Public Health Response: A Collaboration Between Health and Law

Aashish Kiran Shah, M.D.

Department of State Health Services

Health Service Region 6/5S

SARS

Tuberculosis

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State

Five Leading U.S. States by Number of TB Cases, 2006

Avian Influenza

20th Century Influenza Pandemics

H3N2H3N2

1920 1940 1960 1980 2000

H1N1H1N1H2N2H2N2

1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu”

20-40 million deaths20-40 million deaths 2 million deaths2 million deaths 1 million deaths1 million deaths

Rabies

Foodborne Illness

Combating

Realistic Approach: Simple Steps

• Nothing Novel

– Surveillance

• Applicable laws

– Public Health Control Measures

• Individual (Hygiene)

• Community Wide

Surveillance

CDC. 1999-2000 influenza season summary. Available at: http://www.cdc.gov/ncidod/diseases/flu/bigpi.htm.

The Texas Health & Safety Code Chapter 81 and 826 (Legislative Law)

• Reporting of specific diseases/conditions to the local health authority

• Investigation of reportable conditions by the local health authority

• Reporting of any outbreak, exotic disease, or unusual group expression of disease which may be of public health concern

• In the case of rabies, requires designation of Local Rabies Control Authority and what must be reported to them

The Texas Administrative Code (administrative law, written by state health department)• TITLE 25 HEALTH SERVICES

• PART 1 DEPARTMENT OF STATE HEALTH SERVICES

• CHAPTER 97 COMMUNICABLE DISEASES

• SUBCHAPTER A CONTROL OF COMMUNICABLE DISEASES

• RULE §97.2 Who Shall Report

Mandates Who Should Report

– physician, dentist, veterinarian, chiropractor, advanced practice nurse, physician assistant, or person permitted by law to attend a pregnant woman during gestation

– chief administrative officer of a hospital shall appoint one reporting officer

– School authorities: superintendent, principal, teacher, school health official, or counselor of a public or private school and the administrator or health official of a public/private institution of higher learning

– Any person having knowledge that a person or animal is suspected of having a notifiable condition

Failure to Report

• Health department officials can report a physician to the appropriate medical board.

• Medical boards often allow for maximum of two misdemeanors (any reason) prior to medical license suspension or removal.

Failure to report a notifiable condition is a Class B misdemeanor under the Texas Health and Safety Code, §81.049

Public Health Control Measures

Individual

Hand hygieneCough etiquetteInfection controlLiving space controlIsolation of illDesignated care provider

Community

Isolation of illTreatment of illQuarantine of exposedProphylaxis School closureSocial distancing

A Layered Approach

Individual Control Measures

• Handwashing with soap prevents the two clinical syndromes that cause the largest number of childhood deaths globally-namely, diarrhea and acute lower respiratory infections.

• Published evidence indicates that aerosol transmission of influenza can be an important mode of transmission, which has obvious implications for pandemic influenza planning

Individual Control Measures

Lancet and CDC.

12/4/06 20

Community Mitigation

“I hereby order that all theaters, moving picture shows, schools, pool and billiard halls, Sunday schools, cabarets, lodges, societies, public funerals, open air meetings, dance halls and conventions to be at once closed and discontinued until further notice.”

– Mayor Keil October 7, 1918

Decrease the Global and Community Spread of Infection

• Isolation of ill

• Voluntary home quarantine of those exposed to ill or with probable flu

• Use social distancing by:

– Closing schools & childcare programs

– Canceling public events

– Work place social distancing

• Continuity of operations

Community Control Measures

Community Control Measures

• Mathematical modeling has shown that closing schools at the onset of a pandemic could decrease attack rates in a community by about 33%

– Compared to the attack rate when not implementing any control measures

– School closures would likely occur in concert with other control measures

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E x p r e s s a u t h o r i z a t i o n t o c l o s e s c h o o l s d u e t o d i s e a s e o r e p i d e m i c : 7

• The premise is that there is sufficient, clear, and specific legal authority to close schools in preparation for or response to pandemic flu.

• This premise, however, is uncertain.

What does this show?

Collins SD, Frost WH, Gover M, Sydenstricker E: Mortality from influenza and pneumonia in the 50 largest cities of the United States First Edition Washington: U.S. Government Printing Office 1930.

1918 Death Rates: Philadelphia v St. Louis

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Clinical attack rate

Base case (Ro=1.9)Generic social distancingSchool closureSchool closure + generic social distancing60% Case treatment + 60% household prophylaxis60% Case treatment + 60% household prophylaxis + 60% social prophylaxis (60% TAP)60% TAP + School closure + generic social distancing

Longini Model

Who will implement these strategies?

Public Health Officials • Federal, state and local public health agencies

maintain the lead role in preparing for and responding to pandemic influenza

• Hierarchy

• Federal – Centers for Disease Control and Prevention (CDC)

• State – Texas Department of State Health Services (DSHS)

• Local – Houston Department of Health & Human Services/Harris County Public Health & Environmental Services

Public Health’s Authority

• Chapter 81 of the Texas Health and Safety Code establishes the role of the health authority, a physician appointed to administer laws related to public health within their jurisdiction

– Including laws related to community control measures

• Such measures include isolation, quarantine, immunization, detention, restriction, disinfection, decontamination, disinfestation, chemoprophylaxis, preventive therapy, prevention and education

Public Health’s Authority

• The authority to compel disease control measures is derived from the state’s inherent “police powers”

– Police powers refer to the authority of a state government to enact laws and promote regulations to safeguard the health, safety and welfare of its citizens

Public Health’s Authority

•There are 172 local health authorities in Texas, many affiliated with local health departments

•Areas without local health authorities are covered by DSHS regional health authorities

Local Rabies Control Authority (LRCA)

• Chapter 826 of the THSC establishes the required designation of a LRCA by a city council or county commissioners court

– All bites and scratches to people from animals capable of transmitting rabies must be reported to the LRCA

– LCRA must investigate potential exposures and respond appropriately (including testing and quarantine).

Role of the Judiciary

•Chapter 81 of the Texas Health and Safety Code establishes:

• Municipal, county, or district attorneys as jurisdictional representative tasked to enforce a local health authority’s written order in the event of “non-compliance”.

•Criminal and civil penalties for “non compliance”.

-Including laws related to community control measures

•Such measures include isolation, quarantine, immunization, detention, restriction, disinfection, decontamination, disinfestation, chemoprophylaxis, preventive therapy, prevention and education

Role of the Judiciary

•Texas Government Codes 418 and 433 establishes:

•County judges as a possible“chief executive officer” or “presiding officer of the governing body” during the time of a declared disaster or state of emergency.

•This designation allows for broad powers to “control and effectively terminate the emergency”.

•Criminal and civil penalties for “non compliance”.

–Including laws related to community control measures

•Such measures include isolation, quarantine, immunization, detention, restriction, disinfection, decontamination, disinfestation, chemoprophylaxis, preventive therapy, prevention and education

Concluding Thoughts