Welcome

Expert Panel on Isolation and Quarantine June 2-3, 2009

1

Meeting Goals and Objectives

• • •

Goals

Determine how the law can facilitate best practices and policies in isolation and quarantine in the states Make recommendations for best practices in isolation and quarantine law, policy, and practice using data from the national survey and legal review Identify data gaps and ambiguities in current laws, policies and practices of isolation and quarantine in the states • • •

Objectives

Review survey findings regarding policies and the practice of isolation and quarantine in the states Review survey findings of legal practice in states and compare with national review of isolation and quarantine laws in states Engage in iterative group process to identify best practices in isolation and quarantine law, policies and practice 2

Best Practices in Isolation and Quarantine Isolation/Quarantine Expert Panel June 2, 2009 UM Office of Public Health Practice

3

Overview

• • • Survey Response Policy and Practice Legal Basis 4

State Survey Response

• • • • • • Pilot tested in four states Survey administered by CSTE 80% (41/51) completion rate by 50 states + D.C.

78% of surveys were completed by State Epidemiologist (designated key informant) 73% consulted state legal advisor # of responses varied by question 5

Policy and Practice

Number of Times in Past 5 years States have Invoked Isolation and/or Quarantine (n=39 for Individuals, n=35 for Groups)

6

Policy and Practice

• Q & I Decisions and Procedures – 97% consider scientific concerns important or very important in ordering Q & I (95% to terminate Q & I) – Legal concerns were important or very important in isolation (79%) and quarantine (76%) – 53% had different procedures for implementing group versus individual quarantine – – 28% have an electronic tracking system for Q & I 78% of states do not have incentives to enhance compliance 7

Policy and Practice

Criteria used to ORDER and TERMINATE isolation and quarantine 1=not important 2=of little importance 3=moderately important 4=important 5=very important

Response Count ORDER

Scientific (specific disease, transmission patterns, magnitude, severity, etc.) Resources (available personnel, funding, logistical restrictions, etc.) Legal (authority, etc.) Political (public pressure, legislative action, media attention, etc.)

1

0 2 1 8

2

0 9 1 14

3

1 22 5 14

4

26 3 25 1

5

12 2 7 1 39 38 39 38

TERMINATE

Scientific (specific disease, transmission patterns, magnitude, severity, etc.) Resources (available personnel, funding, logistical restrictions, etc.) Legal (authority, etc.) Political (public pressure, legislative action, media attention, etc.) 4 2 8

1

0

2

0 8 1 13

3

2 21 6 14

4

25 4 24 3

5

11 2 5 1

Response Count

38 39 38 39

Policy and Practice

• • Q & I Responsibility – State Health Officer (82%) and Local Health Officer (67%) most often have decision-making authority regarding quarantine and isolation of individuals and groups State Epidemiologist is primary advisor to State Health Officer on Q & I 9

Policy and Practice

Organizations with primary responsibility for Q & I orders

Q & I Component

Monitoring compliance Providing basic necessities to people Medical and mental health evaluation and treatment Social support services Systems support

State Public Health

X X Funding support Transport of persons X

Local Public Health

X X X X X X X

Law Enforcement

X

Hospitals

X

NGOs Other

X X • To maintain group Q & I, states are under-resourced in funding support (66%), physical infrastructure (66%), and human resources (61%) 10

Policy and Practice

• • Response Coordination – – 80% of states engage local public health before making Q & I decisions 87% coordinate Q & I roles and responsibilities with local public health – Tribal health boards (31%) and Indian Health Services (15%) have rarely been engaged Q & I Orders – – 90% of states could obtain a Q & I order within 24 hours 8% could obtain one in 24 to 48 hours 11

Policy and Practice

• Primary payers for healthcare during Q & I – Insured patient • • Private insurance (76%) State health department (32%) – Uninsured patient • • Healthcare facility (57%) State health department (49%) 12

Policy and Practice

• Q & I Preparedness – 20% of states have not conducted any exercise of Q & I – 64% of states reported that ‘10 percent or less’ of the general public is ready for a Q & I order – 51% of states with public education campaigns have focused on the general public • 32% targeted non-English speaking populations – 45% of states used Pandemicflu.gov

education campaign for the public 13

Legal Basis

• Legal procedure mandates – 87% of states have statutes, regulations or both for individual due process – 70% for group due process – 72% mandate “least restrictive alternative” – 46% of states regulate implementation of due process 14

Legal Basis

• Legal Authority – Most statutes and regulations deal with Q & I at the individual level as opposed to group level – 65% have written formal guidance on how to proceed with Q & I orders – Chief Counsel (71%) and Attorneys General (44%) most often serve as legal advisors – – 55% of states agree CDC has legal authority to mandate Q & I 16 states have MOUs with partner agencies on Q & I 15

Legal Basis

Independent legal decision-making authority to declare an emergency for epidemics or other communicable disease threats and/or implement isolation and quarantine of Governor State Health Officer Chief Medical Executive State Epidemiologist State Director of Emergency Preparedness Local Health Officer Other

Emergency Declarations

39 6 0 0

Quarantine of Individuals Isolation of Individuals Quarantine of Groups

9 35 3 4 9 35 3 4 9 32 3 5

Isolation of Groups Response Count

9 33 3 4 39 35 3 5 0 2 3 0 27 6 0 27 5 0 23 7 0 23 5 0 27 10

Others: Municipal and county governments; physician designated by State Health Officer; county or city chief executive official; local health officer for groups only with permission of State Health Officer; Dept of Health and Environment; on-call physicians and other disease control staff with delegated authority; Local Board of Supervisors or designee; Deputy Secretary of Health Planning and Assessment

Legal Basis

Years since Q & I laws Revised/Reviewed < 2 years 2 to 5 years 6 to 10 years > 10 years

Since last Revised (N=41)

24.4% 41.5% 7.3% 26.8%

Since last Reviewed (N=39)

61.5% 35.9% 2.6% 0% 17