# Presentation: 037620

## Quarantine and Isolation:Virginia’s Approach

- Virginia Department of Health
- January, 2005

## VEB Dec 2004

## Isolation and Quarantine

- Part 1: Purpose and History

**Notes:**
Discussion divided into 3 parts:
1) Purpose and History of I + Q
2) a) Legal basis of I + Q and b) Communicable Diseases of Public Significance
3) a) Communicable Diseases of Public Health Threat and b) Issues and Challenges
Each section has an opportunity to ask questions.
Presentation lasts about 1.5 hours (depending on questions)

## Communicable Disease Responses

**No restrictions**

**Community-wide measures to increase social distance**

**Compulsory activity restrictions**
**Curfews on activities**
**Closing of mass transit **
**Closing access routes**
**Closing borders**

**Targeted population-specific restrictions**

**Number of cases/exposed**
**Exposure category**
**Known**
**Unknown (unlinked)**
**Generations of transmission**
**Morbidity and mortality**
**Ease/rapidity of spread **
**Movement in/out of community**
**Resources for response**
**Risk of public panic**

**Notes:**
Activities to control disease can include:
Primary and secondary preventive interventions:
Vaccination
Prophylaxis
PPE (masks, gloves, etc.)
Enhanced disease surveillance and symptom monitoring
Rapid diagnosis and treatment of ill
Restrictions on group assembly
Travel restrictions
Cancellation of public events
Close public places, mass public transit
“Snow days”
Isolation and quarantine
Cordon sanitaire (sanitary/quarantine line)

## Effect of Increasing Social Distance

- Exponentiation

- Suppression

**Ro = 2.0**
**Progression = 1:2:4:8:16**

**Ro = 0.67**
**Progression = 1:2:4:3:2**

**Notes:**
Ways to increase Social Distance:
Implement “Snow Day”restrictions (shelter-in-place)
Close schools, daycare centers, etc
Cancel large public gatherings (concerts, theaters)
Minimize other exposures (markets, churches, public transit)
Encourage non-essential workers to stay home
Telecommunting can minimize economic impact
Consider additional community measures􀂃
Temperature or other symptom monitoring 
Distribution of surgical masks, barrier precautions, hand hygiene
Scaling back transportation services (holiday schedule)

Contagion epidemic modeling
R<1 is extinction/quenching

Modern quarantine does not have to be absolute to be effective 
Even partial or “leaky” quarantine can reduce disease spread
Partial quarantine can be an effective supplement to vaccination

## Need for Public Health Legal Tools

- Global spread of highly contagious diseases
- New diseases or disease strains
- Bioterrorism preparedness
- Zoonotic diseases
- Reassessment of traditional public health legal authorities

**Notes:**
Examples of recent events:
Anthrax – need for joint training and cooperation between public health and law enforcement
West Nile Fever – law around chemical abatement
Smallpox vaccine – liability and compensation
SARS – quarantine and isolation
Monkeypox – integration of federal and state agency efforts

## Isolation and Quarantine

- Isolation: separation (for period of communicability) of _known infected persons_ to prevent transmission of an infectious agent
- Quarantine: restriction of activities during the incubation period of _healthy persons_ exposed to a communicable disease to prevent transmission _if_ infection occurs

## Not “all or none”
Complete: full-time confinement or restriction of movement
Modified: a selective, partial limitation of freedom of movement or actions 
Protective (isolation): separation of a susceptible individual from an environment where transmission is occurring to prevent acquiring a communicable disease

- Complete: full-time confinement or restriction of movement
- Modified: a selective, partial limitation of freedom of movement or actions
- Protective (isolation): separation of a susceptible individual from an environment where transmission is occurring to prevent acquiring a communicable disease

- Isolation and Quarantine

**Notes:**
Examples of modified isolation:
Meets particular situations (e.g., exclusion of children from school, restriction from engaging in a particular occupation, requirements for procedures to limit disease transmission) – eg. “Work quarantine” for healthcare workers
Example of protective isolation
Exclusion of a susceptible, unimmunized child from a school in which an outbreak, potential epidemic, or epidemic of a vaccine preventable disease has been identified

## Isolation and Quarantine History

- Long history of use of isolation/quarantine:
- Leprosy
- Old Testament: Isolation for persons with leprosy
- Emperor Justinian, Rome
- 532 AD: Persons arriving into Constantinople from “contaminated localities” placed in special housing
- Plague
- 14th-15th centuries: Venice imposed harbor quarantine (It. *quaranta* - 40-day period of detention for arriving ships)

## US Isolation and Quarantine

- 1647: Mass. Bay Colony restricted ships from West Indies due to plague
- 1660’s: First colonial quarantine laws
- 1796: First federal quarantine law (repealed)
- 1880’s: NYC inspection of ships, passengers and cargo
- Quarantinable diseases: cholera, yellow fever, plague, leprosy, smallpox
- Staten Island as isolation hospital/quarantine station

## “Typhoid Mary”

- 1907: Mary Mallon (“Typhoid Mary”) involuntarily admitted to NYC Detention Hospital
- Held for three years due to non-compliance
- Released on condition that not work with food
- Took job as a hospital cook => infected dozens
- Re-admitted involuntarily for isolation (life-long)

## Modern Quarantine and IsolationLessons from SARS

- Toronto: quarantine/isolation for 2003 SARS outbreak control
- Vast majority complied voluntarily:
- 29,000 people isolated/quarantined (HD staff, private physicians, or employers)
- Only 27 legal orders needed
- High levels of compliance with voluntary measures
- Extensive community education efforts
- Clear messages

**Notes:**
? Will future outbreaks, esp in the US, have such high levels of compliance?

## Quarantine has negative connotations
Black Death, Yellow fever, Pandemic Flu
Detention camps equate disease with crime
Stigmatizes victims (e.g., foreign born)
Historical abuses of power
Quarantine works
Effective tool to prevent spread of contagion
As good or better than other tools in the box

- Black Death, Yellow fever, Pandemic Flu
- Detention camps equate disease with crime
- Stigmatizes victims (e.g.,* *foreign born)
- Historical abuses of power
- Quarantine works
- Effective tool to prevent spread of contagion
- As good or better than other tools in the box

- Quarantine’s Dichotomy

## Isolation and Quarantine

- Legal Basis

## Indications for Isolation/Quarantine

- Dangerous and contagious disease
- Exposed “well” can be separated from “ill”
- Resources available to support interventions
- Ensure essential needs
- Monitor health status
- Provide medical care
- Implement isolation of those who become ill
- Continue only long enough to ensure not contagious (e.g., quarantine = incubation period)

**Notes:**
From an ethical and practical standpoint, only use Q+I when:

## Civil Commitment

- Government’s restriction of a person not guilty of a crime
- Must balance:
- Community’s right to be protected from harm by individuals
- 					**Against**
- Constitutionally protected freedoms of individuals
- Authority resides at several levels of government

**Public good**

**Civil liberties**

**Notes:**
From US legal perspective:

## Background: Statute (Law)

- Legislative act declaring, commanding, or prohibiting an act
- Fed laws: Congress enacts statutes
- VA State laws: Require passage by both houses and approval by the Governor

## Background: Regulation

- Rule or order to clarify and facilitate enforcement of statute
- Based on delegation of authority from legislative branch
- Issued under the executive branch (President for Fed, Governor for State)
- Has full force of law, but subordinate to statutory law
- Punishments are usually civil - can be appealed to judges

## U.S. Federal I+Q Law

- “Enumerated powers” - authority from Commerce Clause:
- Congress shall have the power ... “To regulate Commerce with foreign Nations, and among the several States... .”  Art I, Section 8

## Federal I+Q Regulations

- 42 US Code, Sec. 264
- HHS Secretary responsible for preventing introduction/spread of communicable diseases to US and between states
- For Presidentially declared diseases (2003):
- Cholera
- Diphtheria
- Infectious TB
- Plague
- Smallpox
- Yellow fever
- Viral hemorrhagic fevers
- SARS

**Notes:**
Public Health Services Act (1944)
Articulates the quarantine authority of the Federal government
Authorizes “...apprehension, detention, and conditional release of individuals to prevent spread of communicable disease”
Applies to persons:
infected with a communicable disease in a qualifying stage”
Communicable stage
Pre-Communicable if likely to cause a public health emergency
arriving from foreign countries or moving state to state

Title 42 U.S.C. Section 264 (Section 361 of the Public Health Service Act) gives the Secretary of Health and Human Services responsibility for preventing the introduction, transmission, and spread of communicable diseases from foreign countries into the U.S. and within the U.S. and its territories/possessions, and CDC has the authority to “detain, medically examine, or conditionally release individuals suspected of carrying a communicable disease” under regulations found at 42 C.F.R. Parts 70 and 71. Violation of a quarantine and isolation order is a federal criminal misdemeanor.

On April 4, 2003, at the request of the CDC, President Bush signed Executive Order 13295, adding SARS to the list of communicable diseases for which federal isolation and quarantine is authorized. Thus, SARS joined cholera, diphtheria, infectious tuberculosis, plague, smallpox, yellow fever, and viral hemorrhagic fevers as communicable diseases detainable by the federal government.

However, the federal system in the U.S. would present a challenge, since “the CDC has no regulatory powers to implement prevention and control measures outside the national quarantine system, as those powers reside with the states.”

## Federal Role

- May apprehend, detain or conditionally release individuals
- Used only if threat to public health and refusal to cooperate voluntarily
- Violation of federal quarantine a criminal misdemeanor (fine +/or imprisonment)
- Federal gov’t last used involuntary quarantine in 1963 (smallpox case)
- CDC uses Public Health Service Act to monitor/temporarily detain individuals suspected of disease

## State I+Q Law

- Federal authority concurrent w/state’s
- States have “reserved powers” (10th Amendment) - includes “Police powers”:
- “Enact laws...that safeguard the health, welfare, and morals of [their] citizens”
- Authority to regulate private interests for the public good

**Notes:**
In the U.S., individual states are responsible for public health control measures within their borders as part of the police power recognized by the U.S. Constitution. Significant variation exists among states and localities in terms of laws governing quarantine and isolation measures. The fact that state and local authorities have power over quarantine and isolation within their borders but the federal government is responsible for interstate and international control of the spread of disease makes cooperation and clear communication among the various levels of government essential to effective management of an infectious disease outbreak.

Examples of States’ Police Power:
Require a child to be vaccinated as a condition of attending school
Involuntarily detain a person who has a communicable disease
Search, seize, and destroy property in order to control disease spread, sometimes without compensation
Throw up a cordon sanitaire around a city to prevent disease spread

EXCEPTIONS
International importation of disease
Interstate spread of disease
Certain Indian lands
Federal reservations (prisons, hospitals, etc.)

## Fed-State Responsibility

- States generally responsible for public health matters within their borders, including:
- Restrict a person’s personal liberty
- Restrict a person’s ability to work
- Seize property without compensation
- HHS Secretary may:
- Accept state and local assistance in the enforcement of federal quarantine regulations
- Assist states and local officials in the control of communicable diseases
- Federal, state, and local health authorities may simultaneously have separate but concurrent legal quarantine power (e.g., arriving aircraft at a city airport)

## Questions?

## Isolation and Quarantine

- Part 2:
-  Virginia Laws and Regulations
-  Communicable Disease of Public Health Significance

## Control of Communicable Disease

- LHD performs public health interventions for diseases such as
- HIV infection
- Infectious syphilis
- Active TB disease
- ...and many other diseases
- LHD may _recommend_ appropriate public health control measures (e.g., quarantine, isolation, immunization, decontamination or tx)

## Noncompliance...

- When a person voluntarily complies w/LHD recommendations for control of communicable disease =>
- 		no additional intervention is necessary
- Laws/regulations designed to address situations where voluntary compliance fails

## State Isolation and Quarantine Law

- Most State’s laws for I+Q have typically been:
- Overly broad
- Lacking in clear standards and authority
- Disease-specific (e.g., TB)
- Lacking in adequate due process measures
- Questionable in applicability to groups

**Notes:**
Draft model of state emergency health powers act: Commissioned by CDC after 9/11
Current public health laws  too antiquated and inadequate to ensure a strong emergency response?
A tool for states to use in assessing adequacy of relevant public health laws

## Example: ‘Old’ Virginia Code

- § 32.1-43. Authority of Commissioner to require quarantine, etc.
- “The Commissioner shall have authority to require quarantine, vaccination or treatment of any individual when he determines any such measure to be necessary to control the spread of any disease of public health importance.”

##  However...

- Although extensive provisions in isolation statutes – no clear standards for quarantine
- Applies to “individuals” - no clear method for quarantine of:
- Groups of people
- Geographic areas
- Public or private facilities
- Liability issues not addressed
- Due Process - no notice, hearing, counsel, appeal provisions
- Result = ambiguity and susceptibility to legal challenge

**Notes:**
Need specific Due Process measures designed for groups and infrastructure in VDH, law enforcement and judiciary to manage it

## Virginia Approach

- Since the middle of an epidemic is not the best time to be rewriting laws...
- 		...need proactive planning for interdisciplinary legal preparedness:
- April 2004, Virginia enacts HB 1483
- Amends Chapter 2 of Title 32.1 of the Code of Virginia to address Quarantine and Isolation
- Nov 2004: Board of Health promulgates emergency regulations

**Notes:**
Also not the right time to talk to law enforcement regarding their role in implementation of the detention and isolation orders!  

## Key Players

- Board of Health
- State Health Commissioner
- District Health Director
- Public Health Nurses
- VDH Office of Epidemiology
- VA District Attorney
- Law Enforcement
- 		and many others...

**Notes:**
The State Board of Health (“board”) has the responsibility for promulgating regulations pertaining to the reporting and control of diseases of public health importance and to meet any emergency or to prevent a potential emergency caused by a disease dangerous to the public health 
The State Health Commissioner (“commissioner”) is the executive officer for the State Board of Health with the authority of the board when it is not in session, subject to the rules and regulations of and review by the board.  The commissioner has the authority to require quarantine, isolation, immunization, decontamination or treatment of any individual or group of individuals when he determines any such measure to be necessary to control the spread of any disease of public health importance and the authority to issue orders of isolation 
District Health Director – surveillance, investigation and reporting of diseases in jurisdiction; institutes disease control measures
VDH Office of Epidemiology – assist in collecting data, coordinating efforts
VA District Attorney – counsel on legal actions

## Issues Addressed

- Notice
- Initial detention, post deprivation rights
- Right to counsel
- Clear and convincing evidence
- Least restrictive means: tied to particular circumstances, have scientific basis
- Application to individuals, groups or geographic areas (“Affected Areas”)
- Anonymity of patients and practitioners

## New/Revised Concepts

- Affected area
- Communicable Disease of Public Health Threat
- Distinct from Comm Disease of Public Health Signif
- Voluntary vs Involuntary
- Essential needs
- Exceptional circumstances
- Individual: a person or _companion animal_
- Least restrictive
- Commissioner – may (or may not) delegate authority to designee

**Notes:**
Affected area: any part or the whole of the Commonwealth, which has been identified as where individuals reside, or may be located, who are known to have been exposed to or infected with or who are reasonably suspected to have been exposed to or infected with a communicable disease of public health threat. 
Companion animal: any domestic or feral dog, domestic or feral cat, nonhuman primate, guinea pig, hamster, rabbit not raised for human food or fiber, exotic or native animal, reptile, exotic or native bird, or any feral animal or any animal under the care, custody, or ownership of a person or any animal that is bought, sold, traded, or bartered by any person.  Does not include agricultural animals, game species, or any animals regulated under federal law as research animals.
Essential needs: basic human needs for sustenance including, but not limited to, food, water and health care, e.g., medications, therapies, testing, and durable medical equipment. 
Exceptional circumstances: the presence, as determined by the commissioner in his sole discretion, of one or more factors that may affect the ability of the department to effectively control a communicable disease of public health threat. Factors to be considered include, but are not limited to: 
characteristics or suspected characteristics of the disease-causing organism or suspected disease-causing organism such as virulence, routes of transmission, minimum infectious dose, rapidity of disease spread, the potential for extensive disease spread, and the existence and availability of demonstrated effective treatment; 
known or suspected risk factors for infection
the potential magnitude of the effect of the disease on the health and welfare of the public; and, 
the extent of voluntary compliance with public health recommendations.
The determination of exceptional circumstances by the commissioner may take into account the experience or results of investigation in Virginia, another state or another country.
Least restrictive: the minimal limitation of the freedom of movement and communication of an individual while under an order of isolation or an order of quarantine that also effectively protects unexposed and susceptible individuals from disease transmission.
Commissioner: means the State Health Commissioner, or his duly designated officer or agent, unless stated in a provision of these regulations that it applies to the State Health Commissioner in his sole discretion.

## Illness of Public Health Importance

- Communicable Disease of Public Health Significance

- Communicable Disease of Public Health Threat

- Illness/Disease

**Notes:**
Condition: any adverse health event such as a disease, an infection, a syndrome, or procedure (e.g., results of a physical exam, laboratory test, or imaging interpretation) indicating an exposure of public health importance has occurred

Communicable disease of public health significance: an illness caused by an infectious agent that may be transmitted from one individual to another.  This includes, but is not limited to, infections caused by human immunodeficiency viruses, blood-borne pathogens, and tubercle bacillus.

Communicable disease of public health threat: an illness of public health significance caused by an  infectious agent that may be readily transmitted from one individual to another and creates a risk of death or significant injury (does not include HIV or TB unless used as a bioterrorism weapon)

## Regulations

- When normal measures insufficient, the local health director may use Article 3.01 (communicable diseases of public health significance),
- Or,
- Provide sufficient information to enable the commissioner to prepare an order or orders of isolation and/or quarantine under Article 3.02 (communicable diseases of public health threat)

## Virginia Isolation and Quarantine Flow Diagram

## Isolation for Communicable Diseases of Public Health Significance

- VAC Article 3.01

## Communicable Disease of Public Health Significance

- Illness caused by an infectious agent that may be transmitted from one individual to another
- Includes, but is not limited to, infections caused by HIV, blood-borne pathogens, and TB

## ?Non-Compliant?

- Health Director can:
- Request medical evaluation
- Order counseling/education
- Order treatment
- 	May occur individually, or together
- If health director has evidence that a person is placing others at risk (e.g., a documented history of non-adherence) then....

## Non-Compliance

- Health director works with:
- Office of Epi - petitions commissioner for Emergency Detention Order
- Local law enforcement officials (police, sheriff, etc.) - to detain case
- Office of Epi and AG – (within 48 hrs of detention) petitions for Court Ordered Isolation

**Notes:**
AG = Office of the Attorney General

## Emergency Detention

- Law enforcement conducts person to court, or to their home or the least restrictive willing facility (but not a jail/prison) for temporary detention until the court can review the case
- Person must:
- Be notified of the cause for the isolation; and,
- Have access to legal counsel

## Order of Isolation

- Court may issue order for isolation in the person's home, another residence, an institution or other place (including a detention facility, if necessary) if it finds:
- The person is infected with a communicable disease of public health significance
- The person is engaging in at-risk behavior with an _intentional_ disregard for the health of others; and,
- There is no other reasonable way to reduce the risk to the public
- Closed (“locked”) hearing

**Notes:**
Per Jane Moore: These are "locked", very limited access proceedings and not open to the public.  Only the legal representation from both sides, the patient, the judge and witnesses are permitted in the court room.   Everyone has to explain their purpose.....sometimes people have been asked to leave.  The court room is then actually locked until the conclusion of the proceeding. 

## Details

- Duration: 120 days (or less if the person no longer a threat to the health of others)
- Appeals: within 30 days - however, during the appeal process the person is still bound by the order
- Continuation: re-petition for new order (≤120 d) if the original reasons for the order still exist

## LHD Responsibilities

- Deliver appropriate medical records to the Office of Epidemiology for transfer to the AG's office.  Records should include:
- Copy of medical eval (detailed diagnosis of disease)
- Copies of x-ray reports and lab reports (e.g., smears, culture results)
- Documentation of efforts to counsel patient on disease, tx and expected behaviors for compliance
- Documentation of patient non-adherence to recommendations
- Basis of determination of danger to public health
- Copies of formal requests issued by the health director

## LHD Responsibilities (cont.)

- Contact appropriate local law enforcement (police, sheriff, etc.) to plan order implementation
- Identify “least restrictive willing facility" (_**not**_ a jail or correctional facility) where person may be confined until court hearing
- Testify in trial, if required

## Examples/Resources

- _[http://vdhweb/epi/tb/index.htm](http://vdhweb/epi/tb/index.htm)__ (internal)_

## VA TB Control Laws Guidebook

- http://www.vdh.virginia.gov/epi/tb/guidebook.html

## VA TB Control Laws Guidebook

- Includes details on:
- Issuing an Examination Request
- Issuing Counseling Order
- Issuing Treatment Order
- Issuing Emergency Detention Order
- Court-Ordered Isolation
- Website (_[http://vdhweb/epi/tb/guidebook.html](http://vdhweb/epi/tb/guidebook.html)__) contains templates for LHD use_

## Questions?

## Isolation and Quarantine

- Part 3:
- Communicable Diseases of Public Health Threat
- Issues and Challenges

## Isolation and Quarantine for Communicable Diseases of Public Health Threat

- 12 VAC 5-90-105.  Isolation.
- 12 VAC 5-90-110.  Quarantine.

## Background Concepts

- Communicable Disease of Public Health Threat
- Communicable disease of public health significance that is readily transmitted and creates a risk of death or significant injury (not including TB or HIV)
- E.g., smallpox, pneumonic plague, viral hemorrhagic fever

## Background Concepts (cont.)

- Exceptional Circumstances
- Factors (as determined by commissioner) that affect ability to effectively control a communicable disease
- Includes:
- Organism (virulence, routes of transmission, minimum infectious dose, rapidity of spread)
- Potential for extensive disease spread
- Existence and availability of effective treatment
- Known or suspected risk factors
- Potential magnitude of the effect on welfare of the public
- Extent of _voluntary compliance_
- May take into account the experience or results of investigations in Virginia, other states or countries

## Commissioner (only) may invoke Article 3.02 to isolate or quarantine an individual(s) if: 
1.	They are known/suspected to have been infected with or exposed to a communicable disease of public health threat, and
2.	Exceptional circumstances make Article 3.01 of the Code of Virginia insufficient, or the individual or individuals have failed or refused to comply voluntarily with control measures, and
3.	Isolation/quarantine is the necessary means to contain the threat
The commissioner may isolate or quarantine people within an affected area if, in addition, the Governor has declared a state of emergency for that part of the Commonwealth

- 1.	They are known/suspected to have been infected with or exposed to a communicable disease of public health threat, _and_
- 2.	Exceptional circumstances make Article 3.01 of the *Code of Virginia* insufficient, or the individual or individuals have failed or refused to comply voluntarily with control measures, _and_
- 3.	Isolation/quarantine is the necessary means to contain the threat
- The commissioner may isolate or quarantine people within an _affected area_ if, in addition, the Governor has declared a state of emergency for that part of the Commonwealth

- Isolation and Quarantine

## Additional Requirements

- Least restrictive environment necessary to contain threat
- Quarantined persons confined separately from isolated persons, as practicable
- If quarantined person symptomatic, remove from quarantine and place in isolation
- Regular monitoring of the health status
- Immediate release if person poses no risk of transmitting
- Site must be safely and hygienically maintained with adequate food, clothing, health care, and other essential needs

## Home Quarantine/Isolation

- Before implementing, consider:
- Availability of caregiver to assist patient
- Access to telephone, electricity, heat, water
- Access to groceries, meds, and other needs
- Family members at high-risk or who cannot comply w/infection control methods (e.g., children)
- If multi-family dwelling: separate air handling system (if appropriate)
- Ideally, separate bedroom and bathroom for the patient

## Documentation for Orders

- Prepare a record of findings, including*:*
- Identify the communicable disease of public health threat
- Reasons why exceptional circumstances apply and isolation/quarantine is necessary
- Sufficient information to provide reasonable notice to persons
- Means by which the quarantine is to be implemented
- Geographic parameters, if involving an affected area
- Duration of the order
- Directions for compliance
- Opportunities for person(s) to notify employers, family, attorneys
- The penalty that may be imposed for noncompliance
- Right to seek judicial review of the order
- Sufficient information must be maintained by LHD to enable follow-up of individuals for health status evaluation and compliance with the order

**Notes:**
Required by § 32.1-48.12 of the Code of Virginia

## Court Review of Order(s)

- Following issuance of order, commissioner must file a petition seeking *ex parte* court review and confirmation of the order
- Filed with the circuit court for the city or county in which the person or persons resides
- In the case of an affected area: filed in the circuit court of the affected jurisdiction or jurisdictions

**Notes:**
Petition to be filed in the person’s District Court in accordance with existing laws and rules of the court unless national emergency
If a petition is filed, court must hold hearing within 72 hours (7 days if hearing is on conditions of I/Q)
District court will exercise statewide jurisdiction and conduct these hearings
Venue consolidated in “seat of government” (Circuit Court for the City of Richmond)
Avoids requiring Commissioner/staff to travel during an emergency
Localizes risk to the courts
ex parte = “on behalf of only one party, without notice to any other party”

## Court Review of Order(s) 

- Petition includes:
- Copy of the order or equivalent
- Summary of the findings for the order, including:
- Identity of person(s)
- Basis for the order
- Specific communicable disease
- Site of the isolation/quarantine
- Date and time when commences
- Any conditions of the order
- The commissioner may file some or all of any petition under seal

## Court Findings

- The court shall grant the petition to extend the order upon finding:
- Probable cause that isolation/quarantine was the necessary means to contain the disease
- Implementation is in the least restrictive environment necessary
- After reviewing any information filed under seal, the court shall reseal relevant materials to the extent necessary to protect public health and safety

## Appeals

- A person subject to an order may file a petition to appeal
- A hearing on the appeal held within 48 hrs
- Person must prove that they do not need to be isolated/quarantined
- Filing of appeal does not stay the order
- Court may consolidate multiple appeals into single proceeding
- The court may:
- Vacate
- Modify, or
- Confirm the order

## Hearing Procedures

- Person has a right to *appear* at the hearing
- How that person appears will depend upon individual case
- May need to use telephone and ITV video
- If the person appears by electronic means, steps to ensure the person has immediate ability to consult with counsel if counsel is not with the person
- Full infection control measures will be followed by all participants

## LHD Responsibilities

- Assesses the situation and gathers info for record of findings – shares w/Office of Epi for preparation of orders
- Identifies a place of isolation/quarantine and least restrictive means that effectively protects unexposed and susceptible individuals
- Ensures delivery of order(s) by an appropriate party, in person to the extent practicable
- The commissioner can decide if print, radio, television, internet, and/or other available means may be used

## Ensures that law-enforcement personnel responsible for enforcing orders are informed of measures to take to protect themselves
Monitors the health of those under an order (e.g., regular telephone calls, visits, self-reports, report of caregivers or healthcare providers, etc.)
With local emergency management resources, ensures individual essential needs are met to the extent practicable

- Monitors the health of those under an order (e.g., regular telephone calls, visits, self-reports, report of caregivers or healthcare providers, etc.)
- With local emergency management resources, ensures individual essential needs are met to the extent practicable

- LHD Responsibilities (cont.)

## Enforcement

- If probable cause that an individual may fail to comply with order, the commissioner may issue an emergency detention order
- Person taken immediately into custody by law-enforcement agencies
- Detained for the duration of the order or until the commissioner determines that the risk of noncompliance is no longer present
- Law-enforcement agencies can detain or arrest anyone who may be in violation of an order
- Hold in the least restrictive environment that can provide any required health care, services

## Penalties

- Non-compliance with an order of isolation or quarantine:
- Class 1 misdemeanor (confinement for up to 12 months and/or $2,500 fine)
- Civil penalties ($25,000 maximum per offence)

## Release

- An individual under an order of isolation or quarantine shall be released immediately if:
- The commissioner determines that an individual no longer poses a threat to the public health
- The order has expired, or
- The order has been vacated by the court

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## Affected Areas

- Specific to Diseases of Public Health Threat AND state of emergency declared
- Same procedures/penalties...with some minor differences (e.g., notification)

## Note: Immunity from Liability

- Any person who, in good faith and in the performance of his duties, acts in compliance with the law and regulations shall not be liable for any civil damages for any act or omission (unless the result of gross negligence or willful misconduct)

## Use of Public or Private Property

- If Governor declares state of emergency:
- State Health Commissioner may require the use of any public or private property, building or facility to implement any order of quarantine or isolation
- Owners or operators of any property, building or facility so commandeered are entitled to compensation

## Quarantine and Isolation in Virginia

- Issues and Challenges

## Implementation of Community Containment

- Understanding public health roles and legal authority at local, state, and federal levels
- Coordination and cooperation between public and private healthcare sectors:
- Elected officials
- Media
- Emergency responders
- Public safety
- Transportation authorities
- Law enforcement
- Legal community (judges, lawyers)
- Employers/employees
- Public health
- Healthcare providers

## Current Unresolved Legal Issues

- Compensation for lost wages of persons isolated and quarantined
- Compensation for lost business
- Jurisdiction over federal properties
- Multi-jurisdictional areas, e.g. Northern Virginia

## Implementation Issues

- Develop incident command structure
- Communication between hospitals and PH re: AMA pts
- Identifying community-based facilities
- Providing for essential needs for people who have been isolated or quarantined
- Quarantined should be among first to receive all available disease prevention interventions
- Monitoring large numbers of people - ? electronic methods
- Providing legal counsel for large numbers of people in a short time-frame
- Mental health support

## Implementation Issues (cont.)

- Pre-design materials.  May include:
- Letters requesting voluntary isolation or quarantine
- Involuntary isolation or quarantine orders (multiple situations)
- Petitions for court review of orders
- Draft court orders

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## Implementation Issues (cont.)

- Support documents, including:
- Health Director declaration of support
- Documentation of initial notification
- Confirmation of diagnosis
- Fact sheets
- Notice of process to appeal (req by VA law)
- Draft court summons template
- Home isolation assessment
- Case record system
- Order modification (e.g., from quarantine to isolation)
- Termination order

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| --- | --- |

## Implementation Issues (cont.)

- Ensuring public communication and enforcement on a large scale
- Each level of PH must effectively connect with respective law enforcement counterparts to assist in carrying out involuntary public health order(s)
- Will require good partnerships between local, state, federal and non-governmental (e.g., media, Red Cross) stakeholders

## Summary

- Isolation and quarantine only one aspect of communicable disease control
- Voluntary compliance with isolation and quarantine extremely important
- Virginia law and regulations updated to address legal and procedural concerns with involuntary isolation and quarantine
- Still many issues to work on

##  Resources http://www.phppo.cdc.gov/od/phlp/

**Notes:**
CDC has a public health law program that has many resources related to quarantine and isolation

## Questions?

## References

- F.E. Shaw and R.A. Goodman (Public Health Law Program, CDC): Law as the Basis of Public Health Action
- A. Murphy (Chief Legal Counsel, Illinois DPH): The Evolving Role Of Public Health Law In Containing Infectious Disease
- F.E. Shaw (Public Health Law Program, CDC): Quarantine and Isolation Lawin the States
- A.K. Manka (Minnesota Assistant Attorney General): Comparison of Health Laws
- M. Trippler (Assistant U.S. Attorney): Federal Authority for Isolation and Quarantine
- M.G. Moriarity (Civil Court Administrator, Ramsey District Court): Court Procedures under the Minnesota Emergency Health Powers Act
- R. Lynfield and K. LeDell (Minnesota Department of Health): Modern Isolation and Quarantine Infection Control Issues
- T. Moulton: Quarantine: Law & Collaboration
- S. Gravely (Troutman Sanders): Isolation & Quarantine: Proposed Legislative Amendments
- J. Moore (VDH DTC): Virginia TB Control Act of 2001: What You Need to Know