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     Virginia Department of Health
Social Distancing Legal Consultation
          Situation Manual

          October 9, 2007
 Crowne Plaza Hotel Richmond West
         Situation Manual
                                            FOR OFFICIAL USE ONLY

                                    TABLE OF CONTENTS
Subject                                                                                                                   Page
Introduction ................................................................................................................... 1
      Background .............................................................................................................. 1
      Purpose ................................................................................................................... 1
      Scope ...................................................................................................................... 1
      Objectives ................................................................................................................ 2
      Exercise Structure and Format ................................................................................ 3
      Expected Outcomes ................................................................................................. 4
      Roles and Responsibilities ........................................................................................ 5
      Assumptions and Artificialities ................................................................................. 5
      Exercise Guidelines ................................................................................................. 6
      Representatives ....................................................................................................... 7
      Workgroups ............................................................................................................. 8
      Additional Resources ................................................................................................ 8
Agenda .......................................................................................................................... 9
Background on Influenza ........................................................................................... 10
      Basic Information ................................................................................................... 10
      Influenza Pandemics ............................................................................................. 10
      Avian Influenza A (H5N1) ...................................................................................... 11
Initiating Events (Fictional) ........................................................................................ 12
Movement Restriction - Workgroups......................................................................... 15
      Group A - Fact Pattern ........................................................................................... 15
      Group A – Discussion ............................................................................................ 16
      Group B - Fact Pattern ........................................................................................... 21
      Group B – Discussion ............................................................................................ 22
      Group C - Fact Pattern .......................................................................................... 26
      Group C – Discussion ............................................................................................ 27

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Movement Restriction – Plenary Session ................................................................. 30
Mass Prophylaxis – Plenary Session ........................................................................ 31
     Fact Pattern ........................................................................................................... 31
     Discussion ............................................................................................................. 31
Miscellaneous Legal Issues – Plenary Session ....................................................... 33
     Fact Pattern ........................................................................................................... 33
     Discussion ............................................................................................................. 33
Appendices .................................................................................................................. 36
      Directions to the Crowne Plaza Hotel Richmond West .......................................... 37
      Map to the Crowne Plaza Hotel Richmond West ................................................... 38
      Instructions for Travel Reimbursement ................................................................. 39
      Participant Comment Form .................................................................................... 41
      Acronyms and Abbreviations ................................................................................. 42
      Acknowledgements ............................................................................................... 46
      Key Code of Virginia Social Distancing Statutes .................................................. 47

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In order to improve legal preparedness for public health threats presented by commu-
nicable conditions such as pandemic influenza, the Centers for Disease Control and
Prevention (CDC) and the Association of State and Territorial Health Officers (ASTHO)
implemented the Social Distancing Law Project (SDLP). Eighteen states, including Vir-
ginia, were invited to participate in Phase I of the SDLP, consisting of a comprehensive
assessment of social distancing and other disease control measures at the state and
local level. Phase I was completed in late July 2007.

Thirteen states, including Virginia, have additionally been requested by the CDC and
ASTHO to participate in Phase II of the SDLP: a Legal Consultation Meeting (LCM) to
bring together legal counsel, law enforcement experts, state and local agencies, judges,
and other relevant stakeholders such as community leaders and businesses to address
legal issues related to public health emergencies. In addition to assisting in emergency
preparedness in Virginia, the results of the meetings in each of the participating states
will be compiled by the CDC and ASTHO to characterize national legal preparedness.


The Virginia Social Distancing Legal Consultation Meeting will bring together key stake-
holders to address the current status of legal preparedness in the Commonwealth re-
lated to social distancing and other disease control measures (e.g., isolation, quaran-
tine, curfew, closure of public places, mass prophylaxis, etc.). Participants will identify
and discuss necessary enhancements to preparedness efforts for public health emer-
gencies resulting from communicable conditions. Proposals for policy changes by state
agencies or legislative resolutions by the General Assembly may also be considered.


The Social Distancing Legal Consultation Meeting builds on past legal preparedness
successes, such as the Community Based Emergency Response System (CBERS)
trainings, as well as the Virginia FluEx‟07 Cabinet TTX and the Office of the Attorney
General‟s TTX. This one-day conference will use structured dialogue to further explore
relevant laws, regulations, and processes for social distancing in response to a public
health emergency such as an influenza pandemic. The feasibility of successfully apply-
ing law-based social distancing measures in a pandemic will be explored, and any
areas of legal preparedness that warrant further attention will be addressed.

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This process will emphasize the need for communication, collaboration, coordination,
problem identification and resolution, and is designed to be an open, thought-provoking
exchange of ideas to assist the Commonwealth in evaluating overall preparedness, re-
sponse, and recovery capabilities.

This conference cannot review all aspects of pandemic influenza planning, or some of
the practical issues involved in a pandemic response. The scope is focused on ad-
dressing legal issues around the core legal concerns of social distancing and outbreak
response, such as restriction of movement (e.g., isolation, quarantine), closure of public
places, curfew, mass prophylaxis, inter-jurisdictional and interagency cooperation, and
federal orders, although practical considerations (e.g., staffing shortages, limited deten-
tion space, etc.) may play a role in these areas. Other legal issues, such as the ability
to compel individuals to fulfill essential roles, the ability to alter standards of care, is-
sues related to closure of schools, etc. are important issues that may be covered at a
later date.


Exercise objectives are related to improving participants‟ understanding of response
concepts and identifying good practices as well as areas for enhancement. The Social
Distancing Legal Consultation Meeting focuses on the following objectives identified by
the Centers for Disease Control and Prevention (CDC):
   Explore Virginia laws and regulations related to social distancing and other disease
    control measures, including but not limited to:
      o   Isolation
      o   Quarantine
      o   Curfew
      o   Cancellation of public events
      o   Closure of public places
      o   Travel restrictions
      o   Mass prophylaxis
   Engage participating officials in considerations related to social distancing measures
    as part of a response to a communicable disease of public health threat;

   Provide an orientation on roles and responsibilities in a major communicable
    disease outbreak;

   Explore participants‟ opinions/attitudes on the viability and sufficiency of legal
    authorities to implement social distancing measures for the restriction of movement
    of individuals, and to close public places or limit/prohibit large gatherings of people,
    in the event of an influenza pandemic;

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   Identify problems that could arise in executing social distancing measures, including
    procedural, logistical, ethical, or enforcement issues; and,

   Identify additional steps related to legal preparedness that warrant further attention.

Exercise Structure and Format

The Virginia Social Distancing Legal Consultation Meeting TTX is scheduled for Octo-
ber 9, 2007 from 08:30 a.m. until 4:30 p.m. It will be conducted at the Crowne Plaza
Hotel Richmond West, in Richmond, Virginia.

Given the limited time available to discuss such a wide range of issues involved in legal
aspects of social distancing, and to optimize the expertise that has been generously vo-
lunteered, the Legal Consultation Meeting will utilize scenario-based, facilitated group
discussion initiated and driven by presentations and this situation manual (SITMAN).
Scenarios are provided as context for the discussion and to highlight issues, but in
many cases there will be need to explore areas not directly incorporated into the scena-

For some aspects of social distancing, issues require specific expertise – these will be
discussed initially in smaller workgroups, each led by a Group Facilitator. This will ena-
ble focusing on details and tasks of relevance for particular fields. For this exercise,
three workgroups have been developed (see Workgroup Assignments, below).

At the start of the workgroup discussion, participants will be introduced to a specific
scenario, and discuss the key issues. Some issues have been identified from previous
meetings, and are provided to guide discussion. They may highlight pertinent issues for
consideration, and serve as a catalyst for the group discussions to meet exercise objec-
tives. Participants are not required to answer every question, nor are they limited
to these topics. The results of these discussions will be briefly summarized during a
follow-up plenary session – Group Facilitators will identify 3-5 key issues, challenges,
gaps, or priority areas for further discussion. In addition, any areas that may be of gen-
eral interest and require further deliberation during the plenary session will be pre-

For other aspects of social distancing, especially where overlap of responsibility occurs,
discussion during a plenary session can address the critical issues. Interaction among
participants is strongly encouraged to promote communication and better inte-
gration of response activities.
Participants will consider the duties and responsibilities of their organizations in ad-
dressing the various issues raised by the scenario. Participants are encouraged to use
existing plans, but also to think freely and to suggest better solutions as they are identi-
fied. The discussion period offers the chance to recognize gaps, overlaps, and incon-

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sistencies in planning efforts, and good practices. Participants are encouraged to focus
on developing the best possible response through joint problem identification, coordina-
tion, innovation, resolution, and the effective integration of capabilities.

A final session has been included to prioritize areas that remain to be explored and
areas for enhancements captured during the exercise.

Participants are encouraged to use this manual as a reference throughout the exer-
cise, as well as any other documentation useful to them (e.g., the Code of Virginia,
Virginia Administrative Code).

Expected Outcomes

As a result of this exercise, participating individuals will be able to identify:
   The appropriate legal tools that may be employed to delay and/or ameliorate the
    onset of a public health threat related to a communicable disease.

   Challenges to the implementation of the legal tools for the control of public health

   The roles and responsibilities of involved agencies for the control of a
    communicable disease of public health threat.

   Areas for collaboration and communication between different agencies.

   The potential impact of increased hearings related to the management of public
    health emergency and the impact on courts, especially with reduced workforce

   Legal and law enforcement issues related to public vaccine/antiviral administration.

   Issues related to the development and distribution of public messaging.

As a result of these efforts, the Virginia Department of Health, the Virginia Office of the
Attorney General, and the Centers for Disease Control and Prevention will be better
able to implement appropriate legal responses for the management of a communicable
disease of public health threat.

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Roles and Responsibilities

Players respond to the situation presented based on expert knowledge of response
procedures, current plans and procedures, and insights derived from training and expe-

Group Facilitators provide situation updates and moderate discussions. They also
provide additional information or resolve questions as required. Key planning team
members will also assist with facilitation as Subject Matter Experts (SME) during the
tabletop exercise.

Data Collectors will not participate in the discussion periods, but will be present for the
duration of the exercise in workgroups and plenum sessions gathering data and writing
notes about the players‟ responses in order to provide feedback for the Legal Consulta-
tion Meeting report.

Observers support the functional groups in developing responses to the situation in the
caucus sessions; however, they do not participate in the moderated discussion period.

Assumptions and Artificialities

In any exercise, a number of assumptions and artificialities may be necessary to
complete play in the time allotted. During the exercise, the following assumptions and
artificialities apply:

   The scenario is plausible, and events occur as they are presented.

   There are no wrong answers or solutions.

   There are no “hidden agendas” or trick questions.

   All players receive information at the same time.

   In the interest of time, do not overly debate the public health/medical, political, or
    societal merits of any decision or recommendation to enact a social distancing
    measure. Assume that the public health official and/or governor has decided that it
    is in the public‟s best interest to move forward with any or all of the social distancing
    options to contain the spread of disease. The majority of the effort should be
    focused on:

       Can it be done (legally) and the degree of confidence that it will prevail during a
        legal challenge?

       Who has the authority to order the measure, and how would it be accomplished?

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       What are the enforcement challenges that must be considered?

       Are there legal options or alternatives (e.g. different means to an end)?

       What are the legal ramifications that must be considered in dealing with the
        consequences of mandating social distancing countermeasures? This includes
        constitutional rights issues such as freedom of association, equal protection, and
        due process.

   Participants should assume that all jurisdictions are implementing their current
    plans, procedures, and protocols. The existing Code of Virginia and Virginia
    Administrative Code (Regulations) are in effect.

   Pandemic preparedness is built on all-hazards planning principles.

   State agencies will work with public and private partners to coordinate preparedness
    and response efforts designed to reduce the number of people who may become ill
    or die, and to minimize the economic and community impact of a pandemic.

   Federal, state, and local governments will not be able to address all pandemic
    needs or meet all resource requests. Responsibility for preparing for and
    responding to a pandemic spans all sectors. In addition to government entities,
    healthcare, business, faith-based organizations, schools and universities, volunteer
    groups, and individuals have critical roles to play in pandemic preparedness.

   Sustained human-to-human transmission anywhere in the world will be a triggering
    event to initiate a pandemic response by federal, state, and local officials.

Exercise Guidelines

   This is not a test. Varying viewpoints, even disagreements, are expected. This is
    intended to be an open, relaxed environment.
   Respond based on your knowledge of current laws, regulations, policies, and
    procedures, and insights derived from training and experience.
   Decisions are not precedent-setting and may not reflect your organization‟s final
    position on a given issue.
   This is an opportunity to discuss and present multiple options and possible
   Issue identification is valuable; however, suggestions and recommended actions
    that could improve response and preparedness efforts are even more important.
    Problem-solving efforts should be the focus.

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   Assume cooperation and support from other responders and agencies. Feel free to
    interact with other agency representatives and get answers when needed.
   The scenarios, written material, and resources are the basis for discussion. There
    are no situational injects.
   Applicable federal laws and regulations will not be reviewed in detail, but may be
    explored as they apply to state and local legal preparedness.
   School closure, while a potential social distancing tool, will not be included in this


As of October 5, 2007, representatives from the following agencies/organizations have
been confirmed:

       American Red Cross
       Association of State and Territorial Health Officers (ASTHO)
       City and County Attorneys
       Commonwealth Attorneys
       D.C. Department of Health
       Local Police
       Maryland Department of Health and Mental Hygiene
       Metropolitan Washington Airports Authority (MWAA)
       Sheriffs
       Supreme Court of Virginia
       US Centers for Disease Control and Prevention (CDC)
       US Department of Health and Human Services (DHHS)
       Virginia Capitol Police
       Virginia Department of Agriculture and Consumer Services (VDACS)
       Virginia Department of Education
       Virginia Department of Health (VDH)
       Virginia General Assembly
       Virginia Hospital and Healthcare Association (VHHA)

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       Virginia National Guard (VNG)
       Virginia Office of the Attorney General (OAG)
       Virginia Poverty Law Center (VPLC)
       Virginia State Police (VSP)


As noted above, the Legal Consultation Meeting has been designed to address specific
gaps and challenges that have been identified in legal aspects of social distancing me-
thods in Virginia. As such, scenarios and discussion questions focus on both broad
issues as well as very, very specific concerns. To this end, participants have been
grouped into specialty areas that will be able to apply specific expertise to the issues
that the scenarios raise.

These specialty groups will be:
   Group A – Judges, commonwealth attorneys, and legislators, representatives of the
    Attorney General, city and county attorneys, and private attorneys

   Groups B and C – Public health/healthcare/education, law enforcement/military,

There are also issues of common interest, or of overlapping responsibility. These will
be addressed in the plenary sessions.

Name badges will identify an individual‟s assigned workgroup.

Additional Resources

You are encouraged to bring plans and procedures to the exercise that may be neces-
sary to assist you in your decision-making efforts. This Situation Manual (SITMAN) will
also contain additional information on which to base your discussions. As you partici-
pate, draw on your experience and knowledge of how federal, state, local, private sec-
tor and volunteer organizations work together in an emergency response situation.

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                                   EXERCISE AGENDA
                Virginia Social Distancing Legal Consultation Meeting
                           Crowne Plaza Hotel Richmond West
                                      October 9, 2007
    Time                           Activity                                Leader
 8:00 – 8:30    Registration (continental breakfast provided)
 8:30 – 8:40    Welcome                                           Dr. Lisa Kaplowitz
                General Introduction                              Virginia Department of Health

 8:40 – 8:45    Administrative and Safety Remarks                 Christopher Novak, MD, MPH
                                                                  Virginia Department of Health
 8:45 – 9:00    Participant Introductions                         Suzi Silverstein
                                                                  Virginia Department of Health
 9:00 – 9:15    Exercise Purpose, Scope, and Guiding Principles   Suzi Silverstein
                Exercise Ground Rules
 9:15 – 9:45    Virginia Social Distancing Statutes and Regula-   Robin Kurz
                tions (Review)                                    VA Office of the Attorney
 9:45 – 10:00   Tabletop Exercise – Background and Situation      Christopher Novak, MD, MPH
10:00 – 10:10   Break
10:10 – 11:00   Restriction of Movement - Work Groups             Group Facilitators
                  Isolation and Quarantine
                  Curfew
                  Closure of Public Places
11:00 – 12:00   Restriction of Movement Discussion – Plenary      Suzi Silverstein
12:00 – 1:00    Lunch (provided)
 1:00 – 1:10    Mass Prophylaxis – Laws and Regs                  Robin Kurz
 1:10 – 2:00    Mass Prophylaxis – Plenary Session                Suzi Silverstein
 2:00 – 2:15    Miscellaneous Issues – Laws and Regs              Robin Kurz
 2:15 – 3:15    Miscellaneous Issues – Plenary Session            Suzi Silverstein
                  Inter-jurisdictional Cooperation
                  Interagency Cooperation
                  Virginia Enforcement or Assistance with
                    Federal Orders
                  Public Health State of Emergency
 3:15 – 3:30    Break (refreshments provided)
 3:30 – 4:00    Practical Issues Regarding Movement Restriction   Dr. Lisa Kaplowitz
 4:00 – 4:30    Future Efforts/Closing Remarks                    Dr. Lisa Kaplowitz
    4:30        Adjourn

   Please return Participant Comment Forms prior to your departure.

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                           BACKGROUND ON INFLUENZA


Influenza ("the flu") is a viral infection of the lungs. There are two main types of influen-
za virus: A and B. Each type includes many different strains that tend to change each
year. In the US, influenza occurs most often in the late fall and winter months.

Symptoms usually appear 1-3 days after exposure, and can include a sudden onset of
headache, fever, chills, cough, sore throat, and body aches. Although most people are
ill for less than a week, some people have complications and may need to be hospita-

Anyone can get influenza, but it is most serious in the elderly, in people with chronic ill-
nesses, or those with weak immune systems. Influenza spreads very easily, usually
through contact with droplets from the nose and throat of an infected person during
coughing and sneezing. The contagious period probably begins the day before symp-
toms appear and extends for a week.

Influenza Pandemics

An influenza pandemic is a global outbreak of influenza that occurs when a new in-
fluenza A virus appears in the human population, causes serious illness, and then
spreads easily from person to person worldwide. Pandemics are different from sea-
sonal outbreaks of influenza since they are caused by new virus subtypes, subtypes
that have never circulated among people, or subtypes that have not circulated among
people for a long time. Past influenza pandemics have led to high levels of illness,
death, social disruption, and economic loss. For example, the 1918 pandemic killed
over 20 million people worldwide. In the US, future influenza pandemics could cause
between 89,000 and 207,000 deaths and the economic impact could range from $71
billion to $166 billion, not including disruptions to commerce and society.
Compared to many types of disasters, pandemic influenza will have unusual effects:
      The pandemic will last much longer than most other emergency events and may
       include “waves” of influenza activity separated by months;
      The numbers of healthcare workers and first responders available to work can be
       expected to be reduced (they will be at high risk of illness through exposure in
       the community and in healthcare settings, and some may have to miss work to
       care for ill family members).
      Resources in many locations could be limited because of how widespread an in-
       fluenza pandemic would become.

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Just a few other potential problem areas that have already been identified include: 1)
shortages of intensive care beds, ventilators, and other critical care items; 2) shortages
of antiviral agents and antibiotics for treatment of secondary bacterial infections; 3) a
need for ancillary or “non-traditional” treatment centers”; and 4) high demand for social
and counseling services.

Avian Influenza A (H5N1)

In late June 2004, deadly outbreaks of influenza A (H5N1) among poultry were reported
by several countries in Asia (Cambodia, China, Indonesia, Malaysia, Thailand, and
Vietnam). It is believed that these outbreaks are ongoing.

Human cases of influenza A (H5N1) infection have occurred recently in Thailand, Viet-
nam, Cambodia, and Indonesia during large H5N1 outbreaks in poultry. The mortality
rate for these reported cases has been about 50 percent. Most of these cases oc-
curred from contact with infected poultry or contaminated surfaces.

The transmission of H5N1 virus from person to person has been rare and spread has
not continued beyond one person. However, because all influenza viruses have the
ability to change, H5N1 virus could one day acquire the ability to infect humans and
spread easily from one person to another. Since these viruses do not commonly infect
humans, there would be little or no immune protection against them in the human popu-
lation. If the H5N1 virus were able to infect people and spread easily from person to
person, then an “influenza pandemic” could begin.

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                        INITIATING EVENTS (FICTIONAL)

Global Situation

Health officials and organizations around the world remain on high alert because of in-
creasing concerns about the prospect of an influenza pandemic. In mid-June 2007,
several hundred cases of severe respiratory illness in humans were identified in South-
east Asia. Most cases were associated with exposure to backyard poultry and/or
processing operations, though there has been some limited human-to-human transmis-
sion. Viral cultures collected from several of the patients were positive for type A in-
fluenza virus. Isolates were sent to the World Health Organization (WHO) and the Cen-
ters for Disease Control and Prevention (CDC). The CDC determined that the isolates
were type A H5N1.

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Isolates of the influenza strain were sent to the National Institute of Health (NIH) to
begin work on producing a reference strain for vaccine production. Influenza vaccine
manufacturers were placed on alert.
Key United States government Period                 Phase Phase Description
officials have been briefed as                               Humans become infected with a
surveillance intensified throughout                          new virus subtype, but there is no
Southeast Asia and the Pacific Rim.                    3
                                                             or very limited human-to-human
In mid-September, cases appeared
in Hong Kong, Singapore, South Pandemic                      Small clusters of localized out-
Korea, and Japan. Cases were              Alert        4     breaks with limited human-to-
reported in all age groups and                               human transmission
fatality rates approached 45%.                               Larger clusters of a novel influen-
Vaccine is not yet available and                       5     za strain appear, although human-
supplies of anti-viral drugs are                             to-human spread is still localized
limited to stockpiles created to date (hospital, state, and federal).

On Monday, 10 September 2007, the World Health Organization (WHO) adjusted their
pandemic influenza phase from Phase 4 to Phase 5, suggesting that the virus is be-
coming increasingly better adapted to humans. There are increasing reports in the me-
dia that sustained, efficient human-to-human transmission of H5N1-related influenza
has been occurring in Ho Chi Minh City, Vietnam.

The clinical features of the H5N1-related disease appear to be consistent with classical
influenza, with the exception of rapid progression to lower respiratory tract disease in a
higher percentage of symptomatic cases. The incubation period appears to be longer
than with traditional influenza and is currently estimated to be 2-9 days with a median of
four days. The case fatality rate (CFR) of hospitalized cases has been >30%.

The number of hospitalized cases in Southeast Asia is approaching 1,000. The number
of asymptomatic sub-clinical and mild infections remains unknown. There are conflict-
ing reports on the efficacy of antiviral drugs, with more than one institution reporting at
least moderate resistance to oseltamivir (Tamiflu®). However, in an effort to slow the
spread of the virus, the WHO has deployed a large pandemic influenza containment
team for targeted anti-viral prophylaxis. The containment team leader has estimated
the chances of containment as “less than 50 percent.”

In the US, the Centers for Disease Control and Prevention (CDC) agree with the WHO‟s
assessment that we are in Phase 5. The National Strategy for Pandemic Influenza Im-
plementation Plan has been activated. The Department of Health and Human Services
(DHHS) is the lead agency for the medical and public health response, the Department
of Agriculture (USDA) has the lead for the veterinary response, the Department of State
(DOS) will handle international activities, and the Department of Homeland Security
(DHS) is responsible for overall incident management and coordination. The DHHS

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and CDC have instructed individual states to make final preparations to their pandemic
influenza response plans, to include possible utilization of Tamiflu ® stocks in the stra-
tegic national stockpile.

For the past month, the CDC Quarantine Stations have implemented the passenger
screening and quarantine procedures in an attempt to slow entry of the pandemic flu
virus into the United States. Arriving passengers who are ill with symptoms compatible
with influenza are isolated until they are considered no longer infectious or until labora-
tory tests can rule out infection with the H5N1 virus. Passengers with identified expo-
sures are quarantined for 10 days.

                                        Between October 6 and October 8, 2007 five
                                        people traveling from Southeast Asia were iden-
                                        tified with symptoms of influenza by customs of-
                                        ficials at international airports in Paris, London,
                                        and Tokyo. H5N1-related infection was con-
                                        firmed in two of the passengers held in London.
                                        Worldwide, media outlets reported the news and
                                        The Washington Post headline on October 9
                                        reads “People with Bird Flu in UK” in 1.5” print.
                                        An unprecedented media assault is launched on
                                        the American public, the public health sector,
                                        and companies promoting materials claiming to
                                        prevent or treat the “bird flu.”

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Group A - Fact Pattern

On October 7, 2007, a 21 year old resident of Fairfax, Virginia returned from Ho Chi
Minh City, Vietnam to Dulles International Airport, accompanied by his grandparents
(nationals of Vietnam). Despite developing respiratory symptoms the next day, which
he ascribes to seasonal allergies, he participates in a gathering of his extended family
and a large group of friends to celebrate his grandparent‟s 50th wedding anniversary.
More than 100 guests, from across Virginia and three additional states, attend.

As his symptoms worsen, the individual seeks medical care through a local emergency
department. By now, he is exhibiting signs of severe pneumonia and acute respiratory
distress, with conditions worsening by the hour. With his travel history, suspicion of in-
fection with influenza A (H5N1) is high – preliminary testing suggests his illness is due
to influenza A virus.

Public health begins to identify contacts of this patient - as many as 36 people from the
party (including members of the Vietnamese Consulate) have begun to develop respira-
tory symptoms consistent with influenza infection.

Although many participants of the party are making reasonable efforts at cooperating
with public health efforts to reduce the risk of transmission, some (due to language or
cultural barriers, or individual circumstances) are potentially at risk for transmitting the
virus. Orders of isolation or quarantine are necessary to improve compliance with pub-
lic health recommendations. In addition, the index case‟s grandparents are scheduled
to return to Vietnam – although they do not have symptoms of illness, they may be in-
cubating an infection.

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Group A – Discussion

                               Isolation and Quarantine

General issues:
  Are there any general or specific issues related to isolation or quarantine of individ-
  uals that are apparent at this point?

Specific issues:

      As illness spreads and new cases emerge, enforcement of isolation and quaran-
       tine orders could strain courts, which may not themselves be able to maintain
       normal levels of operation (e.g., due to illness).
          o   What capacity do courts have to handle a large number of cases? To
              what extent can civil matters be postponed while dealing with large num-
              bers of isolation/quarantine cases? What measures exist to address staff-
              ing shortages if staff are out due to illness or increased staff are needed
              to address an increased workload? To what extent could distance work-
              ing and administrative leave assist your agencies?
          o   The Code of Virginia gives the court the right to consolidate cases, but
              would a large number of cases filed individually initially be problematic?
          o   The Rules of the Supreme Court permit the court to accept pleadings
              electronically. Is this mechanism in place? Who should the Attorney
              General‟s Office call to set up a hearing? What if the disaster impacted
              communication – are there alternate methods of communication available
              (e.g., faxing or e-mailing documents)?
          o   Who would be appointed as defense counsel? What if attorneys are ill or
              engaging in “self-shielding” behavior? Can service/appearance be com-
          o   Since use of these statutes and regulations is exceptionally rare, there is
              limited defense counsel with experience in these areas (and these may be
              further reduced by illness or self shielding activities). As a result, there
              are uncertainties related to the availability and training of defense counsel
              to adequately ensure due process in such a situation. What should be
              done to improve awareness?
          o   Are there issues of maintaining security at the court under these circums-

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          o   What measures exist to protect the court, including but not limited to, or-
              dering the hearing to be held by telephone or video conference, or order-
              ing those present to take appropriate precautions, including wearing per-
              sonal protective equipment?
          o   What if the court is contaminated – are/could alternate sites be made
              available? Can courts operate in a decentralized/off-site environment?
              To what extent could court processes be met through conferences using
              current technology? Would these conferences be open to the public?
          o   What other plans/options could be developed or are in development to
              address operational and logistic issues for the courts that result from such
              a situation?
      Is the Supreme Court prepared to use expedited review provisions? How would
       a panel of justices be assembled in an emergency? Would an alternate meeting
       site be available, if necessary? Can the Supreme Court be the point of contact if
       a circuit court is closed?
      What measures are available to address the impact of reduced availability of
       Commonwealth attorneys? Have alternate work sites been considered? Are
       there emergency contact plans where Commonwealth attorneys can be reached
       if the office is closed? Is help available from other jurisdictions?
      Criminal prosecution may be the most persuasive way to enforce isola-
       tion/quarantine and executive orders. Would Commonwealth‟s Attorneys make
       these cases a relative priority?
      What methods may be used, or may need to be developed, to address the Sixth
       Amendment (right to a speedy trial) in the event that law enforcement, correc-
       tions, and court functions are impaired?
      What evidence would be necessary to support the health department contention
       that an individual may be infected with the virus? Will limitations in the ability to
       ensure appropriate chain of custody of specimens (e.g., clinical test results in
       hospitals or healthcare facilities) be a critical component in an appeal?
      When ordering isolation or quarantine, VDH is responsible for ensuring that the
       individual‟s essential needs are met to the extent practicable (Code of Virginia
       32.1-48.07). What are potential liabilities related to applying movement restric-
       tions and addressing the expected needs of the restricted individuals?
      VDH may need to utilize mass media (e.g., newspaper, television, radio, internet,
       text mail, reverse 911, etc.) to notify those in affected areas or large groups,
       mass method(s) of communication may be used. By statute, persons subject to
       such an order must receive a copy of § 32.1-48.013 or § 32.1-48.010 (as appro-
       priate) of the Code of Virginia. Would it be adequate to direct persons to a loca-

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       tion, a website, or publication such as a newspaper, where they may obtain this
       information? Could an individual‟s contention that they were not aware of the or-
       der, or did not receive a copy of § 32.1-48.013 or § 32.1-48.010, be used in an
      By definition (Code of Virginia § 32.1-48.01) a communicable disease of public
       health significance, and (Code of Virginia § 32.1-48.06) a communicable disease
       of public health threat are due to infectious agents. However, communicable
       diseases may potentially be caused by non-infectious agents (e.g., polonium-210
       exposure/contamination). Under this circumstance, other tools would need to be
       developed to address restrictions of movements for these situations. Sugges-
      The State Health Commissioner may seal orders only if the information would
       “exacerbate the public health threat or compromise any current or future criminal
       investigation or compromise national security.” These provisions do not include
       the authority to seal the orders to protect the general privacy of the individual.
       Aside from sealing the information on the basis that the public health threat may
       be exacerbated by a reluctance of infected individuals or contacts presenting as
       a result of privacy concerns, this does make protection of the privacy of individu-
       als more difficult.
          o   Are there any potential resolutions to protect patient privacy?
          o   Can the Privacy Act be rescinded in a Pandemic situation? How so and
              under what conditions? What are some potential Federal repercussions?
      No specific penalties exist for violating voluntary isolation or quarantine (e.g.,
       recommendations by the director of a district health department) exist. However,
       could an individual who is aware that they are or may be infected with a commu-
       nicable and who intentionally violates voluntary isolation or quarantine be found
       to be criminally and/or civilly liable?
          o   Are there legal issues related to an infected individual who intentionally
              transmits infection (e.g., consider as battery/homicide/bioterrorism)?
      Are there issues with a lack of liability protection under sovereign immunity for
       physicians who are state employees (e.g., could health directors be held respon-
       sible for illness or death resulting from recommendations for prioritization of ser-
      What penalties, if any, could be applied to state employees who refuse to show
       up for essential work due to a fear of infection? Is this different if they are caring
       for ill individuals? What rewards/incentives (recognition, bonuses, commenda-
       tions) could be used to encourage individuals to work?

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      Some individuals may not be subject to state civil orders. The application of or-
       ders to foreign nationals with diplomatic immunity may be problematic (22
       USC254 et seq.). Comments?
      Are there issues with restricting the movement of individuals between states, and
       thereby impeding trade and commerce? How could this affect the movement of
       products (e.g., poultry) that could potentially transmit infection?
      Travel may be restricted, or individuals may be unwilling to expose themselves
       unnecessarily to the risk of infection. As a result, normal functions (such as pub-
       lic meetings) may need to be adjusted.
          o   What needs to be done to address FOIA laws pertaining to electronic
              meetings, quorums, and public meeting requirements at the state and lo-
              cal levels?
          o   What legislative processes may be needed to suspend meeting notice re-
          o   Can state and local leaders conduct meetings in a decentralized environ-
              ment using available communications technologies? Would these meet-
              ings be open to the public?
      Would this situation meet the legal definition for a communicable disease of pub-
       lic health threat? Why or why not?
      It is unclear how long an order of quarantine could be in effect when applied to
       an affected area: the Code of Virginia (§ 32.1-48.08) specifies the duration of the
       order as “consistent with the known incubation period for such disease or, if the
       incubation period is unknown, for a period anticipated as being consistent with
       the incubation period for other similar infectious agents”. However, for those
       within the affected area, where new cases and new exposures may be occurring
       on an ongoing basis, the application of a specific incubation period to any single
       individual may be problematic. In this situation, how can the termination date on
       the quarantine order for the affected area be appropriately defined?
      Is there any need or ability to contemplate the use of:
          o   Code of Virginia § 37.2-1104 - temporary detention of individuals who are
              incapable of making an informed decision regarding treatment and where
              the medical standard of care calls for testing, observation, or treatment of
              the disorder.
          o   Code of Virginia § 37.2-808 - emergency detention of individuals with
              mental illness, who are a risk to themselves or others, and who are unwil-
              ling to volunteer for necessary hospitalization or treatment.

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      What ability does the Commonwealth and localities have to apply a curfew to
       address public health emergencies? What challenges would be faced in imple-
       menting and enforcing curfews?
      Would there be a role for martial law to manage a state of emergency in the

                                 Closure of Public Places
      Preventing access to property as part of an abatement of a blight could be con-
       sidered a seizure, and might be challenged under the US Bill of Rights (Amend-
       ment IV) protection against unreasonable search and seizure. Would closure of
       public places be considered a form of taking of private property?
      What are the problems that might occur in restricting “mass gatherings” (e.g., a
       suitable definition, situations where may be difficult to apply, liability to state for
       financial loss, etc.)?
      How can just compensation for government use of property be determined?
      To what extent does limited access to public places, and reduced ability for nor-
       mal operations, affect the ability of agencies to meet Freedom of Information Act
       (FOIA) requirements?

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Group B - Fact Pattern

Public health‟s best efforts have slowed, but not stopped, the transmission of the in-
fluenza A H5N1 virus, and cases are being diagnosed in the U.S. Several well-
attended public events have occurred over the past few weeks, contributing to the
spread of influenza virus in Virginia. The state‟s syndromic surveillance system show
increases (by as much as 30%) in the number of individuals seeking emergency care
for influenza-like illness throughout the state (although this is difficult to separate from
normal seasonal increases in respiratory illness, as well as the impact from the „wor-
ried-well‟). Animal surveillance has also detected cases of influenza A H5N1 in wild
birds across the region – this is occurring due to transmission among migrating birds
where species mingle.

A local turkey farm (with close to 1,000,000 birds and more than 30 employees, includ-
ing several undocumented workers) recently reported finding nu-
merous dead geese on the property. Despite precautions, turkeys
on the farm are beginning to appear ill, and in the past few days,
several workers have reported influenza-like illness. Although
these individuals have been prevented from coming into work
while ill, the managers are concerned that other employees, and
more birds, may be incubating illness. The farm is requesting as-
sistance in ways to restrict access onto (and off of) the facility,
recommendations for managing employees and flocks to prevent
further spread, and treatment or prophylaxis for both birds and humans. There are se-
rious concerns that a farm-wide infection could result in a catastrophic loss of birds, a
loss of income for the employees, and decreased tax revenue by the town. The infec-
tion could also spread to other farms, affecting productivity for the region.

JT is a 20 year old 2nd year Agriculture student at the University of Virginia in Char-
lottesville, VA. She and her classmates recently participated in a field trip to local poul-
try farms and processing plants. She has reported to student health with a flu-like ill-
ness for one day. She has a fever, and a rapid flu test is positive for influenza. JT has
a plane ticket for the next day to visit her family in Colorado and she refuses to post-
pone the trip to allow for a proper evaluation (she is preparing to leave in the morning to
go to Reagan International to catch her flight).

The university had already been exploring ways to restrict movement on and off of the
campus. Mechanisms were in place to cohort staff/students to slow the spread of influ-
enza onto campus, as well as between students if infection does occur. College admin-
istrators are also working with the local town where the campus is located to co-ordinate
with a planned curfew (no public meetings anytime, with limited access to public places
by citizens between 7 pm and 7 am).

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Group B - Discussion

                                Isolation and Quarantine

General issues:
  Are there any general or specific issues related to isolation or quarantine of individ-
  uals that are apparent at this point?

Specific issues:
      Is law enforcement willing to arrest someone for noncompliance with an order of
       isolation/quarantine if the officer does not witness the actual noncompliance
       (e.g., it is reported by a neighbor)?
      What concerns would officers have regarding the detention of someone with a
       communicable disease?
      How should law enforcement communicate with local health departments to ob-
       tain information on personal protective equipment (PPE)? Is there an expecta-
       tion by law enforcement that PPE will be provided by the local health depart-
      The court can order the isolation or quarantine of an individual in the person's
       home or another's residence or an institution or other place, including a jail,
       when no other reasonable alternative is available. What are the practical con-
       siderations for enforcing such restrictions of movement?
      Are plans in place to provide health department staff as witnesses for trial to give
       expert testimony on the etiology of disease, as well patient‟s non-compliance?
      Significant efforts have gone into developing the most efficient process (e.g.,
       pre-written orders, detailed guidance for health department staff, etc.) for devel-
       oping orders of isolation and quarantine. Nevertheless, time for the preparation,
       review, transmittal, and delivery of orders of isolation or orders of quarantine will
       be necessary (exercises suggest at least 3-6 hours). During this period, law en-
       forcement has expressed concerns over their authority in detaining individuals.
       Alternatives, such as developing statutes to enable short term detention by law
       enforcement for known or suspected infection with a communicable disease may
       be problematic. What options may need to be considered?
      Law enforcement in Virginia have been uncertain regarding the level of physical
       force that is appropriate to detain an individual in violation of an order of isolation
       or quarantine. However, it may be impossible to dictate in advance how much

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       force can be used. A determination of reasonable force is a factual determina-
       tion to be made by the jury. What else could be done to address this?
      From the Code of Virginia, it is unclear if communicable diseases of public health
       threat are absolute, or that the designation is situational (e.g., a condition may be
       a communicable disease of public health significance in some circumstances,
       but a threat in others…although it is recognized that some conditions are more
       likely to be considered threats). This may impact available options. For exam-
       ple, Code of Virginia § 32.1-48.02 F states that the provisions of the article “shall
       only apply to communicable diseases of public health significance and shall not
       apply to communicable diseases of public health threat.” If communicable dis-
       eases of public health threat are absolute (i.e., a condition always is, or never is),
       does this mean that the ability to use the methods under a communicable dis-
       ease of public health significance DO NOT exist when considering such condi-
       tions. Or is this a safety, where it means that the provisions in Code of Virginia §
       32.1-48.02 do not limit management of a communicable disease of public health
       threat? Could a situation exist where some individuals need to handled as in-
       fected with a communicable disease of public health significance, while others
       are „threats‟ (e.g., due to their particular circumstances)?
      By definition (Code of Virginia § 32.1-48.01) a communicable disease of public
       health significance, and (Code of Virginia § 32.1-48.06) a communicable disease
       of public health threat are due to infectious agents. However, communicable
       diseases may potentially be caused by non-infectious agents (e.g., polonium-210
       exposure/contamination). Under this circumstance, other tools would need to be
       used to address restrictions of movements for these situations. Suggestions?
      Is Code of Virginia § 3.1-729, providing the State Veterinarian with the power to
       „quarantine‟ persons exposed to animal and poultry diseases that may be trans-
       mitted by such persons to animals or poultry if the State Veterinarian determines
       that such quarantine will prevent the spread of such diseases among livestock or
       poultry, adequate?
      What methods may be used to reduce the risk to animals, or the transmission
       from humans to animals (and vice versa)? What laws and regulations apply for
       the control of poultry to prevent transmission and reduce the impact on flocks?
      What role does the control of companion animals play in a public health re-
       sponse? Are these considered property (that may be seized)?
      Who is responsible for controlling potentially infectious companion animals (e.g.,
       birds)? Are these considered property, with issues related to seizure?
      Can interstate/cross border travel be suspended? Are in-state travel restrictions
       legal? How would this affect business (travel industry, movement of supplies

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       and materials)? What measures would be needed to ensure that essential travel
       (e.g., transport of fuel, food, medical supplies) can continue?
      When ordering isolation or quarantine, the district health department is required
       to manage the isolation or quarantine, in conjunction with local emergency man-
       agement resources, such that individual essential needs can be addressed.
       Family, friends, and/or neighbors of individual placed in isolation/quarantine, as
       well as formal aid agencies (e.g., Red Cross, faith-based programs, Social Ser-
       vices, etc.) may be significant resources in caring for individuals. However, the
       actual implementation may strain resources, while „failing‟ (or allegedly failing) to
       meet these obligations may severely undermine the effectiveness of restriction of
       movement. What public health-community/business partnerships could be de-
       veloped to further support efforts to reduce transmission?

      Any general or specific issues related to the application of a curfew to the control
       of communicable disease (e.g., practicality, enforceability, etc.)? What is the
       likely effectiveness of curfew in reducing transmission of influenza? Or is its
       main role likely to be as a tool for maintaining public order and safety, thereby
       freeing up limited resources?
      What are some potential options for minimizing the impact of curfew on individu-
      What are some options for minimizing the impact on communities/businesses
       (e.g., extended hours, infection control, staff, supplies)?
      Can curfew be imposed that allows only essential personnel to leave home?

                                Closure of Public Places
      Can law enforcement enforce public gathering restrictions?
      Code of Virginia § 15.2-926 enables a locality to develop ordinances to prohibit
       loitering in, upon or around any public place, whether on public or private proper-
       ty. While this is a relatively weak form of closure (i.e., individuals could access
       public places as long as they were not „loitering‟), is it possible that it could be
       adequate to reduce the risk of transmission under some circumstances with less
       adverse impact. Would this be useful/practical?
      Quarantine in Virginia is applied to individuals – individuals within an Affected
       Area may be subject to quarantine. However, is there a need for the Common-
       wealth to have the ability to declare a so-called „area quarantine‟ (i.e., restriction
       of access into/out of a location – a „cordon sanitaire‟) – or would this be ade-
       quately covered by Governor‟s order for controlling movement? (Note: this

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       should be considered for conditions in addition to influenza, such as anthrax re-
      Does law enforcement have the capacity to manage a quarantine of an affected
       area or the closure of a public place?
      What authority will the Governor give to DMA/VNG with respect to enforcing pro-
       hibitions on public gatherings?

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Group C - Fact Pattern

Public health‟s best efforts have slowed, but not stopped the spread of the influenza A
H5N1 virus, and increasing numbers of cases are being diagnosed in Virginia. The
state‟s syndromic surveillance system show increases (by as much as 30%) in the
number of individuals seeking emergency care for influenza-like illness throughout the
state (although this is difficult to separate from normal seasonal increases in respiratory
illness, as well as the impact from the „worried-well‟).

Public education campaigns are occurring across the state.
Outbreaks have been reported in a variety of institutions, in-
cluding Corrections facilities, Congregate Care facilities, etc.
More people are seeking medical care than actually need it
due to fear about the new strain of the virus. Citizens are up-
set that a vaccine specific to the pandemic strain is not availa-
ble, and will not be for a long time. People are confused be-
cause a vaccine for the regular seasonal flu is being provided.

Antivirals, which have shown limited effectiveness, are recommended for the treatment
of ill individuals at the highest risk of developing complications and death. Hospitals are
becoming overwhelmed by the number of individuals presenting with influenza. Hospit-
als and other healthcare facilities are short-staffed with many physicians, nurses, and
other healthcare workers absent due to illness, caring for family members, or simply in
fear of their safety. Hospitals are discharging patients earlier than they would normally,
and are canceling elective surgeries and services. Medical clinics are forced to close
as they do not have the staff available to provide services to their patients. They are
recommending that those seeking care report to the hospital ER.

Hospitals and primary care centers try to manage the costs associated with treating a
large number of people and paying staff for extended operational hours. Payment for
those individuals who have no insurance but require long-term care is an issue. These
facilities also face possible medical malpractice litigation from individuals that feel that
they were treated unfairly. Hospitals will have to apply for financial assistance to try to
mitigate expenses.

The Governor recommends closing areas where significant public gathering and mixing
occurs, such as malls, sports complexes, and theaters. However, business owners are
concerned about the loss of revenue from closures, and want to know what types of as-
sistance will be available for recovering from the economic loss.

Grocery stores are already reporting shortages of food supplies due to the impact of the
illness on truckers and distribution chains. Reports of outdated dairy products and

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meats are already being received by VDH, along with reports of diarrhea type illness.
Some people respond to the shortage of medications by breaking into pharmacies and
pharmaceutical warehouses to steal medications. Business owners have been calling
police requesting increased security.

High absenteeism rates are expected in all areas of the public and private sector over
the coming days and weeks. Police, fire and EMS are reporting a reduced ability to re-
spond to calls due to increasing volume as well as staff absenteeism, and Corrections
facilities as well as local jails are severely understaffed, creating a concern with regard
to the ability to handle the inmate population. Shortages in the public works and energy
infrastructure are likely to result in the loss of critical services, and there is concern
about being able to maintain the state‟s IT services. Questions about prohibitions on
social gathering and school closures are mounting.

There has been a marked decline in economic activity and tourism around Virginia.
Many restaurants and other businesses in the Commonwealth have had to close,
putting a number of people, especially low-income earners, out of work.

Group C - Discussion

                               Isolation and Quarantine

General issues:
  Are there any general or specific issues related to isolation or quarantine of individ-
  uals that are apparent at this point?

Specific issues:
      Do hospitals have a procedure to limit hospital access to a small number of mo-
       nitored entrances so that patients and visitors entering the facility can be
       screened for illness (e.g., temperature checks)?
      Do hospitals have a procedure to monitor staff and volunteers for symptoms and
       a policy for “fitness for duty” procedures?
      Do hospitals plan on ensuring safe transportation routes and infection control
       procedures (e.g., patients wearing masks) when transferring patients though the
       hospital (i.e., from ED to inpatient units)?
      Do hospitals have a plan to adjust staff schedules to meet the needs of the re-
       sponse including:
          o   Reassigning staff who have recovered from flu to care for flu patients?

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          o   Reassigning staff at high risk for complications of flu (e.g., pregnant wom-
              en, immunocompromised persons) to low risk duties (e.g., no flu patient
              care or administrative duties only)?
      What would be the need for legal waivers (e.g., restaurant and regulatory inspec-
       tions)? Can/should staff licensing credentials be relaxed to allow inspections by
       personnel not normally assigned to do so? To what extent/in what areas?
      What personal and professional liability do health care providers have related to
       prioritization of care/services/medication/equipment? Discuss issues related to
       potential suits for wrongful death and negligence, and what needs to be done to
       enable healthcare facilities can operate in this environment.
      What authority does local law enforcement have to detain individuals in a public
       health emergency when the incident is not applicable to the isolation and quaran-
       tine process? What length of time is reasonable to maintain the detention?
      What would be some guidance on a “return to work note” requirement? Would
       guidance on self-evaluation of return to work health readiness be practical?
      What are healthcare concerns regarding the state‟s ability to take private proper-
       ty in an emergency (e.g., hospital supplies, such as masks/respirators, antivir-
      How would the receipt of mass prophylaxis or vaccination affect orders or other
       restrictions of movement (e.g., curfew, closure of public places)? This might de-
       pend on the ongoing evaluation of effectiveness of the medication/vaccine.
       However, documented receipt of vaccine or other countermeasures may render
       those individuals immune to injury from the agent – therefore, the applicability of
       movement restrictions may no longer be justified. A similar issue concerns the
       management of individuals who have had the illness and are no longer infec-
       tious, as they may be immune and could safely resume activities.

      Any general or specific issues related to the application of a curfew to the control
       of communicable disease (e.g., practicality, enforceability, etc.)? What is the
       likely effectiveness of curfew in reducing transmission of influenza? Or is its
       main role likely to be as a tool for maintaining public order and safety, thereby
       freeing up limited resources?
      What impact would curfew have on healthcare operations, the ability of patients
       to seek care, etc.?
      What are some potential options for minimizing the impact of curfew on individu-

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      What are some options for minimizing the impact on communities/businesses
       (e.g., extended hours, infection control, staff, supplies)?
      Can curfew be imposed that allows only essential personnel to leave home?

                                Closure of Public Places
      Quarantine in Virginia is applied to individuals – individuals within an Affected
       Area may be subject to quarantine. However, is there a need for the Common-
       wealth to have the ability to declare a so-called „area quarantine‟ (i.e., restriction
       of access into/out of a location – a „cordon sanitaire‟) – or would this adequately
       covered by Governor‟s order for controlling movement? (Note: this should be
       considered for conditions in addition to influenza, such as anthrax release).
      How can agencies balance the need to minimize travel (especially if curfews or
       closure of public places is in place) while continuing to provide essential servic-

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Review the following questions in their entirety and discuss your group’s major con-
cerns at this point in the exercise scenario. Participants are not required to address
every question in this section.

Additional Issues:

      What Constitutional rights issues have been identified? Are there specific con-
       cerns regarding freedom of association, equal protection, due process, etc.?
      Are there additional issues related to the management of private property? How
       can just compensation for government use of property be determined?
      What additional resources does your agency have to address these situations?
      What operations/essential services will me most heavily impacted by an influen-
       za pandemic?
      What do you need to assist in monitoring and responding to the situation?
      What emergency safeguards (e.g., human resource policies) would be imple-
       mented at this point, and how? Who will you need to inform of those decisions,
       and how will enforcement be achieved?
      What control measures would be put in place for Executive staff to decrease the
       risk of staff becoming ill?
      What would be the most important public messages for your agency at this time
       (e.g., change in hours or procedures)? How would this information be dissemi-

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Fact Pattern

Although antivirals have shown limited effectiveness, they have
been recommended for treatment of ill individuals at the high-
est risk of developing complications and death. Certain high
priority groups are also receiving antivirals to prevent infection
(prophylaxis). These priority groups have been developed
based on an evaluation of criticality to Virginia infrastructure.
However, there remains a very limited supply – and distribution
is difficult due to security issues.

Vaccine manufacturers have now produced approximately fifty million doses and Virgin-
ia has been allotted one million doses or enough to vaccinate about one-seventh of the
population. Virginia will continue to receive an additional 500,000 every three months
for the next year equating to an additional two million doses. These are being distri-
buted though various local initiatives.


Review the following questions and discuss your major concerns regarding the use of
mass chemoprophylaxis and vaccination to prevent the further transmission of pandem-
ic influenza. Participants are not required to address every question in this section.

      With regard to vaccines and antivirals:
          o    What are the ethical and legal issues on distribution of limited supplies?
          o    Who determines vaccine and antiviral priority groups?
          o    How will you communicate the priority group decision to the public and
               promote uniform acceptance across the state?
          o    What storage and transportation control plans exist to support vaccine
               and antiviral distribution?
      What legal authority does the state have to require a specific private sector re-
       sponse to state resource requests (e.g., prioritization of antivirals)? Does an
       Memorandum of Understanding have to be pre-arranged? Can the Governor di-
       rect the use of private resources? Can the state seize antivirals or vaccine for
       use (Code of Virginia § 44-146.17)? What are the potential functional and legal

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      What civil rights issues exist (e.g., whether or not to prioritize US citizens over
       undocumented or foreign individuals) for receipt of resources?
      Antiviral and vaccine prioritization – is there liability for the state in assigning
       priority groups? Is there legal protection for persons/agencies making and priori-
       tizing vaccine/anti-viral allocation decisions? Is there liability for healthcare in fol-
       lowing (or not following) guidelines?
      If an individual NOT under an order of quarantine or isolation refuses prophylaxis
       for a possible exposure, then depending on the likely risk of exposure (e.g.,
       presence within an affected area, versus general risk) would exceptional cir-
       cumstances exist where the State Health Commissioner might need to order iso-
       lation or quarantine until such time as the individual is no longer considered a
      Do hospitals have plans to manage dispensing antiviral medications to staff
       (mass vaccination/mass prophylaxis plan) and in administering vaccines (when
      The Virginia State Police reports complaints on the sale of counterfeit vaccine
       and antivirals, unsubstantiated claims for treatments, price gouging on medica-
       tions, re-sale of PEP received from state by higher priority group individuals to
       others, etc. What can be done to address this issue, and by what agency?
      What storage, transportation, and distribution control legal issues exist in regards
       to vaccine and antivirals (e.g., security, traffic control, adverse reactions, pre-
       scribing oversight)?
      Some agency Annexes provide direction to "[b]egin evaluating critical service de-
       livery in context of resources available and risk." Have agency essential services
       been prioritized?
          o   For example, will the Transportation sector suspend manual toll collection
              and DMV Customer Service Center operations, and will Interstate Rest
              Areas close?
          o   Will legally required programs that normally involve social interaction be
          o   Will waivers be enacted to support delivery of critical goods/services (e.g.,
              CDL hours, HOV lane use)?

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Fact Pattern

                             Terrorists see the potential chaos, and the ready availability
                             of a serious infectious disease, as an opportunity. On a
                             flight from London, England to Dulles International Airport,
                             three young male passengers with varying levels of febrile
                             illness are identified by the crew – one, in a state of deli-
                             rium, makes various threats against Americans.

The flight crew calls ahead to Dulles for instructions, and is directed to land and taxi to
a secure location.


      How would the potential terrorists need to be managed, both physically (to pre-
       vent further transmission) and legally (potentially infected with a communicable
       disease of public health threat, and resistant to control measures such as isola-
      How would the other passengers be managed, including providing security, clini-
       cal assessment, and the potential for quarantine (including orders of quaran-

               Inter-jurisdictional Cooperation/Interagency Cooperation
      Code of Virginia § 32.1-48.014 specifically authorizes, pursuant to 42 U.S.C. 264
       et seq. and 42 C.F.R. Parts 70 and 71, any order of quarantine or isolation is-
       sued by the Director of the Centers for Disease Control and Prevention affecting
       the Commonwealth or the Metropolitan Washington Airports Authority to be en-
       forced by local law-enforcement officers or officers of the Metropolitan Washing-
       ton Airports Authority with jurisdiction over the facility involved in the quarantine
       or isolation order. Any issues/concerns with this?
      Are there any foreseeable gaps/barriers in the application of state and federal
       public health laws to multi-jurisdictional entities (e.g., airports such as Dulles and
       Reagan National), cross-jurisdictional situations (e.g., Tribal lands, districts bor-
       dering on other states or D.C., non-U.S. citizens, etc.), federal facilities (e.g.,
       federal prisons, military bases, national parks), and diplomats/foreign nationals?

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      Who is the primary authority for direct communications with neighboring states
       on response and containment efforts?
      Practical barriers do exist in terms of the transmittal of protected health informa-
       tion. For example, in order to protect patient confidentiality the electronic trans-
       fer of documents containing protected health information is limited by the Virginia
       Department of Health to within the e-mail system (i.e., behind the firewall). Al-
       though protected health information may be transmitted to others, including
       those outside the VDH firewall, this must occur through fax, courier, or mail. As
       a result, delays in the transmittal of information, or the requirement to transcribe
       paper documents to electronic formats, could impede the implementation of
       movement restrictions. Would any methods exist to enable relaxing some secu-
       rity measures to facilitate processing?

              Virginia Enforcement or Assistance with Federal Orders
      What issues regarding the enforcement of federal orders by local and state law
       enforcement need to be further explored?

                          Public Health State of Emergency
      Are there specific issues in an Emergency Declaration that addresses a pandem-
       ic influenza response that you might foresee as being useful to consider from
       your perspective?
      The due process measures related to other forms of social distancing during a
       declared state of emergency are less clearly defined. Should an individual chal-
       lenge one or more provisions of the Governor‟s declaration of a state of emer-
       gency (e.g., to restrict access to a site) or the acquisition of public or private
       property under Code of Virginia § 32.1-48.017, would they file a writ in the state
       court, or potentially a federal action?

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                             Other Issues (as time permits)

      Continuity of Operations within agencies: there is a need to maintain court and
       law enforcement functions (e.g., delegate authority, cross-training), while the re-
       duced capacity may be several weeks or more. What options are available for
       augmenting capacity/ensuring continuity of operations?
      What suspension of normal religious requirements for caring for the dead could
      Can ordinances regarding burial methods and places be relaxed to enable more
       rapid management?
      Will the state require medico-legal death investigations for all deaths (flu-related
       or not) outside of medical institutions?
      Can legal protections be developed that healthcare professionals providing
       treatment in a pandemic influenza environment will be held harmless for making
       allocation of resource decisions are in line with the accepted community stan-
       dard or practice under disaster conditions? Determine organization(s) responsi-
       ble for developing modified standards of care guidelines and ensure appropriate
       guidance is being created and disseminated to appropriate providers. Does le-
       gal protection exist for those healthcare providers enacting modified standards of
       care guidance? Is there liability for re-directing resources (e.g., removing some
       individuals from ventilators to treat others)?
      What is the adequacy of Code of Virginia § 44-146.17 for directing use of re-
       sources and restricting movement?
      What are potential impacts on some industries (e.g., business insurance for the
       poultry industry, life insurance for the unexpected increase in loss of life, unem-
       ployment insurance demands) that may need to be identified to mitigate unanti-
       cipated consequences (e.g., loopholes that may affect payments to survivors)
       comparable to those issues that occurred in defining „flood‟ versus „storm‟ dam-
       age following Hurricane Katrina in New Orleans.
      Who is responsible for establishing a Virginia Missing Persons database?
      Who pays the costs of human remains identification (approximately $3000.00
       per individual if DNA is not used and $4000 if DNA is used)?
      Will a “Modified Standards of Care” policy be necessary for healthcare provid-
       ers/hospitals/congregate care? What are the legal and ethical issues associated
       with this decision?

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             6531 West Broad Street
             Richmond, VA 23230
             Tel: (804) 285-9951

Public Transportation Options:
  From Richmond International Airport (RIC):
      o Distance: 15 MI / 24.14 KM West to Hotel
      o Taxi Charge (one way): $28.00
      o Time by taxi: 20 minutes
   From Train:
      o Station Name: Amtrak Train Station
      o Distance: 3 MI / 4.83 KM to Hotel
      o Taxi Fee From Train Station: $10.00

Driving Directions (see maps, below):
    I-95S
    EXIT #79 TO I-64W
    EXIT #183B BROAD ST (US-250)
    I-95N
    EXIT 79 TO I-64W
    EXIT #183B BROAD ST (US-250)
    I-64W TO I-95N
    EXIT 79 - I-64W
    EXIT #183B BROAD ST (US-250)
    EXIT #183B BROAD ST (US-250)

Complimentary parking is available on site.

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      Participants must make their own travel arrangements. Please note that individ-
       uals will be personally responsible for payment of any non-cancellation costs.
      A block of rooms at the government rate has been held at the hotel – reserva-
       tions may be made at 1-877-2-CROWNE (877-227-6963) or at
      Virginia state travel regulations are available at
      All expenses (for which reimbursement is requested) must be reasonable and
       compliant with the above regulations.
      Meal and lodging per diems are in place – the Virginia Department of Health is
       unable to pay more than the stated amount. Per diem calculations should ex-
       clude meals for breakfast and lunch, as these will be provided at the conference.
      Participants requesting reimbursement will submit a completed travel reim-
       bursement voucher form (see example below), along with original receipts (lodg-
       ing, tolls, parking, etc.), to get their refund. Guidance regarding preparation of
       the form is available at A copy
       of the reimbursement form will be provided at the conference.
       Please retain a copy of any submitted original documents.
      Those traveling via personal vehicle are eligible for the personal vehicle mileage
       rate of $0.485/mile. If any other mode of transportation is used (e.g., train), addi-
       tional requirements may apply – please consult the Virginia Department of

Please contact Mike Fuschini (Virginia Department of Health) at 804-864-8123 with any
travel-related or reimbursement questions.

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                             PARTICIPANT COMMENT FORM

Name (print): ______________________________________________________________
Contact Number: (           )_________________ E-mail:____________________________
Exercise Name and Date: _____________________________________________________

1. Was the exercise organized and effective?
Excellent Good Fair Unsatisfactory N/A
                                         

2. Was equipment adequate and operable, and was material provided in the quantity needed?
Excellent Good Fair Unsatisfactory N/A
                                         

3. Was the operational information provided sufficient for exercise conduct and performance?
Excellent Good Fair Unsatisfactory N/A
                                           

4. Was the exercise beneficial to your training? (Please offer suggested improvements.)
Excellent Good Fair Unsatisfactory N/A
                                             

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                      ACRONYMS AND ABBREVIATIONS

      AAR             After Action Report
      AG              Virginia Office of Attorney General
      ANG             Air National Guard
      ARNG            Army National Guard
      ASTHO           Association of State and Territorial Health Officials

      CDC             Centers for Disease Control and Prevention
      CERT            Community Emergency Response Team
      CSTE            Council of State and Territorial Epidemiologists

      DCLS            Division of Consolidated Laboratory Services
      DHHS            Department of Health and Human Services
      DHS             Department of Homeland Security
      DMAS            Department of Medical Assistance Services
      DMAT            Disaster Medical Assistance Team
      DMORT           Disaster Mortuary Operational Response Team
      DoD             Department of Defense
      DOH             Department of Health
      DOJ             Department of Justice
      DOS             Department of State
      DOT             Department of Transportation
      DS              Dispensing site for meds/vaccine
      DX              Dispensing Site

      EAS             Emergency Alert System (formerly EBS – Emergency
                      Broadcast System)
      EMS             Emergency Medical Services
      EMT             Emergency Medical Technician
      EOP             Emergency Operations Plan
      EPA             Environmental Protection Agency
      EPI, Epi        Epidemiology, -ist
      ERP             Emergency Response Preparedness
      ESF             Emergency Support Function
      EST             Emergency Support Team

      FBI             Federal Bureau of Investigation
      FedEx           Federal Express
      FEMA            Federal Emergency Management Agency
      FOG             Field Operations Guide
      FRP             Federal Response Plan

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      GIS          Geographic Information System

      HIPAA        Health Insurance Portability and Accountability Act
      HRSA         Health Resources Service Agency

      IAD          Dulles International Airport
      IAP          Incident Action Plan
      ICP          Infection Control Practitioner
      ICS          Incident Command System
      ICU          Intensive Care Unit (PICU – Pediatric, NICU – Neonatal)
      ID           Infectious Disease
      ILI          Influenza-Like Illness
      IO           Information Officer

      JIC          Joint Information Center
      JOC          Joint Operations Center
      JTF-CS       Joint Task Force Civil Support

      LE/LEA       Law Enforcement/Law Enforcement Agency
      LEPC         Local Emergency Planning Committee
      LHD          Local Health District
      LO           Liaison Officer

      MCI          Mass Casualty Incident
      ME           Medical Examiner
      MEDEVAC      Medical Evacuation
      MMRS         Metropolitan Medical Response System
      MMST         Metropolitan Medical Strike Team
      MOU          Memorandum of Understanding
      MRC          Medical Reserve Corp
      MSEL         Master Scenario Events List

      NACCHO       National Association of City and County Health Officials
      NALPH Form   Name/Address/Phone/Health History Form
      NCID         National Center for Infectious Diseases
      NDMS         National Disaster Medical System
      NG           National Guard
      NIH          National Institutes of Health
      NIMS         National Incident Management system
      NMRT         National Medical Response Team
      NRP          National Response Plan
      NTSB         National Transportation Safety Board

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      OAG          Office of the Attorney General
      OCME         Office of Chief Medical Examiner
      OCP          Office of Commonwealth Preparedness
      ODP          Office for Domestic Preparedness
      OEMS         Office of Emergency Medical Services

      PAO          Public Affairs Officer
      PDD          Presidential Decision Directive
      PFO          Principal Federal Officer
      PHS          Public Health Service
      PIO          Public Information Officer
      POC          Point of Contact
      POD          Point of dispensing
      PPE          Personal Protective Equipment
      PSA          Public Service Announcement

      RHCC         Regional Healthcare Coordinating Centers
      ROC          Regional Operations Center
      RRT          Regional Response Team
      RSS          Receipt, Staging, Storing site for push pack or VMI

      SAC          Special Agent-in-Charge (FBI)
      SCBA         Self-Contained Breathing Apparatus
      SIOC         Strategic Information and Operations Center
      SITMAN       Situation Manual
      SITREP       Situation Report
      SNS          Strategic National Stockpile
      SO           Safety Officer
      SOP          Standard Operating Procedure

      TARU         Technical Assistance Response Unit
      TEU          Technical Escort Unit
      TFR          Temporary Flight Restrictions
      TTX          Table Top Exercise
      TX           Treatment Facility

      UC           Unified Command
      UCS          Unified Command System
      UIC          Unified Incident Command
      UPS          United Parcel Service
      USCG         United States Coast Guard
      USPHS        United States Public Health Service

      VA           Department of Veterans Affairs

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      VAERS        CDC form completed for individuals who experience an ad-
                   verse reaction to a vaccine (Vaccine Adverse Event Report-
                   ing System)
      VCP          Virginia Capitol Police
      VCU          Virginia Commonwealth University
      VDAC         Virginia Department of Agriculture and Consumer Affairs
      VDoC         Virginia Department of Corrections
      VDEM         Virginia Department of Emergency Management
      VDFP         Virginia Department of Fire Programs
      VDH          Virginia Department of Health
      VDOT         Virginia Department of Transportation
      VEOC         Virginia Emergency Operations Center
      VERT         Virginia Emergency Response Team
      VGIF         Virginia Department of Game and Inland Fisheries
      VHHA         Virginia Hospital and Healthcare Association
      VITA         Virginia Information Technology Agency (VITA)
      VNG          Virginia National Guard (VNG)
      VSP          Virginia State Police
      VEOC         Virginia Emergency Operations Center
      VMI          Vendor Managed Inventory

      WHO          World Health Organization
      WMD          Weapons of Mass Destruction

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      Funding for the Social Distancing Law Project has been provided by the Associa-
      tion of State and Territorial Health Officers (ASTHO) through the Centers for
      Disease Control and Prevention (CDC)

      Special thanks to Steve Harrison (VDH) for providing the material used during
      the tabletop exercise.

      Special thanks to Suzi Silverstein and Sherri Chedester (VDH) for logistic sup-
      port in planning and implementing the Legal Consultation Meeting.

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