Manual: 7.0 Environmental Health Reviewed by: Leadership Team Approved by: Health Director Effective Date:8/15/06 Revision Dates: 10/10 Reviewed Dates: 8/12;4/13 Gov t/health/accreditation/2013/eh Surry County Health & Nutrition Center Surveillance Policy and Procedure Policy: The Surry County Health and Nutrition Center will provide services and perform activities for the control of chemical, biological, or radiological hazards within Surry County, and will adhere to State laws and current recommendations of the NC DHHS Division of Public Health. Communicable disease reporting is an essential component of the comprehensive surveillance system, and provides necessary and timely information to permit investigation, regardless of the nature of the hazard. Requirements for disease reporting are mandated by state law and regulations and will be strictly followed by the staff. Purpose: To set standards for the comprehensive public health surveillance system at the Surry County Health and Nutrition Center Definitions: Workforce: Employees, (including contract personnel), volunteers, trainees, students and other persons, when in the performance of work for SCH&NC will be under direct control of SCH&NC, whether or not they are paid by SCH&NC. Communicable Disease: An illness due to a specific contagious agent, or its toxic products, that arises through transmission of that agent or its products from an infected person, animal or inanimate reservoir to a susceptible host; either directly or indirectly through an intermediate plant or animal host, vector, or the inanimate environment. Hazard: Any agent (biological, chemical or radiological) that could possibly adversely affect humans, animals, or property. Report of Disease: An official report notifying an appropriate authority of the occurrence of a specified communicable or other disease in humans or in animals. Surveillance Form: An official communicable disease data collection form that meets both the CDC and NC DHHS Division of Public Health s requirements for disease reporting. Epi: Epidemiology DHHS: Department of Health & Human Services SCHNC: Surry County Health & Nutrition Center CDC: Centers for Disease Control and Prevention NCEDSS: North Carolina Electronic Disease Surveillance System 1
Applicable Law, Rules and References: 1. Public Health and Related Laws of North Carolina Article 6. Communicable Disease Part 1. In General 130A 133 through 151, Part 2. Immunization 130A 152. 2. GS 90-12.2. States that in an event where the Governor, a county or a municipality has declared a disaster or emergency, the State Medical Board may waive requirements to permit provision of emergency health services to the public. 3. GS 90-21.16 Covers limitation of liability for volunteer healthcare professionals. 4. GS 90.85.24 States that in an event where the Governor, a county or a municipality has declared a disaster or emergency, the State Pharmacy Board may waive requirements to permit the provision of drugs, devices and professional services to the public. 5. GS 15A-401. Covers the powers of law enforcement regarding detention and arrest for violation of communicable disease orders and suspected terrorist attack orders. 6. GS15A-534.5. States that a defendant must by clear and convincing evidence pose a threat to health and safety of others to be detained for violation of a communicable disease order. 7. GS130A-2. Provides definitions for communicable disease, outbreaks and isolation and quarantine authority. 8. GS 130-25. Specifies that violation of a communicable disease isolation or quarantine order is a Class 1 Misdemeanor, with a maximum two-year sentence. 9. GS 130A-41. Defines powers and duties of the Local Health Director, including the authority to investigate communicable diseases and conditions, and exercise quarantine and isolation pursuant to GS 130A-145. 10. GS 130A-143. Defines confidentiality of records and outlines the authority for release of records when necessary to protect public health (as part of control measures for communicable diseases and conditions). 11. GS 130A-144. Outlines the duties and requirements of the Local Health Director regarding disease investigation and surveillance, and the application of control measures for reportable diseases and conditions. 12. GS 130A-145. Empowers the Local Health Director to exercise quarantine and isolation authority so long as public health is endangered, all other means for correcting the problems have been exhausted and no less restrictive alternative exists. 13. GS130A-475. Defines the authority of the State Health Director to dictate actions such as requiring exams, tests, limiting access to buildings or facilities, limiting freedom of movement; or ordering evacuations, when he or she suspects a public health threat may exist; and that the threat may have been caused by a terrorist incident using a nuclear, biological, or chemical agent. 14. GS 130A-476. Gives a healthcare provider, a person in charge of a health care facility or a unit of state or local government the ability to report to the State Health Director or Local Health Director any events that may indicate the existence of a case or outbreak of an illness, condition, or health hazard that may 2
have been caused by a terrorist incident using nuclear, biological or chemical agents. 15. GS 166A-14. Immunity and exemption. States that all functions and all other activities relating to emergency management are governmental functions. Neither the state nor any emergency management worker, except in cases of willful misconduct, gross negligence or bad faith shall be liable for the death of or injury to persons or for damage to property as a result of any such activity. Any requirement for a license to practice any professional, mechanical or other skill shall not apply to any authorized emergency management worker who shall, in the course of performing his duties as such, practice such professional, mechanical or other skill during a state of disaster. 16. 10A NCAC 41A.0101. Lists reportable communicable diseases and conditions, and the time frame for reporting. 17. 10A NCAC 41A.0102. Outlines the procedures for reporting of communicable diseases and conditions. 18. 10A NCAC, 41A.0103. Lists duties of the Local Health Director to report communicable diseases. 19. 10A NCAC 41A.0201. Defines general control measures for communicable diseases. Except as noted in the section, specifies that the recommendations for testing, diagnosis, treatment, follow-up, and prevention of transmission for each disease or condition as outlined in the American Public Health Association s Control of Communicable Disease Manual shall be the required control measures. 20. 10ANCAC 41A.0208. Defines control measures for smallpox and vaccinia disease. States the guidelines and recommendations of the Centers for Disease Control and Prevention (CDC) for prevention of spread of smallpox and vaccinia shall supersede those in the Control of Communicable Disease Manual. Responsible Person(s): All Disease Control staff must consistently use this procedure in the administration of the communicable disease control duties. The Surry County Health and Nutrition Center Response Call-Down List will be used to alert the necessary parties that need to respond to a hazard. Equipment Required: Equipment required for investigations will be similar to that as described in the Communicable Disease Manual. Procedures: Surveillance Procedure: 1. Prompt recognition and identification of a potential hazard is the first step in the control of the incident. Although the focus of surveillance is communicable disease related, conditions such as food and water safety and chemical threats are also monitored. 2. Disease Control Division will generate surveillance data from a wide-range of formal and informal sources. 3. Formal reports will be received from private providers, hospitals and laboratories. 3
4. Informal, or unofficial reports, are received through the news media, public health email services, websites, and telephone calls from the general public, which address bioterrorism threats, rumors of unusual disease events and potential disease outbreaks. 5. SCH&NC will also receive disease reports and/or information about unusual patterns of disease or absences from community agencies including Emergency Medical Services (EMS), daycare centers, adult care facilities, the school system and home health agencies. 6. When a possible etiological agent or bioterrorism is suspected, SCH&NC will initiate regular contact with these groups, as well as local pharmacies, large employers, veterinarians and funeral homes (as appropriate to the incident). 7. Surveillance priorities will be directed to those diseases/conditions outlined in 10ANCAC 41A.0101. 8. Staff must be constantly aware of emerging infectious diseases, bioterrorism threats and unusual disease patterns. 9. Surveillance activities include: a. Detection: identifying cases and outbreaks b. Confirmation: epidemiological and laboratory confirmation c. Reporting: early warning and routine d. Analysis and interpretation: preparing and periodically updating graphs, tables and charts to describe time, person, and place for reported diseases and conditions, identifying unusual trends or patterns or the exceeding of a threshold value, interpreting results, discussing possible public health action e. Control/response: case management, contact tracing, infection control measures, including isolation and quarantine, immunization activities, specific treatment, preventive and control measures, community information and education, alerting nearby counties and State f. Outbreak/investigation: case finding (records, active surveillance), collection and transport of specimens, confirmation testing, interpretation of results (epidemiological and laboratory) g. Evaluation and monitoring Epidemiology and Communicable Disease Investigation 1. Epidemiology will be used to further determine whether a disease occurrence is an unusual event that should raise concern, or the result of a naturally occurring infectious disease. 2. The SCH&NC Epi-Team will be activated, as necessary, to examine potential chemical, biological, and/or radiological hazards with regard to the potential for human disease. 3. The ultimate goals of epidemiology and communicable disease investigations are to: a. Categorize disease b. Prevent new outbreaks c. Contain existing outbreaks d. Minimize morbidity and mortality by preventing exposure 4
e. Interrupting the chain of transmission f. Identifying persons who need post-exposure prophylaxis and treatment. 4. Epidemiology, surveillance and investigation efforts will continue as long as new cases occur and present for medical care, new casualties caused by the illness are identified and reported, or until the incubation period for the disease in the exposed population has expired. 5. The epidemiologic and communicable disease investigations seek to: a. Identify and characterize the illness or disease and track the condition back to the original source(s) of exposure. b. Identify the risk factors associated with exposure. c. Identify variables that influence morbidity and mortality. d. Trace each new case and their contacts to determine if additional sources of contagion or exposure exist. 6. The Surry County Health & Nutrition Center will coordinate the initial epidemiologic and communicable disease investigations in the county in response to potential hazards, including those due to suspected or probable bioterrorism. 7. SCH&NC will coordinate with NCDPH and CDC epidemiologists when the bioterrorist attack is directed against human populations, and with NC Department of Agriculture and Consumer Services and Veterinarians when the biological agent also impacts poultry or livestock. 8. SCH&NC staff will coordinate the disease and epidemiology investigations with local law enforcement, and with the FBI and/or SBI, who will be conducting concurrent criminal investigations of bioterrorist attacks. 9. When epidemiology and communicable disease resources in the SCH&NC become overwhelmed, or are found to be insufficient, assistance may be requested from PHRST 5 and NCDPH, and also from other counties through the Emergency Management Assistance Compact (EMAC). 10. NCDPH may request additional staff from CDC to join the investigation. Communicable Disease Reporting Procedure: 1. Communicable Disease (CD) reports are received by mail, fax or telephone from area physicians. 2. CD report forms are given to the CD nurse or designee in her absence. 3. CD report will be initiated by nurse, when required. 4. The nurse will complete the CD report, and enter the information into NCEDSS after completion of follow up. 5. The CD report may be completed by the nurse via telephone call with the physician for those diseases requiring immediate attention, and which also have 24 hour reporting time frames. 6. CD reports will be checked for accuracy prior to data entry, and to prevent duplicate entry of reports. 7. Notification to the State will occur via telephone, fax, email, or Health Alert Network (HAN) by the CD Nurse or CD Supervisor upon receipt of a disease with major public health importance or an outbreak situation. 8. Information will be kept on a communicable disease paper log by CD clerical staff. 5
9. Reports of verified case of TB (CDC72.9A) will be entered into NCEDSS. 10. All STD cases will be entered into NCEDSS except for Syphilis and HIV. They will be sent to the Regional Office in Winston-Salem Laboratory Diagnosis: 1. Laboratory diagnosis is a critical step towards rapid identification of a hazardous agent, an outbreak, or bioterrorist event. The North Carolina State Lab of Public Health (SLPH) is the primary public health laboratory providing support to the SCH&NC. The SLPH is responsible for providing diagnostic expertise and guidance for specimen handling in disease investigations and suspected bioterrorist attacks. However, the FBI or SBI may also send samples to the State Crime Lab for Testing. 2. The SLPH is equipped with a Bio-Safety Level 3 laboratory. During a biological event, specimen packaging and transport must be coordinated with the SLPH. 3. Transportation to the lab will often also be coordinated with local law enforcement, which will ensure the proper chain of custody for criminal investigations is maintained, from the time of collection of the specimens until its arrival at the SLPH or State Crime Lab. 4. The SLPH accepts samples at the request of the FBI, SBI, PHRST Teams, Local Health Departments, Regional Response Teams and HAZMAT ONLY. Reference Plans and Policies: Bioterrorism Preparedness and Response Plan; Epi-Team Manual; Communicable Disease Manual; Response Call-Down List Employee non-compliance to this policy could result in a non-compliance notification and/or be subject to the disciplinary process. 6