presumably low or absent in most human populations, single serum samples can be used to screen for the prevalence of antibody to avian viruses. However, if infection of humans with avian viruses is suspected, the testing of paired acute and convalescent sera in the microneutralization test would provide a more definitive answer regarding the occurrence of infection. Conventional neutralization tests for influenza viruses based on the inhibition of cytopathogenic effect (CPE)-formation in MDCK cell cultures are laborious and rather slow, but in combination with rapid culture assay principles the neutralization test can yield results within 2 days. For HPAI viruses, neutralization tests should be performed at BSL-3 enhanced conditions.


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APPENDIX 2. REFERENCE TESTING GUIDELINES FOR POTENTIAL PANDEMIC STRAINS OF INFLUENZA State and local laboratories may conduct initial testing on patient specimens for influenza A or potential highly pathogenic strains, if laboratory capacity is available. Due to the spread of avian influenza A (H5N1) in poultry in Asia, laboratories should be on the alert for avian and human H5 viruses. Influenza A viruses other than currently circulating H1 and H3 subtypes should also be considered as potentially pandemic if detected in humans. State/local laboratories should send specimens to CDC if:

• A sample tested by the state or local laboratory is positive for H5 or another novel subtype;

A laboratory should test for influenza A (H5) only if it is able to do so by PCR or has a BSL-3-enhanced facility for influenza A (H5) viral culture. Shipping procedures for potential pandemic strains of influenza are provided in Appendix 4.


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APPENDIX 3. LABORATORY BIOSAFETY GUIDELINES FOR HANDLING AND PROCESSING SPECIMENS OR ISOLATES OF NOVEL INFLUENZA STRAINS Clinical specimens from suspected novel influenza cases may be tested by RT-PCR using standard BSL-2 work practices in a Class II biological safety cabinet for initial processing of patient specimens. If a specimen is confirmed positive for influenza A (H5N1) by RT-PCR, additional testing should be performed only under BSL-3 conditions with enhancements. CDC’s Influenza Branch should be informed immediately by contacting the CDC Director’s Emergency Operations Center (DEOC) at (770) 488-7100. A detailed description of recommended facilities, practices, and protective equipment for the various laboratory biosafety levels can be found in the CDC/NIH Biosafety in Microbiological and Biomedical Laboratories (BMBL) manual at www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4toc.htm BSL-3 with enhancements and Animal Biosafety Level 3 include all BSL-3 practices, procedures, and facilities, plus the use of negative-pressure, HEPA-filtered respirators or positive air-purifying respirators, and clothing change and personal showering protocols. Additional practices and/or restrictions may be added as conditions of USDA-APHIS permits. Registration of personnel and facilities with the Select Agent Program is required for work with highly pathogenic avian influenza (HPAI) viruses, which are classified as agricultural select agents. State and local public health laboratories may test clinical specimens from suspected novel influenza cases by RT-PCR using standard BSL-2 work practices in a Class II biological safety cabinet. Commercial rapid antigen detection testing may also be conducted under BSL-2 biocontainment conditions. Highly pathogenic avian influenza A (H5) and A (H7) viruses are classified as select agents. USDA regulations require that these viruses (as well as exotic low pathogenic avian influenza viruses) be handled under BSL-3 laboratory containment conditions, with enhancements (i.e., controlled-access double-door entry with change room and shower, use of respirators, decontamination of all wastes, and showering of all personnel). The USDA must certify laboratories that work with these viruses. Laboratories should not perform virus isolation on respiratory specimens from patients who may be infected with an avian influenza virus unless stringent BSL-3 enhanced containment conditions can be met and diagnostic work can be kept separate from studies with other human influenza A viruses (i.e., H1 or H3). Therefore, respiratory virus cultures should not be performed in most clinical laboratories. Cultures for patients suspected of having influenza A (H5N1) infection should be sent only to state laboratories with appropriate BSL-3 with enhancement containment facilities or to CDC.


http://www.cdc.gov/od/ohs/biosfty/bmbl4/bmbl4toc.htm

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APPENDIX 4. GUIDELINES FOR COLLECTING AND SHIPPING SPECIMENS FOR INFLUENZA DIAGNOSTICS Key Messages Appropriate specimens for influenza testing vary by type of test. Before collecting specimens, review the infection control precautions described in Appendix 3. A. Respiratory Specimens Eight types of respiratory specimens may be collected for viral and/or bacterial diagnostics: 1) Nasopharyngeal wash/aspirates, 2) Nasopharyngeal swabs, 3) Oropharyngeal swabs, 4) Broncheoalveolar lavage, 5) Tracheal aspirate, 6) Pleural fluid tap, 7) Sputum, and 8) Autopsy specimens. Nasopharyngeal wash/aspirates are the specimen of choice for detection of most respiratory viruses and are the preferred specimen type for children aged <2 years. Respiratory specimens for detection of most respiratory pathogens, and influenza in particular, are optimally collected within the first 3 days of the onset of illness. Before collecting specimens, review the infection control precautions in Supplement 4. B. Collecting specimens from the upper respiratory tract 1. Nasopharyngeal wash/aspirate Have the patient sit with head tilted slightly backward. Instill 1 ml–1.5 ml of nonbacteriostatic saline (pH 7.0) into one nostril. Flush a plastic catheter or tubing with 2 ml–3 ml of saline. Insert the tubing into the nostril parallel to the palate. Aspirate nasopharyngeal secretions. Repeat this procedure for the other nostril. Collect the specimens in sterile vials. Label each specimen container with the patient’s ID number and the date collected.


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If shipping domestically, use cold packs to keep the sample at 4°C. If shipping internationally, pack in dry ice (see shipping instructions below). 2. Nasopharyngeal or oropharyngeal swabs Use only sterile dacron or rayon swabs with plastic shafts. Do not use calcium alginate swabs or swabs with wooden sticks, as they may contain substances that inactivate some viruses and inhibit PCR testing. To obtain a nasopharyngeal swab, insert a swab into the nostril parallel to the palate. Leave the swab in place for a few seconds to absorb secretions. Swab both nostrils. To obtain an oropharyngeal swab, swab the posterior pharynx and tonsillar areas, avoiding the tongue. Place the swabs immediately into sterile vials containing 2 ml of viral transport media. Break the applicator sticks off near the tip to permit tightening of the cap. Label each specimen container with the patient’s ID number and the date the sample was collected. If shipping domestically, use cold packs to keep the sample at 4°C. If shipping internationally, pack in dry ice (see shipping instructions below). B. Collecting specimens from the lower respiratory tract 1. Broncheoalveolar lavage, tracheal aspirate, or pleural fluid taps During bronchoalveolar lavage or tracheal aspirate, use a double-tube system to maximum shielding from oropharyngeal secretions. Centrifuge half of the specimen and fix the cell pellet in formalin. Place the remaining unspun fluid in sterile vials with external caps and internal O-ring seals. If there is no internal O-ring seal, then seal tightly with the available cap and secure with Parafilm®. Label each specimen container with the patient’s ID number and the date the sample was collected. If shipping domestically, use cold packs to keep the sample at 4°C. If shipping internationally, ship fixed cells at room temperature and unfixed cells frozen (see shipping instructions below). 2. Sputum Educate the patient about the difference between sputum and oral secretions. Have the patient rinse the mouth with water and then expectorate deep cough sputum directly into a sterile screw-cap sputum collection cup or sterile dry container.


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If shipping domestically, use cold packs to keep the sample at 4°C. If shipping internationally, pack in dry ice (see shipping instructions below). BLOOD COMPONENTS Both acute and convalescent serum specimens should be collected for antibody testing. Collect convalescent serum specimens 2–4 weeks after the onset of illness. To collect serum for antibody testing: Collect 5 ml–10 ml of whole blood in a serum separator tube. Allow the blood to clot, centrifuge briefly, and collect all resulting sera in vials with external caps and internal O-ring seals. If there is no internal O-ring seal, then seal tightly with the available cap and secure with Parafilm®. The minimum amount of serum preferred for each test is 200 microliters, which can easily be obtained from 5 ml of whole blood. A minimum of 1 cc of whole blood is needed for testing of pediatric patients. If possible, collect 1 cc in an EDTA tube and in a clotting tube. If only 1cc can be obtained, use a clotting tube. Label each specimen container with the patient’s ID number and the date the specimen was collected. If unfrozen and transported domestically, ship with cold packs to keep the sample at 4°C. If frozen or transported internationally, ship on dry ice. AUTOPSY SPECIMENS CDC can perform immunohistochemical (IHC) staining for influenza A (H5) viruses on autopsy specimens. Viral antigens may be focal and sparsely distributed in patients with influenza, and are most frequently detected in respiratory epithelium of large airways. Larger airways (particularly primary and segmental bronchi) have the highest yield for detection of influenza viruses by IHC staining. Collection of the appropriate tissues ensures the best chance of detecting the virus by (IHC) stains. If influenza is suspected, a minimum total of eight blocks or fixed-tissue specimens representing samples from each of the following sites should be obtained and submitted for evaluation: Central (hilar) lung with segmental bronchi Right and left primary bronchi Trachea (proximal and distal) Representative pulmonary parenchyma from right and left lung In addition, representative tissues from major organs should be submitted for evaluation. In particular, for patients with suspected myocarditis or encephalitis, specimens should include myocardium (right and left ventricle) and CNS


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(cerebral cortex, basal ganglia, pons, medulla, and cerebellum). Specimens should be included from any other organ showing significant gross or microscopic pathology. Specimens may be submitted as: Fixed, unprocessed tissue in 10% neutral buffered formalin, or Tissue blocks containing formalin-fixed, paraffin-embedded specimens, or Unstained sections cut at 3 microns placed on charged glass slides (10 slides per specimen) Specimens should be sent at room temperature (NOT FROZEN). Fresh-frozen unfixed tissue specimens may be submitted for RT-PCR. Include a copy of the autopsy report (preliminary, or final if available), and a cover letter outlining a brief clinical history and the submitter’s full name, title, complete mailing address, phone, and fax numbers, in the event that CDC pathologists require further information. Referring pathologists may direct specific questions to CDC pathologists. The contact number for the Infectious Disease Pathology Activity is (404) 639-3133, or the pathologists can be contacted 24 hours a day, seven days a week through the CDC Emergency Response Hotline at (770) 488-7100. SHIPPING INSTRUCTIONS State and local health departments should call the CDC Emergency Response Hotline, (770)-488-7100, before sending specimens for influenza A reference testing. This number is available 24 hours a day, seven days a week. Hotline staff will notify a member of the Influenza Branch who will contact the health department to answer questions and provide guidance. In some cases, the state health department may arrange for a clinical laboratory to send samples directly to CDC. Specimens should be sent by Priority Overnight Shipping for receipt within 24 hours. Samples (such as fresh-frozen autopsy samples for RT-PCR or other clinical materials) may be frozen at –70 if the package cannot be shipped within a specified time (e.g., if the specimen is collected on a Friday but cannot be shipped until Monday). When sending clinical specimens, include the specimen inventory sheet (see below), include the assigned CDC case ID number, and note “Influenza surveillance” on all materials and specimens sent. Include the CDC case ID number on all materials forwarded to CDC. Protocols for standard interstate shipment of etiologic agents should be followed and are available at http://www.cdc.gov/od/ohs/biosfty/shipregs.htm. All shipments must comply with current DOT/IATA shipping regulations.


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VI. HEALTHCARE PLANNING

The following is a plan addressing “Surge Capacity” corresponding to Health and Human Services “HHS Pandemic Influenza Plan” Part 2, Supplement 3, Healthcare Planning, S3-III.A. Planning for provision of care in hospitals. 2.h) Surge capacity. The plan consists of an overall “umbrella” plan for the County at the Health Department level as well as the individual plans for each hospital in San Mateo County. Supplement 3 contains a number of additional elements that need still to be developed for the hospital pandemic flu plans including hospital surveillance, communications, education and training, triage, clinical evaluation, admission procedures, facility access, occupational health, use and administration of vaccines and antiviral drugs, security, and mortuary issues. Additionally plans for provision of care in non-hospital healthcare settings and alternative sites need to be developed. Work on the above elements should begin in early 2006 and will need to involve the Health Department, all hospitals in San Mateo County, the Office of Emergency, the fire service, and local law enforcement. The plan below will be divided into categories for strategies to be undertaken and notifications within each element for the “Stage” of the event (Green, Yellow, Red, and Black).

Introduction In California, and across the nation, over the last decade health care cost containment measures have resulted in narrowing the margin of excess staff and available patient care beds. Hospital downsizing and hospital closures have been common strategies. In most areas there is little “surge” capacity to meet periods of exceptionally high patient volume. This was demonstrated in 1997-98 when an unusually severe flu season caused serious hospital overcrowding.


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Fortunately, San Mateo County was able to handle the increased patient load with less difficulty than some other areas of the State, such as Los Angeles County which has been particularly hard hit by hospital closures. During “every day” operations, hospitals serving our community are able to provide hospital services without difficulty. Such services include emergency department care, in-patient hospitalization including critical and acute care, elective non-emergency surgery and other interventions, emergency surgery and other interventions, diagnostic services, and on-going treatment of chronic conditions. The hospitals’ capacity to provide these services is dependent upon each hospital’s physical plant, bed capacity, staffing, and equipment and supplies. Generally the number of people needing hospital services is fairly constant and the normal capacity of our local hospitals is able to meet the community’s needs without difficulty. There is some seasonal variation such as the flu in winter months. In some years the increased volume of seriously ill flu patients has stretched our local resources so that measures have been taken to be able to accommodate a greater volume of patients needing hospitalization; one example is canceling elective surgeries. In a disaster event, such as large mass casualty incident, our local hospitals would not be able to accommodate a large number of casualties and we would need to use strategies such as transferring patients to locations outside the affected area and bringing resources into San Mateo County from outside our Region. In a flu pandemic these strategies would likely be unavailable, as all areas of the nation would likely be affected. In a flu pandemic it will be important to stretch our local resources in order to meet the healthcare needs of our community as much as possible. In order to do this we will try to use our available resources as efficiently as possible. This will mean curtailing non-essential services, using staff in non-traditional ways, providing services in places not used in ordinary times, anticipating the services that will be needed, and building capacity for equipment and supplies. In the event that a flu pandemic occurs similar to the 1918 event, our local hospitals will not be able to provide healthcare sufficient to meet demand. Current projections for San Mateo County in such an event are that 14,470 people would require hospitalization for the nine to twelve month pandemic period. These patient cases would not be evenly distributed over this period and cases would occur in several waves. Planning for such an event should improve our ability to respond but there should not be an expectation that there will be “healthcare as usual.” It is possible that at some point the hospitals may no longer be able to provide anything but austere care and that ill persons will need to be cared for in the home or other


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non-hospital setting. We believe that planning for a pandemic will improve our ability to respond to a flu pandemic event but there should be no assumption that this planning will keep such an event from being catastrophic in San Mateo County. Implementing our County flu pandemic hospital surge plan, and each hospital’s individual surge plan, will be a stepped-approach. This stepped approach will include those strategies to be undertaken early in the event (such as discharging in-patients early) through those strategies that would be taken as a last ditch effort late in a catastrophic situation (e.g., limiting to austere care, closing hospitals). In the later stages of the pandemic it will likely be necessary to ration healthcare. Examples would be determining which patients should have priority for ventilators. A plan for such rationing should be undertaken early in the planning process.

Essential Hospital Surge Strategies Surge strategies are aimed at increasing capacity to provide the most important healthcare services to patients in most need. The strategies focus on four elements:

1. Staffing 2. Acute care bed capacity 3. Consumable and durable supplies 4. Continuation of essential medical services


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Alert Levels As per the previous “Concept of Operation” section, alert levels have been established to activate responses. The County Health Officer will be responsible for determining when to change alert levels. The County plan will identify general strategies based upon the various alert levels. Each hospital will undertake its own strategies, as outlined in its plan, based upon the countywide alert level.

Alert Level Hospital Conditions Green - little or no human transmission Plan for bed capacity, staffing, supplies

during an outbreak of pandemic influenza

Yellow - limited to moderate human transmission

Hospitals are receiving H5 patients on a limited basis; PPE issued; isolation of patients; prepare for essential services only;

Red - extensive human transmission Receiving H5 patients on a large scale; conduct essential services only; vacation leaves cancelled; all ventilators in use; inter-hospital transfers; request for DMATs to staff non-hospital facilities

Black - controlled and uncontrollable human transmission

Staff shortages; patient to staff ratio is huge; city services limited – sporadic trash collection; laundry shortages; morgue overflow; care is austere


May 2, 2006

Element 1. Staffing

Considerations Staffing will be a major challenge for hospitals during a flu pandemic for the some of the following reasons:

• There will be large numbers of seriously ill patients (possibly 14,470 over a nine to twelve month period).

• Since the pandemic will probably be universal we will likely be “on our own” for the duration of the event; mutual aid will not be an option.

• There are very few healthcare workers currently not employed in health care that would be able to (or willing to) return to the local healthcare workforce.

• Whereas historically large numbers of volunteer health care workers respond to disasters this may not be the case in a pandemic

• It is probable that many healthcare workers will become ill • Some healthcare workers will opt to stay home to care for ill family

member or to care for children/dependents whose normal day care provider is now unavailable

• Childcare may be very limited and possibly prohibited by the Health Officer

• While we may be able to augment the healthcare workforce with other personnel who do not traditionally provide healthcare, labor pools of available and willing personnel are probably limited.

• Early notification that flu pandemic is beginning will help hospitals prepare to implement their plans.


May 2, 2006

Hospital Strategies for Staffing Recruiting/Processing Staff Strategies Hospitals should establish process for rapid employment processes. Develop rapid credentialing process for healthcare professionals Develop rapid screening process for public volunteers Establish dialogue with local healthcare professions education programs (e.g. medicine, nursing, technicians) regarding use of trainees in hospitals during pandemic. Develop list of local non-hospital healthcare providers as resources for staffing and assets Identify Mass Care Sites in event that sufficient staff is available during peak periods of pandemic. Training Strategies Develop education/training content and materials for “just in time” training of:

• hospital personnel (that normally provide non-essential services) in functions needed for essential services during pandemic.

• healthcare personnel not normally working in the hospital setting (e.g., paramedics, emergency medical technicians, clinic staff).

• currently licensed health care providers (e.g., physicians, nurses) returning

to work force. • lay public volunteers

Administrative Strategies Establish policies for administrative personnel to maintain professional licenses Identify essential-support personnel titles needed to provide essential healthcare and hospital services (e.g., respiratory therapist, pharmacists, environmental and engineering services, food and nutrition services, clerical, medical records, information technology, laboratory, administration). Create lists of non-essential positions that could be reassigned during pandemic that could be cross-trained for essential positions during pandemic. Develop strategies to support staff during pandemic (e.g., providing psychological support, occupational health support, resources for families). Develop processes for utilizing health care trainees to assist in providing essential hospital services (e.g., nursing and medical students). Set up process ahead of time for “just in time” training, procedures, job action sheets, etc. Develop procedures/processes for orienting new staff (including physicians, nurses, other health professionals, auxiliary staff, paramedics, emergency medical technicians, lay public volunteers). Develop methods for identification of staff during pandemic. Identify potential housing for out-of-area staff during pandemic. Work with various groups who may be able to provide lay public patient care (e.g.,


May 2, 2006

Administrative Strategies faith-based community groups, ethnic community groups, senior centers). Legal Strategies Identify insurance and liability issues related to use of non-hospital staff. Meet with unions and agree on staffing issues for pandemic. Develop MOUs between local hospitals to permit sharing of staff, waiving credentialing for staff of other local hospitals, and determine how salary issues will be addressed for shared employees. Identify liability issues related to using lay public and families to assist in staffing hospitals in late stages of pandemic. Recruiting/Processing Staff Strategies Implement rapid employment processes. Contact out-of-hospital health care entities and seek to recruit staff to provide in-hospital essential services during pandemic. Training Strategies Conduct education/training training to personnel:

• hospital personnel (that normally provide non-essential services) in functions needed for essential services during pandemic.

• “just-in-time” training for healthcare personnel not normally working in the hospital setting (e.g., paramedics, emergency medical technicians, clinic staff).

• currently licensed health care providers (e.g., physicians, nurses) returning to work force.

Administrative Strategies Prepare to reassign staff providing non-essential services to function in essential services. Review processes for utilizing non-hospital staff to assist in providing essential hospital services to include:

• nursing students • medical students • other healthcare students • paramedics • emergency medical technicians • lay public volunteers

Legal Strategies Implement any processes that were identified as needed during Green planning process for insurance and liability issues related to use of non-


May 2, 2006

Legal Strategies hospital staff. Notify unions and implement agreed upon staffing procedures for pandemic.

Continue all above Yellow strategies. Strategies for Recruiting/Processing Staff Truncate credentialing process to allow qualified volunteers to serve in hospital Develop strategies to support staff during pandemic (e.g., providing psychological support, occupational health support, resources for families).

Training Strategies Conduct “just in time” training of for:

• healthcare personnel not normally working in the hospital setting (e.g., paramedics, emergency medical technicians, clinic staff).

• lay public volunteers willing to assist in staffing hospitals • families and lay public to use to care for flu patients at home, in non-

hospital facilities, or within a hospital if staff is unavailable.

Administrative Strategies Reassign staff providing non-essential services to function in essential services. Institute processes for utilizing non-hospital staff to assist in providing essential hospital services to include:

• nursing students • medical students • other healthcare students • paramedics • emergency medical technicians • lay public volunteers

Obtain housing for out-of-county staff (if needed). Responsible: Hospitals Implement strategies to support staff during pandemic (e.g., providing psychological support, occupational health support, resources for families).

Legal Strategies Implement any processes that were identified as needed during Green planning process for insurance and liability issues related to use of lay public.


May 2, 2006

2. Continue to use all above Yellow and Red strategies.

Strategies for Recruiting/Processing

State of emergency in effect; able bodied volunteers accepted and assigned to needed duties based on short interview

If sufficient staff available (e.g., DMATs) open Mass Care Site.


May 2, 2006

Element 2. Acute Care Bed Capacity Considerations Bed capacity will be a major challenge for hospitals during a pandemic for the some of the following reasons:

• There will be large numbers of seriously ill patients (possibly 14,470 over a nine to twelve month period with).

• Because of the anticipation of limitations on the availability of staff as discussed above it will not be possible to provide mass care in non-hospital locations. In localized disasters (e.g., earthquake, hurricane) mass care in non-hospital locations is possible. This will likely not be possible in a pandemic flu event although we will include it as a contingency in the event that staff can be procured e.g., Disaster Medical Assistance Teams.

• With such large numbers of patients needing hospitalization and so few staff available, caring for patients would be easier in multi-patient locations (e.g., large wards) but modern hospitals do not have these type of patient accommodations.

• Home healthcare agencies may also be very short staffed during a pandemic so it may not be possible to arrange at-home care for patients who have been discharged early from hospitals.

• Note: Not related to hospitals – County should work with various groups who may be able to provide lay public patient care (e.g., faith-based community groups, ethnic community groups, senior centers).

Primary Strategies to increase capacity: There are two basic strategies:

1. Open additional beds or patient treatment spaces. 2. Curtail non-essential healthcare services so that all available beds (and

patient spaces) will be available for essential healthcare services. Types of beds Licensed: The maximum number of beds for which a hospital holds a license to operate. Many hospitals do not operate all of the beds for which they are licensed. They may be physically available or physically unavailable.

Physically available: Beds that are licensed and physically set up, and available for use. These are beds regularly maintained in the hospital for the use of patients. These beds may be staffed or un-staffed.

Staffed: Beds licensed and physically available; staff are on hand to attend to the patient who occupies or might occupy the bed.


May 2, 2006

Staffed beds include beds that are occupied and those that are vacant.

Occupied: Beds with patients. Vacant: Beds that are vacant and to which patients can be transported immediately. These beds are licensed, physically available, and have staff on hand to attend to a patient who will occupy the bed.

Un-staffed: Beds that are licensed and physically available but have no current staff on hand to attend to a patient who would occupy that bed.

Physically unavailable: These are beds included in the license that may be in the repair shop or in storage. They are not immediately available for a patient.

Unlicensed: These are beds that exist but are not currently licensed. They may be physically available, such as recovery room beds, or physically unavailable, such as those in storage. Other Patient Spaces: This refers to physical spaces that could be used for patient care activities during a disaster and that have been identified in the hospital’s surge plan. Examples include surge tents or large vacant spaces where stretchers or cots could be placed.


May 2, 2006

Our local hospitals, based on their Flu Surge Plans, have identified the following total acute care bed/patient space capacity.

Acute Care Patient Space Type CountyMIL & PEN KRC SET SMC STC SEQ KSS

Occupied Beds 1345 189 130 227 383 116 192 108 Vacant Beds 59 22 0 23 0 5 0 9 Unstaffed Beds 339 50 205 26 37 1 20 0 Physically unavailable beds 107 0 75 10 0 0 20 2 Available but not licensed beds 124 32 15 10 12 0 33 22 Unavailable and unlicensed beds 16 6 0 0 0 0 0 10 Exam tables 384 0 50 46 85 25 0 160 Litter 2 0 0 0 0 0 2 0 Gurneys 184 26 30 45 37 6 10 30 WestCots 150 0 20 30 30 10 30 20 Cots (military style) 68 40 12 6 0 0 0 10 Mattresses 80 8 0 44 28 0 0 0 Summary Licensed Beds 1850 261 410 286 420 122 232 119 Normal Operating Capacity 1404 211 130 250 383 121 192 117 Unlicensed Beds 140 38 15 10 12 0 33 32 Other patient spaces 840 74 112 171 180 41 42 220 Surge Capacity 1426 162 407 217 229 42 115 254 Total Patient Capacity 2858 373 537 467 612 163 307 371 Surge Capacity Percent (Surge/Normal) 101.6% 76.8% 313.1% 86.8% 59.8% 34.7% 59.9% 217.1%


May 2, 2006

Bed Capacity Strategies Green Strategies to Conserve Resources Develop plans for identifying patients that could be discharged early in late Yellow stage of pandemic event. Establish dialogue with home healthcare agencies regarding need for home healthcare agencies to increase capacity during pandemic to care for:

• early patient discharges (non-flu patients) in pandemic • seriously ill non-flu patients unable to be admitted to hospital • seriously ill flu patients unable to be admitted to hospital and without

access to family/friends to care for them. Develop policies and procedures for accelerating hospital discharge of patients (e.g., ensuring physician cooperation). Develop policies, procedures, processes for curtailing non-essential admissions and services. Develop plans and procedures for cohorting flu patients. Develop process for identifying need to request waivers from regulators on bed use and nursing ratios. Develop policies and procedures for shifting patients between nursing units to free up bed space in critical care areas and to cohort influenza patients. Strategies to Increase Bed/Patient Space Capacity Identify beds for each “category” – licensed, unlicensed, patient space. Identify “patient space” areas that could be used for patients. Identify patient rooms that could accommodate more than one bed. Identify process to rapidly identify licensed beds, physically available beds, staffed beds (vacant, occupied). Determine number of isolation rooms. Develop cohorting protocols based on patient’ stage of recovery and infectivity. Yellow

Strategies to Conserve Resources Early Yellow: Begin to identify patients for early discharge and begin planning for their discharge (e.g., arrange for in-home care). Late Yellow: Discharge patients who have been identified as able to be discharged early. Work with home healthcare agencies regarding need for home healthcare agencies to increase capacity during pandemic to care for:

• early patient discharges (non-flu patients) in pandemic Implement policies and procedures for accelerating hospital discharge of patients


May 2, 2006

Strategies to Conserve Resources (e.g., ensuring physician cooperation). Take steps necessary to curtail non-essential admissions and services. Implement cohorting of flu patients. Strategies to Increase Bed/Patient Space Capacity Prepare to utilize all beds (licensed and unlicensed).

Red Continue Yellow Strategies Strategies to Conserve Resources Work with home healthcare agencies regarding need for home healthcare agencies to increase capacity during pandemic to care for:

• seriously ill non-flu patients unable to be admitted to hospital • seriously ill flu patients unable to be admitted to hospital and without

access to family/friends to care for them. Shift patients between nursing units to free up bed space in critical care areas and to cohort influenza patients. Black Continue Yellow and Red Strategies As Much As Possible Strategies to Conserve Resources Discharge patients as many inpatients as possible. Curtail admission for all patients whose care is not essential at this time. Implement plan for rationing medical care (e.g., ventilators, admissions).


May 2, 2006

Element 3. Consumable and Durable Supplies

Considerations

• Normal hospital operations and budget requirements dictate “Just In Time” (JIT) inventory strategies; very limited inventory on hand and reliance on vendor efficiency

• There are a limited number of vendors and these vendors supply many hospitals.

• Inventory space is limited • The strategic national stockpile (SNS) will be insufficient to supply the

nation. • Past experience shows the first resource to be depleted during a flu

epidemic is ventilators • Consumable and durable supplies that will be needed during a flu

pandemic can be anticipated. The primary categories are: • Personal protective equipment

o N-95 masks o Surgical masks o Face shields/eye protection o Gowns o Gloves

• Patient Treatment/Support o Ventilators o Portable oxygen o Compressed air o Respiratory care equipment o Anti-virals o Antibiotics to treat bacterial complications

vancomycin ceftriaxone levofloxacin or moxifloxicin azithromycin doxycyline imepenem

(A local pharmaceutical stockpile exists and contains some doxycycline.)

o IV supplies and IV pumps o Central line kits o Beds/cots o Morgue packs o Facial tissues o Linen o Tympanic thermometers


May 2, 2006

• Other o Temperature o Additional power supply for patient spaces o Cleaning and disinfecting supplies o Hand cleaner o Stethoscopes o Morgue packs

• Issues relative to droplet vs. airborne spread of flu virus. o Flu is spread by droplet. o A well-fitting surgical mask is adequate protection in most situations

involving close contact between health care workers and flu patients. o Some procedures may generate increased small-particle aerosols of

respiratory sections (e.g., endotracheal intubation, nebulizer treatment, bronchoscopy, suctioning). For these procedures healthcare workers should wear a N-95 mask.


May 2, 2006

Consumable and Durable Supplies Strategies GREEN Strategies Re: Consumable and Durable Supplies Develop inventory and location of all ventilators. Consider stockpiling enough consumable supplies for a pandemic wave (6-8 weeks). Review procedures for tracking consumable and durable supplies and establish revisions to procedure to implement during pandemic. Determine triggers for ordering more supplies. Develop a strategy for acquiring additional equipment. Develop SEMS/NIMS processes to communicate need for additional consumable and durable supplies. Establish contingency plans for situations in which primary sources of medical supplies become limited. Yellow Strategies Re: Consumable and Durable Supplies Use triggers for ordering more supplies. Acquire additional equipment as needed. Red Continue to use all Yellow strategies above. Strategies Re: Consumable and Durable Supplies Using SEMS/NIMS procedures request needed consumable and durable supplies by contacting Regional Disaster Medical Health Coordinator Region 2. Procure durable medical equipment as needed and available from local businesses that rent medical equipment. 3. BLACK Continue to use all Yellow and Red strategies above. Strategies Re: Consumable and Durable Supplies Using SEMS/NIMS procedures request Strategic National Stockpile by contacting Regional Disaster Medical Health Coordinator Region 2.


May 2, 2006

Element 4. Continuation of Essential Medical Services Considerations:

• Essential medical services will need to continue. Examples include, but are not limited to: o Trauma o Acute medical conditions such as acute coronary syndrome, stroke,

malignancy, internal bleeding, respiratory failure, etc. o Obstetrics & neonatal o On-going treatment for chronic conditions such as hemodialysis,

infusion centers for chemotherapy, parenteral nutrition o Provision for essential medications for patients who cannot, or should

not travel to pharmacies • At some point during the pandemic it may be necessary to ration certain

services. There should be a thoughtful plan for rationing care that is developed with input from ethicists and the medical community.

GREEN Strategies for Continuation of Essential Medical Services Develop plans for how essential care areas will continue to be staffed and supplied during pandemic. Develop training materials and supplies that can be used to train and supply families for certain home care procedures (e.g., peritoneal dialysis, parenteral nutrition). YELLOW Strategies for Continuation of Essential Medical Services Implement plans for maintaining essential healthcare services. RED Continue Yellow strategies as above. Strategies for Continuation of Essential Medical Services Begin rationing care in accordance with plan. BLACK Continue Yellow and Red strategies as above.


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VII. INFECTION CONTROL STRATEGIES

Infection control strategies have been developed by the Health and Human Services Agency (HHS). The information contained is broad and applicable to all jurisdictions. The discussion includes transmission methods, personal protection equipment (PPE), infectious patient management, hygiene, waste disposal, environmental cleaning and disinfection, and issues specific to healthcare settings. San Mateo County Health encourages all healthcare professionals to read the document at: http://www.hhs.gov/pandemicflu/plan/sup4.html


http://www.hhs.gov/pandemicflu/plan/sup4.html

May 2, 2006


May 2, 2006

VIII. CLINICAL GUIDELINES AND THE ROLE OF PUBLIC HEALTH

This section is designed to serve as a guide for clinicians, with the understanding that the management of influenza is based primarily on sound clinical judgment regarding the individual patient as well as an assessment of locally available resources, such as rapid diagnostics, antiviral drugs, and hospital beds. Early antiviral therapy shortens the duration of illness due to seasonal influenza and would be expected to have similar effects on illness due to novel or pandemic influenza viruses. The guidance is available at the CDC website (www.cdc.gov/flu/) and is current as of October 2005.


http://www.cdc.gov/flu/

May 2, 2006


May 2, 2006

IX. VACCINE AND ANTIVIRAL DISTRIBUTION AND USE

“Push” versus “Pull” Strategies There are two strategies to supplying antivirals and vaccine to the public. A “push” strategy refers to bulk delivery of medications to specific locations, with delivery to individuals via postal carriers, commercial delivery services, local city vehicles, etc. A “pull” strategy refers to the setting of Points of Distribution (PODs), or NETVACs, where the medication is dispensed directly to the public. Each has advantages and disadvantages specific to local city conditions. In the context of pandemic influenza, a “pull” strategy may not be advisable. Large public gatherings for the purpose of receiving medications may unnecessarily expose otherwise healthy individuals to contagious people. Cities may also find their geography does not allow for efficient traffic and crowd control. County health workers may not be able to staff the NETVACs. The benefit of a “pull” strategy is the concentration of qualified healthcare workers administering vaccine and dispensing drugs in a controlled environment, with centrally located units for ease of logistic support. The “push” strategy puts the distribution of antivirals and administration of vaccine into non-healthcare individuals. Crowd and traffic control is no longer an issue at the sacrifice of controlled dispensation, possibly exposing a minority of the public to drugs to which contraindications may be dangerous. A “push” method is heavily dependent and city resources and planning. The County’s responsibility would end with the delivery of bulk supplies to a location of the City’s choosing.


May 2, 2006

NETVAC (Neighborhood Emergency Triage, Vaccination, and Antibiotic Center)

Purpose To provide operational and logistical capacity to set up and manage temporary sites for targeted or mass prophylaxis, including pandemic influenza, care of worried-well, and distribution of health information to the public. Overview NETVAC sites are designed to be activated when the event requires that either a large number of people need prophylaxis and/or the prophylaxis must be given within a specified time frame. 48 sites within 3 zones in San Mateo County have been designated as NETVAC sites. The extent and sequence in which sites are opened is the purview of the Health Officer, resources permitting. If one NETVAC site is activated, the NETVAC Zone Director will remain part of the DCP Field Response section. If 2-48 sites are activated, the NETVAC Zone Director will report to and receive direction from the highest level of operational command currently operating. Upon a call to activate, ___xxx____ will notify the administrative Supervising PHN, who will in turn contact the appropriate number of Senior PHNs (NETVAC Zone Directors) and PHNs. The NETVAC Area Supervisor (Health Services Managers) will report to the Health Department to receive a briefing from the Operations Section Chief and NETVAC Zone Director and begin to activate their staff. They will then proceed to their pre-determined city EOC. The NETVAC Zone Director will be the primary communication conduit between the Operations Section Chief and the NETVAC Area Supervisor. The PHNs are designated and trained as NETVAC Unit Leaders (Clinic Managers) of the specific NETVAC clinics. They will fulfill that role in partnership with an Administrative Assistant. Objectives • Open the NETVAC site; set up and staff site to accomplish assigned mission.

Definitions of Scalable NETVAC Activation:

Small Scale: o Only one NETVAC site is activated. o The NETVAC Zone Director will report to the NETVAC Unit Leader. o The clinic is staffed from within Health Department resources.

Medium Scale: o One to six NETVAC sites are activated.


May 2, 2006

o The NETVAC Zone Director will report to the highest level and receive direction from the highest level of operational command currently operating.

o Clinics are staffed with Health Department resources Large Scale: o When a large subset (greater than 10,000) of the population or the entire

population of San Mateo County requires prophylaxis/immunization. o The NETVAC Zone Director will report to the highest level and receive

direction from the highest level of operational command currently operating.

o When staffing demands exceed Health Department resources, staff for the clinics will be drawn from other community partners and the general public.


May 2, 2006


May 2, 2006

HEALTH DEPARTMENT ORGANIZATION DURING MASS PROPHYLAXIS



May 2, 2006



May 2, 2006

NETVAC ICS STRUCTURE



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Greeter/Screener4

Flow Monitor2

Medical Evaluator &Shooter

2

Express Line1

Express Line1

Special Populations/Families w/children

2

Home (Exit)Hospital/Clinic

Note:Sole licensed person at

this station only

NETVAC Patient Flow Chart

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NETVAC POSITION DESCRIPTION

NETVAC Position Checklists: Operations Section Chief NETVAC Zone Director NETVAC Area Supervisor NETVAC Unit Leader

(Clinic Manager) Administrative Assistant City Liaison* Facility Liaison Mental Health Staff Logistics

No individual checklists for: administrative, security, greeters, triage/ screeners, pharmacy staff, medical staff, translators, runners/volunteers. Checklist per Focus A Lead

* Checklist per Focus A Lead

San Mateo County Pandemic Flu Plan

May 2, 2006

NETVAC SITE

POSITION

Overview of Job Description

# Per Site/ Shift

Comments

Operations Section Chief

Determine #, sequence, and focus of site activation

Maintain oversight of emergency Request SNS support if necessary

1 Located at Public Health Dept (DOC) or Redwood City (EOC)

NETVAC Zone Director Provide initial briefing of Zone Coordinators Notify EMS to start process to open

individual sites Provide liaison between Zone Coordinators

and Zone hospitals

1 Located at DOC

NETVAC Area Supervisor Notify staff to begin NETVAC start-up sequence

Brief Clinic Managers Liaison between Clinic Managers and

NETVAC Coordinator Coordinate staffing for individual sites Provide liaison between PHD and Zone

hospitals

1 Located at city EOC

Facility Liaison Open the individual facility Coordinates access to onsite resources and

supplies Coordinate between the Clinic Manager and

law enforcement for security and traffic flow needs

Assist with communication

1

NETVAC Unit Leader (Clinic Manager)

Direct physical setup of NETVAC site Coordinate with Facility Liaison for security,

traffic flow Ensure briefing of clinic mission to staff Supervises clinic activities and staff Ensure that clinic staff and first responders

receive vaccination/prophylaxis Work w/ Administrative Assistant on issues

of administrative function, logistics Keep Zone Coordinator appraised of

activities, needs

1

Administrative Assistant Coordinate administrative functions 1 Works with Unit Leader


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Position

Overview of Job Description # Per Site/ Shift

Comments

Administrative Functions Record-keeping Forms distribution/collection Photocopying Communications Staffing rosters Set up and maintain telephone, fax and

computer communications

4-6 Works with Administrative Assistant

Mental Health Provide on-site counseling, as needed, to NETVAC staff and public

Provide critical-incident stress debriefings as needed

6 There will be an overall managing Mental Health professional

Greeters/Screeners Greet clients in line outside NETVAC site Identify symptomatic persons; refer them to

Medical Evaluator Distribute informational material and forms Registers the public Provide early alert of situations that may

require additional security attention Review patient history for persons w/

contraindications for prophylaxis or vaccination

Answer questions Stamps right hand of public:

Green color: Express Line Red color: Medical Evaluator Blue color: Special Populations Families with children

4

Flow Monitor Direct client flow into the clinic according to right hand stamp color

2

Vaccinators/Dispensers Vaccinate and/or dispense medications

4

Pharmacy Manager/ Technicians

Coordinate receipt, distribution, and security of pharmaceutical supplies, vaccines and medications

Track pharmacy supplies to ensure that quantity remains sufficient, and available in appropriate doses; repackage as needed

Ensure proper storage requirements for medications or vaccines maintained

Track and return unused vaccines

3

Medical Evaluator Respond to medical emergencies that occur on site, from minor/related to clinic mission, to serious medical emergencies that may be incidental and not related to clinic mission

Assist w/ patient screening and medical evaluation

Provides vaccine/antiviral to patients who meet the criteria

Coordinates transport of patients who need to be transferred to hospitals/clinics

1


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Position

Overview of Job Description # Per Site/ Shift

Comments

Translators Assist NETVAC staff when language translation is needed on site

Assist in preparing educational materials

2-3

Runners/Volunteers Miscellaneous Tasks: Deliver supplies, equipment, paperwork,food Assist w/ communications Direct traffic Distributes antivirals at red, green, and blue

lines Registers the public Crowd control Classifies people according to their

vaccination needs (stamps hands) Provides vaccines after onsite training

10

Security (includes traffic control)

Oversee personnel assigned to security activities

Assign and coordinate use of cell phones/ pagers

Establish staff check-in and check-out procedures, including adequate identification

Maintain communication w/ local law enforcement

Ensure orderly flow of traffic and parking Ensure orderly movement of recipients

through the clinic process Provide necessary control of persons if they

become unruly Ensure security of supplies, especially

medications or vaccines

Works with Facility Liaison

Logistics Ensure that all necessary supplies are on-site and available in sufficient quantity during NETVAC operations

Maintain inventory of supplies Assist w/ storage and distribution within the

clinic as needed

Works with Assistant Clinic Manager


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JOB ACTION CHECKLIST

OPERATIONS SECTION CHIEF

Position Assigned to: _______________________________________ Reports to: Small Scale: Health Officer Telephone: _____________________ Medium/Large Scale: Health Director Location: ________________________ Date: _________________ Shift: _________________

Mission: Overall responsibility and management of Health Department response to incident which has required NETVAC-level response. Activation Process/Immediate Actions:

Determine objectives and strategies (need to immunize or provide mass prophylaxis and scale of response needed)

Activate the DOC. Request opening of operational area EOC if medium or large scale response initiated

Determine NETVAC sites that will be opened and order of opening Determine and distribute vaccination/oral antibiotic instructions (including

priorities) and protocols Review or develop standing orders for immunization or prophylaxis Activate local stockpile Request the Strategic National Stockpile (SNS) if needed

Ongoing Process/Intermediate Actions:

Consult with the Regional Medical Health Operational Area Coordinator (RMHOAC), California Department of Health Services (DHS), and/or Centers for Disease Control and Prevention (CDC)

Establish and maintain daily briefings on situation for County and city officials. Advises Agency Director and PH Division Directors.

Determine if special needs populations (residential facilities such as skilled nursing facilities or assisted living centers) can be protected by isolation or quarantine instead of prophylaxis

Assure staff safety, including immunization or prophylaxis of first responders and health care workers

Approve resource requests Approve personnel and public information draft materials from the PIO Review and revise the PH response as necessary Begin response assessment


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Recovery Process/Long-Term Actions (Emergency Controlled):

Order demobilization when appropriate Participate in post-event debriefing Evaluate Public Health response Modify protocols as necessary Develop recommendations for future emergency response


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NETVAC ZONE DIRECTOR

Position Assigned to: _______________________________________ Reports to: Small Scale: DCP Unit Leader Telephone:_____________________ Medium/Large Scale: Operations Section Chief Location: ________________________ Date: _________________Shift:_________________

Mission:

Act as a resource to the IC in determining location and order of activation of NETVAC sites

Provide initial briefing for NETVAC Area Supervisor Serve as primary liaison between PH and activated sites Serve as secondary liaison for NETVAC logistical issues,

including coordination of SNS deliveries

Activation Process/Immediate Actions:

Receive appointment from Operations Section Chief Read this entire checklist Obtain briefing from Health Officer/Operations Section

Chief Advise IC on location of NETVAC sites to be activated Identify yourself as the NETVAC Zone Director Brief NETVAC Area Supervisor at Health Department. With

them, determine Initial instructions and priorities Hours of operation/shift requirements Frequency of communications Back-up plan for communications

Distribute NETVAC Go-Kits to NETVAC Area Supervisors for sites to be activated


Establish and maintain routine communication between DOC and NETVAC Area Supervisors

Monitor staffing issues, logistical needs, activity levels, and special issues that arise; problem-solve as needed


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Relay resource requests Maintain an activities log Continually review and revise the NETVAC response as

necessary Begin response assessment


Relay orders for and direct demobilization when appropriate

Collect site and zone logs from the NETVAC Area Supervisor

Prepare an after action report Participate in post-event debriefing Develop recommendations for future emergency

responses


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NETVAC AREA SUPERVISOR

Position Assigned to: _______________________________________ Reports to: DCP NETVAC Zone Director Telephone: _____________________ Location: ________________________ Date: _________________ Shift_________________

Mission:

Provide direction and supervision to NETVAC Unit Leaders as sites within a specified NETVAC zone

Arrange logistical support (both personnel and supplies) for the NETVAC Unit Leaders


When notified by PHN Administration that the Health Officer has requested activation of NETVAC sites, report to the Department Operations Center (DOC) at the Public Health Department for an operational briefing

Put on appropriate identification, including ID badge With the NETVAC Zone Director, determine initial instructions and priorities Read this entire checklist, the NETVAC Unit Leader checklist, and the

Facility Liaison Checklist Contact your NETVAC Unit Leaders. Instruct them to:

Contact their Facility Liaison Meet you for a briefing and to pick up their NETVAC Go-Kit

Set up your workspace. Request administrative assistance, and brief that staff.

Brief the NETVAC Unit Leaders: Distribute the support paperwork Determine classifications of staff needed at the sites Activate their support staff phone tree Establish means, frequency, and backup communication plans


Ensure that NETVAC Unit Leaders have established liaisons for traffic control and security

Contact the American Red Cross to ensure that canteen services are en route to each site

Staffing:


May 2, 2006

With the NETVAC Zone Director, determine NETVAC hours of operation, # of shifts required (8 hr vs. 12 hr shifts, 16-24 hr/day operations)

Prepare staffing rosters; communicate these to the NETVAC Unit Leaders

Prior to each shift change, contact assigned NETVAC staff member to provide instructions on when/where to report for each NETVAC shift at each NETVAC site in the zone

Receive requests for medical staffing, equipment, and supplies from NETVAC Unit Leaders.

Contact the NETVAC Zone Director to: Ensure that supply/re-supply transportation is set up Liaison between NETVAC Unit Leaders and delivery of supplies from

the local pharmaceutical stockpile or SNS stockpile Problem-solve Maintain an activities log Continually review and revise the NETVAC response as necessary Begin response assessment At the end of the shift, brief the incoming NETVAC Area Supervisor


Relay orders for and direct demobilization when appropriate Collect site and zone logs from the NETVAC Area Supervisor Prepare an after action report Participate in post-event debriefing Develop recommendations for future emergency responses


May 2, 2006


NETVAC UNIT LEADER

(CLINIC MANAGER)

Position Assigned to: _______________________________________ Reports to: NETVAC Area Supervisor Telephone: _____________________ Location: ________________________ Date: _________________ Shift: _______________

Mission: Oversee delivery of mass prophylaxis or vaccination. Includes coordination with the city site manager and the American Red Cross, supervision of medical staff, and activities. Activation Process/Immediate Actions:

Read this entire checklist Put on appropriate identification Get briefing from the NETVAC Area Supervisor and pick up NETVAC Go-Kit Proceed to assigned NETVAC site; contact the NETVAC Area Supervisor to

report your arrival Activate your support staff phone tree Upon arrival, introduce yourself to the Facility Liaison Review the Facility Contact Checklist with the Facility Liaison Familiarize self with clinic spaces; set up as necessary

Traffic flow Set up chairs and tables Place signage for traffic flow and to label major activities; include

areas off limits to general public, areas to separate persons who may be symptomatic

Equipment and communications Storage of supplies NETVAC worker sign-in table and log Break area for NETVAC staff

Review w/ Facility Liaison provisions for Traffic control Security (for personnel and supplies/pharmaceuticals) Communications equipment/photocopy equipment Emergency generators/back-up power Port-O-Potties

Introduce yourself to and brief your support staff


May 2, 2006

Assign and distribute special identification badges, job action checklists/clothing identifiers, and brief on location/specific personal protective equipment (PPE) for current scenario

Report status of clinic readiness to NETVAC Area Supervisor Ongoing Process/Intermediate Actions:

Supervise clinic and staff activities Ensure that support staff, first responders, and their respective families

receive immunization or prophylaxis as needed Ensure that staff has everything needed to compete their tasks Working with the Administrative Assistant, request supplies through NETVAC Area

Supervisor

Monitor staff for signs of fatigue/stress – schedule staff breaks and meals Monitor flow of traffic through the site Report status of site to NETVAC Area Supervisor on a regular basis

(frequency to be determined by NETVAC Zone Director) Assure staff safety Collect job action sheets at end of each shift Brief incoming NETVAC Unit Leader

Recovery Process/Long-Term Actions:

Help staff to disassemble site Assure that all supplies and equipment are transported back or stored for

next day Hand out evaluation forms for staff to complete Collect all paperwork Turn in job action sheets to NETVAC Area Supervisor Submit after action report, attend debrief as instructed


May 2, 2006


NETVAC ADMINISTRATIVE ASSISTANT

Position Assigned to: _______________________________________ Reports to: NETVAC Unit Leader Telephone: _________________________ Location: ________________________ Date: _________________Shift:_________________

Mission: Oversee administrative support functions of NETVAC site. Will work closely with the NETVAC Unit Leader and Facility Liaison. Activation Process/Immediate Actions:

After assignment by the Logistics Section Chief, read this entire checklist Put on appropriate identification – ID badge Proceed to assigned NETVAC site Activate your support staff phone tree Upon arrival, introduce yourself to the NETVAC Unit Leader and Facility

Liaison Obtain briefing and administrative paperwork/forms from NETVAC Unit

Leader; review them Assist with check-in of NETVAC staff, volunteers; assist with issuance of

identification badges and clothing Assign and brief administrative support staff daily and as needed on

instructions and priorities Familiarize self with clinic spaces; assist with set up as necessary

Traffic flow Equipment and communications Photocopy equipment Storage of supplies NETVAC worker sign-in table and log Break area for NETVAC staff

Report status of administrative support readiness to NETVAC Unit Leader Ongoing Process/Intermediate Actions:

Supervise activities, ensure that administrative staff has everything needed to compete their tasks. Activities include:

Tracking staff and volunteer hours Registration of patients Data entry Answering the phone


May 2, 2006

Tracking inventory of supplies and paperwork; photocopying as needed

Documentation of cost of operation Working with the Clinic Manager, request supplies through Zone

Coordinator Working with the Facility Liaison, accept supplies Monitor administrative staff for signs of fatigue/stress – schedule staff breaks and meals Brief incoming Administrative Assistant



next day Hand out evaluation forms for staff to complete Collect all paperwork Turn in job action sheets to NETVAC Unit Leader Provide information for after action report, attend debrief as instructed


May 2, 2006


FACILITY LIAISON

Position Assigned to: _______________________________________ Reports to: NETVAC Unit Leader Telephone: _____________________ Location: ________________________ Date: _________________Shift:_________________

Mission: Facilitate and coordinate with Public Health use of NETVAC site to accomplish mission. Activation Process/Immediate Actions:

Upon notification by the City Liaison (Emergency Services Coordinator), If during working hours, inform facility, make arrangements to

reassign activities as needed If after working hours,

report to assigned NETVAC site unlock site activate your staff phone tree for support staff if needed

Introduce yourself to the NETVAC Unit Leader and Administrative Assistant; give NETVAC Unit Leaders a set of keys

Put on appropriate identification – ID badge or clothing Obtain briefing from NETVAC Unit Leader about expected number of

clients, duration of activation, and hours of operation Verify with City Contact that security personnel are en route to site. [Note:

Facility cannot be opened until security personnel are on site.] Locate NETVAC site activation box containing forms, supplies, floor layout

diagram, etc. Move supplies to NETVAC area. If pre-identified furniture (tables, chairs, equipment) is on site, move to

NETVAC area Identify telephone lines for use by NETVAC staff. If telephones are available

on site, move them to the room(s) and connect them to telephone lines. If telephones are not available, verify with the City Emergency Coordinator that they are en route

Verify with City Emergency Coordinator that parking and traffic control routes are set up

Familiarize self with plan for clinic spaces; assist with set up according to plan

Traffic flow within clinic Equipment and communications Photocopy equipment Storage of supplies


May 2, 2006

Directional signage Entrances and exits Restrooms, including handicapped facilities Traffic flow through the clinic

Secure any areas or rooms that are not to be open to the public Post facility rules

Check operability of lighting, power, and water systems. Arrange for backup generator if required.

Arrange for Port-O-Potties Direct arriving volunteers to park off-site (if needed) to allow for client

parking Assist American Red Cross to set up canteen and other support operations Report status of readiness to NETVAC Unit Leader If NETVAC operations are projected to last more than 12 hours, contact

your replacement and make arrangements for scheduling Ongoing Process/Intermediate Actions:

Assist Administrative Assistant with logistical issues such as supply storage

areas Trouble-shoot Keep log of pertinent activities Brief incoming Facility Liaison



next day Retrieve keys to facility from NETVAC Unit Leader Provide information for after action report, attend debrief


May 2, 2006


MENTAL HEALTH SPECIALIST

Position Assigned to: _______________________________________ Reports to: MH Unit Leader: NETVAC Zone Director Telephone:_____________________ MH Worker: MH Unit Leader Location: ________________________ Date: _________________Shift:_________________

Mission:

Provide mental health information and education Provide assistance dealing with actual or potential behavioral issues of

persons entering the NETVAC, including communication, mental health assessments, and crisis intervention

Attends to mental health needs of on-site staff Assists with debriefing process Unit Leader: Coordinates all mental health personnel on-site


When notified by PHN Administration, read entire checklist Report to assigned NETVAC site, introduce yourself to site staff Put on appropriate identification, including ID badge. Attend overall staff briefing Familiarize yourself with all site workstations Unit Leader: With the NETVAC Unit Leader, determine initial instructions

and priorities; brief and assign staff

Ongoing Process/Intermediate Actions: (Broken down by station)

Unit Leader Continually assess traffic flow from MH viewpoint and MH worker

fatigue levels; adjust assignments accordingly Keep NETVAC Unit Leader apprised of problems or potential

problems, MH staffing issues Attend to mental health needs of on-site NETVAC staff Facilitate flow of information among staff and during shift transition,

including “real-time lessons learned” Conduct end-of-shift debriefings of MH staff Keep action log of pertinent events

Greeting Area & Line


May 2, 2006

Deal with behavioral issues as people enter and remain in line De-escalate potentially disruptive behavior Address children and family issues Distribute and communicate information to those in the line, including

rumor control

Roamer-Distribution Area Intervene at ‘hot-spots’ and bottlenecks Be available to provide crisis intervention for difficult people

Medical Evaluation Area

Provide clinical mental health assessments and interventions Assist in triage matters Provide 5150 assessments Provide traditional mental health information and education Address general concerns; make referrals to appropriate resources


Turn in daily logs Identify issues for the After Action Report Participate in post-event debriefings Develop recommendations for future emergency responses


May 2, 2006


NETVAC LOGISTICS LEAD

Position Assigned to: _______________________________________ Reports to: NETVAC Unit Leader Telephone: _____________________ Location: ________________________ Date: _________________ Shift: _____________

Mission: Oversee logistical support for NETVAC site. Will work closely with the NETVAC Unit Leader, Administrative Assistant, and Facility Liaison. Activation Process/Immediate Actions:

After assignment by the Logistics Section Chief, read this entire checklist Put on appropriate identification – ID badge, onsite specific identifying

clothing as directed Proceed to assigned NETVAC site Activate your support staff phone tree (if applicable) Upon arrival, introduce yourself to the NETVAC Unit Leader, Administrative

Assistant, and Facility Liaison Obtain brief briefing and administrative paperwork/forms from NETVAC Unit

Leader; review them Attend staff briefing Assign and brief logistical support staff daily and as needed on instructions

and priorities

Familiarize self with clinic spaces; assist with set up as necessary Traffic flow through NETVAC stations Equipment and communications Photocopy equipment Storage of supplies NETVAC worker sign-in table and log Break area for NETVAC staff

Familiarize yourself with list of consumable supplies needed for specific

NETVAC mission Report status of logistical support readiness to NETVAC Unit Leader


May 2, 2006


Supervise work activities; ensure that logistics staff has supplies and support to compete their tasks. Activities include:

Continual restocking of supplies at individual NETVAC stations as appropriate

Routine and as needed inventory of supplies Reorder, receipt, and restock of bulk supplies; documentation of the

above Coordination of transportation of persons and supplies from

NETVAC site Documentation of cost of operation

Work with the NETVAC Unit Leader to request supplies through NETVAC Area

Supervisor Working with the Facility Liaison, accept and store supplies Monitor logistics staff for signs of fatigue/stress – schedule staff breaks and meals Brief incoming Logistics Leader



next day Hand out evaluation forms for staff to complete Collect all paperwork Turn in job action sheets to NETVAC Unit Leader Provide information for after action report, attend debrief as instructed


May 2, 2006


NETVAC GENERIC FUNCTION

Position Assigned to: _______________________________________ Reports to: ____________________________ Telephone: _____________________ Location: ________________________ Date: _______________ Shift: _____________________

Mission: To perform tasks as assigned Activation Process/Immediate Actions:

After assignment, read this entire checklist Put on County ID badge Proceed to assigned NETVAC site Upon arrival, sign in at the NETVAC worker sign-in table Attend briefing and receive specific assignment; put on further identification

or identifying clothing if provided

The briefing will include an introduction to the Clinic Manager and Administrative Assistant, and an explanation of

why the NETVAC site has been activated a general overview of how the site and staff members will function

(color-codes for specific jobs, anticipated client traffic flow through the clinic)

anticipated length of NETVAC operational hours how long your shift(s) will be any precautions or personal protective equipment you might need a brief description of the resources available on site, including

personnel, food, where the break area is Receive prophylaxis or vaccination when directed Familiarize self with clinic spaces; assist with set up as necessary

Traffic flow Equipment and communications, photocopy, fax Storage of supplies


You will be given specific tasks. Ask for clarification as needed Your ‘boss’ should know where you are Remember to stay hydrated and to take breaks when assigned Be sure to log in and out accurately


May 2, 2006



next day Provide information for after action report, attend debrief as instructed


May 2, 2006

Personnel Phone Tree In case of an emergency it is essential to activate staff in an efficient and timely manner. Cooperation is needed to develop telephone trees for each department and to update it every six months at a minimum. On the following page is the telephone tree to be used with the personnel resources of the NETVAC. Once adapted to your department configuration, the telephone tree should be placed in the Public Health Shared Drive, in the folder “PH Telephone Tree,” and updated at least every six months.


May 2, 2006

Name Title

Home: Cell:

Pager:

Name Title

Home: Cell:

Pager:

Name Title

Home: Cell:

Pager:

Name Title

Home: Cell:

Pager:

Name Title

Home: Cell:

Pager:

Name Title

Home: Cell:

Pager:8

Name Title

Home: Cell:

Pager:

Name Title

Home: Cell:

Pager:

Name Title

Home: Cell:

Pager:

Name Title

Home: Cell:

Pager:

Name Title

Home: Cell:

Pager:

Name Title

Home: Cell:

Pager:

Name Title

Home: Cell:

Pager:

Name Title

Home: Cell:

Pager:


May 2, 2006


Physical Requirements and Logistical Considerations

NETVAC SITE INFORMATION FORM Please fax this form to__________by__(date)_

1. BASICS

City:______________________________________________________________________________ Name of site(s):_____________________________________________________________________ Location:__________________________________________________________________________ Contact person who can activate the site on a 24-hour basis:

Name:_________________________________________________________________________ Phone number:__________________________________________________________________

ACCESSIBILITY Is the site accessible to at least one major access road? YES NO Is the site accessible to mass transportation? YES NO Is the site handicap-accessible? YES NO Number of parking spaces:____________________________________________________________ 3. SIZE Approximate number of total square feet available and in what configuration. Ideally, each site would have at least one large auditorium-type space with additional smaller rooms. Schools may be ideal for this purpose. __________________________________________________________________________________ __________________________________________________________________________________ 4. INFRASTRUCTURE Does the facility have: Heat YES NO Air conditioning YES NO Phone lines YES NO Number_____________ Fax machine YES NO Number_____________ Copy machine YES NO Number_____________ Extension cords YES NO Number_____________ Paper YES NO Computer with High-speed internet YES NO Number_____________ Tables and chairs YES NO Number_____________ Refrigerator YES NO TV/ VCR/radio YES NO Number_____________ Printer YES NO Number_____________ Floor plan sent to Public Health Department YES NO Clinic design available YES NO Backup generator YES NO Toilet facilities (how many)__________________________________________________________ Handicap-accessible toilets (how many)________________________________________________ 5. SECURITY Is there a fence around the site? YES NO

May 2, 2006

NETVAC SITES



May 2, 2006



May 2, 2006

Enteric Go Kit Contents

Product Order # Description Manufacturer

Unit of Order

# Needed

On Hand

3BY-90187 Rescue Backpack 1 1 2

0.200 Latex gloves - sm Medline 100/bx 5 pr bx

0.201 Latex gloves - med Medline 100/bx 8 pr bx

0.202 Latex gloves - lg Medline 100/bx 5 pr bx

0.417 Vinyl gloves - sm Medline 100/bx 3 pr

0.418 Vinyl gloves - med Medline 100/bx 5 pr bx

0.419 Vinyl gloves - lg Medline 100/bx 3 pr bx

0.437 Disposable Gowns 3M 15/case 6 17

2200 N-95 mask 3M 20/bx 6 20

19-041-712 Plastic Goggles Fisher 1 5 10

0.133 Fluidshield Masks Tecnol 25/bx 5 25

0.134 Procedure Masks Tecnol 50/bx 5 bx

Red Biohazard Bags 2 bx

0.191 Biohaz Specimen Bags pk 10

Enteric: C&S 8 10

Enteric: O&P 4 5

0.161 Tongue Blades 500/box 10 bx

0.166 Sterile Specimen Cont Cardinal ea 5 75

TMSIR3 Thermometer Braun 1 1 1

TMSPC Disposable Probe Covers Braun 800/cs 40 800

0.127 Alcohol Swabs box 1/2 box

0.138 Waterless towelettes box 1/2 box 200

Hand sanitizer Ecolab bottle 4

0.187 Brown Paper Bags ea 10

CD Book 1 1


May 2, 2006

Respiratory Go Kit Contents

Stock or Product Order

# Description Manufacturer Unit of Order

# Needed

to Stock

Kit On

Hand

3BY-90187 Rescue Backpack 1 1 1

Digital Camera 1 1

CD Book 1 1

33-34 Punch Bx Kit 4.0mm Miltex 50/box 3 1

Latex gloves - sm Medline 100/bx 5 pr

Latex gloves - med Medline 100/bx 8 pr

Latex gloves - lg Medline 100/bx 5 pr

Vinyl gloves - sm Medline 100/bx 3 pr

Vinyl gloves - med Medline 100/bx 5 pr

Vinyl gloves - lg Medline 100/bx 3 pr

N-95 respirator 3M 20/bx 6

Fluidshield mask Technol 25/bx 6

Procedure mask Technol 50/bx 6

Disposable gown 3M 15/bx 6

Plastic goggles Fisher 1 5

1912 Suture Set (sterile) 1 2 4

0.566SN1699G Suture Monosof 50/box 2 1

Lidocaine 1% injectable 25/bx 1

1317 Sterile needle 25 ga x 5/8" BD 100/box 8 bx

1313 Sterile needle 20 ga x 1" BD 100/box 6 bx

14-959-90 Sterile Dacron Swabs Fisher 1000/bx 20 bx

0.275 Scalpel w/ #10 blade ea 3 6 bx

3001 Microscope Slides Allegiance box 1 box 2 bx

HS 15986 Plastic 5-Slide Mailer Fisher 25/pk 4 25

Red Biohazard Trash Bag Fisher 200/bx 145.37 bx

695110 Sterile Screw-capped plastic vial 1.5ml capacity E&K Scientific 100/bx 10

13-374-16 Parafilm Fisher 125/bx 10 x


May 2, 2006

0.2688 Blood Tubes: 6cc yellow BD 100/pk 8 pk

367856 Blood Tubes: 3cc purple BD 100/pk 8 pk

4500 Vacutainer sleeve Bioplexus 250/box 2 bx

21 ga 1" phlebotomy needle Bioplexus 1000/cs 3 100

1359 12cc syringe Monoject 100/bx 4 bx

1352 3cc syringe Monoject 100/bx 3 bx

0.029 23ga butterfly BD 100/box 3 bx

0.39.0 Sharps container (1 qt) ea 1 4

0.191 Biohazard Spec Bags - sm pk 3

0.127 Alcohol Swabs box box

0.138 Waterless towelettes 100/bx 20 pks 200

0.372 Band Aids box 1 box

Hand Sanitizer 4 oz /case 4

Viral Transport Media PHL vial 3

Formalin-fixed biopsy collection kit

IVAC oral thermometer

probes

4BB-84023 Insulated Cooler Bag Lab Safety Supply ea 1 2

4BB84077 Reusable Hot/Cold Packs Lab Safety Supply 12/pk 2 12


May 2, 2006

Minimal Clinic Equipment/Supplies

Each NETVAC site is set up with assistance from the facility owner/operator and the City OES Logistics Section. The following list summarizes logistics requirements (supplies and equipment) for one NETVAC site.

LOGISTICS REQUIREMENTS FOR ONE NETVAC SITE ITEM QUANTITIES/NOTES

Chairs 200

Clipboards 500

Computer, with software and high-speed printer 2

Computers, laptop 21 (if on-site data entry is done)

Copier (leased) 1

Crowd control systems (ropes, cones, stakes) 500 feet of caution tape, 40 stakes or cones

Documentation collection bins 300

Duct tape rolls 5

25 feet 22

Flip chart with pens 2

Floodlights (number depends on site location)

Tables 30

Hand stamps with pads (red, green, blue) 10 – 15

Office supplies: red pens, lined pads, rulers, staplers, staples, staple remover, paper clips, tape, Post-it notes

Quantities to be determined from setup

Pens or pencils for registration 1,500

Power strips 25

ITEM QUANTITIES/NOTES Presentation system (computer projector/screen)

1

Radio, battery, battery charger, spare battery

1

Sign-making supplies 40 poster boards, 10 markers, string or posts

Telephones and telephone lines 10

Vehicle (for internal support) 1


May 2, 2006

Water, bottled, pint, case/24 Operational Area or City EOC to request canteen support from American Red Cross (ARC)

Food for NETVAC site staff Operational Area or City EOC to request canteen support from ARC

Note: See complete NETVAC Logistics Needs Spreadsheet below for additional requirements (pharmacy, medical, and forms). The Public Health Division provides these items.

CHILDREN’S ANTIVIRAL MEDICATION DOSAGES (FOR INFLUENZA) Oseltamivir (Tamiflu) 75 mg capsules, 60 mg/5 ml Influenza A and B, Treatment [>1 yo, <15 kg, <33 lb] Dose: 30 mg PO bid x5d; Start: w/in 48h of symptoms onset [>1 yo, 15-22 kg, 34-49 lb] Dose: 45 mg PO bid x5d; Start: w/in 48h of symptoms onset [23-40 kg, 50-88 lb] Dose: 60 mg PO bid x5d; Start: w/in 48h of symptoms onset [>40 kg, >88 lb] Dose: 75 mg PO bid x5d; Start: w/in 48h of symptoms onset Influenza A and B, Prophylaxis [>13 yo] Dose: 75 mg PO qd; Start: w/in 48h of exposure; Info: give >7d Renal Dosing [adjust dose amount] CrCl <30: decreased dose, amount not defined; HD: not defined Hepatic Dosing [not defined] Amantadine Influenza A, Treatment [1-10 yo] Dose: 5 mg/kg/d PO div bid x3-5d; Start: w/in 48h of symptoms onset; Max: 150 mg/d; Info: D/C w/in 24-48h of symptoms resolution [>10 yo] Dose: 100 mg PO bid x3-5d; Start: w/in 48h of symptoms onset; Max: 200 mg/d; Alt: 5 mg/kg/d PO div bid x3-5d; Info: D/C w/in 24-48h of symptoms resolution Influenza A, Prophylaxis [1-10 yo] Dose: 5 mg/kg/d PO div bid; Start: prior to or immediately upon exposure; Max:


May 2, 2006

150 mg/d [>10 yo] Dose: 100 mg PO bid; Start: prior to or immediately upon exposure; Max: 200 mg/d; Alt: 5 mg/kg/d PO div bid Renal Dosing [adjust dose frequency] CrCl 10-50: give q48-72h; CrCl <10: give q7d; HD/CAPD: no supplement


May 2, 2006

Hepatic Dosing [not defined] hepatic impairment: caution advised Amantadine dosage, children 1-10 years old 50 mg/5 ml, dose 5 mg/kg/day or 2.5 mg/kg/dose bid Mg (ml) Per dose

Mid weight in kg (mg/2.5)

Mid weight in lb (kg x 2.2)

Weight range (pounds)

10 (1) 4 (n/a) 8.8 (n/a) 25 (2.5) 10 22 15-23 30 (3) 12 26.4 24-30 40 (4) 16 35.2 31-39 50 (5) 20 44 40-48 60 (6) 24 52.8 49-57 70 (7) 28 61.6 58-65 75 (7.5) 30 66 66 and

above Rimantadine Influenza A, Prophylaxis [1-10 yo] Dose: 5 mg/kg/d PO div qd-bid; Start: prior to or immediately. upon exposure; Max: 150 mg/d [>10 yo] Dose: 100 mg PO bid; Start: prior to or immediately. upon exposure; Max: 200 mg/d; Alt: 5 mg/kg/d PO div bid Renal Dosing [1-10 yo] Info: specific pediatric dosing adjustments not defined; see adult renal dosing for guidance [>10 yo] CrCl <10: 100 mg qd; HD: not defined Hepatic Dosing [1-10 yo] Info: specific pediatric dosing adjustments not defined; see adult hepatic dosing for guidance [>10 yo] severe impairment: 100 mg qd


May 2, 2006

ASSUMPTIONS TO SET UP A NETVAC Demographics

• San Mateo County Population: 700,000 • Estimated number of days to provide vaccine/antiviral prophylaxis: 10

days • Priority groups: to be determined by CDC and State authorities • Number of shifts/day: two 12 hour shifts/day, including a 15% staff

downtime • Number of licensed staff/site: 1 • Percentage of families with children to be treated: 35% • Time required to vaccinate: 1 minute/person

Sites

• Number of NETVACs to be activated: Initially one, localized in the area where the cluster of cases starts. If needed, four more NETVAC sites will be opened, all of them strategically located in different areas of the county. If the outbreak spreads out throughout San Mateo, a total of 48 NETVACs will be made available.

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Clinic Flow

• As the public arrives to the NETVAC, a single line will be formed, where four greeters/screeners will check people for allergies/contraindications/special medical circumstances. Priority groups protocol to be followed as needed.

• Greeters/screeners will assist the public to register on the roster while waiting in line. Registration will be limited to signature of the recipient.

• Greeters/screeners will classify patients by stamping their right hand as follows: Green color: gives access to one of the two express lines. One staff assigned to each one of the express lines. Red color: medical evaluation is required. Two staff will be assigned to this area, one of them a licensed person. Blue color: directed to area for special populations or families with children. Two staff to be assigned to this table


May 2, 2006

• Following the screening, two flow monitors will direct the public to the

corresponding tables inside the NETVACs. • Medical evaluator will have the option to provide vaccine/prophylaxis to

the patient, or to initiate transfer to a medical center. • Once the patient has received vaccine/prophylaxis, he/she will be sent

home immediately. • If a second dose of vaccine is required, posters in different languages will

be displayed throughout the NETVAC with specific instructions regarding this issue.

• If available, antivirals will be distributed by staff while patients wait in one of the four lines inside the NETVAC site.

• Translators provided by the cities and Health Department will be available on site, as needed.


May 2, 2006

X. COMMUNITY DISEASE CONTROL AND PREVENTION— LEGAL ASPECTS

I. INTRODUCTION This section incorporates the practice guide, “Health Officer Practice Guide for Communicable Disease Control in California,” as applicable to the San Mateo County Health Department Pandemic Influenza Plan. This guide was created to provide guidance to local Health Officers in California when responding to bioterrorism as well as to actual or suspected cases of naturally occurring communicable disease. The guide discusses mechanisms that are available or not available prior to the calling of a local or statewide emergency. If a local emergency has been called, the user of this practice guide should also review the guide entitled, Authority and Responsibility of Local Health Officers in Emergencies and Disasters.

1

The practice guide is a collaborative project of the Public Health Law Work Group. It was drafted by several County Counsel and City Attorney Offices, and edited by several Health Officers. It was then reviewed by representatives of the California Conference of Local Health Officers, County Health Executives Association of California, and the California Department of Health Services. It serves merely as a starting point and will hopefully help trigger a more detailed analysis and discussions between Health Officers and their legal counsel. While the users of the guide may want to turn to the particular area of the guide that specifically addresses the proposed action to be taken, such as ordering a mass quarantine, it is important that the user also refer to other general topic areas that are applicable to all Health Officer activities. The first of such topic areas can be found in Section II, General Authority of the Health Officer, which gives an overview of the general statutory powers of Health Officers. Because there is no specific statutory authority for many of the particular orders that a Health Officer may wish to make, the authority for these actions will ultimately


May 2, 2006

flow from the Health Officer’s general authority to “take measures as may be necessary to prevent the spread of the disease or occurrence of additional cases.” Health Officers must exercise their power in a manner that is consistent with the protections afforded to individuals under the United States and California constitutions. Any Health Officer order must have an adequate justification if it impacts or limits liberty, freedom of movement, bodily integrity, privacy or property. The necessity of the order should be balanced against the extent of the infringement on the individual’s rights. The justification for the order becomes more demanding as the individual interests at stake become more significant. What is sufficient in one set of circumstances may not be sufficient in another. These protections are discussed in the Section III, Constitutional Parameters Impacting Authority of the Health Officer. Other general topic areas include: (1) Enforcement Of Health Officer Authority, which presents a discussion on the types of preliminary procedural considerations that should be analyzed when issuing Health Officer orders; (2) Interjurisdictional Coordination and Cooperation, for those events when the Health Officer may need to coordinate with various federal, state, and local agencies, and (3) Confidentiality of Health Information and Media Resources and Management, both of which address the Health Officer’s release of confidential health information in carrying out public health activities. II. GENERAL AUTHORITY OF THE HEALTH OFFICER A. HEALTH OFFICER DEFINED For purposes of the Communicable Disease Prevention and Control Act, the term “Health Officer” is defined to include county, city, and district Health Officers, and city and district health boards, but does not include advisory health boards.

2

Although the county Health Officer is not defined specifically as the “local health officer” in statutes dealing with communicable disease control, several Health and Safety Code sections define the two terms interchangeably, e.g., “health officer” or “local health officer”, each of which includes his or her designee.

3

B. SOURCES OF HEALTH OFFICER AUTHORITY 1. Appointment by the Governing Body. The position and powers of the Health Officer derive from statute, but the appointment of each Health Officer is based upon the actions of the local governing body.

4

The statutes authorize the appointment of a Health Officer in each county and city

5

and the purpose for which each position is filled by the local authority.

6

The Health Officer is required to observe and enforce (1) local orders and ordinances pertaining to the public health; (2) orders prescribed by the State Department of Health Services (DHS); and (3) statutes relating to the public health. Health Officers appointed by county Boards of Supervisors can act as a


May 2, 2006

city Health Officer, if the city by ordinance, resolution, or contract designates the county Health Officer to be the city Health Officer.

7

2. Local Ordinances and Resolutions Under the California Constitution, cities and counties may enforce within their limits “all local, police, sanitary, and other ordinances and regulations not in conflict with general laws.”

8 The governing body of each city and county is

required by statute to take measures necessary for the preservation and protection of the public health, including the adoption, if indicated, of ordinances and resolutions not in conflict with the general laws.

9 It is the duty of the Health

Officer to enforce these ordinances and resolutions. 3. State Statutes The Health and Safety code contains the statutes pertaining to communicable disease prevention and control as well as the authority of the Health Officer.

10

4. DHS Regulations and Orders Title 17 of the California Code of Regulations contain the regulations of DHS applicable to Health Officers.

11 In addition to the regulations, DHS may issue

direct orders to Health Officers. The Health Officer must, when required by DHS, act to enforce all DHS orders, rules and regulations.

12

When the public health is menaced, the Health Officer’s actions may be controlled and regulated by DHS.

13

DHS regulations and orders set the minimum measures to be observed by the Health Officer. The Health Officer may take more stringent measures where circumstances require. For a more extensive discussion of the powers of DHS, see Section V, Interjurisdictional Coordination and Cooperation. C. HEALTH OFFICER AUTHORITY TO INVESTIGATE AND REPORT DISEASE DHS is mandated to create a list of reportable diseases and conditions. Specified providers of health care and under certain circumstances, individuals are required by regulation to report those diseases and conditions to the Health Officer

14

and Health Officers in turn, must report specified diseases to DHS.15

In addition, Health Officers may require providers of health care in their respective jurisdictions to disclose a disease that is not listed in the DHS regulations.

16

Health Officers are also the agent of DHS for conducting certain studies

17

and undertaking investigations and actions as directed by DHS.

18

Health Officer’s disclosure of information is governed by the California Code of Regulations (CCR),

19

the Health Insurance Portability and Accountability Act of 1996 (HIPAA),

20

the Confidentiality of Medical Information Act contained in California Civil Code §56.10, and may be subject to various other confidentiality statutes, some of which are described in Section VI, Confidentiality of Health Information.


May 2, 2006

The primary purpose of these reporting requirements is to alert Health Officers to the presence of disease within their jurisdiction.

21

Upon receiving a report of communicable disease, Health Officers shall take whatever steps as may be necessary for the investigation and control of spread of the disease, condition or outbreak reported. Under DHS regulations, the Health Officer must provide for an examination of the person or animal in order to verify the diagnosis, existence, or outbreak of the disease, investigate the source and take appropriate steps to prevent or control the spread of the disease.

22

In circumstances involving an “immediate menace to the public health” caused by calamity, such as flood, storm, fire, earthquake, explosion, accident, or other disaster, the Health Officer may close the area where the menace to public health exists.

23

D. HEALTH OFFICER AUTHORITY TO PREVENT AND CONTROL COMMUNICABLE DISEASE In order to receive state funding, Health Officers must provide: "Communicable disease control, including availability of adequate isolation facilities, and the control of acute communicable diseases..., based upon provision of .... appropriate preventive measures for the particular communicable disease hazards in the community."

24

To fulfill this requirement, Health Officers are authorized to control contagious, infectious, or communicable disease and may “take measures as may be necessary” to prevent and control the spread of disease within the territory under their jurisdiction.

25

This statutory provision alone can authorize all manner of measures taken by Health Officers, provided that the measures are necessary to prevent the spread of disease. In the sections of this practice guide that address specific measures, the section will commence with a discussion of this general authority, followed by a discussion of the statutes that specifically authorize the particular measure. For example, the general authority can be cited to support the imposition of isolation or quarantine. However, the Health Officer has additional statutory authority to isolate and quarantine,

26

including on a mass level so long as the quarantine is not imposed on another city or county without the consent of DHS.

27

This is discussed with more detail in Section VIII, Limiting the Movement of Individuals and Groups. This general authority may also include the ability to close or restrict public assemblies or gatherings, require evacuation, examination, inspection, vaccination, decontamination, disinfection, property destruction or commandeering, and to compel assistance. Each of these potential actions will be addressed more directly in the sections that follow.


May 2, 2006

E. HEALTH OFFICER’S JURISDICTIONAL TERRITORY AND ENFORCEMENT OF HEALTH OFFICER ORDERS The Health Officers’ general powers authorize him/her to act in the unincorporated areas of the county

28

and those of the city Health Officer authorize action within the city’s borders.

29

A city may by ordinance, resolution, or contract authorize the enforcement of public health laws by the county Health Officer within the city. A county may contract with a city for the enforcement of public health laws by the city in county’s jurisdiction. City and county Health Officer enforcement authority in each other’s jurisdiction may be authorized by agreement.

30

The enforcement of the communicable disease control laws is generally initiated by an order from the Health Officer that an individual act or refrain from acting in a particular manner. An individual must comply with the Health Officer’s orders, or risk civil or criminal sanctions.

31

These sanctions can include up to and including fines and imprisonment, depending upon the nature of the circumstances. Issues of enforcement are addressed in more detail in Section IV, Enforcement of Health Officer Authority. F. HEALTH OFFICER POWERS, DUTIES AND RESPONSIBILITIES ARE CIRCUMSCRIBED BY CONSTITUTIONAL LIMITATIONS Although Health Officers are statutorily mandated to take all necessary measures to prevent the transmission of disease, and with it the attendant authority to enforce orders,

32

such power is not unlimited. Because the Health Officer’s exercise of authority may impact, curtail or impair an individual’s protected rights and liberties, constitutional considerations may arise. See Section III, Constitutional Parameters Impacting Authority of the Health Officer. G. HEALTH OFFICER AUTHORITY TO DECLARE A LOCAL EMERGENCY In situations involving hazardous and or medical waste release that is an immediate threat to the public health, Health Officers may declare a “county health emergency.”

33

If a local emergency is due to factors other than hazardous or medical waste, the Health Officer cannot declare a local emergency

34

unless expressly granted that authority by the local governing body.

35

Few California counties have granted such short-term authority to its Health Officer. Any formal declaration of local emergency or county health emergency issued by a Health Officer must be ratified by the local governing body within a very limited number of days to remain effective.


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III. CONSTITUTIONAL PARAMETERS IMPACTING THE AUTHORITY OF THE HEALTH OFFICER A. PROTECTING PUBLIC HEALTH IS AN EXERCISE OF POLICE POWER The Health and Safety Code grants broad powers to Health Officers to promote public health or safety. Actions taken under this statutory authority are an exercise of police power.

36

Courts have held that: “The preservation of the public health is universally conceded to be one of the duties devolving upon the state as a sovereignty, and whatever reasonably tends to preserve the public health is a subject upon which the legislature, within its police power, may take action.”

37

This police power is limited by the protections contained in the United States and California Constitutions as interpreted by the courts. B. HEALTH OFFICER ACTIONS MUST BE CONSISTENT WITH CONSTITUTIONAL REQUIREMENTS 1. United States and California Constitutional Requirements

38

Both the U.S. and California Constitutions provide that life, liberty, or property shall not be deprived without due process of law. Due process rights protect individuals from excessive “government intrusion.” This is especially relevant to Health Officer’s orders because violation of such orders carries a risk of imprisonment. Due process requires “fundamental fairness” in governmental action. There are two major components to the concept of fundamental fairness. One addresses the adequate justification for the anticipated action (“substantive due process”) and the other concerns the steps used in carrying out the anticipated action (“procedural due process”). Health Officer orders should not be arbitrary, oppressive or unreasonable.39 2. Health Officers Should Have Adequate Justification Any Health Officer order must have an adequate justification if it impacts or limits liberty, freedom of movement, bodily integrity, privacy, or property. Disease control is generally considered adequate justification if there are sufficient facts to support the action and the action is appropriately tailored to fit the particular circumstances. The necessity of the order is balanced against the extent of the infringement on the individual’s rights.

40

The justification for the order becomes more demanding as the individual interests at stake become more significant. What is sufficient in one set of circumstances may not be sufficient in another.

41

Health Officers should be aware that they need adequate justification to intrude on a patient’s freedom of movement, bodily integrity, or privacy, and they should make every effort to minimize the impact on personal liberty.


May 2, 2006

a. Health Officers should have reasonable grounds for the proposed action Reasonable grounds

42

consist of (1) the Health Officer’s reasonable belief43

that a case of a reportable disease, or any other contagious, infectious or communicable disease exists, or has recently existed, or may spread into

44

the territory under his or her jurisdiction and (2) facts supporting the Health Officer’s determination that the proposed action may be necessary to prevent the spread of the disease or occurrence of additional cases.

45

b. The Health Officer’s order should be narrowly tailored and the least restrictive alternative The parameters of the order must be narrowly tailored to meet the Health Officer’s goal in stopping the spread of disease.

46

Only those measures reasonably necessary may be taken to protect the public health and the intrusion must be only until such time as the person no longer poses a threat to public health.

47

3. Health Officers Should Take Into Account Any Necessary Procedural Safeguards Depending upon the nature of the public health risk, all of the surrounding circumstances and the kind of restrictions sought to be imposed, the Health Officer must consider what procedural safeguards or processes are due to ensure that the restrictions are fairly imposed. This generally includes fair notice and the opportunity to be heard. Some statutes provide for a specific hearing process,

48 but in general communicable disease control statutes do not provide a

specific mechanism to challenge the order.49

Due Process is a flexible concept and calls for such protections as a particular situation demands.

50

The extent to which procedural safeguards must be available depends on a balancing of the interests at stake in each case. In some instances where the liberty or property interests at stake are substantial, such as a prolonged isolation in a confined facility or the destruction of a substantial amount of property, this balancing may result in the need for a formal hearing procedure that includes the right of confrontation and cross-examination, as well as a limited right to an attorney.

51

In others, all that may be required is for the Health Officer to provide a phone number to lodge objections. Specific procedural safeguards for particular Health Officer actions are addressed in their respective sections of this document. The Health Officer's order is the notice to the individual(s) that they must comply with the Health Officer’s directive. This order must be in a form calculated to reach the individuals subject to it, set forth its conditions,

52

duration,53

any potential penalty for violation,

54

and the facts55

and legal basis56

to support the order. The order also may need to explain the method by which a person may register


May 2, 2006

objections. The required content for orders directed toward specific actions or events are addressed in their respective sections in this practice guide. 4. Health Officer Actions Involving Searches and Seizures. Orders that involve the seizure, destruction

57

or search of personal and real property, must be reasonable under the circumstances. If consent is not obtained, a warrant may be required to search, seize and dispose of personal or real property in a manner not otherwise statutorily authorized, such as routine inspection.

58

An exception may be available for exigent circumstances or where the intrusion serves “special governmental needs” beyond ordinary law enforcement, such as where the search serves public health or safety objectives.

59

The requirement for obtaining either consent or a warrant is due to the protections of the United States and California Constitutions,

60

which may also require compensation to the owner for property loss or damage.

61

Physical examination and diagnostic testing of individuals may constitute an unreasonable search in some instances. See Section IX, Involuntary Vaccination, Examination, Decontamination and Treatment. C. OTHER CONSTITUTIONAL CONSIDERATIONS In addition to due process requirements, other constitutional provisions may be implicated by Health Officer actions. These include, but are not limited to, privacy, freedom of assembly, equal protection, and freedom against cruel and unusual punishment.

62

IV. ENFORCEMENT OF HEALTH OFFICER AUTHORITY A. THE AUTHORITY TO ENFORCE HEALTH OFFICER ORDERS DERIVES FROM THE STATUTORY DUTIES AND POWERS OF THE HEALTH OFFICER One of the methods used to control the spread of communicable disease is the issuance of orders by the Health Officer. These orders consist of a demand by the Health Officer to persons or businesses to either do something or refrain from doing something. Sometimes, the recipient of an order does not comply. In such cases, there needs to be “enforcement” of the order. To “enforce” literally means “to give force to.”

63

There are two methods that can be used to enforce a Health Officer order: criminal enforcement and civil enforcement. A failure to comply with an order of the Health Officer may constitute a public offense.

64

If not complied with, the demand or order may be followed by the application of physical force in the form of an arrest of the person who has failed to comply.

65

This is known as criminal enforcement. Civil enforcement, is the obtaining of a court order ordering the person or business to comply with the Health Officer’s order. Both of these methods are discussed in more detail below in subsection D.


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The authority to enforce Health Officer orders is derived from the police powers of the state, county, or city.

66

Article XI, Section 7 of the California Constitution provides that: "A county or city may make and enforce within its limits all local, police, sanitary, and other ordinances and regulations not in conflict with general laws."

67

Health Officers must enforce and observe orders and ordinances of the Board of Supervisors or the City Council,

68

as applicable, DHS Orders69

and state statutes and regulations relating to public health.

70

The legal basis for the enforcement of Health Officer orders derives from the Health Officer’s duty to uphold and enforce statutes, regulations, local ordinances, and DHS orders.

71

Additional enforcement authority is contained in statutes that expressly mandate compliance with specified Health Officer orders.

72

B. ENFORCEMENT OF HEALTH OFFICER ORDERS MUST MEET CONSTITUTIONAL DUE PROCESS REQUIREMENTS The Health Officer’s authority is limited by the United States and California Constitutions, which protect individuals from excessive government intrusion. See Section III, Constitutional Parameters Impacting Authority of the Health Officer. C. PRELIMINARY STEPS TO ENFORCEMENT There are preliminary procedural considerations depending upon the avenue of enforcement involved. The first consideration is that there must be legal authority for the issuance of the order, in other words, the order must be valid. In addition, the facts and circumstances surrounding the order should be considered. These considerations may include the threat to public health, the facts that supported the issuance of the order, how the order was delivered, the nature of the order, the contents of the order, the recipient’s ability to understand and comply with the order, the compliance date, any statutorily required contents, and supporting documentation. The supporting documentation should demonstrate that the failure of the person or entity to comply with the Health Officer’s order presents a substantial risk to the public health or welfare. It should also show that the subject of the order had a reasonable opportunity to voluntarily comply under the circumstances.

73

This is necessary to meet the constitutional parameters discussed in Section III. Additional procedural considerations for enforcement of particular Health Officer orders, such as isolation and quarantine and inspection of property, are addressed in their respective sections. D. ENFORCEMENT METHODS IN THE EVENT OF NON-COMPLIANCE WITH HEALTH OFFICER ORDERS Other than orders issued under the tuberculosis statutes, there is no statutorily prescribed procedure for the enforcement of Health Officer orders.

74

A Health Officer has two enforcement avenues available in the event of non-compliance:


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civil and criminal. The appropriate avenue available in each situation will depend on state and local laws granting the authority to act, the existing circumstances and local policies, procedures and limitations on the powers of the Health Officer.

75

Although legal counsel will be involved in both the civil and criminal court processes, the active participation of the Health Officer to assist in the preparation of court documents as well as testimony should be anticipated. 1. Civil Civil enforcement actions are those pursued through the civil court system. Counsel will file a civil complaint for the Health Officer requesting a court order compelling compliance with the Health Officer’s order or any applicable statute, regulation or ordinance, and requesting the imposition of civil penalties. Civil actions also can be used to obtain an injunction to prohibit an action that is contrary to the public health. The nature of the relief sought depends upon the terms contained in the ordinance, statute, or regulation relied upon for the basis of the enforcement action. In situations involving the search or seizure of property, Health Officers should discuss the necessity of obtaining an administrative warrant with their legal counsel. 2. Criminal Criminal enforcement actions are those pursued through law enforcement and or the criminal court system. A violation of a Health Officer order may constitute a crime.

76

Various statutes, ordinances, and regulations provide for criminal sanctions.

77

For orders issued under the laws pertaining to communicable disease control, violations of those statutes

78

and Health Officer orders made pursuant to the DHS orders, rules, and regulations regarding quarantine and disinfection

79

are misdemeanors. In addition, every person charged with the performance of any duty under the laws of this state relating to the preservation of the public health, who willfully neglects or refuses to perform the same, is guilty of a misdemeanor.

80

When quarantine or isolation, either strict or modified, is established by a Health Officer, all persons are required to obey the Health Officer’s rules, orders, and regulations.

81

The power to arrest persons for crimes and public offenses is set forth in the Penal Code. An arrest is the taking of a person into custody as authorized by law. Because Health Officers do not have peace officer status,

82

criminal enforcement requires local law enforcement involvement and may also include the District Attorney and Probation department.

83

a. Referrals to the District Attorney The Health Officer may refer matters to the District Attorney for prosecution. The referral should include the following information: the facts, the nature of the


May 2, 2006

offense, who committed the offense, why the offense endangers the public health, whether or not time is of the essence and, where appropriate, any recommendations regarding a penalty. As with all referrals made to the District Attorney, it is within the discretion of the District Attorney as to whether to prosecute. When a court order has been obtained, the Probation Officer or District Attorney may require the assistance of the Health Officer regarding detention and or terms of probation. b. Requests for warrants In conjunction with the referral to the District Attorney, the Health Officer may want to discuss with the District Attorney whether a warrant for the arrest of the individual be requested. Once issued, the warrant must be served by law enforcement officers, most likely the sheriff or local police. E. ENFORCEMENT OF COURT ORDERS Once court orders are issued, counsel representing the Health Officer in civil matters and the District Attorney in criminal matters will undertake any necessary follow-up enforcement procedures. The follow-up steps can include service of the order and initiation of contempt of court proceedings for continued violations. F. PREPAREDNESS POINTS 1 Health Officers may wish to meet with the District Attorney to establish a

protocol or procedure for making public health referrals for prosecution. Such protocol or procedures will expedite the handling of matters that may be time sensitive. The procedures should be reviewed periodically, particularly to ensure that the Health Officer is aware of the current deputy district attorney assigned to handle such matters.

2 Health Officers may wish to consider developing a relationship with local law enforcement agencies to establish a protocol for obtaining their assistance in with enforcing public health related court orders.

3 Health Officers may wish to consider developing a relationship with the Court Executive Officer and the Presiding Judge to establish a protocol for the processing and obtaining of public health related court orders.

V. INTERJURISDICTIONAL COORDINATION AND COOPERATION During an outbreak of disease within the Health Officer’s jurisdiction, the Health Officer may need to coordinate with various federal, state, and local agencies. These agencies fall into several categories: (1) the Governor, under the powers of the executive branch of the government; (2) public health agencies, such as the State Department of Health Services or the U.S. Public Health Service, which may also have or claim some authority to respond to the outbreak; (3) non-public health agencies, such as law enforcement, that may have a role in the response


May 2, 2006

to outbreaks; (4) non-public health agencies that may or may not be subject to control by the Health Officer but have property or facilities within the geographic area; and (5) neighboring local jurisdictions impacted by the event. A. STATE DEPARTMENT OF HEALTH SERVICES 1. General Authority of DHS The State Department of Health Services (DHS) advises all local health authorities, and is required to control and regulate the actions of Health Officers when in its judgment public health is menaced.

84

However, the frontline responsibility to respond to outbreaks of disease rests with the Health Officer.

85

DHS is unlikely to assert its authority over actions of the Health Officer unless a public health menace results from a Health Officer’s failure or inability to appropriately respond. The Health Officer must also respond to any DHS request for reported information.

86

2. Disease Surveillance In the area of communicable disease control, DHS may be involved in the surveillance and response to an outbreak of disease, depending upon the pathogen involved.

87

At its request, the Health Officer must report a local epidemic to DHS.

88

a. Reportable diseases DHS is statutorily required to establish a list of reportable diseases or conditions,

89

both communicable and non-communicable, and the list must include the urgency of reporting each disease or condition.

90

Health care providers and, specified circumstances, individuals must report to the Health Officer cases or suspected cases of the diseases or conditions on the list within the timeframe specified.

91

b. Immediately reportable diseases The Health Officer reports immediately by telephone to DHS cases and suspect cases of anthrax, botulism, brucellosis, cholera, dengue, diarrhea of the newborn (outbreaks), diphtheria, plague, rabies (human only), smallpox (variola), tularemia, varicella deaths, viral hemorrhagic fevers, yellow fever, the occurrence of any unusual diseases, and outbreaks of any disease.

92

Diseases implicated in potential acts of bioterrorism must be reported to the Health Officer immediately by telephone.

93

These diseases include anthrax, botulism (infant, foodborne, wound, or other), cholera, plague, varicella (deaths only), smallpox, and viral hemorrhagic fevers (crimean-congo, ebola, lassa, and marburg viruses).


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c. Morbidity and case reports and studies In addition, the Health Officer is required to provide weekly morbidity reports and case reports for specific diseases, including those potentially implicated in bioterrorism and those requested by DHS.

94

DHS can further request that the Health Officer conduct a special morbidity and mortality study.

95

3. Overlapping Authority of DHS and Health Officers DHS and the Health Officer have some specific powers in common.

96

However, DHS also has the power to govern the actions of the Health Officer

97

through its orders, rules, and regulations.

98

DHS has the authority to require the Health Officer to enforce all DHS orders, rules, and regulations.

99

DHS orders, rules, and regulations generally set the minimum measures. Health Officers may take more stringent measures where circumstances require. a. Possession and control of persons Once informed by the Health Officer of any contagious, infectious or communicable disease, DHS may, if it considers it proper, take possession or control of the body of any living person, or the corpse of any deceased person to address the disease.

100

b. Isolation and quarantine DHS also has the power to quarantine, isolate, inspect, and disinfect persons, animals, houses, rooms, other property, places, cities, or localities, whenever in its judgment the action is necessary to protect or preserve the public health.

101

DHS can establish and maintain places of isolation and quarantine,

102

and may destroy personal property when ordinary means of disinfection are considered unsafe, and when the property is in its judgment, an imminent menace to the public health.

103

The Health Officer must ensure adequate isolation and/or appropriate quarantine, and comply with all general and special rules, regulations, and orders of DHS, in carrying out the quarantine or isolation.

104

DHS may also require that the local health officer establish and maintain places of quarantine or isolation that shall be subject to the special directions of DHS.

105

Where DHS determines it necessary, it can direct the Health Officer to quarantine or isolate and disinfect persons, animals, houses, or rooms, in accordance with general and specific instructions of DHS.

106

c. Destruction of property DHS may also direct the Health Officer to destroy personal property when ordinary means of disinfection are considered unsafe and when the property is,


May 2, 2006

in the judgment of DHS, an imminent menace to the public health107

and when DHS determines it is necessary for the protection or preservation of the public health. 4. DHS Written Consent Required for Multi-Jurisdictional Quarantines in California No quarantine shall be established by a county or city against another county or city without the written consent of DHS.

108

For other preventive measures that may involve multiple jurisdictions, the Health Officer needs the cooperation of the other jurisdictions.

B. UNITED STATES PUBLIC HEALTH SERVICE 1. U.S. Surgeon General Authority in National and Multi-National Events The Surgeon General of the U.S. Public Health Service

109

is authorized to make and enforce “such regulations necessary to prevent the introduction, transmission, or spread of communicable diseases from foreign countries into the United States or its possessions, or from one state or possession into any other state or possession.”

110

a. International quarantine by exclusion Whenever the Surgeon General determines that there is serious danger of the introduction of disease from a foreign country into the United States and that a suspension of the right to introduce persons and property from that country is required in the interest of the public health, he or she may prohibit, in whole or in part, the introduction of persons and property from such countries or places.

111

This is, in effect, quarantine by exclusion. The Surgeon General manages quarantine stations to prevent the introduction of communicable diseases into the states and possessions of the United States

112

and is authorized to adopt regulations pertaining to air navigation and aircraft.

113

There are regulatory requirements that ship captains and airline pilots inform the quarantine station of an illness or death aboard the vessel or aircraft prior to arrival at their destination.

114

b. State authority not preempted by Surgeon General The authority of the Surgeon General, however, does not pre-empt the authority of the states.

115


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c. International travel: Once either a vessel, aircraft, or other means of conveyance arrives from an international destination, and before those passengers, crew, or other individuals clear customs, those individuals have not formally entered the U.S. The health jurisdiction over these individuals are vested with the Surgeon General. Once they have cleared customs, health jurisdiction over those individuals resides at the local level. C. DIRECTOR OF CENTERS FOR DISEASE CONTROL AND PREVENTION Whenever the Director of the Centers for Disease Control and Prevention (CDC) determines that the measures taken by health authorities of any state (including political subdivisions thereof) are insufficient to prevent the spread of any of the communicable diseases from such state or possession to any other state or possession, the CDC Director may “take such measures to prevent such spread of the diseases as he/she deems reasonably necessary.”

116

This authority is similar to the general authority granted to state and Health Officers, including the authority to quarantine.

117

Isolation and quarantine are also specifically authorized by regulation.

118

If there is a potential that a disease within the Health Officer’s jurisdiction may spread into another state, it is advisable that the Health Officer work cooperatively with DHS and the CDC to ensure that appropriate measures are taken to prevent its spread. D. HEALTH OFFICER JURISDICTION WITHIN FEDERAL ENCLAVES 1. State Control Over Its Territory May be Limited by Federal Ownership of Specific Territory Within the State Generally, the state has sole authority and control over all places within in its constitutionally-defined boundaries. However, when property within the state is ceded to, purchased, or condemned by the United States, the state’s authority and control may be qualified by the terms of the cession or the laws under which the purchase or condemnation is made.

119

Jurisdiction over several tracts of California land has been ceded to the United States for military or national park purposes.

120

However, some of these tracts may revert back to the state upon the occurrence of specific acts or events.

121

a. Where state legislature does not consent to federal government acquisition of state land With respect to lands acquired other than by cession from the state,

122

the state has ceded concurrent criminal jurisdiction on land held by the United States for military or national forest purposes if specific conditions have been satisfied.

123


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b. Where state legislature consents to federal acquisition of state land Where jurisdiction has been ceded, Congress is empowered under the United States Constitution to exercise exclusive jurisdiction in all cases over all places purchased by the consent of the state legislature for the erection of forts, magazines, arsenals, dock-yards, and other needful buildings.

124

Thus, this federal authority is exclusive of local authority, and a Health Officer cannot exercise authority on such property.

125

To determine whether jurisdiction has been ceded in specific cases, the Health Officer must consult with legal counsel.

126

E. LAW ENFORCEMENT 1. Peace Officer Enforceme nt of Health Officer Orders Law enforcement agencies such as the Sheriff’s office or the local police department enforce Health Officer orders

127

because Health Officers do not have peace officer status.

128

Peace officers have the broadest authority to effectuate an arrest,

129

and are protected in their use of reasonable force to do so.130

Therefore, criminal enforcement requires local law enforcement involvement

131

and may also include the District Attorney

132

and Probation133

department.134

Further, the enforcement of civil orders for detention, isolation or quarantine of individuals will likely be conducted with assistance from law enforcement. 2. Law Enforcement Authority and Control of a Crime Scene Where a reported exposure to a biological pathogen is considered to be the result of a perceived deliberate act in violation of state and federal laws,

135

the location of the exposure or source of exposure will likely be treated as a crime scene by federal, state, or local law enforcement officials. This can create conflicts if the Health Officer considers it necessary to access the location or persons involved to prevent the spread of disease.

136

Once law enforcement officials are involved for purposes of carrying out their responsibilities under the criminal law, rather than enforcing Health Officer orders, the Health Officer must cooperate with the law enforcement authority.

137

It is a crime to interfere with federal officers

138

and state or local peace officers139

in the performance of their duty. 3. Standardized Emergency Management System (SEMS) Acts of perceived bioterrorism will likely be responded to under the California Standardized Emergency Management System (SEMS).

140

SEMS uses the Incident Command System (ICS) to respond at the field level. Under the ICS, response will be headed by an Incident Commander (IC), initially the senior first-responder to arrive at the scene. As the incident grows, the IC may delegate a number of activities, such as planning, operations, logistics, and


May 2, 2006

finance/administration. Where multiple jurisdictions and agencies become involved, a “unified command” structure will emerge. The Health Officer responding to an act of perceived bioterrorism must coordinate with the Incident Commander or unified command.

141

F. OTHER LOCAL JURISDICTIONS 1. Disease Origin or Exposed Person Believed to be Outside the Jurisdiction If a disease is one in which the Health Officer determines that the source of infection is important and believed to be outside the local jurisdiction, the Health Officer must notify DHS or the other Health Officer under whose jurisdiction the infection was probably contracted. Similar notification must be given if exposed persons who should be quarantined or evaluated for evidence of the disease are believed to be living outside the jurisdiction of the Health Officer.

142

2. Mutual Aid If local resources are insufficient to respond to an outbreak of disease, it may be possible to invoke mutual aid from adjoining or nearby jurisdictions under the Emergency Services Act even though a local declaration of emergency has not yet been enacted.

143

G. NATIVE AMERICAN TRIBES Native American tribes have the right to make and be governed by their own laws. However, this does not exclude all state regulatory authority on the reservation. State sovereignty does not end at a reservation's border.

144

1. Disease Outbreak That Threatens To Spread Beyond The Reservation When state interests outside the reservation are implicated, states may regulate the activities even of tribe members on tribal land.

145

Thus, if an outbreak of disease within the borders of a reservation threatens to spread beyond its borders, a Health Officer may be able to enforce orders within those borders. 2. Validity and Enforcement of Health Officer Orders Issued While Individual is Outside the Reservation It is also well established that states have criminal jurisdiction over reservation Indians for crimes committed off the reservation.

146

Thus, if a tribal member is subjected to an order of isolation outside the reservation, then violates that order and returns to the reservation, the state would have criminal jurisdiction over that individual.

147


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H. UNIVERSITY OF CALIFORNIA FACILITIES 1. Health Officers Have Jurisdiction at UC Facilities Article IX, Section 9 of the California Constitution grants broad powers to the Regents of the University of California (UC) and subjects the UC to limited control by the California Legislature.

148

One of the areas in which UC is subject to legislative control is when the control constitutes an exercise of the police power governing private persons and corporations in general. Statutes, regulations, and ordinances pertaining to the control of communicable diseases are based upon the police power of the state and may be applied to UC. In addition, legislation regulating specific activities on matters of statewide concern rather than internal university affairs, may be applied to UC.

149

Statutes and regulations pertaining to the control of communicable diseases are statutes of statewide concern and thus should apply to UC. Therefore, statutes and regulations for communicable disease control that do not generally apply to the public; e.g., disease reporting and hospital infection control requirements, but regulate matters of statewide concern, would apply to UC. The jurisdiction of the Health Officer extends to the unincorporated territory of the county and to the territory of a city within the county upon the consent of the local governing body. The Health Officer has jurisdiction over the UC facility if it is located within the territory of the Health Officer. 2. The UC Police Department Has Primary, But Not Exclusive, Authority at UC Facilities Members of the UC Police Department have the status of peace officers. Their authority extends to any place in the state. Their primary duty is the enforcement of the law upon the campuses of the UC and an area within one mile of the exterior boundaries of each campus, and in and about other grounds under the control of the UC Regents.

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However, the jurisdiction of UC Police Department is not exclusive and county sheriffs and/or police departments with jurisdiction over territories in which UC campuses or facilities are located could enforce the orders. I. PREPAREDNESS POINTERS 1. Health Officers should establish, in advance, direct emergency communication with DHS, CDC, and fellow Health Officers, as well as pre-planned protocols. This will greatly enhance the effectiveness and timeliness of cross-jurisdictional emergency and incident responses. 1 Health Officers can establish direct lines of communication and protocols

between the Health Officer and local law enforcement regarding Health


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Officer orders, as well as in anticipation of more extraordinary events, such as a calamity or bioterrorism.

2 Health Officers should actively participate in local emergency planning so that the Health Officer role is already defined should a bioterrorism event occur within the jurisdiction. Health Officers may also want to review the California Terrorism Response Plan

151

to identify what state and federal resources may be available to respond in an event of bioterrorism.

3 Health Officers can get familiar with local emergency response plans and mutual aid agreements.

4 Health Officers can do advance planning with Native American jurisdictions to establish pre-planned protocols. This will greatly enhance the effectiveness and timeliness of cross-jurisdictional emergency and incident responses.

5 Health Officers can do advanced planning with local enforcement in regards to responding to a scene of an actual or potential biological or chemical attack. This type of event can be both a federal and state crime and a major health issue. If a port of international entry is involved, the complexities multiply exponentially. However, if the local jurisdiction decides to respond to these events, required activities will go much more smoothly if they are worked out ahead of time. These scenes ultimately must be handled through a unified command structure. Since unified command takes some time to set up, there are several ways this can be handled quickly, each with its pros and cons. Due to the need to control access to the scene and limit additional exposures, Health Officers may want to have these scenes handled as crime scenes initially while ensuring access to public health personnel who need to respond. This may be the most expeditious way of controlling the scene and limiting the movement of people. However, law enforcement officials are generally extremely reluctant to enter a scene where the potential for exposure to biological agents or persons ill with a communicable disease might be located. Consequently, these scenes could initially be handled as health events with law enforcement officers provided with and instructed in the proper use of personal protective equipment to assist with enforcement of the health officer’s directives. This would require the Health Officer to be able to mobilize enough personnel to adequately assess and control the situation in a timely fashion.

6 Health Officers with UC campuses and facilities in their jurisdiction can coordinate with the Chancellor and the Student Health Service to manage outbreaks of disease among students housed in UC facilities. The Health Officer should initially coordinate with the UC Police Department for purposes of enforcing orders on campus.

7 Health Officers should consult with County Counsel to determine whether jurisdiction has been ceded by the federal government in regards to specific federal property before exercising authority within that facility. For example, although offices of the U.S. Postal Service are federal property, in the absence of a cession of jurisdiction, this property may be subject to


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concurrent jurisdiction of state and federal authorities.152

VI. CONFIDENTIALITY OF HEALTH INFORMATION A. THE RELEASE OF PATIENT INFORMATION IS RESTRICTED BY BOTH FEDERAL AND CALIFORNIA LAW 1. Release of Patient Information in Manner That Does Not Violate State and Federal Law All health care providers must follow the requirements of the California Confidentiality of Medical Information Act (“CMIA”),

153

and the federal Health Insurance and Portability and Accountability Act of 1996 (“HIPAA”).

154

However, both HIPAA and CMIA allow health care providers to disclose confidential medical information to state and local health officials for purposes of preventing or controlling disease where the disclosure is required by law.

155

Most, if not all, public health agencies are healthcare providers and are covered entities subject to HIPAA. If the covered entity is also a public health authority, the covered entity is permitted to use patient health information in all cases in which it is permitted to disclose such information for public health activities. a. Patient information is protected whether or not the patient is living Both HIPAA and CMIA apply whether or not the patient is still living. b. Release of information means either oral or written release Both HIPAA and CMIA protect the release of patient information whether the release is orally or in writing. c. Same rules apply to multiple patients/casualties There are no special statutory rules governing the release of patient identifiable information in situations involving multiple patients or casualties. The same process of balancing patient privacy rights and the need for the community to know the information must be done in mass events as well. 2. Balance Patients’ Statutory Privacy Rights and the Community’s Need to Know Certain circumstances may require the release of patient health information by the Health Officer to protect the public’s health and safety. When this occurs, Health Officers need to balance the patients’ rights of confidentiality of medical information versus the community’s need to know about a suspected or actual outbreak of a communicable disease.


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B. USING HEALTH INFORMATION FOR PUBLIC HEALTH ACTIVITIES 1. Release of Health Information Permitted But It Must Be the Minimum Necessary Amount of Information HIPAA permits public health agencies to use patient health information for public health activities. These activities include but are not limited to preventing or controlling disease, injury or disability, reporting disease, reporting injuries, reporting vital events, conduct of public health surveillance, conduct of public health investigations, conduct of public health interventions, or to a foreign government agency that is acting in collaboration with a public health authority.

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HIPAA specifically allows the release of information, when authorized by law, to persons who may be at risk of contracting or spreading a disease.

157

To the extent that the release of information is truly needed in order to prevent or control disease, injury or disability, the release should be allowable under HIPAA. However, only the “minimum necessary” of patient health information can be released.

158

Because HIPAA does not specify what information constitutes “minimum necessary” information, Health Officers must use their judgment as to what information can be released on a case-by-case basis. 2. Release Information That Cannot Be Linked to a Specific Patient Health Officers should not refer to the medical condition or treatment received by an individual and also disclose the individual’s name or other identifiable information unless that information is necessary for a designated public health activity. a. Individually identifiable information-California law California law defines "individually identifiable" as information that includes or contains any element of personal identifying information sufficient to allow identification of the individual, such as the patient's name, address, electronic mail address, telephone number, or social security number, or other information that, alone or in combination with other publicly available information, reveals the individual's identity.”

159 HIPAA contains a similar definition of identifiable

information as stated below. b. Individually identifiable information- Federal law HIPAA regulations provide in pertinent part: “Health information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual is not individually identifiable health information.”

160

The regulations set forth the conditions that must be present in order to determine that the information is not individually identifiable health information.

161


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c. Size of community may have an impact As reflected in both state law and HIPAA, the size of the community may have an impact on the amount of identifying information that can be released. It is important to note, especially in small communities, the phrases “alone or in combination with other publicly available information,” and “information that could be used, alone or in combination with other reasonably available information, by an anticipated recipient.” A violation of an individual’s privacy rights may occur even if the information on its face does not identify the patient. For example, in a small community, merely providing the age and gender of a deceased patient could lead to the patient’s identification if the media then obtains a copy of the death certificate. In larger communities, this may be less of an issue. In all instances, Health Officers should be cautious as to what information is released and be certain that such release is necessary. The DHS Public Affairs Office uses the following guidelines for the release of information: (1) counties or cities with populations of over 250,000 – the gender, age, and condition of the patient; (2) counties or cities with a population between 50,000 and 250,000 - the gender, condition of the patient, and whether the patient is an adult or juvenile; (3) and counties or cities with populations under 50,000 – the gender and condition of the patient. d. Large number of patients In a situation where there are a large number of patients, the Health Officer may inform the media of the number of patients that have been brought into the facilities by gender or age group (e.g., adults, teens, children, etc.), the general cause of their ailments such as, for example, possible exposure to anthrax, and their general condition, as long as the information it is not identifiable to a specific patient. C. RESPONDING TO PUBLIC RECORDS REQUESTS Pursuant to the Public Records Act, public records, which are broadly defined,

162

are open to inspection and may be copied.

163

This includes computerized record keeping and electronic mail.

164

Much of the routine business that Health Officers are involved with is subject to the Public Records Act. In determining whether a document must be disclosed, the Health Officer has the burden of demonstrating that a record which is established as a public record is either (1) exempt from disclosure under express provisions of the Public Records Act,

165

or (2) on the facts of the particular case, the public interest is served by not making the records public outweighs the public interest served by disclosure of the record.

166

There is a specific exemption that permits the withholding of patient medical information under the Public Records Act.

167

In addition there is an exemption for records “the disclosure of which is exempted or prohibited pursuant to federal or


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state law”168

and, as discussed above, the release of medical information may violate HIPAA as well as state law. Once a public record request is received, Health Officers should contact their legal counsel to review what documents must be released and the deadlines for compliance. VII. MEDIA RESOURCES AND MANAGEMENT A. RELEASING GENERAL NON-MEDICAL INFORMATION TO THE MEDIA 1. Media as a Method of Communication There may be situations in which the media can help to disseminate information to the public about a threatened or actual disease outbreak. The media can broadcast facts about the disease and steps that the public should take in order to stop its spread. If there are orders or specific instructions to be given to the public, the media can help with that effort. The media can also be used to enlist the public’s help and cooperation. 2. Responding to Media Requests for General Information If the media asks questions about a threatened or actual disease outbreak or other public health threat, there is no legal duty to give information to the media. The media may follow-up with a public request made under the Public Records Act.

169

This act defines what is a public record,170

what is not a public record,171

and the time period to produce the record. For example, Confidential Morbidity Reports (CMRs) are not public records to the extent that they disclose the identity of an individual.

172

B. RELEASE OF PATIENT HEALTH INFORMATION TO THE MEDIA 1. Balance Patients’ Statutory Privacy Rights and the Community’s Need to Know As discussed in Section VI, Confidentiality of Health Information, the release of patient information is restricted by both Federal HIPAA regulations and California law contained in CMIA.

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When releasing a person’s health information to the media, Health Officers need to balance the person’s rights of confidentiality of medical information versus the community’s need to know about a suspected or actual outbreak of a communicable disease.

174

2. Health Information Is Protected Whether or Not the Person Is Living Both HIPAA and CMIA apply whether or not the person is still living.


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3. Release of Information Means Either Oral or Written Release Both HIPAA and CMIA protect the release of health information whether the release is oral or in writing. 4. Same Rules Apply to Multiple Patients/Casualties There are no special statutory rules governing the release of patient identifiable information in situations involving multiple patients/casualties. The same process of balancing patient privacy rights and the need for the community to know the information must be used for mass events as well. 5. Using Health Information for Public Health Activities HIPAA permits public health agencies to use patient health information for public health activities.

175

However, only the “minimum necessary” of patient health information can be released.

176

Because HIPAA does not specify what information constitutes “minimum necessary” information, Health Officers must use their judgment as to what information can be released on a case-by-case basis. 6. Release Information That Cannot Be Linked to a Specific Patient Health Officers should not refer to the medical condition or treatment received by a patient and also disclose the patient’s name or other identifiable information unless that information is necessary for a designated public health activity. See Section VI, Confidentiality of Health Information, for a discussion of what constitutes identifiable information. 7. Media Knows Identity of the Patient If the media requests specific information and knows the identity of the patient and the hospital, those inquiries should be referred to the hospital for a response. Health Officers should not verify the identity of the patient or the facility for the media. Health Officers should work closely with the hospital because the hospital will know if the patient has requested that information be withheld. The hospital can also obtain a written release from the patient if the media wants detailed information. a. If the patient has not requested that the information be withheld If the patient has not requested that the information be withheld and a request contains the patient’s name, the hospital may release the patient’s condition “described in general terms that do not communicate specific medical information about the individual.”

177

For such patients, their condition can be described as (1) undetermined; (2) good; (3) fair; (4) serious; or (5) critical.


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b. Activities requiring a prior written authorization Under HIPAA, the following activities require prior written authorization from a patient (or parent or guardian of a minor or legal authority for persons incapacitated): (1) issuing a detailed statement (anything beyond the one word description); (2) photographing or videotaping patients; and (3) interviewing patients.

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8. Media Knows the Identity of a Deceased Patient If the media requests specific information and knows the identity of the decedent through information obtained from a death certificate, only the information that is in the public portion of the death certificate can be released or commented on. The rest of the death certificate is not a public record and the patient’s right to keep this medical information confidential survives the death of the patient. A. PREPAREDNESS POINTS 1 Health Officers or public health agencies should set up an internal process to

be used in communicating with the media. Health Officers or Public Health Agencies should designate one person to regularly and consistently coordinate responses to requests from media, especially if they relate to protected health information. For each situation that arises, it is also important to designate a “single point of contact” for that given situation. This minimizes the chance for miscommunication with the press.

2 Health Officers can, in order to minimize the number of individuals the press needs to contact, tell the news media ahead of time who is the designated media person.

3 Health Officers can ensure that staff receives specialized training in dealing with the media, especially in crisis communication. Materials for such training have been developed by the Federal Centers for Disease Control and Prevention (CDC).

4 Health Officers can keep other Health Department management, elected officials, and county or city administrations up-to-date when talking to the press on matters of public health importance. In certain scenarios, there may be multiple county departments or other non-county agencies involved. There may need to be coordination among these agencies in regard to media contact.

VIII. LIMITING THE MOVEMENT OF INDIVIDUALS AND GROUPS A. ISOLATION AND QUARANTINE IN NON-TUBERCULOSIS CONTEXT Prevention and control of highly communicable diseases that threaten public health may require the use of isolation and/or quarantine.

179

There is a statutory process designed to prevent and control tuberculosis through involuntary


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treatment, isolation, and detention. No other disease or threat to public health has its own statutorily prescribed set of procedures. While reference to tuberculosis statutes may provide useful general guidance when dealing with other communicable diseases, they are not specifically applicable outside of the tuberculosis context.

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However, Health Officer isolation or quarantine actions must be consistent with constitutional requirements discussed in Section III, Constitutional Parameters Impacting Authority of the Health Officer.

181

1. Authority to Isolate and Quarantine In addition to the general authority to take steps necessary to control contagious, infectious, and communicable disease,

182

Health Officers have the specific statutory authority to require strict or modified isolation or quarantine of persons and/or places.

183

Health Officers may also quarantine any place or person when the procedure is necessary to enforce the regulations of DHS.

184

However, no quarantine may be imposed upon another city or county without written consent of DHS.

185

In certain situations, Health Officers may be directed to enforce a DHS mass quarantine order.

186

2. Distinction Between Isolation and Quarantine Isolation refers to the separation of persons who have been infected with an infectious agent from other persons. Quarantine refers to the separation and restriction of movement of persons who, while not yet ill, have been or may have been exposed to an infectious agent and, therefore, may become infectious.

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a. Isolation

188

Isolation is the separation of infected persons from other persons for the period of communicability in such places and under such conditions as will prevent the transmission of the infectious agent. Isolation orders can be either strict or modified. i. Strict isolation If the particular disease requires strict isolation, Health Officers must insure that instructions are given to the patient and members of the household, defining the place of isolation, and identifying the measures to be taken to prevent the spread of the disease. Strict isolation includes an extensive series of measures that are detailed in regulation.

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ii. Modified isolation Modified isolation has no specified requirements beyond separation of infected persons to prevent transmission of disease. The isolation technique will depend


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upon the particular disease. Health Officers must issue appropriate instructions prescribing the isolation technique to be followed as detailed in regulation.

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b. Quarantine Quarantine is the limitation of freedom of movement of persons or animals that have been or may have been exposed to a communicable disease for a period of time equal to the longest usual incubation period of the disease, in such manner as to prevent effective contact with those not so exposed.

191

3. Places of Quarantine or Isolation There are several alternatives for the location of the isolation or quarantine of persons.

192

Statutes give DHS authority to establish and maintain its own places of quarantine or isolation,

193

and to require Health Officers to establish and maintain places of quarantine or isolation that are subject to the special directions of DHS.

194

People in isolation or quarantine may be cared for in their homes,

195 in hospitals, or in designated healthcare facilities.

196

Home isolation may be the easiest and the least intrusive, but compliance is the most difficult to monitor.

197 Health Officers should use caution in considering the use of jails for

isolation and quarantine.198

4. Constitutional Considerations Even though the private interest affected by isolation or quarantine is perhaps the most significant private interest of all, personal liberty, courts have long held that “[h]ealth authorities possess the power to place under quarantine restrictions persons whom they have reasonable cause to believe are afflicted with infectious or contagious diseases.”

199

Enforcement of involuntary quarantine and isolation orders will trigger application of constitutional safeguards such as notice, a pre- or post-confinement hearing

200

within a reasonable time, and all the attendant procedural protections discussed in Section III, Constitutional Parameters Impacting the Authority of the Health Officer. Isolation and quarantine orders cannot be “arbitrary, oppressive, and unreasonable.” These orders must have documentation that factually supports the justification for the proposed isolation and/or quarantine. 5. Large-Scale Quarantine/Isolation Health Officer sequestration of large groups or geographic areas is considered where there is a serious risk of widespread disease transmission with sufficient risk of serious illness or death.


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a. Health Officer’s authority may be impacted by the scale and location of the outbreak When a contagious event affects or has potential to spread into the jurisdictional boundaries of a Health Officer from another jurisdiction, the Health Officer needs DHS’s written consent to establish a quarantine.

201

If large sections of the state are implicated, DHS will direct the Health Officer’s actions. Where national or inter-state measures are needed, the CDC has authority upon executive decision to be made by the President.

202

See Section V, Interjurisdictional Coordination and Cooperation. b. Practical considerations There are also several practical considerations to be resolved before imposing a quarantine or isolation of large numbers of people. These considerations include but are not limited to: • Existence of effective lesser restrictive means to achieve disease control.

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• Substantial human and material resources may be necessary. • Those quarantined must be detained in safe and hygienic locations. • Adequate food and other necessities must be provided. • Access to appropriate medical care.

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• Ability to provide rapid vaccination or treatment. • Availability of medical supplies. • Ability to effectively monitor and timely enforce orders. • Applicability of disease control reporting requirements.

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• Applicability of medical information confidentiality requirement.206

6. Isolation and Quarantine Orders There is no express content or method of service statutorily mandated for isolation and quarantine orders.

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However, these Health Officer orders must be consistent with applicable constitutional requirements discussed above and in Section III, Constitutional Parameters Impacting Authority of the Health Officer. As with any other Health Officer order, the content and appropriate procedures for isolation and quarantine orders are fact dependent and must be determined by the particular circumstances.

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a. Form of the order In general, isolation and quarantine orders should be in writing. However, facts and circumstances may dictate the initial use of an oral order, which will be confirmed in writing at the earliest possible opportunity.


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b. Contents of the order The following is a checklist of potential items to consider, but not necessarily include in isolation or quarantine orders: • Subject of the Order • Individual Orders: Identity and address of the person when known, or if

unknown, as detailed a description of the subject as available • Mass Orders: Target population/geographic area, described as specifically

and narrowly as possible • The specific directives that the individual(s) must follow

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• Duration of the order and date of release

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• Potential penalty for a violation

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• Supporting facts212

• Statutory authority and any other legal basis to support the order • Method and opportunity to challenge the order • Location of the isolation-health facility, home, and the reason for any out-of-

home isolation213

• Any additional information specific to the event triggering the need for the

order • Language of the individual • Whether the patient is a minor • Mental capacity of the individual • Signature and title of Health Officer • Signature of the patient acknowledging the receipt of order as discussed

below • Right to representation, if any, for the subject of the order • Method(s) of informing the individuals subject to the order as discussed below c. Service of the orders i. Orders directed to individuals To ensure immediate effectiveness of the order and successful enforcement, individual isolation and quarantine orders should be personally handed to the individual.

214

The date and time that the individual was given the order should be documented as well as who handed the order to the individual. This method of service does not require the signature of the subject of the order to be effective. In general, it is statutorily sufficient to serve Health Officer’s orders by registered or certified mail

.215

However, an order is not effective until and unless the registered or certified return receipt on the envelope containing the order is signed by the subject of the order.


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ii. Orders directed to a mass Dependent upon factors such as the nature of the incident, potential number of individuals implicated as well as the geographic area concerned, the methods of communicating the isolation and quarantine order will vary. Personal service, mail, media, posting of the venue, site, or place in question, or combination of these and other methods can be used to communicate the directives to the target group or area. To ensure reaching the broadest population in the most effective manner and to ensure successful enforcement, Health Officers may want to employ multiple communication methods. 7. Enforcement Authority for Quarantine and Isolation In addition the general enforcement authority discussed in Section IV, Enforcement of Health Officer Authority, there is a specific statute mandating compliance with orders of quarantine or isolation.

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A violation of an isolation or quarantine order constitutes a misdemeanor.

217

It is also a misdemeanor for any person with a contagious, infectious, or communicable disease to willfully expose himself or herself to another person.

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8. Challenges to Isolation and Quarantine Orders Any challenge to a quarantine or isolation order should be resolved within a reasonable time. Prior to issuing quarantine and isolation orders, it may be useful to consider how challenges to the order can be registered and resolved. For large-scale isolation and quarantine events, Health Officers may want to have protocols and procedures in place that may involve internal processes or interaction with other agencies as well as the courts. B. TEMPORARY CLOSURES OF PUBLIC GATHERINGS When it cannot be quickly determined which specific persons are actually ill or exposed and/or there is no need to control all of their movements, temporary closures of public gatherings may be an appropriate disease control measure. If the closures involve multiple venues and appear likely to exceed several days, Health Officers should consider and consult with local officials as to whether a local emergency should be declared. 1. Authority For Temporary Closures of Public Gatherings Whenever an immediate menace to the public health or safety is created by a calamity including a flood, storm, fire, earthquake, explosion, accident, or other disaster, the Health Officer may close the area where the menace exists under specified conditions. In such a closure, the persons within the affected area can be ordered to leave.

219

In addition to this specific power, the general powers of the


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Health Officer to control the spread of disease discussed in Section II, General Authority of the Health Officer, also apply to temporary closures of public gatherings.

220

When the gathering is subject to a permitting requirement, the Health Officer may consider consulting with the permitting agency to explore the possibility of an immediate permit suspension. 2. Constitutional Considerations Closures of public gatherings raise issues regarding freedom of assembly, freedom of speech, due process and equal protection rights. Closure orders cannot be “arbitrary, oppressive, and unreasonable,” and must be narrowly drawn to be free from vagueness and over-breadth. These orders must have documentation that factually supports the justification for the proposed closure. The process for issuing and enforcing the orders should adhere to applicable procedural protections discussed in Section III, Constitutional Parameters Impacting Authority of the Health Officer.

221

3. Form of the Orders There is no express content or method of service statutorily mandated for closure orders. In general, closure orders should be in writing. However, facts and circumstances may dictate the initial use of an oral order that will be confirmed in writing at the earliest possible opportunity. As with any other Health Officer order, the content and appropriate procedures for closure are fact dependent and must be determined by the particular circumstances.

222

4. Contents of the Order The following is a checklist of potential items to consider, but not necessarily include in closure orders: • Subject of the Order: Target population/geographic area described as

specifically and narrowly as possible • The specific directives that the individuals must follow • Right to representation, if any, for the subject of the order • Parameters and conditions of the order

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• Duration of the order-both beginning and end dates and times • Potential penalty for a violation • Supporting facts

224

• Statutory authority and any other legal basis to support the order • Method and opportunity to challenge the order • Any additional information specific to the event triggering the need for the

order • Languages of the individuals • Signature and title of Health Officer


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• Method(s) of informing the individuals subject to the order as discussed below a. Service of the order Dependent upon factors such as the nature of the incident, potential number of individuals implicated as well as the geographic area concerned, the method(s) of communicating the closure order will vary. Personal service, mail, media, posting of the venue, site, or place in question, or combination of these and other methods can be used to communicate the directives to the target group or area. To ensure reaching the broadest population in the most effective manner and to ensure successful enforcement, the Health Officer may want to employ multiple communication methods. As discussed in the context of closures and other emergency orders, to avoid any challenges on constitutional grounds, orders need to be narrowly drawn, Health Officers should describe with particularity the activities being modified or curtailed, the reason for the action, and the length of time the closure or restriction will occur. An opportunity to consult should be given before the effective date of the order unless the situation is suddenly grave, such as a toxic release, in which case no prior opportunity need be afforded, but an opportunity for the event sponsor to object should be accorded as soon afterward as it may safely be conducted. C. EVACUATION Health Officers may find it necessary for the protection of public health and safety to order the immediate movement of individuals away from a particular building or geographic area. 1. Authority for Evacuation Orders Express statutory authority provides that “Whenever an immediate menace to the public health or safety is created by a calamity including a flood, storm, fire, earthquake, explosion, accident, or other disaster,…” the Health Officer “…may close the area where the menace exists…” under specified conditions. The statute further provides that the Health Officer can order persons within the affected area to leave.

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In addition to this specific power, the general powers of the Health Officer to control the spread of disease discussed in Section II, “General Authority of the Health Officer,” are also applicable in an evacuation event. 2. Constitutional Considerations Evacuations raise issues regarding freedom of assembly, freedom of speech, due process and equal protection rights. Evacuation orders cannot be “arbitrary, oppressive and unreasonable,” and must be narrowly drawn to be free from vagueness and over breadth. These orders must ha ve documentation that factually supports the justification for the proposed evacuation. The process for


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issuing and enforcing the orders should adhere to the applicable procedural protections discussed in Section III, “Constitutional Parameters Impacting Authority of the Health Officer.”

226

3. Form of the Orders There is no express content or method of service statutorily mandated for evacuation orders. In general, evacuation orders should be in writing and posted on the subject area or site. However, facts and circumstance may dictate the use of an initial oral order, which will be confirmed in writing at the earliest possible opportunity. As with any other Health Officer order, the content and appropriate procedures for closure are fact dependent and must be determined by the particular circumstances.

227

D. CURFEWS 1. Curfews Can Be Implemented Only After a Local Emergency Has Been Declared or Through Enactment of an Ordinance Prevention and control of highly communicable diseases that threaten public health may require the use of a curfew. However, curfews may only be imposed after (1) the declaration of a local emergency

228

by the “governing body of a city, county, or city and county, or by an official designated by ordinance”;

229

or (2) in a non-emergency situation pursuant to a local ordinance. Unless a Health Officer has been designated by a local ordinance to declare a local emergency, Health Officers have no independent authority to implement a curfew.

230

2. Constitutional Considerations Curfews raise issues regarding freedom of assembly, freedom of speech, due process and equal protection rights. Curfew orders cannot be “arbitrary, oppressive, and unreasonable,” must be based on a clear showing of necessity, and must be narrowly drawn to be free from vagueness and over breadth. The process for issuing and enforcing the orders should adhere to the applicable procedural protections discussed in Section III, Constitutional Parameters Impacting Authority of the Health Officer.

231

3. Curfews Orders Issued After the Declaration of a Local Emergency a. Orders must be necessary for the protection of life or property, in writing, have specific duration and be given widespread notice The statutory scheme for declaring local emergencies provides that emergency curfew orders (1) Can be issued only after an emergency is proclaimed; (2) Are lawful only so long as an emergency exists; (3) Must be necessary for the protection of life and property; (4) Must be in writing; (5) Must be given


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widespread publicity and notice; and (6) Any amendment or rescission must be in writing and be given widespread publicity and notice.

232

Other than these requirements, there is no express content or method of service statutorily mandated for curfew orders. However, curfew orders must be consistent with the applicable constitutional requirements discussed above and in Section III, Constitutional Parameters Impacting Authority of the Health Officer. The content and appropriate procedures for curfew orders are fact dependent and must be determined by the particular circumstances. b. Contents of the Order The following is a checklist of potential items to consider, but not necessarily include in curfew orders: • Authority for Declaration of Emergency and fact that emergency has been

declared. • Reason for Declaration of Emergency. • Basis for need for Curfew.

233

• Details of curfew restrictions regarding locations, hours, and/or for population.

234

• Languages of the individuals. • Parameters and conditions of the order.

235

• Potential penalty for a violation. • Exemption of police officers, firefighters, emergency personnel authorized

representatives of the media. • Enforcement authority. • Method and opportunity to challenge the order. • Any additional information specific to the event triggering the need for the

order. • Right to representation, if any, for the subject of the order. • Signature and title of designated official. • Method(s) of informing the individuals subject to the order (see Service of the Order below). c. Service of the order Dependent upon factors such as the nature of the incident, potential number of individuals implicated as well as the geographic area concerned, the method(s) of communicating curfew orders will vary. Personal service, mail, media, posting the venue, site, or place in question, or combination of these and other methods can be used to communicate the directives to the target group or area. To ensure reaching the broadest population in the most effective manner and to ensure successful enforcement, Health Officers may want to employ multiple communication methods.


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E. PREPAREDNESS POINTS 1 Health Officers should, in planning for isolation and quarantine, address home

isolation of patients, the availability and use of existing or temporary structures as alternative facilities for isolation, the management of patients housed at home or in alternative facilities, and resources for supplies and services.

2 Health Officers can, when dealing with large "temporary" events, work with the city or county to craft and adopt standing conditions for temporary event permits which the agency can adopt and which the permittee can be required to accept ahead of time. Such conditions could include Health Officer authority to immediately suspend all issued permits.

3 Health Officers can, in regards to areas zoned for uses such as commercial, industrial, recreational and sports venues, churches, auditoriums, theatres, hotels and convention centers, work with planning agencies to develop permit conditions addressing immediate closures, contingency plans, and required equipment.

4 Health Officers can, in regards to closures of public gathering made pursuant to Penal Code §409.5(a), work in conjunction with law enforcement, fire protection, and other agencies, such as the Department of Parks and Recreation in plan responses. Advance establishment of protocols and procedures will expedite coordination and cooperation.

IX. INVOLUNTARY INVESTIGATION, EXAMINATION, DECONTAMINATION, TREATMENT, AND VACCINATION Investigation, examination, decontamination, treatment, and vaccination constitute a spectrum of measures that may, under certain circumstances, be available to the Health Officer if such action is necessary to contain the spread of communicable disease. A discussion of these powers is contained in Section II, General Authority of the Health Officer. For more intrusive action,

236

there must be more compelling factual justification. Additionally, these actions involve medical procedures of examination, treatment, testing, and the laws governing the requirement for patient consent apply. The Health Officer is vested with considerable discretion as to what actions should be taken to control the spread of infectious disease.

237

However, the extent of the exercise of this power and discretion is limited by the factors discussed, in Section III, Constitutional Parameters Impacting Authority of the Health Officer. A. INVOLUNTARY INVESTIGATION, EXAMINATION, AND DIAGNOSTIC TESTING 1. General Authority and Discretion to Investigate, Examine, and Test


May 2, 2006

Health Officers may investigate238

as well as conduct or order examinations 239

and testing

240

of persons241

and animals,242

under specified circumstances.243

Health Officers may also perform these functions when requested by DHS.

244

Expressly included in the investigatory role is the authority to order examinations of allegedly infected persons to verify the existence of the disease.

245

Such preliminary investigation and the measures taken to address the situation may be only those reasonably necessary to protect the public health.

246

Generally, investigation includes examination and testing.

247

The type of examination is left to a Health Officer’s discretion because the statutory language reads, “to make such exams as are deemed necessary.”

248

In the tuberculosis context, the statutory scheme expressly provides that “examination” includes “conducting tests, including, but not limited to skin tests, laboratory examination and X-rays, as recommended by” anyone from the articulated authorized list of persons, including Health Officers.

249

While this statutory authority is directed to one particular type of disease, it serves to demonstrate the breadth of functions that may be incorporated by the term “examination." 2. Court Order Required for Non-cooperation Although Health Officers have the power to investigate

250

and to issue and seek enforcement of examination and testing orders,

251

they cannot enforce orders for involuntarily examination, testing or treatment without either (1) the subject’s consent or (2) obtaining a court order. If the subject refuses to comply with the court’s order, Health Officers may implement isolation and quarantine and or institute a contempt of court proceedings. Failing voluntary cooperation or consent to treatment by the infected person subject to the issued orders, the Health Officer may be statutorily authorized to isolate and quarantine such individuals.

252

This authority extends to the temporary detention of an individual believed to have been exposed to biological agents

253

or other contaminants in order to verify exposure and carry out decontamination procedures, provided that such actions are reasonably necessary to protect the public health.

254

The least restrictive and least invasive principles, as described in Section III, Constitutional Parameters Impacting Authority of the Health Officer, should also be considered in this context.

255

Any intrusion must be limited to only such time as needed to complete the examination and/or determine that the person no longer poses a menace to the health of society.

256

3. Mass Investigation, Examination, and Diagnostic Testing The same principles discussed above would apply to mass involuntary


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investigation, examination, and diagnostic testing. B. INVOLUNTARY DECONTAMINATION, DISINFECTION, AND TREATMENT 1. General Authority and Discretion to Decontaminate, Disinfect, and Treat Health Officers may issue orders for decontamination, disinfection, and/or treatment, if necessary to control or prevent the spread of the disease, condition or outbreak.

257

The type of treatment, like the type of examination, is left to the Health Officer’s discretion

258

as is necessary and appropriate to address the circumstances of the presented situation. In addition, DHS may request the Health Officer to assist with

259

and perform such functions as disinfection, 260

treatment and decontamination.261

2. Court Order Required for Non-cooperation. Although, Health Officers may have the power to order decontamination, disinfection, and/or treatment, they cannot enforce such orders without either (1) the subject’s consent or (2) obtaining a court order. If the subject refuses to comply with the court’s order, the Health Officer may implement isolation and quarantine and/or institute a contempt of court proceedings. The least restrictive and least invasive principles described in Section III, Constitutional Parameters Impacting Authority of the Health Officer, should also be considered in this context. Any intrusion must be limited to only such time as needed to complete the examination and/or determine that the person no longer poses a menace to the health of society. Failing voluntary cooperation or consent to treatment by the infected person subject to the issued orders, the Health Officer may be statutorily authorized to isolate and quarantine such individuals.

262

This authority extends to the temporary detention of an individual believed to have been exposed to biological agents

263

or other contaminants in order to verify exposure and carry out decontamination procedures, provided that such actions are reasonably necessary to protect the public health.

264

The least restrictive and least invasive principles described in Section III, “Constitutional Parameters Impacting Authority of the Officer,”

265

should also be considered in this context. Any intrusion should be limited to only such time as needed under the circumstances to complete the treatment, decontamination, or disinfection and/or determine that the person no longer poses a menace to the health of society.

266


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3. Mass Involuntary Decontamination, Disinfection, and Treatment The same principles discussed above apply to mass involuntary decontamination, disinfection, and treatment. C. VACCINATION AND IMMUNIZATION 1. Limited Express Statutory Authority for Voluntary Vaccination Programs In addition to the Health Officer’s general authority to take steps necessary to control or prevent the spread of communicable disease, there is limited express statutory authority for use of vaccination as a measure to address public health and safety concerns under particular circumstances.

267

However, such measures are voluntary.

268

Health Officers have the statutory authority to “organize and maintain a program to make immunizations available” to all persons required by the Health and Safety Code to be immunized,

269

and for which immunizations must be documented.

270

2. No Express Statutory Authority in California for Compulsory Vaccination, Absent Court Order, or Declaration of Emergency There is no statutory authority for involuntary vaccination or immunization.

271

In those circumstances in which DHS or the Health Officer determines that the public health and safety requires vaccination or immunization to control and contain the spread of an infectious disease, or to enforce existing statutory immunization mandates, the Health Officer may: • Seek voluntary consent

272

as defined and understood in the standard health care context.

• Impose Isolation and Quarantine where the necessary criteria and procedures are met (See Isolation & Quarantine, and Enforcement sections).

• Petition for a court order. 3. Mass Involuntary Vaccination/Immunization The same principles discussed above would apply to mass involuntary vaccination, and immunization. D. PREPAREDNESS POINTS 1 Health Officers may wish to meet with the courts, counsel, the public

defender, district attorney, and members of the medical community, as well as the community-at-large to prepare sample Petition, Declaration, and Order Forms in anticipation of a need to implement involuntary individual or mass vaccination orders.

2 Health Officers may want to provide advance education and planning for mass/large scale immunization or vaccination events, including solicitation of


May 2, 2006

health care volunteers, pharmaceutical cache acquisition and storage, as well as dispensary location. This may encourage voluntary participation, minimize anxiety, assuage individual resistance, and alert the public to its availability.

3 Health Officers may, when seeking a court order to enforce a Health Officer order for examination, include in the proposed order, the full breadth of authority that may be needed to fully conduct all potential forms of examination, including testing. The actual exercise of the authority can be suitably tailored to meet the specific needs of the investigation and examination without resort to the courts for additional authority as the investigation progresses.

X. INSPECTION, SEIZURE, DECONTAMINATION, DISINFECTION, AND DESTRUCTION OF REAL AND PERSONAL PROPERTY A. INSPECTION AND SEIZURE The Health Officers’ general statutory authority

273

to investigate and take measures necessary to prevent spread of contagious disease gives them the power to inspect and seize real property

274

and personal property..275

Although this power extends to real and personal property, in most instances, Health Officers will seize only personal property and will quarantine real property. In addition, when acting as the local enforcement agency under state law, Health Officers have express statutory authority to inspect and seize property under specific circumstances.

276

Health Officers’ ability to inspect and seize property is conditioned upon the property owner or occupants’ consent to the inspection. If consent is either (1) refused or (2) cannot be obtained, an inspection or search warrant is required absent “exigent circumstances.”

277

As discussed in Section III, Constitutional Parameters Impacting Authority of the Health Officer, the constitutions of the United States and California both prohibit unreasonable searches and seizures. A warrantless search or seizure of personal property or warrantless entry into a home or business,

278

in order to administratively investigate a health hazard is presumptively unreasonable absent consent.

279

This presumption can be overcome by a showing of an emergency situation in which there is such a serious and urgent threat to public health and safety that a warrant cannot be obtained in time to carry out the necessary measures to eliminate, reduce, or contain the threat.

B. DECONTAMINATION, DISINFECTION, AND DESTRUCTION If seized or quarantined property requires decontamination, disinfection, or destruction to protect public health and safety, absent express statutory authority permitting it under certain circumstances

280

or DHS authorization, Health Officers must first obtain either the owners’ consent or court orders to take such actions,


May 2, 2006

unless there are exigent circumstances. As with searches and seizures, a court order may not necessarily be required. If an urgent situation exists, and the court order cannot be obtained in time to carry out the necessary measures to eliminate, reduce, or contain the serious threat to public health and safety, Health Officers may choose to take action until the emergency no longer exists and a court order can be obtained. C. OWNER COMPENSATION Depending upon the specific facts of each unique set of circumstances, property owners may be entitled to seek compensation.

281

XI. RATIONING OF RESOURCES A. AUTHORITY FOR HEALTH OFFICERS TO ORDER RATIONING Where there is a potentially limited resource

282

and the limited quantity creates or contributes to a public health and safety threat, Health Officers may determine that this resource should be rationed. Rationing activities can range from orders limiting the use of a resource to actual resource distribution. If there is an actual or suspected case of disease within a Health Officer’s jurisdiction, the Health Officer may rely upon the general Health Officer powers to ration certain resources.

283

However, Health Officers have no express statutory authority to ration resources. Health Officer authority to ration may also be derived from orders issued by the Governor,

284

DHS,285

or other state or federal agency. In the absence of such state agency orders, Health Officers must obtain the declaration of a local emergency

286

prior to using rationing as a preventive measure.

287

Several other federal and state agencies have specific regulatory and enforcement powers in particular areas such as air quality, food, water, and some drugs.

288

B. CONTENT OF RATIONING ORDERS Health Officers’ orders issued pursuant a directive from the Governor or DHS, or other state or federal agency must be consistent with the parameters of the directive. All other Health Officer rationing orders must be narrowly drawn to be free from vagueness and over breadth. These orders must have documentation that factually supports the justification for the proposed rationing. The process for issuing and enforcing the orders should adhere to applicable procedural protections discussed in Section III, Constitutional Parameters Impacting Authority of the Health Officer. The following is a checklist of potential items to consider, but not necessarily include in a rationing order:


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• Subject of the Order: Target population/geographic area described as specifically and narrowly as possible.

289

• The specific directives that the individuals must follow. • Method(s) of informing the individuals subject to the order. • Parameters and conditions of the order.

290

• Duration of the order—both beginning and end dates and times. • Potential penalty for a violation. • Supporting facts.

291

• Statutory authority and any other legal basis to support the order. • Method and opportunity to challenge the order. • Any additional information specific to the event triggering the need for the

order. • Languages of the individuals. • Signature and title of Health Officer. • Right to representation, if any, for the subject of the order. C. PREPAREDNESS POINTS 1 Health Officers should establish lines of communication with pharmaceutical

companies, distributors, local pharmacies, and local healthcare providers. 2 Health Officers should coordinate with those state and federal agencies that

have specific regulatory and enforcement powers in areas such as air quality, food and drug, and water.

XII. COMMANDEERING A. COMMANDEERING REAL OR PERSONAL PROPERTY Certain circumstances may dictate the need to use real or personal property

292

belonging to private individuals or businesses to protect public health and safety. Commandeering is distinguished from rationing in that commandeering involves taking involuntary possession of resources or facilities. Rationing is setting forth the parameters of resource distribution. Commandeering differs from quarantine and isolation in that commandeering involves the taking possession of a space rather than a restriction of occupant movement. B. AUTHORITY TO COMMANDEER REAL OR PERSONAL PROPERTY If there is an actual or suspected case of disease within the Health Officer’s jurisdiction, the Health Officer may rely upon the general Health Officer powers to commandeer real and personal property.

293

However, Health Officers have no express statutory authority to commandeer. Health Officer authority to commandeer may also be derived from orders issued by the Governor,

294

DHS,295

or other state or federal agency. In the absence of


May 2, 2006

such state agency orders, Health Officers must obtain the declaration of a local emergency

296

prior to commandeering property as a preventive measure.297

Such use may impact property rights protected by the United States and California Constitutions. Considerations similar to those discussed in Section X, Inspection, Seizure, Decontamination, Disinfection, and Destruction of Real and Personal Property,” also apply in the commandeering context. C. CONTENT OF COMMANDEERING ORDERS Health Officer orders issued pursuant to a directive from the Governor or DHS or other state or federal agency, must be consistent with the parameters of the directive. All other Health Officer commandeering orders must be narrowly drawn to be free from vagueness and over breadth. Orders should specify only the minimum amount of property to be commandeered, which will respond to the emergency situation. These orders must have documentation that factually supports the justification for the proposed commandeering. The process for issuing and enforcing the orders should adhere to applicable procedural protections discussed in Section II, Constitutional Parameters Impacting Authority of the Health Officer. The following is a checklist of potential items to consider, but not necessarily include in a commandeering order: • Subject of the Order: Target population/geographic area described as

specifically and narrowly as possible.298

• The specific directives that the individuals must follow.

299

• Method(s) of informing the individuals subject to the order. • Parameters and conditions of the order.

300

• Duration of the order, both beginning and end dates and times. • Potential penalty for a violation. • Supporting facts.

301

• Statutory authority and any other legal basis to support the order. • Method and opportunity to challenge the order. • Any additional information specific to the event triggering the need for the

order. • Languages of the individuals. • Signature and title of Health Officer. • Right to representation, if any, for the subject of the order. • Owner Compensation. Depending upon the specific facts of each unique set of circumstances, property owners may be entitled to seek compensation.

302

D. PREPAREDNESS POINTS 1 Health Officers can determine what medical resources might be necessary to

address various common medical emergency scenarios: limited impact, wide-


May 2, 2006

spread impact, and catastrophic impact. 2 Health Officers can survey local and regional governmental and private

availability and supply of potentially necessary medical services and supplies. 3 Health Officers can consider building reserves and stockpiles of non-

perishable medical goods and supplies. 4 Health Officers can survey local suppliers to determine availability of medical

goods and services. 5 Health Officers can enter into standby agreements with suppliers of medical

services and goods. 6 Health Officers can obtain medical goods and services pursuant to any local

agreements. 7 Health Officers can, if routine availability of medical goods and services is not

sufficient, survey availability through mutual aid agreements. 8 Health Officers can, if medical supplies and services are not adequate, work

through the local emergency services organization to obtain a declaration of local emergency.

XIII. CONSCRIPTION A. CONSCRIPTION Certain circumstances may dictate the need to order private citizens

303

to provide services that will assist in the protection of public health and safety. Involuntary servitude is prohibited by the United States and California Constitutions.

304

This section does not address the power to command the aid of citizens during a declared emergency under the Emergency Services Act.

305

B. AUTHORITY TO CONSCRIPT Absent a declaration of emergency under the Emergency Services Act, Health Officers have no specific or general statutory authority to conscript the aid of private citizens.

306

Any such authority would be derived from the Governor307

or DHS

308

orders pursuant to a declared emergency. In the absence of such state agency orders, Health Officers must obtain the declaration of a local emergency

309

prior to conscription. C. PREPAREDNESS POINTS 1 Health Officers can determine what private sector volunteers and government

personnel might be available to address the various common medical emergency scenarios: limited impact, wide-spread impact, and catastrophic impact.

2 Health Officers can survey local and regional governmental and private availability and supply of potentially necessary medical workers and/or individuals who could carry out the responsibilities of the Health Officer and protect the public health during an emergency.


May 2, 2006

3 Health Officers can consider first utilizing all area public employees who are declared disaster services workers pursuant to Government Code Section 3100, et seq. to carry out the responsibilities of the Health Officer.

4 Health Officers can enter into standby agreements with nearby medical facilities to utilize their medical personnel if necessary in a declared emergency.

5 Health Officers can, if the number of medical and/or nonmedical personnel is not adequate, work through the local emergency services organization to obtain a declaration of local emergency.

6 Health Officers can coordinate with local law enforcement agencies in regard to what kind of assistance they can provide through any conscription authority they may have.

L:\CLIENT\P_DEPTS\PHEALTH\Public Health Law Group\Draft Guidelines\Dec 14 draft Practice Guide.doc TABLE OF AUTHORITIES CALIFORNIA CASES: Black Panther Party v. Kehoe (1974) 42 Cal.App.3d 645 Brown v. State of California (1993) 21 Cal.App.4th 1500 City of San Jose v. Superior Court (1999) 74 Cal. App.4

th 1008

Coelho v. Truckell (1935)9 Cal.App.2d 47 Derrick v. Ontario Community (1975) 47 Cal.App.3d 145 Jacobson v. Massachusetts (1905) 197 U.S. 11. Jones v. Czapkay (1960) 182 Cal.App.2d 192, 199. Ex parte Arata (1921) 52 Cal.App. 380 Ex Parte Dillon (1919) 44 Cal.App. 239 In re Arata (1919) 52 Cal.App. 380 In re Halko (1966) 246 Cal.App.2d 553 In re Juan C. (1994) 28 Cal.App.4th 1093 In re Milstead (1919) 44 Cal.App. 239 In re Martin (1948) 83 Cal.App.2d 164 In re Quackenbush (1996) 41 Cal.App.4th 1301 Leslie’s Pool Mart Inc. v. Dept of Food & Ag.


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(1990) 223 Cal. App. 3d 1524 Patrick v. Riley (1930) 209 Cal. 350 People v. Celis (2004) 33 Cal.4th 677. People v. McKelvy (1972) 23 Cal.App.3d 1027 People v. Ramirez (1979) 25 Cal. 3d 260 People v. Richardson (1994) 33 Cal.App.4th Supp. 11 San Gabriel Tribune v. City of West Covina (1983) 143 Cal. App. 3d 762 Souvannarath v. Hadden (2002) 95 Cal. App. 4

th 1115

Teamsters Local 856 v. Priceless, LLC, (2003) 112 Cal.App.4th 1500 Teresi v. State of California (1986) 180 Cal.App.3d 239. FEDERAL CASES: Bykosky v. Borough of Middletown (1975) 401 F.Supp. 1242 Cafeteria and Restaurant Workers Union v. McElroy (1961) 367 U.S. 886. Camara v. Municipal Court of San Francisco (1967) 387 U.S. 523 Halvonic v. Reagan (1972) 457 F.2d 311 Jacobsen v. Massachusetts (1905) 197 U.S. 11 Jew Ho v. Williamson (1900) 103 F. 10 Morrissey v. Brewer (1972) 408 U.S. 481 CALIFORNIA STATUTES: Business And Professions Code: §1206 Civil Code: §56 §56.05 Government Code: §110 §8550 §111 §8607 §113 §8630 §115 §8634 §126 §11181 §6250 §26601 §6252 §6253 §6254 §6255 §6276.30 Nevada v. Hicks (2001) 533 U.S. 353 Nunez v. San Diego


May 2, 2006

(9th Cir. 1997) 114 F.3d 935 Reno v. Flores (1993) 507 U.S. 292 Town of Wibaux v. Brown, Slip Copy, 2005 WL 1270295 U.S. v. Warne (1960) 190 F.Supp.645 Washington v. Confederated Tribes of Colville Reservation (1980) 447 U.S. 134. Health And Safety Code: §11181 §100180 §100182 §100275 §100325 §101000 §101025 §101030 §101040 §101080 §101310 §101375 §101400 §101405 §101415 §101450 §101460 §101470 §101475 §109875 §113960 §120100 §120105 §120115 §120125 §120130 §120135 Penal Code: §15 §16 §19 §148 §409.5 §830 §834 Water Code: §350 §120140 §120145 §120150 §120175 §120185 §120190 §120195 §120200 §120205 §120210 §120215 §120220 §120225 §120250 §120275 §120280 §120290 §120295 §120325 §121350 §121365 §121525 §120530 §120585 §835 §836 §836.5 §11415 §11419

CALIFORNIA REGULATIONS: California Code of Regulations, Title 17: §2500 §2501 §2502 §2515 §2516 §2518 §2520 §2524 §2534 §2540 §2550 §2566 §2574 §2603 §2606 §2612 §2613 §2614 §2622 §2628 §2636 §2641.50 CALIFORNIA CONSTITUTION: Article XI, §7 Article 1, §3(b) Article 1, §19 FEDERAL STATUTES AND REGULATIONS: 42 C.F.R. §70.2. 42 C.F.R. §70.4, 42 C.F.R. §70.4 42 C.F.R. §70.6 42 C.F.R. §71.21 45 C.F.R.§160.101 45 C.F.R §160 45 C.F.R §164. 45 C.F.R.§164.502 45 C.F.R. §164.508 45 C.F.R. §164.510 45 C.F.R.§164.512 45 C.F.R §164.514 18 U.S.C.§175 18 U.S.C. §111 42 U.S.C.§264 42 U.S.C. §265. 42 U.S.C. §267. 42 U.S.C. §270. 42 U.S.C. §264. UNITED STATES CONSTITUTION: 1

st Amendment 5th Amendment 8

th Amendment 14th Amendment Art. 1, Section

8, Clause 17 Art. VI, Clause 2 OTHER SOURCES: American Red Cross Preparedness Guide, Controlling the Spread of Contagious Diseases.


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Authority and Responsibility of Local Health Officers in Emergencies and Disasters, D. David Abbott [Emergency Preparedness Office] and Jack S. McGurk, (Chief of Environmental Management Branch), Department of Health Services, State of California (September 30, 1998). Bioterrorism, Public Health and the Law, Legal Basis for Large-Scale Quarantine, Vernellia R. Randall, American Medical Association Department of Health and Human Services, Centers for Disease Control and Prevention. (September 2004). “Incident Command System: Independent Study Course,” Emergency Management Institute, Federal Emergency Management Agency, IS-195, Jan., 1998. Severe Acute Respiratory Syndrome, Department of Health and Human Services, Centers for Disease Control and Prevention, , May 3, 2005 The Ethics of Quarantine, Ross Upshur, M.D., MSc, MA, November 2003, Vol. 5, Number 11, 1 Opinion California Attorney General. 541

1

Authority and Responsibility of Local Health Officers in Emergencies and Disasters. D. David Abbott [Emergency Preparedness Office] and Jack S. McGurk, (Chief of Environmental Management Branch), Department of Health Services, State of California (September 30, 1998). 2

California Health and Safety Code, (hereinafter, “H&S”), §120100 et seq. 3

H&S §120115(k), 17 California Code of Regulations (hereinafter, “C.C.R.”), §§2501 and 2641.50. 4

Pursuant to H&S §101025, the board of supervisors of each county derives authority to preserve and protect the public health in the unincorporated areas of each county by ordinance, regulations, and orders not in conflict with general law. The county health officer position is authorized by H&S §101000. The governing body of a city derives authority to preserve and protect the public health by regulation and adoption of ordinances, regulations, and orders pursuant to H&S §101450. The city health officer position is authorized by H&S §101460, which also provides authority for the city to make such an appointment. 5

H&S §§101000, 101460. 6

H&S §§101025,101030;101375,101400;101405,101415,101450, and 101470. 7

H&S §§101375, 101400. 8

California Constitution, Article, (hereinafter, “Cal. Const., art.”), XI, Section 7 “A county or city may make and enforce within its limits all local, police, sanitary, and other ordinances and regulations not in conflict with general laws.” 9

H&S §101025. 10

Division 105 of the H&S, starting at §120100. Division 105 consists of several 'Parts', entitled (1) “Administration of Communicable Disease Prevention and Control,” (2) “Immunizations,” (3) “Sexually Transmitted Disease,” (4) “Human Immunodeficiency Virus (HIV),” (5) “Tuberculosis,” (6) “Veterinary Public Health and Safety,” and (7) “Hepatitis C.” These statutes can be accessed online at “www.leginfo.ca.gov/calaw”. 11

See 17 C.C.R. §2500 and follo wing. Under H&S §100275, DHS is authorized to adopt regulations for the execution of its duties. 12

H&S §§120130, 120145, 120190, 120195, 120200, 120210, 120215 and 120175. 13

H&S §100180. 14

H&S §120130, under which DHS must establish and publish a list of reportable diseases and conditions. The list is found in 17 C.C.R. §2500 and includes the reporting of any unusual disease and outbreaks of any unlisted disease. 15

H&S §120130 mandates the Health Officer to report diseases as required by DHS. 17 C.C.R. § 2500(g) requires the Health Officer to report information to DHS as requested. 17 C.C.R. §2500(d) mandates the Health Officer to report health care provider reports to DHS. Unless there is a written authorization, the information requested does not include drug and alcohol records protected by the Part 2 of Title 42 of the Code of Federal Regulations, (hereinafter, “C.F.R.”). 16

H&S §120175. 17

17 C.C.R. §2501. The Health Officer is required to conduct morbidity/mortality studies at DHS request.


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18

H&S §2502. The Health Officer is the agent of DHS when conducting morbidity/mortality investigations and exercising DHS investigation and action powers granted by Government Code (hereinafter, “Gov.”), §11181. DHS is also authorized to conduct such studies pursuant to H&S §100325. H&S §11181 permits DHS inspection of books, records and other items. Therefore the Health Officer acting at DHS direction and has the same authority to inspect records. 19

17 C.C.R. §2500(f) and (g). The Health Officer may report to the DHS in confidence certain confidential medical information, other than drug and alcohol information, unless written authorization for such information is obtained. 20

45 C.F.R., Parts 160 and 164. 21

If the disease is not yet present within the Health Officer’s jurisdiction, the Health Officer may take preventive steps to control spread of disease into the jurisdiction. H&S §120175 and 17 C.C.R. §2501. 22

17 C.C.R. §2501 23

Penal Code (hereinafter, “Pen.”), §409.5. 24

17 C.C.R §2501. 25

H&S §120175. 26

H&S §120130 (c); H&S §121365 (g) provides specific authority for the local health officer to require isolation. 27

The authority to require a mass quarantine is implied by a reading of H&S §120175 (control of contagious, infectious and communicable disease) in conjunction with H&S §120205. The Health Officer may impose mass quarantine as directed by DHS pursuant to H&S §§120145 and 120195. 28

H&S §101030 (for a county Health Officer). 29

H&S §101470 (for a city Health Officer). 30

H&S §§101375, 101400, 101405 and 101415. 31

H&S §100182 and Pen. §409.5(c). 32

In re Martin (1948) 83 Cal.App.2d 164, 167. 33

H&S §101080. 34

Gov. §§8550 et. seq; H&S §101310. 35

As noted in the Introduction, this guide is intended only to address those circumstances arising prior to the formal Declaration of Emergency. DHS has published a comprehensive document for such circumstances. See: Authority and Responsibility of Local Health Officers in Emergencies and Disasters, D. David Abbott [Emergency Preparedness Office] and Jack S. McGurk, (Chief of Environmental Management Branch), Department of Health Services, State of California (September 30, 1998). 36

Coelho v. Truckell (1935) 9 Cal.App.2d 47. 37

Patrick v. Riley (1930) 209 Cal. 350, 354. 38

U.S. Constitution, 5th

and 14th

Amendments; California Constitution. Article 1, §§7, 15. 39

People v. Ramirez (1979) 25 Cal. 3d 260, 267. 40

An individual's constitutionally protected interest in avoiding physical restraint may be overridden in certain contexts. Communicable disease control is one such context. "The liberty secured by the Constitution of the United States to every person within its jurisdiction does not import an absolute right in each person to be, at all times and in all circumstances, wholly free from restraint. There are manifold restraints to which every person is necessarily subject for the common good. On any other basis organized society could not exist with safety to its members." Jacobsen v. Massachusetts, (1905). 197 U.S. 11, 26. 41

In re Martin, (1948) 83 Cal.App.2d 164, 168-169. 42

Example of grounds include: the individual had been exposed to contagion or infectious influences, someone had contracted the disease from the individual, the individual was one who came within a group which medical statistics or established medical studies or statistics show that a majority of whom are diseased, the home or region from where an individual came was in quarantine or otherwise identified as subject to the disease, the individual had engaged in activity which exposed him or her to the disease. In re Martin (1948) 83 Cal.App.2d 164, 167; In re Arata (1919) 52 Cal.App. 380, 385. 43

Depending upon the circumstances surrounding the need for the proposed order, “suspicion” alone may be insufficient to justify depriving persons of their liberty or property. In re Arata (1919) 523 Cal.App. 380, 383.


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44

The Health Officer’s authority to take necessary measures to prevent the spread of disease that does not yet exist within his or her jurisdiction derives from DHS authority and the Health Officer’s mandate to follow the rules, regulations and orders of DHS. Further authority derives from the statutory scheme taken as whole which empowers the Health Officer to take the actions necessary to fulfill his or her duty to control the spread of disease and to take preventive measures. 45

Health and Safety Code, (hereinafter, “H&S”), §120175; In re Halko (1966) 246 Cal.App.2d 553, 558. 46

Reno v. Flores (1993) 507 U.S. 292,301-302; Jew Ho v. Williamson, (1900) 103 F. 10, 26. 47

In re Milstead (1919) 44 Cal.App. 239, 244. 48

For example, the tuberculosis control statutes at H&S §121350, et seq. 49

Writs of habeas corpus or administrative mandamus are two methods that might be used to challenge Health Officer orders. 50

Morrissey v. Brewer (1972) 408 U.S. 481. 51

For example, in cases involving the seizure of property by Health Officials, a pre-seizure hearing is constitutionally required absent extraordinary circumstances. Leslie’s Pool Mart Inc. v. Department of Food and Agriculture (1990) 223 Cal. App. 3d 1524, 1532-33. 52

H&S §120225. 53

17 California Code of Regulations, (hereinafter, “C.C.R.”), §§ 2515 and 2520. 54

H&S §120295. 55

Such as facts obtained from communicable disease reports as well as medical tests results and epidemiological investigation. H&S §120250; 17 C.C.R. 2500(b). 56

Most orders are based upon the discretionary powers contained in H&S §§120175 and 120130(c) and their accompanying DHS regulations. The orders may also be based upon county or city ordinances or upon the enforcement of general orders concerning quarantine or isolation directed by DHS. H&S §120195. 57

H&S §§120150 and 120210 authorize destruction of personal property when ordinary means of disinfection are considered unsafe and an imminent menace to the public health. 58

A warrantless search of property to investigate a potential health hazard, absent an emergency situation, is unconstitutional; Camara v. Municipal Court of San Francisco (1967) 387 U.S. 523: see also In re Quackenbush (1996) 41 Cal.App.4

th

1301.) 59

See Section X, “Inspection, Seizure, Decontamination, Disinfection, And Destruction Of Real And Personal Property”; Love v. Superior Court (1990) 226 Cal. App. 3d 736, 741. 60

The Fifth and Fourteenth Amendments of the U.S. Constitution prohibit the taking of private property without just compensation. The necessity for such compensation depends on the facts and circumstances of each situation. The Fourth and Fourteenth Amendments prohibit unreasonable search and seizure. Article 1, §19 of the California Constitution prohibits the taking of private property without just compensation. 61

Brown v. State of California (1993) 21 Cal.App.4th 1500. 62

First and Eighth Amendments of the U.S. Constitution. Cal. Const., Article I. 63

Health and Safety Code, (hereinafter, “H&S”), §120105. 64

H&S §§100182, 120275; Penal Code, (hereinafter, “Pen.”) §§15, 16, 19. 65

Pen. §§834, 835, 836, and 836.5. 66

Patrick v. Riley, (1930) 209 Cal.350, 354. “The preservation of the public health is universally conceded to be one of the duties devolving upon the state as a sovereignty, and whatever reasonably tends to preserve the public health is a subject upon which the legislature, within its police power, may take action.” 67

See also H&S §§101450, 101025. 68

H&S §101470. 69

H&S §120195. 70

H&S §§121075, 101030, 17 C.C.R. §2501. 71

A city may contract with a county for the enforcement of public health laws by the county in the city’s jurisdiction. H&S §101030. A county may contract with a city for the enforcement of public health laws by the city in the county’s jurisdiction. See H&S §§101375, 101400, 101405 and 101415. 72

For example, see H&S §§120220 (isolation and quarantine), 121365 (tuberculosis). 73

However, the urgency in some circumstances may not require that showing.


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74

The requirements contained in this statutory scheme reflects the unique nature and lengthy treatment period for tuberculosis. Accordingly, analogy to and applicability of that scheme’s mandates to other public health threats is not necessarily dictated. 75

Since a Health Officer does not have peace officer status, enforcement may require the cooperation of law enforcement. See Section VIII, “Limitation of Movement Of Individuals.” 76

H&S §120275 "Any person who after being provided with notice or upon demand of any health officer, refuses or neglects to conform to any rule, order or regulation prescribed by department respecting a quarantine or disinfection of persons, animals, things or places, is guilty of a misdemeanor." Under H&S §100182, every person charged with the performance of any duty under the laws of this state relating to the preservation of the public health, who willfully neglects or refuses to perform the same, is guilty of a misdemeanor. 77

H&S §120290. Anyone afflicted with any contagious, infectious or communicable disease who willfully exposes himself, or anyone who willfully exposes another person afflicted with any contagious, infectious or communicable disease is guilty of a misdemeanor. 78

H&S §120295. 79

H&S §120275. 80

H&S §100180. 81

H&S §120220. 82

Local agencies could by ordinance give Health Officers and their designated employees the authority to arrest a person without a warrant “whenever the officer or employee has reasonable cause to believe that the person to be arrested has committed a misdemeanor in the presence of the officer or employee that is a violation of a statute or ordinance that the officer or employee has the duty to enforce.” Pen. §836.5, some counties have adopted such ordinances. 83

Government Code, (hereinafter, “Gov.”), §26601provides that “The sheriff shall arrest and take before the nearest magistrate for examination all persons who attempt to commit or who have committed a public offense.” 84

H&S §100180. 85

H&S §120175, §101030 (county), §101475 (city), §120195 & §120585; 17 California Code of Regulations, (hereinafter, “C.C.R.”), §2501(a). 86

17 C.C.R. §2501(g). 87

H&S §120125. 88

H&S §120185. 89

17 C.C.R. §2500. 90

H&S §120130(a). 91

17 C.C.R. §2500(b). 92

17 C.C.R. §2502(c). 93

17 C.C.R. §2500(h). 94

17 C.C.R. §2502(a), (b) & (d). 95

17 C.C.R. §2501(a). 96

For example, DHS may investigate and take measures necessary to ascertain the nature of the disease and prevent its spread upon being informed by the Health Officer of any contagious, infectious, or communicable disease. H&S §120125. 97

For example, each Health Officer is required by state law to enforce all orders, rules, and regulations concerning quarantine or isolation prescribed or directed by DHS. H&S §120195. 98

H&S §120130(b) authorizes DHS to adopt these regulations. 99

H&S §120195. It is a misdemeanor for a Health Officer to refuse or neglect to comply with a specific DHS order. H&S §100182. 100

H&S §120140. 101

H&S §120145. 102

H&S §120135. 103

H&S §120150. 104

H&S §120215.


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105

H&S §120200. 106

Regulations containing case and contact requirements are found in Title 17 C.C.R. 2550 et. seq. Not all of these regulations require quarantine or isolation, consequently these regulations should be consulted when deciding how to handle a case or suspected case of reportable disease. 107

H&S §120210. When property is destroyed pursuant to this section, the governing body of the locality where the destruction occurs may make adequate provision for compensation in proper cases for those injured thereby. 108

See, for example, H&S §120205. 109

The Surgeon General now functions under the Assistant Secretary for Health, U.S. Department of Health and Human Services. As such the regulations adopted by the Surgeon General are in effect those of the Secretary. 110

42 United States Code, (hereinafter, “U.S.C.”), §264(a); see 42 California Federal Rules, (hereinafter, “C.F.R.”), Parts 70-71. 111

42 U.S.C. §265. 112

42 U.S.C. §267. 113

42 U.S.C. §270. 114

42 C.F.R. §§70.4, 71.21. 115

42 U.S.C. §264(e). 116

42 C.F.R. §70.2. 117

If national measures are needed, upon executive decision to be made by the President, the CDC has authority to impose quarantine where there is a risk of infectious disease transmission across state lines. 42 U.S.C. §264(a); The CDC has advised that it anticipates the need to use its delegated federal authority only in rare situations. American Red Cross Preparedness Guide, Controlling the Spread of Contagious Diseases. 118

42 C.F.R. §70.6. In the 2003 SARS outbreak, quarantine of large groups was used only in selected settings where extensive transmission occurred. Department of Health and Human Services, Centers for Disease Control and Prevention. (September 2004). 119

Government Code, (hereinafter, “Gov.”), §110. 120

Gov. §111. 121

See, for example, Gov. §§113-115. 122

See U.S. v. Warne (1960) 190 F.Supp.645, at 651, for a discussion of the distinction between purchase-by-consent and cession statutes. 123

Gov. §126. 124

Art. 1, Section 8, Clause 17 of the U.S. Constitution. 125

The Supremacy Clause (Art. VI, cl. 2) of the U. S. Constitution. 126

For example, although offices of the U.S. Postal Service are federal property, in the absence of a cession of jurisdiction, this property may be subject to concurrent jurisdiction of state and federal authorities. See Town of Wibaux v. Brown, Slip Copy, 2005 WL 1270295. 127

See, example, In re Martin (1948) 83 Cal.App.2d 164; Gov. §§26602, 41601; H&S §100106, 101029. 128

See Penal Code (hereinafter, “Pen.”), §§830, et seq. Local agencies could give this power to Health Officers, see footnote 93 129

See Pen. §836. 130

Pen. §835a. 131

H&S §120275 (misdemeanor to violate or refuse to obey a DHS quarantine/disinfection rule, order, or regulation prescribed by DHS); H&S §120290 (misdemeanor for any person with a contagious, infectious or communicable disease to willfully expose himself or herself to another person, and misdemeanor to willfully expose a diseased person to another person); H&S §120220 (all persons to obey rules, orders and regulations of Health Officer); H&S §§121365 and 120280 (criminal sanctions upon violation of a TB order); Pen. §409.5(a) and(c) (misdemeanor for violation of contaminated area closure); Pen. §§17 and 19. 132

For example, H&S §121365.


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133

H&S §120280. Person convicted of violating Health Officer order may be placed on probation upon condition that the Health Officer order be complied with fully. 134

Gov. §26601 “The sheriff shall arrest and take before the nearest magistrate for examination all persons who attempt to commit or who have committed a public offense.” 135

See Pen. §§11415 et. seq. 18 U.S.C., §§175 et. seq.. 136

See Pen. §409.5. Law enforcement and Health Officers, among others, have authority to close contaminated areas. 137

Pen. §409.3. 138

18 U.S.C. §111. 139

Pen. §148. 140

Gov. §8607. SEMS is in compliance with the National Incident Management System, “NIMS”. See “www.fema.gov/nims/”. 141

See “Incident Command System: Independent Study Course,” Emergency Management Institute, Federal Emergency Management Agency, IS-195, Jan., 1998. 142

17 C.C.R. §2501(b). 143

Gov. §8607. 144

Nevada v. Hicks (2001) 533 U.S. 353. Held that the sheriff would have the corollary right to enter a reservation (including Indian-fee lands) for enforcement purposes. The case noted at p. 361-362 that “[t]hough tribes are often referred to as "sovereign" entities, it was "long ago" that "the Court departed from Chief Justice Marshall's view that 'the laws of [a State] can have no force' within reservation boundaries. `Ordinarily,’ it is now clear, `an Indian reservation is considered part of the territory of the State,’ ” citing, U.S. Dept. of Interior, Federal Indian Law 510 n. 1 (1958). 145

See Washington v. Confederated Tribes of Colville Reservation, (1980) 447 U.S. 134. 146

Nevada v. Hicks (2001) 533 U.S. 353, 362. 147

Nevada v. Hicks (2001) 533 U.S. 353, 362. 148

Cal. Const., art. IX, sec. 9 – “The University of California shall constitute a public trust, to be administered by the existing corporation known as "The Regents of the University of California," with full powers of organization and government, subject only to such legislative control as may be necessary to insure the security of its funds and compliance with the terms of the endowments of the university and such competitive bidding procedures as may be made applicable to the university by statute for the letting of construction contracts, sales of real property, and purchasing of materials, goods, and services.” 149

San Francisco Labor Council v. Regents of University of California (1980) 26 Cal. 3d 785. 150

Pen. 830.2 (b), Educ. 92600. 151

This document may be found under Plans and Publications at website of the Governor’s Office of Emergency Services at “www.oes.ca.gov.” 152

See Town of Wibaux v. Brown, Slip Copy, 2005 WL 1270295, Mont.,2005. 153

Civil Code §56 et. seq. 154

45 Code of Federal Regulations, (hereinafter, “C.F.R.”), §160.101 et. seq. 155

See Civil Code 56.10(b)(9); 45 C.F.R. §164.512(b)(1)(i) – “(b)(1) A covered entity may disclose protected health information for the public health activities and purposes described in this paragraph to: (i) A public health authority that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, including, but not limited to, the reporting of disease, injury, vital events such as birth or death, and the conduct of public health surveillance, public health investigations, and public health interventions; or, at the direction of a public health authority, to an official of a foreign government agency that is acting in collaboration with a public health authority.” 156

45 C.F.R. §164.512(b)(2). 157

45 C.F.R. §164.512(b)(1). 158

45 C.F.R. §164.502(b)(1) "This subdivision of the Privacy Rule states that only patient health information which is necessary to accomplish the intended purpose of a use, disclosure, or request for information, is to be accessed for this purpose." 159

Civil Code §56.05(g).


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160

45 C.F.R. §164.514(a). 161

45 C.F.R. §5164.514(b) “A covered entity may determine that health information is not individually identifiable health information only if: (1) A person with appropriate knowledge of and experience with generally accepted statistical and scientific principles and methods for rendering information not individually identifiable: (i) Applying such principles and methods, determines that the risk is very small that the information could be used, alone or in combination with other reasonably available information, by an anticipated recipient to identify an individual who is a subject of the information; and (ii) Documents the methods and results of the analysis that justify such determination; or (2)(i) The following identifiers of the individual or of relatives, employers, or household members of the individual, are removed: (A) Names; (B) All geographic subdivisions smaller than a State, including street address, city, county, precinct, zip code, and their equivalent geocodes, except for the initial three digits of a zip code if, according to the current publicly available data from the Bureau of the Census: (1) The geographic unit formed by combining all zip codes with the same three initial digits contains more than 20,000 people; and (2) The initial three digits of a zip code for all such geographic units containing 20,000 or fewer people is changed to 000. (C) All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older; 45 C.F.R. §164.514(b) The list goes on to include deletion of telephone numbers, fax numbers; electronic mail addresses; social security numbers; medical record numbers etc. 162

Government Code, (hereinafter, “Gov.”), §6252 (e) "Public records" includes any writing containing information relating to the conduct of the public's business prepared, owned, used, or retained by any state or local agency regardless of physical form or characteristics. "Public records" in the custody of, or maintained by, the Governor's office means any writing prepared on or after January 6, 1975. See also Gov. §6252 (g) "Writing" means any handwriting, typewriting, printing, photostating, photographing, photocopying, transmitting by electronic mail or facsimile, and every other means of recording upon any tangible thing any form of communication or representation, including letters, words, pictures, sounds, or symbols, or combinations thereof, and any record thereby created, regardless of the manner in which the record has been stored (emphasis added.). 163

Gov. §6253; see also Cal. Const., art. I, §3, subd. (b). 164

San Gabriel Tribune v. City of West Covina (1983) 143 Cal. App. 3d 762. 165

Even if a particular item is not specifically exempt from disclosure, Gov. §6255 establishes a catch-all provision that permits withholding of a record if the agency can justify nondisclosure "by demonstrating that ... on the facts of the particular case the public interest served by not disclosing the record clearly outweighs the public interest served by disclosure of the record." A claim that disclosure of a particular item violates an individual's constitutional right to privacy is analyzed under essentially the same balancing test as is used in evaluating the Gov. §6255 catch-all exemption. Teamsters Local 856 v. Priceless, LLC, (2003) 112 Cal.App.4th 1500, 1511. 166

Gov. §6255, City of San Jose v. Superior Court (1999) 74 Cal. App. 4th

1008, 1017-1019. 167

Gov. §6254(c) "[p]ersonal, medical or similar files, the disclosure of which would constitute an unwarranted invasion of personal privacy". 168

Gov. §6254(k). 169

Government Code, (hereinafter, “Gov.”) §6250 et seq. See discussion on responding to public records act requests in Section VI, “Confidentiality of Health Information.” 170

Gov. §6252 (e) "Public records" includes any writing containing information relating to the conduct of the public's business prepared, owned, used, or retained by any state or local agency regardless of physical form or characteristics. See also Gov. §6252 (g) "Writing" means any handwriting, typewriting, printing, photostating, photographing, photocopying, transmitting by electronic mail or facsimile, and every other means of recording upon any tangible thing any form of communication or representation, including letters, words, pictures, sounds, or symbols, or combinations thereof, and any record thereby created, regardless of the manner in which the record has been stored (emphasis added). 171

There is an exemption for release of patient medical information under the Public Records Act. See Gov. §6254(c) "[p]ersonal, medical or similar files, the disclosure of which would constitute an


May 2, 2006

unwarranted invasion of personal privacy" and Gov. Code §6254(k) “Records, the disclosure of which is exempted or prohibited pursuant to federal or state law…” Even if a particular item is not specifically exempt from disclosure, Gov. §6255 establishes a catch-all provision that permits withholding of a record if the agency can justify nondisclosure "by demonstrating that ... on the facts of the particular case the public interest served by not disclosing the record clearly outweighs the public interest served by disclosure of the record." A claim that disclosure of a particular item violates an individual's constitutional right to privacy is analy zed under essentially the same balancing test as is used in evaluating the Gov. §6255 catch-all exemption. Teamsters Local 856 v. Priceless, LLC, (2003) 112 Cal.App.4th 1500, 1511. 172

Gov. §6276.30; Health & Safety Code, (hereinafter, “H&S”), §100330. Records in morbidity studies are confidential and exempt from production under the public records act but the statistical compilations from the records which excludes personal identifying information is not. 173

Health care providers must follow the requirements of the California Confidentiality of Medical Information Act (“CMIA”) and the Health Information and Portability and Accountability Act of 1996 (“HIPAA”). 174

The California courts have equated the right of privacy with the right “to be let alone,” which must be balanced against public interest in the dissemination of information demanded by democratic processes.” Black Panther Party v. Kehoe (1974) 42 Cal.App.3d 645, 652. 175

45 Code of Federal Regulations, (hereinafter, “C.F.R.”), §164.512(b)(i) provides that public health purposes include but are not limited to: preventing or controlling disease, injury or disability, reporting disease, reporting injuries, reporting vital events, conduct of public health surveillance, conduct of public health investigations, conduct of public health interventions, or to a foreign government agency that is acting in collaboration with a public health authority. 176

45 C.F.R. §164.502(b)(1). The subdivision of the Privacy Rule states that “only patient health information which is necessary to accomplish the intended purpose of a use, disclosure, or request for information, is to be accessed for this purpose." 177

45 C.F.R. §164.510(a)(1)(i)(C). 178

45 C.F.R. §164.508. 179

Data from modeling studies suggest that community containment measures such as quarantine are effective for controlling an outbreak even if compliance is less than perfect. Optimally, quarantine applied on a voluntary basis will afford sufficient compliance to attain the necessary effect. Department of Health and Hu man Services, Centers for Disease Control and Prevention, Severe Acute Respiratory Syndrome, May 3, 2005. See www.cdc.gov/ncidod/sars/factsheet.180

For example, SARS, West Nile Virus or Asian Flu. 181

Health Officers should be aware that they need a strong justification to intrude on a patient’s freedom of movement, bodily integrity, or privacy, and they should make every effort to minimize the impact on personal liberty. 182

Health and Safety Code, (hereinafter, “H&S”), §120175, See discussion contained in Section II, “General Authority of the Health Officer.” 183

H&S §120130(c); see also H&S §121365(g), giving specific authority for the local health officer to require isolation. 184

H&S §120585. 185

H&S §120205. 186

H&S §§120145,120195. Each Health Officer is charged with enforcing all orders, rules and regulations concerning quarantine or isolation prescribed or directed by the Department of Health. 187

Department of Health and Human Services, Centers For Disease Control And Prevention, September 2004; 17 California Code of Regulations, (hereinafter, “C.C.R.”), §§2518 and 2520. 188

17 C.C.R. 2515. 189

17 C.C.R. §2516. 190

17 C.C.R. §2518. 191

17 C.C.R. §2520. 192

During the 2003 global outbreak of SARS, seriously ill patients were cared for in hospitals, and those with mild illness were cared for at home. (Department of Health and Human Services, Centers for


http://www.cdc.gov/ncidod/sars/factsheet.

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Disease Control and Prevention, Isolation and Quarantine, September 2004.) 193

H&S §120135. 194

H&S §120200. 195

H&S §120225. 196

H&S §121365. 197

Home isolation minimizes property and liberty intrusions and associated costs. Each of these are factors considered in the determination process to be used in carrying out the isolation order. 198

Souvannarath v. Hadden (2002) 95 Cal. App. 4th

1115 (court found that the Legislature intended to prohibit the use of jails as tuberculosis detention facilities). 199

In re Application of Arata (1921) 52 Cal. App. 380, 383. 200

In some instances, this balancing may result in the need for a formal hearing procedure that includes the right of confrontation and cross-examination, as well as a limited right to an attorney. See Morrissey v. Brewer (1972) 408 U.S. 471. In others, due process may require only that the administrative agency comply with the statutory limitations on its authority. See Cafeteria and Restaurant Workers Union v. McElroy (1961) 367 U.S. 886. 201

H&S §120205. The scale of the problem may also lend itself to state leadership. 202

42 U.S.C. §264(a) and (b). 203

For example voluntary home curfew or public event restrictions. 204

Bioterrorism, Public Health and the Law, Legal Basis for Large-Scale Quarantine,Vernellia R. Randall,; American Medical Association, The Ethics of Quarantine, Ross Upshur, M.D., MSc, MA, November 2003, Vol. 5, Number 11. 205

H&S §120130, 17 C.C.R. §2500. 206

45 Code of Federal Regulations, (hereinafter, “C.F.R.”), Health Insurance Portability and Accountability Act of 1996; Civil Code §56.10. 207

For an example of statutorily mandated content and procedures applicable to tuberculosis orders. See H&S §§121365 et. seq. 208

Due to the intrusive nature of these orders, Health Officers may wish to consult with legal counsel. 209

For example, prescribed course of medication, infection control precautions, or limitation on movement or interactions with others. 210

Where uncertain, a date should be inserted and upon expiration a new order should be issued and served. 211

If there will be a potential for a penalty of imprisonment or fine, it must be specially set forth in the order. 212

Include specific facts such as, the individual has a dis ease or there are reasonable grounds to believe that the individual has a disease, epidemiologic evidence, clinical evidence, laboratory test results, likelihood of disease transmission, the threat to public health and safety. 213

For example, the person is unable or refuses to take medication or take necessary precautions. 214

Use of both methods of service may be optimal. 215

H&S §120105. “Whenever in the Communicable Disease Prevention and Control Act (Section 27), service or notice of any order or demand is provided for, it shall be sufficient to do so by registered or certified mail if a receipt therefore signed by the person to be served or notified is obtained. The receipt shall be prima facie evidence of the service or notice in any civil or criminal action.” 216

H&S §120220. “When quarantine or isolation, either strict or modified, is established by a health officer, all persons shall obey his or her rules, orders, and regulations.” 217

H&S §120275. “Any person who, after notice, violates, or who, upon the demand of any health officer, refuses or neglects to conform to, any rule, order, or regulation prescribed by the department respecting a quarantine or disinfection of persons, animals, things, or places, is guilty of a misdemeanor.” 218

H&S §120290. “Exc ept as provided in section 120291 or in the case of the removal of an afflicted person in a manner the least dangerous to the public health, any person afflicted with any contagious, infectious, or communicable disease who willfully exposes himself or herself to another person, and any person who willfully exposes another person afflicted with the disease to someone else, is guilty of a misdemeanor.”


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219

Penal Code, (hereinafter, “Pen.”) §409.5. 220

This is in addition to any express statutory authority for particular closures such as food establishments (H&S §113960) and certain funerals (17 C.C.R. §2538). 221

Nunez v. San Diego (9th Cir. 1997) 114 F.3d 935; Bykosky v. Borough of Middletown (1975) 401 F.Supp. 1242 Halvonic v. Reagan (1972) 457 F.2d 311; People v. Richardson (1994) 33 Cal.App.4th Supp. 11; In re Juan C. (1994) 28 Cal.App.4th 1093; People v. McKelvy (1972) 23 Cal.App.3d 1027, 1035. 222


Persons of common intelligence should not have to guess at the order’s meaning. The order should be specific enough to prevent arbitrary and discriminatory interpretation and enforcement by the police. 224

For example, a factual explanation of why there is an emergency, information regarding specific damage to property or injury to life and the need for the protection of the public’s health and safety. 225

Pen. §409.5. 226

See generally, Nunez v. San Diego (9th Cir. 1997) 114 F.3d 935; Bykosky v. Borough of Middletown (1975) 401 F.Supp. 1242; Halvonic v. Reagan (1972) 457 F.2d 311; People v. Richardson (1994) 33 Cal.App.4th Supp. 11; In re Juan C. (1994) 28 Cal.App.4th 1093; People v. McKelvy (1972) 23 Cal.App.3d 1027, 1035. 227


Government Code (“Gov.”) § 8634. “During a local emergency the governing body of a political subdivision, or officials designated thereby, may promulgate orders and regulations necessary to provide for the protection of life and property, including orders or regulations imposing a curfew within designated boundaries where necessary to preserve the public order and safety. Such orders and regulations and amendments and rescissions thereof shall be in writ ing and shall be given widespread publicity and notice. The authorization granted by this chapter to impose a curfew shall not be construed as restricting in any manner the existing authority of counties and cities and any city and county to impose pursuant to the police power a curfew for any other lawful purpose.” 229

Gov. §8630(a). “A local emergency may be proclaimed only by the governing body of a city, county, or city and county, or by an official designated by ordinance adopted by that governing body. (b) Whenever a local emergency is proclaimed by an official designated by ordinance, the local emergency shall not remain in effect for a period in excess of seven days unless it has been ratified by the governing body. (c)(1) The governing body shall review, at its regularly scheduled meetings until the local emergency is terminated, the need for continuing the local emergency. However, in no event shall a review take place more than 21 days after the previous review. (2) Notwithstanding paragraph (1), if the governing body meets weekly, it shall review the need for continuing the local emergency at least every 14 days, until the local emergency is terminated. (d) The governing body shall proclaim the termination of the local emergency at the earliest possible date that conditions warrant.” 230

Due to the nature of a curfew order, Health Officers will be working with law enforcement in regards to enforcing the order. 231

See generally, Nunez v. San Diego (9th Cir. 1997) 114 F.3d 935; Bykosky v. Borough of Middletown (1975) 401 F.Supp. 1242, Halvonic v. Reagan (1972) 457 F.2d 311; People v. Richardson (1994) 33 Cal.App.4th Supp. 11; In re Juan C. (1994) 28 Cal.App.4th 1093; People v. McKelvy (1972) 23 Cal.App.3d 1027, 1035. 232

See text of Gov. §8634 in footnote 225. 233


If the curfew does not apply to all persons within a designated area, there should be a factual basis for its selective application. 235

Persons of common intelligence should not have to guess at the order’s meaning. The order should be definite enough to prevent arbitrary and discriminatory enforcement by the police. 236

For example, involuntary tests and vaccinations. 237

Derrick v. Ontario Community (1975) 47 Cal.App.3d 145; Jew Ho v. Williamson (1900) 103 F. 10. 238

17 California Code of Regulations, (hereinafter, “C.C.R.”), §2540. “Health Officer shall after suitable investigation take additional steps necessary as he deems necessary to prevent the spread of communicable disease or a disease suspected of being communicable in order to protect the public


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health.” (emphasis added). 239

17 C.C.R. §§2534 (common carriers), 2606 (rabies); Ex Parte Dillon (1919) 44 Cal.App. 239. 240

17 C.C.R. §2501(a). The Health Officer “shall take whatever steps deemed necessary for the investigation and control of the disease, condition or outbreak reported. If the Health Officer finds that the nature of the disease and the circumstances of the case, unusual disease, or outbreak warrant such action, the Health Officer shall make or cause to be made an examination of any person who or animal which has been reported pursuant to Sections 2500 or 2505 to verify the diagnosis, or the existence of an unusual disease, or outbreak” and “make an investigation to determine the source of infection.” “Laboratory test” means a clinical laboratory test or examination as defined in Business and Professions Code, Section 1206(a)(4); 17 C.C.R. §2534. 241

17 C.C.R. §§2612 (Salmonella), 2613 (Shigella), 2628 (Typhoid). 242

17 C.C.R. §§2603(2) and (3) (lab tests of pet birds); 2606 (rabid animals). 243

17 C.C.R. §§2501(a), 2540, 1 Opn.Cal.Atty.Gen. 541, 542 citing In re Travers (1920) 48 Cal.App.764, 766. 244

Health and Safety Code, (hereinafter, “H&S”), §§120145, 120175; Ex parte Arata (1921) 52 Cal.App. 380. 245

17 C.C.R. §2501(a). 246


For example, in the venereal disease context, it is expected that investigation will include examination and testing. 17 C.C.R. §2636(h). 248

Jones v. Czapkay (1960) 182 Cal.App.2d 192, 199. 249

H&S §120115(f). 250

17 C.C.R. §§2501(a), 2540 (General Clause), 2574(c) (Food Poisoning), 2622 (Trichinosis). 251

In re Martin (1948) 83 Cal.App.2d 164, 167. 252

H&S §120215, See discussion in Section VIII, “Limitation of Movement Of Individual and Groups; Subsection A Isolation and Quarantine In Non-Tuberculosis Context.” 253

Pen. Code §11419 provides a list of biological agents that includes anthrax, smallpox virus, pneumonic plague, botulism, and hemorrhagic fever virus. 254


An examination that consists of visual inspection conducted without removal of clothing is most likely permissible without a court order. But if the individual refuses to present for the examination or inspection or to provide testing samples upon service of a Health Officer order, resort to the court may be the only option. 256


H&S §120175, 17 C.C.R. § 2501(a). It is uncertain if these measures can be taken in circumstances involving chemical agent that is not of a biological origin. 258

Jones v. Czapkay (1960) 182 Cal.App.2d 192, 199. 259

The Health Officer is charged with enforcing and observing both the statutes related to public health, and the orders and regulations prescribed by the Department of Health Services. H&S §§101030, 120130, 120190, 120195, 120200, 120210, 120215, and 120175. 260

17 C.C.R. §2524. Disinfection is included in isolation and quarantine measures. “Each person released from quarantine or isolation shall bathe and wash his hair with soap and hot water and put on clean clothes. The area of isolation shall be disinfected according to the instructions of the Health Officer.” H & S §120275. “Any person, who, after notice, violates, or who, upon the demand of any Health Officer, refuses or neglects to conform to, any rule, order or regulation prescribed by the department respecting quarantine or disinfection of person, animals, things, or places, is guilty of a misdemeanor.” 261

H&S §120530. “Any state agency conducting a public hospital shall admit acute venereal disease cases, when, in the opinion of the department or Health Officer with jurisdiction, persons infected with venereal disease may be a menace to public health.” 262

H&S §120215; See discussion in Section VIII, “Limitation of Movement Of Individual and Groups; Subsection A Isolation and Quarantine In Non-Tuberculosis Context.” 263

Pen. §11419 provides a list of b iological agents that includes anthrax, smallpox virus, pneumonic plague, botulism, and hemorrhagic fever virus. 264

In re Milstead (1919) 44 Cal.App. 239, 244.


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265

Freedom of religion along other constitutional rights may implicated. 266


Such as described in 17 C.C.R. §§2636(h) (tuberculosis), 2614 (smallpox), and 2566 (diphtheria). 268

17 C.C.R. §2566(f). The Health Officer shall take appropriate measures to encourage and facilitate a continuing program of active immunization against diphtheria for all children within the Health Officer jurisdiction (emphasis added). 17 C.C.R. §2614. The Health Officer is required to provide smallpox vaccinations for persons who have been exposed to a case or suspected case of smallpox. 269

H&S §120350. 270

H§S §§120325 et. seq. , 121525 (TB examinations). 271

California has not adopted Model State Health Emergency Powers Act which authorizes compulsory vaccination during a “state of public health emergency.” See also Jacobson v. Massachusetts (1905) 197 U.S. 11. 272

Standard medical definition of consent may apply. 273

Health and Safety Code, (hereinafter, “H&S”), §120175, 17 California Code of Regulations, (hereinafter, “C.C.R.”) §2501. See discussion in Section II, “General Authority Of The Health Officer.” In addition, certain local nuisance abatement ordinances may provide additional or alternate authority. A Health Officer has express authority to inspect real or personal property when necessary to enforce the regulations of DHS. 274

Real property consists of land and the buildings located on it. 275

Personal property consists of possessions such as clothing, cars, equipment, and furniture. 276

For example, in cases of sexually transmitted diseases, inspection of restaurants, underground fuel tanks, and hazardous waste there is an express statute authorizing inspection and seizure. 277

For example, imminent spread of contamination and disease that is a serious threat to public health and safety, or the need to prevent imminent release of hazardous materials, or an immediate risk of serious danger to the public inside or outside the building. For a discussion of the concept of exigency and the need for a warrant in a criminal context, see People v. Celis (2004) 33 Cal.4th 677. 278

A warrant might be required to search commercial property in a manner that is not otherwise statutorily authorized, such as routine inspections. 279

People v. Celis (2004) 33 Cal.4th 677. 280

H&S §§120150 and 120210 authorize the destruction of personal property when ordinary means of disinfection are considered unsafe and there is an imminent menace to the public health. 281

Brown v. State of California (1993) 21 Cal.App.4th 1500; Teresi v. State of California (1986) 180 Cal.App.3d 239. 282

For example, medication, pharmaceuticals, medical equipment and supplies. Rationing is distinguished from commandeering in that rationing involves the setting of the parameters of resource distribution and commandeering involves taking involuntary possession of resources or facilities. 283

Health and Safety Code, (hereinafter, “H&S”), §120175; 17 California Code of Regulations, (hereinafter, “C.C.R.”), §2501. For the general powers of the Health Officer see Section II, “General Authority of the California Local Health Officer.” 284

Government Code, (hereinafter, “Gov.”), §8550 et seq. 285

See Section III, “Interjuridictional Coordination and Cooperation.” 286

Gov. §8630. 287

H&S §101040. 288

For example, Sherman Food, Drug, and Cosmetic Law (H&S §§109875 et. seq.), State Department of Water Resources and the State Water Resources Control Board (Water Code §350). 289

If the rationing does not apply to all persons within a designated area, there should be a factual basis for its selective application. 290



This can include medication, pharmaceuticals, medical equipment and supplies. 293

Health and Safety Code, (hereinafter, “H&S”), §120175, 17 California Code of Regulations, (hereinafter, “C.C.R.”), §2501. For the general powers of the Health Officer see Section II. “General


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Authority of the California Local Health Officer.” 294

Government Code, (hereinafter, “Gov.”), §8550 et seq. 295


Gov. §8630. 297

H&S §101040. 298

If the commandeering does not apply to all persons within a designated area, there should be a factual basis for its selective application. 299

The order should specify with as much detail as possible the property to be surrendered and the precise terms, conditions and location that the property is to be surrendered to the appropriate authority. 300



Brown v. State of California (1993) 21 Cal.App.4th 1500; Teresi v. State of California (1986) 180 Cal.App.3d 239. 303

For examp le, health service workers and providers, lab technicians, administrators, drivers, building contractors. 304

Statutorily authorized conscription for limited periods for the purpose of the protection of public health and safety is not considered involuntary servitude. 305

See Gov. §8610. “The governing body of a county, city and county, or city may, by ordinance or resolution, authorize public officers, employees, and registered volunteers to command the aid of citizens when necessary in the execution of their duties during a state of war emergency, a state of emergency, or a local emergency.” 306

H&S §120175, 17 C.C.R. §2501. For the general powers of the Health Officer see Section II, “General Authority of the Local Health Officer.” 307

Gov. §8550 et. seq.. 308


Gov. §8630. After a local emergency is declared, the Health Officer must determine that conscription of persons is a preventive measure necessary to protect and preserve the public health. "Preventive measure" means abatement, correction, removal or any other protective step that may be taken against any public health hazard that is caused by a disaster and affects the public health. H&S §101040.


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XI. TRAVEL-RELATED RISK OF DISEASE TRANSMISSION

San Francisco International Airport (SFIA) is located within the geographic jurisdiction of the San Mateo County Health Department. It is a multi-jurisdictional organization and governed by various Federal and State agencies, the City and County of San Francisco, and San Mateo County. An effort is underway to facilitate communications and cooperation between the agencies in order to more efficiently manage quarantine and isolation issues as they present themselves at the airport. As of this writing, a protocol has been presented in draft form that closely mirrors the procedure for managing SARS. A system is in place for the quarantine station at SFIA to notify the San Mateo County Health Department regarding issues involving arriving sick passengers and their disposition. Currently there is good cooperation between the agencies in an informal setting and mostly reliant on the good intent of the personnel involved. However, to formalize the cooperation will require much work that will be pursued in Phase II of the Pandemic Influence Plan.


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XII. PUBLIC HEALTH COMMUNICATIONS

This Influenza Pandemic Annex supplements the San Mateo County Health Department’s Crisis and Emergency Risk Communication (CERC) Plan. The Annex is a preparedness plan that addresses all phases of pandemic as outlined by the World Health Organization. The Health Department should consider the context of the local situation before activating the CERC Plan. Potential thresholds and triggers that might indicate that communications demands are likely to escalate quickly include developments that raise the health risk of county residents, for example if a human case of avian influenza is reported in the San Francisco Bay Area. Influenza Pandemic Preparedness Activities Pandemic preparedness is a continuous effort. In this way the Pandemic Annex differs from the CERC plan, which is designed for emergency response. Outlined below are the activities the Health Department will engage in during the pandemic phases. INTERPANDEMIC AND PANDEMIC ALERT PERIODS • Assess and monitor readiness to meet communications needs in preparation

for an influenza pandemic, including regular review and update of communications plans.

• Plan and coordinate emergency communication activities with private industry, education, and non-profit partners (e.g., local American Red Cross chapters).

• Identify and train lead subject-specific spokespersons. • Provide public health communications staff with training on risk

communications for use during an influenza pandemic. • Develop and maintain up-to-date communications contacts.


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• Participate in tabletop exercises and other collaborative preparations to assess readiness.

• Address rumors and false reports regarding pandemic influenza threats. • Confirm any contingency contracts needed for communications resources

during a pandemic PANDEMIC PERIOD • Contact key community partners and implement frequent update briefings. • As appropriate, implement and maintain community resources, such as

hotlines and websites to respond to local questions from the public and professional groups.

• Tailor communications services and key messages to specific local audiences.

• In coordination with epidemiologic and medical personnel, obtain and track information daily on the numbers and location of newly hospitalized cases, newly quarantined persons, and hospitals with pandemic influenza cases. Use these reports to determine priorities among community outreach and education efforts, and to prepare for updates to media organizations in coordination with federal partners.

Messages and audiences Strategic communications activities based on scientifically derived risk communications principles are an integral part of a comprehensive public health response before, during, and after an influenza pandemic. Effective communication guides the public, the news media, healthcare providers, and other groups in responding appropriately to outbreak situations and complying with public health measures. Communications preparedness for an influenza pandemic follows seven key risk communications concepts. • When health risks are uncertain, as likely will be the case during an influenza

pandemic, people need information about what is known and unknown, as well as interim guidance to formulate decisions to help protect their health and the health of others.

• Coordination of message development and release of information among federal, state, and local health officials is critical to help avoid confusion that can undermine public trust, raise fear and anxiety, and impede response measures.

• Guidance to community members about how to protect themselves and their family members and colleagues is an essential component of crisis management.

• Information provided to the public should be technically correct and succinct without seeming patronizing.


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• Information presented during an influenza pandemic should minimize speculation and avoid over-interpretation of data, overly confident assessments of investigations, and control measures.

• An influenza pandemic will generate immediate, intense, and sustained demand for information from the public, healthcare providers, policy makers, and news media. Healthcare workers and public health staff are likely to be involved in media relations and public health communications.

• Timely and transparent dissemination of accurate, science-based information about pandemic influenza and the progress of the response can build public trust and confidence.

During the Interpandemic Period, national, state, and local health communications professionals should focus on preparedness planning and on building flexible, sustainable communications networks. During the Pandemic Period, they should focus on well-coordinated health communications to support public health interventions designed to help limit influenza-associated morbidity and mortality. On the pages that follow are the Health Department’s influenza public information matrix describing objectives, actions and messages for each pandemic phase. Next is a notification/coordination worksheet for pandemic that lists groups the Health Department should communicate in all phases. Although messages and methods for reaching these audiences will differ, the topics that must be addressed are the same.


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PANDEMIC INFLUENZA PLAN PUBLIC INFORMATION MATRIX Phases of Response

Objectives Actions Messages

Inter-Pandemic Period Phases 1-2

Maintain an appropriate level of awareness and understanding of pandemic. Ensure that information can be shared rapidly among health authorities, other partners and the public. Ensure collaborative working relationships with the media regarding epidemics, including the roles, responsibilities and operating practices of the Health Department.

Establish phased communications strategy for pandemic influenza. Plan and test capacity for meeting expected information demands for diverse audiences. Establish networks among key response stakeholders, including risk communicators, non-health government departments, and professional and technical groups. Familiarize news media with plans, preparedness activities and decision-making related to seasonal and pandemic influenza.

Influenza: seasonal, avian, pandemic Hygiene and personal protection Preparedness

Pandemic Alert Phase 3

Communicate transparently with the public regarding possible outbreak progression and contingencies to be expected. Ensure that appropriate information is shared rapidly among health authorities, other partners and the public, including what is known and unknown. Gain acceptance of quarantine, isolation and social distancing as measures to control spread of disease. Gain acceptance of vaccine and antiviral rationing and priority groups. Increase knowledge and awareness of pandemic and encourage preparedness. Increase knowledge of avian influenza and how it spreads from animals to

Identify target groups for delivery of key messages; develop appropriate materials, formats and language options. Work with partners to ensure consistent messages are delivered. Address the issue of stigmatization of individuals/families/communities affected by human infection with the animal strain. Review and update information materials for news media, general public, health workers and policymakers. Review communications systems and facilities to ensure that they are functioning optimally, and that contact lists are up to date.

Influenza: seasonal, avian, pandemic Vaccine & antivirals Quarantine, isolation & social distancing Flu and local animals Hygiene and personal protection Preparedness NETVAC County plan Travel health precaution Advice on how to behave if ill after travel in affected areas Address rumors and misinformation


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humans. Build trust and confidence in the Health Department.


Prepare the public and partners for a possible rapid progression of events and possible contingency measures. Ensure that appropriate information is shared rapidly among health authorities, other partners and the public, including what is known and unknown.

Reinforce and intensify key messages on prevention of human-to-human spread. Explain rationale and update public on all aspects of outbreak response and likely next steps. Provide instruction in self-protection. Address the issue of stigmatization of individuals families/communities affected by human infection with the animal strain. Re-emphasize infection-control measures in the community, health-care settings, and long-term care facilities.

Influenza: seasonal, avian, pandemic Vaccine & antivirals Quarantine, isolation & social distancing Flu and local animals Hygiene and personal protection Preparedness NETVAC County plan Travel health warning Advice on how to behave if ill after travel in affected areas Minimize stigmatization Address rumors and misinformation


To prepare the public and other partners for a likely rapid progression of events, additional contingency measures, and disruptions to normal life.

Redefine key messages; set reasonable public expectations; emphasize need to comply with public health measures despite their possible limitations. Utilize last “window of opportunity” to refine communications strategies and systems in anticipation of imminent pandemic. Inform public about interventions that may be modified or implemented during a pandemic, e.g.

Influenza: seasonal, avian, pandemic Vaccine & antivirals Quarantine, isolation & social distancing Flu and local animals Hygiene and personal protection Preparedness


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prioritization of health-care services and supplies, travel restrictions, shortages of basic commodities, etc.

NETVAC County plan Potential shortages Travel health warning Advice on what to do if ill after travel in affected areas Minimize stigmatization Address rumors and misinformation

Pandemic

Ensure public access to regularly-updated official sources and focal points for credible, consistent information related to the pandemic. Maintain open and accessible channels for advice to the public on specific subjects (e.g. travel, social gatherings, etc.). Achieve public acceptance and support for local responses and contingency measures. Ensure rapid sharing of information regarding progress of the pandemic among health authorities, other relevant government departments and other partners. Prevent the spread of disease. Support health and mental health needs of victims and families.

Counties not yet affected Keep news media, public, professional partners and other stakeholders informed about progress of pandemic in affected areas; prepare audiences for imminent onset of pandemic activity. Redefine key messages; set reasonable public expectations; emphasize need to comply with public health measures despite their possible limitations. Utilize last “window of opportunity” to refine communications strategies and systems in anticipation of imminent pandemic. Inform public about interventions that may be modified or implemented during a pandemic, e.g. prioritization of health-care services and supplies, travel restrictions, shortages of basic commodities, etc. Affected counties

Influenza: seasonal, avian, pandemic Vaccine & antivirals Quarantine, isolation & social distancing School/Work/Public Spaces – Closure voluntary home confinement of symptomatic persons Flu and local animals Hygiene and personal protection Public campaign to encourage prompt self-diagnosis urge population to check for fever once a day Preparedness NETVAC County plan Expected shortages


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PANDEMIC INFLUENZA PLAN PUBLIC INFORMATION MATRIX Phases oResp

f onse


Remain open and transparent.

Maintain capacity for meeting expected information demands. Activate all elements of communications plan. Acknowledge public anxiety, grief and distress associated with pandemic. Audit outcomes of communications activities to refine current response and inform future pandemic planning. Subsided (end of pandemic or between waves) Evaluate communications response during previous phases; review lessons learned. Publicly address community emotions after the pandemic. Make people aware of uncertainties associated with subsequent waves.

Travel restrictions Advice on how to behave if ill after travel in affected areas Minimize stigmatization Hospitals Limited access Other health care emergencies Updates on hospital beds. Auxiliary hospitals? What to expect if a loved one dies: bodies released? Wakes? Open coffins? Space in cemeteries?

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Group Notifications Contact Name Contact Phone Numbers

Local Government

Board of Supervisors

County Manager

City / county fire, police public information offices

County Office of Emergency Services

County Counsel

Schools

Bay Area Health Dept public information officers

County Employees

State Government State health director’s public information officer

Elected officials

Federal Government Elected officials

Centers for Disease Control & Prevention (SFO Quarantine Station)

Our Partners

Hospital public information officers

Healthcare providers

Community-based/faith-based organizations

American Medical Response (AMR) ambulance service provider

Media


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Group Notifications Contact Name Contact Phone Numbers

Veterinarians

Our Stakeholders

Emergency Medical Care Committee (EMCC) and Emergency Medical Services Medical Advisory Committee

Commission on Aging and Commission on Disabilities

Mental Health Board

San Mateo County Medical Association

Travelers

Families

Clients

Special Populations*

Business Leaders

Unions/Workers

Legal Advocates


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XIII. PSYCHOSOCIAL WORKFORCE SUPPORT SERVICES

Rationale The response to an influenza pandemic will pose substantial physical, personal, social, and emotional challenges to healthcare providers, public health officials, and other emergency responders and essential service workers. Experience with disaster relief efforts suggests that enhanced workforce support activities can help responders remain effective during emergencies. During an influenza pandemic, however, the occupational stresses experienced by healthcare providers and other responders are likely to differ from those faced by relief workers in the aftermath of a natural disaster. Globally and nationally, a pandemic might last for more than a year, while disease outbreaks in local communities may last 5 to 10 weeks. Medical and public health responders and their families will be at personal risk for as long as the pandemic continues in their community. Special planning is therefore needed to ensure that hospitals, public health agencies, first-responder organizations, and employers of essential service workers are prepared to help employees maximize personal resilience and professional performance. An essential part of this planning effort involves the expansion of current alliances and the creation of new ones with community-based organizations and non-governmental organizations with expertise in and resources for psychosocial support services or training. Appendix I contains the San Mateo County Mental Health plan for worker support. Responsibilities in Workforce Support


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INTERPANDEMIC AND PANDEMIC ALERT PERIODS Lay the groundwork for the development and implementation of workforce resilience programs to maximize responders’ performance and personal resilience during a public health emergency. Use behavioral health expertise to develop public health messages, train staff on the use of personal protective equipment (PPE), and conduct other relevant activities. Institutionalizing Psychosocial Support Services Local health agencies should consider incorporating psychosocial support services into occupational health and emergency preparedness planning for an influenza pandemic. Public health planners should also contact community-based organizations and non-governmental organizations to determine the types of psychological and social support services and training courses available in their jurisdictions. Public health officials should consider needs for information sharing with emergency planners in schools, law enforcement agencies, and local businesses. Planning for the provision of psychosocial support services might include the following activities: • Ensuring that administrators, managers, and supervisors are familiar with and

actively encourage the use of tools and techniques for supporting staff and their families during times of crisis.

• Training staff (e.g., social workers, psychiatrists, nurses, psychologists, counselors) in behavioral techniques to help employees cope with grief, stress, exhaustion, anger, and fear during an emergency.

• If feasible, providing training in psychological support services to persons who are not behavioral health professionals (e.g., primary-care clinicians, emergency department staff, medical/surgical staff, safety and security personnel, behavioral health staff, chaplains, community leaders, staff of cultural and faith-based organizations).

• Identifying additional resources that can be available to employees and their families during and after a pandemic.

• Developing strategies to assist staff who have childcare or elder-care responsibilities or other special needs that might affect their ability to work during a pandemic.


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Preparing Workforce Support Materials Employers of response workers and providers of essential services should obtain or prepare workforce support materials (in hard copy or electronic format) for distribution during a pandemic. These materials should be designed to do the following: • Educate and inform employees about emotional responses they might

experience or observe in their colleagues and families (including children) during an influenza pandemic and about techniques for coping with these emotions.

• Educate employees about the importance of developing “family communication plans” so that family members can maintain contact during an emergency.

• Describe workforce support services that will be available during an emergency, including confidential behavioral health services and employee assistance programs.

• Answer questions about infection control practices to prevent the spread of pandemic influenza in the workplace and employment issues related to illness, sick pay, staff rotation, and family concerns.

Issues to be considered are: • Stressors related to pandemic influenza • Signs of distress • Traumatic grief • Psychosocial aspects related to management of mass fatalities • Stress management and coping strategies • Strategies for building and sustaining personal resilience • Behavioral and psychological support resources • Strategies for helping children and families in times of crisis • Strategies for working with highly agitated patients Developing Workforce Resilience Programs Local health agencies should consider establishing workforce resilience programs that will help deployed workers prepare for, cope with, and recover from the social and psychological challenges of emergency field work. To prepare for implementation of workforce resilience programs to cope with the special challenges posed by an influenza pandemic, agencies should do the following: • Plan for a long response (i.e., more than 1 year). • Identify pre-deployment briefing materials. • Augment employee assistance programs with social support services for the

families of deployed workers.


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• Provide program administrators and counselors with information on: • Cognitive, physiological, behavioral, and emotional symptoms that might

be exhibited by patients and their families (especially children), including symptoms that might indicate severe mental disturbance.

• Self-care in the field (i.e., actions to safeguard physical and emotional health and maintain a sense of control and self-efficacy).

• Cultural (e.g., professional, educational, geographic, ethnic) differences that can affect communication.

• Potential impact of a pandemic on special populations (e.g., children, ethnic or cultural groups, the elderly).

PANDEMIC PERIOD Implement workforce resilience programs. Delivering Psychosocial Support Services Public health agencies should make full use of public health techniques and communication tools that can help response workers manage emotional stress and family issues and build coping skills and resilience. These tools can include: • Stress control/resilience teams. These teams can assist and support

employees and foster cohesion and morale by: • Monitoring employee health and well-being (in collaboration with

occupational health clinics, if possible). • Staffing “rest and recuperation sites”. • Distributing informational materials.

Rest and recuperation sites • Sites can be stocked with healthy snacks and relaxation materials (e.g.,

music, relaxation tapes, movies), as well as pamphlets or notices about workforce support services.

• Confidential telephone support lines staffed by behavioral health professionals

Services For Families Services to families of employees who work in the field, work long hours, and/or remain in hospitals or other workplaces overnight might include: • Help with elder care and childcare. • Help with other issues related to the care or well-being of children. • Provision of cell phone or wireless communication devices to allow regular

communication among family members. • Provision of information via websites or hotlines. • Access to expert advice and answers to questions about disease control

measures and self-care.


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Implementing Workforce Resilience Programs During an influenza pandemic, state and local health agencies should consider implementing workforce resilience programs that meet the special needs of deployed workers—including workers who do not change job site but whose assignments shift to respond to the pandemic—and the central operations personnel who support them around the clock. First-responder or nongovernmental organizations that send employees or volunteers to assist patients at home or in hospitals might establish similar programs. Workforce resilience programs could provide the following services: 1. Pre-deployment/assignment Conduct briefings and training on behavioral health, resilience, stress management issues, and coping skills. Train supervisors in strategies for maintaining a supportive work environment. 2. During deployment/assignment To support responders in the field: • Deploy several persons as a team and/or assign “buddies” to maintain

frequent contact and provide mutual help in coping with daily stresses. • Frequently monitor the occupational safety, health, and psychological well-

being of deployed staff. • Provide access to activities that help reduce stress (e.g., rest, hot showers,

nutritious snacks, light exercise). • Provide behavioral health services, as requested. For central operations personnel: • Enlist stress control or resilience teams to monitor employees’ occupational

safety, health, and psychological well-being. • Establish rest and recuperation sites, and encourage their use. • Provide behavioral health services, as requested. For families of responders: • Enlist employee assistance programs to provide family members with

instrumental support (e.g., assistance obtaining food and medicine) and psychosocial support (e.g., family support groups, bereavement counseling, and courses on resilience, coping skills, and stress management).

• Provide a suggestion box for input via e-mail or anonymous voicemail with a toll-free number.

Continue to provide outreach to employees’ families to address ongoing psychological and social issues. Throughout the response, policies on personnel health and safety should be reviewed and revised, as needed.


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3. Post-deployment/assignment Interview responders and family members (including children) to assess lessons learned that might be applied to future emergency response efforts. Provide ongoing access to post-emergency psychosocial support services for responders and their families (on-site or through partner organizations). Conduct an ongoing evaluation of the after-effects of the pandemic on employees’ health, morale, and productivity.


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Appendix I

San Mateo County Mental Health Interventions

In Flu Pandemic

Section 1. Overview And Accessing Mental Health Section 2. Pre-Pandemic – Public Health Message Section 3. Pre-Pandemic – Management Planning Section 4. During The Pandemic Period – Employee Support Section 5. Post Pandemic Period – Employees Support Section 6. Appendix – Handout Materials – Appropriate to distribute to employees, their families and the public a. Common Responses to Stress b. Menu for Self-Care c. Support for Children in Pandemic d. Grief Support

Section 1 – Overview and Accessing Mental Health

Working during a public health crisis can be rewarding but it is also inevitably stressful. Stress prevention and mitigation for the public and employees involved during the crisis; needs to be addressed in two contexts, the organizational and the individual. Adopting a stress preventative perspective allows workers and management to anticipate stressors and plan for mitigation and recovery. Following are some basic suggestions and an outline for stress prevention and management during the course of a flu pandemic. This plan is general in nature because the emotional intensity, duration, and impact upon workers and the community are unknown. As the reality of the situation unfolds adjustments and modifications can be made which respond to the changing scene. It is therefore important that public health and mental health form a close partnership during a public heath crisis so that adjustments in programs and response can be made.


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ACCESSING MENTAL HEALTH BY PUBLIC HEALTH 1. The Community Response Team (CRT) is available for consultation or direct

services. The team is available 24/7 and is accessed after-hours through SMMC –PES. Team members have had special training in crisis response and have had many years experience in providing mental health intervention in a variety of circumstances.

Following the Health Department’s release of a memo to employees or the public, the CRT would be available to evaluate and plan for release of future messages and if indicated, also plan for specific responses to groups or individuals with Public Health, based on the feedback provided. In the event of a flu pandemic it would use the memo released by the Health Department as a guideline for contact and discussion with individuals or groups.

2. In the event that the Health Department DOC is activated the Mental Health

Leader is a member of this DOC. This would provide assess and linkage to the entire mental health system for youth and adults.

3. In the event of a public health crisis in San Mateo County that was beyond the

capacity of the county’s mental health CRT to respond to, mutual aid could be contacted. This could access specially trained mental health services from other counties, the Red Cross and the Veterans Administration PTSD unit.


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Section 2 – Pre-Pandemic Public Health Message

OVERVIEW AND GENERAL GUIDELINES—Effective “risk communication” (communication during times of high stress, high concern or crisis) is crucial to restoring a community’s equilibrium at all stages of a crisis. It is an early and important psychosocial support. The higher the stress and concern regarding a crisis event the greater the need to communicate. Risk communication can be used to mitigate the psychological impact of a community health crisis. It is the first psychological intervention. Public announcements, and messages through the media, must be incorporated and used in a positive way as the media’s message amplifies psychological and social response to events. Employees and the public should be provided with simple, clear, consistent, accurate, and redundant information related to the event and what to do. The higher the stress, the more difficulty there will be for hearing, understanding, and remembering information. The message should provide a realistic appreciation of the threat but avoid sensationalism (which the media looks for). These messages can assist in preventing a fear-driven, overreaction and psychologically damaging responses. Before you construct your message, analyze your latest observations and feedback about the target group and identify their major concerns. Incorporate these concerns in your message.

S – A – M – P – L – E

[Put memo on SMCO stationary to establish credibility and prepare it in English, Spanish, and other languages as the community requires]

DATE/TIME: TO: THE GENERAL PUBLIC AND EMPLOYEES FROM: SCOTT MORROW, M.D. (or designee, preferably an M.D.) SAN MATEO COUNTY PUBLIC HEALTH DEPARTMENT (Note: It’s important to establish visible and accessible leadership from trusted sources). RE: FLU PANDEMIC As you know, San Mateo County, like the rest of the country, is facing an outbreak of influenza (the flu). As you know the flu this year is different from previous years in that it is causing more people to get sick and it is (or may) causing more deaths (give an honest appraisal but don’t overstate). This communication is intended to provide you some basic information about the flu. It will explain how the flu is contracted, what you can do to avoid being affected,


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and what to do if you or a member of your family becomes sick. (This is intended to empower and reduce the sense of fear, anxiety, and helplessness, by suggesting ways of coping with positive, constructive solution-oriented key messages.) Influenza is a virus that is spread in respiratory droplets the air and by direct contact by someone who is affected. You can lessen your risk of being affected by:

Washing your hands frequently Avoid touching you mouth/eyes/nose without first washing your hands. Avoid crowded areas Get plenty of rest, eat well Avoid people who are sick Nurture yourself, be positive, have a devotional moment (this may not

be science but psychologically is helpful) If you become ill and have a fever, nausea, vomiting, headache, fatigue, dry cough, sore throat, nasal congestion, or muscle aches you should:

Stay home and rest Cover you mouth when you cough or sneeze Drink plenty of liquids Treat symptoms

You should call your doctor if symptoms persist or become worse. Antiviral treatment (Tami flu): Where to get? County to offer? (If County is giving out medicine and it is in short supply, explain who gets it and why). Identify any at-risk groups: The flu is especially risky to the elderly and those with existing medical problems, such as chronic heart or lung conditions, diabetes, kidney problems, cancer, those receiving chemotherapy, sickle cell, pregnant, and those with specific compromised medical conditions. Delineate any special considerations or recommendations. Parental fears for children must be addressed. Where to Call for More Information: (650)_______________


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This initial number may be a generic message that delivers consistent and updated information with a way for the caller to leave a message. This message should also be contained on the Health Department’s web site. A log should be maintained that categorizes the nature of each call and identifies specific concerns. This feedback data will guide future communications/press releases and will convey what people most need and want to know and are most concerned about. Messages should be brief, concise, and clear. Be as positive as possible. The log will serve as an instrument for doing a needs assessment and will help plan for future announcements as well as actions by Public Health and Mental Health, such as talking about certain issues with a specific groups. A hot line may provide an opportunity for the community not only to receive medical information but also emotional support. Consideration should be given to having mental health back-up (following triage) of this line, particularly if after medical information/advice is given, the individual seems to need to go on talking. The public will rarely seek mental health services in times of crisis if the services are solely identified as “mental health”. Mental health services need to be subtly integrated into other activities, programs, and services and referrals from Public Health to Mental Health will need to be subtle. Providing the factual information and practical solution-oriented recommendation (what to do and how to avoid becoming sick) is the first step in providing psychosocial support to the community. This mitigates a community’s sense of helplessness and creates a recovery environment. A sense of autonomy and solution focus is fostered. The possibility of panic and psychological after-effects is reduced. The San Mateo County Health Department will continue to make every effort to provide you with the latest information and advice. Contact us if we can be of assistance. The most important messages should be in the first and last positions. Before releasing your memo, test it with subjects who don’t work in the Health Department, including individuals with limited English skills, and make any needed revisions.


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Section 3 – PRE-PANDEMIC – Management Planning Provide clear management structure and leadership. This will contribute to creating a less stressful work environment and will help staff to do their job. Keep in mind that, “Most people pull together and function during and after a disaster, but their effectiveness is diminished.” • Provide orientation for all workers. Define purpose and goals, what to expect,

what is safe, what is recommended and what to avoid. • Ask for input and suggestions • Establish clear chain of command and reporting relations. • Provide available and accessible supervisors who have easy links to

management. • Be open and sensitive to workers concerns and view of situation along with

clear expectations. • Establish shifts no longer than 12 hours, followed by 12 hours off. (Mistakes

and stress reactions increase the longer the hours). • Conduct briefings at beginning of shifts with overlapping so outgoing workers

brief incoming. Allow time to vent or discuss their emotions. • Provide job descriptions but encourage everyone to be flexible as

assignments will evolve and change. • Suspend non-essential tasks and delegate remaining workloads so workers

can devote their time and attention to the crisis assignment. • Rotate workers between low and high-stress jobs. • Establish rest and recuperation areas away from view of work site. Don’t have

a television turned onto the news as it only adds to stress loads. • Assign person to monitor stress levels, worker fatigue, and assess workers’

functioning regularly. (Observe for emotional, cognitive, behavioral, or physical signs of stress.) Note if staff is having difficult making decisions, concentrating, being forgetful, or becoming irritable or easily angered. Counsel, adjust assignments, or send home individuals whom are showing signs of being overstressed and/or are too caught up in crisis.

• Provide outreach to workers families and address their psychological and social needs. If workers pandemic response is having a significant impact upon their families consider setting up a support line or group to offer information, as well as education about normal stress reactions. This may be possibly jointly staffed by Public Health and Mental Health or the Employee Assistance program.(See Appendix, Support for Children During Pandemic and Grief-related Materials.) • Request consultation from mental health as needed.


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Section 4. During The Pandemic Period – Employee Support Provide plan for stress management for employees and enhanced worker support. • Nurture team support. Find and foster the most positive view of each and the

overall situation. Provide praise when appropriate. Encourage venting. • Create buddy system to maintain frequent contact and offer support and

mutual help in coping with stresses. At the end of each day talk about the emotional reactions you have experienced.

• Insist on regular breaks and time away from work environment. Walking and deep breathing are good de-stressors.

• Provide healthy snacks. Discourage coffee donuts, sugar, and intake; instead provide water, juice, fresh fruit, and veggies. (Sugar and caffeine contribute to stress reactions.)

• Identify worker issues and concerns, rumors, fears, and anxiety. Develop plan for mitigation using accurate information and clear, simple, consistent language. Provide other interventions as needed (see Section 5).

• Encourage staff to call home regularly and stay in contact with family and friends. Maintain reminders of home, e.g., pictures, mementoes, at their workstation.

• Distribute Common Responses to Stress (see Appendix) to show normal reactions and early warning signs for stress.

• Provide coping strategies for stress to staff; distribute handout, MENU FOR SELF-CARE (see Appendix).


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Section 5. Post Pandemic Period – Employees Support

Overview Demobilization should be offered when the mission is completed and before staff is released to regular duty or home. If the pandemic is prolonged, defusing may be periodically scheduled during the course of the operation. Consult with lead staff to assess stress levels and staff’s functioning to determine frequency or need for defusings. Defusings and demobilization provide a transition from the event to the regular routine. It facilitates re-entry. The goal is to reduce stress, assess group needs, and provide guidance, information, and positive expectations. Defusing means “to render something harmless before it can do damage”. In this context it is hoped that the defusing will lessen the emotional distress and sequelae associated with the incident and provide positive ways of coping for what remains and what may later emerge. Defusing and demobilizations are led by the clinic manager and mental health leader in informal group settings with all staff in attendance. Staff is reassured that they can just listen and that this is not a therapy group. This process should be conducted in a quiet and private area where you won’t be interrupted. Allow 45 minutes to an hour for this group. It is not a critique of the event, e.g., what you did wrong or could to better. Do that later without everyone in attendance. This group is for the emotional health of the group. If a particular group of employees were exposed to a significant trauma that the whole group was not exposed to, it is advisable to do this group separately. You don’t want to expose the whole group to more trauma than they initially received. Demobilization/Defusing Steps Introduction: (Manager) Provide a summary of the event to date, e.g., numbers served, tasks accomplished, so everyone can see the whole picture. Affirm the value of personnel in this process. Recognize employee’s efforts by citing specific accomplishments and the most difficult tasks that were addressed during the course of the special assignment. Help staff find some positive meaning in their work and service to the public. Exploration: (Mental Health Leader) Facilitate a discussion of experience the group just had. Ask the group if there is anything they would like to say. What were the most challenging aspects of the experience? What have been the rewards? What are some things you will be


May 2, 2006

taking with you from this experience? Describe a meaningful incident that happened during your work. What do you anticipate your transition will be like in returning to your normal routine? What do you think will be helpful with this transition? Provided an opportunity for staff to make comments and vent. Share information and answer questions. Information and Teaching: (Mental Health Leader) Summarize the group’s experience. Review normal stress reactions that some staff may already be experiencing, some may develop later, and some may escape altogether. Help the group to see that their reactions are probably similar to what others are experiencing. Assure the groups that stress symptoms are normal under the circumstances. Provide a description of common cognitive, physical, emotional, and behavioral signs of stress. Let the group know that it is common to later feel “let down” after participating in an event such as the one of which they were just a part. Reassure staff that most people get over these reactions on their own quite nicely with the passage of time by following some basic guidelines (Provide handouts of Common Stress Reactions and Menu For Self Care). Ask the group if they want a later debriefing, e.g., more time for discussion of event and reactions. If participation in the event was highly stressful and/or was observed to have a significant emotional impact, it may be advisable to just announce that a debriefing will take place a week or so later (date/time/place). Indicate that staff is strongly encouraged to attend the subsequent debriefing, and what one may say may be helpful to someone else, but participation is voluntary. Establish support links—provide phone numbers to call for Employee Assistance Program. Beverages and snacks to be provided following debriefing. Mental health staff to make themselves available once the group is completed for one-on-one consultation. Family Care Post Pandemic • Consider offering the group to worker’s families. Provide information, support,

and an opportunity to debrief.


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SECTION 6. APPENDIX – HANDOUT MATERIALS – APPROPRIATE TO DISTRIBUTE TO EMPLOYEES, THEIR FAMILIES AND THE PUBLIC

Common Responses To Stress During A Community Crisis

Most people recover very well from these.

You may have some of these – you may not. You may feel: --loss of emotional control or inappropriate emotional response --anxiety, apprehension, worry --irritability, restlessness, agitation, grouchy --feelings of depression, moodiness, periods of crying --anger, blaming --feelings overwhelmed --less interest in usual activities --feelings of isolation, detachment, lonely --feelings of guilt about surviving --denial or holding in feelings You may experience: --headaches --upset stomach --soreness in muscles --hot or cold spells, sweating or chills --rapid heart rate --faintness or dizziness (seek medical evaluation) --numbness or tingling in parts of the body --feeling a “lump in the throat” --Pains in chest, trouble breathing (seek medical evaluation) --easily startled --muscles shaking, twitching --feeling tired and weak --sleep problems, --hyperactivity --outbursts of anger or frequent arguments --inability to express self verbally or in writing --withdrawal, wanting to be alone --increased use of alcohol, tobacco, other drugs --avoidance of activities or places that reminds you of traumatic events --family problems


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--loss or increase of appetite You may have trouble with: --staying on task --confusion --poor problem solving --slowness of thinking or difficulty paying attention --forgetfulness, memory problems --difficulty making decisions --nightmares --thinking about the same thing over and over

Menu for Self-Care: Ways to Help Manage Your Stress Basic Concepts and Suggestions: • Maintain contact and connection with primary social supports. • Talk about your thoughts and feelings that keep returning with someone who

is a good listener. Discuss the difficult parts. This helps you “let the steam out”, integrate, and move on from the experience. Be gentle with yourself. There will always be things you could have done differently. Also remember to discuss the positive contribution you made and the good that will come from your participation.

• Nurture and pamper yourself. Get plenty of rest. Allow yourself downtime and don’t push yourself. Spend time with your support system of family and friends and dog or cat. Take a leisurely hot bath, get a massage. Plan extra time to do usual tasks; you may not be able to function as efficiently as usual. Allow others to help with your tasks; you’re not the only one who can do it.

• Remember what you did previously to cope with stress and practice it. • Eat well and take your time. Avoid caffeine, fast foods, and sugar. Drink

sufficient water. Avoid overeating. • Accept whatever feeling you are having and recognize that others who were

involved in the same incident may be on a different timetable of emotions. Be patient with yourself and others.

• Turn off your radio and television when the news is being broadcast. Too much trauma exposure just increases the unease, promotes feeling overwhelmed, and slows returning to normal. This is also good advice if you have children. The younger they are the less they should watch of the news.

• Find some release for what is inside. Write down your thoughts and feelings in journal, paint, draw, make music, or dance.

• Do some mild exercise—walking is great—be present, watch your breath, breathe deeply with long, slow exhalations. Let go and release tension and discomfort with each exhalation. See each inhalation as restoring yourself.

• If you are having trouble sleeping don’t stay in bed for too long trying to fall asleep as this may just increase restlessness, anxiety, and rumination.


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Instead get up, read a book, listen to some soothing music, or watch an old favorite movie until you are sleepy.

• See a funny movie or play. Go to the theater. It is okay to laugh and enjoy yourself. Affirm life.

• Read an inspiring quote or religious passage. Maintain your spiritual practice. • Don’t immediately make major changes in your life—give yourself some time

first. • Don’t try to self-medicate, numb out with ETOH or other agents. You will

recover more quickly without them. • Gradually resume your normal routine. • Remember no one who responds to a mass casualty event is untouched by it. • Profound sadness, grief, and anger are normal reactions to an abnormal

event. • Seek professional assistance if you feel you are getting stuck with repeated

thoughts or emotions about the experience or are having difficulty returning to your normal routine. Ask for a debriefing or see someone through Employee Assistance. Don’t feel bad about asking for help; it is not uncommon to have some reaction after this type of experience and remember, it usually passes.

Helping Your Child Cope Tips for Parents and Care Givers

It is normal for children to have emotional and physical reactions to an event such as the flu pandemic. Here are some ways to help them cope with their feelings. Common Responses Following a traumatic event some children may: • Be afraid to be left alone or afraid to sleep alone. The child may want to sleep

with a parent or another person. They may have nightmares. • Be afraid of the disaster recurring. They may ask, “Will it come again?” • Be angry. They may hit, throw, and/or kick to show their anger. • Act inappropriately happy. • Become more active and restless. • Behave as they did when younger. They may start sucking their thumb,

wetting the bed, asking for a bottle, and/or wanting to be held. • Be quiet and withdrawn—not wanting to talk about the experience. • Become upset easily—crying and whining. • Feel guilty that they caused the disaster because of some previous behavior. • Refuse to go to school or to childcare—not want to be out of your sight. • Become afraid of loud noises, rain, or storms.


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• Some children may never show distress because they do not feel upset. Other children may not give evidence of being upset until several weeks or months later.

What to Do: • Talk with your child, providing simple, accurate information to questions. • Listen to what your child says and how your child says it. Is there fear,

anxiety, or insecurity? Your repeating the child’s words may be very helpful, such as, “You are afraid that….” This helps both you and the child clarify feelings.

• Be aware of what your child is seeing or hearing on TV or radio—try to make sure that they are not overwhelmed with repeated stories and pictures of the event. Let your child ask questions and talk about his/her feelings.

• Reassure your child. “We are together. We care about you. We will take care of you.”

• Talk with your child about your own feelings. • You may need to repeat information and reassurances many times. Do not

stop responding just because you told the child once. • Hold the child. Provide comfort. Touching is important for children during this

period. • Spend extra time putting your child to bed. Talk and offer assurance. Leave a

nightlight on if necessary. • Observe your child at play. Listen to what is said and how the child plays.

Frequently, children express feelings of fear or anger while playing with dolls, trucks, or friends.

• Provide play experiences to relieve tension. Work with play-dough, paint, play in water, etc. If children show the need to hit or kick, give them something safe like a pillow, ball, or balloon.

Support for Children During Pandemic Ages 1 -5 • Give additional verbal assurance, attention, support, and physical comfort • Provide comforting bedtime routines • Avoid unnecessary separations and arrange for consistent care giving • Permit child to sleep in parents’ room temporary • Encourage expression regarding losses • Give name to feelings • Prevent media exposure of disaster trauma by turning off television news • Encourage expression through play activities Ages 6 to 11


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• Give additional attention, consideration and reassurance. • Relax expectations of performance at home and school temporarily • Set gentle but firm limits for acting out behavior • Encourage verbal and play expression of thoughts and feeling • Listen to the child’s retelling of pandemic events • Provide realistic, age-appropriate information about what happened and what

will happen next • Involve the child in preparations of family efforts to be safe Ages 12 to 18 • Give additional attention and consideration • Relax expectations of performance at home and school temporarily • Encourage discussion of disaster experiences with peers and family • Avoid insistence on discussion of feeling with parents. • Encourage physical activities • Support participation in usual community activities, sports, clubs, etc. • Address depression, suicidal ideation, and reckless behavior directly. Seek

professional assistance if indicated.


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In Times of Grief and Loss A Family Manifesto

If you need space to be quiet and alone, I will honor your needs. If you want to be close, I will make every effort to relate in a loving and receptive way. Talking about our loved one, sharing memories and pondering the “why’s” of our loss are necessary parts of grieving. When you want to talk, I will do my best to listen without judgment of your thoughts and feelings. We don’t need to hide our sorrow or find places to cry alone. When tears come, you are invited to let them flow. I will try to do the same. We will never take for granted that we are doing well just because we aren’t talking about our loss. Let us agree to regularly check with each other, discussing ways to be more supportive and nurturing. During the first year and perhaps beyond, we will make a point to celebrate the memory of our loved one on holidays and anniversaries. We’ll expect to feel a greater depth of sadness on these days and we’ll try to plan meaningful activities together. Disposing of personal items that belonged to the person we loved will be done slowly, making every attempt to consider all of our feelings. Sometimes our sorrow will affect our family relationships in surprising or unpleasant ways. When this occurs, we will try our best to explore our feelings, making every effort to resolve them together. Some of our family members will adjust to our loss sooner than others and that is okay. We understand that no one of us can meet all of another person’s needs, especially during this difficult time of grief. It is all right if we turn to people outside our family for help and support. If one of us is “touchy”, moody or says something we don’t mean, we will try to remember that we have all been deeply injured in different ways. We realize that pain lingers even when it is not discussed. We understand that the world too soon forgets about our loss and acts as if nothing ever happened. For this reason, our family will support each other over the long haul. We will not assume that any of us is either too young or too old to grieve. Trying to be “strong” for others often postpones grief and the rebuilding process. I do not expect you to be strong for me. Rather, I will take responsibility for my own healing.

Kara – In Times of Grief and Loss


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How to Help Someone Who is Suffering From Loss DO let your genuine concern and caring show. DO be available to listen or to help with whatever else seems needed at the time. DO say you are sorry about what happened and about their pain. DO allow them to express as much unhappiness as they are feeling at the moment and are willing to share. DO encourage them to be patient with themselves, not to expect too much of themselves and not to impose any "shoulds" on themselves. DO allow them to talk about their loss as much and as often as they want to. DO talk about the special endearing qualities of the person they've lost. DO reassure them that they did everything that they could. DON'T let your own sense of helplessness keep you from reaching out. DON'T avoid them because you are uncomfortable (being avoided by friends adds pain to an already painful experience). DON'T say that you "know how they feel." (Unless you've experienced their loss yourself you probably don't know how they feel.) DON'T say "you ought to be feeling better by now" or anything else that implies a judgment about their feelings. DON'T tell them what they should feel or do. DON'T change the subject when they mention their loss or their loved one. DON'T avoid mentioning their loss out of fear of reminding them of their pain (You can be sure they haven't forgotten it.) DON'T try to find something positive (e.g., a moral lesson, closer family ties, etc.) about the loss. DON'T point out "at least they have [their other family member(s)]" DON'T say they "can always have another..." DON'T suggest that they "should be grateful for their..." DON'T make any comments, which in any way suggest that their loss was their fault (there will be enough feelings of doubt and guilt without any help from their friends). Kara – How to Help Someone Who is Suffering From a Loss


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PHYSICAL EFFECTS OF GRIEF

Although grief is usually referred to as an emotional reaction to loss, there are often physical effects as well. Researchers have discovered that the following physical symptoms are not uncommon for those suffering from loss. • Decreased Energy • Sleep Difficulties (too much or too little; interrupted sleep) • Tearfulness and Crying • Tension and Anxiety • Weight Loss or Gain • Lack of Physical Strength • Physical Exhaustion • Feelings of Emptiness or Heaviness • Heart Palpitations • Nervousness • Restlessness • Shortness of Breath • Forgetfulness • Lack of Concentration • Headaches • Anorexia and other Gastrointestinal Disturbances • Tightness and/or Pain in the Chest

Kara – Physical Effects of Grief


May 2, 2006

Realistic Expectations During the Grief Process

• Grief will take longer than most people think. • Grief takes more energy that we ever imagine. • Grief shows itself in all spheres of our lives—emotional, social, physical, and

spiritual. • We feel grief not only for the actual person we lost, but also for our hopes,

dreams, unfulfilled expectations, and unmet needs. • New losses bring up unresolved grief from our past, often forcing us to cope

with an array of confusing feelings at once. • Grief can temporarily affect our decision-making and problem-solving abilities

and cause difficulties in concentrating. • Sometimes grief makes us feel we "are going crazy”. • Society has unrealistic expectations about grief and the mourning process

and people may respond inappropriately to you. • Grief may cause a variety of physical symptoms, like sleeplessness, tightness

in the chest, and decreased energy. • Family members may not always provide the support we expect, and their

grief may be very different from ours. • Sometimes people have the necessary social support to help them through

loss. But more often, they need to reach out for support, let others know what they need, and actively build a network that facilitates personal growth and renewal.

Kara – Realistic Expectations During the Grief Process


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The Grief Process Avoidance Just as the human body goes into shock after physical trauma, so too does the human mind when confronted with the initial reality or loss. This is a normal reaction. Feelings that characterize this phase of the grief process are disbelief, numbness, helplessness, anger, confusion, and an inability to concentrate. As reality begins to seep in and shock wears off, denial usually occurs. Denial is a natural therapy—it functions as a buffer, allowing us to absorb the reality of loss a little bit at a time. Confrontation This is the most challenging period of grief. It is often a time of raw, acute, knife-like pain. It is the time when grief is experienced most intensely and our reactions most acute. Great extremes of emotion are felt, sometimes for very brief but intense periods of time. Feelings may include fear, anger, sadness, guilt, anxiety, despair, regression, isolation, abandonment, and betrayal. It is common to feel emotionally “out of control" and to experience physical symptoms such as sleep difficulties, tightness in the chest, and restlessness. This period of grief may last from six months to several years, depending upon our relationship with the deceased. It is a journey of duality—a time when we face both personal and interpersonal challenges to rebuild life without the person(s) we lost. In our private journey, we must confront our own feelings and remembrances while finding new identity and hope for the future. In the journey with others, we must find supportive helpers, cope with conflict, and renegotiate new roles and relationships with those around us. Re-establishment and Re-entry Grief declines gradually as we begin a slow emotional and social re-entry into the everyday world. Our loss is not forgotten, but we begin to heal from the acute pain of grief. A new identity emerges. We know we will survive, but we will never quite be the same. We are changed by our loss and begin to establish an identity in a world that no longer includes our loved one(s). This stage of grief never arrives all at once and often co-exists with the previous stages. Guilt may accompany this stage as we continue to live while our loved one has died. There may be conflict, ambivalence, and continued anxiety. It is important to work through these feelings in order to fully invest in life again. Certain dates, special anniversaries, events, and stimuli bring upsurges in grief, often years later. These are natural occurrences in the journey through grief. They help us know that the memories of our loved ones live on in our hearts always and that their lives and love will never be forgotten. Kara – The Grief Process


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May 2, 2006

XIV. CORONER’S OFFICE

Rationale A pandemic influenza outbreak is expected to place a huge burden on the Coroner’s Office. With a predicted high mortality rate for planning purposes, the workload of the Coroner, such as transportation and storage, is expected to at least double. Extra personnel and facilities will need to be used to manage the large number of deaths. Pre-pandemic planning by the Coroner’s Office is therefore essential to provide quality post-mortem care and documentation. Goals The goals of the Coroner’s Office during normal operations are to: • Ensure the proper transportation, storage, and disposition of bodies • Investigate cause of death, if necessary • Ensure worker safety in the handling of contagious material • Provide the Health Department with statistics • Perform autopsies, as necessary In addition to the above, the goals of the Coroner’s Office during pandemic influenza are to: • Implement procedures to follow Health Officer instructions to expedite

receiving of bodies, transportation, storage, and disposition • Continue to perform autopsies on deceased individuals whose cause of death

is unknown or undiagnosed and determined not to be from influenza • Coordinate the planning efforts of funeral homes and cemeteries in

preparation for surge


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Overview During a normal year, of the 5,000 people who die annually in San Mateo County, the Coroner’s office processes approximately 500-600 deaths per year. Of that amount, 100 per year are for individuals who have no next of kin and are for storage and transportation only. The remaining 400-500 bodies are for those individuals who have no diagnosis or known cause of death. Typically, people in this category would not have expired with a physician in attendance within 20 days, e.g., a person found on the street, died at home, from a crime scene, or a skilled nursing facility. There is an expected two-fold increase in the mortality rate in San Mateo County during a pandemic influenza outbreak. For the Coroner’s Office, this translates to 200 annual “no next of kin”, storage and transportation-only cases, and 1000 annual deaths requiring an autopsy. Overall storage will need to be found for 200 bodies per week. See Figure 1.


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Figure 1.

Death (5000 normal+ 5000 Flu = 10,000)

Diagnosis?

Next of Kin?

Yes9000

No1000

Yes No

To Coroner for Storage &Transportation Only

To Next of Kin/FuneralHome (4400) + Flu (4400)

Normal: 100/year + Pandemic: 100/year

Coroner for Autopsy/Toxicology

Normal: 500/year + Pandemic: 500/year

Annual StorageRequirements

4400 + 100 + 500 =5000

Weekly StorageRequirements

100 avg200 with surge


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Mitigation of Surge Once a pandemic influenza state of emergency has been declared by the Board of Supervisors, the Health Officer will issue an order to the Coroner to abbreviate the regulations in the processing of people who have expired without a doctor in attendance for 20 days preceding death or without a diagnosis. If, in the opinion of the Coroner, a person appears to have died from influenza, no autopsy is needed. Investigation into cause of death, transportation, and storage will be the primary focus of the Coroner’s Department. Investigation The primary duty of investigating the cause of death for those cases not in the care of a medical doctor in the 20 days preceding death is with the Coroner. During normal operations, one investigator is needed per scene. The current number of investigators on staff at any one time is 4. During a pandemic, the number of investigators will need to be increased to 8. Additional investigators will be sourced through OES on an as needed basis. Storage Current storage capacity at San Mateo Medical Center is 30 bodies, with five bodies in storage during normal operations. The average storage period is about one week. During pandemic influenza, storage will be necessary for 200 bodies per week, i.e., space will be needed for 175 bodies. Solutions that should be considered for storage of an additional 175 bodies per week include the following: • Refrigerator trailers parked at SMMC • Use of the Sequoia Hall at the Expo Center • A tarp covered ice rink in San Mateo • Increased Use of Crematoria Refrigerator trucks: An MOU is in place with OES for a private company to supply two refrigerator trailers. The trailers will be parked in the rear lot of SMMC. The Sheriff’s Department will provide security. Ksl Latek Ilko Plskbs: Lorem ipsum dolor sit amet, consectetuer adipiscing elit. Pellentesque sit amet ipsum ac risus aliquet fringilla. Quisque elementum pharetra lacus. Ut lorem mi, venenatis non, pharetra sed, aliquet vitae, elit. Cras orci nibh, volutpat sit amet,


May 2, 2006

gravida eu, iaculis eu, nunc. Aliquam erat volutpat. Phasellus ac ante. Proin dui diam, posuere eu, tempor nonummy, tincidunt at, diam. Duis pede magna, aliquam nec, tincidunt vel, dapibus eget, augue. Etiam volutpat urna in odio. Vestibulum eleifend interdum mi. Quisque libero. Pellentesque consectetuer lorem et leo. Suspendisse commodo viverra tellus. Nunc vitae dolor ut leo gravida facilisis. Ice Rink: Negotiations are under way by the Coroner’s office to use the ice rink located in Bridge Point Shopping Center. In the event of an emergency, the ice rink would be closed to the public, the surface covered with a tarp, and bodies stored on top. The Sheriffs’ Department will supply security of the facility. Transportation Current transportation needs are met by a contractor who supplies X number of vehicles per day for the routine transportation of bodies. There is one van in the county pool reserved for special cases. It is anticipated that the contractor will need to increase the vehicle count to 5X in order to meet the transportation demands of an influenza pandemic. Bodies requiring special handling because of their weight will need to be planned for. County vehicles with lift gates will need to be identified in advance. The department to which those vehicles are currently assigned will need to be informed of their possible use by the Coroner’s office and agree to the plan. Equipment The normal equipment used to hold and transport a body is a gurney. It is anticipated that gurneys will be in short supply during an event and alternative means of locally transporting bodies will need to be arranged. Military stretchers will be requested through OES on an as needed basis. Although not wheeled, the legs of the stretcher will allow bodies to be stored off of surfaces and carried more easily. Body bags have been purchased and stored for emergency use through OES. Statistics & Reporting The Coroner’s department will continue to supply the Health Department with statistics regarding morbidity activity. During a pandemic influenza event, it is important that the Health Officer receive data that indicate geographic and


May 2, 2006

community mortality rates. As per current practice, these reports should be faxed to the Health Administration. Safety Safeguards must be in place to ensure the protection of all personnel handling deceased individuals who have succumbed to contagious influenza. It is recommended that face shields be worn to prevent accidental eye contact with airborne droplets of sputum or excreta. A standard surgical mask should be worn to prevent the inhalation of the same. Disposable gloves should be worn to prevent any contact with bodily fluids. Training in the use of protective equipment should be a regular part of periodic exercises. There should be special attention given to the removal of equipment to prevent cross-contamination.


May 2, 2006
