The Maryland Office of the Attorney General and the DHMH Office of Preparedness and Response Present a Symposium on LEGAL ISSUES IN PUBLIC HEALTH EMERGENCIES – MASS PROPHYLAXIS AND SOCIAL DISTANCINGCatastrophic Health Emergency Law  ANTHRAX SCENARIO – Prelude : The Maryland Office of the Attorney General and the DHMH Office of Preparedness and Response Present a Symposium on LEGAL ISSUES IN PUBLIC HEALTH EMERGENCIES – MASS PROPHYLAXIS AND SOCIAL DISTANCING Catastrophic Health Emergency Law ANTHRAX SCENARIO – Prelude Daniel O’Brien Office of the Attorney General Principal Counsel, DHMH 11-14-7oagsocdishypo2


THE GATHERINGS: THE GATHERINGS Preparations for July 4th http://www.nps.gov/nama/


NATIONAL HOLIDAY : NATIONAL HOLIDAY District of Columbia Maryland Virginia http://www.bigfoto.com /themes/fireworks/index.htm


NATIONAL MALL SECURITY : NATIONAL MALL SECURITY Fences Checking packages “Exercising” – mass migration from city http://www.nps.gov/history/nr/travel/wash/dc70.htm


EVENTS AROUND REGION: EVENTS AROUND REGION Large and small gatherings All with fireworks Three major firework producers support most regional activities


LOCATIONS : LOCATIONS National Mall 500,000 Baltimore Inner Harbor 190,000 Annapolis waterfront 50,000 Towson 60,000 http://www.mdisfun.org/Baltimore_Attractions_Travelocity2.html


WEATHER ASSESSMENTS : WEATHER ASSESSMENTS Long range tracking of weather Forecast for region Slight winds in afternoon Overnight - lessening to 5mph No rain for next week predicted http://www.srh.noaa.gov/ffc/html/svrwx5297.shtml


ANONYMOUS CALL : ANONYMOUS CALL July 5th call to FBI headquarters in DC Cryptic – 12:15 am Fireworks contaminated with anthrax Four cities affected “Hundreds of thousands dead in days” http://www.fbi.gov/libref/historic/hooverbuilding/hqhistory.htm


LOCAL ALERTS : LOCAL ALERTS FBI and other federal officials consult Decision made to alert State and city officials Calls made between 2:15 and 3:30 am http://www.fbi.gov/page2/dec06/predators120606.htm


CONFIRMATION – BIOSENSORS : CONFIRMATION – BIOSENSORS Unusual positive readings Begin around midnight Aerosolized anthrax reports Calls to DHMH labs seeking support http://www.sandia.gov/news/resources/image-gallery/index.html


REGIONAL ACTIVATION : REGIONAL ACTIVATION Assessment of risk http://www.dhs.gov/xinfoshare Many firework celebrations Don’t know which affected Decision – Activate CRI plans for: National Capital and Baltimore regions /


Letter Threats : Letter Threats http://www.fbi.gov/pressrel/pressrel01/102301.htm


SAMPLE TESTING : SAMPLE TESTING FBI/Military police deliver initial samples to CDC and DHMH labs for testing Demand chain of custody assurances http://www.fbi.gov/hq/lab/labhome.htm


The Maryland Office of the Attorney General and the DHMH Office of Preparedness and Response Present a Symposium on LEGAL ISSUES IN PUBLIC HEALTH EMERGENCIES – MASS PROPHYLAXIS AND SOCIAL DISTANCINGCatastrophic Health Emergency Law ANTHRAX SCENARIO - Response: The Maryland Office of the Attorney General and the DHMH Office of Preparedness and Response Present a Symposium on LEGAL ISSUES IN PUBLIC HEALTH EMERGENCIES – MASS PROPHYLAXIS AND SOCIAL DISTANCING Catastrophic Health Emergency Law ANTHRAX SCENARIO - Response Daniel O’Brien Office of the Attorney General Principal Counsel, DHMH 11-12-7oagsocdishypo1


REQUEST FOR SNS : REQUEST FOR SNS Governor requests deployment of Strategic National Stockpile Request approved by CDC for NCR and Maryland http://emergency.cdc.gov/stockpile/index.asp


DEPLOYMENT SNS : DEPLOYMENT SNS SNS scheduled to arrive at “Receive, Staging and Storage Sites” Around 4:00 am


VOLUNTEER NOTIFICATION : VOLUNTEER NOTIFICATION Early call down efforts within DHMH Command center activated at MEMA and DHMH Board exec directors reached between 3 and 5 am.


VOLUNTEER CONTACT EFFORTS : VOLUNTEER CONTACT EFFORTS DHMH volunteer lists activated Local health staff support needed


VOLUNTEER CALL UP : VOLUNTEER CALL UP Throughout July 5: Multiple efforts to locate and alert volunteers DHMH, boards, hospitals, Red Cross….. Central clearinghouse needed? http://www.miemss.org/


LHD ASKED “Scope of Practice”: LHD ASKED “Scope of Practice” www.whitehouse.gov/ omb/budget/fy2006/hhs.html


VOLUNTEER IDENTIFCATION : VOLUNTEER IDENTIFCATION Health care providers to bring institutional Ids Difficulty entering distribution sites during the day


The Maryland Office of the Attorney General and the DHMH Office of Preparedness and Response Present a Symposium on LEGAL ISSUES IN PUBLIC HEALTH EMERGENCIES – MASS PROPHYLAXIS AND SOCIAL DISTANCINGCatastrophic Health Emergency Law ANTHRAX SCENARIO – MASS TREATMENT: The Maryland Office of the Attorney General and the DHMH Office of Preparedness and Response Present a Symposium on LEGAL ISSUES IN PUBLIC HEALTH EMERGENCIES – MASS PROPHYLAXIS AND SOCIAL DISTANCING Catastrophic Health Emergency Law ANTHRAX SCENARIO – MASS TREATMENT Daniel O’Brien Office of the Attorney General Principal Counsel, DHMH 11-12-7oagsocdishypo1


SCOPE OF AFFECTED AREA : SCOPE OF AFFECTED AREA


CHE – SECRETARY’S DIRECTIVE: CHE – SECRETARY’S DIRECTIVE Blast email to hospitals requiring reporting of anthrax exposure symptoms Not able to reach clinics and doctors offices http://www.nhscareers.nhs.uk/copyright.shtml


CHE – DHMH SECRETARY’S DECLARATION : CHE – DHMH SECRETARY’S DECLARATION 7:00 am – Formal Declaration signed Anticipates Governor’s declaration Directs widest possible cooperative efforts Deployment of volunteers and State medical staff http://www.who.int/substance_abuse/activities/global_initiative/pictures/en/


CHE – GOVERNOR’S EXECUTIVE ORDER: CHE – GOVERNOR’S EXECUTIVE ORDER 9:30 am – Executive Order signed MEMA ordered into full operation EMS, Police and Fire to support medical efforts Mandatory cooperation with DHMH efforts


PROVIDER LIMITATIONS: PROVIDER LIMITATIONS Secretary expands scope of practice for certain HCPs


ANCILLARY LIMITATIONS : ANCILLARY LIMITATIONS Ambulances on bypass and not responding to emergencies FEMA library


SNS ASSETS DISTRIBUTION: SNS ASSETS DISTRIBUTION


EMERGENCY DISTRIBUTION : EMERGENCY DISTRIBUTION July 5 – 11:00 am: Governor announces need for all residents to receive medication Directions on location and specifics over radio WITHIN 36 HOURS


MEDICAL SYSTEM SURGE : MEDICAL SYSTEM SURGE Afternoon and evening July 5 Hospitals and clinics overwhelmed Seek State directions on prioritization of patients


MASS DISPENSING SITES : MASS DISPENSING SITES


SITE MANAGEMENT : SITE MANAGEMENT Media want site location information Police support requested Distribution of medication by private trucking companies http://www.dhs.gov/xprepresp/


SITE ORGANIZATION : SITE ORGANIZATION Mixture of volunteers and gov’t employees arrive Insufficient pharmacists and licensed health care professionals Lay workers asked to participate http://www.hss.state.ak.us/press/images/Sitka_4.jpg


MEDICATIONS ARRIVE Some in bulk, some not, directions unclear : MEDICATIONS ARRIVE Some in bulk, some not, directions unclear


COLLEGE CAMPUSES AND RESIDENTIAL SITES : COLLEGE CAMPUSES AND RESIDENTIAL SITES Seek special distribution allotments Propose to handle dispensing and administration


DELAYED DELIVERIES : DELAYED DELIVERIES Some sites in northern Maryland counties receive no medications Local health officer directs hospitals to deliver med supplies to distribution sites


The Maryland Office of the Attorney General and the DHMH Office of Preparedness and Response Present a Symposium on LEGAL ISSUES IN PUBLIC HEALTH EMERGENCIES – MASS PROPHYLAXIS AND SOCIAL DISTANCINGCatastrophic Health Emergency Law PAN FLU SCENARIO - Outbreak: The Maryland Office of the Attorney General and the DHMH Office of Preparedness and Response Present a Symposium on LEGAL ISSUES IN PUBLIC HEALTH EMERGENCIES – MASS PROPHYLAXIS AND SOCIAL DISTANCING Catastrophic Health Emergency Law PAN FLU SCENARIO - Outbreak Daniel O’Brien Office of the Attorney General Principal Counsel, DHMH 11-12-7oagsocdishypo1


August 2: August 2 WHO reports significant increase in suspect avian flu cases in Vietnam.


August 4– Associated with small family flocks : August 4– Associated with small family flocks http://www.publicdomainpictures.net/browse-category.php?s=10


August 15: August 15 WHO tracking Person to person transmission rare Isolates identified Type A H5N1


August 20: August 20 WHO on high alert Small clusters w/localized outbreaks Limited human to human transmission in SE Asia http ://www.who.int/substance_abuse/activities/global_initiative/pictures/en/


August 27: August 27 WHO issues travel advisory CDC advises limits on non-essential travel to Vietnam and China


September 7: September 7 WHO deploys containment teams to Japan and Vietnam Team leader – possibility of containment 50/50


October 1: October 1 Continuing outbreaks across SE Asia No vaccine available Unconfirmed hospital reports Fatality up to 45% http://www.who.int/csr/disease/avian_influenza/en/


October 10: October 10 Airlines report 5 suspect cases arrived on Tokyo flight Some passengers detained but most in general population


October 12 : October 12 UK Newspapers “BIRD FLU IN ENGLAND” Widespread public reaction


October 15: October 15 WHO & EU teams in SE Asia reporting sustained human to human transmission WHO upgrades Pandemic alert to Phase 5 - 6.


October 15 – Clinical Features : October 15 – Clinical Features Consistent with classical influenza But more rapid progression to lower respiratory tract Longer incubation period Median 4 days Average 2 to 9 Case fatality greater than 30%


The Maryland Office of the Attorney General and the DHMH Office of Preparedness and Response Present a Symposium on LEGAL ISSUES IN PUBLIC HEALTH EMERGENCIES – MASS PROPHYLAXIS AND SOCIAL DISTANCINGCatastrophic Health Emergency Law FIFTH SCENARIO - Containment: The Maryland Office of the Attorney General and the DHMH Office of Preparedness and Response Present a Symposium on LEGAL ISSUES IN PUBLIC HEALTH EMERGENCIES – MASS PROPHYLAXIS AND SOCIAL DISTANCING Catastrophic Health Emergency Law FIFTH SCENARIO - Containment Daniel O’Brien Office of the Attorney General Principal Counsel, DHMH 11-12-7oagsocdishypo1


October 16: October 16 21 year old U of Md. student arrives at BWI Returning from study abroad in Ho Chi Minh City Increasing fever and discomfort during flight


October 16 – Afternoon : October 16 – Afternoon 3:30 pm - Pilot radios BWI tower for medical assistance 4:45 pm - Medics board and confirm passenger has CDC flu symptoms DHMH physician on call approves isolation and quarantine


October 16 – Evening : October 16 – Evening DHMH interviews plane passengers All released Second passenger from Tokyo becomes ill that night


October 17 : October 17 Second student passenger attends family gathering 22 relatives Leaves early and returns to dorm http://www.cob.calpoly.edu/mm/gallery/view_photo.php?set_albumName=Studentpics1&id=IMG_0041


October 18: October 18 Student seen in crowded U of Md. Student Health Suite Taken to local hospital Report submitted to LHO and DHMH Labs


October 20: October 20 DHMH contact tracing from family party 10 participants show symptoms


October 21 : October 21 Secretary orders quarantine of student contacts Difficulty locating and serving affected persons Police assistance sought to deliver notices


October 25: October 25 DHMH Secretary issues public advisory on need to self monitor symptoms Exposed family member notifies LHD that he intends to travel to Europe tomorrow


October 26 : October 26 Numerous family members and student unwilling to follow voluntary quarantine recommendations Must work – salary and employer demands


October 26: 5:05 p.m.: October 26: 5:05 p.m. MDOT AAG reaches Anne Arundel Circuit Court judge and asks for verbal approval of isolation order issued by DHMH on call physician


October 27: October 27 Anne Arundel Circuit Court holds release hearings Defense counsel files petition for habeas corpus Demands in -court hearing


October 27: October 27 No clear medical advice on protective measures Individual circuit and district court judges improvise measures including such as . . . .


The Maryland Office of the Attorney General and the DHMH Office of Preparedness and Response Present a Symposium on LEGAL ISSUES IN PUBLIC HEALTH EMERGENCIES – MASS PROPHYLAXIS AND SOCIAL DISTANCINGCatastrophic Health Emergency Law SIXTH SCENARIO - Suppression: The Maryland Office of the Attorney General and the DHMH Office of Preparedness and Response Present a Symposium on LEGAL ISSUES IN PUBLIC HEALTH EMERGENCIES – MASS PROPHYLAXIS AND SOCIAL DISTANCING Catastrophic Health Emergency Law SIXTH SCENARIO - Suppression Daniel O’Brien Office of the Attorney General Principal Counsel, DHMH 11-12-7oagsocdishypo1


October 27: October 27 WHO reports number of confirmed SE Asia cases over 1,000 Many thousand milder cases Tamiflu – conflicting reports Some resistance?


October 30 National Alerts: October 30 National Alerts


October 31 : October 31 Federal directives to states Prepare final flu intervention efforts SNS discussions States to inventory Tamiflu and other supplies http://www.whitehouse.gov/homeland/pandemic-influenza-implementation.html


Slide68: 250 Annapolis residents have presented to hospitals in Anne Arundel County with flu-like symptoms (coughing, fever, myalgia).


November 2 : November 2 State agencies survey major private sector resources Retailers unable to meet demands Shortages anticipated


December 15: December 15 Widespread reports of flu – like illness in Prince Georges 500 patients hospitalized Fatality around 18% Tamiflu moderately effective


December 20: December 20 Statewide outbreaks reported Eastern Shore less affected All hospitals on ambulance bypass Clinical staff – 25% absentee rates Supply shortages in hospitals


December 22: December 22 Local officials impose local travel restrictions


December 23: December 23 Talbot County Courts institute “virtual” hearing plan per shelter in place order Chief Judge convenes statewide conference call to discuss


December 24: December 24 21 jurisdictions requesting court representative at local emergency command site MEMA seeking court representative


December 25 – Travel restrictions : December 25 – Travel restrictions


January 4: January 4 Maryland courts begin full COOP implementation 25% staff absentee rate 37 release hearings scheduled in 6 counties


January 15 : January 15 FEMA urges voluntary restriction of all non-essential public gatherings Trial courts identify essential proceedings