The Control of Emerging Infectious Diseases: What Can We Actually Do? Tim Hilderman, MD FRCPC Medical Officer of Health, Vaccines MHSAL

The Control of Emerging Infectious Diseases: What Can We Actually Do? Tim Hilderman, MD FRCPC Medical Officer of Health, Vaccines MHSAL

DISCLOSURE STATEMENT Tim Hilderman, MD FRCPC The Control of Emerging Infectious Diseases: What Can We Actually Do? Type of relationship Modest (less than 10K) Please specify organization name Significant (greater than $10K) Please specify organization name A - Consulting Fees/Honoraria B - Speaker s Bureau C - Equity Interests/Stock Options/Royalty Income/Non Royalty Payments D - Officer, Director, Or In Any Other Fiduciary Role E - Ownership/Partnership/Principal F- Research Grants/Educational Grants G- Fellowship Support H Salary I - Intellectual Property Rights J - Other Financial Benefit There are no relationships to disclose X 2

Objectives 1) Utilize the basic principles of communicable disease control in travel health practice 2) Critique the strengths and limitations of Manitoba s Public Health Act as it pertains to infectious disease 3) Select the appropriate intervention in the control efforts designed to mitigate a travel acquired communicable disease threat

The Principles of Communicable Disease Control in Emergencies Rapid Assessment Prevention Surveillance Outbreak Control

Rapid Assessment Identify the communicable disease threat faced by the population Assess for epidemic potential Assess susceptibility of the population Estimate morbidity and mortality Identify mitigation measures

Prevention Control Vectors (Malaria) Implement Vaccination Campaigns (Measles) Provide essential clinical services Provide essential laboratory services Establish Infection Prevention and Control Protocols

Surveillance Detect outbreaks early Report diseases of epidemic potential immediately Monitor disease trends

Control Outbreaks Prepare outbreak response team/stockpiles/laboratory support/standard treatment protocols Detect surveillance/early warning system Confirm laboratory tests Respond investigation/control measures Evaluate

International Health Regulations The International Health Regulations (IHR) are an international legal instrument that is binding on 196 countries across the globe, including all the Member States of WHO. Their aim is to help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide.

Purpose and Scope IHR (2005) to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade.

10 Things you need to know* Know the IHR; purpose, scope, principles and concepts Update national legislation Recognize shared realities and the need for collective defences Monitor and report on IHR implementation progress Notify, report, consult and inform WHO Understand WHO s role in international event detection, joint assessment and response Participate in the PHEIC determination and WHO recommendationsmaking processes Strengthen national surveillance and response capacities Increase public health security at ports airports and ground crossings Use and disseminate IHR health documents at points of entry

What the HECK is a PHEIC? A public health emergency of international concern an extraordinary event which is determined to constitute a public health risk to other States through the international spread of disease and to potentially require a coordinated international response. serious, sudden, unusual or unexpected; carries implications for public health beyond the affected State s national border; and may require immediate international action.

The Emergency Committees Determine if the event constitutes a public health emergency of international concern (PHEIC); Temporary Recommendations that should be taken by the country experiencing an emergency of international concern, or by other countries, to prevent or reduce the international spread of disease and avoid unnecessary interference with international trade and travel The WHO Director-General makes the final decision re: PHEIC and Temporary Recommendations to address the situation, based on advice from the Emergency Committee, information provided by the State Parties, scientific experts and an assessment of risk to human health, risk of international spread of disease and of risk of interference with international travel.

IHR Emergency Committees Review Committee on the role of IHR IHR Emergency Committee on Ebola IHR Emergency Committee on MERS-CoV IHR Emergency Committee on poliovirus IHR Emergency Committee on yellow fever IHR Emergency Committee on Zika virus

Public Health Agency of Canada Prevent and control infectious diseases; Prepare for and respond to public health emergencies; Serve as a central point for sharing Canada's expertise with the rest of the world; Apply international research and development to Canada's communicable disease programs; and Strengthen intergovernmental collaboration on public health and facilitate national approaches to public health policy and planning.

Canadian Border Services! Ensure the free flow of legitimate people and goods by monitoring, investigating, detaining and removing those people or goods in violation of the relevant laws. Ensure trade security, manage access to Canada and work together with business and other government organizations.

Quarantine Program To prevent the introduction and spread of communicable diseases that are of significant harm to public health, the Quarantine Program collaborates with border health partners, such as the Canadian Border Services Agency, to administer the Quarantine Act, 24 hours per day, 7 days per week, at all Canadian international points of entry. Through this program, Quarantine Officers provide services (in person or remotely) to all points of entry through six quarantine stations, which are located in the following cities: Calgary, Halifax, Montréal, Ottawa, Toronto, and Vancouver.

Quarantine Officers Train border health partners (including Canadian Border Services Agency officers) to screen arriving international travellers for signs and symptoms of communicable disease of significant harm to public health; Collaborate with partners (such as point of entry authorities, other government departments, and local emergency medical and public health authorities) to ensure efficient notification and response to communicable disease events; Perform health assessments on ill travellers arriving in or in the process of departing from Canada;

Quarantine Officers Refer ill travellers to hospitals or local public health authorities for further measures, as appropriate; Notify CBSA and airlines of travelers who may pose a risk to public health in order to prevent them from departing Canada and to be identified when entering Canada, so they may be referred to a Quarantine Officer for assessment; Work in collaboration with the International Health Regulations to communicate potential public health risks globally. The Quarantine Act authorizes quarantine officers to implement various control measures to prevent the introduction and spread of communicable disease. Under the Act, failure to comply can carry fees and penalties

Isolation vs. Quarantine Isolation and quarantine are public health practices used to stop or limit the spread of disease. Isolation is used to separate ill persons who have a communicable disease from those who are healthy. Isolation restricts the movement of ill persons to help stop the spread of certain diseases. Quarantine is used to separate and restrict the movement of well persons who may have been exposed to a communicable disease to see if they become ill. Quarantine can also help limit the spread of communicable disease. Isolation and quarantine are used to protect the public by preventing exposure to infected persons or to persons who may be infected.

Ebola Virus Disease Situation report EVD 2014-2016 28,616 Ebola cases reported in Guinea, Liberia and Sierra Leone 11,310 deaths.

EVD The 2014 2016 outbreak in West Africa was the largest and most complex Ebola outbreak since the virus was first discovered in 1976. There were more cases and deaths in this outbreak than all others combined. It also spread between countries, starting in Guinea then moving across land borders to Sierra Leone and Liberia

MB EVD PH Response Driven by MHSAL CDC Protocol Protocol intended to support the work of public health staff that are dealing with travelers who are coming from Ebola affected countries, as well as managing the contacts of domestic cases of Ebola Virus Disease (EVD) and potential laboratory Level 4 exposures at the National Microbiology Laboratory (NML) in Winnipeg, Manitoba.

EVD Risk Manitoba categorized the risk status of EVD affected countries into three categories: 1. Those with ongoing, widespread, and intense EVD transmission, or; 2. Those with an initial case or cases and/or localized transmission, or; 3. Those with a previous EVD case or cases, now declared free of EVD.

Step 1 Travelers to Canada from countries with ongoing, widespread, and intense EVD transmission will be screened at their port of entry by Canadian Border Services and referred immediately to a Quarantine Officer (QO) who will do an EVD risk assessment. Travelers classified as risk Group 5 will be given a federal order to report to the public health authority at their port of entry into Canada (the majority being in Montreal and Toronto) and will be restricted from any onward travel.

Group 5 Direct contact with blood/body fluids of a confirmed EVD case (including HCW using PPE with breach).

Order to Report Travelers classified as risk Group 2/3 or 4 for EVD during the screening risk assessment will be given a federal order to report within 24 hours to the appropriate regional public health authority.

Step 2 All travelers from countries with ongoing, widespread, and intense EVD transmission returning to Manitoba who do not have Winnipeg as a final destination will be requested by a port of entry QO to contact the Medical Officer of Health prior to, or immediately after, arrival in Winnipeg and before any onward travel beyond city limits. This process will allow the Medical Officer of Health, in consultation with regional public health staff, to assess the final destination for public health follow-up. Guidelines for remote or rural areas where public health followup of EVD contacts during the 21 day symptom monitoring period could be difficult were also developed

Public Health Practice Grp. 5 Teach symptom recognition twice daily temperature checks (supply thermometer if necessary) avoid antipyretics Instruct individual to postpone elective medical visits and other elective procedures Instruct individual to maintain good respiratory and hand hygiene Instruct individual to self-isolate and call 911 or local emergency number if signs or symptoms occur Active Monitoring (Direct Active Monitoring if compliance and competency cannot be assured) Restrict Travel using no fly list Restrict Movement (no public conveyance {plane/bus/taxi} individual cannot come within 2 metres (6 ft) of another individual in a public

The Public Health Act Consider use of statutory powers under the Public Health Act if compliance cannot be assured

EVD PH Measures To ensure an appropriate and consistent approach to the public health management of an asymptomatic yet high risk contact of Ebola virus disease (EVD) who is non-compliant with the appropriate public health (PH) interventions and follow up measures (referred to in this document as EVD PH measures ) as outlined in the Manitoba Health EVD Public Health (PH) Management Interim Guidelines.

Non-Compliant! Has been deemed by public health to be a high risk EVD contact (Group 5) Has been informed by public health of appropriate EVD PH measures as defined by the EVD Public Health Management Interim Guidelines; Has been counseled on the virulent and communicable nature of EVD, and the importance of appropriate EVD PH measures; Has been offered assistance in addressing barriers that may prevent client from complying with the appropriate public health interventions and follow up; Is non-compliant with appropriate EVD PH measures

Underlying Principles The primary concern of public health officials should be to reduce the risk of EVD transmission to others; Public health interventions must balance the rights of the individual with the duty to protect the public, where risk to public safety may override the rights of the individual; Public health officials should exercise good judgment in employing the set of available options taking into consideration the context of the client and the specifics of the case.

Involuntary Measures If after exploring all reasonable available supportive non-coercive voluntary avenues to facilitate compliance, public health determines that traveller is, or will be, non-compliant with appropriate EVD PH measures, an Advisory Team should be convened.

Issuing a Communicable Disease Order for Quarantine Issued by the Medical Officer of Health under Section 43(1) Communicable Disease Order under The Public Health Act (C.C.S.M. c. P210), a Should include the plan of action should this order be violated, (i.e. preparing a Section 53(1) Emergency Detention Order under The Public Health Act (C.C.S.M. c. P210))

Emergency Detention Order s. 53(1) Emergency Detention Order issued verbally to appropriate law enforcement agency (e.g., WPS), and confirmed in writing within 72 hours (s. 100) (Form 3A, see below and template)

Application to Continue Detention Application to Continue Detention (s. 54) must be submitted to Justice for a hearing as soon as possible but no later than 72 hours after client is apprehended: 1: Contact Civil Legal Services for assistance; 2: Ensure necessary arrangements to have client participate by telephone, teleconference, or similar means (see s. 48, s. 49, s. 52 for details related to hearing); 3: Present the following documents to Law Courts: A: s. 43 CD Order (Form 1A, see template); B: s. 53 Emergency Detention Order (Form 3A, see template) C: s. 54 Application to Continue Detention or For Order Under Section 49 for Virulent Disease (CRT20118, see template) D: Any additional supporting documents (e.g., evidence of client non-compliance

Order to Continue Detention Order to Continue Detention for Virulent Disease (s. 54) will be issued by the court and signed by the Judicial Justice of the Peace (Form CRT20119)