public health 101 – an introduction for public health stakeholders southwest center for advanced...
TRANSCRIPT
Public Health 101 – An Introduction for
Public Health Stakeholders
Southwest Center for Advanced Public Health Practice
Tarrant County Public Health, TX
2009
Presented by
Public Health 101
2009 NACCHO/APC Road Show
Course Objectives
• Identify the basic roles and responsibilities of a local public health agency
• Discuss the importance of collaboration between public health and its stakeholders in the event of an emergency
• Provide examples of events that are within the scope of public health preparedness
• Explain and demonstrate how public health utilizes ICS during emergencies
• Describe several of the main steps in an outbreak investigation
• List scenarios where public health and first responders are most likely to interface
Course OutlineI. Introduction to Public HealthII. Public Health PreparednessIII. Incident Command System (ICS)IV. Public Health Response to EmergenciesV. Strategic National Stockpile (SNS)VI. Introduction to EpidemiologyVII. Isolation and QuarantineVIII. Case Study: Avian Influenza Outbreak
What is Health?
• Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
Public Health vs. MedicinePublic Health Medicine
Patient Entire Populations Individuals
Intervention
Assess, Policy Development & Assurance
Medical Treatment
Process System Management
Patient Management
Outcome Healthy Community
Healing
Public Health Objectives
• Prevent epidemics and the spread of disease• Protect against environmental hazards• Prevent injuries• Promote and encourage healthy behaviors• Respond to disasters and assist communities in
recovery• Assure the quality and accessibility of health
services
… derived from American Public Health Association, Ten Essential Services
Typical Menu of Public Health Services• Personal Health Services (clinical services)
– Immunizations– STD/HIV testing and counseling– Chronic disease counseling– Tuberculosis services– Family planning and maternal & child health
services– Travel health services
BUT…providing direct clinical services is only one part of the mission of a local health department
Population BasedPublic Health Services
• Environmental Health• Infectious Disease Control and
Investigation• Laboratory Services• Health Education Services
The Public Health System Federal Agencies
State Agencies
Local Agencies
Public Health’s Many PartnersPublic Health’s Many Partners
MCOs
Home Health
Parks
Economic Development
Mass Transit
Employers
Nursing Homes
Mental Health
Drug Treatment
Civic GroupsCHCs
Laboratory Facilities
Hospitals
EMSCommunity
Centers
Doctors
Health Department
Churches
Philanthropist
Elected Officials
Tribal Health
Schools
Police
Fire
Corrections
Environmental Health
Which level of government is responsible for protecting public
health?
• 10th Amendment to the U.S. Constitution: – All powers not delegated to the
Federal government shall be reserved for the state governments
• States are responsible for protecting public health
What is Public Health Preparedness?
“Plans,procedures, policies, training, and equipmentnecessary tomaximize the ability to prevent,respond and recover from major events.”(HSPD-21)
Public Health PreparednessBuilds Infrastructure for:
Public Health EmergenciesBioterrorism, pandemics
Everyday health threatsInfectious & foodborne
diseases
Preparedness and Bioterrorism
What is bioterrorism???
-- The use of... Bacteria Viruses Parasites Their by-products
…in a terrorist act.
Preparedness and Bioterrorism
• Possible agents of bioterrorism– Anthrax– Smallpox– Plague– Botulism
Preparedness and Bioterrorism
• What might an attack of bioterrorism look like?– Not necessarily explosions or plumes of
smoke
– May not be readily apparent and detectable
– Sick people arrive at hospitals or doctors’ offices
– Delayed recognition and diagnosis
– Population panic
Roles in Preparedness
• Planning• Coordination/Collaboration• Training and Exercise• Response• Evaluation and Corrective
Action
Collaboration is critical to success!
Roles in Preparedness
Situation Examples: – Outbreaks from
contaminated food or water, infectious diseases, etc.
– Natural disasters: hurricanes, floods, fires
Roles in Preparedness
• Examples of public health job roles:– Health threats
investigator– Public
service/media– Post-event tracking– Environmental
investigators
Incident Command System
• Allows a more effective, efficient response to emergencies
• Examples:– HazMat incidents– Terrorist incidents– Natural disasters– Incidents involving
multiple casualties
Incident Command & Public Health
• In the event of a public health emergency the public health director will interact with the local EOC or incident command post.
• The public health Department of Operations Center (DOC) may be activated to facilitate tactical communications.
Public Health Responding to Emergencies
• In what type events would you expect Public Health to assume lead role for providing health and medical services ?
Public Health Preparedness Summary
• Build public health infrastructure to respond to threats from:– Bioterrorism– Natural disasters & disease outbreaks
• Requires collaboration between agencies:– Planning – Training & exercises– Response – Communication – Management of resources
Strategic National Stockpile
Strategic National Stockpile (SNS)
• A national stockpile available in the event of a major terrorist attack against the civilian US population
• National repository consisting of:– Pharmaceuticals (i.e., antibiotics and vaccines)– Antidotes and antitoxins– Medical and surgical supplies
Strategic National Stockpile
• SNS is a federal asset deployed locally after a major disaster– The governor of the affected state
requests deployment of SNS from:
Strategic National Stockpile
• Delivered within 12 hours of federal decision to deploy SNS assets– 12-hour “Push Package”– Push packages are
warehoused in strategically- positioned locations around the US
Local Response to Strategic National Stockpile
SNS deployment is a large-scale event requiring adequate:•Security
Pre–determined Points of Distribution
•Crowd control•Traffic control
Local Response to Strategic National Stockpile
• Essential that First Responders and others in contact with exposed civilians are the first to be medicated
Local Response to Strategic National Stockpile
• Must prepare to dispense medicine to a large number of people in a relatively short time span
Local Response to Strategic National Stockpile
•Expect to work with Public Health:•Work collaboratively•Implement emergency response
according to prior planning •Have conducted prior training and
exercises•Interagency Cross-Training
Epidemiology
What is Epidemiology?
Study of the spread and causes of diseases or events in specified populations, and the control of health problems.
Epidemiology concerned with OUTBREAKS
• An adverse health event involving an unusual increase in cases among a certain population of individuals, within a certain period of time, in a certain location
• Infectious diseases
• Environmental
• Behavioral
• Forensic
• Disaster
Areas of Epidemiology
• Person
• Place
• Time
Key Elements in Epidemiology
Epidemiology Study Examples(risk or exposure outcome)
• Smoking (exposure) increases the risk of developing Lung Cancer (outcome)
Epidemiology Study Examples(risk or exposure outcome)
• Eating undercooked hamburger (exposure) increases the risk of infection with the bacteria E. coli (outcome).
• Getting a flu shot (exposure) decreases the risk of becoming ill with the flu (outcome).
Epidemiology Study Examples(risk or exposure outcome)
Simplified Steps in an Outbreak Investigation
1. Confirm outbreak and verify diagnosis
2. Perform field work and complete study
3. Implement control and prevention measures
4. Communicate findings
Disease Reporting: Notifiable Diseases
• Healthcare providers are required by law to report patients with certain diseases and conditions:– Report immediately (in most states)
• Potential BT agents (anthrax, smallpox, plague)• Botulism (foodborne)• Viral hemorrhagic fever, including Ebola• Other selected contagious serious diseases that
may affect children and immune compromised or un-protected victims
Isolation and Quarantine Protocol
History of Quarantine
• In the fourteenth century, to protect cities from plague epidemics, ships arriving in Venice from infected ports had to sit at anchor for forty days before landing.
• “Quarantine” is derived from the Latin word quaresma, meaning forty.
Definitions:
Isolation:• The separation of someone who’s
infected or contaminated from others so that the infection or contamination is not spread
Quarantine• Limitation of freedom of movement
of a well person who’s been exposed to an infectious agent
What Does it Mean to be Isolated or Quarantined?
• No contact with any new people• Can not leave home or place of
containment• For evaluation and verification purposes
patient needs to check in with Public Health every day
What is Voluntary Compliance?
•Voluntary compliance with isolation, quarantine or other control measures means a patient cooperates and complies with Public Health’s instructions to comply with the recommended control measures in order to prevent the spread of disease.
What is Involuntary Detention?
• This is what Public Health will pursue if an individual does not voluntarily comply with an ordered control measure.
To What or Who Can “Control Measures” be Imposed?
• Person (s)• Groups (5 or more individuals)• Area (city block, ZIP code, county)
– Buildings (hospital, hotel, business)*– Common Carrier (plane, bus, train)*
Who Can Enforce these Rules?
• Local law enforcement must enforce an order issued by local health authority.
Questions?
Case study: Influenza Outbreak
Background on avian influenza:Strains of influenza that infect birdsCirculate among wild water birdsBird-to-bird transmission via:
Fecal material Saliva
Nasal & respiratory secretions
A new bacteria or virus that can infect humans Nearly all people have no
immunity to the new organism High mortality rate Easily spread from person to
person.
A Pandemic A Pandemic is a is a World-Wide EpidemicWorld-Wide Epidemic
Background – Avian Influenza
– Varying severity and infectiousness among birds
– The highly pathological avian influenza (HPAI) is the virus that is a pandemic among migrating water fowl.
– Potential to combine with human flu virus to produce a “new” influenza transmissible to humans that could be lethal.
Viral reassortment
• Mixing of viral genes from two different animal species simultaneously
Example: Human infected with human and avian influenza virus at the same time
Influenza Virus Transmission
Influenza viruses have the potential to mutate rapidly and gain the ability to spread from:
• Birds to farm animals (i.e., pigs)
• Animals to humans
• Birds to humans (directly)
Avian Influenza Virus Transmission Concerns
1. Strain efficiently transmitted between birds and humans
2. Strain efficiently transmitted from human to human
Influenza Outbreak Scenario
Scenario:A highly infectious form of avian influenza begins to circulate among poultry at a farm in Hong Kong.
Influenza Outbreak
• The owner of the farm also has several pig pens
• The pig pens are located right next to the bird cages
• The feed troughs for both the pigs and poultry are often interchanged
Influenza Outbreak
• The avian flu virus mutates and infects several of the pigs.
• The virus mutates again and is transmitted from one of the pigs to the farm owner.
Bird →Pig →Human
Influenza Outbreak
• The farm owner wakes up one morning suffering from:– Fever– Sore throat– Coughing– Muscle aches
Influenza Outbreak
• In the afternoon, he travels into the crowded capital city to sell his poultry at the local market.
• He is in extremely close contact with customers for several hours.
Influenza Outbreak• A couple days
later, several of the customers from the market begin to show symptoms of flu-like illness:– Coughing– Fever– Sore throat– Muscle aches
Influenza Outbreak
• Several of them work in the kitchen of a nearby hotel restaurant
• The restaurant is popular among Americans on business trips in Hong Kong.
Influenza Outbreak
• A Tarrant County resident traveling in Hong Kong on a business trip stays at the hotel.
• He eats at the hotel restaurant on an evening in which one of the infected workers is preparing food.
Influenza Outbreak
• The businessman is infected with flu.
• Within a few days of eating at the restaurant, he exhibits flu-like symptoms.
• The following day, he flies home to DFW.
Influenza Outbreak
Influenza Outbreak
Within days after the resident returns home, local hospitals see an increase in patients presenting with:
• coughing• fever• muscle aches
Influenza Outbreak
• Local physicians report similar trends in symptoms seen in recent days in their private practices.
Influenza Outbreak
• Over the next couple days, several EMS workers who’ve been transporting ill patients, call in sick to work complaining of flu-like symptoms.
• The work-force loses capacity because so many employees have fallen ill.
Question 1
• What factors might be contributing to EMS staff contracting influenza?
(Hint: prior influenza vaccination likely would NOT be effective in preventing infection from an avian flu virus)
Answer
• Staff were not taking appropriate protective measures around infected persons:– Not regularly washing hands after contact with
sick individuals– Failing to wear personal protective equipment
(masks and gloves)– Failing to disinfect contaminated surfaces and
medical equipment after transporting patients
Question 2
• Could this influenza outbreak have been prevented completely?
AnswerHighly unlikely :
– Population has little to no immunity against a new avian flu virus strain
– Prior influenza vaccination not protective against avian flu virus strain
– Minimum of 6 months needed to develop a new flu vaccine
However . . .
Question 3
• Could the magnitude of this outbreak have been reduced?
AnswerYes – it is likely the magnitude of the outbreak could have been reduced by: – Earlier attention to health alerts– Regular hand washing after
contact with patients– Wearing personal protective
equipment (masks, gloves, gowns)
– Regularly disinfecting surfaces and medical equipment
Question 4
• Would a quarantine be required?
Answer• Yes - general quarantine precautions
would apply:– An infected patient (with SARS, Avian, TB or
even H1N1) on an international flight CAN be detained at the airport terminal
– CDC, airport and local public health authorities can request flight manifests and have passengers undergo medical screening for their safety
– A non-compliant patient can be arrested and sent to forced isolation or quarantine
Question 5
• Why would a non-compliant person be arrested and sent to forced isolation or quarantine?
Answer
• So the non-compliant patient does not endanger the public or themselves.
Influenza Outbreak Summary
• BE RESPONSIBLE!!• It is especially important . . .
– Wash hands or use sanitizers regularly– Practice good respiratory hygiene and
cough etiquette– Don’t come to work when you are sick– Get a flu shot each year
Influenza Outbreak Disclaimer
Disclaimer: Currently no sustainable human-to-
human transmission of bird flu has been reported
However, cases of human-to-human transmission continue to occur and the virus continues to mutate
Therefore, we must be prepared for Therefore, we must be prepared for this possibilitythis possibility
Conclusions and Questions
CreditsThis course was made possible through the efforts of public health
and EMS staff from Dekalb County, GA and Tarrant County, TX:Darren Collins*, MPH, Dekalb
Jason Craw* DekalbBill Stephens, MS, Tarrant
Kay Sanyal-Mukherji, MPH, TarrantMicky Moerbe, MPH, Tarrant
Diana Cervantes, MS, TarrantJennifer Dowdy, MPH, Tarrant
Mark Fulmer, MS, TarrantTerry Lafon, RN, Tarrant
Teresa Bates, LVN, Tarrant Donald Fisher, MS, Tarrant
Reviewed by Dr. Elvin Adams, MD, FACEP, Health Authority, Tarrant
This training was produced by the Southwest Center for Advanced Public Health Practice (Center) at Tarrant County Public Health, and was supported by Cooperative Agreement Number U50/CCU302718 from the Centers for Disease Control and Prevention (CDC) to the National Association of County and
City Health Officials (NACCHO). Its contents are solely the responsibility of Center and do not necessarily represent the official views of CDC or NACCHO
* - Originating authors