Preparing for and Responding to Bioterrorism: Information for the Public Health Workforce

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Preparing for and Responding to Bioterrorism
Information for the Public Health Workforce
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Acknowledgements
This presentation, and the accompanying
instructors manual, were prepared by Jennifer
Brennan Braden, MD, MPH, at the Northwest Center
for Public Health Practice in Seattle, WA, for
the purpose of educating public health employees
in the general aspects of bioterrorism
preparedness and response. Instructors are
encouraged to freely use all or portions of the
material for its intended purpose. The
following people and organizations provided
information and/or support in the development of
this curriculum. A complete list of resources
can be found in the accompanying instructors
guide.
Patrick OCarroll, MD, MPH Project Coordinator
Centers for Disease Control and Prevention
Judith Yarrow Design and Editing Health Policy
and Analysis University of WA Washington State
Department of Health
Jeff Duchin, MD Jane Koehler, DVM,
MPH Communicable Disease Control, Epidemiology
and Immunization Section Public Health - Seattle
and King County Ed Walker, MD University of
WA Department of Psychiatry
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Consequence ManagementFor Public Health
Professional StaffModule B
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Consequence ManagementLearning Objectives

• Describe the role of local public health in
  consequence management following a public health
  emergency
• Describe the roles of state and federal health
  agencies in consequence management

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Consequence ManagementLearning Objectives

• Identify factors determining the need for
  isolation or quarantine and describe the
  potential adverse consequences
• Describe the basic structure and components of
  the National Pharmaceutical Stockpile and how and
  when it is employed

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Consequence ManagementLearning Objectives

• Recognize the potential psychological responses,
  on individual and community levels, following a
  BT event, threat, or other public health
  emergency
• Be able to provide basic disaster counseling and
  know when to refer for abnormal responses

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Consequence Management Legal Basis for Local
Efforts

• State police powers give states the authority to
  prescribe within the limits of state and federal
  constitutions, reasonable laws necessary to
  preserve the public order, health, safety,
  welfare, and morals.
• RCW 70.05.070 gives the local health officer
  power to take such measures as he or she deems
  necessary in order to promote the public health.

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Consequence Management Federal Support

• Federal Response Plan, Emergency Support Function
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• Provides federal assistance to supplement state
  and local resources in response to public health
  and medical needs following a major disaster or
  emergency, or during a developing potential
  medical situation
• Directed by DHHS
• CDC lead for protecting health and safety

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Consequence ManagementRole of Public Health

• Education and information updates
• Between staff/agency divisions
• With other coordinating agencies
• With the media and public
• Evaluation and referral of phone calls and
  requests for information or services
• Follow-up of cases/victims and contacts

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Consequence ManagementRole of Public Health

• In cooperation with other agencies
• Mass antibiotic prophylaxis and
• immunization
• Quarantine and isolation
• Closure of public places/institutions when
  indicated
• Evaluating and referring reports of suspicious
  packages or substances

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Consequence ManagementProtocols and Procedures

• Be familiar with your agencys protocols and
  procedures in an emergency for
• Triaging calls and clinic patients
• Quarantine and isolation
• Designated quarantine sites
• Designated staff
• Infection control precautions
• Prerequisites or precautions for entering and
  exiting facilities

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Consequence ManagementProtocols and Procedures

• Administering antibiotic prophylaxis or
  immunizations
• Designated sites
• Determining eligibility/need and
  contraindications
• Record-keeping
• Infection control precautions
• Counseling re adverse effects and risks
• Follow-up procedures

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CDC Definition Quarantine vs. Isolation

• Isolation
• The separation of a person or group of persons
  from other people to prevent the spread of
  infection
• Quarantine
• Restriction of activities or limitation of
  freedom of movement of those presumed exposed to
  a communicable disease in such a manner as to
  prevent effective contact with those not so
  exposed

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CDC Definition Quarantine vs. Isolation

• Quarantine measures may include
• Suspension of public gatherings
• Closure of public places
• Restriction of travel
• Cordon sanitaire

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QuarantineLegal authority Local Level

• When confined to a specific locale (community,
  state) rests with local and/or state health
  authorities (police power)
• Few states have specific policies/procedures for
  deciding whether quarantine is warranted in a
  specific situation
• Be familiar with the laws pertaining to
  quarantine or that might be interpreted as
  applying to quarantine existing in your state

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Medical Reasons for Isolation or Quarantine

• Isolation
• Disease transmitted person-to-person
• i.e., plague pneumonia, smallpox, viral
  hemorrhagic fevers
• Degree of isolation appropriate for mode of
  transmission (e.g., respiratory, direct contact)
• Quarantine
• Disease may be transmitted by exposed persons,
  prior to recognition of symptoms or diagnosis
• Smallpox infectious at rash onset, but rash may
  be overlooked in early stages

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Quarantine Other Factors to Consider

• Is it practical and feasible?
• Defined geographic area of risk
• Resources to enforce and maintain
• Time period required
• Do the potential benefits outweigh the risks?

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Quarantine Potential Adverse Consequences

• Increased risk of disease transmission in
  quarantined population
• Mistrust of government
• Civil disobedience ? violence
• Social stigmatization
• Economic effects
• Businesses in quarantined area
• Businesses relying on goods and services from
  quarantined area

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Isolation CDC Smallpox Response Plan

• Facility Categories
• Type C Contagious
• Confirmed and probable cases
• Type X Uncertain diagnosis
• Vaccinated febrile contacts without rash
• Type R Asymptomatic
• Non-febrile contacts

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Type C FacilitiesCDC Smallpox Response Plan

• Non-shared heating, air-conditioning, and
  ventilation systems
• Exhaust all air out through HEPA filter, or at
  least 100 yds from other occupied areas
• Adequate water, heating, cooling, and closed
  window ventilation
• Able to provide high-level medical care
• (incl. vent support and cardiac resuscitation)

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Type X Facilities CDC Smallpox Response Plan

• Same isolation and
• general supply
• requirements as
• Type C facility
• Able to provide basic medical care
• (e.g., monitoring vital signs)

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Type R Facilities CDC Smallpox Response Plan

• May be the persons home
• or
• Hotel/motel if warranted due to logistical or
  other reasons

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National Pharmaceutical StockpilePurpose

• Provides resources to respond to both biologic
  and chemical attacks
• Requested by governor
• Managed by Centers for Disease Control and
  Prevention

More on NPS...
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National Pharmaceutical StockpilePush Packages

• Contain color-coded inventory
• Pharmaceuticals - stock rotated before expiration
• IV supplies, airway supplies, ventilators
• Bandages and personal protective equipment

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More on NPS...
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National Pharmaceutical StockpileVendor-Managed
Inventory

• Agreements with pharmaceutical manufacturers to
  make large stocks available on demand
• Shipped to arrive within 24-36 hours after
  requested
• VA hospitals have an agreement with CDC to assist
  in the procurement and maintenance of NPS

More on NPS...
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Psychological Response toA Public Health
Emergency

• Reaction to the event itself
• Anticipation of future events
• Reaction to public health measures taken to
  manage/control disease and injury
• Isolation and quarantine
• Prophylactic measures
• Prioritization/rationing of resources
• Reaction to misinformation (e.g., myths, rumors)

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Psychological Aftermath of Crisis Role of Public
Health

• Educating and informing clinicians and the public
  about current risks and protective measures
• Coordination of and referral to medical and
  social support resources
• Ensuring the needs of populations at-risk for
  psychological sequelae are addressed

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The Psychological Aftermath of Crisis Additional
Roles for the Allied Health Professional

• Active listening and encouragement
• Basic disaster/crisis counseling
• Identification and referral of abnormal stress
  responses
• Encouragement of re-entry into social roles, when
  appropriate
• Discouragement of repeated exposure to trauma
  (e.g., TV replays, newspaper articles)
• Communication of medical risks, as appropriate

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Key Concepts of Disaster Mental Health

• Two types of disaster trauma
• Individual
• Community
• Most people pull together and function during and
  after a disaster, but their effectiveness is
  diminished
• Social support systems are crucial to recovery

Source US DHHS. Key Concepts Of Disaster Mental
Health
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Key Concepts of Disaster Mental Health

• Disaster stress and grief reactions are normal
  responses to an abnormal situation.
• Many emotional reactions of disaster survivors
  stem from living problems brought about by the
  disaster.
• Most people do not see themselves as needing
  mental health services following disaster and
  will not seek such services.

Source US DHHS. Key Concepts Of Disaster Mental
Health
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Psychological and Behavioral Responses to Trauma
and Disaster

• Depression
• Sadness
• Demoralization
• Isolation/withdrawal
• Difficulty concentrating
• Sleep and appetite disturbances

• Physical Complaints
• Fatigue
• Aches and pains
• Stomach and intestinal complaints
• Headache
• Skin rashes

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Psychological and Behavioral Responses to Trauma
and Disaster

• Anxiety
• Re-experiencing
• Numbing
• Hyperarousal
• Shock and disbelief
• Fear
• Panic
• Anger
• Irritability

• Behavioral
• ? substance use
• alcohol, caffeine, tobacco
• Interpersonal conflict
• Impaired work/school performance

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Responses to Trauma - Children

• After any disaster, children are most afraid
  that
• The event will happen again
• Someone will be injured or killed
• They will be separated from the family
• They will be left alone

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Responses to Trauma - Children

• Influenced by developmental stage
• May include
• Depressed or irritable mood
• Decreased school performance
• Increased dependence and clinginess
• Changes in appetite - ? or ?
• Sleep disturbances
• Physical complaints (e.g., stomach aches,
  headache)

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Responses to TraumaSchool-Age Children

• Preschool-2nd grade
• Separation anxiety
• Avoidance
• Regressive symptoms
• Fear of the dark
• 3rd-6th graders
• Re-enactment through traumatic play
• Withdrawal from friends
• Aggressive behavior at home or school
• Hyperactivity that wasnt present earlier

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Responses to TraumaAdolescents

• Increased risk-taking behavior
• Decline in previous responsible behavior
• Social withdrawal
• Apathy
• Rebellion at home or school

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Helping Children Cope After Trauma

• Assume they know a disaster has occurred
• Talk with them calmly and openly at their level
• Ask what they think has happened, and about their
  fears
• Share your own fears and reassure
• Emphasize the normal routine
• Limit media re-exposure
• Allow expression in private ways (i.e., drawing)

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Psychological Responses Following a Biological
Terrorist Attack

• Attribution of arousal symptoms to infection
• Scapegoating
• Panic and paranoia
• Loss of faith in social institutions

• Magical thinking about microbes and viruses
• Fear of invisible agents
• Fear of contagion

Source Holloway et al. JAMA 1997278(5)425-7
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Factors Influencing Response to Traumatic Events

• Degree and nature of exposure
• Developed coping mechanisms/strategies
• Available resources and support
• Ability to understand what occurred/is happening
• Developmental level
• Personal meaning of the event

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At-risk Populations for Psychiatric Sequelae
Following Traumatic Stress

• Those exposed to the dead and injured
• Eye witnesses and those endangered by event
• Emergency first-responders
• Medical personnel caring for victims
• The elderly
• The very young

Source Norwood et al. Disaster psychiatry
principles and practice.
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At-risk Populations for Psychiatric Sequelae
Following Traumatic Stress

• Those with a history of exposure to other traumas
  or with recent or subsequent major life stressors
  or emotional strain
• Chronic poverty, homelessness, unemployment, or
  discrimination
• Those with chronic medical or
• psychological disorders

SourceACOEM Disaster Preparedness web site
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Disaster Counseling Skills

• Establishing rapport
• Caring eye contact, calm presence, nonjudgmental
  and empathic listening
• Active listening
• Allow silence
• Attend nonverbally
• Paraphrase
• Reflect feelings
• Allow expressions of emotions

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Disaster Counseling Skills

• Problem solving
• Identify and define the problem
• Assess current functioning and coping
• Evaluate available resources
• Develop and implement a plan

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When to Refer for Mental Health Services

• Symptoms are persistent and overwhelm or
  interfere with the persons normal functioning
• Depression
• Anxiety
• Repeated thoughts/memories of traumatic event
• Disorientation
• Psychotic symptoms hallucinations, delusions
• Suicidal thoughts or plans

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When to Refer for Mental Health Services

• Inability to care for self
• Problematic use of alcohol or drugs
• Includes use of illegal, as well as overuse of
  legal substances
• Domestic violence/abuse

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Stress Management for Public Health Workers

• Take care of yourself
• Get sufficient sleep
• Eat regular meals
• Keep caffeine and alcohol consumption moderate
• Talk through your feelings with a safe confident
• Family member
• Mental health or other health care provider
• Seek help when feelings overwhelm or interfere
  with your ability to function

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Summary of Key Points

• The initial and primary response to the
  consequences of a terrorist event occurs at the
  local level.
• ESF 8 provides for federal assistance to
  supplement state and local efforts in response to
  a public health emergency.
• Medical, practical, and feasibility
  considerations are important in the decision to
  implement quarantine.

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Summary of Key Points

• Individual, community, and event-specific factors
  influence the psychological response to a public
  health emergency.
• Most individuals will function adequately
  following a traumatic event, but a few will need
  psychological or medical intervention.
• Many emotional reactions of disaster survivors
  stem from living problems brought about by the
  disaster.

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Summary of Key Points

• The psychological response and long-term effects
  following a traumatic event are influenced by an
  individuals unique combination of health,
  developmental level, resources, and experiences.
• Anxiety responses are most likely following a
  biological attack, but depression, physical
  symptoms, and substance use may also occur.

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Resources

• Centers for Disease Control and Prevention
• Barbera J, et al. Large-scale quarantine
  following biological terrorism in the United
  States.

http//www.bt.cdc.gov
JAMA. 20012862711-2717
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Resources

• American Psychiatric Association
• info on disaster
  psychiatry
• Federal Emergency Management Agency
• DHHS/SAMHSA - disaster mental health info, and
  links to publications

http//www.psych.org
http//www.fema.gov
http//www.mentalhealth.org/cmhs/EmergencyServices
/