High Priority Infectious Disease Standard Operating Guidelines (HPID SOG)
DRAFT January 22, 2020
Department of Public Health SAN BERNARDINO COUNTY High Priority Infectious Disease Standard Operating Guide (HPID SOG)
RECORD OF CHANGES ...... 4
SECTION I: OVERVIEW ...... 5 A. INTRODUCTION ...... 6 1. BACKGROUND ...... 6 2. PURPOSE AND SCOPE ...... 6 3. HPID SOG ORGANIZATION...... 7 B. DEPARTMENT OPERATIONS CENTER (DOC) ...... 8 1. ACTIVATION ...... 8 2. COMMUNICATIONS ...... 8 3. NOTIFICATION ...... 9 4. ROLES AND RESPONSIBILITIES ...... 10 C. EPIDEMIOLOGY ...... 11 1. CASE DEFINITIONS ...... 11 2. CONFIDENTIAL MORBIDITY REPORT (CMR) ...... 12 3. UNUSUAL CONDITIONS TO REPORT ...... 14 D. MONITORING ...... 15 1. REPORTING A SUSPECT CASE/PERSON UNDER INVESTIGATION (PUI) TO PUBLIC HEALTH ...... 15 2. CONTACT INVESTIGATION AND CASE MANAGEMENT STAFFING ...... 15 3. MONITORING STEPS ...... 15 4. POST-INCIDENT PERSONNEL MONITORING ...... 17
SECTION II: HIGH PRIORITY INFECTIOUS DISEASES (HPID) ...... 18 A. HPID MATRIX ...... 19 B. HPID CATEGORIZATION ...... 23 C. HPID INFORMATION SHEETS ...... 24 1. Anthrax* – Bacillus anthracis ...... 24 2. Botulism – Clostridium botulinum ...... 24 3. Brucellosis – Brucella species ...... 25 4. Cholera – Vibrio cholerae ...... 25 5. Viral Hemorrhagic Fevers – Ebola, Marburg, Lassa Viruses...... 25 6. Glanders* – Burkholderia mallei ...... 26 7. Pandemic Influenza – Orthomyxoviridae Influenzavirus A, B, C ...... 26 8. Middle Eastern Respiratory Virus (MERS) / Severe Acute Respiratory Virus (SARS) – Coronavirus ...... 30 9. Measles – Paramyxioviridae Morbillivirus ...... 27 10. Melioidosis (Whitmore’s Disease) – Burkholderia pseudomallei ...... 27 11. Smallpox* – Poxviridae Orthopoxvirus ...... 28 12. Tularemia* – Francisella tularensis ...... 28 13. Plague* – Yersinia pestis ...... 29 14. Zika Virus – Flavivirus ...... 29
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SECTION III: NON-PHARMACEUTICAL INTERVENTIONS (NPI) AND INFECTION CONTROL PRECAUTIONS ...... 31 A. NPI OVERVIEW ...... 32 B. NPI IMPLEMENTATION TIMELINE ...... 32 1. TRIGGERS FOR NPI USE ...... 32 2. DURATION OF NPI USE ...... 32 3. DE-ESCALATION OF NPI USE ...... 32 C. PERSONAL NPI ...... 33 1. PERSONAL PROTECTIVE EQUIPMENT ...... 33 2. PERSONAL PROTECTIVE MEASURES FOR EVERYDAY USE ...... 33 D. COMMUNITY NPI ...... 34 1. SOCIAL DISTANCING MEASURES ...... 34 2. SCHOOL CLOSURES AND DISMISSALS ...... 34 3. TEMPORARY CLOSURE OF PUBLIC GATHERINGS ...... 34 4. EVACUATION ...... 36 E. ENVIRONMENTAL NPI ...... 37 F. INFECTION CONTROL PRECAUTIONS ...... 37 1. OVERVIEW ...... 37 2. MATRIX – SUMMARY OF INFECTION CONTROL PRECAUTIONS ...... 38 3. STANDARD PRECAUTIONS ...... 42 4. TRANSMISSION-BASED PRECAUTIONS ...... 45 G. ISOLATION AND QUARANTINE ...... 48 1. INTRODUCTION ...... 48 2. RESPONSIBILITY AND AUTHORITY ...... 48 3. PROCEDURE FOR AN ORDER FOR ISOLATION OR QUARANTINE ...... 49 4. ENFORCEMENT OF QUARANTINE AND ISOLATION ...... 50 5. LAW ENFORCEMENT FOR NON-COMPLIANCE ...... 50 H. MENTAL AND BEHAVIORAL HEALTH CONSIDERATIONS ...... 51 I. NPI FOR TOP 3 NATURAL DISASTERS AND SEVERE WEATHER ...... 52
SECTION IV: APPENDIX ...... 55 A. PUBLIC HEALTH INFECTIOUS DISEASE EMERGENCY ALGORITHM ...... 56 B. ACRONYMS ...... 57 C. DEFINITIONS ...... 59
SECTION V: ANNEX ...... 62 1. Aerosol Transmissible Diseases (ATD) Exposure Plan ...... 63
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San Bernardino County Department of Public Health (SBCDPH) will revise and update the High Priority Infectious Disease Standard Operating Guidelines (HPID SOG) and annexes every three years or as changes are needed based on real incidents and lessons learned. Revisions will be documented in the “Update/Revision List Form” of each version.
The HPID SOG will be reviewed and approved by the Preparedness and Response Program (PRP) and the Communicable Disease Section (CDS). The SBCDPH Health Officer will provide final approval of revisions.
Change Date of Version Revised By Description of Change # Change Melanie 1 3.0 4/25/19 Updated 6/25/18 GID-SOG. Bruno Added information under Section I: Overview. Vanessa Reformatted document. 2 4.0 5/9/19 Morales Edited Infection Control section. Included Standard and Transmission-based Precautions Matrix. Updated information under Unusual Conditions to Report Updated Section II High Priority Infectious Diseases Table with additional diseases Ruchi Under High Priority Diseases, included updated and/or additional links to 3 5.0 8/13/19 Pancholy infectious disease quick sheets Included suggestion to remove Glanders and Melioidosis from the list of high priority diseases Included additional examples under Section III. Non-Pharmaceutical Interventions (NPI) Reformatted styles Vanessa 4 6.0 10/2/19 Morales Moved “Communication” before “Notification” Edited infectious disease list Vanessa 5 7.0 10/7/19 Morales Added reference to EOM to Unusual Events section Corrected typos, font sizes, italicization of bacterial and viral taxa at family level and below Added titles to tables Vanessa Included bullets in tables 6 8.0 01/22/20 Morales Updated acronym list Included “Recommendation” for those with artificial nails Defined CDC Tier 1 epidemiology competencies Numbered diseases within matrix 7 8 9 10 11 12
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Section I: Overview
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1. BACKGROUND The High Priority Infectious Disease Standard Operating Guide (HPID SOG) was developed within the framework of the San Bernardino County Department of Public Health (SBCDPH) Preparedness and Response Program (PRP) and Communicable Disease Section (CDS) to strengthen emergency preparedness and response capabilities concerning infectious disease emergencies. Infectious disease emergencies stem from biological agents that inflict widespread illness and/or death within a population and may include: Naturally occurring outbreaks (e.g. measles, mumps, meningococcal disease) Emerging infectious diseases (e.g. SARS, avian influenza) Re-emerging infectious diseases (e.g. cholera, bubonic plague) Pandemics (e.g. novel influenza) Bioterrorism (e.g. aerosolized anthrax release) Multiple factors must be considered when responding to an infectious disease emergency, including the type of biological agent, scale of exposure, mode of transmission, intentionality, etc. Additionally, infectious disease emergencies may increase the risk of communicable disease spread during and after the incident, thus requiring specialized mitigation, planning, and response interventions to prevent and control the spread of further disease. The intent of SBCDPH is to minimize the impact of infectious disease outbreaks by: 1. Limiting the number of illness and deaths 2. Reducing the spread of the disease 3. Preserving continuity of essential government functions 4. Minimizing social disruption 5. Minimizing economic loss
2. PURPOSE AND SCOPE SBCDPH CDS routinely receives reports of infectious disease cases, conducts investigations, and implements disease containment measures. The HPID SOG is intended to be used for any infectious disease emergency requiring a response that exceeds CDS’s normal disease control capacity. Some outbreaks or situations will require limited response activities; other situations will require largescale response efforts that involve many sections within SBCDPH and or many county agencies. Activities that may be implemented during an infectious disease emergency response include: Coordination with other city, regional, state and federal agencies and other organizations responding to a large public health emergency. Development and dissemination of information and guidance for the medical community, responders, general public, and special population settings. Public health disease containment measures such as: infection control, mass prophylaxis, isolation and quarantine. Coordination of medical care systems and management of alternate care and/or shelter sites Epidemiological surveillance and investigation activities such as surveillance, investigation, and lab testing. Collection and analysis of data to inform the development of objectives and tactics.
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Intended Audience: The SBCDPH HPID SOG is intended to provide the SBCDPH Department Operations Center (DOC) responders with basic information and guidelines to assist decision making within the DOC. The HPID SOG provides an overview of the DOC’s role in an infectious disease response, information on select high priority infectious diseases, and guidelines for infection control. Reasoning for HPID Selection: Although there are numerous infectious diseases, the HPID SOG focuses on those that pose an elevated threat to public health and will require major multi-sectoral responses and rational allocation of limited resources, such as medical countermeasures. The HPID were selected from the Center for Disease Control (CDC) list of bioterrorism agents/diseases, World Health Organization (WHO) list of high priority diseases, San Bernardino County Confidential Morbidity Report (CMR), and Biowatch list of priority biological agents. HPID SOG is Subject to Revision: The HPID SOG is subject to revision as guidance is received from the California Department of Public Health (CDPH), CDC, Emergency Medical Services Administrator’s Association of California (EMSAAC), California Department of Industrial Relations, the California Occupational Safety and Health Administration (Cal/OSHA) and other federal departments, as well as from local experience gained in testing and conducting simulation exercises, or a real-world event. In the event of an infectious disease emergency, SBCDPH will supplement information in this SOG with guidance received from state and federal agencies.
3. HPID SOG ORGANIZATION The HPID SOG includes a base guideline, appendix, and annex. The base guideline is organized into three sections.
CONTENTS DESCRIPTION
Section I Overview of HPID, DOC roles and responsibilities, epidemiology case definitions and reporting
Section II HPID matrix and disease specifics
Non-pharmaceutical Interventions, including: isolation, quarantine, social distancing, and Section III infection control precautions
Detailed instructions and tools to be used in the event of a public health emergency. Resources Appendix include: protocols, forms, guidelines, memorandum of understandings (MOU), and other documents
Specific recommendations and plans for select diseases including: Aerosol Transmissible Annex Diseases (ATD), Viral Hemorrhagic Fever (VHF) such as Ebola, and Pandemic Influenza.
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1. ACTIVATION Reference Document: SBCDPH Department Emergency Operations Plan (DEOP) Initial Response: In the event of an infectious disease emergency, the Health Officer or Public Health Director will activate appropriate parts of SBCDPH DEOP, this HPID SOG, as well as the SBCDPH DOC. The SBCDPH DOC will coordinate the infectious disease response and follow activation procedures outlined in the SBCDPH DEOP. Upon activation of the SBCDPH DOC:
Health Officer or Public Health Director SBCDPH DOC:
Notify the Operational Area (OA) Emergency Operation Serve as the command center to coordinate the Center (EOC) to request activation. local response to an HPID emergency. In coordination with the OA EOC, request a local state Provide an incident management structure that is of emergency proclamation if it has not been declared. National Incident Management System (NIMS) Notify and deploy assigned staff to the DOC, see DEOP compliant and facilitates core functions of and DOC Organization Chart. Command, Operations, Planning, Logistics, and Initiate internal notification procedures utilizing the Administration and Finance Sections. California Health Alert Network (CAHAN). SBCDPH DOC Operations Section will determine Act as the Incident Commander and enact public health the extent of the response and request that the directives. DOC Director assemble DOC personnel. If the OA EOC is activated, deploy to the OA EOC to manage the Medical Health Branch of the EOC, and assume the role of Medical and Health Operational Area Coordinator (MHOAC).
2. COMMUNICATIONS Reference Document: San Bernardino Crisis and Emergency Risk Communications (CERC) Plan Communications and requests will follow ICS guidelines. During an emergency event SBCDPH will utilize the following means of communication: MODE FUNCTION Rapid Emergency Digital Data Information Network (ReddiNet) and Notify staff, hospitals, clinics and medical providers of events related to HPID. California Health Alert Network (CAHAN) Emergency System for Advance Registration of Volunteer Health Identify physicians by specialty, pharmacists, and registered nurses licensed to Professionals (ESAR-VHP) and/or practice in San Bernardino County. Disaster Healthcare Volunteers (DHV) Contact information, languages spoken, and professional licensure of staff that Database of San Bernardino County may be asked to respond during an event. This information will be obtained from Employees County Human Resources as needed. PIO is a member of the DOC Management team and reports directly to the DOC Public Information Officer (PIO) Director. The DOC PIO will implement the SBCDPH CERC Plan. Includes risk communication messages on HPIDs, contraindications and adverse events appropriate for the general public in English, Spanish, and other Risk Communication Messages languages as appropriate. Messages have been developed as part of SBCDPH’s CERC Plan.
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3. NOTIFICATION Reference Document: CDPH Emergency Operations Manual (EOM) Internal Notification
The Health Officer, Director of Public Health, or designee determines the magnitude/scope of response and mobilization of staff, and initiates internal notification procedures.
Communication with field staff will be accomplished via: CAHAN Telephones Cellular phones Email 800 MHz radio Amateur (HAM) radio Satellite phone
Upon confirmation of an HPID outbreak in Southern California, the Health Officer or designee will notify the following individuals and release a public health press release:
Health Officer Director of Public Health The Board of Supervisors County Office of Emergency Services (OES) Inland Counties Emergency Medical Agency (ICEMA) Administrator County Public Information Officer (PIO) Regional Disaster Medical Health Coordination (RDMHC) Program
The MHOAC program will communicate information and needs for additional resources through the medical health branch as outlined in the CDPH EOM.
External Notification
External communication regarding the nature/magnitude of the incident and the required response is initiated via the following communication pathways. Hospitals are alerted via the Rapid Emergency Digital Data Information Network (ReddiNet) system. Communications to the hospitals via ReddiNet are conducted through ICEMA. Other medical and health clinicians and partners are notified by telephone and email.
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4. ROLES AND RESPONSIBILITIES
Reference Document: SBCDPH DEOP
SBCDPH has primary responsibility to establish event or incident objectives and response strategies and to task other supporting agencies during an infectious disease emergency (e.g. outbreaks of meningitis, bioterrorism, pandemic influenza). DOC staff who have the skills necessary to fulfill required roles for the response will be activated. DOC staff should include public health subject matter experts, command, and general staff. Command and control of public health response activities will be operated using Standardized Emergency Management System (SEMS). Designated SBCDPH staff will perform core functional roles within the DOC, as well as in the field, as delineated in the SBCDPH DOC Organizational Chart. The DOC Organizational Chart is updated on an annual basis and is part of the DEOP.
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The primary objectives of epidemiology and disease surveillance are to (1) determine the extent of morbidity within the community, (2) evaluate risks of transmission, and (3) rapidly intervene when appropriate. The reporting of communicable diseases must be timely for surveillance to be effective. Confidentiality of patient information is always protected subject to compliance with disease control and other laws.
1. CASE DEFINITIONS
Purpose of a case definition: Development of a clear case definition is critical to effective investigation of an outbreak. Use of a common case definition allows for standardization of the cases of interest both within an ongoing outbreak investigation and possibly between outbreak investigations that differ over time or geographic location. Developing outbreak case definitions: A case definition includes criteria for person, place, time, and clinical features. These should be specific to the outbreak under investigation. "Person" describes key characteristics the patients share in common. For example, this description may include: age, sex, race, occupation and exclusion criteria (e.g., “persons with no history of X disease”). "Place" typically describes a specific geographic location (state, county) or facility associated with the outbreak (X nursing home, Y high school). "Time" is used to delineate a period of time associated with illness onset for the cases under investigation. Limiting the time period enables exclusion of similar illnesses which are unrelated to the outbreak of interest. Initially, "clinical features" should be simple and objective (e.g., sudden onset of fever and cough). The clinical criteria may later be characterized by the presence of specific laboratory findings.
Common components and examples of an outbreak case definition: Descriptive Element Examples Features Age Group “children under the age of 5 years” Sex “males” “females” Person Occupation “health care workers at hospital X” Exclusion Criteria “persons with no previous history of chronic cough or asthma” Race Geographic location “resident of Y county or state” Place Facility “living in X nursing home”; “student at Y high school” Time Illness onset “onset of illness between May 4 and July 31, 2019” “clinical or radiographically confirmed pneumonia” Clinical Features Pneumonia “shortness of breath and fever” Laboratory Criteria Cultures; serology Pneumococcus isolated from blood; rapid influenza test positive
* Please note components of an outbreak case definition vary for each outbreak CDC: https://www.cdc.gov/urdo/downloads/CaseDefinitions.pdf
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2. CONFIDENTIAL MORBIDITY REPORT (CMR) The Communicable Disease Section relies on our public health partners to report more than 85 communicable diseases as mandated by California law. The Confidential Morbidity Report (CMR) is required to be completed by providers and is used to report any reportable disease or condition.
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3. UNUSUAL CONDITIONS TO REPORT In addition to HPID selected for the HPID SOG, some unusual conditions may also need to be reported to the San Bernardino County Health Officer, CDPH, or CDC to help identify emerging infectious diseases and those that may result from biological terrorism. Unusual conditions are required to be reported through Confidential Morbidity Reports (CMR) and immediately by telephone. The timely diagnosis and reporting of infectious diseases that are unusual, acute, severe, and/or highly transmissible is critical to implementing immediate disease control and prevention measures.
UNUSUAL PATTERNS OF DISEASE PATTERN EXAMPLE Multiple similarly presenting cases, especially if Persons who attended the same event or who worked in the same these are geographically associated or closely building. clustered in time. Report of a novel influenza strain (e.g., influenza A, H1N2) or Identification of an uncommon or novel disease in confirmation of Nipah virus in a resident that reported recent foreign the County of San Bernardino. travel to an endemic country (e.g. India). An increase in a common syndrome occurring out An influenza outbreak that occurs at a summer camp affecting a large of season. number of campers and staff Many cases of chickenpox-like illness in adult patients expected to be An unusual age distribution for common diseases. immune. Diseases that initially affect animals (West Nile virus) depict a reverse Reverse or Unnatural Spread of Disease pattern and human disease precedes animal disease. Presence of greater than expected number of During the West Nile virus outbreak in the U.S. in 1999, many local dead animals in a geographic area. A regionalized crows and exotic birds at the Bronx zoo died. animal die-off may provide a clue that an agent
has been released that may also affect residents. Severe illness in a young patient without immunologic defects, Serious, unexpected, unexplained acute illness underlying illness, recent travel or other exposure to a potential source with atypical host characteristics. of infection
Per the CA EOM, an unusual event is defined as an incident that significantly impacts or threatens public health, environmental health, or emergency medical services. An unusual event may be self-limiting or a precursor to emergency system activation, which occurs when the DOC and/or EOC are activated within the OA. The DOC will collaborate with the SBCDPH CDS to determine if unusual diseases and/or cases are reportable and whether an immediate investigation is required. Due to their rarity, some of the following diseases and conditions may not be immediately recognizable. However, like the diseases listed on the matrix, they require immediate notification to SBCDPH (within one hour): Meningococcal infections Domoic acid poisoning Diphtheria Rabies Hantavirus infection Viral Hemorrhagic Fevers, human or Yellow fever animal (e.g., Crimean-Congo, Shiga toxin (in feces or producing E. Ebola, Lassa, and Marburg) coli) Any novel viral infections with Hemolytic Uremic Syndrome pandemic potential Scrombroid fish poisoning Occurrence of any unusual disease Ciguatera fish poisoning Outbreaks of any disease Paralytic shellfish poisoning
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1. REPORTING A SUSPECT CASE/PERSON UNDER INVESTIGATION (PUI) TO PUBLIC HEALTH CDPH adopted guidelines from the CDC that advise healthcare providers in the U.S. to work with the local health departments to screen and monitor patients with an infection due to an HPID, particularly if they have traveled to a region or country with widespread transmission, if they are a patient under investigation for the HPID infection, or if they are a patient who meets the case definition.
2. CONTACT INVESTIGATION AND CASE MANAGEMENT STAFFING SBCDPH CDS is responsible for case and contact investigation and management, utilizing existing epidemiologists and communicable disease investigators (CDI). If additional contact tracing support is needed, CDS will pull from the disease investigation surge pool of Public Health staff (health educators, nutritionists, etc.) that have been trained in basic disease control interviewing. SBCDPH DOC may also pull from a pool of local university students that meet the CDC’s Tier 1: entry-level epidemiology competencies, which requires proficiency in conducting routine epidemiologic functions comprising of surveillance, data collection, and data analysis using basic epidemiologic methods.
3. MONITORING STEPS Notifying Public Health Upon identification of a Person Under Investigation (PUI) for a HPID or confirmed case of the HPID, the reporting party shall immediately contact the Local Public Health Officer, or the Health Officer’s designee, at 1-800-722-4794 during normal business hours or 909-356-3805 after hours. After hours calls will be routed to the SBCDPH Duty Officer who will follow the call-down list in their manual. After hours, the SBCDPH Health Officer or designee will call the CDPH Duty Officer to report a suspect case. The reporting party shall provide the following information: Name, Date of Birth (DOB), and location of patient Criteria used to determine if person is a PUI Names and locations of household members or persons having close contact with the patient (if known) Names of health care providers, EMS, First Responder and Law Enforcement Personnel who have cared for or had direct contact with the patient (if known). “Direct Contact” includes criteria for Low-Risk or High-Risk Exposure according to CDC criteria or having been within 3 feet of the PUI while not wearing recommended personal protective equipment (PPE). Current CDC Risk criteria located on the CDC website INDIVIDUALS ACTIONS MONITORED
Once informed of a suspect patient, SBCDPH CDS will: Suspect and 1. Collect clinical information and epidemiologic risk factors, and review the PUI criteria with the Confirmed reporting party Cases 2. Record initial case information on the CDPH Case Report form, available in CalREDIE and CDPH website 3. If the patient meets the criteria for a PUI, CDS staff will:
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a. Ensure the reporting party is aware of the current specimen collection and local submission guidelines located on the SBDPH website: www.sbcounty.gov/dph b. Obtain information on the infection control measures currently in place in the facility c. Obtain initial information on suspected contacts, including: friends, family, household members, and/or healthcare workers, law enforcement, and emergency response staff and record information. These contacts will later be interviewed and classified according to the current CDC epidemiologic risk categories found on the CDC website 4. CDS staff will inform the local Health Officer of the suspect case 5. CDS will report the suspect case to the CDPH point of contact during working hours or after hours to the CDPH Duty Officer 6. CDS will contact first responder agencies (according to local policy) to follow-up on potentially-exposed personnel identified in the earlier report 7. The local Health Officer shall determine the need for isolation, quarantine or monitoring of each health care provider and first responders that have had contact with the PUI. The respective agency’s Risk Management or Employee Health will document any personnel who are isolated, quarantined, or monitored by SBCDPH 8. PUI criteria can be found on the CDC website CDS staff will determine the risk level of each contact identified to a suspect or confirmed case Contacts of using CDC criteria. In consultation with the local Health Officer, CDS will monitor and control Suspect and movement of these contacts, issuing orders of isolation and quarantine as necessary. SBCDPH Confirmed CDS will monitor contacts’ symptoms for 21 days after their last exposure (or as determined Cases based on the disease), or until the suspect cases are ruled out, and utilize the statewide morbidity database, CalREDIE, to record and report this information.
A Returning Traveler is defined as any person who was present in a country with an active HPID outbreak within the last 21 days or pre-determined number of days based on the type of disease. CDS will perform the following tasks once notified of a traveler returning from countries with an HPID Outbreak: 1. Interview the Returning Traveler with the CDPH Disease Travel History Form to assess whether the returning traveler definition has been met and assess if exposure may have occurred. If there is indication that an exposure may have occurred, assign a risk category based on CDC guidance 2. If a traveler is determined to be in the “high risk” or “some risk” category, alert the Health Travelers Officer 3. Issue an order from the Health Officer for quarantine that outlines specific isolation requirements based on an individual risk assessment 4. Implement other public health action, including a system for daily monitoring, based on level of risk 5. Instruct the traveler to contact SBCDPH and remain isolated at home if symptoms develop, based on type of HPID. 6. Report interview results and follow-up plan in CalREDIE 7. Update traveler temperature and symptom data daily in CalREDIE.
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Returning Traveler Interviews: The local Health Officer or designee will call CDPH to report a symptomatic traveler. If patient movement is necessary, SBCDPH will consult with CDPH and CDC. CDPH recommends that traveler interviews and daily symptom checks occur via telephone, Skype, FaceTime, or other real time electronic means to minimize any potential exposure to local public health investigators. If a local public health department prefers to make home visits, it is recommended that staff call ahead to ensure that the contact is not symptomatic; additional training and access to PPE might be recommended.
4. POST-INCIDENT PERSONNEL MONITORING In coordination with local health department, risk level will be determined for each potentially exposed employee. If there is some level of risk determined, either direct active or active monitoring of body temperature and symptoms will be recorded twice daily in accordance with CDC guidelines. Specific strategies regarding isolation, quarantine, and/or work restriction will be determined by the nature of the incident and patient care operations in consultation with the local health officer, and LEMSA. If post-exposure prophylaxis (PEP) is administered, SBCDPH CDS will continue to monitor for signs and symptoms of infection and for possible adverse effects of the drug. Exposed persons will be monitored until completion of prophylaxis regimen and will undergo post-testing for antibodies.
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Section II: High Priority Infectious Diseases (HPID)
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The following matrix includes a list of high priority infectious diseases (HPID) that require immediate reporting to the County Health Officer and/or CDPH and CDC. For more information, see HPID Information Sheet section. * Denotes diseases monitored through the Biowatch Program
HPID MATRIX Disease/ Transmission Incubation Signs & Symptoms Mortality Diagnostic Prevention & Geographic Isolation & Cleaning Transport Agent Period Rate Testing Treatment Region PPE & Waste
PEP following . Skin lesion Direct contact 1-5 days < 1% environmental . Not spread . Black scab exposure: 60 days of person to Basic antimicrobials (either person transport doxycycline, . Contact, and waste Growing . Fever ciprofloxacin, or Airborne, and precautions bacteria from . Sore throat levofloxacin) and post Spores exist Standard Standard Proper 1. Ingestion blood or . Abdominal pain Around exposure vaccine. in the soil precautions to disinfection burial or Anthrax* (infected 2-5 days tissue . Nausea 50% Prevention: Avoid worldwide. be followed. procedures cremation (Bacillus meat) samples . Vomiting touching or handling . Wear of remains anthracis) . Diarrhea infected animals. respirator (N95 is required. . Lethargy Hand washing for 30- mask) and Airborne . Fever 60 seconds with soap protective (inhaled 1-6 days . Cough Around and water after spore clothing spores) . Muscle ache 90% contact. . Difficulty breathing . Double or blurred Do not wait for Foodborne vision Stool Culture laboratory . Not spread 2. 6 hours10 . Difficulty breathing Basic Wound confirmation to begin Spores exist person to Standard Botulism days . Drooping eyelids transport Infant 5% Culture treatment. in the soil person. disinfection (Clostridium . Slurred speech and waste Botulinum . Botulism antitoxin worldwide. . Standard procedures botulinum) . Difficulty swallowing precautions toxin assay . Antibiotic (for Precautions Wound . Dry mouth 12-72 hours wound) (injection) . Muscle weakness Ingestion . Fever (undercooked/ . Sweats . Not spread
unpasteurized . Malaise person to Blood Basic 3. products) . Loss of appetite Provide antimicrobial Worldwide in person Standard Culture transport Brucellosis Airborne 1-3 weeks . Headache 2% prophylaxis following domestic and . Contact, disinfection Brucella and waste (Brucella spp) Contact . Fatigue laboratory exposure. wild animals Airborne, and procedure agglutination precautions (wounds or . Muscle/ back/ joint Standard titer mucous pain Precautions membranes) . Long-term infection
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Disease/ Transmission Incubation Signs & Symptoms Mortality Diagnostic Prevention & Geographic Isolation & Cleaning Transport Agent Period Rate Testing Treatment Region PPE & Waste . Rarely spread Primarily 4. Direct contact directly Basic . Watery diarrhea Treat with rapid Africa, South Standard Cholera 2 hours – 5 Stool Culture . Standard and transport . Vomiting <1% administration of Asia, and disinfection (Vibrio Ingestion days Vomitus Contact and waste . Leg cramps fluids and antibiotics. Southeast procedure cholera) (water or Culture precautions to precautions Asia seafood) be followed . Standard, Contact, and Droplet Precautions . Patient isolated Category A Symptomolo in a single- waste . Fever gy and patient room. Use an precautions . Severe headache 5. history of . Barrier EPA- Appropriate . Fatigue Ebola / possible protection registered waste . Muscle/stomach pain Marburg exposure Treat symptoms as against blood disinfectant handling. Direct Contact 2-21 days . Weakness 50% Africa (Filovirus, within 21 they present and body fluids suitable for . Diarrhea Arenavirus) days upon entry into non- . Vomiting Lab testing patients’ rooms enveloped . Unexplained bleeding after onset of (single globes viruses or bruising symptoms and impermeable gown, face/eye protection with masks, gloves, or face shields) . Puss-filled skin . Airborne and 1-14 days nodules Standard 6. Droplet (shorter for . Swelling of lymph Middle East, Basic Growing Precautions Standard Glanders* inhalation, nodes Asia, Africa, transport 40% organism Treat with antibiotics . Laboratory disinfectant (Burkholderia longer for . Fatigue and South and waste from tissue workers to use procedure mallei) Ingestion skin . Fever America precautions BSL-3 lab (infected exposure) . Chills precautions meat) . Malaise
. Chest/sinus Direct contact Rapid Treat symptoms or Basic 7. congestion . Droplet, Contact, influenza provide antivirals transport Influenza, . Chills/fever (may be Endemic to Contact and Droplet, diagnostic Prevention: and waste novel strains not present) U.S. and Standard and 1-4 days 10% tests (RIDT) Administer seasonal precautions (human) . Unproductive cough other precautions to Standard Viral Culture influenza vaccine (Influenza) . Malaise countries be followed disinfection Influenza Respiratory hygiene Droplet . Headache procedure PCR and cough etiquette . Sore throat
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Disease/ Transmission Incubation Signs & Symptoms Mortality Diagnostic Prevention & Geographic Isolation & Cleaning Transport Agent Period Rate Testing Treatment Region PPE & Waste . Airborne , Viral Culture Droplet, and For exposed, non- Measles Standard 8. Droplet . Fever vaccinated persons: Antibody, Precautions Measles . Malaise post-exposure Basic IgM Europe, . Health-care Standard (rubeola) . Cough vaccine within 72 transport 7-14 days <1% (Rubeola Asia, Pacific, workers should disinfection (Measles . Runny nose hours or immune and waste IgM) and Africa use N95 procedure virus)) . Conjunctivitis globulin within 6 days. precautions Measles respirators . Rash Prevention: Pre- Airborne Antibody, upon entry into exposure vaccination IgG (Rubeola a patient’s IgG) room. . Asymptomatic infection . Rarely spread Direct contact . Localized skin ulcers/ directly abscesses . Airborne, . Swelling of lymph Lab testing Most cases Contact, and 9. nodes and growing Post-exposure originate in Standard Standard Meliodosis . Chronic pneumonia bacterium prophylaxis Southeast precautions to Droplet 1-21 days 10-40% disinfectant Burkholderia . Fulminant septic shock from blood or Asia and be followed procedure pseudomallei) with abscesses in tissue Treat with antibiotics Norther . Note: multiple internal sample Australia Laboratory organs workers to use Ingestion . Low white blood cell BSL-3 lab count precautions . Raised liver enzymes . High fever Post-exposure Use an . Sever malaise Category A vaccination (within 1-3 . Contact, EPA- 10. Direct contact . Exhaustion waste Clinical days of exposure) Eradicated, Airborne, and registered Smallpox* . Headache/back ache precautions presentation Prevention: N95 or but a Standard disinfectant (Variola virus) 7-17 days . Rash starting on face, 30-97% and lab higher respiratory potential Precautions suitable for One case = arms and in mouth, Handle testing protection for bioweapon . Isolate patient non- outbreak progressing to trunk, laundry Droplet susceptible in AIIR enveloped legs, palms and soles carefully individuals viruses of feet Blood test for Direct contact antibodies to bacterium or . Chills growing . Not spread . Fever 11. bacteria from Worldwide in person to Basic . Headache/body aches Standard Tularemia* Ingestion blood or wild animals, person transport 3-5 days . Cough 2% Treat with antibiotics disinfectant (Francisella tissue especially . Standard and waste . Pain/tightness in chest procedure tularensis) samples rabbits precautions to precautions . Swollen lymph nodes F. tularensis be followed . Ulcer at wound site Vector Ab Titre F. tularensis IFA
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Disease/ Transmission Incubation Signs & Symptoms Mortality Diagnostic Prevention & Geographic Isolation & Cleaning Transport Agent Period Rate Testing Treatment Region PPE & Waste . Fever . Chills . Follow airborne Airborne 1-8 days . Cough Treat with antibiotics. and droplet 12. Worldwide in . Headache Prophylactic isolation Basic Plague, Droplet 1-6 days fleas, carried Standard . Nausea Blood antibiotics should be precautions. transport human or (Pneumonic) 50-100% by rodents or disinfection . Vomiting Culture given to anyone in . Contacts of and waste animal* other wild procedures . Difficulty breathing Y. pestis Ag direct contact with patient should precautions (Yersinia animals 1-8 days . Chest pain infected patient be identified for pestis) Vector . Swollen, painful lymph surveillance node Vector (bite of Supportive therapy an infected Prevention: Note: most infected Aedes aegypti Mosquito repellant persons are or Aedes containing DEET to asymptomatic. However, albopictus Travel exposed skin an Endemic in 13. the following symptoms Basic mosquito) history, clothing most US Standard Zika Virus may develop: . Standard transport Sexual 3-7 days <1% symptomolog Wear long-sleeved regions and disinfection. Infection . Fever precautions and waste contact y and lab shirts and long pants several other procedure (Flavivirus) . Rash precautions testing Use air conditioning countries . Headache and/or Mother to . Joint/muscle pain windows/screens to unborn child . Red eyes keep mosquitoes outside homes.
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Although there are numerous infectious diseases, the HPID SOG focuses on those that pose a threat to public health and will require major multi-sectoral responses and rational allocation of limited resources, such as medical countermeasures. The HPID were selected from the CDC and WHO list of high priority diseases, San Bernardino County CMR, and Biowatch list of priority biological agents. The CDC has categorized biological agents/diseases into three categories:
CDC CATEGORIZATION OF BIOLOGICAL AGENTS/DISEASES CATEGORY A CATEGORY B CATEGORY C
Category A pathogens are those Category B pathogens are the Category C pathogens are the third organisms/biological agents that second highest priority highest priority and include pose the highest risk to national organisms/biological agents. emerging pathogens that could be security and public health because engineered for mass dissemination they: They: in the future because of: Can be easily disseminated or Are moderately easy to Availability transmitted from person to disseminate Ease of production and person Result in moderate morbidity dissemination Result in high mortality rates rates and low mortality rates Potential for high morbidity and and have the potential for major Require specific enhancements mortality rates and major health public health impact for diagnostic capacity and impact Might cause public panic and enhanced disease surveillance social disruption Require special action for public health preparedness
1st Priority 2nd Priority 3rd Priority
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Reference Document: Additional HPID info sheets can be found on the PRP server: L:\Epidemiology\High Priority Infectious Disease (HPID) SOG\HPID - FY 2019-2020\HPID-SOG Appendix The following is a list of HPID that require immediate reporting to the County Health Officer and/or CDPH and CDC. Disease background, reason for prioritization, and information sheet are provided in this section. * Denotes diseases monitored through the Biowatch Program
1. Anthrax* – Bacillus anthracis . Quick Sheet: https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/AnthraxFactSheet.pdf.
. Background: Anthrax is currently considered one of the most serious bioterrorism threats. Beginning in the second half of the 20thCentury, B. anthracis was developed by several countries as part of their biological weapons (BW) programs. Most notably, in October 2001, anthrax attacks were perpetrated in the US via the mail, when 7 envelopes containing B. anthracis spores were sent through the US postal system (4 were recovered). Twenty-two cases of anthrax resulted (11 inhalational, 11 cutaneous), and 5 people died from inhalational anthrax.
. Reason for Prioritization: (Category A agent) Several factors contribute to concern about the potential use of B. anthracis as a biological weapon: o B. anthracis is widely available in microbe banks around the world. o B. anthracis is widely available naturally in endemic areas. o There is evidence that techniques for mass production and aerosol dissemination of anthrax have been developed. o The hardiness of anthrax spores in the environment may make anthrax aerosol dissemination more effective than many other potential agents. o Untreated inhalational anthrax has a high fatality rate. o Antibiotic-resistant strains of B. anthracis exist in nature and could be used in an intentional release. o Anthrax has been used in the past as a biological weapon.
2. Botulism – Clostridium botulinum Quick Sheet: https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/BotulismFactShe et.pdf
Background: Botulism is a serious, but rare, paralytic illness caused by neurotoxins (botulinum toxin) produced by the common bacterium, Clostridium botulinum, which is found throughout the world in soil and ocean sediment. Normally, the bacterium exists in the environment as a dormant spore; however, in low oxygen (anaerobic) environments such as in canned foods, deep wounds, or the intestinal tract, the spores germinate into active bacteria, multiply, and produce toxin.
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Reason for Prioritization: (Category A Agent) A deliberate release of botulinum toxin could be in the form of an aerosolized weapon or contamination of the food or water supply with C. botulinum or botulinum toxin. Several countries developed botulinum toxin as aerosol weapons in the past. Animal models suggest that inhaling 0.7-0.9 µg of aerosolized botulinum toxin would be enough to kill a standard weight person (70 kg or 154 lbs).
3. Brucellosis – Brucella species Quick Sheet: https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/BrucellosisFactS heet.pdf
Background: Brucellosis is a bacterial disease caused by various Brucella species, which mainly infect cattle, swine, goats, sheep and dogs. Humans generally acquire the disease through direct contact with infected animals, by eating or drinking contaminated animal products, or by inhaling airborne agents. The majority of cases are caused by ingesting unpasteurized milk or cheese from infected goats or sheep. Person-to-person transmission is rare. The disease causes flu-like symptoms, including fever, weakness, malaise and weight loss.
Reason for Prioritization: (Category B Agent) Brucella species can be easily cultured from infected animals and human materials. Also, it can be transferred, stored and disseminated easily. An intentional contamination of food with Brucella species could pose a threat with low mortality rate. Brucella spp. is highly infectious through aerosol route, making it an attractive pathogen to be used as a potential agent for biological warfare purposes.
4. Cholera – Vibrio cholerae Quick Sheet: https://www.cdc.gov/cholera/healthprofessionals.html https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/VibrioFactSheet. pdf
Background: Cholera is an acute, diarrheal illness caused by infection of the intestine with the bacterium Vibrio cholerae. An estimated 3-5 million cases and over 100,000 deaths occur each year around the world. The infection is often mild or without symptoms, but can sometimes be severe. Approximately one in 10 (5 to 10 percent) infected persons will have severe disease characterized by profuse watery diarrhea, vomiting, and leg cramps. In these people, rapid loss of body fluids leads to dehydration and shock. Without treatment, death can occur within hours.
Reason for Prioritization: (Category B Agent). Because the bacteria that cause cholera, Vibrio cholerae, are spread through contaminated water, cholera has the potential to generate an explosive outbreak.
5. Viral Hemorrhagic Fevers – Ebola, Marburg, Lassa Viruses Ebola & Marburg - Filoviridae Filovirus / Lassa Virus - Arenaviridae Arenavirus For more information: Refer to SBCDPH Ebola Response Plan
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Quick Sheet: https://www.cdc.gov/vhf/ebola/index.html
Background: Ebola virus disease, first recognized in 1976 in the Democratic Republic of the Congo, is a serious and often fatal illness in humans and nonhuman primates caused by infection with one of five Ebola virus species (four of which can infect humans). The virus is spread through direct contact with the bodily fluids of a sick person and can cause fever, headache, muscle pain, weakness, fatigue, diarrhea, vomiting, stomach pain and hemorrhage (severe bleeding).
Reason for Prioritization: (Category A Agent). Ebola and Marburg viruses are rare but have caused periodic cases and deadly outbreaks in Africa since they were first recognized. The largest outbreak of Ebola virus disease, which occurred in West Africa from 2014 to 2016, caused more than 28,600 infections and more than 11,300 deaths, according to the World Health Organization. There are no licensed treatments or vaccines for Ebola or Marburg virus diseases; however, various experimental countermeasures are under preclinical or clinical evaluation.
6. Glanders* – Burkholderia mallei . Quick Sheet: http://www.centerforhealthsecurity.org/resources/fact- sheets/pdfs/glanders_melodosis.pdf
. Background: Horses, mules, and donkeys are animals most often afflicted by glanders, but the disease can spread to other animals. In humans, the main route of transmission has been occupational exposure among workers who handle infected animals; however, infection may also occur if contaminated meat is ingested or if respiratory secretions are inhaled.
. Reason for Prioritization: (Category B Agent). B. mallei was one of the first agents to be used for biowarfare in the modern era. During World War I, German agents targeted horses and livestock in the United States, Romania, Spain, Norway, and Argentina through inoculation and feed contamination. Several countries experimented with glanders bioweapons in the second half of the 20th century.
7. Pandemic Influenza – Orthomyxoviridae Influenzavirus A, B, C . For more information: Refer to SBCDPH Pandemic Influenza Response Plan.
. Quick Sheet: https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/FluAnd RespiratoryIllnessOutbreakQuicksheet.pdf
. Background: Influenza, or flu, is a contagious respiratory infection caused by several flu viruses that infect the nose, throat and lungs. People infected with the seasonal flu virus feel miserable with fever, chills, muscle aches, coughing, congestion, headache and fatigue for a week or so. Most people who get the flu get better within two weeks, but some people may develop serious complications, such as pneumonia. Pandemic influenza is when a new flu virus strain occurs that can spread easily from person-to-person and the virus is one for which most people have no immunity.
. Reason for Prioritization: (Category C Agent). Each year, seasonal influenza sickens millions and causes thousands of hospitalizations and flu-related deaths. Even healthy people can get very sick from the flu and spread it to others. Flu infection can present particularly serious problems for young
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children, the elderly, pregnant women and people with certain medical conditions, such as asthma and heart disease. Pandemic flu is a potential threat and may occur when a new flu virus strain emerges for which humans have little to no immunity, which enables the virus to spread easily from person-to- person. Flu viruses of this type can sicken millions around the globe.
8. Measles – Paramyxioviridae Morbillivirus Quick Sheet for Investigation of Measles: https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/M easles-Quicksheet.pdf.
Quick Sheet for Prophylaxis on Measles: https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/IM M-MeaslesIGPEPQuicksheet.pdf.
Background: Measles is a highly contagious, serious disease caused by a virus. Before the introduction of measles vaccine in 1963 and widespread vaccination, major epidemics occurred approximately every 2–3 years and measles caused an estimated 2.6 million deaths each year. Measles is caused by a virus in the paramyxovirus family and it is normally passed through direct contact and through the air. The virus infects the respiratory tract, then spreads throughout the body. Measles is a human disease and is not known to occur in animals. Accelerated immunization activities have had a major impact on reducing measles deaths.
Reason for Prioritization: Measles is an Emerging Infectious Disease (new in FY14).
9. Melioidosis (Whitmore’s Disease) – Burkholderia pseudomallei Quick Sheet: http://www.centerforhealthsecurity.org/resources/fact- sheets/pdfs/glanders_melodosis.pdf.
Background: Like glanders, melioidosis is a disease that afflicts both humans and animals. It has varied clinical presentations, including asymptomatic infection, localized skin ulcers/abscesses, chronic pneumonia, and fulminant septic shock with abscesses in multiple internal organs. Most cases originate in Southeast Asia-where it is a common cause of pneumonia-and northern Australia. And most cases are the result of exposure to the bacteria in muddy soils or surface water. Unlike B. mallei, B. pseudomalleiis found in the environment, where it resides in water and soil.
Reason for Prioritization: (Category B Agent) Several countries have studied B. pseudomallei for use as a bioweapon. Melioidosis is considered a potential biological weapon because of the ease with which strains may be obtained from the environment, the ability to engineer strains that are resistant to multiple antibiotics, and the lack of a vaccine.
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10. Smallpox* – Poxviridae Orthopoxvirus Quick Sheet: www.cdc.gov/smallpox/index.html?CDC_AA_refVal=https%3A%2F%2Femergency.cdc.gov%2Fa gent%2Fsmallpox%2Findex.asp
Background: Smallpox is a highly contagious and deadly disease caused by the variola virus. It was estimated to have infected 300 million people in the 20th Century before it became the only human infectious disease ever to be completely eradicated. After the eradication of smallpox, the WHO recommended that all remaining specimens of variola be destroyed or sent to 1 of 2 designated high containment reference laboratories located in the U.S. and Russia. Today, the only potential source of smallpox infection is an unintentional laboratory release or a biological attack.
Reason for Prioritization: (Category A Agent) Smallpox is considered one of the most serious bioterrorist threats. It was used as a biological weapon during the French and Indian Wars, (1754 to 1767) when British soldiers distributed smallpox-infected blankets to American Indians. In the 1980s, the Soviet Union developed variola as an aerosol biological weapon and produced tons of virus-laden material annually intended for intercontinental ballistic missiles. Several factors contribute to the concern about the use of smallpox as a biological weapon. Variola can spread from person to person, there is no widely available or licensed treatment for the disease, it has a high fatality rate, the global population is extremely vulnerable to the disease since smallpox immunization has ceased, variola is relatively stable as an aerosol, and the infectious dose is small.
11. Tularemia* – Francisella tularensis Quick Sheet: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Tularemia.aspx.
Background: Small mammals such as voles, mice, squirrels, and rabbits are natural reservoirs for F. tularensis. These animals acquire tularemia through bites from ticks, fleas, and mosquitoes and also through contact with contaminated environments. Naturally acquired human infection can occur through bites from infected arthropods (usually ticks); contact with infected animal tissues or fluids; direct contact with or ingestion of contaminated water, food, or soil; or inhalation of aerosolized bacteria. Aerosol dissemination of F. tularensis in a populated area would be expected to result in the abrupt onset of large numbers of cases of acute, nonspecific respiratory febrile illness beginning 3 to 5 days later.
Reason for Prioritization: (Category A Agent) F. tularensis is considered to be a serious potential bioterrorist threat because it is one of the most infectious pathogenic bacteria known- inhalation of as few as 10 organisms can cause disease-and it has substantial capacity to cause serious illness and death. The bacterium was developed into an aerosol biological weapon by several countries in the past. According to WHO, if 50 kg (110 pounds) of virulent F. tularensis were dispersed as an aerosol over a metropolitan area with a population of 5 million, there would be an estimated 250,000 incapacitating casualties, including 19,000 deaths.
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12. Plague* – Yersinia pestis Quick Sheet:
Background: Plague is a disease that affects humans and other mammals. People typically get infected after being bitten by a rodent flea that is carrying the bacterium or by handling a plague- infected animal. Although the disease killed millions in Europe during the Middle Ages, antibiotics effectively treat plague today. Without prompt treatment, plague can cause serious illness or death.
Reason for Prioritization: (Category A Agent) Plague is a category A pathogen which are those organisms/biological agents that pose the highest risk to national security and public health because they can be easily disseminated or transmitted from person to person, result in high mortality rates and have the potential for major public health impact, might cause public panic and social disruption, and require special action for public health preparedness.
13. Zika Virus – Flavivirus Quick Sheet: https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/ZikaQandA.pdf https://www.cdc.gov/zika/pdfs/fs-zika-basics.pdf
Background: Zika virus is primarily transmitted to humans through the bite of infected Aedes aegypti mosquitoes. Zika virus can be transmitted from an infected pregnant woman to her baby during pregnancy and can result in serious birth defects, including microcephaly. Less commonly, the virus can be spread through intercourse or blood transfusion. 20 percent of people who are infected by Zika virus develop symptoms. The illness is generally mild and includes fever, rash, joint pain and conjunctivitis (red eyes). Illness lasts several days to a week. In non-pregnant people, the virus is generally eliminated from the body after a few weeks although it may remain longer in semen.
Reason for Prioritization: (Category B Agent) In May 2015, the Pan American Health Organization issued an alert regarding the first confirmed Zika virus infection in Brazil. Since that time, Brazil and other countries and territories in Central and South America, as well as the Caribbean have experienced ongoing Zika virus transmission. The first cases of locally transmitted Zika virus in the continental United States were confirmed in Florida in July 2016, followed by Texas in November 2016. The majority of Zika cases in the continental U.S. have been among people who travelled to affected countries.
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14. Middle Eastern Respiratory Virus (MERS) / Severe Acute Respiratory Virus (SARS) – Coronavirus Mers-CoV Quick Sheet: https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/Immunization/M ERS-Quicksheet.pdf
Sars-CoV Information: https://www.cdc.gov/sars/guidance/c-healthcare/recommended.pdf
. Background: Middle East Respiratory Syndrome (MERS-CoV) is a viral respiratory illness that was first reported in Saudi Arabia in 2012 and has since spread to several other countries. Most people infected with MERS-CoV developed severe acute respiratory illness, including fever, cough, and shortness of breath; many of them died. Severe acute respiratory syndrome (SARS-CoV), also a severe viral respiratory illness, was first reported in Asia in February 2003 and spread to dozens of countries before being contained. Since 2004, there have been no known SARS cases. Both MERS and SARS belong to a family of viruses called coronaviruses.
. Reason for Prioritization: (Category C Agent). In 2003, a novel coronavirus emerged from China and swept across the globe, causing deadly illness. More than 8,000 people fell ill with severe acute respiratory syndrome (SARS), and 774 died. The SARS coronavirus drew the collective focus of researchers throughout the world, but the disease disappeared quickly. No cases of SARS have been reported since 2004. In 2012, a new coronavirus emerged, causing an illness similar to SARS. Again, researchers across the globe have initiated studies to understand the Middle East respiratory syndrome coronavirus (MERS-CoV)—and how to stop it.
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Section III: Non- Pharmaceutical Interventions (NPI) and Infection Control Precautions
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Reference Document: CDC Community Mitigation Guidelines https://www.cdc.gov/mmwr/volumes/66/rr/rr6601a1.htm NPIs, also known as community mitigation measures, are actions that persons and communities can take to help slow the spread of illnesses. SBCDPH along with other community agencies, schools, employers and county residents, have been asked to plan for these interventions in order to limit the spread of a pandemic, reduce morbidity and mortality, lessen the impact on the economy, and maintain society function. Three major goals for NPI use during mitigation efforts during an HPID emergency include: 1. Delay the exponential growth in incident cases and buy time for production and distribution of a well-matched strain vaccine, 2. Decrease the epidemic peak, and 3. Reduce the total number of incident cases, thus reducing community morbidity and mortality.
1. TRIGGERS FOR NPI USE SBCDPH will activate implementation of NPIs upon the declaration from WHO or the first cluster of cases within the United States. This trigger will be defined by a laboratory confirmed cluster of infection and evidence of community transmission (i.e., epidemiologically linked cases from more than one household).
2. DURATION OF NPI USE SBCDPH will continue NPI implementation as long as susceptible individuals are present in the County of San Bernardino and/or up to a specified number of weeks, depending on the type, circulation, and virulence of the biological agent.
3. DE-ESCALATION OF NPI USE As the assessed global, national, and local risk reduces, de-escalation of actions may occur, and reduction in response activities, such as the deactivation of NPI implementation, or movement towards recovery actions may be appropriate, according to risk assessments principally based on virological/bacteriological, epidemiological, and clinical data. The Health Officer will be responsible for public health decisions based on risk assessments that answer the following key questions about an HPID: How rapidly are new cases accruing? What types of illnesses and complications are being seen? What groups of people (e.g. age groups or groups at risk of severe outcomes) will become severely ill and die? Is the agent sensitive to specific medical countermeasures? How many people will become ill? What will be the impact on the health care sector, including such factors as health care utilization and impact on the health care workforce?
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NPIs that can be implemented by individual persons include the following:
1. PERSONAL PROTECTIVE EQUIPMENT (PPE) For communicable disease exposure, PPE is specialized clothing or equipment used to prevent contact with hazardous substances. Its use is an integral part of infection control and prevention measures that protect workers from exposure to blood, body fluids, and other potentially infectious materials. PPE such as gowns, gloves, masks, and goggles provide physical barriers that prevent the hands, skin, clothing, eyes, nose, and mouth from coming in contact with infectious agents. PPE is used to reduce transmission of communicable diseases when other measures such as engineering controls and work practices cannot completely eliminate exposure. See Infection Control Precautions section for more information on types of PPE.
2. PERSONAL PROTECTIVE MEASURES FOR EVERYDAY USE
PPE FOR EVERYDAY USE Persons cover coughs and sneezes, preferably with a tissue, and then dispose of tissues and disinfect hands immediately after a cough or sneeze, or (if a tissue is Respiratory not available) cough or sneeze into a shirt sleeve. Touching the eyes, nose, and Etiquette mouth should be avoided to help slow the spread of germs (https://www.cdc.gov/flu/protect/covercough.htm). Persons perform regular and thorough hand washing with soap and water (or use Hand Hygiene alcohol-based hand sanitizers containing at least 60% ethanol or isopropanol when soap and water are not available). Persons with illness may opt to stay home for a recommended amount of time, Voluntary Home except to obtain medical care or other necessities. For example, persons with Isolation (i.e., influenza stay home for at least 24 hours after a fever or signs of a fever (chills, staying home when sweating, and feeling warm or flushed) are gone. To ensure that fever is gone, ill or self-isolation) patients’ temperatures are to be monitored in the absence of medication that lowers fever. If a member of the household is symptomatic with a confirmed or probable HPID, then all members of the household should stay home for a recommended number of days (based on the type/severity of the disease) to help prevent the disease from spreading in the community. For example, certain infected (but not yet Voluntary Home symptomatic) household members could begin shedding influenza virus at least a Quarantine day before exhibiting symptoms and could infect friends, neighbors, and others in the community before exhibiting any symptoms. During influenza season, exposed household members of symptomatic persons (with confirmed or probable pandemic influenza) should stay home for up to 3 days (the estimated incubation period for seasonal influenza) starting from their initial contact with the ill person.
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Community level NPIs include the following:
1. SOCIAL DISTANCING MEASURES Reduce disease transmission by decreasing the frequency and duration of social contact among persons of all ages. These measures are common-sense approaches to limiting face-to-face contact, which reduces person-to-person transmission. The social distancing measures can be implemented in a range of different community settings, including schools, workplaces, and public places where people gather (e.g., parks, religious institutions, theaters, and sports arenas). The choice of implementing the social distancing measures depends on the severity of the public health emergency. Multiple social distancing measures can be implemented simultaneously. Increasing the distance to at least three feet between persons when possible might reduce person-to person transmission. This applies to apparently healthy persons without symptoms. In the event of a very severe or extreme pandemic, this recommended minimal distance between people might be increased. Persons in community settings who show symptoms consistent with an HPID and who might be infected with (probable) biological agent in question should be separated from well persons as soon as practical, be sent home, and practice voluntary home isolation.
School: If schools remain open during a pandemic, divide school classes into smaller groups of students and rearrange desks so students are spaced at least three feet from each other in the classroom. Workplace: Alter workplace environments and schedules to decrease social density. Enable institution of workplace leave policies that align incentives and facilitate adherence with NPIs. In addition, during the event of a major infectious disease outbreak, workplaces can offer telecommuting and/or replace in-person meetings with video or telephone conferences. Mass gatherings: Postpone, modify, or cancel mass gatherings.
2. SCHOOL CLOSURES AND DISMISSALS These include temporary closures and dismissals of child care facilities, K–12 schools, and institutions of higher education. Depending on the severity of the pandemic, these measures might range from everyday preventive actions to preemptive, coordinated school closures and dismissals. Preemptive school dismissals can be used to disrupt transmission of illness before many students and staff members become ill. Coordinated dismissals refer to the simultaneous or sequential closing of schools in a jurisdiction. Target Population: o Children in child care centers and preschools o School-aged children and teens in K–12 schools o Young adults in institutions of higher education School Closure: closing a school and sending all the students and staff members home School Dismissal: a school might stay open for staff members while the children stay home
3. TEMPORARY CLOSURE OF PUBLIC GATHERINGS Closure of public gatherings may be very effective in a highly infectious disease that is transmitted by air or close contact. The Health Officer may close an area where an immediate menace to the public health exists and may also temporarily close public gatherings. If the closures involve multiple
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venues and appear likely to exceed several days, the Health Officer should consult with the Board of Supervisors, County Administration Office, and City Managers as to whether a local emergency should be declared. Where a venue is subject to a permitting process, the permitting agency may be consulted for possible immediate suspension of the permit. Constitutional Considerations Closures of public gatherings raise issues regarding freedom of assembly, freedom of speech, due process and equal protection rights. Before proceeding with an order for involuntary isolation or quarantine, the following must be considered: Provision for due process of law and fundamental fairness principles Ensure that there is adequate justification that is clearly stated in plain language; the order cannot be “arbitrary, oppressive and unreasonable” Reasonable grounds for the proposed action. Order should be narrowly drawn and the process must provide for the constitutional safeguards of notice and an opportunity to be heard, e.g., pre- or post-confinement hearing. The Health Officer order (i.e. quarantine, social distancing) serves as “notice”. The order may be initially oral, but should be confirmed in writing at the earliest possible opportunity. The procedures made available for subjects of the order will depend on the scale of the event (numbers of people subject to the order) and the degree to which individual liberties are restricted. Examples of available procedures: o Phone number where a person can register their objection o Pre- or post-confinement hearing Procedure for an Order for Closure of Public Gatherings 1) The Order for a Closure of Public Gathering may initially be oral, but should be followed by an order written and signed by the Health Officer. A checklist of potential items to consider, but not necessarily include in closure orders: Subject of the order: Target population/geographic area described as specifically and narrowly as possible The specific directives that the individuals must follow Right to representation, if any, for the subject of the order Parameters and conditions of the order Duration of the order-both beginning and end dates and times Potential penalty for a violation Supporting facts Statutory authority and any other legal basis to support the order Method and opportunity to challenge the order Any additional information specific to the event triggering the need for the order Languages of the individuals Signature and title of Health Officer Method(s) of informing the individuals subject to the order as discussed below The content and appropriate procedures for closure orders are fact dependent and must be determined by the particular circumstances. 2) Service of the order The method(s) of communicating the closure order will vary, depending on the nature of the incident, potential number of individuals affected as well as the geographic area
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concerned. Personal service, mail, media, posting of the venue, site, or place in question, or combination of these and other methods can be used to communicate the directives to the target group or area. The Health Officer may want to employ multiple communication methods. The orders need to be narrowly drawn and the Health Officer should describe specifically the activities being modified or curtailed, the reason for the action, and the length of time the closure or restriction will occur. 3) Enforcement authority for Order for Closure of Public Gatherings Requirement to comply with a Health Officer Order for Closure of: H&S §120220 requires that all persons shall obey the Health Officer’s rules, orders, and regulations for isolation or quarantine. Penalty for violation of a Health Officer Order for Closure of a Public Gatherings H&S §120275 stipulates that violation of a Health Officer Order for measures necessary to protect the public health is a misdemeanor. 4) Challenges to Orders for Closure of Public Gatherings An opportunity to consult should be given before the effective date of the order unless the situation is suddenly grave, but an opportunity for the event sponsor or venue owner to object should be accorded as soon afterward as it may safely be conducted. 5) Extension or Termination of the Order for Closure of Public Gatherings The order should be written for a specific period of time under most circumstances according to the known characteristics of the outbreak. If no specific termination time is written in the order, then a specific time for review of the order shall be written in the order; the review shall determine whether to terminate the order or to extend the order with appropriate justification for extension. A notification should be written and served to the subject of the Order for termination or extension; for an extension, supporting facts for the extension, any changes in instructions, and a new review date should be specified.
4. EVACUATION The Health Officer may find it necessary for the protection of public health and safety to order immediate movement of individuals away from a particular building or geographic area. The Health Officer may close an area “under immediate menace to the public health or safety” “created by a calamity including a flood, storm, fire earthquake, explosion, accident or other disaster,” Penal Code §409.5. The Health Officer can also order persons within the affected area to leave. The general powers of the Health Officer to control the spread of disease are also applicable in an evacuation event. H&S §120175.
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Environmental surface cleaning measures can help mitigate transmission of HPID biological agents from frequently touched surfaces and objects (e.g., tables, door knobs, toys, desks, computer keyboards). Environmental surface cleaning measures should be implemented in homes, schools, workplaces, and other places where persons gather. These measures involve cleaning surfaces with detergent-based cleaners or disinfectants that have been registered with the Environmental Protection Agency (EPA). The cleaning and disinfection of all patient-care areas is important for frequently touched surfaces, especially those closest to the patient, that are most likely to be contaminated (e.g., bedrails, bedside tables, commodes, doorknobs, sinks, surfaces and equipment in close proximity to the patient). The frequency or intensity of cleaning will vary based on the patient’s level of hygiene, the degree of environmental contamination, and certain enteric diseases. For example, increased environmental cleaning is recommended in long term care facilities and pediatric facilities where patients with stool and urine incontinence are encountered more frequently. In the event of a smallpox or Ebola outbreak, stronger disinfectants will be required to decontaminate surfaces and equipment along with PPEs that are highly recommended or required by the health officer based on type of agent. For example, an EPA registered hospital disinfectant with a label claim for a non- enveloped virus (norovirus, rotavirus) should be used to disinfect environmental surfaces in rooms of patients with confirmed Ebola virus disease. Special care may also be required for the handling of soiled linens and patient care materials. OSHA and CDC recommendations should be used to ensure proper cleaning and decontamination procedures are followed.
1. OVERVIEW There are two tiers of CDC precautions to prevent transmission of infectious agents, Standard Precautions and Transmission-Based Precautions. Standard Precautions: are intended to be applied to the care of all patients in all healthcare settings, regardless of the suspected or confirmed presence of an infectious agent. Transmission-Based Precautions: are for patients who are known or suspected to be infected or colonized with infectious agents, including certain epidemiologically important pathogens, which require additional control measures to effectively prevent transmission. Transmission-Based Precautions are used empirically, according to the clinical syndrome and the likely etiologic agents at the time, and then modified when the pathogen is identified or a transmissible infectious etiology is ruled out.
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2. MATRIX – SUMMARY OF INFECTION CONTROL PRECAUTIONS
Transport Precautions Patient Care Considerations PPE Environment Considerations
Patient Placement - Prioritize single-patient room if patient is at increased risk of Needles and Other Sharps - Do not transmission, is likely to contaminate the recap, bend, break, or hand- environment, does not maintain appropriate manipulate used needles; if recapping hygiene, or is at increased risk of acquiring is required, use a one-handed scoop infection or developing adverse outcome Gloves - For touching blood, bodily fluids, technique only; use safety features following infection. secretions, excretions, contaminated items; for when available; place used sharps in touching mucous membranes and non-intact skin puncture-resistant container Patient Resuscitation - Use mouthpiece, Standard resuscitation bag, other ventilation devices to Gown - During procedures and patient-care Soiled patient-care equipment - prevent contact with mouth and oral secretions activities when contact of clothing/exposed skin Handle in a manner that prevents Apply standard set of with blood/body fluids, secretions, and excretions transfer of microorganisms to others protections based on the Hand Hygiene - Wash hands after touching is anticipated. and to the environment; wear gloves if patient’s symptoms and clinical blood, body fluids, secretions, excretions, visibly contaminated; perform hand care rather than a specific contaminated items; immediately after Mask, eye protection (goggles), face shield - hygiene. suspected organism. PPE is removing gloves; between patient contacts During procedures and patient-care activities based on how the disease is likely to generate splashes or sprays of blood, Environmental Control - Develop transmitted and is applied as Respiratory Hygiene / Cough Etiquette - body fluids, secretions, especially suctioning, procedures for routine care, cleaning, needed. Cover mouth/nose when sneezing/coughing; endotracheal intubation. During aerosol- and disinfection of environmental use tissues and dispose in no-touch generating procedures on patients with surfaces, especially frequently receptacle; observe hand hygiene after soiling suspected or proven infections transmitted by touched surfaces in patient-care of hands with respiratory secretions; wear respiratory aerosols wear a fit-tested N95 or areas. surgical mask if tolerated or maintain spatial higher respirator in addition to gloves, gown and separation, >3 feet if possible. face/eye protection. Textiles and Laundry - Handle in a manner that prevents transfer of microorganisms to others and to the environment
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Precautions Patient Care Considerations Transport Considerations PPE Environment
Patient-Care Equipment, Instruments, Gloves Devices: Patient Placement - In order of When touching the patient’s intact skin availability: Handle according to Standard or surfaces and articles in close Precautions Prioritize patients with conditions that In acute care hospitals, long-term care, proximity to the patient may facilitate transmission in single- In acute care hospitals, LTC, and other residential settings, limit Don gloves upon entry into the residential settings, use disposable Contact patient room. transport and movement of patients room/cubicle noncritical patient-care equipment Provide impermeable Cohort patients who are infected with outside of room to medically-necessary (e.g. blood pressure cuffs) or barriers to infectious same pathogen. purposes. Gowns implement patient dedicated use. agents that are either If necessary to place infected patient with If transport is necessary, ensure that When anticipating clothing will have highly pathogenic, drug non-infected patient; If common use of equipment is infected areas of patient’s body are direct contact with the patient or unavoidable, clean and disinfect resistant, contagious, or Avoid placing infected patients in the contained/covered. contaminated surfaces/equipment in before use on another patient. that can easily be same room as patients who are at risk Remove and dispose contaminated close proximity to the patient. contracted or spread to of adverse outcome from infection or PPE and perform hand hygiene prior to Don gown upon entry into room/cubicle Environmental Measures other environments via that may facilitate transmission transport. Doff gown and observe hand hygiene Ensure frequent cleaning and fomites and surface Ensure that patients are separated (>3ft Don clean PPE to handle patient at before leaving the patient-care disinfection of rooms (e.g. daily) with a contact. (Standard + apart, draw privacy curtain) transport destination environment focus on frequently touched surfaces Contact) Change protective attire and perform and equipment in the immediate hand hygiene between contacts in same After gown removal, ensure clothing and skin do not contact potentially vicinity of patient. (e.g. bed rails, room contaminated surfaces. table, bedside commode, lavatory surfaces, doorknobs)
Patient Placement - In order of availability: Prioritize patients with conditions that may facilitate transmission in single- In acute care hospitals, long-term care, patient room. and other residential settings, limit Cohort patients who are infected with transport and movement of patients Droplet same pathogen. outside of room to medically-necessary Mask - Don mask upon entry into the Provide additional If necessary to place infected patient purposes. patient room/cubicle. respiratory protection with non-infected patient; If transport or movement in healthcare against inhalation of Avoid placing infected patients in the setting is necessary, instruct patient to Eye Protection - No recommendation Standard Precaution protocols larger infectious droplets same room as patients who are at risk wear a mask and follow CDC’s for routinely wearing eye protection (>5 micrograms). of adverse outcome from infection or Respiratory Hygiene/Cough Etiquette (e.g. goggles, face shield) (Standard + Droplet) that may facilitate transmission No mask is required for persons Ensure that patients are separated (>3ft transporting patients on Droplet apart, draw privacy curtain) Precautions Change protective attire and perform hand hygiene between contacts in same room. Instruct patients to follow Respiratory Hygiene/Cough Etiquette
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Precautions Patient Care Considerations Transport Considerations PPE Environment
Environmental Controls: Filter incoming air using central or Patient Placement In acute care hospitals, long-term care, point-of-use HEPA filters In acute care hospitals, long-term care, and other residential settings, limit Direct room airflow with the air supply place patients who require Airborne transport and movement of patients on one side of the room that moves air Precautions in Airborne Infection Isolation outside of room to medically-necessary across the patient bed and out through Room (AIIR) that has been constructed purposes. an exhaust on the opposite side of the with current guidelines (see Airborne If transport or movement outside an Personnel Restrictions - Restrict room Airborne Precaution section for guidelines) AIIR is necessary, instruct patients to susceptible healthcare personnel from Ensure positive air pressure in room Provide respiratory If AIIR unavailable, transfer patient to wear a surgical mask and observe entering rooms of infected patients if relative to the corridor protection against facility that has AIIR. Respiratory Hygiene/Cough Etiquette. other immune healthcare personnel are Monitor air pressure daily with visual inhalation of infectious During an outbreak where large numbers available. If transport is necessary, ensure that indicators aerosols (agents that of patients require AIIR: infected areas of patient’s body are Ensure well-sealed rooms that prevent remain infectious over Consult with infection control contained/covered. Mask - Wear Fit-Tested NIOSH infiltration of outside air. long distances when professional to determine safety of Healthcare Professional transporting approved N95 or higher level respirator Lower dust levels by using smooth suspended in air) alternative rooms patients who are on Airborne when entering room or home of a nonporous surfaces and finishes. Wet (Standard + Airborne) Cohort patients Precautions do not need to wear a patient. dust horizontal surfaces. Use temporary portable solutions to mask or respiratory during transport if create negative pressure environment the patient is wearing a mask and Avoid carpeting in hallways and patient rooms (e.g. exhaust fan). See Airborne infectious skin lesions are covered. Precaution Section for more info. Minimize length of time that patients who require a Protective Environment are outside their rooms for diagnostic procedures and other activities. Special
Respiratory Wear fit-tested National Institute of Precautions: Occupational Safety and Health Wear appropriate PPE (i.e., N95 PR or After transport in vehicle: (NIOSH)-approved N95 PR/ P100 or Aerosol above). Leave vehicle unoccupied with PAPR when caring for ATD individuals Transmissible Individuals should remain in an AIIR Provide the ATD individual an N-95 windows open for at least one in an AIIR. except for procedures that cannot be surgical mask during the transport. (1) hour with a sign indicating Disease (ATD) PAPR for high hazard procedures on done in the AIIR. Seat the ATD individual in the rear actual time from (1) hour after individuals or animal carcasses with seat on the far right side opposite from ATD individual exited the Provide respiratory An AII sign will be placed on the suspected or confirmed infectious outside of the room to alert staff to use the transporting SBCDPH employee. vehicle. protection against disease. proper precautions and will only be Ensure the vehicle has: Within 24 hours utilize a Zymex inhalation of infectious Individuals must wear a plain surgical removed when the room is safe to Windows opened to allow for front to decontamination unit (located at the aerosols as well as mask when out of the AIIR . enter without respiratory protection. rear ventilation, and PRP office) for vehicle impermeable barrier to If the surgical mask becomes wet or Ventilation controls set to the fresh air decontamination. reduce spread of highly torn during transport, a new N-95 or vent setting with the fan set to high. pathogenic viruses on surgical mask and a plastic bag for the surfaces and via fomites old mask will be provided. (Standard + Contact + Droplet + Airborne)
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Precautions Patient Care Considerations Transport Considerations PPE Environment Viral Hemorrhagic Fever (VHF) i.e. Barrier protection against blood and body fluids (single gloves and fluid- Ebola, Marburg, resistant or impermeable gown, Lassa Virus face/eye protection with masks, Consider applying an impermeable goggles or face shields) Disease Single-patient room preferred Provide maximal barrier sheet or cocoon to the patient Largest viral load in final stages of Appropriate waste handling Emphasize hand hygiene impermeable barrier and illness where double gloves, leg and respiratory protection shoe coverings may be used. against highly N95 or higher respirators when pathogenic VHF viruses performing aerosol generating (Droplet + Contact + procedures Standard)
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3. STANDARD PRECAUTIONS Standard Precautions combine the major features of Universal Precautions (UP) and Body Substance Isolation (BSI) and are based on the principle that all blood, body fluids, secretions, excretions except sweat, non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard Precautions include a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. These include: hand hygiene; use of gloves, gown, masks, eye protection, or face shield, depending on the anticipated exposure and safe injection practices. Assume that every person is potentially infected or colonized with an organism that could be transmitted in the health care setting and apply the following infection control practices during delivery of health care. Hand Hygiene During the delivery of healthcare, avoid unnecessary touching of surfaces in close proximity to the patient to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. When hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water. If hands are not visibly soiled, or after removing visible material with non-antimicrobial soap and water, the preferred method of hand decontamination is with alcohol-based hand rub. Perform hand hygiene in the following clinical situations: o Before having direct contact with patients o After contact with blood, body fluids or excretions, mucous membranes, non-intact skin, or wound dressings o After contact with a patient’s intact skin o If hands will be moving from a contaminated-body site to a clean body site during patient care o After contact with inanimate objects in the immediate vicinity of the patient o After removing gloves Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if contact with spores (e.g. Bacillus anthracis). Alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores. Recommendation: Do not wear artificial fingernails or extenders if duties include direct contact with patients at high risk for infection and associated adverse outcomes. Respiratory Hygiene / Cough Etiquette Implement the following measures to contain respiratory secretions in patients and accompanying individuals who have signs and symptoms of a respiratory infection, beginning at the point of initial encounter in a healthcare setting: Post signs at entrances and in strategic places within ambulatory and inpatient settings with instructions to patients and other persons with symptoms of a respiratory infection to cover their mouths/noses when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after hands have been in contact with respiratory secretions. Provide tissues and no-touch receptacles for disposal of tissues Provide resources and instructions for performing hand hygiene in or near waiting areas in ambulatory and inpatient settings; provide conveniently-located dispensers of alcohol-based hand rubs and where signs are available, supplies for handwashing
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During periods of increased prevalence of respiratory infections in the community, offer masks for coughing patients and other symptomatic persons upon entry into the facility tor medical office and encourage them to maintain special separation, ideally a distance of at least three feet from other in common waiting areas Personal Protective Equipment Wear PPE when nature of the anticipated patient interaction indicates that contact with blood or body fluids may occur. Prevent contamination of clothing and skin when doffing PPE Before leaving the patients room/cubicle, remove and discard PPE. Gloves Wear gloves if contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated intact skin could occur. Disposable medical exam gloves for direct patient care. Disposable medical exam gloves or reusable utility gloves for cleaning environment or medical equipment. Remove gloves after contact with a patient and/or the surrounding environment (including medical equipment) using proper technique to prevent hand contamination. Do not wear the same pair of gloves for the care of more than one patient. Do not wash gloves for the purpose of reuse since this practice has been associated with transmission of pathogens. Change gloves during patient care if the hands will move form a contaminated body-site to a clean body-site. Gowns Wear a gown, that is appropriate to the task, to protect skin and prevent soiling or contamination of clothing during procedures and patient-care activities when contact with blood, body fluids, secretions, or excretions is anticipated. o Wear a gown for direct patient contact if the patient has uncontained secretions or excretions o Remove gown and perform hand hygiene before leaving the patient’s environment Do not reuse gowns, even for repeated contacts with the same patient. Routine donning of gowns upon entrance into a high risk unit is not indicated. Mouth, Nose, Eye Protection Use PPE to protect the mucous membranes of the eyes, nose, and mouth during procedures and patient-care activates that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task performed. During aerosol-generating procedures (e.g. bronchoscopy, suctioning of respiratory tract, endotracheal intubation) in patients who are not suspected of being infected with an agent for which respiratory protection is otherwise recommended wear one of the following: o Face shield that fully covers the front and sides of the face o Mask with attached shield o Mask and goggles Patient Placement Place patients who pose a risk for transmission to others in a single-patient room when available. Determine patient placement based on the following principles:
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o Route(s) of transmission of the known or suspected infectious agent o Risk factors for transmission in the infected patient o Risk factors for adverse outcomes resulting from an Hospital Acquired Infection (HAI) in other patients in the area or room being considered for patient-placement o Availability of single-patient rooms o Patient options for room-sharing (e.g., cohorting patients with the same infection)
Safe Injection Practices Use aseptic technique to avoid contamination of sterile injection equipment Do not administer medication from a syringe to multiple patients, even if the needle or cannula on the syringe is changed. Use fluid infusion and administration for one patient only and dispose appropriately after use. Consider a syringe or needle/cannula contaminated once it has been used to enter or connect to a patient’s intravenous infusion bag or administration set. Use single-dose vials for parenteral medications whenever possible. Do not administer medications from single-dose vials or ampules to multiple patients or combine leftover contents for later use. If multidose vials must be used, both the needle or cannula and syringe used to access the multidose vials must be sterile Do not keep multidose vials in the immediate patient treatment area and store in accordance with the manufacturer’s recommendations; discard if sterility is compromised or questionable. Do not use bags or bottles for intravenous solution as a common source of supply for multiple patients. Infection control practices for special lumbar puncture procedures: wear a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space Worker safety: Adhere to federal and state requirements for protection of healthcare personnel from exposure to bloodborne pathogen Care of the Environment Establish policies and procedures for routine and targeted cleaning of environmental surfaces as indicated by the level of patient contact and degree of soiling Clean and disinfect surfaces that are likely to be contaminated with pathogens, including those that are in close proximity to the patient and frequently touched surfaces in the patient care environment on a more frequent schedule compared to that for other surfaces. Use EPA-registered disinfectants that have microbiocidal activity against the pathogens most likely to contaminate the patient care environment. Use in accordance with manufacturer’s instructions Patient-Care Equipment and Instruments/Devices o Establish policies and procedures for containing, transporting, and handling patient- care equipment and instruments/devices that may be contaminated with blood or body fluids. o Remove organic material from critical and semi-critical instrument/devices using recommended cleaning agents before high level disinfection and sterilization to enable effective disinfection and sterilization processes o Wear PPE according to the level of anticipated contamination, when handling patient- care equipment and instruments/devices that is visibly soiled or may have been in contact with blood or body fluids. Textiles and Laundry
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o Handle textiles and fabrics with minimum agitation to avoid contamination of air, surfaces, and persons
4. TRANSMISSION-BASED PRECAUTIONS There are three categories of Transmission-Based Precautions: Contact Precautions, Droplet Precautions, and Airborne Precautions. Transmission-Based Precautions are used when the route(s) of transmission is (are) not completely interrupted using Standard Precautions alone. For some diseases that have multiple routes of transmission (e.g. SARS), more than one Transmission-Based Precautions category may be used. When used either singly or in combination, they are always used in addition to Standard Precautions. When Transmission-Based Precautions are indicated, efforts must be made to counteract possible adverse effects on patients i.e. anxiety, depression, and other mood disturbances, perceptions of stigma, reduced contact with clinical staff, and increases in preventable adverse events in order to improve acceptance by the patients and adherence by healthcare workers. Two categories have been added to the HPID SOG: Special Respiratory Precautions and Ebola/Viral Hemorrhagic Fever Precautions. Contact Transmission Use Contact Precautions for patients with known or suspected infections or evidence of syndromes that represent and increased risk for contact transmission. Contact transmission is divided into two subgroups: Direct Contact: occurs when microorganisms are transferred from one infected person to another without a contaminated intermediate object or person. Indirect Contact: involves the transfer of an infectious agent through a contaminated intermediate object or person. E.g. Transfer of pathogen to an inanimate object. Instruments, clothing, devices, etc. that are inadequately decontaminated. Contact Precautions also apply where the presence of excessive wound drainage, fecal incontinence, or other discharges from the body suggest an increased potential for extensive environmental contamination and risk of transmission. Airborne Transmission Airborne transmission occurs by dissemination of either airborne droplet nuclei or small particles in the respirable size range containing infectious agents that remain infective over time and distance. Microorganisms carried in this manner may be dispersed over long distances by air currents and may be inhaled by susceptible individuals who have not had face to face contact with the infectious individual. Special air handling and ventilation systems are required, such as AIIRs, to contain and then safely remove the infectious agent. Respiratory protection with NIOSH certified N95 or higher level respirator is recommended for healthcare personnel entering the AIIR. Droplet Transmission Droplet transmission is technically a form of contact transmission and some infectious agents transmitted by the droplet route also may be transmitted by the direct and indirect contact routes. Respiratory droplets carrying infectious pathogens transmit infection when they travel directly from the respiratory tract of the infectious individual to susceptible mucosal surfaces of the recipient, generally over short distances, necessitating facial protection. Respiratory droplets are generated when an infected person coughs, sneezes, or talks or during medical procedures involving the chest (e.g. suctioning, endotracheal intubation, CPR, etc.). Area of risk is ≤3 feet
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around the patient, but can higher, and depends on velocity and mechanism by which respiratory droplets are propelled from the sources, the density of respiratory secretions, environmental factors such as temperature and humidity, and the ability of the pathogen to maintain infectivity over that distance. Droplet sizes are defined as 5 micro meters and does not remain infective over long distances and therefore does not require special air handling and ventilation. Special Respiratory Precautions: Aerosol Transmissible Diseases (ATD) Exposure Plan An aerosol is a solid particle or liquid droplet suspended in air (or another gas), even temporarily. Examples include a droplet within influenza virus emitted through a cough or sneeze, or a dust particle with aerosolized anthrax. Aerosol Transmissible Disease (ATD) is a disease that can be transmitted by either 1) inhaling particles/droplets or 2) Direct contact between particles/droplets and mucous membranes in the respiratory tract. An aerosol transmissible pathogen (ATP) is a pathogen that, when present in an aerosol and with sufficient exposure, may result in disease transmission. See Annex: ATD Exposure Plan for detailed preparedness and response. Viral Hemorrhagic Fever (VHF) – i.e. Ebola, Marburg, Lassa Virus Disease The hemorrhagic fever viruses are a mixed group of viruses that cause serious disease with high fever, skin rash, bleeding diathesis, and in some cases, high mortality. Person-to-person transmission is associated primarily with direct blood and body fluid contact. Percutaneous exposure to contaminated blood carries a particularly high risk for transmission and increased mortality. Postmortem handling of infected bodies is an important risk for transmission. See Annex: Ebola Virus Disease Plan for detailed emergency response.
Clinical Symptoms and Presentation for Levels of PPE High Risk For suspected or confirmed VHF patients who exhibit bleeding, vomiting, diarrhea, a clinical condition that may warrant invasive or aerosol-generating procedures (e.g., intubation, suctioning, resuscitation), or overall worsening of symptoms, the required level of PPE for employees caring for or moving the patient, and for all employees working in the patient room is Ensemble I. It is recommended that the hospital’s Infectious Disease Physician and/or Infection Preventionist assess the suspected or confirmed VHF patient status and determine the appropriate level of PPE on an ongoing basis during the care of the patient. For EMS personnel providing direct patient care should be in Ensemble I at all times during the provision of care Ensemble I Viral resistant, impermeable coverall (with hood and booties). PPE that covers all surfaces of the body, including the head and neck, coverings for the eyes, mouth, nose and skin. The hair must be completely enclosed Double gloves, long (inner and outer) Impermeable rubber over-boots (or equivalent) to provide continuous fluid protection Powered-Air Purifying Respirator (PAPR), with shrouded hood or cowl, with P- 100 or N-100 cartridges or a Chemical, Biological, Radiological, Nuclear, Explosive (CBRNE) PAPR with FR-57 cartridges and shrouded hood Impermeable surgical gown or apron for additional splash protection
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Some Risk The PPE recommendations when caring for the clinically stable, suspected or confirmed VHF patient without symptoms of bleeding, vomiting, diarrhea, or a clinical condition that may warrant invasive or aerosol-generating procedures is Ensemble II. EMS or other first responders having close contact (within three feet) with a person suspected of being infected with VHF and no direct patient contact should use Ensemble II: Ensemble II Splash resistant coverall (with hood and booties) tape over zipper Double gloves (inner and outer) Rubber over-boots Face shield which covers front and sides P-100 or N-100 filtering face piece fluid resistant respirator Low Risk Disease investigators or law enforcement personnel in a room for a brief period of time without direct or close contact (more than three feet) with a person who may have had close contact with a suspect and/or confirmed Ebola patient should use Ensemble III. Ensemble III Coverall (with hood) Double gloves (inner and outer) Rubber over-boots Face-shield which covers front and sides N-95 filtering face piece fluid resistant respirator No Risk If the patient provides a negative travel history and no other likely exposure then standard universal precautions should be utilized. Refer to your local agency protocols for Standard Universal Precautions. Any respiratory procedures or management of a suspected VHF patient actively vomiting or having diarrhea warrants Ensemble I PPE. For prolonged transports of confirmed or high risk patients, Ensemble I PPE is required.
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1. INTRODUCTION Public health quarantine and isolation are legal authorities that may be, but rarely are, implemented to prevent the spread of communicable diseases. Both are usually imposed by health officials on a voluntary basis; however, federal, state, and local officials have the authority to impose mandatory quarantine and isolation when necessary to protect the public’s health. Isolation is for people who are sick with a contagious disease. They are separated from others until they are no longer considered contagious. Hospitals isolate some patients so they do not infect others with their illness. People in isolation may be cared for in their homes, hospitals, or in designated facilities. Quarantine is for people who were exposed to a contagious disease but are not sick. They are separated from others as they could become sick and contagious. People may be asked to stay in their homes so they do not possibly spread the disease to others. Use of quarantine or isolation powers may create sensitive issues related to civil liberties. Individuals have rights to due process of law, and generally, isolation or quarantine must be carried out in the least restrictive setting necessary to maintain public health.
2. RESPONSIBILITY AND AUTHORITY The federal government has authority, through the CDC, to monitor and respond to the spread of communicable diseases across national or state borders, or if the state government is unwilling or unable to effectively respond. CDC's authority to exercise quarantine and isolation powers for specific diseases derives from a series of presidential CDC Executive Orders most recently updated in 2014. Under these orders, federal quarantine and isolation powers currently apply to the following diseases: Cholera; Diphtheria; infectious Tuberculosis; Plague; Smallpox; Yellow Fever; Viral Hemorrhagic Fevers (Lassa, Marburg, Ebola, Crimean-Congo, South American, and others not yet isolated or named); Influenza caused by new or re-emergent flu viruses that are causing, or have the potential to cause, a pandemic; and severe acute respiratory syndromes. State and local governments are primarily responsible for maintaining public health and CDPH controlling the spread of diseases within state borders. Among other state public health emergency preparedness powers, every state, the District of Columbia and most territories have laws authorizing quarantine and isolation, usually through the state’s health authority. The local county health officer has the authority to order quarantine of people who may have an infectious disease that threatens public health. The Local Health Officer will issue SBCDPH quarantine orders for individuals and establish limitations of quarantine on a case-by-case basis. These limitations are based on the CDPH guidance.
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3. PROCEDURE FOR AN ORDER FOR ISOLATION OR QUARANTINE 1) The Order for Isolation or Quarantine is developed at the DOC level and signed by the Health Officer and contains the following: Subject of the order Individual Orders: Identity and address of the person when known, or if unknown, as detailed a description of the subject as available Mass Orders: Target population/geographic area, described as specifically and narrowly as possible The specific directive that the individual(s) must follow Duration of the order and date of release Potential penalty for a violation Supporting facts Statutory authority and any other legal basis to support the order Method and opportunity to challenge the order Location of the isolation or health facility or home and the reason for any out-of-home isolation Any additional information specific to the event triggering the need for the order Information regarding support services for isolation or quarantine and how to obtain them, if needed, including contact information (may be an attachment to the order itself) Language of the individual Whether the patient is a minor Mental capacity of the individual Signature and title of Health Officer Signature of the patient acknowledging the receipt of order Right to representation, if any, for the subject of the order Method(s) of informing the individuals subject to the order 2) Service of the order Orders directed to individuals o To ensure immediate effectiveness of the order and successful enforcement, individual isolation and quarantine orders should be personally handed to the individual. The date and time that the individual was given the order should be documented as well as who handed the order to the individual. This method of service does not require the signature of the subject of the order to be effective. o An order may be sent registered or certified mail, but an order is not effective until and unless the registered or certified return receipt on the envelope containing the order is signed by the subject of the order. Orders directed to a mass o Personal service, mail, media, posting of the venue, site, or place in question, or combination of these and other methods can be used to communicate the directive to the target group or area. To ensure reaching the broadest population in the most effective manner and to ensure successful enforcement, Health Officer may want to employ multiple communication methods. 3) Enforcement authority for isolation and quarantine and penalties Requirement to comply with a Health Officer Order for Isolation or Quarantine o H&S §120220 requires that all persons shall obey the Health Officer’s rules, orders, and regulations for isolation or quarantine. Penalty for violation of a Health Officer Order for Isolation or Quarantine
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o H&S §120275 stipulates that violation of a Health Officer Order for Isolation or Quarantine is a misdemeanor. 4) Extension or Termination of the Order for Isolation or Quarantine The Order should be written for a specific period of time under most circumstances according to the known characteristics of the outbreak. If no specific termination time is written in the Order, then a specific time for review of the Order shall be written in the Order; the review shall determine whether to terminate the Order or to extend the Order with appropriate justification for extension. A notification should be written and served to the subject of the Order for termination or extension; for an extension, supporting facts for the extension, any changes in instructions, and a new review date should be specified.
4. ENFORCEMENT OF QUARANTINE AND ISOLATION In the event of noncompliance with an isolation or quarantine order, the San Bernardino County Health Officer may pursue civil or criminal legal actions against the noncompliant individual. Although legal counsel will be involved in both the civil and criminal court processes, the active participation of the Health Officer or his designee to assist in the preparation of court documents as well as testimony should be anticipated. Any person who fails to comply with an isolation or quarantine order issued by the Health Officer or his designee is guilty of a misdemeanor. Upon the receipt of information that an order has been violated, the Health Officer or his/her designee shall: Consult with the Public Health Director, and advise San Bernardino County Counsel, and/or the San Bernardino County Sheriff Department, and/or local law enforcement agency, immediately by fax (so there is written documentation) and by phone. The Health Officer, or his/her designee, shall include in the fax notification of any information in his possession relating to the subject matter of the order and of the violation(s). The Health Officer shall pursue civil or criminal legal action against the individual who has violated the order, based on advice of County Counsel.
5. LAW ENFORCEMENT FOR NON-COMPLIANCE The Department of Public Health will issue a local isolation and/or quarantine order if a person is suspected or identified to be quarantined. The Local Health Officer will request assistance, from the MHOAC to the OA EOC, and request support from the San Bernardino County Sheriff’s Department, or other law enforcement agency, to enforce a public health order.
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SBCDPH and San Bernardino County Department of Behavioral Health (SBCDBH) have developed procedures for quarantine and/or isolation to include mental and behavioral health considerations. These procedures would be implemented in the event of isolation, quarantine, and mass fatality during an HPID emergency. SBCDBH has the ability to deploy Community Crisis Response Teams (CCRTs) in the event of an emergency. The CCRT is a community-based mobile crisis response program for those experiencing a psychiatric emergency. The members of the CCRT are qualified behavioral health professionals trained to assist individuals in psychological distress during heightened emotional situations, such as a public health emergency. CCRT utilizes specially trained mobile crisis response teams to provide crisis interventions, assessments, case management, relapse prevention, and medication referrals. Additional services include linkage to resources through collaboration with law enforcement, hospitals, Children and Family Services, Adult Protective Services, Department of Aging and Adult Services, American Red Cross, schools, and other community organizations. These professionals will be of assistance during a crisis to provide mental health counseling services within the OA. The SBCDBH CCRT members are trained to: Assess the emotional magnitude of the disaster on residents and workers through on-going mental health needs assessments Assist in the restoration of emotional balance of emergency/disaster survivors to pre-disaster level of functioning by providing basic mental health crisis counseling interventions and supportive mental health services Educate those individuals in isolation/quarantine and their family members on recognizing stress symptomatology and to impart coping skills to facilitate mental recovery Facilitate access to those meeting 5150 criteria or those in need of long term counseling services Assist in the establishing of social networks, while individuals are in isolation/quarantine, via telehealth strategies, for long-term recovery and support SBCDBH will incorporate telehealth strategies to facilitate communication between behavioral health professionals and patients that are isolated or quarantined. Family during family visits may also utilize telehealth strategies. Modes of communication will be provided by SBCDBH and may include the following resources: Cell phone with video conferencing capability Tablet with video conferencing capability Laptop with video conferencing capability Cellular or internet capabilities for devices SBCDBH will provide specified mental health staffing if requested from SBCDPH. If SBCDBH does not have the ability to fulfill a request within their agency, SBCDBH will request additional resources through the Medical Health Operational Area Coordinator (MHOAC). The MHOAC Program is responsible for monitoring, ensuring, and procuring medical and health resources during local emergency or disaster.
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San Bernardino County identified 3 highest priority natural disasters based on a Multi-Jurisdictional Hazard Mitigation Plan Risk Assessment. These natural disasters include: Wildfire, Earthquake, and Flood. The following section provides NPI recommendations for specific threats that may result from a Wildfire, Earthquake, or Flood.
NPI
ygiene Natural Hazard Protective Measures
Disaster PPE
Isolation
Quarantine
Evacuation
Restrictions
Decontamination
Movement/Travel
Social Distancing
Personal H Waterborne Earthquake x x x x x x x Examples include diarrheal diseases, Hepatitis A and E, and Leptospirosis. Diseases Wildfire Throw away food that may have come in contact with flood or storm water; perishable foods that have Flood not been refrigerated properly due to power outages; and those with an unusual odor, color, or texture. Do not use water you suspect or have been told is contaminated to wash dishes, brush your teeth, wash and prepare food, wash your hands, make ice, or make baby formula. Safe water for drinking, cooking, and personal hygiene includes bottled, boiled, or treated water.
Diseases Earthquake x x x x x x x Examples include Measles, Meningitis, and acute respiratory infections. See HPID matrix for more Associated Wildfire information. with Flood Isolation and quarantine Overcrowding Restrictions on movement and travel advisory/warnings Social distancing External decontamination Hygiene Precautionary protective behaviors
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NPI
Natural Hazard Protective Measures
Disaster PPE
Isolation
Quarantine
Evacuation
Restrictions
Decontamination
Movement/Travel
Social Distancing
Personal Hygiene Chemical Earthquake x x x x x x x Stay out of floodwater. It can contain human and livestock waste, coal ash, and other contaminants Exposure Wildfire that can lead to illness. Flood Call 911 or the national poison control center at 1-800-222-1222 if you suspect someone has been poisoned by a chemical. Call the Animal Poison Control Center at 1-888-426-4435 if you suspect a pet has been poisoned by a chemical. Call local authorities or the National Response Center at 1-800-424-8802 to report oil and chemical spills, abandoned containers, or other containers you suspect may contain chemicals. Do not touch or move unknown containers. Listen to announcements or alerts from authorities about chemical safety and disposal issues. Listen to local announcements for guidance on what to do in the event of a chemical release. You may need to evacuate or stay inside (shelter in place) until you are told it is safe to leave. Wash skin that may have come into contact with chemicals or floodwater with soap and clean water as soon as possible. You may need to remove and dispose of your clothing, then decontaminate yourself to reduce or remove the chemical so it is no longer a hazard. Vectorborn Earthquake x x x x x Examples include Malaria, Dengue, and Zika. e Diseases Wildfire Insects: Vector control interventions such as insecticides, EPA registered insect repellent, traps, and Flood protective nets and protective clothing such as long-sleeved shirts and pants. https://www.cdc.gov/ncezid/dvbd/about/prevent-bites.html Animal Hazards: Avoid wild or stray animals https://www.cdc.gov/disasters/animalhazards/facts.html Rodents: Removing food sources, water, and items that provide shelter for rodents is the best way to prevent contact with rodents. Where necessary, control rodents by using an integrated pest management approach that includes environmental sanitation, proper food storage, rodent-proofing, trapping, and poisoning. https://www.cdc.gov/disasters/rodents.html
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NPI
Natural
Hazard Protective Measures Disaster
ns
PPE Personal Hygiene Isolation Quarantine Social Distancing Movement/Travel Restrictio Evacuation Decontamination Injury Earthquake x x Examples include Tetanus, Fungal Infections, and Trench Foot. Wildfire Immediately clean out all open wounds and cuts with soap and clean water. Keep wounds covered with Flood clean, dry bandages that are large enough to cover the wound and contain any pus or drainage. Change bandages as needed and when drainage can be seen through the bandage. Contact a doctor to find out whether more treatment is needed (such as a tetanus shot). If a wound gets red, swells, or drains, seek immediate medical attention. Carbon Earthquake x x x Never run a generator, pressure washer, or any gasoline-powered engine inside an enclosed structure Monoxide Wildfire even if the doors or windows are open, unless the equipment is professionally installed and vented. Flood If CO poisoning is suspected, call 911 or your local Poison Control Center at 1-800-222-1222 or consult a health care professional right away. Smoke Earthquake x x x x NIOSH Approved N95 Particulate Filtering Facepiece Respirators or respiratory protection devices with Wildfire a higher level of protection Stay indoors Reduce activity Use HEPA air cleaners indoors Consider relocation of sensitive individuals out of smoky area Evacuation
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SECTION IV: APPENDIX
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DECISION INSTRUMENT FOR THE ASSESSMENT AND NOTIFICATION OF EVENTS THAT MAY CONSTITUTE A PUBLIC HEALTH EMERGENCY OF INTERNATIONAL CONCERN
Events detected by national surveillance system
An event involving the A case of the following following diseases shall Any event of potential diseases is unusual or always lead to utilization international public health unexpected and may have of the algorithm because concern, including those serious public health impact they have demonstrated of unknown causes or and thus shall be notified: the ability to cause sources and those Smallpox serious public health OR involving other events or OR Poliomyelitis due to wild-type impact and to spread diseases than those listed poliovirus rapidly internationally: in the box on the left and Human influenza caused by the box on the right shall Cholera a new subtype lead to utilization of the Pneumonic plague Severe acute respiratory algorithm. Yellow fever syndrome (SARS) Viral Hemorrhagic fevers (Ebola, Lassa, Marburg) West Nile fever Is the public health impact Other diseases that are YES of the event serious? of special national or regional concern
Is the event unusual NO or unexpected? Is the event unusual or unexpected?
YES NO YES NO
Is there a significant risk of international spread? Is there significant risk of international spread?
YES NO YES NO
Is there a significant risk of international travel or trade restrictions?
Not notified at this stage. YES NO Reassess when more information becomes available.
EVENT SHALL BE NOTIFIED TO WORLD HEALTH ORGANIZATION UNDER THE INTERNATIONAL HEALTH REGULATIONS
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ACC Animal Care and Control ACS Alternate Clinic Site AFN Access and Functional Needs AIIR Airborne Infection Isolation Room ARMC Arrowhead Regional Medical Center BOS Board of Supervisors CAHAN California Health Alert Network CALMAT California Disaster Medical Assistance Teams CCRT Community Crisis Response Team CCRT Crisis Community Response Team CD Communicable Disease CDC Centers for Disease Control (and Prevention) CDI Communicable Disease Investigator CDPH California Department of Public Health CDS Communicable Disease Section CERC Crisis and Emergency Risk Communications CERT Community Emergency Response Team COG Continuity of Government COOP Continuity of Operations Plan DBH Department of Behavioral Health DEOP Department Emergency Operations Plan DHV Disaster Health Volunteer DMAT Disaster Medical Assistance Teams DOC Departmental Operations Center DOT Federal Department of Transportation DPH Department of Public Health DRIC Designated Representative In Charge DSAT Division of Select Agents and Toxins ED / ER Emergency Department / Emergency Room EMS Emergency Medical Services EMT Emergency Medical Technician EOC Emergency Operations Center ERG Emergency Relocation Group ESAR-VHP Emergency System for Advance Registration of Volunteer Health Professionals FBI Federal Bureau of Investigation FOG Field Operations Guide GAACS Government Authorized Alternate Care Site HAI Hospital Acquired Infection HCW Healthcare Workers HEPA High-efficiency Particulate Air HICS Hospital Emergency Incident Command System HPID SOG High Priority Infectious Disease Standard Operating Guidelines HPP Hospital Preparedness Program IATA International Air Transport Association ICEMA Inland Counties Emergency Medical Agency ICS Incident Command System ILI Influenza Like Illness ILINet Influenza Like Illness Surveillance Network JIT Just in Time Training LRN Laboratory Response Network MHOAC Medical Health Operational Area Coordinator MOU Memorandum of Understanding
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MRC Medical Reserve Corps NFOG Nurses Field Operations Guide NIMS National Incident Management System NIOSH National Institute for Occupational Safety and Health NPI Non-pharmaceutical Intervention NRP National Response Plan OA Operational Area OES Office of Emergency Services PCR Polymerase Chain Reaction PEP Post-exposure Prophylaxis PIO Public Information Officer POD Point of Dispensing PPE Personal Protective Equipment PRP Preparedness and Response PSA Public Service Announcement ReddiNet Rapid Emergency Digital Data Information Network RN Registered Nurse rRT-PCR real time Reverse Polymerase Chain Reaction RSS Receipt, Storage, and Staging SARS Severe Acute Respiratory Syndrome SBCDBH San Bernardino County Department of Behavioral Health SBCDPH San Bernardino County Department of Public Health SBCMS San Bernardino County Medical Society SEMS Standardized Emergency Management System SNS Strategic National Stockpile SOP Standard Operating Procedures USDA United States Department of Agriculture VAERS Vaccine Adverse Event Reporting System VHF Viral Hemorrhagic Fever VRDL Viral and Rickettsial Disease Laboratory WebEOC Web Based Emergency Operations Center WHO World Health Organization
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Occurs when infectious agents are carried by dust or droplet nuclei suspended in the Airborne Transmission air. These particles can stay suspended in the air for long periods of time and may be blown over long distances. Prescription medicines (pills, liquid, an inhaled powder, or an intravenous solution) that Antiviral Treatment fight against flu viruses in your body. In February 1957, a new influenza A (H2N2) virus emerged in East Asia, triggering a Asian Influenza pandemic (“Asian Flu”). The estimated number of deaths was 1.1 million worldwide and 116,000 in the United States. a member of a large group of unicellular microorganisms which have cell walls but lack Bacteria organelles and an organized nucleus, including some which can cause disease. A biological attack, or bioterrorism, is the intentional release of viruses, bacteria, or other germs that can sicken or kill people, livestock, or crops. Bacillus anthracis, the Bioterrorism bacteria that causes anthrax, is one of the most likely agents to be used in a biological attack. Case Contact An individual exposed to a confirmed or suspected case of a communicable disease. The signs, symptoms and/or lab results necessary for classification of a person reported for disease or condition as a confirmed, probable or suspected case. Case Case Definition definitions are published by the Centers for Disease Control and Prevention (CDC) for nationally notifiable diseases. The U.S. public health system and primary healthcare providers must be prepared to address various biological agents, including pathogens that are rarely seen in the United States. High-priority agents include organisms that pose a risk to national Category A Agent security because they can be easily disseminated or transmitted from person to person; result in high mortality rates and have the potential for major public health impact; might cause public panic and social disruption; and require special action for public health preparedness. Second highest priority agents include those that are moderately easy to disseminate; Category B Agent result in moderate morbidity rates and low mortality rates; and require specific enhancements of CDC’s diagnostic capacity and enhanced disease surveillance. The U.S. public health system and primary healthcare providers must be prepared to address various biological agents, including pathogens that are rarely seen in the United States. High-priority agents include organisms that pose a risk to national Category C Agent security because they can be easily disseminated or transmitted from person to person; result in high mortality rates and have the potential for major public health impact; might cause public panic and social disruption; and require special action for public health preparedness. Chemoprophylaxis The use of drugs to prevent disease. An unusual aggregation, real or perceived, of health events that are grouped together Cluster in time and space and that are reported to a health agency. In some instances, a single event of some diseases may constitute an outbreak. An illness that can be transmitted from an infected person, animal or inanimate Communicable Disease reservoir to a susceptible host. Community mitigation aims to slow the spread of a novel influenza A virus in Community Mitigation communities through the use of non-pharmaceutical interventions (NPIs) and through travel and border health measures. A reported case of disease or condition that has been fully investigated and found to Confirmed Case have satisfied the most recent communicable disease surveillance case definitions established by the CDC and/or the California Department of Public Health (CDPH). Transmission through skin-to-skin contact, kissing, and sexual intercourse. This can Direct Contact also refer to contact with soil or vegetation harboring infectious organisms. Doff(ing) The act of removing Personal Protective Equipment (PPE). Don(ning) The act of putting on Personal Protective Equipment (PPE). Transmission through spray with relatively large, short-range aerosol produced by Droplet Spread sneezing, coughing, or even talking.
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Diseases that (1) have not occurred in humans before (this type of emergence is difficult to establish and is probably rare); (2) have occurred previously but affected Emerging Infectious only small numbers of people in isolated places (AIDS and Ebola hemorrhagic fever Disease are examples); or (3) have occurred throughout human history but have only recently been recognized as distinct diseases due to an infectious agent (Lyme disease and gastric ulcers are examples). Enteric Disease Any organism that causes intestinal illness i.e., Salmonella or Giardia. A case in which: the patient has had contact with one or more persons who either have/had the disease or have been exposed to a point source of infection (i.e., a single source of infection, such as an event leading to a foodborne-disease outbreak, to Epidemiologically linked which all confirmed case-patients were exposed) transmission of the agent by the case usual modes of transmission is plausible. A case may be considered epidemiologically linked to a laboratory-confirmed case if at least one case in the chain of transmission is laboratory confirmed. Epidemiology is the method used to find the causes of health outcomes and diseases in populations. In epidemiology, the patient is the community and individuals are viewed collectively. By definition, epidemiology is the study (scientific, systematic, and Epidemiology data-driven) of the distribution (frequency, pattern) and determinants (causes, risk factors) of health-related states and events (not just diseases) in specified populations (neighborhood, school, city, state, country, and global). H1N1 Swine flu is a subtype of influenza A virus (a communicable viral disease), which causes upper, and potentially, lower respiratory tract infections in the host it infects, H1N1 resulting in symptoms such as nasal secretions, chills, fever, decreased appetite, and possibly lower respiratory tract disease. In 2009 a strain of swine flu called H1N1 infected many people around the world. Diseases are caused by pathogenic microorganisms, such as bacteria, viruses, parasites or fungi; the diseases can be spread, directly or indirectly, from one person Infectious Disease to another. Zoonotic diseases are infectious diseases of animals that can cause disease when transmitted to humans. Separation of people known or suspected (via signs, symptoms, or laboratory criteria) Isolation to be infected with a contagious disease from those who are not sick to prevent them from transmitting disease to others. The separation of ill persons from those who are healthy. Restricts the movement of ill Isolation persons to help stop the spread of certain diseases. A case that is confirmed by one or more of the laboratory methods listed in the case Laboratory Confirmed definition under Laboratory Criteria for Diagnosis. Although other laboratory methods Case can be used in clinical diagnosis, only those listed are accepted as laboratory confirmation for national reporting purposes. Morbidity has been defined as any departure, subjective or objective, from a state of Morbidity physiological or psychological well-being. Mortality The state of being subject to death. Novel influenza infections are those due to influenza viruses that differ from strains Novel Influenza Virus currently circulating among humans The occurrence of cases of a disease or illness above the expected or baseline level, usually over a given period of time, in a geographic area or facility, or in a specific Outbreak population group. The number of cases indicating the presence of an outbreak will vary according to the disease agent, size and type of population exposed, previous exposure to the agent, and the time and place of occurrence. Pandemic Worldwide spread of a new disease. An influenza pandemic is a global outbreak of a new influenza A virus. Pandemics Pandemic Influenza happen when new (novel) influenza A viruses emerge which are able to infect people easily and spread from person to person in an efficient and sustained way. Probably Case A case that is classified as probable for reporting purposes. Prophylaxis is defined as a process of guarding against the development of a specific Prophylaxis disease by a treatment or action that affects pathogenesis.
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An occurrence or imminent threat of an illness or health condition, caused by bio Public Health terrorism, epidemic or pandemic disease, or a novel and highly fatal infectious agent or Emergency biological toxin that poses a substantial risk of a significant number of human facilities or incidents or permanent or long-term disability. Compulsory separation, including restriction of movement, of people who have potentially been exposed to a contagious disease, until it can be determined whether Quarantine they have become sick or no longer pose a risk to others, for example, based on time elapsed from their potential exposure. Diseases that once were major health problems globally or in a particular country, and then declined dramatically, but are again becoming health problems for a significant Re-emerging Infectious proportion of the population (malaria and tuberculosis are examples). Many specialists Disease in infectious diseases include re-emerging diseases as a subcategory of emerging diseases. Any person who was present in the last 21 days in a country with an active infectious Returning Traveler Disease outbreak. Public health safety intervention used to reduce the likelihood of transmitting Social Distancing communicable disease The 1918 influenza pandemic was the most severe pandemic in recent history. It was caused by an H1N1 virus with genes of avian origin. Although there is not universal Spanish Influenza consensus regarding where the virus originated, it spread worldwide during 1918- 1919. DPH regular status employees, public service employees (PSE) and, contract Staff employees, interns, externs, volunteers, work experience (WEX) workers, and professional services contractors/vendors. the ongoing, systematic collection, analysis, and interpretation of health-related data Surveillance essential to planning, implementation, and evaluation of public health practice Suspect Case A case that is classified as suspected for reporting purposes. Structure that brings together the Incident Commanders of the major organizations involved in the incident in order to coordinate an effective response, while at the same Unified Command time allowing each to carry out their own jurisdictional, legal, and functional responsibilities. Such as animals and insects such as mosquitos, fleas, and ticks that may carry an Vectors infectious agent through purely mechanical means or may support growth or changes in the agent. Includes food, water, biologic products (blood), and fomites (inanimate objects such as Vehicle Transmission handkerchiefs, bedding, or surgical scalpels) which may passively carry a pathogen. Small parasite that cannot reproduce by itself. Once it infects a susceptible cell, Virus however, a virus can direct the cell machinery to produce more viruses. Most viruses have either RNA or DNA as their genetic material.
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SECTION V: ANNEX
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1. Aerosol Transmissible Diseases (ATD) Exposure Plan The following section includes guidance for employees to reduce or eliminate infection with aerosol transmissible diseases by addressing workplace hazards and providing procedures to prevent exposure. The ATD guidance complies with CDC, CDPH, and California Occupational safety and Health Administration (Cal/OSHA) requirements. Aerosol Transmissible Disease (ATD) is a disease that can be transmitted by either a. Inhaling particles/droplets; or b. Direct contact between particles/droplets and mucous membranes in the respiratory tract or eyes. Aerosol Transmissible Pathogen (ATP) is a pathogen that, when present in an aerosol and with sufficient exposure, may result in disease transmission. Employee Respiratory Fit Testing Employees must be medically cleared prior to Respiratory Fit-Testing. The Respiratory Protection Administrator (RPA) will institute the following procedures in conjunction with the Center for Employee Health and Wellness (CEHW) medical evaluation: The RPA shall provide the employee with the Respirator Use Form Medical Questionnaire which will be used for the employee’s medical evaluation. This form can be obtained from the Department of Risk Management (DRM) Safety Officer. The employee must send the questionnaire to:
Center for Employee Health and Wellness Medical Director Respiratory Protection Evaluations 555 North D Street #100 San Bernardino, CA 92415
(Note: Employee will need to send a copy to the RPA for follow up and tracking) The RPA shall ensure that a follow-up medical examination was conducted by CEHW. The medical examination shall include any medical tests, consultations or diagnostic procedures the Medical Director deems necessary to make a final determination. The Respirator Use Form Medical Questionnaire and examination shall be administered confidentially during the employee’s normal working hours and administered in a manner that ensures the employee understands its content. CEHW shall provide the employee with an opportunity to discuss the Respirator Use Form Medical Questionnaire and examination results. The Respirator Use Form Medical Questionnaire must include the following information: o The type and weight of the respirator to be used by the employee, o The duration and frequency of respirator use (including use for rescue and escape), o The expected physical work effort, o Additional protective clothing and equipment to be worn, o Temperature and humidity extremes that may be encountered, and o MSDS, name of contaminants, hazardous substances and physical form of chemical. In determining the employee’s ability to use a respirator, the RPA shall: o Obtain a written recommendation regarding the employee’s ability to use the respirator from the CEHW and should include the following information: Any limitations on respirator use related to the medical condition of the employee, or relating to the workplace conditions in which the respirator will be used,
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The need, if any, for follow-up medical evaluations, and A statement that the CEHW has provided the employee with a copy of the written recommendation. o If the respirator is a negative pressure respirator and the CEHW finds a medical condition that may place the employee’s health at increased ris, the County shall provide a PAPR if the CEHW medical evaluation finds that the employee can use such a respirator. If a subsequent medical evaluation finds that the employee is medically able to use a negative pressure respirator, then the County is no longer required to provide a PAPR. The RPA shall provide additional medical evaluations that comply with the requirements of this section if: o An employee reports medical signs or symptoms that are related to the ability to use a respirator, o The CEHW, supervisor, or the RPA suspects that an employee needs to be reevaluated, o Information from the respiratory protection program, including observations made during fit testing and program evaluation, indicates a need for employee reevaluation, or o A change occurs in workplace conditions (e.g., physical work effort, protective clothing, temperature, etc.) that may result in a substantial increase in physiological burden placed on an employee. Precautions for Managing Infectious Individuals 1. Respiratory Hygiene and Cough Etiquette measures have been implemented at the first point of contact to limit SBCDPH employee and visitor exposure to infectious individuals during periods when they are not in AIIRs. 2. Suspected or known cases of ATD will be identified and these individuals will be provided with disposable tissues, hand hygiene materials and plain surgical masks. These patients need to be isolated in such a manner that contact with SBCDPH employee(s) not wearing respiratory protection is eliminated or minimized until transfer or placement in an AIIR or designated respiratory isolation area can be accomplished. 3. Individuals with the following signs and symptoms should be considered possibly infected with an ATD: Exhibit signs and symptoms of an influenza-like-illness (ILI) during March through October, the months outside of the typical period for seasonal influenza; these signs and symptoms generally include combination of the following: Coughing not explained by non-infectious conditions Fever (100° [37.8°C]) or greater Sweating Chills Muscle aches Weakness Malaise Other respiratory symptoms The individual states he/she has an ATD, or has been exposed to an infectious ATD case, excluding the common cold and seasonal influenza. 4. Any suspect or known case of any ATD will be placed in the AIIR in a timely manner. Individuals placed in an AIIR will be instructed to remain in their room unless essential procedures that cannot be performed in the room are required. Individuals will, if tolerated, wear a plain surgical mask while outside of the AIIR or designated respiratory isolation area. 5. Individuals suspected or known to be infected with an ATD will be placed in an appropriate isolation room, using All Precautions. Individuals requiring AII will be placed in an AIIR. If no
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AIIR is available, the individual will be placed in a regular room with the door closed except for entering and exiting. For individuals requiring AII and in a regular room, a high efficiency particulate air (HEPA) filtration unit and N95 PR for employees entering the room are also required. The individual will be transferred to an AIIR as soon as one is available. 6. Where no AIIR or area is available and the treating physician determines that it would be detrimental to the individual’s condition to delay performing the procedure, high hazard procedures may be conducted in non-AII areas. In that case, employees working in the room where the procedure is performed will use appropriate PPE.
EXPOSURE INCIDENTS The SBCDPH ATD Exposure Control Plan contains procedures for SBCDPH employees and SBCDPH supervisors to follow in the event of an exposure incident, including determining which employees had a significant exposure. 1. The procedures SBCDPH Administration will use: Evaluates each exposure incident, to determine the cause, and to revise existing procedures to prevent future incidents. Communicates with SBCDPH employees and other departments/agencies regarding the suspected or confirmed infectious disease status of individuals to whom employees are exposed in the course of their duties. Communicates with other employers regarding exposure incidents, including procedures for providing or receiving notification to and from health care providers about the disease status of referred individuals. Ensures that there is an adequate supply of PPE and other equipment necessary to minimize employee exposure to ATPs, in normal operations and in foreseeable emergencies. 2. If an employee has been determined to have been exposed to a Reportable Aerosol Transmissible Disease (RATD) case or suspected case, the departments will collaborate with SBCDPH Communicable Disease Services. These cases will be reported to the SBCDPH Health Officer, in accordance with CCR, Title 17, § 2505. 3. Within 72 hours after becoming aware of an exposure incident SBCDPH will in accordance to the extent that the information is available: Notify other departments/agencies, whose employees may have been exposed to the case or material. Include in the notification the nature, date, and time of the exposure. Provide information on the source individual or animals allowed by the Health Insurance Portability and Accountability Act (HIPAA). Note: These department/agency employees may include, but are not limited to, paramedics, emergency medical technicians (EMTs), emergency responders, home health care personnel, homeless shelter personnel, personnel at referring health care facilities or agencies, and corrections personnel. SBCDPH, in consultation with SBCDPH Communicable Disease Services and the Health Officer, when aware that employees may have been exposed to an RATD case or suspected case, or to an exposure incident involving an Aerosol Transmissible Pathogen – Laboratory (ATP-L), do all of the following:
Within a timeframe that is reasonable for the specific disease, but in no case later than 72 hours, as applicable, report the case to the Health Officer.
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Conduct a contact investigation to determine which employees had significant exposures by recording: Names and any other employee identifier of individuals who were included in the investigation. Basis for any determination that an employee need not be included in post- exposure follow-up because the employee did not have a significant exposure or because SBCDPH has determined the employee is immune to the infection in accordance with applicable public health guidelines. Name of the person making the determination, and the identity of any medical provider(s) or the Health Officer consulted. A copy of the investigation will be made available to the Health Officer and Risk Management upon request.
Within a timeframe that is reasonable for the specific disease, but in no case later than 96 hours of becoming aware of the potential exposure, notify all employees who had significant exposures of the date, time, and nature of the exposure. Some diseases, such as meningococcal disease, require prompt prophylaxis of exposed individuals to prevent disease. Some diseases, such as Varicella (chickenpox), have a limited window in which to administer vaccine to non-immune contacts. Exposure to some diseases may create a need to temporarily remove an employee from certain duties during a potential period of communicability. For other diseases, such as Mycobacterium tuberculosis (MTB), there may not be a need for immediate medical intervention; however, prompt follow up is important to the success of identifying exposed employees. As soon as feasible, SBCDPH will provide a post-exposure evaluation to all employees who had a significant exposure.
4. Precautionary removal recommendation from the physician or other licensed health care professional: SBCDPH Administration will consult with Human Resources and refer the employee to CEHW for any opinion regarding whether precautionary removal from the employee's regular assignment is necessary to prevent spread of the disease agent by the employee and what type of alternate work assignment may be provided. Where the medical provider or Health Officer recommends precautionary removal, CEHW will notify Human Resources.
Exception: Precautionary removal provisions do not extend to any period of time during which the employee is unable to work for reasons other than precautionary removal.
5. Written opinion from the physician or other licensed health care professional: The employee will be provided with a copy of the written opinion from SBCDPH Administration or of the medical provider within 15 working days of the completion of all required medical evaluations. For all RATD and ATP-L exposure incidents, the written opinion shall be limited to the following information: o The employee's: Applicable RATD test status for the exposure of concern, and Infectivity status. o A statement that the employee has been:
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Informed of the results of the medical evaluation and has been offered any applicable vaccinations, prophylaxis, or treatment. Told about any medical conditions and/or treatment and that the employee has been informed of treatment options, and Any recommendations for precautionary removal from the employee's regular assignment. All other findings or diagnosis will remain confidential and will not be included in the written report.
HEALTHCARE WORKER MEDICAL SERVICES, SCREENING, POST EXPOSURE EVALUATION 1. SBCDPH Program Manager/ Program Coordinator will provide information on available medical services, screening and post exposure evaluation to any employee with an occupational exposure to TB and other ATDs, infection with ATP and ATP-L, as recommended by the CDC and/or the CDPH. 2. When medical services are required, SBCDPH em plo yees will be referred to the CEHW. Non-County exposed individuals will be referred to their agency occupational health physician or the Emergency Department. Medical services shall be: a. Performed in the CEHW or by a designated medical provider, b. Provided according to current applicable public health recommendations, and c. Provided in a manner that ensures the confidentiality of employees and ATP individuals. Test results and other information regarding exposure incidents and TB conversions will be provided without providing the name of the source individual. 3. Following an exposure incident, the employee will be advised that he/she may refuse to consent to vaccination, post-exposure evaluation and follow-up provided by SBCDPH (Employee may refuse consent to vaccination, post exposure follow-up after completing a declination form). Employees requesting medical services from an outside or personal physician will be referred to Human Resources. 4. Vaccines and Vaccinations: a. Through the CEHW and new employee process, SBCDPH will offer all susceptible employees, with the potential for occupational exposure, vaccine doses at no cost as listed in the table below. b. Recommended vaccinations shall be made available to all employees who have occupational exposure within ten (10) working days of initial assignment unless: i. The employee has previously received the recommended vaccination(s) and is not due to receive another vaccination dose; or ii. SBCDPH has determined that the employee is immune in accordance with current CDC and CDPH guidelines; or iii. The vaccine(s) is contraindicated for medical reasons. c. The following vaccination schedule for the prevention of ATDs will be followed in accordance with the standard and recommendation of CDC: Vaccine Schedule Influenza One dose annually Measles Two doses Mumps Two doses – adults MMRV 1 X Rubella One dose Tetanus, Diphtheria and Acellular Pertussis One dose, booster as recommended (Tdap) Varicella-zoster (VZV) Two doses
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d. SBCDPH will make additional vaccination(s) available to employees within 120 days of the issuance of new CDC or CDPH recommendations. e. Participation in a pre-screening program is not a prerequisite for receiving a vaccine, unless CDC or CDPH guidelines recommend prescreening prior to administration of the vaccine. f. If the employee initially declines a vaccination, but at a later date, while still covered under the standard, decides to accept the vaccination, SBCDPH will make the vaccination available within ten (10) working days of that request. g. SBCDPH will ensure that employees who decline to accept a recommended and offered vaccination sign the declination form for each declined vaccine. h. Immunization records from an outside provider will be reviewed and the employee will be offered additional immunizations in accordance with the Advisory Committee on Immunization Practices (ACIP). Exception: Where SBCDPH cannot implement these procedures because of the lack of availability of vaccine, SBCDPH will document efforts made to obtain the vaccine in a timely manner and inform employees of the status of the vaccine availability. SBCDPH will check on the availability of the vaccine at least every 60 working days and inform employees when the vaccine becomes available. TRAINING All SBCDPH employees with occupational exposure will be trained on the SBCDPH ATD Exposure Control Plan and attend a Fit Testing Program at the time of initial assignment to tasks with potential exposure, whenever the Plan changes, and annually thereafter, by SBCDPH Trainer. Employees will have the opportunity to ask questions and have the questions answered within 24 hours. The Training and Fit Testing Program will consist of: General explanation of ATDs and signs and symptoms that require medical evaluation Screening methods and criteria for individuals who require a referral Source control measures and how they are communicated Referral procedures Temporary risk reduction measures for referral cases Medical services procedures Information on the vaccines program Bitrex Fit Testing Issuance of an N95 and/or P100 PPE to be placed in a sealed bag and properly stored per policy Please refer to the following classification list of staff who are identified and required to attend annual PPE certification and training. Classification Health Education Specialist II Health Services Assistant I Animal Control Officer Laboratory Assistant Automated Systems Analyst LRN Coordinator Business Systems Analyst LVN II Clinic Supervisor MD's Clinical Therapist Medical Emergency Planning Specialist Communicable Disease Investigator Nurse Practitioners Division Chief Office Assistant II Epidemiologist Office Assistant III Exec Sec II Physician Assistant Executive Staff Program Coordinator Health Education Specialist I Program Manager
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Public Health Lab Tech Supervising Animal Control Officer Public Health Microbiologist II Supervising Health Education Specialist Public Health Microbiologist III Supervising Office Assistant Public Health Nurse II Supervising Office Specialist Public Service Employees Supervising Public Health Nurse RN II Warehouse Worker Sec I WEX worker Sec II Public Health Nutritionist Social Worker II Supervising Health Services Assistant
Note: Annual PPE recertification must occur annually per County fiscal year.
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