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					Essential Communication
in the Context of Public
Health Emergency
Detection and Response


                        Tuesday Nov. 7, 2006
          American Public Health Association
                            Annual Meeting

           Patricia M. Sweeney, JD, MPH, RN
Patricia M. Sweeney, JD, MPH, RN
University of Pittsburgh Graduate School of
Public Health psweeney@pitt.edu




                     Michael P. Allswede, DO
                   Conemaugh Health System
                          mallswede@conemaugh.net
         Background



Communication           Effective response




            Detection
       Study purpose


 To discern if current legal
 infrastructure permits
 communication essential to
 early detection of intentional
 infectious disease outbreaks
                  Clinical
                  Medicine




    Law           Forensic      Public
Enforcement     Epidemiology    Health




   Domains and Channels of Communication
          Methodology

   Literature search

     Domestic  incidents of infectious
      disease outbreaks

     Past   20 years

     Ample    documentation
                       Methodology
   U.S. FORENSIC EPIDEMIOLOGY CASE ANALYSES

   West Nile Virus (New York, NY), August-October 1999
   Inhalation and cutaneous anthrax (NY, NJ, FL, Washington, DC), September-
    December 2001
   Inhalation anthrax (Oxford, CT), November 2001
   Hepatitis A (Pittsburgh, PA), October-November 2003
   Bubonic plague (New York, NY), November 2002
   Anthrax hoax (Washington, DC), April 1997
   Brucellosis (NH and Boston, MA), March-April 1999
   Monkeypox (Milwaukee, WI), May-June 2003
   Hantavirus (NM and Four Corners), May-September 1993
   Severe Acute Respiratory Syndrome (SARS),(San Jose, CA), April 2003
   Plague samples (Lubbock, TX), January 2003
   Kombucha tea poisoning (IA), April-May 1995
   Salmonella typhimurium outbreak (The Dalles, OR), September 1984
              Methodology
   Analyzed open source documents
   Developed chronologic case studies
    denoting every documented
    communication
   Applied current legal standards to facts
   Analyzed laws, regulations and legal
    principles underlying communication
               Findings




Clinical Medicine     Public Health


        Open communication
               Findings



Clinical Medicine   Law Enforcement



      Constrained communication
            Findings



Public Health     Law Enforcement



    Constrained communication
        Communication between
Clinical Medicine       Public Health
 Supported by
  State   Disease Prevention and Control Statutes
  Child   abuse reporting laws
  Mandated     reporting of specified injuries
  Legal   duty to warn third persons
     Communication between
Clinical Medicine Public Health
Limited by
   Variability   in state disease reporting statutes
    – Mandated reporters
    – Time requirements
    – Diagnosis certainty

   Privacy   concerns
    – Confidential medical records
    – HIPAA protected health information
      Communication between
                Clinical Medicine
Public Health
                Law Enforcement

Supported by
   State Public Health powers

Limited by
   Disclosure limited to purpose of law
   Chilling affect of criminalization of public
      health disclosures
        Communication between
Clinical Medicine   Law Enforcement
      Supported by
         HIPAA



      Limited by
         HIPAA

         Physician  – Patient privilege
         Liability for unauthorized disclosure
      Communication between
law enforcement       public health

    Limited by
       Compromising investigation
       Compromising classified sources
       Compromising ability to prosecute
             Recommendations
   Revise disease reporting statutes
     include suspicion of illness
     specified indicators of potential BT


   HIPAA “carve out” for indicators of BT/
    intentional outbreak

   Create new mechanisms for collection and
    analysis of threat intelligence

   Permit progressively open communication
    based upon threat assessment
             Conclusion

A formal mechanism providing a systematic,
     transparent, reviewable process for
    information sharing between clinical
      medicine, public health, and law
 enforcement is needed to permit the early
detection of an intentional infectious disease
                  outbreak.
Patricia M. Sweeney, JD, MPH, RN
University of Pittsburgh Graduate School of
Public Health psweeney@pitt.edu




                     Michael P. Allswede, DO
                   Conemaugh Health System
                          mallswede@conemaugh.net

				
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