West Virginia
Infectious Disease Epidemiology Program

Initial Assessment by Local Health | Initial Response within WVDHHR | Objectives/Purpose of Epi Investigation | Central Epi Team | Rapid Epi Response Teams | Public Health Command and Control | Clinical Characteristics of BT Agents | Laboratory Diagnosis of BT Agents

(Note: This is the first draft protocol released to local health departments on October 12, 2001. This protocol should be followed until a final version can be released.)

Initial Assessment by Local Public Health Agencies with Help from Infection Control Nurse

1. Rapidly triage reports of respiratory disease by gathering the following information:

1. Number of ill persons
2. Setting (school, nursing home, community, etc)
3. Age distribution of ill persons
4. Do ill individuals have underlying disease or are they previously healthy?
5. Symptoms
6. Date(s) of onset of illness
7. Duration of illness – time to full recovery
8. Does anyone have pneumonia? How many?
9. Results of sputum gram stain and blood cultures, and other studies.
10. Are any patients sick enough to be in the hospital? How many?
11. Are any patients moribund? How many?
12. Has anyone died? How many?
13. Name and phone number of person reporting illness.

2. If clusters of pneumonia resulting in critical illness or deaths among previously healthy persons are identified through initial triage, contact the Infectious Disease Epidemiology Program (IDEP) immediately, day or night (at 304-558-5358 or 1-800-423-1271 from 8:30 AM to 5:00 PM or 304-558-4117 weekends and after hours). Review the situation with IDEP. Anticipate that you will be asked to:

1. Immediately begin active surveillance with other health care providers in the county.
   
   
2. Alert your regional epidemiologist to expand active surveillance throughout the region.
   
   
3. Identify staffing for rapid response team(s) in your county.

3. If the pattern of illness suggests influenza A or B or other seasonal respiratory illness, a rapid and efficient outbreak investigation is helpful to document that illness is present in the community and alert providers to take precautions with their high risk patients. Consult IDEP ASAP.
   
   
4. Pneumonia clusters may also be due to multiple other diseases of public health significance: pneumococcus, Legionella, leptospirosis, psittacosis, hantavirus, etc. Consult IDEP as soon as possible.
   
   
5. Pneumonia clusters and outbreaks may also be due to mycoplasma, adenovirus, parainfluenza, RSV, etc. While state and local health departments are often not as familiar with these diseases, having a specific etiologic agent for an outbreak of respiratory disease is very useful for educating and reassuring the public and providers about what is going on in the community. Notify IDEP.

Initial Response within WVDHHR

Triage is the responsibility of medical epidemiologist(s) within the Division of Surveillance and Disease Control.

1. If medical epidemiologist(s) believe that the possibility of a serious outbreak exists likely due to unintentional causes, e.g., Legionellosis, invasive pneumococcal disease, then a rapid response team should be formed with representation from the state, regional epidemiologist and local health departments. That team will go on-site to lead and complete the investigation.
   
   
2. If medical epidemiologist(s) believe that there is a possibility of a serious outbreak due to intentional causes, then:

1. Notification should proceed directly from medical epidemiologist to the State Epidemiologist, and then to DHHR Disaster Coordinator.
   
   
2. The BT Coordinator (or alternate lead person from DSDC) should then proceed to form Rapid Epi Response Teams, usually one team per health care facility or closely located group of health care facilities. Staffing on each team should generally consist of a state and a regional or local person. Staffing must remain flexible depending on need and case load. Any significant back-log of case investigations must be addressed by swinging in additional staff in a timely fashion. In the event that a disease outbreak appears to be community-based, a street-based rapid epi response team must also be formed.
   
   
3. If there is a high probability of an intentional incident, CDC should be consulted immediately at 770-488-7100.

Objectives/Purpose of the Epidemiological Investigation and Response

1. Establish the existence of an outbreak.
   
   
2. Organize the information.
   
   
3. Establish the most likely agent(s) responsible for the outbreak through documentation of clinical signs and symptoms, and person, place and time data, and assuring that adequate laboratory testing is performed.
   
   
4. Rapidly differentiate outbreak likely due to unintentional causes versus intentional causes.
   
   
5. For intentional outbreaks, determine the most likely source of exposure through interviews of patients and family members to identify common exposures during the incubation period of the suspected agent.
   
   
6. Based on the early information regarding exposures, formulate recommendations for prophylaxis, if indicated. For anthrax and plague, it may be necessary to make preliminary recommendations for prophylaxis based on open-ended interview information without performing a more rigorous case-control study.
   
   
7. Conduct epidemiological investigations testing hypotheses, as necessary.
   
   
8. Identify / enumerate the population at risk so that exposed / not yet symptomatic individuals can be prophylaxed and emergency responders can anticipate supply, equipment and manpower needs.
   
   
9. Quantify and document ongoing human health consequences to fully inform policymakers in real time.
   
   
10. Evaluate (in real time) control strategies, allowing readjustment as needed.
    
    
11. Develop background information to inform public and providers.
    
    
12. Supply information for informed policy development.

Composition and Function of the Central Epi Team

1. Composition and duties

1. State Epidemiologist - as always, primary advocate for her staff. Identifies staffing, clears out barriers, etc.
   
   
2. Bioterrorism Coordinator - lead investigator / lead communicator with teams in field, lead communicator on epi issues with Public Health Command and Control. Link to CDC. Link to USAMRIID. Link to weather info, if needed (prevailing wind direction, etc. on day of event).
   
   
3. Medical Epidemiologist(s) - clinical input into study design and forms, draft recommendations for prophylaxis, development of information for providers and the public on disease manifestations, outcome, treatment, prophylaxis, etc. Divide time between Rapid Epi Response Teams and the Central office.
   
   
4. Data entry clerk - entry of study data.
   
   
5. Epidemiologist(s) / analyst(s) - QA of data and analysis, development of graphics, tables in real time to report results, access census data to estimate population at risk in event of community-based outbreak, GIS mapping.
   

2. Functions

1. Study design and oversight of data collection and data management.
   
   
2. Oversight of Rapid Epi Response Teams.
   
   
3. Regular summarization of results to forward to Public Health Command and Control:
   
   

1. Enumeration of human health consequences
   
2. Conclusions about etiology
   
3. Information about the population thought to be exposed and how and where they were exposed
   
4. Estimates of size of population thought to be at risk
   
5. GIS maps showing location of cases in the event of a community-based outbreak
   
6. Real-time feedback of information on human health consequences
   

4. Development of recommendations for prophylaxis.
   
   
5. Development of background information for providers and public.
   
   
6. Timely identification of staffing problems (too many, too few, fatigue, stress, etc.) and timely referral to Public Health Command and Control for resolution if the problems cannot be resolved within DSDC.
   
   
7. Communication and consultation with local health departments and health care providers on medical and epi issues.
   
   
8. Communication with and consultation with CDC and Ft Dietrich, as needed.
   
   

Functions and Composition of the Rapid Epi Response Teams

1. Health care facility - based teams

1. Functions
   

1. Case finding
   
2. Case ascertainment
   
3. Data collection
   
4. Assurance that clinical specimens are obtained appropriately for diagnostic purposes
   
5. Data transmittal to Central Epi Team
   
6. Two way communication with Central Epi Team
   
7. Two way communication with Infection Control Practitioner or other hospital personnel
   

2. Composition
   

1. State employee with a clinical background
   
2. Local health department employee with a clinical background
   
3. Infection control practitioner as liaison to hospital / facility
   
4. Medical Epidemiologist - on the first team out, until the situation stabilizes, and as needed
   

2. Street - based teams

1. Functions
   

1. Case finding
   
2. Case ascertainment
   
3. Outreach to exposed individuals who have not sought medical care or other individuals who do not have access for whatever reason
   
4. Data collection, to include GIS data on cases if needed to determine the extent of the exposure
   
5. Direct one-on-one education of the public
   
6. May be paired with medical outreach / home health services
   
7. Contact tracing
   

2. Composition
   

1. State employee(s) with clinical or environmental background
   
2. Health educator
   
3. Local employee(s) with clinical or environmental background
   
4. Local law enforcement official, if judged necessary for protection
   

Activation of Public Health Command and Control

DHHR Disaster Coordinator has the responsibility to activate Public Health Command and Control.

1. Functions

1. Review and clearance of policy recommendations from the Central Epi unit.
   
   
2. Allocation and reallocation of staffing, as needed.
   
   
3. Organizing and oversight of implementation of employee health functions, including provision of vaccine or prophylactic antibiotics to employees, if needed
   
   
4. Organizing and implementing employee advocacy, to include counseling or other services to prevent post-traumatic stress disorder in employees.
   
   
5. Communications.
   
   
6. Communication and coordination with EOC.
   
   
7. Oversight of the logistics of medication and vaccine distribution and delivery and organization of mass prophylaxis clinics, if indicated.
   
   
8. Host staff meeting at least daily for the duration of the emergency.
   
   
9. Monitoring stress / psychological response among DHHR employees and proactively initiating counseling / debriefing for employees
   
   
10. Implementing employee health recommendations appropriate for agent (may include provision of personal protective equipment or prophylactic immunizations for employees in the field).
    
    
11. Implementing employee health recommendations in the event that HHR employees are exposed (if even by virtue of place of residence) so that critical staffing can be maintained.
    
    

2. Suggested composition

1. State Health Commissioner
   
   
2. State Epidemiologist
   
   
3. BT Coordinator
   
   
4. Emergency Medical Services
   
   
5. Public Health Nursing and Administration
   
   
6. HAN
   
   
7. Office of Laboratory Services
   
   
8. Office of Environmental Health
   
   
9. DHHR Management Information Systems (MIS)
   
   
10. West Virginia Department of Environmental Protection (DEP)
    
    
11. Bureau for Behavioral Health Services
    
    

Quick Overview of Clinical Characteristics of Respiratory BT Agents

There are five major BT agents that may present as respiratory illness. Rapidly distinguishing between these agents is critical because prophylactic antibiotics are effective against anthrax, Q-Fever, Plague, and Tularemia; and suspicion of pneumonic plague necessitates immediate isolation (droplet precautions) for all suspect cases. Here is a quick rundown of key clinical and epidemiological signs and symptoms that might be expected if patients present with respiratory illness after covert release of an aerosolized biological agent:

Quick Reference to Laboratory Diagnosis

NOTE: In most situations, it is also important to rule out other common infectious agents including influenza, respiratory viruses, and legionella, pneumococcus, hantavirus, psittacosis, chlamydia pneumoniae, etc.

Prophylaxis and Treatment - Major Concepts

See specifc recommendations from JAMA / USAMRIID.

Specific treatment and chemoprophylaxis is available for anthrax, plague, tularemia, Q Fever. Treatment of respiratory ricin / Staph enterotoxin B is supportive.

Isolation - Major Concepts

Standard precautions are sufficient for anthrax, Q fever, tularemia, Staph enterotoxin B, and Ricin.

Droplet precautions must be used for pneumonic plague.

Decontamination - Major Concept

Soap and water, if needed at all. Risk of secondary aerosolization is negligible for all agents. (Not a good place to use staff time)

Contact Tracing and Contact Assessment

Becomes critical for pneumonic plague. Should be combined into the functions of the Street-based epi team(s). This would necessitate expansion of the size and number of street epi team(s). Exposed persons should be tracked and followed through the incubation period and evaluated / isolated at first sign of illness.