1. Welcome to the Virginia Social Distancing Legal Consultation Meeting Crowne Plaza Richmond West October 9, 2007

2. Introduction Dr. Lisa Kaplowitz Deputy Commissioner for Emergency Preparedness and Response, VDH

3. Introduction Legal preparedness for public health threats is critical Legal preparedness for public health threats is critical Virginia has made important progress, such as: Virginia has made important progress, such as: 2003: Updated legislation to address communicable diseases of public health threat2003: Updated legislation to address communicable diseases of public health threat 2006: Trainings on legal issues and pandemic influenza2006: Trainings on legal issues and pandemic influenza

4. Social Distancing Law Project (SDLP) To assist states, CDC and ASTHO have implemented a Social Distancing Law Project (SDLP) To assist states, CDC and ASTHO have implemented a Social Distancing Law Project (SDLP) Phase I Phase I Comprehensive legal assessment of disease control measures at state and local levelComprehensive legal assessment of disease control measures at state and local level Completed July 2007Completed July 2007 Phase II: Legal Consultation Meeting (LCM) Phase II: Legal Consultation Meeting (LCM) Purpose: bring together key stakeholders to further explore legal issues related to public health emergencies related to communicable conditionsPurpose: bring together key stakeholders to further explore legal issues related to public health emergencies related to communicable conditions

5. Workgroup and Plenary Sessions In-depth expert discussion with inter-agency sharing In-depth expert discussion with inter-agency sharing Three workgroups: Three workgroups: Red/A, Yellow/B, and Green/CRed/A, Yellow/B, and Green/C See name badge for assignmentSee name badge for assignment

6. Participants American Red Cross American Red Cross Association of State and Territorial Health Officers (ASTHO) Association of State and Territorial Health Officers (ASTHO) City and County Attorneys City and County Attorneys Commonwealth Attorneys Commonwealth Attorneys D.C. Department of Health D.C. Department of Health Local Police Local Police Maryland Department of Health and Mental Hygiene Maryland Department of Health and Mental Hygiene Metropolitan Washington Airports Authority (MWAA) Metropolitan Washington Airports Authority (MWAA) Sheriffs Sheriffs Supreme Court of Virginia Supreme Court of Virginia US Centers for Disease Control and Prevention (CDC) US Centers for Disease Control and Prevention (CDC) US Department of Health and Human Services (DHHS) US Department of Health and Human Services (DHHS) Virginia Capitol Police Virginia Capitol Police Virginia Department of Agriculture and Consumer Services (VDACS) Virginia Department of Agriculture and Consumer Services (VDACS) Virginia Department of Education Virginia Department of Education Virginia Department of Health (VDH) Virginia Department of Health (VDH) Virginia General Assembly Virginia General Assembly Virginia Hospital and Healthcare Association (VHHA) Virginia Hospital and Healthcare Association (VHHA) Virginia National Guard (VNG) Virginia National Guard (VNG) Virginia Office of the Attorney General (OAG) Virginia Office of the Attorney General (OAG) Virginia Poverty Law Center (VPLC) Virginia Poverty Law Center (VPLC) Virginia State Police (VSP) Virginia State Police (VSP)

7. Administrative and Safety Issues Dr. Christopher Novak Office of Epidemiology, VDH

8. Legal Consultation Meeting Materials: Materials: Situation manualSituation manual PresentationsPresentations FormsForms Evaluation Evaluation Travel reimbursement (if necessary) Travel reimbursement (if necessary)

9. Administration Responses are being recorded to facilitate data gathering Responses are being recorded to facilitate data gathering Please use microphones for plenary sessionsPlease use microphones for plenary sessions For response, please state name and agencyFor response, please state name and agency Decisions are not precedent-setting and may not reflect your organizations final position on a given issueDecisions are not precedent-setting and may not reflect your organizations final position on a given issue

10. Safety and Comfort Evacuation Evacuation RosterRoster DoorsDoors Assembly pointAssembly point Restrooms Restrooms Mobile phones, pagers Mobile phones, pagers Please turn to silent modePlease turn to silent mode Refreshments Refreshments

11. Purpose, Scope, and Principles Suzi Silverstein Emergency Preparedness and Response, VDH

12. Purpose Identify and discuss potential enhancements to legal preparedness for public health emergencies resulting from communicable conditions Identify and discuss potential enhancements to legal preparedness for public health emergencies resulting from communicable conditions May lead to changes in policy, procedures, regulation, or law May lead to changes in policy, procedures, regulation, or law Outcomes from 2006 OAG meeting led to specific amendments to VA lawOutcomes from 2006 OAG meeting led to specific amendments to VA law

13. Focus for Today Social distancing and other disease control measures, including but not limited to: Social distancing and other disease control measures, including but not limited to: IsolationIsolation QuarantineQuarantine Self-shieldingSelf-shielding CurfewCurfew Cancellation of public eventsCancellation of public events Closure of public placesClosure of public places Travel restrictionsTravel restrictions Mass prophylaxis/vaccinationMass prophylaxis/vaccination Also, addressing: Also, addressing: Communication/cooperationCommunication/cooperation Declaration of State of EmergencyDeclaration of State of Emergency

14. Activities Explore opinions/attitudes on the viability and sufficiency of legal authorities in VA Explore opinions/attitudes on the viability and sufficiency of legal authorities in VA Identify problems that could arise in executing social distancing measures Identify problems that could arise in executing social distancing measures Procedural, logistical, ethical, or enforcement issuesProcedural, logistical, ethical, or enforcement issues Identify additional steps related to legal preparedness that warrant further attention Identify additional steps related to legal preparedness that warrant further attention

15. Scope Can specific action be done (legally) and degree of confidence that it will prevail during a legal challenge? Can specific action be done (legally) and 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? Who has the authority to order the measure, and how would it be accomplished? What are the enforcement challenges that must be considered? What are the enforcement challenges that must be considered? Are there legal options or alternatives? Are there legal options or alternatives? What are the legal ramifications that must be considered? What are the legal ramifications that must be considered? Constitutional rights issues such as freedom of association, equal protection, and due processConstitutional rights issues such as freedom of association, equal protection, and due process

16. Principles The Situation Manual contains many issues that have been identified through past discussions and exercises The Situation Manual contains many issues that have been identified through past discussions and exercises Some are relatively simple – others are extremely complex Some are relatively simple – others are extremely complex Todays LCM likely cannot cover all of the issues Todays LCM likely cannot cover all of the issues Address as many issues in as much detail as possibleAddress as many issues in as much detail as possible Identify problems/gaps/challengesIdentify problems/gaps/challenges

17. Roles Players: participate in discussion based on expert knowledge and experience Players: participate in discussion based on expert knowledge and experience Group Facilitators: moderate discussions and access outside assistance (clarification on issues, details regarding scenarios) Group Facilitators: moderate discussions and access outside assistance (clarification on issues, details regarding scenarios) Data Collectors: gather information and record the players responses Data Collectors: gather information and record the players responses Observers: may participate as desired Observers: may participate as desired

18. Social Distancing: Legal Authority Robin Kurz Virginia Office of the Attorney General

19. Social Distancing Governors Authority Governors Authority Local Governments AuthorityLocal Governments Authority State Health Commissioners Authority State Health Commissioners Authority

20. Governors Authority Commonwealth of Virginia Emergency Services and Disaster Law of 2000. Commonwealth of Virginia Emergency Services and Disaster Law of 2000. Va. Code § 44-146.13 et seq. Governor may declare state of emergency. Governor may declare state of emergency.

21. Governors Authority Issue executive orders and proclaim rules for purposes of emergency. Issue executive orders and proclaim rules for purposes of emergency. Direct and compel evacuation of all or part of the populace from any stricken or threatened area. Direct and compel evacuation of all or part of the populace from any stricken or threatened area. Prescribe routes, modes of transportation, and destination. Prescribe routes, modes of transportation, and destination. Control ingress and egress at emergency area, including movement of persons and occupancy of premises. Control ingress and egress at emergency area, including movement of persons and occupancy of premises. Va. Code § 44-146.17

22. Governors Authority Executive orders have force and effect of law. Violation thereof shall be punishable as a Class 1 misdemeanor if order so states. Executive orders have force and effect of law. Violation thereof shall be punishable as a Class 1 misdemeanor if order so states. Va. Code § 44-146.17

23. Local Government Authority When Governor declares a state of emergency, each political subdivision within the disaster area may, under the supervision of the Governor: When Governor declares a state of emergency, each political subdivision within the disaster area may, under the supervision of the Governor: Control use, sale, production, and distribution of food, fuel, clothing, materials, goods, services, and resource systems that do not impact other political subdivisions.Control use, sale, production, and distribution of food, fuel, clothing, materials, goods, services, and resource systems that do not impact other political subdivisions. Enter into contracts and incur obligations without usual formalities.Enter into contracts and incur obligations without usual formalities. Protect the health and safety of persons and property.Protect the health and safety of persons and property. Provide emergency assistance to victims.Provide emergency assistance to victims. Va. Code § 44-146.19

24. Local Government Authority When locality declares an emergency, it may: When locality declares an emergency, it may: Control use, sale, production, and distribution of food, fuel, clothing, materials, goods, services, and resource systems that do not impact other political subdivisions.Control use, sale, production, and distribution of food, fuel, clothing, materials, goods, services, and resource systems that do not impact other political subdivisions. Enter into contracts and incur obligations without usual formalities.Enter into contracts and incur obligations without usual formalities. Protect the health and safety of persons and property.Protect the health and safety of persons and property. Provide emergency assistance to victimsProvide emergency assistance to victims If Governor has declared state of emergency, may w/ supervision act outside capabilities of local govt.If Governor has declared state of emergency, may w/ supervision act outside capabilities of local govt. Va. Code § 44-146.21

25. State Health Commissioners Authority Orders of Isolation and Quarantine Orders of Isolation and Quarantine

26. Background: Isolation and Quarantine Isolation: separation (for period of communicability) of known infected persons to prevent transmission of an infectious agent. 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. Quarantine: restriction of activities during the incubation period of healthy persons exposed to a communicable disease to prevent transmission.

27. Isolation for Communicable Diseases of Public Health Significance Petition filed in General District Court. Petition filed in General District Court. Designed for one person and for diseases that do not spread rapidly, such as tuberculosis. Designed for one person and for diseases that do not spread rapidly, such as tuberculosis. Very due process heavy. Very due process heavy. No detailed procedure for quarantine. No detailed procedure for quarantine. Va. Code § 32.1-48.01 to 32.1-48.04

28. Isolation and Quarantine for Communicable Disease of Public Health Threat Disease of public health threat. Disease of public health threat. Readily transmittedReadily transmitted Risk of death or significant injury or impairmentRisk of death or significant injury or impairment E.g. smallpox, ebola, pandemic flu, pneumonic plagueE.g. smallpox, ebola, pandemic flu, pneumonic plague Exceptional circumstances or individual does not voluntarily comply with Health Depts recommendations. Exceptional circumstances or individual does not voluntarily comply with Health Depts recommendations. Va. Code § 32.1-48.05 - 32.1-48.017 12 VAC 5-90-103, 12 VAC 5-90-105

29. Order of Isolation State Health Commissioner issues Order of Isolation setting forth: State Health Commissioner issues Order of Isolation setting forth: Identity of person(s) or affected areaIdentity of person(s) or affected area Site of isolationSite of isolation Date and time that isolation commencesDate and time that isolation commences Communicable disease of public health threatCommunicable disease of public health threat Bases for isolationBases for isolation Timely opportunities for subject to notify employer, family, and attorneyTimely opportunities for subject to notify employer, family, and attorney Penalty for noncompliance with orderPenalty for noncompliance with order A copy of Va. Code § 32.1-48.013 re: appealsA copy of Va. Code § 32.1-48.013 re: appeals Va. Code § 32.1-48.012

30. Order of Quarantine State Health Commissioner issues Order of Quarantine setting forth: State Health Commissioner issues Order of Quarantine setting forth: Communicable disease of public health threatCommunicable disease of public health threat Reasonable notice of order to subjectsReasonable notice of order to subjects Means by which quarantine implementedMeans by which quarantine implemented Geographic parameters of quarantineGeographic parameters of quarantine Duration of quarantineDuration of quarantine Directions for complianceDirections for compliance Timely opportunity to notify employer, family, and attorneyTimely opportunity to notify employer, family, and attorney Penalties for noncompliancePenalties for noncompliance Copy of Va. Code § 32.1-48.010 re: appealsCopy of Va. Code § 32.1-48.010 re: appeals Va. Code § 32.1-48.09

31. Delivery of Order(s) Order delivered to person(s) affected in so far as practicable Order delivered to person(s) affected in so far as practicable If number of persons is too great, Commissioner shall cause order to be communicated to the persons residing or located in the affected area If number of persons is too great, Commissioner shall cause order to be communicated to the persons residing or located in the affected area Order remains in place while petition for ex parte review is pending Order remains in place while petition for ex parte review is pending

32. Ex parte Court Review of Order(s) Commissioner shall file a petition seeking an ex parte court review and confirmation as soon as practicable after issuing the Order. Commissioner shall file a petition seeking an ex parte court review and confirmation as soon as practicable after issuing the Order. Petition filed in circuit court in county or city where person resides or in the circuit court of the affected area. Petition filed in circuit court in county or city where person resides or in the circuit court of the affected area. Petition includes a copy of the order and a summary of the findings upon which the Commissioner relied. Petition includes a copy of the order and a summary of the findings upon which the Commissioner relied. The Commissioner may file some or all of any petition under seal. The Commissioner may file some or all of any petition under seal. Va. Code §§ 32.1-48.09, 32.1-48.012

33. Court Findings The court shall grant the petition to confirm/extend the order upon finding: The court shall grant the petition to confirm/extend the order upon finding: Probable cause that isolation/quarantine was the necessary means to contain the diseaseProbable cause that isolation/quarantine was the necessary means to contain the disease Implementation is in the least restrictive environment necessaryImplementation is in the least restrictive environment necessary The Court shall give due deference to the specialized expertise of the Commissioner. The Court shall give due deference to the specialized expertise of the Commissioner. Va. Code §§ 32.1-48.09, 32.1-48.012

34. Appeal of Order Person subject to order may file a petition for appeal in the circuit court. Person subject to order may file a petition for appeal in the circuit court. Person appealing has burden of proving that does not need to be isolated or quarantined. Person appealing has burden of proving that does not need to be isolated or quarantined. Court shall not conduct de novo review, but shall consider existing record and supplemental evidence as the court considers relevant. Court shall not conduct de novo review, but shall consider existing record and supplemental evidence as the court considers relevant.

35. Appeal of Order Appeal shall not stay order. Appeal shall not stay order. Hearing shall be held within 48 hours. Hearing shall be held within 48 hours. In extraordinary circumstances, for good cause shown, the Commissioner may request a continuance.In extraordinary circumstances, for good cause shown, the Commissioner may request a continuance. Court may consolidate multiple appeals. Court may consolidate multiple appeals. Court shall appoint counsel for those unable to afford attorney. Court shall appoint counsel for those unable to afford attorney. Interpreters. Interpreters. Va. Code §§ 32.1-48.010, 32.1-48.012

36. Appeal of Order Court may: Court may: Confirm,Confirm, Modify, orModify, or Vacate the order.Vacate the order. Any party may file appeal of courts decision to the Supreme Court of Virginia. Any party may file appeal of courts decision to the Supreme Court of Virginia.

37. Appeal to Supreme Court of Virginia Petition for Appeal. Petition for Appeal. Brief in Opposition due w/in 48 hours or Court may grant petition before Brief in Opposition filed. Brief in Opposition due w/in 48 hours or Court may grant petition before Brief in Opposition filed. Court shall act on petition w/in 72 hours of filing. Court shall act on petition w/in 72 hours of filing. Court may permit oral argument. Court may permit oral argument. Court has the authority to alter these time frames. Court has the authority to alter these time frames. Rule 5:43

38. Health and Safety The Court shall hold hearings in a way to protect health and safety The Court shall hold hearings in a way to protect health and safety Hearing by telephone or video conferenceHearing by telephone or video conference Personal protective equipmentPersonal protective equipment Rules 3.24, 5:43, 7A:16

39. Enforcement of Isolation & Quarantine Enforced by law enforcement agencies and Commonwealth Attorneys Class 1 Misdemeanor Class 1 Misdemeanor Confinement for up to 12 monthsConfinement for up to 12 months Fine of up to $2,500Fine of up to $2,500 Injunction Injunction Civil Penalties Civil Penalties Va. Code §§ 32.1-27, 32.1-48.014

40. 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 commissioner determines that an individual no longer poses a threat to the public health The order has expired, or The order has expired, or The order has been vacated by the court The order has been vacated by the court

41. Other Forms of Movement Restriction Federal isolation and quarantine laws Federal isolation and quarantine laws State veterinarian can restrict animals. State veterinarian can restrict animals. Va. Code § 3.1-726 to 728 Curfew for minors. Curfew for minors. Va. Code § 15.2-926 Temporary detention of individuals incapable of making informed decisions. Temporary detention of individuals incapable of making informed decisions. Va. Code § 37.2-1103. Emergency detention of individuals w/mental illness. Emergency detention of individuals w/mental illness. Va. Code § 37.2-808

42. Tabletop: Background/Situation Dr. Christopher Novak Office of Epidemiology, VDH

43. Scenarios - Background Influenza virus Influenza virus Infects human respiratory tractInfects human respiratory tract Different strains – previous infection (or vaccination) provides some immunityDifferent strains – previous infection (or vaccination) provides some immunity Seasonal outbreaks (usually winter/spring)Seasonal outbreaks (usually winter/spring) Highly contagious (contact, droplet, ?airborne)Highly contagious (contact, droplet, ?airborne) Contagious period begins before symptoms appear and lasts about a weekContagious period begins before symptoms appear and lasts about a week

44. Pandemic Influenza New strain, or strain that has not circulated for a long time New strain, or strain that has not circulated for a long time Little or no immunity in humans Little or no immunity in humans May cause high levels of illness, death, social disruption, and economic loss May cause high levels of illness, death, social disruption, and economic loss Spanish Flu (1918) Spanish Flu (1918)

45. The Problem With Pandemics… Last much longer than most other emergency events Last much longer than most other emergency events May come in waves May come in waves Healthcare workers and first responders will be affected Healthcare workers and first responders will be affected High risk of illnessHigh risk of illness Care for ill family membersCare for ill family members Wide range of resources could be limited due to broad impact Wide range of resources could be limited due to broad impact Medication, supplies, ventilators, food, fuel, etc.Medication, supplies, ventilators, food, fuel, etc.

46. Group A Scenario Arrival at Dulles of person who becomes ill next day Arrival at Dulles of person who becomes ill next day Exposes large number of Virginia residents after symptoms develop Exposes large number of Virginia residents after symptoms develop Large number of people potentially exposed Large number of people potentially exposed Orders of isolation/quarantine issued Orders of isolation/quarantine issued

47. Group B Scenario Agriculture student develops symptoms Agriculture student develops symptoms Exposure of poultry to pandemic strain Exposure of poultry to pandemic strain Efforts to restrict movement on and off university campus, including establishment of curfew Efforts to restrict movement on and off university campus, including establishment of curfew

48. Group C Scenario Impact of pandemic on healthcare system, including hospitals Impact of pandemic on healthcare system, including hospitals Canceling of public gatherings Canceling of public gatherings Widespread shortages Widespread shortages High absenteeism High absenteeism Public information campaigns Public information campaigns

49. Movement Restrictions Workgroups will meet to review their specific scenario details Workgroups will meet to review their specific scenario details Red/Group A – Facilitator: Steve Gravely Red/Group A – Facilitator: Steve Gravely Yellow/Group B – Facilitator: Dr. Diane Woolard Yellow/Group B – Facilitator: Dr. Diane Woolard Green/Group C – Facilitator: Dr. Lisa Kaplowitz Green/Group C – Facilitator: Dr. Lisa Kaplowitz Scenarios provide general contextScenarios provide general context Issues for discussion should be explored to the best of the groups abilitiesIssues for discussion should be explored to the best of the groups abilities Plenary session will follow to share key findings and to identify larger issues Plenary session will follow to share key findings and to identify larger issues

50. Break Resume in Salon II (here) in 10 minutes...

51. Movement Restrictions Workgroups Red/Group A – Facilitator: Steve Gravely Yellow/Group B – Facilitator: Dr. Diane Woolard Green/Group C – Facilitator: Dr. Lisa Kaplowitz 50 minutes

52. Movement Restrictions Plenary Session Suzi Silverstein Emergency Preparedness and Response, VDH

53. Group A - Key Issues General or specific issues identified? General or specific issues identified?

54. Group A - Key Issues (cont)

55. Group A – Additional Thoughts Constitutional rights issues that have been identified Constitutional rights issues that have been identified Surge capacity of courts Surge capacity of courts Improving awareness/training Improving awareness/training Continuity of operations options Continuity of operations options Issues regarding orders of isolation and quarantine Issues regarding orders of isolation and quarantine Non-infectious communicable diseases of public health threat (e.g., Polonium-210) Non-infectious communicable diseases of public health threat (e.g., Polonium-210) Individual privacy protection Individual privacy protection Legal issues regarding accidental or intentional infection Legal issues regarding accidental or intentional infection Civil or criminal penaltiesCivil or criminal penalties

56. Group A – Additional Thoughts (cont) Duration of order of quarantine for affected areas – problematic? Duration of order of quarantine for affected areas – problematic? Distribution of orders to individuals in affected areas Distribution of orders to individuals in affected areas Determination of just compensation for government use of private property Determination of just compensation for government use of private property Curfew Curfew Need for additional statutesNeed for additional statutes Closure of public places Closure of public places Seizure of property?Seizure of property? Compensation?Compensation? Civil rights issues?Civil rights issues?

57. Group B – Key Issues General or specific issues identified? General or specific issues identified?

58. Group B - Key Issues (cont)

59. Group B – Additional Thoughts Surge capacity of law enforcement Surge capacity of law enforcement Issues regarding orders of isolation and quarantine Issues regarding orders of isolation and quarantine Detention of noncompliant individual if non-compliance not witnessed by officerDetention of noncompliant individual if non-compliance not witnessed by officer Witnesses for enforcement Witnesses for enforcement Public health department staff time/resource demandsPublic health department staff time/resource demands

60. Group B – Additional Thoughts (cont) Physical force for movement restriction, curfew, closure of public places Physical force for movement restriction, curfew, closure of public places Control of animals that may transmit agent Control of animals that may transmit agent Companion animalsCompanion animals Livestock/poultryLivestock/poultry WildlifeWildlife Important public messages for your agency at this time (e.g., change in hours or procedures) Important public messages for your agency at this time (e.g., change in hours or procedures) How would this information be disseminated?How would this information be disseminated? Curfew Curfew Minimizing impactMinimizing impact Closure of public places Closure of public places Legislation regarding cordon sanitaire?Legislation regarding cordon sanitaire?

61. Group C – Key Issues General or specific issues identified? General or specific issues identified?

62. Group C - Key Issues (cont)

63. Group C – Additional Thoughts Surge capacity of healthcare Surge capacity of healthcare Continuity of operations options Continuity of operations options Return to work policies for healthcare, business Return to work policies for healthcare, business Doctors note?Doctors note? Temporary waivers for licensing/credentials of businesses – what can be relaxed? Temporary waivers for licensing/credentials of businesses – what can be relaxed? How would prophylaxis, vaccination, or prior infection affect movement restrictions? How would prophylaxis, vaccination, or prior infection affect movement restrictions?

64. Group C – Additional Thoughts (cont) Curfew Curfew Minimizing impactMinimizing impact Closure of public places Closure of public places Concerns regarding appropriate access to healthcare, essential needsConcerns regarding appropriate access to healthcare, essential needs

65. Lunch Break Sapphire Grill Resume in Salon II (here) at 1:00 p.m.

66. Mass Prophylaxis Robin Kurz Virginia Office of the Attorney General

67. Mass Prophylaxis State Health Commissioner may require immediate immunization of all persons in an epidemic of a disease of public health importance unless detrimental to a persons health as certified by a physician. State Health Commissioner may require immediate immunization of all persons in an epidemic of a disease of public health importance unless detrimental to a persons health as certified by a physician. Va. Code § 32.1-48

68. Drug Control Non-emergency Virginias Drug Control Act restricts who can dispense prescription drugs and who can give immunizations. Virginias Drug Control Act restricts who can dispense prescription drugs and who can give immunizations. Va. Code § 54.1-3401; Va. Code § 54.1-3408 Prescriptions drugs given by a physician, nurse practitioner, physicians assistant, vet, etc. Prescriptions drugs given by a physician, nurse practitioner, physicians assistant, vet, etc. Immunizations by a pharmacist or licensed nurse Immunizations by a pharmacist or licensed nurse

69. Mass Prophylaxis O. In addition, this section shall not prevent the administration or dispensing of drugs and devices by persons if they are authorized by the State Health Commissioner in accordance with protocols established by the State Health Commissioner pursuant to § 32.1-42.1 when (i) the Governor has declared a disaster or a state of emergency or the United States Secretary of Health and Human Services has issued a declaration of an actual or potential bioterrorism incident or other actual or potential public health emergency; (ii) it is necessary to permit the provision of needed drugs or devices; and (iii) such persons have received the training necessary to safely administer or dispense the needed drugs or devices. Such persons shall administer or dispense all drugs or devices under the direction, control and supervision of the State Health Commissioner. O. In addition, this section shall not prevent the administration or dispensing of drugs and devices by persons if they are authorized by the State Health Commissioner in accordance with protocols established by the State Health Commissioner pursuant to § 32.1-42.1 when (i) the Governor has declared a disaster or a state of emergency or the United States Secretary of Health and Human Services has issued a declaration of an actual or potential bioterrorism incident or other actual or potential public health emergency; (ii) it is necessary to permit the provision of needed drugs or devices; and (iii) such persons have received the training necessary to safely administer or dispense the needed drugs or devices. Such persons shall administer or dispense all drugs or devices under the direction, control and supervision of the State Health Commissioner.32.1-42.1 Va. Code § 54.1-3408(O)

70. Mass Prophylaxis Such persons shall administer or dispense all drugs or devices under the direction, control and supervision of the Commissioner. The Commissioner shall develop protocols, in consultation with the Department of Health Professions, that address the required training of such persons and procedures for such persons to use in administering or dispensing drugs or devices. Such persons shall administer or dispense all drugs or devices under the direction, control and supervision of the Commissioner. The Commissioner shall develop protocols, in consultation with the Department of Health Professions, that address the required training of such persons and procedures for such persons to use in administering or dispensing drugs or devices. Va. Code § 32.1-42.1

71. Mass Prophylaxis Animals Animals Broad power to eradicate and prevent the spread of diseasesBroad power to eradicate and prevent the spread of diseases Va. Code §§ 3.1-726 to 728

72. Mass Prophylaxis Governor has the ability to suspend licensure requirements of health professionals. Governor has the ability to suspend licensure requirements of health professionals. 2002 Va. AG 202

73. Mass Prophylaxis Plenary Session Suzi Silverstein Emergency Preparedness and Response, VDH

74. Mass Prophylaxis - Issues General or specific issues? General or specific issues? Ethical and legal issues on distribution of limited supplies Ethical and legal issues on distribution of limited supplies Essential personnel versus highest riskEssential personnel versus highest risk Could/should non-citizens be denied accessCould/should non-citizens be denied access Who determines vaccine and antiviral priority groups? Who determines vaccine and antiviral priority groups? How to communicate priority group decisions to the public and staff to promote acceptance? How to communicate priority group decisions to the public and staff to promote acceptance? What storage and transportation control plans exist to support vaccine and antiviral distribution? What storage and transportation control plans exist to support vaccine and antiviral distribution?

75. Mass Prophylaxis – Issues (cont) What is the legal authority for the state to require specific private sector response to state resource requests (e.g., prioritization of antivirals)? What is the legal authority for the state to require specific private sector response to state resource requests (e.g., prioritization of antivirals)? Does an Memorandum of Understanding have to be pre-arranged? Does an Memorandum of Understanding have to be pre-arranged? Can the Governor direct the use of private resources? Can the Governor direct the use of private resources? Can the state seize antivirals or vaccine for use (Code of Virginia § 44-146.17)? Can the state seize antivirals or vaccine for use (Code of Virginia § 44-146.17)? What are the potential functional and legal consequences?What are the potential functional and legal consequences?

76. Mass Prophylaxis – Issues (cont) Liability for the state in assigning priority groups? Liability for the state in assigning priority groups? Legal protection for persons/agencies making and prioritizing vaccine/anti- viral allocation decisions? Legal protection for persons/agencies making and prioritizing vaccine/anti- viral allocation decisions? Liability for healthcare in following (or not following) guidelines? Liability for healthcare in following (or not following) guidelines?

77. Mass Prophylaxis – Issues (cont) What hospital plans exist to manage the dispensing of antiviral medications and vaccines to staff? What hospital plans exist to manage the dispensing of antiviral medications and vaccines to staff? Methods to address counterfeit vaccine and antivirals, unsubstantiated claims for treatments, price gouging, re-sale of PEP received from state by higher priority group individuals to others Methods to address counterfeit vaccine and antivirals, unsubstantiated claims for treatments, price gouging, re-sale of PEP received from state by higher priority group individuals to others Other potential criminal activities to be considered (e.g., life insurance scams)?Other potential criminal activities to be considered (e.g., life insurance scams)?

78. Mass Prophylaxis – Issues (cont) Storage, transportation, and distribution legal issues for vaccine and antivirals Storage, transportation, and distribution legal issues for vaccine and antivirals E.g., security, traffic control, adverse reactions, prescribing oversightE.g., security, traffic control, adverse reactions, prescribing oversight

79. Miscellaneous Legal Issues Robin Kurz Virginia Office of the Attorney General

80. Cooperation Inter-jurisdictional cooperation Inter-jurisdictional cooperation Intra-jurisdictional cooperation Intra-jurisdictional cooperation Cooperation with federal government Cooperation with federal government

81. Cooperation Governor may enter into mutual aid agreements with other states. May authorize use of personnel, equipment, supplies, and materials of the Commonwealth or a locality. Governor may enter into mutual aid agreements with other states. May authorize use of personnel, equipment, supplies, and materials of the Commonwealth or a locality. Va. Code § 44-146.17

82. Cooperation Emergency Management Assistance Compact (EMAC) allows for mutual aid between member states in an emergency. Emergency Management Assistance Compact (EMAC) allows for mutual aid between member states in an emergency. Warning communities adjacent to areaWarning communities adjacent to area Protect and assure delivery of services, food, water, energy, medicine, equipment, resourcesProtect and assure delivery of services, food, water, energy, medicine, equipment, resources Loan of human and material resourcesLoan of human and material resources Temporary suspension of statutes or ordinances that would restrict aboveTemporary suspension of statutes or ordinances that would restrict above

83. Cooperation EMAC EMAC Assisting states agents deemed certified or permitted to render aidAssisting states agents deemed certified or permitted to render aid For liability purposes, assisting states agents are deemed agents of the requesting stateFor liability purposes, assisting states agents are deemed agents of the requesting state Va. Code § 44-146.28:1

84. Cooperation Localities Localities Governing bodies of localities may contract with each other for mutual aid of equipment and materials to maintain peace and order.Governing bodies of localities may contract with each other for mutual aid of equipment and materials to maintain peace and order. Va. Code § 15.2-1736 Localities may enter into reciprocal agreements with localities outside Virginia for mutual aid.Localities may enter into reciprocal agreements with localities outside Virginia for mutual aid. Va. Code § 15.2-1727

85. Cooperation Localities Localities Law enforcement may call upon adjoining localities for assistance.Law enforcement may call upon adjoining localities for assistance. Va. Code §§ 15.2-1730, 15.2-1731 Law enforcement may go beyond the territorial limits of locality to assist.Law enforcement may go beyond the territorial limits of locality to assist. Va. Code § 15.2-1724

86. Cooperation Federal orders Federal orders Federal Quarantine 42 U.S.C. § 243(a), 42 C.F.R. § 70.2, 21 C.F.R. § 1240.30Federal Quarantine 42 U.S.C. § 243(a), 42 C.F.R. § 70.2, 21 C.F.R. § 1240.30 Federal order of quarantine or isolation may be enforced by local law- enforcement officers or officers of the Metropolitan Washington Airports Authority. Federal order of quarantine or isolation may be enforced by local law- enforcement officers or officers of the Metropolitan Washington Airports Authority. Va. Code § 32.1-48.014(D)

87. Cooperation Federal Orders Federal Orders In areas of exclusive federal jurisdiction in Virginia, contiguous locality may enter into a mutual aid agreement with federal authority.In areas of exclusive federal jurisdiction in Virginia, contiguous locality may enter into a mutual aid agreement with federal authority. Va. Code § 15.2-1728 Enforcement of state and county laws by federal officers on federal property.Enforcement of state and county laws by federal officers on federal property. Va. Code § 15.2-1729

88. Cooperation Governor, or locality on behalf of Governor, may accept federal aid Governor, or locality on behalf of Governor, may accept federal aid Va. Code § 44-146.27

89. Miscellaneous Legal Issues Suzi Silverstein Emergency Preparedness and Response, VDH

90. Miscellaneous Issues Does the scenario highlight any issues regarding communication/cooperation among agencies regarding: Does the scenario highlight any issues regarding communication/cooperation among agencies regarding: Physical management (to prevent further transmission)Physical management (to prevent further transmission) Communication and legal management (multiple jurisdictions)Communication and legal management (multiple jurisdictions) How would the other passengers be managed, including providing security, clinical assessment, and the potential for quarantine (including orders of quarantine)? How would the other passengers be managed, including providing security, clinical assessment, and the potential for quarantine (including orders of quarantine)?

91. Miscellaneous Issues (cont) Order of quarantine or isolation issued by the Director of the Centers for Disease Control and Prevention affecting the Commonwealth or the Metropolitan Washington Airports Authority may be enforced by local law-enforcement officers or officers of the Metropolitan Washington Airports Authority with jurisdiction over the facility involved in the quarantine or isolation order. Any issues/concerns? Order of quarantine or isolation issued by the Director of the Centers for Disease Control and Prevention affecting the Commonwealth or the Metropolitan Washington Airports Authority may be enforced by local law-enforcement officers or officers of the Metropolitan Washington Airports Authority with jurisdiction over the facility involved in the quarantine or isolation order. Any issues/concerns?

92. Break Resume in Salon II (here) in 15 minutes...

93. Movement Restrictions – Practical Issues Panel Discussion Moderated by: Dr. Lisa Kaplowitz Deputy Commissioner for Emergency Preparedness and Response, VDH

94. Practical Issues Optimal location for isolation and quarantine Optimal location for isolation and quarantine Usually, a residenceUsually, a residence Other options?Other options? Centralized facilities Centralized facilities E.g., treatment, quarantineE.g., treatment, quarantine Location, supplies, security…Location, supplies, security… Provision for essential needs Provision for essential needs Developing, serving, managing, and enforcing a large number of orders Developing, serving, managing, and enforcing a large number of orders Transmittal of health informationTransmittal of health information

95. Practical Issues (cont) Ripple effect Ripple effect E.g., closure of events may have anticipated consequencesE.g., closure of events may have anticipated consequences Trigger points for various interventions Trigger points for various interventions Prioritization of resources Prioritization of resources Recovery Recovery How would prophylaxis, vaccination, or prior infection affect movement restrictions? How would prophylaxis, vaccination, or prior infection affect movement restrictions?

96. Future Efforts and Closing Remarks Dr. Lisa Kaplowitz Deputy Commissioner for Emergency Preparedness and Response, VDH

97. Future Efforts Address gaps and challenges in legal preparedness for social distancing and disease control Address gaps and challenges in legal preparedness for social distancing and disease control Non-infectious communicable diseases of public health threat?Non-infectious communicable diseases of public health threat? Temporary detention for communicable disease?Temporary detention for communicable disease? Protection of health information?Protection of health information? Compensation?Compensation? Additional components of emergency declaration?Additional components of emergency declaration? Others?Others?

98. Future Efforts (cont) Additional work in other legal areas Additional work in other legal areas School ClosureSchool Closure LiabilityLiability Public health Public health Law enforcement Law enforcement Healthcare Healthcare FinancialFinancial Unemployment insurance Unemployment insurance Life insurance Life insurance Altered standards of careAltered standards of care

99. Additional Thoughts? Comments? Comments? Concerns? Concerns? Queries? Queries? Proposals? Proposals? Suggestions? Suggestions? Ideas? Ideas? Recommendations? Recommendations?

100. Please complete and leave the evaluation forms Please take travel reimbursement information (if needed)