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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

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- LEGAL CONSIDERATIONS FOR PANDEMIC INFLUENZA -



The Legal Considerations Section includes the following subsections:

• Legal Issues
Describes substantive legal issues that are likely to arise in a pandemic and how they are being addressed.

• Legal Resources
Lists available legal resources and indicates where they may be found. These include model documents such as legal orders that the Commissioner might issue; background documents on websites; etc.

• Partnerships and Outreach
Describes committees and advisory groups that have legal components and/or are addressing legal issues.

• Training
Describes past, current and future training programs on legal issues.

• Other Agencies
Lists legal issues that are the responsibility of other state agencies.

• Miscellaneous
Addresses additional minor legal issues.

LEGAL ISSUES

1. Emergency Declarations
There are two statutes in Massachusetts that allow the Governor to declare an emergency.
Public Health Emergency. Under M.G.L. c. 17, § 2A, if the Governor declares that an emergency exists which is detrimental to the public health, the DPH Commissioner may, with the approval of the Governor and the Public Health Council, “take such action and incur such liabilities as he may deem necessary to assure the maintenance of public health and the prevention of disease.” In addition, with the approval of the Public Health Council, the Commissioner may “establish procedures to be followed during such emergency to insure the continuation of essential public health services and the enforcement of the same.”

• Pandemic Period: The Commissioner and senior DPH staff will be in continuous close touch with the Governor’s office. If the Commissioner determines that the situation warrants a declaration of public health emergency based on epidemiological information, speed of disease spread, etc., he would request that the Governor issue such a declaration. Once the declaration is made, the Commissioner would have all necessary authority to issue orders; waive statutes and regulations that impede emergency response; seize property if necessary, etc.

State of Emergency. Under Chapter 639 of the Acts of 1950, the Governor may declare a state of emergency due to (among other circumstances) “the occurrence of any disaster or catastrophe resulting from attack, sabotage or other hostile action; or from riot or other civil disturbance; or from fire, flood, earthquake or other natural causes.” Because an influenza pandemic can be considered a catastrophe resulting from natural causes, the Governor might decide to declare a state of emergency concurrent with declaring a public health emergency, or without declaring a public health emergency.
By the terms of the statute, a state of emergency confers upon the Governor extraordinary powers to protect the lives and property of the citizens of the Commonwealth and to enforce the laws. In practice, if a state of emergency were declared during a pandemic, MEMA would activate the State Emergency Operations Center and DPH would be a crucial participant in emergency response under ESF-8. It is expected that the Governor would delegate broad health-related powers to the DPH Commissioner, with the result that there would be little if any practical difference between a declared public health emergency and a declared state of emergency.
DPH legal counsel are familiar with the powers available under both types of emergency declarations, and would advise policy makers on appropriate legal means to achieve policy goals.

2. Restrictions on Personal Liberty
Isolation and Quarantine. Legal preparations have been and are continuing to be made to isolate or quarantine individuals or groups of people, should DPH policy makers decide that such measures are necessary to protect the public health during the Pandemic Alert Period and/or the Pandemic Period.
• Massachusetts statutes and regulations authorize isolation and quarantine for diseases dangerous to the public health.
• Legal materials for isolation and quarantine of individuals, originally developed for SARS, have been modified for pandemic flu. These are complied into a set of documents known as “Legal Nuts and Bolts of Isolation and Quarantine,” available from the DPH Office of General Counsel and the Health Education Unit, Division of Epidemiology and Immunization. They include documents that state and local health authorities would use for stepwise enforcement of isolation and quarantine, beginning with letters requesting voluntary cooperation, up to court pleadings and related documents to compel isolation.
• Due process protections have been considered in drafting these documents, guided by the principle that whatever measure is used should be the least restrictive of personal liberty while protecting public health. Non-custodial orders (e.g. home isolation) may be appealed by a telephone call to a health official, while custodial measures (e.g. isolation in a hospital) would in most cases require a court order. Efforts will be made to ensure that people who are subject to court proceedings for mandatory isolation or quarantine have access to attorneys. Judges may be contacted at any time, day or night, through the State Police.

Other Restrictions on Personal Liberty. It is possible that a wide variety of other measures might become necessary to protect the public health during a Pandemic Alert Period or Pandemic Period, some of which impose certain restrictions on personal liberty. Examples include requiring people to self-monitor for medical conditions; requiring medical evaluations and/or vaccinations, prophylaxis, or medical treatment; closing businesses, public transportation; etc.

• Templates have been drafted for orders that the DPH Commissioner could issue during a public health emergency, and additional templates are in process. The templates include findings or statements that the measures being ordered are the least restrictive alternative or the most reasonable way to address the threat to public health.

3. Use of Volunteers
During the Pandemic Period, there will almost certainly be a shortage of doctors, nurses, and other health care workers to care for patients. Using HRSA funds, DPH is creating the Massachusetts System for Advance Registration of Volunteer Health Professionals (MSAR), a database of registered and pre-credentialed volunteers who can be called up by the Commissioner when the need arises. The database will initially contain various categories of health care volunteers, and will later be expanded to include others (translators, etc.).

Three legal documents underlie MSAR:
• MSAR Program Policy
• Participation Agreement (to be signed by participating organizations)
• Individual Terms and Conditions (to be signed by individual volunteers)

Credentialing
Pre-credentialing will be accomplished either by hospitals that sign the Participation Agreement with DPH, or by other organizations, through a contract with DPH, for practitioners who are not affiliated with a hospital. DPH legal counsel are working with the health care licensing boards and hospitals to ensure that credentialing and license restriction issues are handled consistently and in accordance with the HRSA guidelines and state law.
The many locally-based Medical Reserve Corps (MRCs) around the Commonwealth also provide a potential source of volunteers. MRC members are being encouraged to join the MSAR system, and DPH has contracted with a vendor who is providing coordination between the MRC system and MSAR.

Liability
Protection from malpractice liability for MSAR volunteers when they are working in other than their regular place of employment is an important consideration. While there are no liability statutes or regulations specific to MSAR, depending on the circumstances MSAR volunteers may be able to take advantage of various existing laws. A summary document and PowerPoint presentation dealing with liability protections for Massachusetts health care volunteers responding to a disaster may be found at http://www.mass.gov/dph/bioterrorism/advisorygrps/index.htm

Worker’s Compensation
Currently there is no Workers’ Compensation coverage for MSAR volunteers, unless the volunteer is considered by his or her employer to be within the scope of employment when activated under MSAR. The MSAR Statewide Advisory Committee will continue to study this issue.

4. Mutual Aid
Local Mutual Aid
Through the Center for Emergency Preparedness and the Regional Coordinators, DPH is encouraging city and town boards of health and health departments to enter into agreements to assist neighboring communities with public health resources in times of need. A template has been developed that can be used and modified by local government officials to fit their particular legal structure and needs. A significant number of communities across the Commonwealth have signed mutual aid agreements to date.

Interstate Mutual Aid
Massachusetts is a member of the Emergency Management Assistance Compact (EMAC), which allows states to share personnel and material resources in times of disaster, pursuant to a Governor’s request for assistance. MEMA is the coordinating agency for EMAC in Massachusetts. DPH would work closely with MEMA if Massachusetts required public health assistance from other states, or if Massachusetts received an out-of-state EMAC request for public health assets.

International Mutual Aid
Massachusetts is a member of the International Emergency Management Assistance Memorandum of Understanding, also known as IEMAC (International Emergency Management Assistance Compact). This agreement covers the six New England states and five Eastern Canadian provinces (Quebec, New Brunswick, Nova Scotia, Prince Edward Island and Newfoundland & Labrador). DPH legal counsel is actively involved in identifying and addressing legal issues in the implementation of IEMAC, towards the goal that Canadian public health assets would be available to Massachusetts if needed.

 

5. Data Sharing
For obvious reasons, sharing of information is crucial to efforts to predict, prevent, and contain a pandemic during all phases (Interpandemic, Pandemic Alert, and Pandemic Periods). Also, during the Pandemic Alert and Pandemic Periods, there may be a need for sharing of more personal health information than is the case under normal circumstances. The following summarizes legal authorities and issues related to data sharing.

Provision of Data to Governmental Authorities
DPH will need identifying information about cases, suspect cases, and contacts in order to track the disease outbreak and implement containment measures. Current law gives the Department broad authority to require health care providers and organizations to report dangerous diseases, through M.G.L. c. 111, § 7 and its implementing regulations, 105 CMR 300.000. This statute and regulations also authorize DPH to undertake broad disease surveillance activities.
Many diseases, including influenza, are reportable to local boards of health, which are then required to report to DPH within 24 hours. If a disease is not among those listed as reportable, 105 CMR 300.150 allows the Commissioner to require reporting of and surveillance for diseases or conditions which are newly recognized or recently identified or suspected as a public health concern.
The federal Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule contains a broad public health exception to its confidentiality requirements. It allows health care providers and organizations to disclose protected health information to a public health authority for purposes of disease reporting, public health surveillance, public health investigations, and public health interventions. 45 CFR § 164.512(b).
The HIPAA Privacy Rule also contains an exception which allows disclosure of protected health information when the provider or organization believes that the disclosure is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public, and the disclosure is made to a person or persons reasonably able to prevent or lessen the threat. 45 CFR § 164.512(j)(1). For example, this exception would allow a hospital, provider, or DPH to release identifying information to the police, if law enforcement assistance were needed to enforce an isolation or quarantine order against an individual.
Dissemination of Data by DPH and other Governmental Authorities
Under M.G.L. c. 111, § 5, DPH is directed to “conduct sanitary investigations and investigations as to the causes of disease, and especially of epidemics,” and to “disseminate such information relating thereto as it considers proper.” This gives DPH very broad authority to disseminate appropriate information during all pandemic phases.

Under MDPH’s regulations governing reportable diseases, surveillance, and isolation and quarantine requirements (“Disease Regulations”), personally identifying information may be disclosed by MDPH or a local board of health when necessary for disease investigation, control, treatment, and prevention purposes. 105 CMR 300.120. When disclosing personal data/health information, state agencies (this does not include local boards of health) are subject to the Massachusetts Fair Information Practices Act (FIPA M.G.L. c. 66A). FIPA bars state agencies from disclosing personal data unless authorized by the subject of the data or by a statute or regulation. In most situations, MDPH’s authority to release information for disease-related purposes pursuant to M.G.L. c. 111, § 5 or 105 CMR 300.120 will be sufficient to permit the release of personal data when necessary for the protection of public health.

During the Pandemic Phase, patients will receive medical treatment in a variety of settings and are likely to be transferred among settings. MDPH plans to track their whereabouts, in order to be able to notify family members and friends of their location at any particular time. To enable this to happen, it is expected that hospitals will provide identifying information to MDPH under a HIPAA waiver (explained in section 6.G. below), or under HIPAA’s “required by law” exception in the event that the MDPH Commissioner issues an order requiring patient tracking. MDPH is not bound by HIPAA in connection with its public health activities, and therefore can release a patient’s location to family members and friends in the interests of public health and safety (restoring calm, avoiding panic, etc.).

6. Waivers of Federal CMS Requirements (“Section 1135 Waivers”)
Waivers of a variety of federal requirements under the federal Medicare, Medicaid, and Children’s Health Programs may become necessary during the Pandemic Period. The Statewide Surge Committee is working with representatives of CMS to identify and plan for all potentially necessary waivers.
Under 42 U.S.C. § 1320b-5 (section 1135 of the Social Security Act), the Secretary of Health and Human Services has authority to waive certain requirements of CMS programs in an emergency area during a federal emergency period. An “emergency area” is a geographical area in which, and an “emergency period” is the period during which, there exist two types of declared emergencies: an emergency or disaster declared by the President under the National Emergencies Act or the Stafford Act, and a public health emergency declared by the Secretary of HHS. 42 U.S.C. § 1320b-5(g)(1). At the Secretary’s discretion, waivers that are authorized after the emergency has occurred may be made retroactive to the beginning of the emergency period. 42 U.S.C. § 1320b-5(c).
With 2 exceptions noted below (EMTALA and HIPAA), the waivers generally last for the duration of the emergency period or until CMS determines that the waiver is no longer necessary. However, if a hospital regains its ability to comply with a waived requirement before the end of the declared emergency period, the waiver of that requirement no longer applies to that hospital.
Requirements authorized to be waived under section 1135 of the Social Security Act are listed below. These are sometimes referred to as “Section 1135 Waivers.”

Available Waivers
A. Conditions of Participation: Subsection (b) (1)
The Secretary of HHS may waive:
a. Conditions of participation or other certification requirements for an individual health care provider or types of providers,
b. Program participation and similar requirements for an individual health care provider or types of providers, and
c. Pre-approval requirements.

 

42 U.S.C. § 1320b-5(b)(1).

B. Licensure of Health Care Professionals: Subsection (b)(2)
The Secretary of HHS may waive “requirements that physicians and other health care professionals be licensed in the state in which they provide services, if they have equivalent licensing in another state and are not affirmatively excluded from practice in that state or in any state a part of which is included in the emergency area.” 42 U.S.C. § 1320b-5(b) (2).

C. EMTALA: Subsection (b)(3)
The Emergency Medical Treatment and Labor Act (EMTALA) prohibits hospitals from transferring a patient with an emergency condition, or a woman in labor, out of the emergency room without screening the person and medically stabilizing him or her. The Secretary of HHS may waive actions under EMTALA (1) if a hospital transfers a person who has not been stabilized, if the transfer is necessitated by the circumstances of the emergency, or (2) if the hospital directs or relocates a person to receive medical screening in an alternate location pursuant to a state emergency preparedness plan. 42 U.S.C. § 1320b-5(b)(3).
An EMTALA waiver will only be in effect if the hospital does not discriminate among individuals that it transfers or relocates on the basis of their source of payment or their ability to pay. It is also limited to the 72-hour period beginning when a hospital implements its disaster protocol. 42 U.S.C. § 1320b-5(b).

D. Physician Referrals: Subsection (b)(4)
The Secretary of HHS may waive sanctions under 42 U.S.C. § 1395nn(g), relating to limitations on physician referrals. 42 U.S.C. § 1320b-5(b)(4).

E. Deadlines and Timetables: Subsection (b)(5)
The Secretary of HHS may modify, not waive, deadlines and timetables for the performance of required activities. 42 U.S.C. § 1320b-5(b)(5).

F. Payments under a Medicare+Choice Plan: Subsection (b)(6)
The Secretary of HHS may waive limitations on payments under 42 U.S.C. § 1395w-21(i) for health care items and services furnished to individuals enrolled in a Medicare+Choice plan by health care professionals or facilities that are not included under that plan. 42 U.S.C. § 1320b-5(b)(6).

G. HIPAA: Subsection (b) (7)
The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule requires health care providers to maintain patient confidentiality in a variety of ways. Under this subsection, the Secretary of HHS may waive sanctions for noncompliance with the following requirements of the HIPAA regulations:

1. Requirements to obtain a patient’s agreement to speak with family members or friends;
2. The requirement to honor a patient’s request to opt out of the facility directory;
3. The requirement to distribute a notice of the uses and disclosures of protected health information that the hospital may make, and of the individual's rights and the hospitals’ duties with respect to protected health information; and
4. The patient’s right to request certain privacy restrictions, and to request communications of protected health information from the hospital by alternative means or at alternative locations. 42 U.S.C. § 1320b-5(b)(7).
As with EMTALA, a HIPAA waiver will only be in effect if the hospital does not discriminate among individuals on the basis of their source of payment or their ability to pay, and it is limited to the 72-hour period beginning when a hospital implements its disaster protocol. 42 U.S.C. § 1320b-5(b).

Additional Waivers Needed

The following types of waivers may also be needed during the Pandemic Period. MDPH is working with regional HHS staff to determine whether and under what authority these waivers may be possible.

• Waivers to allow reimbursement for facilities/practitioners under circumstances where practitioners are being utilized who would not normally be utilized. Examples:
o Practitioners not privileged by the facility within which they are working or do not meet the CMS credentialing criteria
o Volunteer (unpaid) people
o Students & other categories of people who may not fit the CMS conditions of participation for reimbursement
NOTE: These MAY be allowed under Section 1135 (b) (1) allowing HHS to waive conditions of participation

• Waivers to allow Influenza Specialty Care Units (ISCU) or other non-traditional facilities operating under state "special project" licensing waivers to be recognized by CMS for reimbursement purposes.

• Waivers to allow facilities and practitioners to provide care that does not meet CMS approved guidelines while operating under State Alternate Standards of Care waivers.

• Waivers to allow facilities to discharge or transfer patients "against their will" during surge, including discharging patients to home care or an ISCU.

• Waivers that would allow facilities to refuse to admit veterans and require them to seek treatment at Veterans Administration facilities.

• Waivers for EMS agencies to seek reimbursement for patients not transported but examined/triaged/treated at home or transported to an ISCU or physician’s office rather than a hospital.

• Waivers to allow EMS/hospital agencies and practitioners that are CMS participants to act under authority of State Alternate Standards of Care waivers and triage patients via telephone to home care or a physician’s office.
Procedures for Requesting Waivers
DPH will be in continuous contact with hospitals during the Pandemic Period to determine if a waiver or waivers are necessary, and will work with the appropriate federal officials to expedite the process of requesting them.
During the TOPOFF 2 exercise, the legal office of the Illinois DPH requested an EMTALA waiver through the Regional Counsel of HHS. It went up the chain of command and was granted.
7. Use of Alternate Care Sites

During the Pandemic Period, it may become necessary for patients to be treated in non-traditional health care settings. Plans are underway to create Influenza Specialty Care Units (“ISCUs”), which will be satellites of existing hospitals. Each ISCU will serve the communities identified by a hospital to be within its catchment “cluster”, as well as the surge patients discharged from the affiliated hospital. The ISCU will be stood up following MDPH approval of a specific request by the hospital, in a pre-identified and pre-approved facility in a community. Each ISCU will be licensed as a satellite of the hospital under a temporary special project waiver.

Legal staff are involved in planning for the ISCUs so that they may operate under appropriate legal authority and with any necessary waivers. Issues to be addressed include tiered staffing protocols, standing orders, admission and discharge criteria, altered standard of care policies, activation protocols, and others.

8. Altered Standards of Health Care

During the Pandemic Period, it may be necessary to alter prevailing standards of medical care. There may be insufficient health care personnel to deliver optimum care, as well as a shortage of material resources (e.g. ventilators). Legal and ethical guidelines need to be developed to aid decision-making in these circumstances. An official relaxation of the standard of care may become necessary, in order to relieve health care providers and institutions from liability for failure to adhere to prevailing standards under dire circumstances.

At the request of MDPH, the Harvard School of Public Health has convened a working group to analyze these issues and develop guidance. The group includes ethicists and representatives from MDPH, the Harvard School of Public Health, several Massachusetts hospitals, and the American Society of Law, Medicine and Ethics. Hypothetical scenarios have been developed and community-based discussions will be held, which ideally will lead to the development of clear standards.

9. Use of Private Sector Resources

Voluntary loans

Private businesses and individuals may be willing to loan materials or space in buildings to the Commonwealth in the event they are needed, but they may question whether they would be liable should the materials malfunction or should the buildings have defects.

Liability protection for loan of materials by corporations, but not individuals, may exist if the Governor has declared an emergency under Chapter 639 of the Acts of 1950, 33 App. § 13-1 et seq. Section 13-12 of this statute provides that after the Governor declares an emergency under § 13-5, no “person engaged in any civil defense activities while in good faith complying or attempting to comply with this act . . . shall be civilly liable for the death of or any injury to persons or damage to property as [a] result of such activity except that the individual shall be liable for his negligence [emphasis added].” “Civil defense” is defined to include “the preparation for and the carrying out of all emergency functions, . . . for the purpose of minimizing and repairing injury and damage resulting from disasters caused by . . . hostile action . . . or . . . natural causes.” Under this definition, responding to a flu pandemic would be considered a civil defense function. However, it is uncertain whether the word “person” includes corporations.

The loan of space in buildings is even more problematic. Section 13-12A of Chapter 639 only provides protection from negligence for the loan of real estate when the real estate is provided “for the purpose of sheltering persons during an actual, impending or mock enemy attack.” There does not appear to be any other legal protection for a person who loans real estate.




Governmental takings

It is a basic premise of constitutional law that the government may take private property for public use, but it must provide just compensation. U.S. Constitution, Amendment V; Massachusetts Constitution, Article X. Section 13-5 of Chapter 639 of the Acts of 1950 specifies this authority in detail. It states that when the Governor has declared a state of emergency, he may take possession of real estate, machinery, equipment, modes of transportation, food, and fuel. Section 13-5 also specifies procedures by which property owners may have compensation assessed for the taking of their property.

MDPH also has broad powers in situations that threaten public health. If the Governor has declared a public health emergency under chapter 17, s. 2A, the Commissioner may, with the approval of the Governor and the Public Health Council, “take such action and incur such liabilities as he may deem necessary to assure the maintenance of public health and the prevention of disease.” This is very broad authority and is sufficient to allow MDPH to take private property (e.g. medical supplies) if necessary.

Furthermore, M.G.L. c. 111, § 5A allows the Commissioner to determine that it is essential in the interest of the public health to provide the general public with a vaccine or medication and that an emergency exists by reason of a shortage of such product. When the Commissioner makes this determination, DPH may "purchase, produce and distribute such product under such conditions and restrictions as it may prescribe" and may establish rules and priorities for the distribution and use of the product. During a public health emergency, this statute and c. 17, § 2A together allow MDPH to take necessary vaccines, etc. from the private sector and control their distribution.

LEGAL RESOURCES

1. Model Documents
During the Pandemic Period and possibly during the Pandemic Alert Period, it may become necessary for the Commissioner to issue various orders to protect the public health. Various templates for such orders have been drafted, which are located in the DPH Office of General Counsel.

2. Documents for Isolation and Quarantine
The “Legal Nuts and Bolts of Isolation and Quarantine” package includes model health letters, health orders, court pleadings, and related documents. It is available from the DPH Office of General Counsel and the Health Education Unit, Division of Epidemiology and Immunization.

3. Other Legal Information
A summary document and PowerPoint presentation dealing with liability protections for Massachusetts health care volunteers responding to a disaster may be found at http://www.mass.gov/dph/bioterrorism/advisorygrps/index.htm

Additional legal resources and tools include:

• Draft Model State Emergency Health Powers Act
www.publichealthlaw.net/MSEHPA/MSEHPA2.pdf

• Emergency Management Assistance Compact as adopted in Massachusetts http://www.mass.gov/legis/laws/seslaw00/sl000339.htm

• International Emergency Management Assistance Memorandum of Understanding as adopted in Massachusetts
• http://www.mass.gov/legis/laws/seslaw02/sl020300.htm (See section 58)

• Model Memorandum of Understanding for Establishment of Local Public Health Mutual Aid and Assistance System
www.publichealthlaw.net/Resources/ResourcesPDFs/MOU.pdf

• American Bar Association Draft Checklist for State and Local Government Attorneys to Prepare for Possible Disasters
http://www.publichealthlaw.net/Resources/BTlaw.htm

• CDC: Legal Authorities for Isolation and Quarantine (links to information on federal authority for isolation and quarantine)
http://www.cdc.gov/ncidod/sars/legal.htm

• Quarantine and Isolation: Lessons Learned from SARS (A report to CDC)
http://www.louisville.edu/medschool/ibhpl/images/pdf/SARS%20REPORT.pdf

• Checklists on Legal Preparedness for Bioterrorism and other Public Health Emergencies (from the Center for Law and the Public’s Health at Georgetown and Johns Hopkins Universities)
http://www.publichealthlaw.net/Resources/BTlaw.htm

• Legal Materials Related to Public Health Legal Preparedness from CDC’s Public Health Law Program
http://www2a.cdc.gov/phlp/sub_menu.asp

Additional materials and resources may be posted at http://www.cdc.gov/phlp/index.htm

PARTNERSHIPS/OUTREACH

• In 2003-2004, an Emergency Powers Working Group was convened by the Governor’s office and the Attorney General’s office. It included attorneys from many state agencies including MDPH, the Executive Office of Public Safety, the State Police, Environmental Protection, Agriculture, Fire Services, and others. The group completed a tabletop exercise based on a hypothetical release of a mysterious toxic substance, and wrote memos summarizing the authority of each agency.
• There are legal representatives on the following groups that are currently meeting and that include many stakeholders:
o Statewide Surge Committee: Addresses a wide variety of pandemic surge issues
 Surge Clinical Workgroup: in process of being formed. Will address legal issues related to the Influenza Specialty Care Units (ISCUs) including guidance on the care to be delivered, tiered staffing protocols, standing orders, altered standard of care protocols, etc.
o Massachusetts System for Advance Registration (MSAR) Advisory Committee: Planning group for the statewide advance registration system for health care volunteers
o Altered Standards of Care Working Group, chaired by the Harvard School of Public Health: Explores how standards of medical care would be altered in a pandemic
o New England Regional HRSA Group: Shares information and works on regional issues involving hospital preparedness
o International Emergency Management Group: Shares information and works on mutual aid issues for the New England states and Eastern Canadian provinces
TRAINING ON LEGAL ISSUES
1. Training for Local Health Authorities
• The training program entitled “Legal Nuts and Bolts of Isolation and Quarantine” has been presented to local health authorities around the state numerous times, and two more of these trainings will take place by the fall of 2006.
• A training session on liability protections for local health authorities and volunteers has been presented twice.
2. Training for Law Enforcement
• Approximately 1200 state police officers were trained in advance of the Democratic National Convention in the summer of 2004 by counsel to the State Police. Among other things, this training covered the law enforcement community caretaking function and the authority of the police to enforce orders from health officials.
• Some local law enforcement officers have attended the “Legal Nuts & Bolts of Isolation and Quarantine” trainings.
• A training program for state police is being planned for summer 2006, to cover infectious diseases and the use of isolation and quarantine for individuals, groups, and areas. This may be extended to local police at a later date.
3. Training for the Judiciary
• Superior Court judges received materials from the “Legal Nuts and Bolts of Isolation and Quarantine” several years ago. These include health orders and court pleadings, motions, etc.
LEGAL ISSUES WITHIN PURVIEW OF OTHER AGENCIES

• Issues relating to overtime and/or flexibility of hours for staff: The Human Resources Division is working on these.
• Environmental remediation of buildings: This is the responsibility of the Department of Environmental Protection.
• Issues relating to schools: As necessary, MDPH will work with the Department of Education to ensure that school-related issues such as school closures and use of schools as alternate care sites are handled according to law.


MISCELLANEOUS ISSUES
• Use of faith-based organizations: There should be no legal problem if MDPH decides to partner with faith-based organizations to assist or provide services to people during the Pandemic Period. A group called the “Interfaith Alliance” assisted with Hurricane Katrina evacuees on the Cape in the fall of 2005. During that period, the Governor’s office also worked with a coordinated interfaith effort called “MassFaithHelps,” spearheaded by the Black Ministerial Alliance.
• Reintegration of persons subject to isolation/quarantine orders: If necessary, MDPH will issue documents designed to assist with reintegration of persons after isolation or quarantine (e.g., letters to employers or schools explaining that people are no longer infectious), and would assist local health authorities in this effort.


Acronym Full Name of Organization
ACIP Advisory Committee on Immunization Practices
AIDS Acquired Immunodeficiency Syndrome
APHL Association of Public Health Laboratories
ARDS Acute Respiratory Distress Syndrome
ATS American Thoracic Society
BCDC Bureau of Communicable Disease Control
BOH Board of Health
BPHC Boston Public Health Commission
BRFSS Behavioral Risk Factor Surveillance Survey
BSAS Bureau of Substance Abuse Services
BTS British Thoracic Society
CAP Community-acquired Pneumonia
CBC Complete Blood Count
CCLS Center for Clinical and Laboratory Services
CDC Center for Disease Control and Prevention
CEH Center for Environmental Health
CEMP Comprehensive Emergency Management Plan
CEP Center for Emergency Preparedness
CHB Children's Hospital Boston
CMGA Crisis Management Group Associates
CMS Centers for Medicare & Medicaid Services
COG Continuity of Government
COOP Continuity of Operations Plan
COPD Chronic Obstructive Pulmonary Disease
CURB-65 Confusion, Urea nitrogen, Respiratory rate, Blood pressure, 65 yrs.+
DHHS Department of Health and Human Services
DOD Department of Defense
EAP Employee Assistance Program
EARS Early Aberration Reporting System
ED Emergency Department
EDS Emergency Dispensing Site
EDSOTM Emergency Dispensing Site Operation and Management Plan
ELR Electronic Laboratory Reporting
EOHHS Executive Office for Health and Human Services
EMTALA Emergency Medical Treatment and Labor Act
ENDS Early Notification of Death System
EOPS Executive Office of Public Safety
FDA Food and Drug Administration
FFY Federal Fiscal Year
FQHC Federally Qualified Health Centers
GIS Geographic Information Systems
GSK IND Glaxosmithkline Investigational New Drug
HCW Healthcare Workers
HHAN Health and Homeland Alert Network
HIPAA Health Insurance Portability and Accountability Act
HIV Human Immunodeficiency Virus
HPHC/HVMA Harvard Pilgrim Health Care/Vanguard Medical Associates
HRSA Health Resources and Services Administration
HSPD Homeland Security Presidential Directive 8
IDEP The Infectious Disease Emergency Planning
IDSA Infectious Diseases Society of America
ILI Influenza-like Illness
NREVSS National Respiratory and Enteric Virus Surveillance System
IC Incident Commander
ICU Intensive Care Unit
IFA Immunofluorescence Antibody
ISCU Influenza Specialty Care Unit
LHD Local Health Departments
LIMS Laboratory Information Management System
LPAI Low Pathogenic Avian Influenza
LRN Laboratory Response Network
MAA Mutual Aid Agreements
MAESF Massachusetts Emergency Support Function
MAHB Massachusetts Association of Health Boards
MAHP The Massachusetts Association of Health Plans
MAPHN The Massachusetts Association of Public Health Nurses
MassPRO The Massachusetts Quality Improvement Organization
MCAAP The Massachusetts Chapter of the American Academy of Pediatrics
MCB Massachusetts Commission for the Blind
MCDHH Massachusetts Commission for the Deaf and Hard of Hearing
MDAR Massachusetts Department of Agricultural Resources
MDMH Massachusetts Department of Mental Health
MDPH Massachusetts Department of Public Health
MEMA Massachusetts Emergency Management Agency
MEMT Massachusetts Emergency Management Team
M.G.L. Massachusetts General Law
MHA The Massachusetts Hospital Association
MHOA The Massachusetts Health Officers Association
MIDS The Massachusetts Infectious Disease Society
MMS The Massachusetts Medical Society
MNA The Massachusetts Nurses Association
MRC Medical Reserve Corps
MRSA Methicillin-resistant S. Aureus
MSAR Massachusetts System for Advance Registration
MSNO The Massachusetts School Nurse Organization
NEDRIX New England Disaster Recovery Information Exchange
NIMS National Incident Management System
NNDSS National Notifiable Disease Surveillance System
NVSL National Veterinary Services Laboratory
OSHA Occupational Health and Safety Administration
PCR Polymerase Chain Reaction
PHLIS Public Health Information System
PIO Public Information Officer
PORT Patient Outcomes Research Team
PPE Personal Protective Equipment
PSI Pneumonia PORT Severity Index
REVB Respiratory and Enteric Viruses Branch
RMCC Regional Medical Coordinating Center
RSV Respiratory Syncytial Virus
RTD-PCR Real Time Detection
RVRS Registry of Vital Records and Statistics
SARS Severe Acute Respiratory Syndrome
SEOC State Emergency Operations Center
SLI State Laboratory Institute
SPN Sentinel Provider Network
UASI Urban Area Security Initiative
UMass University of Massachusetts
U.S.C. United States Code
USDA United States Department of Agriculture
VAERS Vaccine Adverse Event Reporting System
VIS Vaccine Information Statement
VNA Visiting Nurse Associations
WHO World Health Organization