key: cord-0040680-xkilxnwd
authors: Weinstein, Eric S.
title: Policy Issues in Disaster Preparedness and Response
date: 2009-05-15
journal: Disaster Medicine
DOI: 10.1016/b978-0-323-03253-7.50033-9
sha: 50ebbf8731e27211cdd18170c833235d04794f42
doc_id: 40680
cord_uid: xkilxnwd

nan

c h a p t e r 2 6

At the intersection of public perception, science, the duty of government to act, and the rights of the individual sits public health policy. Guiding the paths of healthcare providers, bureaucrats, and patients is an ongoing collaboration to do the most good for the most people. Citations from the Bible and other ancient texts demonstrate meritorious efforts to reduce the spread of disease. Scholars are quick to point out the lack of appreciation of factual scientific knowledge through centuries of political maneuvering to regulate immigration, forcefully separate innocents to protect the fearful, and hide the unfortunately afflicted from view. This chapter discusses recent examples of public health policy in the light of individuals' rights and the science of public health threats.

In our free, democratic society, policy makers tasked with the authority to protect the public's health must also consider the individual's civil and political rights of liberty, privacy, association, assembly, and expression. 1 No one argues against the need to contain the spread of an illness or reduce the threat to life and property damage by terrorism or a natural or industrial disaster. Gostin 1 writes that it is not improper to restrain the enjoyment of liberty, privacy, or property per se, but it is improper to do so unnecessarily, arbitrarily, inequitably, or brutally. This can take place when government acts against a threat that is not valid or not based on objective, reliable scientific knowledge. Protecting public health is difficult to do when an uncertain, evolving illness begins to affect individuals and there is limited technology and limited acquisition of dynamic relevant information. Many illnesses appear the same early in the course of the illness, and it is not until later that the diagnosis can be affirmed. Consider such an illness affecting dozens, hundreds, or thousands of people spread over continents, with fear mounting and governments pressed into acting immediately. It would be the government's burden to defend and rigorously evaluate the effectiveness of a public health measure adopted to contain and treat this mystery illness in real time. Certainly, a known illness for which research has identified the agent, vectors, susceptible hosts with evidence-based diagnostics, treatment, and cost to society can be addressed by an effective public health policy. The challenge to a public health agency is to reach this familiarity with a new syndrome or toxidrome in short order. 1 The balance between the establishment and maintenance of health and the prevention or reduction of transmission of illness with subsequent inhibition or reduction of the individual's rights should follow the doctrine of least-restrictive alternative to reduce the risk or ameliorate the harm. Legal scholars can assume this role alongside public health authorities who are not versed in the ramifications of invasiveness, the intrusion of an intervention on the individual's rights, or the scope and selection of individuals to receive an intervention. The duration of the intervention should be proportionate to the desired effect, with ongoing review to reduce untoward effects that would limit an individual's rights. 1 A fair public health policy benefits those in need and burdens those who endanger the public's health. These policies should not discriminate against sex, ethnicity, or other demographic factors unless scientifically proven to be accurate and if applied evenly will achieve the intended outcome. A means to address perceived inequalities or lack of sensitivity to individual rights is due process. This check-and-balance opportunity of an individual to seek the decision of others assembled to independently determine the merits of a public health intervention in a timely manner may reduce any further effects of a misapplied policy or ineffective course of action. This unbiased informed decision can fashion redress to rectify any misapplication or unintended consequences of policies. This form of process improvement will achieve more appropriate future policy and build trust in government that permits justice to be served. 2 Unfortunately, time is of the essence when a public health agency is pressured to act against an unknown illness. Review during the course of the dynamics of the response to the threat can and should occur simultaneously to scale back any restrictions on individual rights as the science of the event is established. 3 The uninformed public must trust government to achieve compliance with public health policy as the event unfolds before a wary media. Careful discussions in an open forum will not only make it easier for the policy to be accepted and thus achieve the intended end, but also will help attract unknown individuals or groups to further the policy through their involvement in the process. The common good for the public as a whole can be met by the involvement of the community of individuals. Transparency flushes facts, quells rumors, and dispels myths. Protection of an individual's rights can be ensured if the creation of public health policy adheres to necessity of action through proportional, nondiscriminatory, and fair means. 4

As fate yields opportunity, the writing of this chapter began with the author under the voluntary evacuation issued for coastal South Carolina in response to the thenimpending threat of Hurricane Charley (Aug. 13, 2004) . 5 New evacuation measures had been put into place after the infamous 1998 mandatory evacuation of the Charleston, S.C. area in advance of Hurricane Floyd. That evacuation distressed families in that some sat in traffic for 18 hours along a more-than-150-mile stretch along I-26 up to Columbia. At the time of Hurricane Floyd, roughly 1 ⁄ 7th of the S.C. population participated in the evacuation of the entire coastline, with Hurricane Hugo still fresh on most residents' minds. 6 The public outcry after the flawed Hurricane Floyd evacuation enabled the retrospective science of disaster medicine to produce significant changes to the entire data-gathering process that a S.C. governor uses to declare a mandatory evacuation under state law. 7 Exercises have proven that lane reversals, new highway construction, and strategic placement of hundreds of S.C. law enforcement officers and Department of Transportation workers in concert with computer-aided scenarios have been successful to reduce the time of evacuation to up to 10 hours, despite a surge of migration from at-risk coastal S.C. areas. 8 Shortly after the Hurricane Floyd evacuation, honest assessments took place, with a subsequent increased fund of concrete data used to make the executive decision to issue a mandatory evacuation order. An evacuation order can cost a state millions of dollars, disrupt local economies dependent on tourism, and further decrease an already waning public trust. In an effort to make an evacuation easier, the 2003-2004 S.C. General Assembly voted to amend a 1976 law to allow the governor to order that traffic lanes be reversed so that all lanes in an evacuation area flow in one direction away from the evacuation area. 9

The key to any containment strategy is for the local government executive to issue an emergency order or proclamation establishing a new set of operating proce-dures for public health authorities, the healthcare delivery system, and other government agencies. 10 If an outbreak is local, the county executive or county council would issue the order or proclamation through a welldefined process. If an outbreak is across counties, the governor would issue the order or proclamation. The Emergency Medical Treatment and Labor Act (EMTALA) of 1986 permits regionalization of prehospital care to afford the best possible medical care for victims of trauma; those suffering from an acute cerebrovascular accident (CVA); and patients requiring special services such as pediatrics, obstetrics, and, increasingly, psychiatry. Under an executive order to mitigate the threat of a public health emergency (PHE), patients who meet predetermined criteria developed in a collaborative effort using the most accurate; timely; and, if possible, evidencebased determinations can be directed to an established healthcare facility (HCF) or a newly created facility staffed with the necessary personnel, equipment, and supplies to meet the need. 11 This plan can be accomplished ahead of time in anticipation of an outbreak of known pathogens or in the early phases of a new illness pattern detected through the triggers of syndromic surveillance.

Patients who enter the healthcare system after a telephone call to 911 (or other phone number) for emergency medical transport may be evaluated by an emergency medical technician (EMT) when the ambulance arrives. Currently, certain systems will permit an EMT-paramedic (EMT-P) evaluation for appropriateness of transport via emergency medical services (EMS). This is based on strict criteria developed by off-line medical direction; approved by county officials with appropriate documentation; and, more importantly, communication between the EMT crew, on-line medical control, and subsequent review of each call. 12 In a PHE, the most practical extension of this on-scene or field triage process is for an EMS crew, with an EMT-P, registered nurse (RN), or midlevel provider (physician assistant or nurse practitioner), to perform an evaluation of the patient for preset criteria. These criteria can be determined de novo as the PHE is evolving by the assembled collaborative team process or from prior known, reviewed, and learned outbreak responses. This process must include appropriate education about the outbreak; issuance of equipment, supplies, and personal protective equipment (PPE) to the EMS responders; and a screening process to exclude responders who may be more susceptible or less-thanadequate, placing them more at risk. 13 The patient will enter the PHE evaluation and treatment process, and anyone else at the EMS evaluation site must be considered a contact person and enter the PHE evaluation process. The evaluation site must be assessed for epidemiological concerns and adjudicated accordingly. 13 The dispatch of this PHE field evaluation team (FET) can be accomplished through use of priority medical dispatch or a similar 911 operating system. In a PHE, a person who calls the 911 system (or another telephone number for ambulance service for those regions not yet using 911) will undergo caller interrogation specific for the symptoms and any other information that can be learned. The caller will then be given instructions on first aid for laypersons or the establishment of containment strategies pending arrival of the FET. Priority medical dispatch or a similar system can then send the FET to the scene to perform the evaluation, separate from the usual standard EMS.

If this evaluation determines that the patient is a potential victim of a PHE, the EMS crew can transport the patient to a HCF established to evaluate and treat the presenting symptom complex. If the patient is in distress, he or she will be attended to as per standard operating procedures and then transported to the HCF. 11 The EMS crew will be told what containment strategies and procedures an HCF has undertaken for the patient. During the executive declared PHE, the destination HCF may not be a standard HCF, such as the closest hospital, but it may be a "fever hospital" or an HCF specifically created for the PHE. 13 This location will have healthcare workers (HCWs) who are trained, equipped, supplied, and donned in appropriate PPE. It may be on the grounds of the closest hospital, public health clinic, or in another building with appropriate air exchanges, water, heating and air, food preparation, restrooms, showers, etc. in the community to contain the PHE while allowing other hospitals and HCFs to attend to their usual patient loads without an influx of patients with special needs that may be incapacitating due to the surge in volume or contamination. 11 In a short period, such an unconventional HCF can be fully operational with prepositioned stores or vendor agreements.

Guidelines can be created, extensively reviewed from the go-forward, and adapted as the outbreak proceeds. If a patient is determined to meet predetermined criteria, then the process will continue with the patient discharged home with close monitoring, to another HCF for long-term care, or to another HCF for containment. 3 If the patient does not meet the criteria, then the patient can receive appropriate diagnosis and care at that location and then be transported to an acute-care HCF (hospital, clinic, or physician office) for further evaluation, care, and discharge. 14 The vehicle used to transport the patient and the accompanying personnel will have to undergo containment strategies from the initial PHE HCF to the next location.

EMTALA requires that the dedicated emergency department (ED) of an HCF perform a medical screening examination (MSE) for patients who present asking for a medical evaluation or when the MSE is requested by another person. 15 Patients who self-refer to the ED during an executive declared PHE could receive an MSE by the hospital designated RN or midlevel provider donned in appropriate PPE. This HCW can be screened to ensure that he or she is fit for the assignment, vaccinated accordingly, and in-serviced to the threat at hand. 3 The patient may receive an MSE,accepted by the physician at the PHE HCF, and sent with the appropriate EMTALA transfer documentation. If the patient requires stabilization before transfer to the PHE HCF or requires admission to the HCF for acute-and/or long-term care, this could commence accordingly, with containment strategies observed.

At the HCFs, containment strategies should include training of all employees to the specific presenting symptoms and signs of the PHE, use of PPE for those who rou-tinely meet and greet people at their work stations, and limitations on entrance locations to the public. 3 HCFdesignated HCWs positioned to act as screeners can direct people entering the HCF to a receiving area for a more rigorous evaluation, separate from the ED, if they are coming to the HCF as a visitor or to conduct other business. More importantly, if a patient seeking medical attention enters the HCF though a nontypical entrance, containment strategies can commence accordingly. Signage specific for the PHE can direct patients presenting to the HCF for evaluation to containment areas designed for this initial evaluation.

It is plausible for specially trained HCWs, in tandem with personnel from law enforcement, public safety, department of transportation, or another like agency, to assist in the sorting of patients that self-refer to the HCF at locations removed from the entrance of the HCF. To reduce drunk driving for the public good, law enforcement personnel currently set up road blocks, at which they check driver's licenses, registration, and insurance cards and screen for impaired drivers or passengers or vehicles suspected of being involved in illegal activities. 16 An executive PHE can extend certain powers to law enforcement to assist the public health effort to contain the illness. 17 Queues of traffic at locations safely established in route to a hospital can act as a checkpoint for screening, as previously noted, with direction of patients to the PHE HCF or their usual HCF containment area for an MSE. The vehicle and person(s) in the vehicle will enter the epidemiology evaluation and containment process. If the PHE HCW screening determines that a person fits the PHE symptom complex, the PHE FET can be deployed to conduct further evaluation and transport. The vehicle that carried the patient(s) will then have to be isolated, evaluated for contamination, and decontaminated accordingly.

The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) revised its 1991 recommendations in June 2001 to include the use of vaccinia vaccine if the smallpox (variola) virus was used as an agent of biological terrorism or if a smallpox outbreak were to occur for another unforeseen reason. This plan included pre-exposure vaccination for first responders or treatment teams dispatched to attend to those exposed. 18 Modlin 19 was chair of the ACIP when the 2001 recommendations were released, and he later wrote a cautious editorial in March 2002 asking that policy makers weigh the best available analysis of vaccine-related morbidity and costs against the best available assessment of risk for smallpox release. Fauci 20 followed with similar caution, with a reminder of why the smallpox vaccination program was discontinued in the face of known risks, known transmissions, and known cases worldwide-there were several vaccinerelated deaths each year as the risk of contracting the disease continued to decline. He concurred with the "ring-vaccination" strategy, which worked during past decades and involves isolating those suspected or confirmed of being infected with the virus and then tracing contacts and their contacts for vaccination. This minimized the risk of adverse vaccine events (AVEs) and effectively used limited vaccines and other resources, including manpower to adjudicate the plan. 20 A widespread vaccination program is estimated to produce 4600 serious AVEs and 285 deaths. 21 These numbers are unacceptable to many who are facing no known risk and no substantial proof of smallpox outside of known repositories. 22 , 23 Meltzer, 24 through the CDC, in December 2001 showed that the number of susceptible persons and the assumed rate of transmission are the most important variables influencing the total number of smallpox cases to be expected from an intentional release of smallpox into a community. Data analysis of known outbreaks showed that one infected person would subsequently infect fewer than three persons; these data are important when deciding strategies of containment. The data showed that the ring-vaccination surveillance-containment strategy would yield the fastest time to contain an outbreak with the least number of deaths, but they did not discuss AVEs, the effect of smallpox morbidity, or the costs to adjudicate the strategy. 24 Non-peer review medical journals began detailing reservations about the National Smallpox Vaccination Program (NSVP) within weeks of its announcement. In preparation for the program's Jan. 24, 2003, commencement, hospitals openly questioned the financial burden of prescreening examinations, administering the vaccines, monitoring employees for AVEs, and providing treatment if necessary to the intended 500,000 first responder HCWs. They were also concerned that the risks of such a large-scale program for an unsubstantiated rumor based on loose "what-ifs" could reduce an already short staff because vaccinated workers may have to miss work. Hospitals also noted the risk of their HCWs transmitting vaccinia to patients in their facilities as well as HCW family members. Public health policy in this instance did not address the legal ramifications of compensation to inoculated HCWs who suffered an AVE, temporary or permanent. Who should pay the HCW if he or she cannot work? Would subsequent medical costs be paid through workers' compensation or an HCW's own medical insurance? 25 These questions still have not been answered.

The Homeland Security Act of 2002 extended liability protection to the manufacturers of the vaccine, hospitals administering the vaccine, and individuals receiving the vaccine, presumably if they transmit vaccinia to another person. Hospital attorneys debated what locations were protected because it appeared that hospitals themselves were protected only if their vaccination clinic was onsite but not if they chose an off-site HCF such as a clinic.

Reports of HCW AVEs were accumulating with the commencement of the NSVP, slowing the program to a trickle. If 30% of HCWs in some facilities would have had to miss some work, the staffing nightmare could have been dangerous. In April 2003, the CDC ACIP released a supplement, Recommendations for Using Smallpox Vaccine in a Pre-Event Vaccination Program, to its 2001 smallpox vaccine recommendation, moving the focus from each hospital establishing and maintaining at least one response team to only the state having a team. The acquired knowledge of AVEs supported vaccinating healthy, screened HCWs who had been previously vaccinated to staff HCF treatment teams. Dressings to cover the vaccination site, changed by a specific team, were stressed, as was vigorous handwashing techniques. The pre-NSVP concern about administrative leave was not required unless specific minor AVEs developed. The CDC released preliminary reports 26 of 10 cases of myopericarditis among approximately 240,000 healthy personnel who received the vaccine for the first time and none among 110,000 who received another vaccine as a booster. The report noted two civilian volunteers with AVEs (one with myocarditis and one with pericarditis), a rate greater than what was previously noted in unvaccinated healthy military personnel from 1998 to 2000. More disturbing were the reports of five civilian volunteers who contracted myocardial ischemia-related AVEs, three with infarction and two with angina. Screening noted that four of these five had known cardiovascular risk factors, and the other had known cardiovascular disease. 26 Based on these findings, the CDC ACIP released another supplement, this time excluding persons with cardiac disease or risk factors from the NSVP. 27 Sepkowitz 28 answered the question: How contagious is vaccinia? The research showed a risk of secondary transmission of vaccinia, with an 11% fatality rate, with nosocomial transmission apparently occurring through minor contact with a source case. Incidental transmission in the home was noted to occur more often with sustained, intimate exposure that is believed to be related to differences in immunological competency and dermatological differences. With the recommendation to not grant administrative leave for newly vaccinated HCWs, hospitals would have to weigh the risk of a selfinflicted epidemic for an unrealized, unsubstantiated risk. 28 Data gathered from January to July 4, 2003, did not corroborate the conclusions of Sepkowitz's study; there were no transmissions of vaccinia from 37,875 vaccinated volunteer civilians to other persons. 29 These uncertainties of benefit versus the reduced risk combined with the end of the conventional war in Iraq without finding any evidence of weapons of mass destruction and a contentious medicolegal climate in the United States contributed to a less-than-enthusiastic response to the NSVP.

More than a year after the commencement of the NSVP, policy makers showed HCW who volunteered to be vaccinated that they were listening to their concerns by passing the Smallpox Emergency Personnel Protection Act of 2003 (Dec. 13, 2003) . 30 Funded at $42 million, the program provides financial and medical benefits to eligible members of a smallpox emergency response plan approved by the U.S. Department of Health and Human Services (HHS) who sustain certain medical injuries caused by a smallpox vaccine. In addition, unvaccinated individuals injured after coming into contact with vaccinated members of an emergency response plan-or with a person with whom the vaccinated person had contactmay be eligible for program benefits. The program also provides benefits to survivors of eligible individuals whose death resulted from a covered injury. HHS recognized the disconnect from the NSVP felt by HCWs when it began implementation of the compensation program by publishing a Smallpox Vaccine Injury Compensation 19, 2002 . This stochastic model of outcomes considered a range of threats, including a hoax, and predicted the number of deaths, but not morbidity nor the extent of AVEs, after the use of various measures to contain the spread of smallpox. The study brought policy implications to the forefront, specifically the benefit of isolation while highlighting the lack of case law with concerns of denial of civil liberties. 32 Federal law gives the U.S. Public Health Service the power to detain individuals, for such time and such manner as may be reasonably necessary, believed to be infected with a communicable disease in the communicable stage to prevent transmission of the disease. 33 Containment strategies have been successful for centuries to combat the spread of smallpox. Smallpox is spread via large droplet respiratory transmission from face-to-face contact. In 1988 the World Health Organization determined that air samples taken in the vicinity of smallpox patients were rarely positive. This, coupled with the observation that most patients with uncomplicated disease are not capable of generating a strong enough cough to propel aerosols long distance, builds the clinical case for smallpox containment strategies. 34 Containment vaccination can be directed at the persons at the highest risk for disease-those who had face-to-face contact within 2 meters. 35 Barbera and colleagues 36 published a primer on the containment strategies of quarantine (potentially exposed to an infectious agent) and isolation (suspected infection determined by the manifestation of the agent's symptoms/signs/laboratory confirmation). The term largescale quarantine was defined to assist public health policy planners to distinguish a few patients potentially exposed from the numbers that policy planners envision in bioterrorist scenarios or a pandemic. 36 This clinical strategy is no different than the commonplace school or work excuse that physicians provide ED patients, but on a grand scale to limit the spread of an infectious agent from others. A physician writes an excuse, and the school or employer recognizes that the physician wants to protect the other students or employees from "catching" the illness. The student or employee suffers no consequence or injury from not attending school or showing up for work. Individual citizens appreciate the need for government to prevent significant risk to the health of themselves and others. The public health con-tract between the individual and the government cedes certain rights and liberties to achieve a healthier and safer society. A federal statute applies to interstate commerce or travel between states or countries, whereas a state statute applies to most all other instances that would require compulsory separation of individuals. The framework for public health powers (necessity, effective means, proportionality, and fairness) must be applied to the draconian police powers of quarantine and isolation through the following questions 1 :

1. Does the science of the known infectious disease process support the separation of those infected or those possibly infected from those not infected? 2. Can those separated be placed into quarters that will not further the infectious process, respect their dignity, and provide reasonable levels of comfort? 3. Does the risk of separation of individuals from their families, livelihood, and communities outweigh the risk of not separating them and thus furthering the disease among their families, workplace, or communities? 36

Smallpox is not transmitted during the prodromal phase of high fever that precedes the rash. If an individual is exposed to smallpox, he or she can be quarantined to his or her home and can maintain most levels of normal activity until the start of a fever. Then, these individuals can be isolated until it is clear that the fever is not from smallpox. A close contact of a documented smallpox patient should receive the smallpox vaccine if there are no contraindications. If the exposed person is unwilling to accept the risk of the smallpox vaccine or is found to have contraindications, then a full 18-day quarantine is warranted to observe for the tell-tale sign of fevers. The contact is then isolated to reduce the transmission of smallpox to others, with the possibility of vaccination increased since the prodromal now has smallpox or, if the vaccine is contraindicated, other therapies can be administered. This would be the leastrestrictive alternative to permit observation without complete disruption of the individual's life and those that depend on him or her. 37

Dwosh and colleagues 3 showed clear evidence of swift strategy to contain the severe acute respiratory syndrome (SARS) virus at the Richmond Hill Hospital (Toronto, Canada) in March 2003. Patients and hospital staff who had come into close, unprotected contact with two index SARS patients were identified and told to stay home and monitor themselves for a list of symptoms and signs with calls twice a day from public health officials. Fifteen people who began to exhibit the first signs of the illness, specifically a fever, were then isolated. Thereafter, no further cases of SARS were identified. 3

In May 2003, 1 month after the SARS outbreak had peaked, people in the Haidian District of Beijing who had close contact with a suspected SARS patient for more than 30 minutes' duration were quarantined. At first, quarantine lasted for 14 days and was later reduced to 10 days and then 3 days as the results of quarantine strategy were reviewed. A least-restrictive alternative for travelers entering the area was personal surveillance with close medical supervision to permit prompt recognition of infection or illness without restriction of movement. Only persons who had a history of contact with a SARS patient developed SARS during quarantine. In contrast, none of the people who did not come into contact with a SARS patient developed SARS. There were no cases of secondary transmission of SARS to relatives or other contacts during quarantine. Exposed persons were sent home and told to monitor their temperature and to have all members of the household observe strict handwashing precautions and to use respiratory masks. Review of the data showed that if public health authorities had focused only on persons who had contact with an actively ill SARS patient, the number of quarantined persons would have declined by 66%. Persons exposed to a SARS patient in the incubation phase had little to no risk of contracting SARS. It was determined that a person exposed to a SARS patient could monitor his or her temperature alone while on personal surveillance with public health monitoring. If the person developed a fever, then he or she would be removed from the home and isolated. Such modifications would have returned persons to their routines more promptly and reduced the overall resources spent to observe patients in their homes. As the illness is identified as a separate entity through surveillance, data can be collected in real time to permit these changes on a more dynamic basis. 38

Taiwan public health authorities used different containment strategies; close contacts were quarantined for 14 days from February 2003 until June 10 and then aligned with the World Health Organization 10 days later. Hospital staff and patients in close contacts with SARS patients were quarantined in HCFs; all others were quarantined at home, except for homeless persons, who were asked to go voluntarily to government quarantine centers. This tiered system was extended to travelers to Taiwan from April 28 to July 4. Travelers were quarantined for 10 days in an airport transit hotel, at home, or at a quarantine site designated and paid for by their employer if under business (otherwise by the government). If one of these sites was not available, then the traveler was quarantined at a government center. On June 9, because of pressure from Taiwan business leaders, restrictions were eased for employees of Taiwanese companies based in mainland China who were returning to Taiwan for business. These travelers were allowed to return to work if they wore surgical masks. 39 Persons under quarantine were required to stay where they were quarantined, to wear masks, and observe other precautions, with frequent readings of their temperature. The differences in Level A quarantine (14 days, close contact) and Level B quarantine (traveler, 10 days) were restrictive and not based on science because a traveler could have just as easily come into close contact with a SARS patient and develop a fever as could an HCW or family member of a SARS patient. Yet the Level A person was not permitted to leave the site unless deemed necessary by public health authorities, with all meals delivered. Level B persons were free to go to an open area to exercise and purchase meals. To clearly show the difference in approach,Taiwanese officials used video monitoring of some persons who were contacts of a SARS patient and were found to have violated their quarantine at home. Due to this commonplace occurrence at the end of the outbreak, most at-home quarantine persons were under video monitoring. Persons who completed their quarantine received a payment of the equivalent of U.S. $147.00 and other social services from local authorities. 39 Of the 131,132 persons quarantined, 286 (0.2%) were fined for violations of their quarantine. Of the 50,319 persons in Level A quarantine, 4063 (8%) were placed under video monitoring, and 112 developed SARS. Of the 80,813 persons under Level B quarantine, 21 (0.03%) developed SARS. Those with the highest risk of contracting SARS were exposed HCWs (0.34%), family members of SARS patients (0.33%), and those who were on the same airplane flight who sat within three rows of a SARS patient (0.36%). The lowest percentage of patients were those simply traveling from a SARS-affected area. 39

On March 1, 2003, the spread of SARS in the Hong Kong Special Administrative Region was traced to Prince of Wales Hospital HCWs and their contacts. After slow implementation of internal containment strategiesspecifically, isolation-the outbreak was slowed. The second wave of SARS was traced to a patient who used a toilet in a housing project, which lead to that entire area being quarantined. This was worsened when persons from the affected housing project went to a nearby housing project, not observing quarantine or partially adhering to guidelines. The third wave inundated hospitals as the entire region was in the midst of the outbreak. By April 10,"home quarantine" was implemented for household contacts of confirmed SARS patients. The time lag to identify SARS patients led to a peak on April 17. It was not until April 25 that "home confinement policy" was extended to households with contacts of suspected SARS patients. 40

The Model State Emergency Health Powers Act was enacted Dec. 21, 2001 , to provide a framework for governors, legislatures, and public health officials to review their statutes and regulations to adhere to the following principles: preparedness, surveillance, management of property, protection of persons, and communication. 41 Gostin noted that the body of public health statutes is layered on old statutes implemented in response to a public health threat decades ago and that a review for current evidence-based medicine or a review grounded in sound science are unlikely. As medical theory has expanded with technology, 1 legal appreciation of an individual's rights have also been defined without benefit of public health law keeping pace. Old legal remedies may not apply to current public health dilemmas; insufficient authority may limit effective action; and coordination between local, state, and federal authorities may be hindered by conflicting statutes that have been rendered moot through technology. 41 Coercive powers may be the only means to ensure the safety and health of the public and must not be taken lightly. Public health law gives government the authority to limit personal interests to safeguard the public health through powers bounded by necessity, effective means, proportionality, and fairness; in return individuals forgo autonomy, liberty, or property. The model act itself is divided into the pre-emergency environment for predeclaration powers and the powers that become the governor's to use after declaration of an emergency. The declaration of a public health emergency must meet the following criteria: (1) an occurrence or imminent threat of an illness or public health condition that (2) is caused by bioterrorism or a new or re-emerging infectious agent or biological toxin previously controlled that also (3) poses a high probability of a large number of deaths, serious or long-term disabilities, or widespread exposure to an infectious or toxic agent that poses a significant risk of substantial future harm to a large number of persons. 41 The model act filters redundant statutes, removes statutes that have become irrelevant, and enhances traditional public health powers with an extensive set of conditions, principles, and requirements governing the use of personal control measures. Specific advancements include the use of home confinement or other creative less-restrictive alternatives for containment rather than compulsory isolation or quarantine and permits persons so contained to be afforded due process, appropriate medical care, activities, hygiene, and food. 41 Transparency of communication with the public to explain protective measures and access to mental health will reduce public misperceptions. Immunity is afforded to persons exercising authority under the specific declarations of the governor. As of July 2004, 20 states had enacted laws along the model act guidelines of the 29 states that have introduced similar legislation. 42 Civil libertarians point out the evolution of public health powers, with the federal government retaining authority over interstate and foreign commerce, national defense, and the expenditure of money. Even with the creation of the Department of Homeland Security, the CDC still remains the lead advisory consequence agency in a PHE. In the event of a bioterrorist outbreak, the Federal Bureau of Investigations will provide federal crisis management that is coordinated with a state crisis management agency. In most states, the lead state consequence management agency lacks the depth required in current state law for basic public health to function appropriately. Annas 2 stated that the model act should respond to real problems, but the scenarios that would require use of these powers are not known and are left to the transparency of the process of a state government to recommend to the governor to use in a PHE. These powers are for all biological agents and their toxins, regardless of entry into the public. Annual influenza epidemics, by definition, are a PHE with the full depth of the government prepared to prevent a pandemic. The fear and panic after the anthrax incidents in the fall of 2001 cannot be compared to the reality of a true PHE involving the deployment of community HCWs. There is no empiric evidence that certain containment strategies are unfounded.

Civil libertarians and legal scholars are becoming more familiar with the science of outbreaks and other elements of public health threats. Scientists are becoming more astute in the ethical and legal ramifications of intended therapies and interventions. The synergy and collaboration between these guardians of public interest will increasingly contribute to the government's ability to formulate effective public health policy.

Commentary:When terrorism threatens health: How far are limitations on human rights justified

Bioterrorism, public health, and civil liberties

Identification and containment of an outbreak of SARS in a community hospital

Ethical and legal challenges posed by severe acute respiratory syndrome: implications for the control of severe infectious disease threats

State of South Carolina, Office of the Governor. Gov. Sanford expands voluntary evacuation to entire SC coast

South Carolina's response to hurricane Floyd

South Carolina Code of Laws. §25-1-440 (Additional powers and duties of governor during declared emergency)

Intelligent Transportation Systems. Summary of Regional Hurricane Traffic Operations Workshops

South Carolina General Assembly 115th Session

Center for Law and the Public's Health at Georgetown and Johns Hopkins Universities. The Model State Emergency Health Powers Act. Article IV. Section 401. Declaration

Finding a way through the hospital door: the role of EMTALA in public health emergencies

Dallas: The American College of Emergency Physicians

The role of EMS systems in public health emergencies

Use of quarantine to prevent transmission of SARS-Taiwan

Emergency Medical Treatment and Labor Act, 42 USC §1395dd, Stat a (Medical screening requirement)

Center for Law and the Public's Health at Georgetown and Johns Hopkins Universities. Model State Emergency Health Powers Act. Article IV. Section 404. Enforcement

Advisory Committee on Immunization Practices. Vaccinia (smallpox) vaccine

A mass smallpox vaccination campaign: reasonable or irresponsible?

Smallpox vaccination policy-The need for dialogue

Expected adverse events in a mass smallpox vaccination campaign

A different view of smallpox and vaccination

The king of terrors" revisited: the smallpox vaccination campaign and its lessons for future biopreparedness

Modeling potential responses to smallpox as a bioterrorist weapon

Preparing medical-response teams is easier said than done, according to healthcare providers across the nation

Advisory Committee on Immunization Practices, Healthcare Infection Control Practices Advisory Committee. Recommendations for using smallpox vaccine in a pre-event vaccination program: supplemental recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Healthcare Infection Control Practices Advisory Committee (HICPAC)

Supplemental recommendations on adverse events following smallpox vaccination program: recommendations of the Advisory Committee on Immunization Practices

How contagious is vaccinia?

Update: adverse events following civilian smallpox vaccination-United States

Smallpox Emergency Personnel Protection Act of

Health Resources and Services Administration

A model for a smallpox-vaccination policy

Smallpox and its eradication

Emergency response to a smallpox attack: the case for mass vaccination

Large-scale quarantine following biological terrorism in the United States

Toward a containment strategy for smallpox bioterror: an individual-based computational approach

Efficiency of quarantine during an epidemic of severe acute respiratory syndrome-Beijing, China

Use of quarantine to prevent transmission of severe acute respiratory syndrome-Taiwan

Monitoring the severe acute respiratory syndrome epidemic and assessing effectiveness of interventions in Hong Kong Administrative Region

The Model State Emergency Health Powers Act: planning for and response to bioterrorism and naturally occurring infectious diseases

The Center for Law and the Public's Health at Georgetown and Johns Hopkins Universities. The Turning Point Model State Public Health Act: State Legislative Table