Phone Tag: IP and Epi Communication Charles Clark Field Epidemiology Director

Who are we? Epidemiology Resource Center (ERC) Conduct surveillance to monitor disease trends Investigate communicable disease Maintain Communicable Disease Reporting Rule List of diseases available at: http://www.in.gov/isdh/25366.htm My name is ____________________________ and I am the _____________________ with the Indiana State Department of Health, Epidemiology Resource Center We are a team of individuals responsible for: Conducting surveillance to monitor disease trends and Investigating clusters and outbreaks of communicable disease We maintain the Communicable Disease Reporting Rule which outlines the reporting requirements for physicians, hospitals, and laboratories, along with disease specific requirements for exclusion of ill individuals The list of diseases reportable, by law, to the health department include immediately reportable, and others that must be reported within 24 or 72 hours can be found at the link provided here

Why is the HD calling me? Reportable disease investigation Demographics, H & P, testing results Laboratory specimens Forwarding to state lab ESSENCE follow up NBS Issues Indiana Health Alert Network (IHANs)

IHANs Investigation of Seoul Virus Outbreak Associated with Home-based, Rat-breeding Facilities in Wisconsin and Illinois Call for Cases of Non-tuberculosis Mycobacteria Infections Associated with hCG Injections Zika in the ED: How Emergency Care Staff can Take Action Regional Cluster of Synthetic Cannabis Overdoses From U-47700 Increasing In Indiana MDROs in Outpatient Settings Update: Confirmed Cases Of Mumps At Universities In Indiana

ESSENCE Seasonality ILI Percent for several years

ESSENCE Event Detection Slips and falls graph

When should I call the HD? General consultations Emerging infectious diseases Immediately reportable disease Upon suspicion for some diseases Outbreaks, unusual activity, unusual occurrence Testing guidance PEP/treatment guidance NBS Issues

Vaccine-Preventable Diseases Varicella ALL cases of primary varicella infection (regardless of whether lab testing was done) are reportable (within 72 hours) Diagnoses of shingles are NOT reportable Pertussis All cases of pertussis (regardless of lab testing) are reportable (within 24 hours) CDC requires appropriate tests (PCR or Culture from a nasopharyngeal swab) to consider a case confirmed ALL CASES of chickenpox and pertussis are reportable to public health even if there is not a lab. Chickenpox is within 72 hours of diagnosis Cases of shingles are NOT All cases of pertussis are reportable within 24 hours of diagnosis! VPDs should NOT be removed from a differential just because the patient is vaccinated Some vaccines work better than others, sometimes they fail, etc. Vaccination decreases the likelihood of a certain disease but does not eliminate all risk that a patient could have it. I know we have observed quite a bit of that with our mumps cases last year and this year. NOTE: VPDs should NOT be removed from a differential just because the patient is vaccinated

Rabies Post-exposure Prophylaxis (PEP) Rabies risk in Indiana Bats, skunks, raccoons, and foxes are higher-risk species; dogs and cats are lower-risk species Most dog and cat bites acquired in our state do not require PEP Higher risk: unprovoked bite, animal apparently ill with neuro signs, animal behaving abnormally Exposures of concern Bite Mucous membrane contact with animal saliva, CSF, or CNS tissue Finding a bat in the same room with a sleeping person, impaired person, developmentally disabled person, or unattended child Rabies post-exposure prophylaxis, or PEP, is often given unnecessarily or incorrectly. ISDH epidemiologists are available to help you conduct risk assessments to determine whether PEP is indicated after an animal exposure. We encourage you to contact us—doing so may prevent your patient from unnecessarily receiving a major medical intervention that can be associated with significant out-of-pocket expense! In the United States: Wild animals such as bats, skunks, raccoons, and foxes are higher-risk species because they are reservoirs for rabies. Dogs and cats are lower-risk species; in fact, most dog and cat bites in Indiana do not require PEP. A dog or cat bite might require PEP if the bite is unprovoked or if the animal is exhibiting neuro signs or behaving abnormally. Exposures of concern include animal bites as well as mucous membrane contact with animal saliva, CSF, or CNS tissue. In addition, there could be a rabies exposure concern if a bat is found in the same room with someone who would not be aware or able to reliably describe the exposure, such as a sleeping person, someone impaired by drugs or alcohol, a developmentally disabled person, or unattended child.

Rabies Post-exposure Prophylaxis (PEP) Simply finding a bat in the house is not an indication for PEP unless an exposure occurred If the animal is available, delay administration of PEP until quarantine or testing is completed There is not a time limit on when PEP must be initiated after an exposure Review PEP protocol with your pharmacist before administration to avoid common mistakes More indirect contact, such as simply finding a bat in the house, is not an indication for PEP unless an exposure occurred. If an exposure occurred and the animal is available, it should be placed under quarantine (for dogs and cats) or tested. In most cases, administration of PEP may be safely delayed until the quarantine or testing is completed. It is a common misconception that there is a time window beyond which it is “too late” to give PEP after an exposure. PEP should be given promptly upon recognition that an exposure has occurred, even if there is a delay between the exposure and presentation for medical attention. Errors in PEP administration are very common and can adversely affect its effectiveness. We recommend that you review the protocol with your hospital pharmacist to avoid making common mistakes. You may also review the national guidance (a link has been provided in your handout).

HIPPA Exclusion HIPAA does not prevent disclosure of medical or epidemiological information to public health authorities. Section 1178(b) of HIPPA: “Nothing in this part shall be construed to invalidate or limit the authority, power, or procedures established under any law providing for the reporting of disease…public health surveillance, or public health investigation or intervention.”

IN Administrative Code 410 IAC 1-2.5-77(g) “Local health departments and the Indiana state department of health are authorized to receive protected health information, wherever maintained, without patient authorization for the purposes of public health investigation, and interventions, and as otherwise permitted by law.”

CD Rule 410 IAC 1-2.3 repealed 410 IAC 1-2.5 enacted December 25, 2015 410 IAC 1-2.5-75: Reporting requirements for physicians and hospital administrators 410 IAC 1-2.5-76: Laboratories; reporting requirements 410 IAC 1-2.5-77: Disease intervention measures; responsibility to investigate and implement

Overview of the CD Rule Definitions Reporting requirements for physicians, hospitals, and laboratories Disease intervention measures (general and disease specific) Responsibilities Timeliness References The overall format and organization of the CD Rule are not changing, so in case you need a crash course, here it is! 

Important Links ERC Website: http://www.in.gov/isdh/25154.htm CD Rule: http://www.in.gov/legislative/iac/T04100/A00010.PDF http://www.in.gov/isdh/25366.htm This link is also provided at the bottom of your handout (on both sides).

Questions? Charles Clark Field Epidemiology Director Indiana State Department of Health 317-412-2137 cclark1@isdh.in.gov If anyone is interested in these slides, they can contact me after this training via information here.