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Annex C - Bio-Emergency Surveillance, Epidemiologic Investigation, and Control 
PURPOSE
The Iowa Department of Public Health has revised this document, the purpose of which is to provide a framework for initiating and managing an epidemiologic response to a bio-emergency, whether it is brought about through natural or accidental causes or by a terrorist attack.  This includes delineating and coordinating the roles and responsibilities of state and local public health agencies, and coordinating the activities of these agencies with support organizations.  

Successful response may include:
Rapid detection of unusual health events;
The ability to quickly distinguish among hoaxes, real threats, and actual bio-emergencies;
Ready access to appropriate laboratory services;
Rapid and inclusive dissemination of disease treatment recommendations; 
Rapid identification of secondary victims; and
Timely implementation of feasible and appropriate disease containment measures.

Attachment 7 to this annex is a flowchart depicting the suggested steps that LPHA personnel should take following the detection of a potential or actual bio-emergency affecting their agency's jurisdiction.  

SITUATION
Early detection of the onset of a bio-emergency and an early understanding of its cause and spread will save lives.  This is especially true when one or more of the following is true about the disease precipitating the emergency:

It is rapidly fatal;
-OR-
It is readily treatable or preventable through antibiotic therapy and or vaccine administration;
-OR-
It is transmissible from person to person or between animals and people.

The threat of a major influenza outbreak, in and of itself, more than justifies the need to maintain a robust epidemiologic response capability.   
In addition to influenza and other naturally occurring infectious disease hazards, public health agencies are faced with the possibility of investigating a bio-emergency originating from a terrorist attack.   Specific disease circumstances highly suggestive of a terrorist attack are a confirmed case of smallpox, inhalation anthrax, viral hemorrhagic fever, pneumonic plague, and pneumonic tularemia; a cutaneous anthrax case or cluster of brucellosis cases occurring in persons with no known compatible risk factors; or a higher than expected number of botulism cases occurring at or around the same time.

SURVEILLANCE AND EPIDEMIOLOGIC INVESTIGATION STEPS
In the event of a known or suspected outbreak, regardless of the circumstances of the outbreak (i.e. natural or intentional), consult the IDPH/CADE epidemiologists who are available 24/7 at 800-362-2736.  This consultation is especially important if multiple jurisdictions are involved, as this will facilitate the implementation of standardized protocols and procedures for investigation.  It is imperative to delineate the surveillance roles of this county in collaboration with the IDPH. What follows are steps that will be undertaken as part of investigation.  These steps may occur simultaneously or in a different order.  Surveillance of Pandemic Influenza may be gradually expanded in relation to the World Health Organization's Pandemic Influenza Phases, please see(Appendix/Annex F)

1.Confirm the existence of an outbreak by categorizing cases by time, place, and affected persons using both usual and special surveillance data.
2.Verify the diagnosis by using laboratory methods and consulting with medical care providers.  Use the state laboratory courier when appropriate.
3.Develop a case definition specific for the event. Orient to persons, place and time.  Such a definition may need to change during investigation of the outbreak.
4.Perform a rapid preliminary study to compare those who meet the case definition with those who do not to provide information that will further define the illness and the situation.
5.Develop a hypothesis.  It should address the agent causing the disease, the source of the outbreak, mode of transmission, the relevant exposure period and other contributing factors that led to the illness.  Some of these may be known at the onset of the investigation, whereas determining the others will probably be the goal of the investigation.
6.Plan the detailed investigation by selecting a study design, either cohort or case-control.
7.Develop a questionnaire to use in the investigation.  Include questions on demographic data, illness status, symptoms, laboratory results and exposure details.
8.Conduct interviews with a valid sample (or nearly all) of your target group. For both cohort and case-control studies, ill and well people need to be included in order to make conclusions about the cause of the illness.  
9.Organize and input data for analysis.
10.Compile data, which will involve use of a data entry and analysis program for all but the simplest of investigations.
11.Plot an epidemic curve, a histogram of the number of cases shown on the vertical (y) axis against relevant time periods on the horizontal (x) axis. Its shape can be used to pinpoint a likely exposure period and whether secondary cases have occurred. 
12.Analyze and summarize data.

During the course of the investigation, investigators should share relevant information with community partners.  Diagnostic and epidemiologic information should be provided to medical and public health partners who may include clinicians, hospitals and environmental specialists.  In addition, it is important to provide timely and accurate information as appropriate to non-medical partners such as law enforcement, elected officials, and the news media on the nature of the disease and the progress of the ongoing investigation.   

Prevention and control measures that minimize risk for further exposures should be implemented as early as possible in the response.  Public health should monitor the response to these measures and modify as needed until disease is controlled or eradicated from targeted areas if possible.  Some of these prevention options are discussed further below.  

Contact IDPH as needed for assistance from the Environmental Health Response Team for assistance with environmental health issues (food, water, etc.) 

BIO-EMERGENCY CONTROL AND PREVENTION OPTIONS

LEGAL AUTHORITY

Isolation and quarantine
In accordance with Iowa Code chapters 135 and 139A, and the Iowa Administrative Code (IAC 641-1.8 Isolation and 641-1.9 Quarantine)1, implement isolation and quarantine measures when necessary to control and prevent the spread of a contagious disease.  See the following attachments #9 through #14.

Pursuant to the authority of Iowa Code section 139A.4, the Department of Public Health hereby gives Notice of Intended Action to amend Chapter 1, “Notification and Surveillance of Reportable Communicable and Infectious Diseases, Poisonings and Conditions,” Iowa Administrative Code.  This amendment provides model rules for quarantine and isolation has been adopted by the Greene County Board of Health.  The quarantine and isolation rules for Greene County may be found at Greene County Medical Center Public Health Department, Greene County Medical Center Administrative offices, and the Greene County Auditor's office.
GCMC's Attorney and/or the County Attorney will provide legal interpretation and advice regarding public health laws.

Prophylaxis 
May be administered pre- and/or post-exposure.  Includes vaccine administration and dispensing of pharmaceuticals.  May or may not involve the use of the Strategic National Stockpile (SNS) program.  When the federal government authorizes the use of the SNS program in Iowa, it will be implemented in accordance with the Iowa Emergency Response Plan and the Iowa SNS Operating Procedures.  Vaccine, pharmaceuticals, and other medical supplies allocated to Greene County through the SNS are to be obtained at the designated “distribution node.”  

The locations of the primary and backup Point of Dispensing Sites (POD) for Greene County are kept on file at the local public health agency as a separate document, that is filed with this plan.  The POD document outlines the designation of the POD and the procedures for set up, staffing, supply and demobilization.  

Education
May target health-care providers, the general public, or both, and could include information about disease transmission, infection control precautions, prophylaxis-related contraindications, and prophylaxis-related adverse events.   Materials developed for this purpose should be provided in multiple languages when necessary.  Refer also to Annex B of this plan.

Treatment
Appropriate treatment of the ill will not only save lives and alleviate suffering but is also often an effective tool for controlling the transmission of infectious diseases.  Treatment may include antibiotic/anti-microbial therapy, but with certain disease agents it may be limited to supportive care.  When the number of ill people approaches the number of available hospital beds in the affected area, it may become necessary to establish alternate treatment locations for treating patients who do not require the more advanced medical resources available only at hospitals.  Another option when day-to-day treatment capabilities become overwhelmed is to request that state government activate one or more of Iowa's Disaster Medical Assistance Teams, or DMATs, once they are established and become operational.  IDPH has developed plans and procedures to assist local healthcare facilities with establishing alternate treatment location plans.  Refer also to the Greene County Medical Center (hospital) emergency response plan.

Attachment 1 – Outbreak Detection Notification Points

Attachment 2 – Laboratory Location(s)

Attachment 3 – Lab Specimen Courier(s)

Attachment 4 – Alternate Treatment Center Location(s)

Attachment 5 & 6 – Emergency Vaccination Clinic Location(s) and Emergency Prophylaxis Dispensing Center Location(s)

Attachment 7 - GREENE County LPHA Response to a Potential or Actual Bio Emergency

Attachment 8 – Epidemiologic Investigation

Attachment 9-Isolation and Quarantine Document Checklist

Attachment 10-Voluntary Confinement Letter-EXAMPLE

Attachment 14 - 641-1.12(135, 137, 139A) Quarantine and Isolation