How To Protect Health Information From Public Disclosure

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1 SRHD Communicable Disease Procedure Manual Updated

2 General Procedures: Table of Contents Handling Reports of Notifiable Conditions... 4 CD/Epi Coverage Duty Officer Protocols... 6 Staff Responsibilities for Handling Reports of Notifiable Conditions... 8 Gathering Basic Information about a Notifiable Condition... 8 Notification of Emergency Response Coordinator & Activation of Incident Command System... 9 Issuing Information to the Public Press Releases... 9 Anthrax Arboviral Disease (including West Nile Virus) Botulism Brucellosis Campylobacteriosis Chancroid Chlamydia Cholera Cryptosporidiosis Cyclosporiasis Diphtheria Enterohemorrhagic E. coli (including E. coli O157:H7) Foodborne Illness Complaints Giardiasis Gonorrhea Hantavirus Pulmonary Syndrome Haemophilus influenzae (Invasive Disease) Hepatitis A Hepatitis B Hepatitis B - Perinatal Hepatitis C Herpes simplex, Genital & Neonatal Immunization Reactions Legionellosis Leptospirosis Listeriosis Lyme Disease Malaria Measles (Rubeola) Meningitis, viral Meningocaccal Disease i

3 Mumps Outbreak of Illness from an Unknown Pathogen Paralytic Shellfish Poisoning Pertussis Plague Poliomyelitis Psittacosis (Avian Chlamydiosis) Q Fever Rabies, Animal Bites, & Post-exposure Prophylaxis Relapsing Fever (Borreliosis) Rubella Salmonellosis Shigellosis Smallpox Substantial Exposure to Bodily Fluids Syphilis Tetanus Trichiniosis Tularemia Typhoid Fever Varicella Outbreak Management Vibriosis Waterborne Illness Calls Yersiniosis Appendix A: DOH Notifiable Conditions Posters Appendix B: Glossary & Acronyms Appendix C: Data Mining Tips, Pin Codes, & IC Contact Numbers Appendix D Appendix E: EMS Notification of Infectious Disease Appendix F: References Appendix G: Media Information Appendix H: Interpreter Services Appendix I: Release of Information Guidelines & Patient Confidentiality Appendix J: Conducting an Outbreak Investigation Appendix K: Sample Outbreak Questionnaires Appendix L: Substantial Exposure to Bodily Fluids Forms & References Appendix M Mosquito and Tick Prevention Measures ii

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5 GENERAL PROCEDURES Handling Reports of Notifiable Conditions Spokane Regional Health District staff will investigate and manage all reports of Notifiable Conditions and serious reactions to immunization vaccinations. This policy applies whenever SRHD receives a report of a Notifiable Condition or a serious reaction to immunization. Reportable diseases are defined by the most current version Washington Administrative Code, WAC , updated August See Appendix A for a complete listing of Notifiable Conditions and reporting timelines. Reports may be written, telephoned to voice mail or staff, faxed, or in person. Epidemiology staff checks the CD reporting line/fax at least every two hours during normal business hours and the investigator on-call for the weekend checks it at regular intervals while on duty. After-hours reporters are instructed to dial a 24-hour emergency number when they dial the regular CD report line, or are handled by a live answering service if they call the SRHD main line during non-business hours. SRHD staffs handle reports according to agency policies and procedures to protect the patients/clients health information as per HIPAA. Specific documents that support SRHD confidentiality procedures are the Notice of Privacy Act Appendix I, the Oath of Confidentiality signed by all staff upon hire, the HIPAA and Internet Use policy, and communication to medical providers via letter explaining their provision of protected health information to SRHD in order to control disease. All of these documents are located at the following address: \\helios\home\public\hipaa\ Communicable disease reports are transmitted to WA Department of Health using PHIMS (Public Health Information Management System) which a digital certificate and password to access the database. Investigators only have access to cases who are assigned to their county based upon their residence. SRHD staff will investigate any notification of reportable disease that occurs in Spokane County. Investigation includes logging reports, contacting cases and exposed persons, managing outbreaks, and providing a case report to the state. For out-of-county residents, SRHD staff will notify the appropriate local or state health department or the DOH CD Epi to pursue the case investigation. SRHD staff will keep records of his/her activities. In general, communicable diseases are managed according to (and this manual is based on) guidelines presented in: Heymann, David L., MD. Control of Communicable Diseases Manual, 19th Edition. Washington, DC.: American Public Health Association, (Or most recent edition of same.) The SRHD Health Officer assigns the Tuberculosis Clinic Coordinator, Immunizations Coordinator, Epidemiologists, DOH STD Intervention Specialist, HIV/AIDS Program Coordinator, Communicable Disease Prevention Manager and related support staff to investigate Notifiable Condition case reports as appropriate. When these staff or their designees are not available, the SRHD Health Officer will assign other appropriate staff to manage the cases. Communicable Disease Investigators Comment [SW1]: This paragraph specifically describes confidentiality and how data security is preserved. See also Appendix I pg SRHD Health Officer Epidemiologist Epidemiologist Epidemiologist HIV/AIDS Program Coordinator Immunizations Coordinator Communicable Disease Prevention Manager DOH STD Consultant STD Case Investigator STD Case Investigator TB Program Nurse Joel McCullough MD, MPH Dorothy MacEachern, MS, MPH Mark Springer, DC Bill Edstrom, MPH Susan Sjoberg Cindy Jobb, RN Stacy Wenzl, MHPA Julie Zink Lisa Hinton Alexandra Hayes Julie Tomaro, RN Updated

6 STD Reports: Sexually transmitted disease reports are routed to the Communicable Disease Prevention Administrative Assistant for triage to the appropriate case investigator. Spokane County chlamydia cases are referred to the SRHD STD Case Investigators. Gonorrhea and syphilis (and others listed below) cases are routed to the DOH STD Intervention Specialist: Chancroid Chlamydia trachomatis Gonorrhea Granuloma inguinale Herpes simplex (neonatal or primary genital) Lymphogranuloma venereum SyphilisThe STD Case Investigators or the DOH STD Intervention Specialist will interview prioritized cases, enter STD reports in the STD PHIMS database, and follow up case contacts, including referrals to other regional investigators. Reports that are referred to the SRHD Tuberculosis (TB) Program Coordinator: Suspected cases of tuberculosis must be reported to the SRHD TB Program Coordinator or his/her designee within 24 hours. The TB Program Coordinator will interview cases, submit TB case reports to the DOH TB Surveillance Program, and investigate contacts to active cases of TB. The TB Program staff provides treatment for confirmed cases of TB by direct observed therapy (DOT) and treatment for latent TB infection. Reports that are referred to the SRHD HIV/AIDS Program Coordinator: HIV and AIDS are three-day notifiable conditions. All reports of HIV/AIDS will be referred to the SRHD HIV/AIDS Program Coordinator or his/her designee within 24 hours. The SRHD HIV/AIDS Program Coordinator or his/her designee will follow up with the reporting agency to complete the HIV/AIDS case report. The SRHD HIV/AIDS Program staff will provide follow up (as needed) for the following: case management, referrals to treatment specialists, referrals to the housing authority, referrals to substance use treatment programs and partner notification services. Reports of exposure to bodily fluids or needle sticks are referred to the SRHD HIV/AIDS Program Coordinator or his/her designee (See DPR Administrative Procedure Manual for current designees), who will determine whether the exposure meets the criteria of being a substantial exposure. If so, they will follow up to ensure pre-test counseling and arrange for testing of the source patient, and may require baseline testing of the exposed person as warranted. All other Diseases are referred to SRHD Epidemiologists. See Appendix A for a complete list of notifiable conditions and their reporting timeframes. Clusters of any disease that may indicate an outbreak, epidemic, or related public health hazard: Epidemiology staff will notify and collaborate with the SRHD Health Officer, other SRHD staff, and/or staff from other agencies as appropriate to the nature of the illness cluster. Examples: SRHD Environmental Public Health (EPH) Food Program for a restaurant-based foodborne illness outbreak, DOH CD Epidemiology for botulism cases, Department of Social and Health Services (DSHS) licensing staff for a daycare-based outbreak. Clusters include, but are not limited to, suspected or confirmed outbreaks of food-borne or water-borne disease, chickenpox, influenza, or environmentally related disease. The SRHD EPH Food Program will perform initial investigations of unconfirmed reports of foodborne illness, and will recruit the Epidemiology staff when appropriate. Updated

7 CD/Epi Coverage Duty Officer Protocols Duty Officer This individual is the primary point of contact for the Spokane Regional Health District (SRHD) during non-business hours, i.e., evenings, weekends and holidays, for communicable disease (CD) reports and public health emergencies. During normal business hours the Duty Officer may also receive calls, since this number is published widely as a SRHD epidemiologist contact number. The practice is that the duty officer will forward the duty officer phone to his/her cell phone. 1. Shift The Duty Officer shift lasts from noon on Friday until noon on the following Friday. Shift time and duration may occasionally be altered to accommodate schedule conflicts. 2. Responsibilities The individual will receive, triage and respond to notifications of communicable disease reports and public health emergencies, as appropriate. These notifications may come from the communicable disease report line ( ), the Duty Officer cell phone ( ), and/or SRHD s answering service (Best Line, ). o o o o Duty Officer Cell Phone At all times, the Duty Officer will either carry the Duty Officer cell phone, or an SRHD or personal cell phone to which Duty Officer cell phone has been transferred. Communicable disease calls received during normal business hours will either be handled by the Duty Officer or transferred to an appropriate investigator. Answering Service The Duty Officer will act as the primary point of contact for the answering service through the Duty Officer cell phone ( ) during their shift. RAMSES Updates The Duty Officer will update the RAMSES website daily, following the established procedure in \\helios\home\projects\epr\ramses\ramses Handbook March 2005.doc. Ramses is located at SECURES Notifications The Duty Officer will receive SECURES notifications and act upon them as follows: Types of alerts o High level alerts initial notification of outbreaks/recalls that will likely pertain to Washington residents or which will generate media attention o Medium level alerts updates regarding known outbreaks/recalls, notifications of events outside Washington or not likely to involve Washington residents o Low level alerts informational alerts that likely will not affect Washington residents o Test alerts Twice per year all SRHD staff on SECURES will receive test alerts initiated by an epidemiologist to evaluate timeliness of alerting key agency staff. A report of the test results is provided to the Epi Program Manager and to the Department of Health. SECURES settings for alerts: The duty officer s profile should be set up to utilize his/her cell phone for notification of medium or high-level alerts. Notification of low level alerts will be through the normal procedure, i.e., set to each individual s preference for notification. Management of alerts during regular business hours o The duty officer will utilize his/her judgment in consultation with the Health Officer and/or Emergency Response Coordinator to evaluate medium and high level alerts to ascertain whether they need to be forwarded to appropriate staff in other SRHD programs or to external partners. o Alerts will be forwarded to appropriate staff if the duty officer feels that the information applies to a SRHD program or may impact Spokane residents o High and medium level alerts may be forwarded to external partners if they are of high media interest, high health care provider concern, and/or would affect Spokane county residents. Low level alerts would not be forwarded unless needed as an update to an alert previously sent out. Management of alerts outside of regular business hours o The duty officer will utilize his/her judgment in consultation with the Health Officer and/or Emergency Response Coordinator regarding forwarding alerts to appropriate staff and external partners. Criteria needed for forwarding alerts would include: High level of local media interest, high health care provider concern, and/or significant risk of local cases. o Medium and low level alerts generally do not meet the above criteria and would not be forwarded. Comment [SW2]: This section specifically defines the process for testing the 24/7 response capabilities of the contact system. Updated

8 o CD report line Evenings M-F, the Duty Officer will check the CD report line once each evening between 7 and 10 pm. Weekends/Holidays the Duty Officer will check the CD report line 3-6 times per day with at least one check in the morning, afternoon, and evening. o o o Case investigation Certain reports can be noted and transferred to the appropriate investigator for follow-up on the next workday. Other CD reports should have investigations started on the day of receipt. These may include: Animal Bites Botulism Cholera Diphtheria E. coli O157:H7 Hepatitis A Measles Meningococcal Disease Mumps Shigellosis Disease of suspected bioterrorism origin Outbreak of disease, outside a single household Rare disease of public health significance Case ownership & transfer If the Duty Officer begins an investigation and only makes brief contact with the case, then the Duty Officer will make appropriate notes and transfer the case to an appropriate investigator for follow-up during the next workday. If the Duty Officer has substantial interviews/conversations with the case/contacts, then s/he should complete the investigation, whenever possible. Public health emergencies The Duty Officer will notify the SRHD Emergency Response Coordinator (ERC) of any actual or potential public health emergency per established protocol. 3. Food borne illness complaints The Duty Officer will be the primary point of contact with regards to consultations made between Environmental Public Health and Epidemiology with regards to consultations about food illness complaints reported to SRHD. 4. Time coding The Duty Officer will code actual time related to checking the CD report line as 1 hour per weekend day plus actual time spent related to case follow-up, investigation, and/or communication with the general public, coded to the day which that activity occurred. 5. Qualified Employees The following employees are qualified to be assigned as Duty Officer. Assignments will be made from the primary list unless leave, training, or other reasons result in a conflict. o o Primary List Bill Edstrom Dorothy MacEachern Mark Springer Secondary List Stacy Wenzl Jane Lindstrom Health Officer In the event that Epidemiology staff and/or Duty Officer is unavailable to conduct an investigation when a disease report comes in, the assigned staff should respond as described in the Disease Management section of this manual to a case or an outbreak of reportable illness. Clear documentation should be made so that Epidemiology staff can resume case/contact follow-up when they return. When an epidemiology staff person will be out of the office for a day or more, he or she will transfer over any cases that require immediate or ongoing attention to an available investigator for follow-up. Cases will be transferred back when the lead investigator returns and follow-up comments will be provided in the notes section in PHIMS. Cases transferred within PHIMS to other LHJs will be accompanied by a call to that LHJ s notifiable condition report line with the provision of the name of the condition, patient name and date of birth. Updated

9 Staff Responsibilities for Handling Reports of Notifiable Conditions Action by: Receptionist and/or Answering Service: Epidemiology Support Staff: Epidemiology Investigator (or other assigned communicable disease staff: Action Taken: Receives letter, call, or personal inquiry concerning any notifiable condition or serious reaction to immunization. Refers inquiry to Epidemiology Support Staff or Epidemiology Investigator as appropriate. Receives a direct call, letter, fax, or referral from another program. Maintains list with the phone numbers of Epidemiology staff and other CD investigators and the diseases for which each investigator is responsible. Transfers call/report to appropriate communicable disease investigator immediately, (if available) by telephone, voice mail, in person, or . If the most appropriate investigator is not available, case is given to the next investigator available. If the case is an immediately notifiable condition or has potential to be urgent, Support Staff contacts the Duty Officer by cell phone to notify them of the situation. Tallies CD Statistics for publications. Contacts case (or guardians) to gather additional information and to identify exposed persons and potential sources (see specific disease management procedures). Notifies interviewees that information collected is confidential by law. Follows guidelines listed in the most current edition of APHA s Control of Communicable Diseases Manual and the WA Dept of Health Guidelines for Public Health Investigations. Supplemental information can be obtained from the most current editions of the following (see Appendix F for complete references): MMWR, 5/2/97 46:RR-10, "Case Definitions for Infectious Conditions under Public Health Surveillance" AAP Red Book CDC Pink Book ACIP Guidelines Mandell et Al., Principles and Practice of Infectious Diseases Other standard medical reference texts). Completes record of CD case interview data in PHIMS, and/or on standardized forms available at DOH s Disease Reporting Forms website. As needed, discusses management strategy with the SRHD Health Officer and other communicable disease investigator(s). If the case warrants an extensive response, investigator notifies the ERC, who will collaborate with the SRHD Health Officer, Administrator, and PIO to determine whether or not the Incident Command System (ICS) is needed to support the response to the event. Based on the needs of the event, an Incident Commander (IC) will be assigned and activate key staff as needed to fill appropriate roles. Gathering Basic Information about a Notifiable Condition Refer to Appendix C Data Mining Tips, PIN Codes, and Infection Control Contact Numbers for addition information on how to obtain necessary information to complete a case report. After receiving a letter, call, or personal inquiry regarding a notifiable condition, the Epidemiology Investigator (EI) obtains and records the following information in PHIMS, and/or on the appropriate case report form: 1. The individual reporting the case: Name Phone number 2. The case: Institution or agency (lab, clinic, etc.) Report Date Name Phone number home, work, cell Updated

10 Address Date of birth Sex Date symptoms began Description of symptoms Date of exposure Date of specimen collection Laboratory results Occupation Place of employment name and address School name and address, if applicable Day care center name and address, if applicable Health care provider name and phone number Treatment Medications Probable source 3. Contacts laboratory or health care provider for referenced lab results and/or other related tests and information necessary to complete the form or record entry. If laboratory results are pending, continues investigating report and requests that laboratory staff inform SRHD when results are available. 4. Assures case that information collected for case report is kept confidential. 5. Refers to following Disease Management Section of this manual for specific handling of each disease. 6. Completes PHIMS electronic data records or hard-copy form(s) for the reported disease if PHIMS is unavailable. Forms are available at WA Dept of Health Guidelines for Public Health Investigations. Detail regarding the process for disease investigation follows in section General Disease Investigation Guidelines. Notification of Emergency Response Coordinator & Activation of Incident Command System Some situations or cases may create unusual demand for other SRHD services. In these cases, the affected programs must be notified as early as possible in the course of the investigation. For example, hepatitis A in a food handler would require notifying Environmental Public Health (EPH) to conduct the food establishment investigation, notifying the SRHD Clinic that administration of immune globulin/hepatitis A vaccine to restaurant patrons who have been exposed could become necessary, and notifying front line staff, as well as the answering service, that they may be receiving calls. The SRHD Emergency Response Coordinator (ERC) should be notified of cases that have the potential to involve other divisions, outside agencies, media, or that may exceed routine capacity. If necessary, the ERC will coordinate agency-wide activities in order to allow Epidemiology staff to more efficiently conduct their investigations. The ERC will collaborate with the SRHD Health Officer, Administrator, and PIO to determine whether or not the Incident Command System (ICS) is needed to support the response to the event. Based on the needs of the event, an Incident Commander (IC) will be assigned and activate SRHD s Emergency Response Plan as appropriate. Notification to other programs or individuals should be made by direct phone or in-person contact. To assure accurate transmission of critical information, a follow-up memorandum (hard copy or ) is advisable. Notification by voice mail or message is adequate only if others in the program have been apprised of the issue and know that the message has been left. Issuing Information to the Public Press Releases (Not to be confused with healthcare provider alerts which communicate information to clinics, hospitals, first responders and other healthcare providers about specific disease-related events. These types of communication may not be appropriate for the general public. Information regarding healthcare provider alerts may be found in the Management of Community section for each disease and in Appendix E - EMS Notification of Infectious Diseases.) Situations that may generate interest from the news media or concern among members of the public should be brought to the attention of the SRHD Public Information Officer (PIO). The PIO will coordinate all communication with the media, work with Epidemiologists to develop talking points, press releases, and provide other assistance as outlined in the SRHD Emergency Communications Plan. A Public Health Press Release should include the following information (see sample in Appendix G Media Information and refer to SRHD Emergency Communications Plan for more detailed guidelines): Disease of concern Action taken Known cases Incubation period Updated

11 Symptoms Possible exposure settings Where to obtain further information. Means of prevention Where to report suspected cases The SRHD Health Officer or designee will review and approve or modify the Press Release. The SRHD Public Information Officer distributes approved press releases by telephone, fax, , surface mail or press conference to local media. (See Appendix G - Media List.) Epidemiology support staff may distribute the Press Release by telephone, fax, , or mail to additional audiences depending on the situation, including: Local health care providers Hospitals Clinics Schools Veterinarians All SRHD Division Directors and coordinators of affected programs Health Departments in adjacent counties in Washington and Idaho Washington State Department of Health Communicable Disease Epidemiology SRHD Board of Health Updated

12 Disease Management Section The SRHD Communicable Disease Epidemiologists maintain up-to-date information on disease specific topics for health care providers and the public. The disease specific information is in the form of SRHD created fact sheets and/or links to accurate and reliable information via the internet. The fact sheets and linked sites are reviewed every two years for accuracy and relevance. All materials and references are available via the SRHD website ( under Health Topics A-Z and under the section for Health Care Providers. The Public Health Liaison s, during their bi-annual provider visits, distribute current/updated fact sheets and disease reporting reference materials to health care staff and assist them in maintaining their Communicable Disease Provider Manuals. A fact sheet review/update log is managed by the Administrative Assistant 3 for the HIV/AIDS & PHEPR Programs, as are all of the fact sheets and referenced materials. Updated

13 General Disease Investigation Guidelines When an Epidemiology Investigator (EI) receives a disease report s/he follows these general steps. MANAGEMENT OF CASE 1. Reviews disease specific guidelines, which include WA Dept of Health Guidelines for Public Health Investigations, the disease-specific instructions in this manual APHA Control of Communicable Diseases, the AAP Red Book, or other references listed in Appendix F. 2. Verifies the diagnosis with the laboratory that performed the test. a. For PAML contact client services at , ext 1 and, if prompted, provide 6145 as the code for SRHD. b. For Deaconess Medical Center, Valley Hospital Medical Center, or offices utilizing Empire Health Services for lab services, contact client services at and ask for the laboratory. c. For Quest Diagnostics, contact client services at and, if requested, provide as the account number for SRHD. 3. Contact the clinical care provider(s) who made the diagnosis and/or hospital infection control personal to: a. Assure that they are aware of the test results. b. Assure that they have had the opportunity to inform the case promptly. If medical care provider has not notified the case, or EI is unable to contact the provider, EI must proceed with the investigation. c. Obtain any relevant illness history and/or exposure/risk factor information pertinent to the notifiable condition d. Obtain the demographic information necessary to determine whether the case is a Spokane County resident and to make contact with the case. 4. Refers the case to appropriate local health jurisdiction or to WA State CD Epidemiology if necessary. Provide assistance when requested to other investigators when the case is hospitalized or has possible exposures in Spokane County. 5. Attempts to make contact with the case. If the case cannot be reached by telephone, a message is left (if possible) requesting that the case or case guardian return the call without specifying the reason for the call. If the case repeatedly cannot be reached by telephone, send a letter requesting that the case or case guardian make contact with the EI. a. Uses translation services if necessary. Translation services are provided to SRHD by Pacific Interpreters (Seattle), , SRHD s access number is See Appendix XX, Interpreter Services Invoice. 6. As information to complete the CD case report is gathered, it is entered into the PHIMS web database system. If PHIMS is not available, Epidemiology staff records information on the appropriate paper form available at Disease Reporting Forms. 7. Stresses to case that all information collected is kept confidential. 8. Questions case about illness onset, symptoms, exposures, and contacts that may have been exposed. 9. Informs the case regarding the disease to include: symptoms, transmission, incubation period, period of communicability, and recommendation on prevention/isolation as appropriate. 10. Obtains list from case or parent/guardian of all possible contacts as defined by the WA DOH Notifiable Conditions Guidelines. 11. Coordinates exclusion from work or school as defined by the WA DOH Notifiable Conditions Guidelines. 12. Discusses illness and ways of preventing transmission with case as defined by the WA DOH Notifiable Conditions Guidelines. 13. Refers to APHA Control of Communicable Diseases for specific treatment recommendations. Updated

14 14. Refers case to their personal health care provider for questions regarding treatment, if appropriate. If clinical care providers request information regarding standard treatment regimens, an epidemiologist can provide them with such general information. 15. When a complete CD case report has been entered into PHIMS (or it is determined that one is not obtainable), the record is submitted electronically to DOH CD Epidemiology. If electronic transmission is not possible, staff sends a hardcopy of the completed report to the DOH Data Compiler. (See Appendix D for address.) MANAGEMENT OF CONTACTS 1. Initiate contact with identified contacts of the case. 2. Verifies whether contacts are immune based upon past infection or immunization as appropriate for disease condition. 3. Recommends prophylaxis for all susceptible contacts as defined by the WA DOH Notifiable Conditions Guidelines. 4. Recommends isolation or exemptions when appropriate, according to disease-specific guidelines. 5. Informs contacts of disease as above in #8. 6. Advises contacts to notify their primary care provider of their exposure and to seek care immediately if they become ill. 7. Notifies the Clinic Supervisor if individuals need prophylaxis from Spokane Regional Health District. 8. Coordinates with Clinic Supervisor to determine when contacts can come in for prophylaxis, or to schedule a special clinic. MANAGEMENT OF COMMUNITY 1. Contacts appropriate staff (EPH, Clinic, Laboratory, etc.) or external partners immediately to assist in the investigation to determine the source of infection and mode of transmission. 2. Consults with the SRHD Health Officer to initiate control measures if a common mode of transmission is suspected. 3. The SRHD Emergency Response Coordinator (ERC) or designated alternate is notified by SRHD staff whenever there is an actual or likely involvement of SRHD in the event/incident and any one of the following conditions exists: The event is likely to have a significant impact on the public health of the citizens of Spokane County or the surrounding region. The event generates high public, media, or political interest--acute or serious event that has or may stimulate high levels of concern or interest. The event affects the delivery of normal SRHD services. Outside resources are needed to respond to the event. More than one SRHD Division is involved. There is doubt about whether to notify the ERC. If appropriate, the ERC will notify the SRHD Health Officer, Administrator, affected Division Directors and Public Information Officer (PIO). This group then determines the level of response and whether or not ICS is needed to support the response to the event. If needed, ICS is activated and an Incident Commander (IC) is assigned from a list of identified staff, as identified in SRHD Emergency Preparedness & Response Plan. 4. Initiates and coordinates investigation with other local health departments, DOH, WSDA, USDA, and FDA as indicated if a wider outbreak or common source is suspected. See disease-specific guidelines for specific measures regarding outbreak management. 5. Recommends prophylaxis for high-risk persons (anyone likely to be exposed again) 6. Collaborates with the SRHD Public Information Officer to draft a Public Health Press Release if indicated, and submits it to the SRHD Health Officer for approval. Updated

15 7. Coordinates with SRHD Health Officer to issue Provider Alerts to ERs/Urgent Care facilities, primary care facilities, hospitals, labs, nursing homes, or other care providers, if indicated. Notifies EMS services according to guidelines in Appendix E as appropriate. 8. Coordinates with ERC about cases/situations that have the potential to involve other divisions, outside agencies, media, or that may exceed routine capacity. 9. Is prepared to consult/assist with activation of ICS, mass treatment, or mass prophylaxis activities (as outlined in SRHD Emergency Response Plan) as appropriate. Updated

16 ANTHRAX Because this disease is a potential agent of bioterrorism, EI notifies the SRHD Duty Officer, Emergency Response Coordinator, Health Officer, and WA State CD Epidemiology immediately. (This notification also applies to cases for which anthrax or any other possible agent of bioterrorism is strongly suspected but not yet confirmed by laboratory testing.) When a case of anthrax is reported to SRHD, an Epidemiology Investigator (EI) follows the General Disease Investigation Guidelines at the beginning of this section, with special attention to the notes below: 1. Because of the imminent risk to household members and others who may have the same exposure, the EI must make repeated attempts to contact the case by telephone or in person. 2. Questions the case regarding exposures to all animals, wild and domestic, or related products (see APHA Control of Communicable Diseases for specific examples) within one week of onset of symptoms, and about their travel history. See WA Dept of Health Guidelines for Public Health Investigations. 3. Symptoms: Cutaneous anthrax begins as a painless lesion that in 2-7 days progresses to a blister, and then a depressed black scab. If untreated, leads to blood borne infection and death. Inhalation anthrax resembles a mild upper respiratory infection (cold), progresses to respiratory distress, fever and shock, followed by death. Gastrointestinal anthrax includes nausea, loss of appetite, vomiting and fever, followed by abdominal pain, and severe diarrhea. Transmission: Cutaneous anthrax is transmitted by contact with tissues, hair, wool, hides or other products of infected animals; or with soil or bone meal contaminated by infected animals. Transmission of inhalation anthrax is by inhaling anthrax spores. Transmission of gastrointestinal anthrax is by consuming anthrax-contaminated food. Incubation period: Usually 1-7 days but up to 60 days is possible. Period of communicability: Anthrax is not spread person to person. Articles and soil contaminated with spores may remain infective for years. Prevention: Avoid contact with tissues, hair, wool, hides or other products of infected animals, or with soil or bone meal contaminated by infected animals. Control dust and properly ventilate work areas in hazardous industries. Wear protective clothing. Immunize persons at high risk for exposure. Isolation: Standard precautions for the duration of illness for cutaneous and inhalation anthrax. 4. Obtains a list of others who may have been in contact with animals or related products. 5. Recommends drainage and secretion precautions for the duration of illness. 6. Telephones all contacts to determine if they were exposed to infected animals or animal products. 7. Maintains surveillance of contacts for one week from last exposure. 8. Contacts appropriate SRHD Environmental Public Health (EPH) staff immediately to assist in an investigation to determine the source of infection and mode of transmission. 9. Consults with the SRHD Health Officer to initiate control measures if a common mode of transmission is suspected, e.g., a manufacturing plant. 10. Initiates and coordinates SRHD inspections with other local health departments, DOH, WSDA, USDA, and FDA as indicated if a common source is suspected. See APHA Control of Communicable Diseases Manual for specific measures. 11. Recommends immunization for high-risk persons (laboratory workers who handle the organism, people who work with imported animal hides or potentially infected animal products, military personnel deployed to areas with high risk for exposure) with a cell-free vaccine (The only FDA-licensed human anthrax vaccine in the United States, Anthrax Vaccine Adsorbed (AVA, trade name BioThrax), is produced by Emergent BioSolutions Corporation, formerly known as BioPort Corporation in Lansing, Michigan.). Updated

17 ARBOVIRAL DISEASE (INCLUDING WEST NILE VIRUS) When a case of Arboviral Disease is reported to SRHD, an Epidemiology Investigator (EI) follows the General Disease Investigation Guidelines at the beginning of this section, with special attention to the notes below: MANAGEMENT OF CASE 1. Verifies the diagnosis with the laboratory that performed the test, including the viral species involved. 2. Contacts the clinical care provider(s) who made the diagnosis to: a. Assure they are aware of the test results. b. Assure they have had the opportunity to inform the patient. c. Obtain the demographic information necessary to determine whether the case is a Spokane County resident and to make contact with the case. 3. If the case is a resident of another county or state, refers the case to the appropriate local health jurisdiction or to WA State CD Epidemiology as necessary. Assists other investigators if the case is hospitalized in Spokane. 4. Attempts to make contact with the case. If the case cannot be reached by telephone, a message is left (if possible) requesting the case, case guardian or household member to return the call without specifying the reason for the call. If the case cannot be reached by telephone, sends a letter requesting the case, case guardian make contact with the EI. 5. As information to complete the CD case report is gathered, it is entered into the PHIMS electronic database system. If PHIMS is not available, Epidemiology staff records information on the appropriate form available at Disease Reporting Forms. 6. Stresses to case that all information collected is kept confidential. 7. Questions case about situations with possible exposure to mosquitoes, ticks, or other arthropod vectors, i.e., travel, camping trips, from 15 days before onset of symptoms. 8. Questions case about others in their neighborhood with similar signs and symptoms. 9. Informs case about the disease: Symptoms: Range from asymptomatic to high fever, headache, meningeal signs, disorientation, coma, and death (see APHA Control of Communicable Diseases for complete listing of symptoms). Transmission: Usually by the bite of infective mosquitoes, and occasionally by other insect vectors. Not usually directly transmitted from person to person by casual contact. Transmission of some Arboviral conditions via Blood-transfusion, organ-transplant, and breast-feeding has been reported. Incubation period: variable depending on the disease. Prevention: Avoid exposure to mosquitoes and other vectors by draining standing water, dressing to protect against mosquitoes, using EPA registered insect repellents, and by mosquito eradication programs (see Appendix M Mosquito and Tick Prevention Measures, and APHA Control of Communicable Diseases for list of preventive measures). 10. Refers case to their personal health care provider if the have questions regarding treatment. If clinical care providers request information regarding standard treatment regimens, an epidemiologist can provide them with such general information. 11. When a complete CD case report has been entered into PHIMS (or it is determined that one is not obtainable), the record is submitted electronically to DOH CD Epidemiology. If electronic transmission is not possible, staff sends a hardcopy of the completed report to the DOH Data Compiler. (See Appendix D for address.) MANAGEMENT OF CONTACTS 1. Provides education about means of avoiding mosquito exposure and mosquito habitat reduction. Updated

18 2. Advises symptomatic household contacts or contacts in similar circumstances, e.g., travel companions that blood tests to detect the presence of virus are available, and that most cases recover uneventfully. 3. Informs contacts about the disease, as above. 4. Advises contacts to seek care immediately through their personal health care provider if they are symptomatic or become ill. MANAGEMENT OF COMMUNITY 1. Notifies the ERC if indicated, who will coordinate agency-wide activities including any or all of the following as appropriate: a. Consults with appropriate EH staff immediately to assist in a search for missed cases and the presence of infective mosquitoes, and/or other affected animal species including dead birds. b. Initiates an ERNIE Team meeting if indicated. c. Informs the Department of Health, Washington State Department of Agriculture, FDA, and/or USDA as indicated, if a regionally or locally emergent infectious event is indicated as source. d. Collaborates with the SRHD Public Information Officer to draft a Public Health Press Release if indicated, and submits it to the SRHD Health Officer for approval. e. Coordinates with the SRHD Public Information Officer to distribute the Public Health Press Release as outlined in this manual. f. Coordinates with SRHD Health Officer to issue Provider Alerts to ERs/Urgent Care facilities, primary care facilities, hospitals, labs, nursing homes, or other care providers, if indicated. Updated

19 BOTULISM When a suspected or confirmed case of botulism (Clostridium botulinum intoxication) is reported to SRHD, an Epidemiology Investigator (EI) follows the General Disease Investigation Guidelines at the beginning of this section, with special attention to the notes below: MANAGEMENT OF CASE 1. Verifies the diagnosis with the laboratory that performed the test. 2. Contacts the clinical care provider(s) who made the diagnosis to: a. Assure they are aware of the test results. b. Assure they have had the opportunity to inform the patient. c. Obtain the demographic information necessary to determine whether the case is a Spokane County resident and to make contact with the case. Note: Although this disease is commonly diagnosed, it may potentially be a bioterrorism (BT) issue. If there is a cluster of cases with an unusual distribution or presentation, or a reason to suspect intentional dissemination, EI should notify the SRHD Duty Officer, Emergency Response Coordinator, Health Officer, and WA State CD Epidemiology immediately. 3. Notifies the SRHD Health Officer, Duty Officer, ERC, and WA State CD Epidemiology immediately. (This notification also applies to cases for which botulism is strongly suspected but not yet confirmed by laboratory testing.) 4. If the case is a resident of another county or state, refers the case to the appropriate local health jurisdiction or to WA State CD Epidemiology as necessary. Assists other investigators if the case is hospitalized in Spokane. 5. Attempts to make contact with the case. If the case cannot be reached by telephone, a message is left (if possible) requesting the case, case guardian or household member return the call without specifying the reason for the call. Because of the imminent risk to household members and others who may have the same exposure, the EI must make repeated attempts to contact the case by telephone or in person. 6. As information to complete the CD case report is gathered, it is entered into the PHIMS electronic database system. If PHIMS is not available, Epidemiology staff records information on the appropriate form available at Disease Reporting Forms. 7. Stresses to case that all information collected is kept confidential. 8. Depending on type of illness, questions case about food history, especially home-preserved and commercial food products, wounds, recent surgeries, drug use, and their travel history. a. If suspect foods include commercially prepared food products, the EI notifies WA State CD Epidemiology and the appropriate regulatory agencies, e.g., WSDA, USDA, FDA. (See Appendix D for contact information.) b. If suspect foods were home-preserved, the EI: i. Obtains name of source of food if different from case. ii. Obtains list of persons who have the foods in their possession or have consumed food from same batch as the contaminated food. 9. Assists case in recovering any suspect food for testing and disposal. 10. Initiates immediate search for persons who may have eaten the suspected food. 11. Arranges for immediate testing of any remaining or other suspected food with SRHD EH Food Program, and the DOH Laboratory and WA State CD Epidemiology at (877) or (206) (See Appendix D for contact information.) 12. Informs case about the disease: Symptoms: Foodborne botulism and wound botulism cases have blurred or double vision, difficulty swallowing, and dry mouth, followed by descending symmetrical flaccid paralysis in an alert person. Updated

20 Infant botulism begins with constipation followed by lethargy, listlessness, poor feeding, drooping of eyelids, difficulty in swallowing, and loss of head postural control, which can lead to sudden death. Transmission: Foodborne botulism is transmitted by ingesting toxin in inadequately processed food. Wound botulism is transmitted by contamination of traumatized tissue with C. botulinum spores. Infant botulism is transmitted by ingesting spores rather than preformed toxin. Incubation period: Foodborne botulism hours, with a range of 6 hours to 8 days. Wound botulism days from time of injury. Infant botulism days. Period of communicability: No instances of secondary person-to-person transmission of botulism have been documented. Prevention: Proper processing of canned foods, not consuming food from cans with bulging lids, and not feeding honey to infants. (See APHA Control of Communicable Diseases for further preventive measures.) 13. Refers to APHA Control of Communicable Diseases for specific treatment recommendations. If the case is a candidate for C. botulinum antitoxin, it must be requested from WA State CD Epidemiology at (877) or (206) , who will arrange to have it delivered to the appropriate hospital pharmacy. (See current edition of Emergency Biologics, the Yellow Book. updated annually, for more details.) 14. Refers case to their personal health care provider for questions regarding treatment. If clinical care providers request information regarding standard treatment regimens, an epidemiologist can provide them with such general information. 15. When a complete CD case report has been entered into PHIMS (or it is determined that one is not obtainable), the record is submitted electronically to DOH CD Epidemiology. If electronic transmission is not possible, staff sends a hardcopy of the completed report to the DOH Data Compiler. (See Appendix D for address.) MANAGEMENT OF CONTACTS 1. Telephones all contacts to determine if they have eaten contaminated food. 2. Coordinates with the SRHD EH Food Program to assist in collecting suspect food for testing. 3. Advises those who may have eaten contaminated food and then become ill to seek care immediately through their personal health care provider or local hospital emergency and urgent care centers. 4. Informs contacts about the disease as above. 5. Maintains surveillance of contacts for two weeks from last exposure to contaminated food, except infants- -who should be monitored for 1 month, using CD database entries to document their progress. MANAGEMENT OF COMMUNITY 1. Notifies the ERC if indicated, who will coordinate agency-wide activities including any or all of the following as appropriate: a. Contacts appropriate SRHD EH staff immediately to assist in an investigation to determine the source of the toxin and to collect food samples. Consults with the SRHD Health Officer to initiate control measures if a common mode of transmission is suspected, e.g., a commercially processed product. b. Initiates and coordinates SRHD inspections with other local health departments, DOH, WSDA, USDA, and FDA as indicated if a common source is suspected. (See APHA Control of Communicable Diseases for specific measures.) c. Initiates an ERNIE Team meeting if indicated. d. Collaborates with the SRHD Public Information Officer to draft a Public Health Press Release if indicated, and submits it to the SRHD Health Officer for approval. e. Coordinates with the SRHD Public Information Officer to distribute the Public Health Press Release as outlined in this manual. f. Coordinates with SRHD Health Officer to issue Provider Alerts to ERs/Urgent Care facilities, primary care facilities, hospitals, labs, nursing homes, or other care providers, if indicated. Updated

21 BRUCELLOSIS When a case of brucellosis (Brucella spp.) is reported to SRHD, an Epidemiology Investigator (EI) follows the General Disease Investigation Guidelines at the beginning of this section, with special attention to the notes below: MANAGEMENT OF CASE 1. Verifies the diagnosis with the laboratory that performed the test. 2. Contacts the clinical care provider(s) who made the diagnosis to: a. Assure they are aware of the test results. b. Assure they have had the opportunity to inform the patient. c. Obtain the demographic information necessary to determine whether the case is a Spokane County resident and to make contact with the case. 3. Immediately notifies the SRHD Health Officer, Duty Officer, Emergency Response Coordinator, and WA State CD Epidemiology immediately. (This notification also applies to cases for which brucellosis is strongly suspected but not yet confirmed by laboratory testing.) Note: Although this disease is commonly diagnosed, it potentially may be a bioterrorism (BT) issue. If there is a cluster of cases with an unusual distribution or presentation, or a reason to suspect intentional dissemination, EI should notify the SRHD Duty Officer, Emergency Response Coordinator, Health Officer, and WA State CD Epidemiology immediately. 4. If the case is a resident of another county or state, refers the case to the appropriate local health jurisdiction or to WA State CD Epidemiology as necessary. Assists other investigators if the case is hospitalized in Spokane. 5. Attempts to make contact with the case. If the case cannot be reached by telephone, a message is left (if possible) requesting the case, case guardian or household member return the call without specifying the reason for the call. If the case cannot be reached by telephone, sends a letter requesting the case, case guardian or household member make contact with the EI. 6. As information to complete the CD case report is gathered, it is entered into the PHIMS electronic database system. If PHIMS is not available, Epidemiology staff records information on the appropriate form available at Disease Reporting Forms. 7. Stresses to case that all information collected is kept confidential. 8. Questions case about: a. Food history, particularly consuming unpasteurized milk or dairy products from cows or goats. b. Contact with infected pets or other animals. c. Contacts with other people with suspected or confirmed cases of diarrheal disease. d. Water supply. e. Travel history. 9. Informs the case about the disease: Symptoms: Continued, intermittent or irregular fever, headache, weakness, profuse sweating, chills, joint pain, depression, weight loss, and generalized aching. Transmission: Contact with animal tissue, blood, urine, vaginal discharges, aborted fetuses and especially placentas, and by ingestion of raw milk and dairy products (cheese) from infected animals (see APHA Control of Communicable Diseases for complete explanation.) Incubation period: 5-60 days, usually 1-2 months. Period of communicability: There is no evidence of communicability from person to person. Prevention: Avoid consuming raw/unpasteurized milk or milk products. (See APHA Control of Communicable Diseases for further preventive measures.) Updated