Cantigny Conference 

State Emergency Health Powers 
and the Bioterrorism Threat

http://nationalstrategy.com/

April 26-27, 2001

Sponsored by:
The Centers for Disease Control and Prevention
American Bar Association Standing Committee on Law and National Security
The National Strategy Forum

Underwritten by:
Alfred P. Sloan Foundation

Reporters:
James J. Misrahi
Centers for Disease Control and Prevention
Matthew Foley
National Strategy Forum 

Executive Summary

On April 26-27, 2001, the Centers for Disease Control and Prevention, American Bar Association Standing Committee on Law and National Security, and the National Strategy Forum cosponsored a conference on "State Emergency Public Health Powers & the Bioterrorism Threat." Underwritten by the Alfred P. Sloan Foundation, the conference was held at the Cantigny Conference Center on Colonel Robert R. McCormick’s former estate in suburban Chicago. The conference discussed the role of state emergency public health powers in responding to bioterrorism—the use by terrorists of biological agents that have the potential to cause fatal or incapacitating diseases in a population.

The conference uniquely brought together six different groups that have not traditionally shared the same forum: public health attorneys, public health officers, non-profit organizations, national security attorneys, the national defense community, and academia. The conference focused on identifying what public health powers would be needed in a bioterrorism event; assessing the status of current emergency health powers, determining the gaps in such powers; and developing a framework for future action. The purpose of the conference was not to advocate the implementation of an overall federal solution, but rather, to discuss a grass-roots approach for improving emergency public health powers. The views expressed at the conference are those of the participants and not necessarily of the organizations with which they are affiliated. Conference participants reached the following broad conclusions:

• Many legal and regulatory authorities for responding to an emergency already exist. States must reexamine their health and emergency laws, particularly older laws that were passed 50-80 years ago.
• States may not be adequately prepared for responding to a event of bioterrorism. Public health officers may be unaware of legal authorities, lack access to expert legal advice, or may not be in communication with concerned organizations.
• States must identify gaps in authority and develop procedures for informed, rapid decisionmaking in a crisis. These procedures must be tested in exercises that include state public health officers, legal advisors, and emergency responders—including officials from neighboring jurisdictions.
• If a bioterrorism event occurs, an effective, well-rehearsed response will ensure public safety, and diminish the likelihood of panic that a terrorist may hope to cause.

In addition, conference participants recognized the need for further work in the following areas:

I. Legal Reform. Development of clear laws and understanding of law as a form of public health infrastructure.

• Analysis of existing legal authorities in order to improve the public health response to an emergency.
• Development of a model law with national experts.
• Coordination with academia to improve the public health infrastructure.
• Providing legal advice to the public health community and assisting public health officers to network with other professional organizations.
• Research into issues of immunity and indemnification at the federal and state level.

II. Legal Preparedness. Determining practices and procedures for areas where legal authorities are clear through the use of checklists, model laws, and draft executive orders.

• Drafting of executive orders to be used by political leaders in the event of bioterrorism.
• Improvement of public health regulations.
• Discussion with political leaders concerning indemnification of public health workers.
• Development of procedures to allow medical personnel to work across different jurisdictions.
• Analysis of gaps in current public health authorities among different jurisdictions.
• Inclusion of local government attorneys in discussions of bioterrorism.
• Development of a bioterrorism plan that references legal authorities and includes different interest groups.

III. Education and Training. Analyzing and correcting deficiencies revealed by exercises. Inclusion of lawyers in exercises and establishment of training standards.

• Organization of regional and state conferences on the bioterrorism threat.
• Clearer understanding of bioterrorism from an epidemiological perspective.
• Education on post-traumatic stress.
• Development of training exercises and evaluation of the results.
• Standardization of training exercises.
• Development of a program for civilian biodefense.

IV. Operations and Planning. Clear understanding of how emergency plans will be implemented, as well as roles and responsibilities of different key actors. Minimizing political and legal delays.

• Encouragement of state officials to study federal emergency powers.
• Interagency cooperation in developing a clear support role for the Department of Defense.
• Dissemination of information concerning resources of the Department of Defense.
• Clear communication between health officials and the public during a crisis.
• Discussion of the formation of an on-call emergency response team of experts with rotating membership.
• Development of programs and operations by a national network of public health experts.

V. Partnerships. Outreach to other professional communities such as law enforcement, emergency responders, and the media.

• Outreach to National Association of Governors.
• Discussion of public health response at the International Chiefs of Police Conference on Bioterrorism.
• Outreach to emergency response groups, e.g., police, fire, National Guard.
• Outreach to state governor’s legal staff.
• Elevation of the status of public health in the national security community.
• Network and organization of public health departments and lawyers.
• Development of a multi-disciplinary approach to respond to bioterrorism.
• Discussion of the bioterrorism threat at the American Bar Association Annual Convention.
• Outreach to political leaders at the state and local level.

Session One: In a Bioterrorism Event, What Public Health Powers are Needed?

Moderator: Elizabeth Rindskopf Parker, American Bar Association Standing Committee on Law and National Security

Overview: Gene Matthews, Centers for Disease Control and Prevention.

• This is a unique gathering of six different groups who have not traditionally collaborated: public health law attorneys, public health officers, non-profit organizations, national security attorneys, national defense community, and academia.
• This discussion is not intended to lead to a "big bang" federal approach, but rather to discuss a grass-roots approach for reviewing and improving emergency public health powers at the state and local level.
• Our goal is to develop the outline of an action plan to assist state and local health officers to review the legal powers needed in a bioterrorism emergency.

Federal Needs for State/Local Preparedness, Scott Lillibridge, Centers for Disease Control and Prevention.

• The term weapons of mass destruction has many different definitions; we will discuss agents that have the potential to create an epidemic among large populations without the use of additional weapons or perpetrators.
• The federal government is working to improve public health preparedness at the macro-level: efforts to increase early detection in state laboratories; funds to increase surveillance, training, and planning; establishment of a health alert network to facilitate communication.
• Issues for the federal government include: 1) manage information in an emergency, e.g., access to medical or other records that may be privileged, inter-agency sharing of records and information; 2) control of property, e.g., temporary closure of facilities, procurement of medicines and vaccines, rationing of medicines; and 3) control of persons, e.g., mandatory health examinations, implementation of quarantine, restrictions on public gatherings to prevent the spread of disease.

State & Local Health Perspective on Bioterrorism Role, Rex Archer, Kansas City Department of Health.

• There is a need for increased training and resources for state and local public health departments. Public health officers should have a higher profile within the political infrastructure and the public. Laws are meaningless without the practical ability to carry them out.
• Greater efforts are required in the areas of record collection and data sharing. States need to have clear procedures for reporting of diseases, collecting data on workplace absenteeism, and obtaining information from pharmacies. There is also a need to streamline licensing requirements for medical professionals across state lines. In addition, the practices of managed care organizations may impact negatively on disease surveillance; for example, by discouraging doctors from ordering confirmatory tests.
• Local health officers are authorized to control the use of property in a public health emergency. For example, public health officers may need to commandeer hotel rooms, which may be useful during an event because these rooms generally operate on separate ventilation systems. In addition, public health officers may have to commandeer drive-through facilities, such as those found at fast food restaurants, that could be used to dispense medicines in an emergency. While public health authorities are relatively strong, there is little practical experience in using compulsory measures, as they have not been needed for more than 50 years. Increased authority may be needed.
• Greater efforts are required with respect to management of persons. For example, few health facilities have the surge capacity to deal with a large number of casualties. In addition, the chain of command during a public health emergency must be clarified.

Discussion points and comments.

• Long history of using the power of government to control infectious disease. The history of using the power of government to control infectious diseases dates back to the Middle Ages. In the modern era, as the risk of infectious diseases began to decline (circa 1950), courts began to develop greater protections for individuals.
• Greater need for education of the public and health professionals. When people think of public health they tend to think more of Mother Teresa than Elliot Ness. But in an emergency, public health officers may need to give orders. Even many medical care practitioners don’t realize how public health and medicine fit into national security.
• Need to obtain the public’s trust. Compulsory public health measures require public trust. The public does not realize that more people are killed by infectious diseases than by accidents, or that the risk of a pandemic is greater than that of nuclear war.
• Need for polling and working with human relations experts. Polling and focus group evaluations should be conducted to find out whom the public will trust most in a crisis; for example, federal or state officials, military or civilian leaders, public health officers or law enforcement. Public health officers may use the results of such polling to better communicate with the public in times of crises. In addition, cultural and linguistic diversity must be taken into account as some communities may have greater mistrust of government.
• Legislative foresight and strengthening of legal infrastructure. There are two conflicting dangers that arise from an insufficient legal infrastructure: 1) overreaction, when, for example, the pubic becomes inflamed and pressures political leaders; and 2) underreaction, when public health officers fail to act because they believe that they lack sufficient legal authority or political support. Avoiding these dangers requires a prior legislative scheme. In an emergency, a sound legal basis for action will be particularly important.
• Enforcement authority needs to be clarified. This requires partnering with local law enforcement. In New York City, for example, every public health officer is also a "peace officer" and is accompanied by a police officer when enforcing a detention order for a tuberculosis patient.
• Experience with partnerships and collaborations. Public health officers operate mainly through partnerships and collaborations and have little experience in using coercive public health measures. Exercising such authority may require, for example, that public health officers carry badges identifying themselves. In addition, whether using coercive measures negatively impacts a public health officer’s ability to work cooperatively with the public or private industry needs to be discussed.
• Experience with coercive public health powers. Most public health interventions will be voluntary; however, statutory mechanisms need to be in place for dealing with uncooperative people. Public health officers have some experience in issuing quarantine orders for tuberculosis patients, nuisance abatement, and in closing hotels, restaurants, and schools for public health reasons. While these authorities may be exercised during a bioterrorism event, the magnitude and implementation will be completely different. In addition, different biological agents may necessitate different containment strategies.
• Certification of other doctors to perform duties of medical examiners. In many communities, a medical examiner may be the only person authorized to investigate and determine the cause of a suspicious death. In an emergency, other doctors may have to be certified to perform this function.
• Political issue. Response to a public health emergency, such as bioterrorism or a pandemic epidemic, will be widespread and quickly elevated to elected officials including the state governor. This is not strictly a public health issue, but also a political issue. Clear, open, and lawful response by government officials is necessary for public support and preservation of our national values. Rapid determination of the appropriate balance between coercive government action and individual civil rights is critical.

Session Two: What is the Status of Current Emergency Health Powers?

Moderator: Suzanne Spaulding, American Bar Association

Legal Overview, Larry Gostin, Georgetown University Law Center.

• States are the reservoirs of police powers. The federal government has broad authority under the Commerce Clause, but it may not generally commandeer the levers of state government. While there are a few exceptions, notably New York City, legal authorities to exercise emergency health powers are rarely local. Tribal governments are also sovereign entities and therefore must be involved in the process. Overlapping jurisdictions in a metropolitan area could cause confusion. Different levels of government must clarify which agency has the lead responsibility and authority.
• State laws dealing with public health arose through a piecemeal process and therefore are antiquated and overly specific. The present model focuses on detection (disease reporting, partner notification), identification (outbreak investigations, laboratory control), intervention (school-based vaccinations, directly observed therapy, quarantine), and deterrence (criminal statutes, civil confinement).
• Balanced against statutory authorities are constitutional constraints such as the due process requirements of notice and a fair hearing. There are also substantive laws which limit other statutory authorities, e.g., duty not to discriminate. During the last mass quarantine courts were highly suspicious and critical. A good example is Jew Ho v. Williamson, 103 F. 10, 24 (C.C.N.D. Cal. 1900), where a federal court ruled a quarantine imposed only in predominately Asian-American communities to be unconstitutional. Laws protecting individual rights appear to have superceded those preserving the "common good."

A "Traditional" State Law, John Chapin, Steven Marshall, and Dan Stier, Wisconsin Department of Health and Family Services.

• Wisconsin has had a public health statute since the founding of the State in 1848. Initially, public health was entirely local with authority vested in the local boards of health. Eventually, a state board of health was created with authority to enact statewide regulations for quarantine. In 1905, tuberculosis was specifically named as a disease of public health importance with a specific set of mechanisms to control the disease. While the statute was recodified in 1993, it remained a "traditional" public health statute.
• The key judicial opinions are very old and narrow. A 1909 opinion, for example, states that in order to control disease public health powers bordering on "despotism" are necessary.
• The current statute only addresses "communicable" diseases. There are no specific provisions dealing with bioterrorism or hoaxes. Furthermore, while there are regulations for dispensing drugs to tuberculosis patients, the statute does not address the issue of who may dispense drugs in the event of a mass-casualty event.

A "Newer" State Law, Dr. Richard Hoffman, Colorado Department of Health and Environment.

• Colorado passed a law in March 2000 that specifically addresses bioterrorism, pandemic influenza, and novel infections. The legislature enacted the law without controversy because the public health department was not seeking any additional authorities and required no funding. Rather, the law was designed to remove legal impediments to different groups working together.
• Under the plan, the Colorado Department of Health and Environment may require that hospitals, managed care organizations, and local health departments plan for a bioterrorism emergency. In exchange for filing an approved plan, these entities receive legal immunity. The definition of a "volunteer civil defense worker" was also changed to include a health care worker, thereby expanding eligibility for death benefits. Furthermore, additional regulations have been written authorizing the establishment of a command center, a communications network, and the purchasing of protective equipment for first responders. In addition, a committee was formed to prioritize the dispensing of vaccines among high-risk groups.
• Draft executive orders have been written authorizing the rationing of pharmaceuticals, suspension of licensing requirements for doctors and nurses, and confiscation of cellphones and other communication devices for use by emergency responders. The State compensates the owners for these takings.

Discussion points and comments.

• Gilmore Commission. This commission focuses on partnerships between and among health professionals, emergency responders, and legal experts. New York City is considered a model for informed partnerships demonstrated through training and exercises. The Gilmore Commission, among other things, has recommended the drafting of a model law.
• Intergovernmental Committee. An intergovernmental committee should include a range of both public and private professionals such as emergency room doctors and specialists in post-traumatic stress syndrome. Colorado’s intergovernmental committee includes the state attorney general and proved useful during the "Topoff" exercise.
• Legal resources. Not all public health departments will have the same access to legal resources. Notwithstanding, pre-prepared executive orders may be useful.
• Revising public health laws. There is a risk that revising public health statutes will lead the legislature to weaken, not strengthen, them as may occur with any law where different interest groups may conflict. Many issues, however, that can be addressed through legislation may also be addressed through executive order. While broad authorities may be desirable, practical exercises need to be performed to know how these authorities will work in a crisis situation and to identify any gaps.
• Investigative authorities not clear. Public health departments are unclear about using the resources of the private sector. Rules protecting patient confidentiality may impede public health surveillance. There is also a distinction between surveillance and research, the latter being governed by regulations for the protection of human subjects.
• Federal/State coordination. Many state public health officers are unaware of federal quarantine laws and other federal authorities. The surgeon general is also authorized to impose a quarantine in time of war.

Keynote Address: Dr. John Hamre, Center for Strategic and International Studies

• In the absence of an overarching struggle, the present era has witnessed the resurgence of old animosities. Today, there is either a war or a civil war in every time zone. These wars are particularly vicious, e.g., mutilation of children in Sierra Leone and narco-traffickers controlling large parts of Colombia. While none of these battles represent a direct threat to the United States, they undermine the concept of a stable international order. The era has also seen the emergence of international terrorists and other trans-national actors who have access to financial, technological, and military resources, e.g., Osama bin Laden, drug gangs in the former Soviet Union.

• In the past, terrorism was isolated, episodic, and incoherent; now the opposite is true, terrorism is coherent, organized, and skilled. The present era must deal with the residue of the past era, particularly the Cold War inventory of chemical and biological weapons. In addition, in producing these weapons, a knowledge base of how to build these weapons was also created. Today, there is a dangerous mix around the world of privation and knowledge.

• While we cannot eliminate the knowledge base relating to biological weapons, we can create economic diversions, for example, by getting scientists involved in positive research. As a nation, we should be more interested in eliminating the production capacity and stocks of biological weapons.

• Many consider biological weapons to be more dangerous than nuclear weapons because they can be used anonymously and it is more difficult to track the perpetrator.

• In the event of a terrorist attack, the government must respond effectively, or the public will become frightened and overreact, e.g., internment of Japanese-Americans after Pearl Harbor.

• Suggestions for how the United States can control the threat include: 1) stigmatizing ownership and use of biological weapons; 2) eliminating biological inventory of the Cold War; 3) pushing European allies on the issue of non-proliferation; 4) retooling intelligence system by thinking more along the lines of networking, e.g., attending international science conferences, rather than relying on satellite photographs; and 5) reconsidering the structure of deterrence, e.g., threatening nuclear retaliation in response to a biological or chemical attack is not credible.

• Policymakers need to inform the public about the danger of biological weapons. In general, there is great public skepticism that government can handle this issue responsibly.

Session Three: What are the Gaps?

Moderator: Marci Layton, New York City Department of Health

Legal Gaps, David Fidler, University of Indiana School of Law.

• Debate has focused on two positions: legal gaps and legal obstacles. The first position states that there are legal gaps in the substantive law, i.e., that existing health laws are outdated and need modernization to provide a solid legal foundation for responding to bioterrorism. The objective of this position is legal reform. The second position states that existing authorities are broad enough to encompass bioterrorism and that rather than reform existing authorities, we need to remove obstacles that interfere with our objectives. The objective of this position is legal preparedness. Both positions are valid.

• Colorado has examined its existing laws and developed strategies to remove obstacles to collaborations and increase input into the political framework. Every state should evaluate and make appropriate changes like Colorado. States should move ahead with legal reform or legal preparedness.

• There is a consensus that legal obstacles exist to the effective use of state emergency health powers, e.g., the federal government has problems getting information from state and local governments; federal privacy laws may unduly interfere with state action; and, state licensing requirements may interfere with emergency assistance offered by doctors and nurses from other jurisdictions.

Procedural Challenges to Taking Effective Action, Thomas Inglesby, Johns Hopkins Center for Civilian Biodefense Studies.

• Our objectives in the event of a bioterrorism incident are to minimize death and end the epidemic. In order to achieve these objectives, public health capacities are needed: detect an epidemic, confirm cases of disease, track cases in real time, coordinate and advise hospitals, administer public health interventions, communicate among health officers and the public, and manage scarce resources.

• Assuming that we have all of the necessary public health powers, there are still procedural challenges with which we must deal: 1) decision-making processes—deciding who will be the decision-maker, and making certain that elected officials have access to the experts; 2) public persuasion—offering the public explanations of the risk that are comprehensible and persuading them that the government is acting in their best interests; and 3) implementation—dealing with large casualties with which public health officers are not accustomed.

• We must proceed on parallel tracks, addressing both legal authorities and procedural challenges. This may require a change in the health care system which currently treats the individual patient with the highest regard and is less concerned with the public good.

Expertise and Skills Needed to Successfully Implement, Diana Bontá, California Department of Health Services.

• Public health departments don’t usually operate on a 24-hour basis. It will be difficult to sustain the level of expertise needed to respond to an emergency. In addition, there needs to be better coordination between public health and emergency medical services. It is not unusual for public health officers to work with members of hazmat teams.

• There needs to be a media strategy for public information and rumor control. Public health departments should consider establishing 1-800 numbers.

• There needs to be better coordination between law enforcement and public health officers. In particular, a plan needs to be in place for dealing with hoaxes and suspected releases of biological agents.

Discussion points and comments.

• Legal immunity and indemnification. The corollary of responsibility is liability; officials should not be afraid to exercise their authorities. Public health officers who develop plans to combat bioterrorism and proceed in good faith with those plans could be immunized or indemnified. While it may be possible to remove liability from planning, liability should not be inadvertently imposed if a plan is not followed through precisely—which often happens in an emergency. Policymakers should be wary about inadvertently creating a standard of care. In addition, qualified immunity only protects persons and not entities. The risk in granting immunity to those who develop plans is that those who do not develop plans and do not have immunity may be powerless in an emergency. States should also consider whether to provide immunity to volunteers who are "deputized" by public health officers to render medical assistance in an emergency.

• Balanced response. While it is important to remove obstacles to responding to a bioterrorism event, governmental structures that are designed to protect the individual, e.g., privacy laws, human subjects protections, should not be dismantled.

• Exercises. Exercises are a valuable tool for determining weaknesses in planning. The Topoff exercise helped Colorado in analyzing issues and framing a response. Joint Task Force—Civil Support (DOD) can be a valuable planning resource in helping states develop such exercises. Private consulting companies are also available to assist government agencies in training. More work needs to be done in developing standards for these exercises.

• Legal obstacles. In an emergency, public health officers may need to respond rapidly in order to contain an epidemic and save lives. Laws such as the Administrative Procedure Act (APA) or state "open meetings laws" may delay an emergency public health response. Many of these laws, for example, require that the board of health provide notice and an opportunity for a public meeting before acting. Many manufacturers, in developing vaccines, also require informed consent and duty to warn as part of their contracts.

• Broader planning. A bioterrorism event is not likely to be limited to one jurisdiction. Rather, a bioterrorism event will spread and should be considered a national security threat. Linking public health officers with emergency preparedness people is a good start; however, planning needs to take neighboring states and the Federal government into account.

• Federal response. In a bioterrorism event, the federal government will mobilize resources and tools to manage the event at a macro-level. Implementation at the local level, however, remains a key life-saving component. The federal government’s response to an event should prevent different jurisdictions from competing for scarce resources. The National Pharmaceutical Stockpile Program, for example, should find ways to further break down the quantity of pharmaceuticals sent to a particular jurisdiction to conserve resources that might be needed elsewhere.

Session Four: What are the Next Steps?

Moderator: Kathy Cahill, Centers for Disease Control and Prevention

Summary framework for improving and expanding public health response.

• Legal Reform. Need for clear laws and understanding of law as a form of public health infrastructure.

• Legal Preparedness. Process of determining practices and procedures for areas where legal authorities are clear through the use of checklists, model laws, and draft executive orders. Issues of liability and availability of legal resources among different health departments need to be resolved.

• Education and Training. Exercises are helpful, but they haven’t yet focused on the legal lessons learned. It is important that deficiencies revealed by exercises are analyzed and corrected. It is critical that lawyers be included in these forms of training. There needs to be some mechanism for establishing standards for these exercises.

• Operations and Planning. It is critical that the key actors understand their roles and responsibilities. There must be a clear understanding of how emergency plans will be implemented. Political and legal delay must be kept to a minimum.

• Partnerships. Now is the time for public health practitioners to begin building bridges to other professional communities such as law enforcement, emergency responders, and the media. Public health officers need to understand the public’s perception of disease outbreaks, and determine the best way to communicate with the public.

Future action items.

• Model laws.
• Exercises.
• Checklists.
• Training within the legal community.
• Outreach to ethics community.
• Communication and partnerships.
• Early warning systems.

Initiatives of Cantigny Working Group

• Rex Archer, Kansas City Department of Health. Will raise awareness of the bioterrorism threat and devote efforts to making the local public health officer a trusted member of the community. Will begin process of drafting executive orders for political leaders.

• Odyssias Athanasiou, City of Portsmouth Health Department. Will discuss bioterrorism threat with attorneys.

• Galen Beaufort, Kansas City Law Department. Will begin analyzing existing legal authorities in order to improve the public health response to an emergency.

• Diana Bontá, Department of Health Services. Will raise Cantigny meeting with National Association of Governors. Specifically, will address the possibility of creating an on-call emergency response team of experts with rotating membership.

• M.E. Spike Bowman, Federal Bureau of Investigation. Will encourage state officials to study federal emergency powers.

• Daniel Callahan, Office of the Attorney General of Illinois. Will discuss public health response at the International Chiefs of Police Conference on Bioterrorism.

• Julieann Casani, Maryland Department of Health & Mental Hygiene. Will focus on improving regulations, rather than drafting legislation.

• John Chapin, Wisconsin Department of Health & Family Services. Will begin reaching out to other emergency response groups, e.g., police, national guard, hazmat, and fire. Will discuss gender issues because in Wisconsin the majority of local health officers are women.

• Joni Charme, Department of Defense Joint Task Force Civil Support. Sole purpose of division is to provide assistance to the states. Will begin paving a legal role for clear DOD support. Will appeal for further inter-agency support.

• David Fidler, Indiana University School of Law. Will provide legal advice and assist in networking. Also will developing a law school course called "Weapons of Mass Destruction and the Rule of Law."

• Richard E. Friedman, National Strategy Forum. Need to gauge public reaction to the use of emergency powers for advance planning purposes; will organize regional and state conferences and draft state compacts.

• Richard Goodman, Centers for Disease Control and Prevention. Will work for a clearer understanding of the bioterrorism threat from an epidemiological perspective.

• Lawrence Gostin, Georgetown University Law Center. Will work with a group of national experts to help draft a model law. Will work with academia to improve the public health infrastructure.

• Richard Hoffman, Colorado Department of Health & Environment. Will pursue indemnification and offer sample draft executive orders. Will educate staff on issues of post-traumatic stress. Will conduct a training exercise using pandemic influenza as a model. Discussed the need for a web site.

• Cynthia Honssigner, Colorado State Health Department. Will look into federal laws and research issues of immunity and indemnification. Will outreach with state governor’s legal staff and National Association of Governors.

• Tom Inglesby, Johns Hopkins Center for Civilian Biodefense Studies. Will work to elevate status of public health among national security community and in state programs.

• Martha Katz, Centers for Disease Control and Prevention. Will follow-up with issues of communications and federal quarantine.

• Barry Kellman, DePaul University College of Law. Will begin building partnerships with outside organizations.

• Marci Layton, New York City Department of Health. Will begin to address inter-jurisdictional issues and work on executive orders and checklists.

• Wilfredo Lopez, New York City Department of Health. Will work more closely with legal staff and analyze Colorado regulations.

• Steven Marshall, Wisconsin Division of Public Health. Will work to develop a bioterrorism plan that references legal authorities and includes different interest groups, e.g., local health, managed care, hospitals, pharmacies, media, federal officials. Will work to develop a training exercise and evaluate the results.

• Gene Matthews, Centers for Disease Control and Prevention. Will continue to network and organize public health departments and lawyers.

• Kathy McDill, Department of Defense Joint Task Force Civil Support. Will disseminate information concerning resources of the Department of Defense.

• Clement McGovern, Department of Justice. Will encourage states to reach out to U.S. Attorneys’ Offices and the Federal Bureau of Investigation. Local officials, for example, should coordinate with federal officials to ensure that the victims of an event are not repeatedly interviewed by different law enforcement officers.

• Dan O’Brien, Maryland Department of Health & Mental Hygiene. Will begin outreach to National Association of State Attorneys General.

• Terry O’Brien, Will work on a multi-disciplinary approach towards the threat of bioterrorism.

• Paula Olsiewski, Alfred P. Sloan Foundation. Will begin developing a program for civilian biodefense.

• Elizabeth Rindskopf Parker, University of Wisconsin System. Will discuss Cantigny conference at American Bar Association Annual Convention.

• Robert Sullivan, City of Portsmouth, NH. Will work through professional organizations with municipal lawyers on the state and national level regarding a new national organization or association to increase awareness of the bioterrorism threat and the potential responses to that threat discussed at the conference.

• Dan Stier, Wisconsin Department of Health and Family Services. Will tap into a national network of public health experts to develop programs and operations.

• Kathleen Toomey, Georgia Department of Human Resource. Noted that public health has moved away from servicing a community to a position of regulation. Will work towards increasing the legitimacy of public health programs in the eyes of the public and facilitate the ability of public health officers to access needed tools and resources.

• Michael Wermuth, RAND. Will advocate the standardization of training exercises and the promulgation of a model law.

• Keith Yamanaka, California Department of Health Services. Will begin outreach to political leaders.

Appendix A:

Public Health Powers Needed by a Health Officer in a Bioterrorism Event

Collection of Records and Data.

• Reporting of diseases, unusual clusters, and suspicious events.
• Access to hospital and provider records.
• Data sharing with law enforcement agencies.
• Veterinary reporting.
• Reporting of workplace absenteeism.
• Reporting from pharmacies.

Control of Property.

• Right of access to suspicious premises.
• Emergency closure of facilities.
• Temporary use of hospitals and ability to transfer patients.
• Temporary use of hotel rooms and drive-through facilities.
• Procurement or confiscation of medicines and vaccines.
• Seizure of cellphones and other "walkie-talkie" type equipment.
• Decontamination of buildings.
• Seizure and destruction of contaminated articles.

Management of Persons.

• Identification of exposed persons.
• Mandatory medical examinations.
• Collect lab specimens and perform tests.
• Rationing of medicines.
• Tracking and follow-up of persons.
• Isolation and quarantine.
• Logistical authority for patient management.
• Enforcement authority through police or National Guard.
• Suspension of licensing authority for medical personnel from outside jurisdictions.
• Authorization of other doctors to perform functions of medical examiner.
• Safe disposal of corpses.

Access to Communications and Public Relations.

• Identification of public health officers, e.g., badges.
• Dissemination of accurate information, rumor control, 1-800 number.
• Establishment of a command center.
• Access to elected officials.
• Access to experts in human relations and post-traumatic stress syndrome.
• Diversity training, cultural differences, dissemination of information in multiple languages.

Appendix C:

Colorado Regulations Pertaining to a Bioterrorist Event

STATE OF COLORADO RULES AND REGULATIONS
PERTAINING TO PREPARATIONS FOR A BIOTERRORIST EVENT, PANDEMIC INFLUENZA, OR AN OUTBREAK BY A NOVEL
AND HIGHLY FATAL INFECTIOUS AGENT OR BIOLOGICAL TOXIN

IN 24-32-2103, C.R.S., EMERGENCY EPIDEMIC IS DEFINED AS CASES OF AN ILLNESS OR CONDITION, COMMUNICABLE OR NONCOMMUNICABLE, CAUSED BY BIOTERRORISM, PANDEMIC INFLUENZA, OR NOVEL AND HIGHLY FATAL INFECTIOUS AGENTS OR BIOLOGICAL TOXINS.

Regulation 1. PREPARATIONS BY LOCAL HEALTH AGENCIES FOR AN EMERGENCY EPIDEMIC

1 . EACH COUNTY AND DISTRICT HEALTH DEPARTMENT IN THIS STATE SUBJECT TO SECTION 25-1-501 ET SEQ, C.R.S., IS REQUIRED TO MAINTAIN AN UP-TO-DATE FAX LIST FOR AN EMERGENCY EPIDEMIC. THE FAX LIST SHALL INCLUDE GENERAL OR CRITICAL ACCESS HOSPITALS AND THE LOCAL EMERGENCY MANAGEMENT AGENCY WITHIN THE JURISDICTION OF THE LOCAL HEALTH DEPARTMENT. THE COUNTY OR DISTRICT HEALTH DEPARTMENT IS REQUIRED TO TEST THE FAX LIST BY A BROADCAST FAX AT LEAST TWICE PER YEAR.

2. EACH COUNTY AND DISTRICT HEALTH DEPARTMENT IN THIS STATE SUBJECT TO SECTION 25-1-501 ET SEQ, C.R.S., MUST SIGN BY DECEMBER 31, 2001 A UNIFORM MUTUAL AID AGREEMENT WITH ALL OTHER COUNTY AND DISTRICT HEALTH DEPARTMENTS THAT OBLIGATES THE COUNTY OR DISTRICT HEALTH DEPARTMENT TO RENDER AID DURING AN EMERGENCY EPIDEMIC UNLESS THE COUNTY OR DISTRICT HEALTH DEPARTMENT NEEDS TO WITHHOLD RESOURCES NECESSARY TO PROVIDE REASONABLE PROTECTION FOR ITS OWN JURISDICTION.

3. EACH COUNTY AND DISTRICT LOCAL HEALTH DEPARTMENT SUBJECT TO SECTION 25-1-501 ET SEQ., C.R.S., SHALL PREPARE A PLAN THAT THE AGENCY WILL IMPLEMENT WHEN THE GOVERNOR DECLARES A DISASTER EMERGENCY THAT IS THE RESULT OF AN OCCURRENCE OR IMMINENT THREAT OF AN EMERGENCY EPIDEMIC. THE PLAN SHALL BE SUBMITTED TO THE COLORADO BOARD OF HEALTH BY DECEMBER 31, 2001. IN ADDITION, THE COUNTY OR DISTRICT LOCAL HEALTH DEPARTMENT SHALL PROVIDE A COPY OF THE PLAN SUBMITTED PURSUANT TO THESE REGULATIONS TO THE LOCAL OFFICE OF EMERGENCY MANAGEMENT, TO ALL GENERAL OR CRITICAL ACCESS HOSPITALS, AND TO ALL REGIONAL EMERGENCY MEDICAL AND TRAUMA SERVICES ADVISORY COUNCILS WITHIN THE JURISDICTION OF THE LOCAL HEALTH AGENCY.

THE PLAN SHALL ADDRESS THE FOLLOWING AREAS:

1. ORGANIZATION AND ASSIGNMENT OF POTENTIALLY ALL EMPLOYEES OF THE AGENCY TO WORK ON CONTROLLING THE EMERGENCY EPIDEMIC;
2. HAVING SUFFICIENT SUPPLIES AND A PROCESS FOR THE PROVISION OF PERSONAL PROTECTIVE EQUIPMENT AGAINST BACTERIAL AND VIRAL INFECTIONS TO EMPLOYEES WHO ARE ASSIGNED TO WORK IN AREAS WHERE THEY MAY BE EXPOSED TO ILL AND CONTAGIOUS PERSONS OR TO INFECTIOUS AGENTS AND WASTE; PERSONAL PROTECTIVE EQUIPMENT SHALL, AT A MINIMUM, BE THE EQUIPMENT AND SUPPLIES USED TO ACHIEVE STANDARD PRECAUTIONS;
3. PROCUREMENT AND STORAGE OF AT LEAST FIVE DAYS SUPPLY OF DOXYCYCLINE TO BE USED AS CHEMOPROPHYLAXIS FOR ALL EMPLOYEES. THE PLAN SHALL INCLUDE PROCUREMENT OF ANOTHER ANTIBIOTIC FOR A SMALL NUMBER OF EMPLOYEES WHO MAY BE UNABLE TO TAKE DOXYCYCLINE;
4. AN EMERGENCY, AFTER-HOURS CALL-DOWN LIST OF PERSONS WHO MAY BE NEEDED TO ORGANIZE AND RESPOND TO AN EMERGENCY EPIDEMIC; SUCH LIST SHALL INCLUDE PERSONS WITH EXPERIENCE AND TRAINING IN COMMUNICABLE DISEASE EPIDEMIOLOGY;

E) CREATION OF A COMMAND CENTER WITHIN THE AGENCY FOR THE PURPOSE OF (i) CENTRALIZING TELEPHONE, RADIO, AND OTHER ELECTRONIC COMMUNICATIONS; (ii) COMPILING SURVEILLANCE DATA; AND (iii) MAINTAINING A LOG OF OPERATIONS, DECISIONS, RESOURCES, AND ORDERS NECESSARY TO CONTROL THE EPIDEMIC;

5. CREATION OF AT LEAST THREE TEAMS TO: (i) MONITOR THE SITUATION, INCLUDING INFECTION CONTROL, IN EACH HOSPITAL WITHIN THE AGENCY'S JURISDICTION, DOING THIS ON-SITE AS NECESSARY AND WITH ASSISTANCE FROM THE STATE HEALTH DEPARTMENT AS APPROPRIATE; (ii) ASSESS AND MANAGE INFECTION CONTROL IN THE COMMUNITY OUTSIDE OF THE HOSPITAL; AND (iii) ASSESS AND MANAGE, IN COORDINATION WITH HOSPITALS AND THE COUNTY CORONER, THE DISPOSAL OF HUMAN CORPSES;
6. THE ORGANIZATION, STAFFING, SECURITY, AND LOGISTICS OF THE DISTRIBUTION AND DELIVERY OF ANTIBIOTICS, ANTIVIRAL MEDICATIONS, VACCINES, OR OTHER MEDICATIONS NEEDED IN AN EMERGENCY EPIDEMIC FOLLOWING THE PROVISIONS OF STATE EMERGENCY FUNCTION #8;
7. IDENTIFICATION OF AT LEAST TWO PUBLIC SPOKESPERSONS RESPONSIBLE FOR PROVIDING INFORMATION TO THE CITIZENS OF THE STATE ABOUT HOW TO PROTECT THEMSELVES, WHAT ACTIONS ARE BEING TAKEN TO CONTROL THE EPIDEMIC, AND WHEN THE EPIDEMIC IS OVER; AND
8. IMPLEMENTATION OF A BACK-UP COMMUNICATIONS SYSTEM, SUCH AS 800 MEGAHERTZ RADIOS OR AMATEUR RADIO EMERGENCY SERVICES, THAT WILL BE USED TO COMMUNICATE WITH LOCAL EMERGENCY MANAGEMENT AGENCIES IF AND WHEN TELEPHONE COMMUNICATIONS ARE DISABLED OR NOT FUNCTIONING;

Regulation 2. PREPARATIONS BY GENERAL OR CRITICAL ACCESS HOSPITALS FOR AN EMERGENCY EPIDEMIC

1. EACH GENERAL OR CRITICAL ACCESS HOSPITAL IN THIS STATE IS REQUIRED TO MAINTAIN AN UP-TO-DATE FAX LIST FOR AN EMERGENCY EPIDEMIC. THE FAX LIST SHALL INCLUDE ANY SATELLITE CLINICS, ACUTE CARE FACILITIES, OR TRAUMA CENTERS OPERATED BY THE HOSPITAL; OFFICES OF PHYSICIANS AND HEALTH CARE PROVIDERS ON THE STAFF OF THE HOSPITAL, AS AVAILABLE; AND THE LOCAL HEALTH AGENCY SERVING THE COUNTY IN WHICH THE HOSPITAL IS LOCATED. THE HOSPITAL IS REQUIRED TO TEST THE FAX LIST BY A BROADCAST FAX AT LEAST TWICE PER YEAR.

2. EACH GENERAL OR CRITICAL ACCESS HOSPITAL IN THIS STATE SHALL PREPARE A PLAN THAT THE HOSPITAL WILL IMPLEMENT WHEN THE GOVERNOR DECLARES A DISASTER EMERGENCY THAT IS THE RESULT OF AN OCCURRENCE OR IMMINENT THREAT OF AN EMERGENCY EPIDEMIC. THE PLAN SHALL BE SUBMITTED TO THE COLORADO BOARD OF HEALTH BY DECEMBER 31, 2001. IN ADDITION, THE GENERAL OR CRITICAL ACCESS HOSPITAL SHALL PROVIDE A COPY OF THE PLAN SUBMITTED PURSUANT TO THESE REGULATIONS TO THE LOCAL HEALTH AGENCY, THE LOCAL OFFICE OF EMERGENCY MANAGEMENT, AND THE REGIONAL EMERGENCY MEDICAL AND TRAUMA SERVICES ADVISORY COUNCIL IN THE COUNTY IN WHICH THE HOSPITAL IS LOCATED.

THE PLAN SHALL ADDRESS THE FOLLOWING AREAS:

1. ORGANIZATION, ASSIGNMENT, REASSIGNMENT, AND ALTERATION OF NORMAL WORK SCHEDULES OF ALL MEDICAL STAFF AND ALL EMPLOYEES OF THE HOSPITAL WHO MAY BE CALLED ON TO WORK DURING AN EMERGENCY EPIDEMIC;
2. HAVING SUFFICIENT SUPPLIES AND A PROCESS FOR THE PROVISION OF PERSONAL PROTECTIVE EQUIPMENT AGAINST BACTERIAL AND VIRAL INFECTIONS TO ALL STAFF AND EMPLOYEES WHO ARE ASSIGNED TO WORK IN AREAS WHERE THEY MAY BE EXPOSED TO ILL AND CONTAGIOUS PERSONS OR TO INFECTIOUS AGENTS AND WASTE; PERSONAL PROTECTIVE EQUIPMENT SHALL, AT A MINIMUM, BE THE EQUIPMENT AND SUPPLIES USED TO ACHIEVE STANDARD PRECAUTIONS;
3. PROCUREMENT AND STORAGE OF AT LEAST FIVE DAYS SUPPLY OF

1. DOXYCYCLINE TO BE USED AS CHEMOPROPHYLAXIS FOR ALL EMPLOYEES. THE PLAN SHALL INCLUDE PROCUREMENT OF ANOTHER ANTIBIOTIC FOR A SMALL NUMBER OF EMPLOYEES WHO MAY BE UNABLE TO TAKE DOXYCYCLINE;

1. AN EMERGENCY CALL-DOWN LIST OF OFF-DUTY OR RETIRED HEALTH CARE PROVIDERS WHO MAY BE ASKED TO WORK OR VOLUNTEER AS NEEDED TO RESPOND TO AN EMERGENCY EPIDEMIC;
2. CREATION OF A COMMAND CENTER WITHIN THE HOSPITAL FOR THE PURPOSES OF: (i) CENTRALIZING TELEPHONE, RADIO, AND OTHER ELECTRONIC COMMUNICATIONS; (ii) COMPILING MORBIDITY AND MORTALITY DATA INCLUDING THE NUMBER OF PATIENTS, NUMBER OF AVAILABLE BEDS, AND NUMBER OF WORKING STAFF AND EMPLOYEES; (iii) RECEIVING AND RESPONDING TO EXECUTIVE ORDERS OF THE GOVERNOR REGARDING THE EMERGENCY EPIDEMIC; AND (iv) MAINTAINING A LOG OF OPERATIONS, DECISIONS, AND RESOURCES NECESSARY TO MAINTAIN OPERATIONS DURING THE EPIDEMIC;
3. CREATION OF AT LEAST TWO TEAMS TO ASSESS AND MANAGE: (i) INFECTION CONTROL WITHIN THE HOSPITAL; AND (ii) IN COORDINATION WITH LOCAL HEALTH DEPARTMENTS AND THE COUNTY CORONER, THE DISPOSAL OF HUMAN CORPSES;
4. SECURITY OF THE HOSPITAL FACILITY NECESSARY TO CONTROL LARGE AND UNRULY CROWDS;
5. RAPID TRANSPORT OF HUMAN DIAGNOSTIC SPECIMENS TO THE STATE LABORATORY;