Communicable Diseases: Surveillance and Control Measures

1. Communicable Diseases:Surveillance and Control Measures Emily Sickbert-Bennett, MS Public Health Epidemiologist

2. Public Health Resources in North Carolina Hospital-based Public Health Epidemiologists (11) UNC, Duke, WakeMed, Moses Cone, Cape Fear Valley, New Hanover, Pitt, Durham VA, Baptist, Carolinas, Mission Local Health Departments (86) Divisions: Personal Health, Communicable Disease Control, Public Health Preparedness, Environmental Health, Health Education, Nutrition, Dental State Health Department: Raleigh, NC Centers for Disease Control and Prevention: Atlanta, GA

3. NC Communicable Disease Reporting Law (GS 130A-135) Physicians of patients with suspected or confirmed communicable diseases or conditions must report basic patient information to the health department. NC’s communicable disease reporting law can be found in the State’s General statutes and it says that “Physicians of patients with suspected or confirmed communicable diseases or conditions must report basic patient information to the health department.” A key component of this law is that even patients who are suspected to have certain communicable diseases should be reported to the public health department. This early reporting, even before a laboratory confirmed diagnosis, is so important to the health departments because early interventions in the community are critical to preventing further cases. NC’s communicable disease reporting law can be found in the State’s General statutes and it says that “Physicians of patients with suspected or confirmed communicable diseases or conditions must report basic patient information to the health department.” A key component of this law is that even patients who are suspected to have certain communicable diseases should be reported to the public health department. This early reporting, even before a laboratory confirmed diagnosis, is so important to the health departments because early interventions in the community are critical to preventing further cases.

4. Reporting Communicable Diseases Complete a communicable disease card found at nurses’ stations. Place card in envelope and send card to Hospital Epidemiology (CB#7600) or tube to station #704 where it will be forwarded to the local health department. If disease requires reporting within 24 hours, call health department in the county where patient lives directly before submitting card. Questions? Call Hospital Epidemiology 6-1638 These cards should be available at nurses’ stations throughout the hospital and clinics. Once completed, you may return the card to us in Hospital Epidemiology either through campus mail or the tube station (If you would like, some report cards are available for you to pick up today as well as a reminder card about how to return it to us). If the disease requires reporting within 24 hours (for example, TB, pertussis, hepatitis A, meningococcal disease), please call the health department in addition to submitting the card. If you have any questions along the way, please don’t hesitate to call me in Hospital Epidemiology. These cards should be available at nurses’ stations throughout the hospital and clinics. Once completed, you may return the card to us in Hospital Epidemiology either through campus mail or the tube station (If you would like, some report cards are available for you to pick up today as well as a reminder card about how to return it to us). If the disease requires reporting within 24 hours (for example, TB, pertussis, hepatitis A, meningococcal disease), please call the health department in addition to submitting the card. If you have any questions along the way, please don’t hesitate to call me in Hospital Epidemiology.

5. Today, in NC, there are over 60 diseases that are reportable by law to the health department. If you have a patient with a reportable communicable disease, you should complete a report card (like this one).Today, in NC, there are over 60 diseases that are reportable by law to the health department. If you have a patient with a reportable communicable disease, you should complete a report card (like this one).

6. Reportable Diseases and Conditions List is modified as needed Perceived public health importance High potential for spread Serious and/or severe illnesses Effective control measures available Special interest/study The list of diseases that are reportable by law are modified as needed. Diseases are included based on their perceived public health importance (which may include their high potential for spread or the ability to cause severe illness—like SARS), whether there are effective control measures available (e.g., measles, mumps and rubella are all included because they are important for monitoring the effectiveness of their vaccination program), as well diseases that are under special interest or study, for example West Nile Virus or Hantavirus, which are rare, but emerging diseases. The list of diseases that are reportable by law are modified as needed. Diseases are included based on their perceived public health importance (which may include their high potential for spread or the ability to cause severe illness—like SARS), whether there are effective control measures available (e.g., measles, mumps and rubella are all included because they are important for monitoring the effectiveness of their vaccination program), as well diseases that are under special interest or study, for example West Nile Virus or Hantavirus, which are rare, but emerging diseases.

7. Communicable Disease Reporting and HIPAA Compliance Does not constitute a breach of patient confidentiality. Specifically allowed under HIPAA. Hospital Epidemiology completes disclosure tracking for physician reporting. A common question, I receive is “doesn’t communicable disease reporting to the health department violate HIPAA rules?” The answer is no, it is specifically allowed for under HIPAA and it does not constitute a breach in confidentiality. All of the CD cards that are sent to our office are logged into a Disclosure Tracking database for the Hospital, so that we are fully compliant with all HIPAA and the Hospital policies that require us to keep a record of who receives what information, even though it is allowed to be released. A common question, I receive is “doesn’t communicable disease reporting to the health department violate HIPAA rules?” The answer is no, it is specifically allowed for under HIPAA and it does not constitute a breach in confidentiality. All of the CD cards that are sent to our office are logged into a Disclosure Tracking database for the Hospital, so that we are fully compliant with all HIPAA and the Hospital policies that require us to keep a record of who receives what information, even though it is allowed to be released.

8. One of the biggest challenges with communicable disease surveillance is that the public health department only receives notification of a fraction of the diseases that are required to be reported. In this study examining the surveillance of shigellosis, an acute diarrheal illness, only 6% of infected cases were estimated to be reported to the local health department, which is a tremendous underestimate of the true burden of disease in the community. It’s nearly impossible to detect all cases of illness since some may be asymptomatic and others may never seek medical care, but the goal really is to have the reporting to the public health department approach the number of patients that consult a physician estimated by this study to be 28%.One of the biggest challenges with communicable disease surveillance is that the public health department only receives notification of a fraction of the diseases that are required to be reported. In this study examining the surveillance of shigellosis, an acute diarrheal illness, only 6% of infected cases were estimated to be reported to the local health department, which is a tremendous underestimate of the true burden of disease in the community. It’s nearly impossible to detect all cases of illness since some may be asymptomatic and others may never seek medical care, but the goal really is to have the reporting to the public health department approach the number of patients that consult a physician estimated by this study to be 28%.

9. Reporting Rates Here are the results of another study that was conducted in 11 hospitals in Washington, DC in a 6 month period which showed that reporting rates for several diseases (H. influenzae meningitis, salmonellosis, Meningococcal meningitis, shigellosis, and tuberculosis) ranged from 30-60%. A similar study is underway in NC now, looking at reporting rates for a number of diseases that are reportable by law and our preliminary data shows even lower rates than those reported here. Here are the results of another study that was conducted in 11 hospitals in Washington, DC in a 6 month period which showed that reporting rates for several diseases (H. influenzae meningitis, salmonellosis, Meningococcal meningitis, shigellosis, and tuberculosis) ranged from 30-60%. A similar study is underway in NC now, looking at reporting rates for a number of diseases that are reportable by law and our preliminary data shows even lower rates than those reported here.

10. What happens when a disease is reported to the health department? Another common question is what happens when a disease is reported to the health department? The answer is: It depends on what the disease is—because each disease listed as reportable was chosen for different reason and depending on the public health control measures for that disease, the health department undertakes various activities. Another common question is what happens when a disease is reported to the health department? The answer is: It depends on what the disease is—because each disease listed as reportable was chosen for different reason and depending on the public health control measures for that disease, the health department undertakes various activities.

12. Early Disease Control: Immigration Law of 1891 Now, one of the earliest forms of disease control in the U.S. was the immigration law of 1891 which made it mandatory that all immigrants coming into the United States be given a health inspection by the Public Health Service physicians. The law stipulated the exclusion of "all idiots, insane persons, paupers or persons likely to become public charges, persons suffering from a loathsome or dangerous contagious disease," and criminals. The largest inspection center was on Ellis Island in New York Harbor. Here the physicians are looking at the eyes for signs of trachoma. (Trachoma is an eye infection caused by Chlamydia trachomatis, which may result in chronic scarring and blindness if left untreated.) Now, one of the earliest forms of disease control in the U.S. was the immigration law of 1891 which made it mandatory that all immigrants coming into the United States be given a health inspection by the Public Health Service physicians. The law stipulated the exclusion of "all idiots, insane persons, paupers or persons likely to become public charges, persons suffering from a loathsome or dangerous contagious disease," and criminals. The largest inspection center was on Ellis Island in New York Harbor. Here the physicians are looking at the eyes for signs of trachoma. (Trachoma is an eye infection caused by Chlamydia trachomatis, which may result in chronic scarring and blindness if left untreated.)

13. Health Department Disease Control Activities Include: Treatment or counseling of case Contact tracing for prophylaxis, counseling, screening, treatment Investigation of outbreaks—foodborne, zoonotic Surveillance and research—new and emerging diseases, vaccine-preventable But the modern day health department is much more sophisticated. Their activities range from treatment or counseling of an individual case, to contact tracing and outbreak investigation in the community to surveillance and research on the population level. As the patient’s healthcare provider, you may provide some of the earliest contact measures for your patient (eg. Excluding a HCW with pertussis from work, a child with Shigella from daycare, or a chef with HAV from handling food), but there are many additional activities that the HD initiates once they are notified of a new case. I’ll talk about each of these further sharing some specific examples with you. But the modern day health department is much more sophisticated. Their activities range from treatment or counseling of an individual case, to contact tracing and outbreak investigation in the community to surveillance and research on the population level. As the patient’s healthcare provider, you may provide some of the earliest contact measures for your patient (eg. Excluding a HCW with pertussis from work, a child with Shigella from daycare, or a chef with HAV from handling food), but there are many additional activities that the HD initiates once they are notified of a new case. I’ll talk about each of these further sharing some specific examples with you.

14. Treatment of Case At Orange County Health Department, FREE OF CHARGE: Therapy (e.g., INH, rifampin, ethambutol, and pyrazinamide) for active TB Latent TB treatment Medication for chlamydia, chancroid, gonorrhea, NGU, LGV, syphilis, and trichomoniasis Erythromycin for pertussis In terms of treating cases, at the Orange County HD, several medications are available free of charge to Orange County residents. These include (1) therapy (INH, rifampin, ethambutol, and pyrazinamide) for active TB which is administered by directly observed therapy (2) latent TB treatment (3) medication for chlamydia, chancroid, gonorrhea, NGU, LGV, syphilis, and trichomoniasis and (4) erythromycin for pertussis Please note that the medications available at each HD that are free of charge may vary slightly. In terms of treating cases, at the Orange County HD, several medications are available free of charge to Orange County residents. These include (1) therapy (INH, rifampin, ethambutol, and pyrazinamide) for active TB which is administered by directly observed therapy (2) latent TB treatment (3) medication for chlamydia, chancroid, gonorrhea, NGU, LGV, syphilis, and trichomoniasis and (4) erythromycin for pertussis Please note that the medications available at each HD that are free of charge may vary slightly.

15. Counseling of Cases Nurse or HIV counselor do counseling for HIV and other STDs Counseling includes: Control measures Transmission prevention of STDs to others Risk reduction Coping with chronic STDs In addition to treatment, Health Department nurses or HIV counselors also offer counseling for HIV and STDs. This counseling includes information on: specific control measures preventing transmission risk reduction and coping with chronic STDs. In addition to treatment, Health Department nurses or HIV counselors also offer counseling for HIV and STDs. This counseling includes information on: specific control measures preventing transmission risk reduction and coping with chronic STDs.

16. Example of Counseling for HIV Control Measures : Inform patient they are required (by law) to: Refrain from sexual intercourse unless condoms are used Not share needles or syringes Not donate or sell blood, or other potentially infectious materials Have TB skin test Notify previous, current and future partners Disclose infection status to care providers These HIV control measures should be given at the time of diagnosis, ideally by the physician who ordered the lab tests and received the results. At the Health Department, nurses, HIV counselors and Disease Intervention Specialists also provide patients with the same message that: The legal requirements for a patient with HIV are to: 1) refrain from sexual intercourse unless condoms are used. 2) not share needles or syringes 3) not donate or sell blood, plasma, platelets, semen, ova, tissues, organs or breast milk 4) have a TB skin test 5) notify previous and future sexual and/or needle partners of the infection 6) disclose infection status to medical and dental care providers These HIV control measures should be given at the time of diagnosis, ideally by the physician who ordered the lab tests and received the results. At the Health Department, nurses, HIV counselors and Disease Intervention Specialists also provide patients with the same message that: The legal requirements for a patient with HIV are to: 1) refrain from sexual intercourse unless condoms are used. 2) not share needles or syringes 3) not donate or sell blood, plasma, platelets, semen, ova, tissues, organs or breast milk 4) have a TB skin test 5) notify previous and future sexual and/or needle partners of the infection 6) disclose infection status to medical and dental care providers

17. Example of Counseling for HIV Control Measures : Spouses If the physician knows the identity of the spouse of an HIV-infected patient, he/she can notify and counsel the spouse, with the consent of the patient. Otherwise, when the spouse’s identity is known and no notification and counseling is given by the physician, he/she shall report this information to the health department. Also if the physician knows the identity of the spouse of an HIV-infected patient, he/she can notify and counsel the spouse, with the consent of the patient. Otherwise, when the spouse’s identity is known and no notification and counseling is given by the physician to the spouse, he/she shall report this information to the state health department (regardless of patient consent). By delivering the control measures mentioned on the previous slide and either counseling the spouse or referring the spouse’s contact information to the Health Department—the physician’s responsibility to notify exposed and potentially exposed persons is fulfilled. Also if the physician knows the identity of the spouse of an HIV-infected patient, he/she can notify and counsel the spouse, with the consent of the patient. Otherwise, when the spouse’s identity is known and no notification and counseling is given by the physician to the spouse, he/she shall report this information to the state health department (regardless of patient consent). By delivering the control measures mentioned on the previous slide and either counseling the spouse or referring the spouse’s contact information to the Health Department—the physician’s responsibility to notify exposed and potentially exposed persons is fulfilled.

18. Activities Include: Treatment or counseling of case Contact tracing for prophylaxis, counseling, screening, treatment Investigation of outbreaks—foodborne, zoonotic Surveillance and research—new and emerging diseases, vaccine-preventable Contact tracing is performed for diseases which have the potential for person to person spread in order to offer exposed persons: counseling, screening, and treatment. Contact tracing is performed for diseases which have the potential for person to person spread in order to offer exposed persons: counseling, screening, and treatment.

19. What Is Contact Tracing? The basic concept of contact tracing is to identify individuals that may have been exposed to an infected individual. This is an example of contact tracing diagram which maps out infected individuals and links them to their contacts who must be identified, located and offered treatment, counseling or screening. Notifying the health department immediately of communicable disease cases can greatly minimize the potential for rapid disease spread throughout the community. The basic concept of contact tracing is to identify individuals that may have been exposed to an infected individual. This is an example of contact tracing diagram which maps out infected individuals and links them to their contacts who must be identified, located and offered treatment, counseling or screening. Notifying the health department immediately of communicable disease cases can greatly minimize the potential for rapid disease spread throughout the community.

20. Who are Contacts? Family Friends Students at school Daycare children and workers Co-workers Sexual partners Patients (for Healthcare workers) Customers (for Food service workers) Depending on the nature of disease transmission, contacts may include: family friends students at school daycare children and workers co-workers sexual partners patients customersDepending on the nature of disease transmission, contacts may include: family friends students at school daycare children and workers co-workers sexual partners patients customers

21. Contact Tracing For Syphilis, HIV, and AIDS patients Interviewed, counseled by trained Disease Intervention Specialists (DIS) Partners are located and referred to the health department for testing, additional counseling, etc. For other STDs, partner notification occurs by partner referral. Contact tracing for syphilis, HIV and AIDS patients is conducted by trained Disease Intervention Specialists from the Health Department who interview the patients and locate their partners for counseling and testing at the health departments. For other STDs besides HIV/AIDS and syphilis, partner notification is accomplished by the patient referring their partners for testing. Contact tracing for syphilis, HIV and AIDS patients is conducted by trained Disease Intervention Specialists from the Health Department who interview the patients and locate their partners for counseling and testing at the health departments. For other STDs besides HIV/AIDS and syphilis, partner notification is accomplished by the patient referring their partners for testing.

22. Contact Tracing For TB, Pertussis, Meningococcal meningitis patients Interviewed by trained health department nurses Close contacts are identified and offered testing (e.g., TB) or prophylaxis (e.g., meningococcal meningitis) Patients with latent TB infection are offered free prophylactic treatment Patients with TB, pertussis or meningococcal meningitis are interviewed by trained health department nurses and their close contacts are identified and offered testing (skin test for TB) or prophylaxis (antibiotics for meningococcal meningitis). Exposed contacts who are found to have latent TB infection are also offered free prophylactic treatment. Patients with TB, pertussis or meningococcal meningitis are interviewed by trained health department nurses and their close contacts are identified and offered testing (skin test for TB) or prophylaxis (antibiotics for meningococcal meningitis). Exposed contacts who are found to have latent TB infection are also offered free prophylactic treatment.

23. Post Exposure Prophylaxis Free at Orange Co. HD HAV Immune Globulin Meningococcal Meningitis Rifampin Syphilis Bicillin Rabies Immune Globulin and Vaccine if qualify financially, grant money available at the State Dept. of Public Health to cover cost For contacts who were exposed, several post-exposure prophylaxis treatments are available at the Orange Co HD free of charge. These include: Immune globulin for HAV, rifampin for meningococcal meningitis, bicillin for syphilis and for rabies exposures, there is some grant money available from the State Dept of Public Health to cover the cost of immune globulin and vaccine. For contacts who were exposed, several post-exposure prophylaxis treatments are available at the Orange Co HD free of charge. These include: Immune globulin for HAV, rifampin for meningococcal meningitis, bicillin for syphilis and for rabies exposures, there is some grant money available from the State Dept of Public Health to cover the cost of immune globulin and vaccine.

24. Contact Tracing Been shown effective if: Latency period is long (Lat_P) Avg. connections per node is small (K) Network is spatially clustered Mathematical models of contact tracing have shown the efficacy of this strategy in reducing the final epidemic size especially when the latency period of a disease is long (like in the case of TB), where the average connections per node is small (so not a huge number of contacts) and when the network is spatially clustered. Mathematical models of contact tracing have shown the efficacy of this strategy in reducing the final epidemic size especially when the latency period of a disease is long (like in the case of TB), where the average connections per node is small (so not a huge number of contacts) and when the network is spatially clustered.

25. TB: Contact Tracing April 1994 Traveler-- multi-drug resistant TB Honolulu Chicago Baltimore Baltimore Chicago Honolulu Here’s an example of contact tracing that was conducted for a TB exposure. The results of this investigation were published in the NEJM in 1996. In April of 1994, a traveler from Honolulu flew to Baltimore (via Chicago) for a visit, then returned to Honolulu from Baltimore (again through Chicago). She spent 8 or 9 hours on the Chicago to Honolulu flight. Upon her return home, she was found to have multi-drug resistant TB. Here’s an example of contact tracing that was conducted for a TB exposure. The results of this investigation were published in the NEJM in 1996. In April of 1994, a traveler from Honolulu flew to Baltimore (via Chicago) for a visit, then returned to Honolulu from Baltimore (again through Chicago). She spent 8 or 9 hours on the Chicago to Honolulu flight. Upon her return home, she was found to have multi-drug resistant TB.

27. TB: Contact Tracing Health department identified contacts from passenger manifests on 4 flights Questionnaire: TB risk factors Skin testing (baseline then 12 weeks after exposure) After her diagnosis was confirmed, the health department obtained the passenger manifests from the airline flights to identify the possible contacts. Each contact was given a questionnaire that asked about their TB risk factors and were given TB skin testing immediately to determine the baseline and then 12 weeks after the exposure to assess the presence of new infection. After her diagnosis was confirmed, the health department obtained the passenger manifests from the airline flights to identify the possible contacts. Each contact was given a questionnaire that asked about their TB risk factors and were given TB skin testing immediately to determine the baseline and then 12 weeks after the exposure to assess the presence of new infection.

28. TB: Contact Tracing Of 760 passengers and crew members 6 (0.8%) Conversions (all on Chicago to Honolulu flight) Contacts seated within 2 rows of the index case were 8.5 times as likely to have a positive skin test or conversion than those in the rest of the cabin. For conversions, preventive therapy offered and watch for signs of disease The results of this targeted skin testing showed that of the 760 passengers and crew members 6 people (or 0.8%) who were on the Chicago to Honolulu flight. had newly positive skin tests indicating recent infection, and contacts who were seated within 2 rows of the index case were 8.5 times as likely to have a positive skin test or conversion than those in the rest of the cabin. These newly infected contacts were offered preventive therapy and counseled to watch carefully for signs of disease. The results of this targeted skin testing showed that of the 760 passengers and crew members 6 people (or 0.8%) who were on the Chicago to Honolulu flight. had newly positive skin tests indicating recent infection, and contacts who were seated within 2 rows of the index case were 8.5 times as likely to have a positive skin test or conversion than those in the rest of the cabin. These newly infected contacts were offered preventive therapy and counseled to watch carefully for signs of disease.

29. Activities Include: Treatment or counseling of case Contact tracing for prophylaxis, counseling, screening, treatment Investigation of outbreaks—foodborne, zoonotic Surveillance and research—new and emerging diseases, vaccine-preventable When the health department receives more reports of a disease than expected, they may initiate an investigation of the outbreak. When the health department receives more reports of a disease than expected, they may initiate an investigation of the outbreak.

30. E.coli O157:H7 Outbreak:Verify diagnosis and confirm outbreak A recent example of an outbreak investigation in NC was an outbreak that occurred in October 2004 at the NC State Fair. Over a short time period, there were 3 cases of hemolytic uremic syndrome cases hospitalized at area hospitals. 2 of the 3 cases also grew E.coli 0157:H7 from stool specimens sent to the lab. Upon initial investigation, the health department discovered that all 3 of these children had visited petting zoos at the State Fair. A recent example of an outbreak investigation in NC was an outbreak that occurred in October 2004 at the NC State Fair. Over a short time period, there were 3 cases of hemolytic uremic syndrome cases hospitalized at area hospitals. 2 of the 3 cases also grew E.coli 0157:H7 from stool specimens sent to the lab. Upon initial investigation, the health department discovered that all 3 of these children had visited petting zoos at the State Fair.

31. Active case finding for children with bloody diarrhea was initiated in area hospitals and clinics. In total, 43 confirmed cases were identified with an additional 6 probable and 59 suspect cases. Active case finding for children with bloody diarrhea was initiated in area hospitals and clinics. In total, 43 confirmed cases were identified with an additional 6 probable and 59 suspect cases.

32. E.coli O157:H7 Outbreak:Results from Case Control Study Illness-Associated Exposures A case control study was undertaken with the controls selected from the source population of fair attendees. These study results suggested that among those attending the petting zoo, the odds of having an infection was 7.2 times the odds of not having an infection. This exposure to the petting zoo had a much higher OR than exposure to other animal exhibits. A case control study was undertaken with the controls selected from the source population of fair attendees. These study results suggested that among those attending the petting zoo, the odds of having an infection was 7.2 times the odds of not having an infection. This exposure to the petting zoo had a much higher OR than exposure to other animal exhibits.

33. E.coli O157:H7 Outbreak: Results from Case Control Study Among the visitors who were younger than 5 years old at the petting zoo, several exposures predisposed them to illness—falling or sitting on the ground had an OR of 3.2, touching or stepping in manure with an OR of 6.9, and sucking thumb, pacifer or sippy cup with an OR of 10.6. Among the visitors who were younger than 5 years old at the petting zoo, several exposures predisposed them to illness—falling or sitting on the ground had an OR of 3.2, touching or stepping in manure with an OR of 6.9, and sucking thumb, pacifer or sippy cup with an OR of 10.6.

34. E.coli O157:H7 Outbreak:Plan and execute additional studies Environmental Sampling at Fairgrounds 8 of 122 samples yielded E.coli O157:H7 Petting Zoo B: 10/15 (66%) samples positive All PFGE Pattern A In addition, the health department did environmental sampling at various locations at the fairgrounds and specifically within the implicated petting zoo. Of the 122 samples collected around the fairgrounds, 7% were positive for E.coli O157:H7 suggesting a more widespread contamination. Within the petting zoo, 66% of the samples were found to be positive for E.coli 0157:H7 and upon molecular analysis with pulsed field gel electrophoresis, all E.coli 0157:H7 isolates were identical.In addition, the health department did environmental sampling at various locations at the fairgrounds and specifically within the implicated petting zoo. Of the 122 samples collected around the fairgrounds, 7% were positive for E.coli O157:H7 suggesting a more widespread contamination. Within the petting zoo, 66% of the samples were found to be positive for E.coli 0157:H7 and upon molecular analysis with pulsed field gel electrophoresis, all E.coli 0157:H7 isolates were identical.

35. E.coli O157:H7 Outbreak:Implement & evaluate control measures Prevent manure contact Implement engineering controls Assure behavioral supervision Increase zoonotic disease awareness Improve signage—risks, prevention messages Provide soap and running water In addition to alcohol-rubs The results of this investigation led to recommendations for control measures that have since been implemented at the State Fairgrounds. Manure contact is minimized with engineering controls (like fences around the animals). General zoonotic disease awareness is improved with additional signage in the petting zoos and soap and water hand washing stations have been set up in addition to making available the alcohol-based hand rubs within the petting zoos. The results of this investigation led to recommendations for control measures that have since been implemented at the State Fairgrounds. Manure contact is minimized with engineering controls (like fences around the animals). General zoonotic disease awareness is improved with additional signage in the petting zoos and soap and water hand washing stations have been set up in addition to making available the alcohol-based hand rubs within the petting zoos.

36. Activities Include: Treatment or counseling of case Contact tracing for prophylaxis, counseling, screening, treatment Investigation of outbreaks—foodborne, zoonotic Surveillance and research—new and emerging diseases, vaccine-preventable Finally, the data from the communicable disease report cards is used for surveillance of disease trends and research for new and emerging diseases and vaccine preventable diseases. Finally, the data from the communicable disease report cards is used for surveillance of disease trends and research for new and emerging diseases and vaccine preventable diseases.

37. Surveillance and Research Data from communicable disease reports are tabulated, analyzed and Used to guide public health policy decisions and assist in clinical decision making These data from communicable disease reports are tabulated, analyzed and can be used to guide public health policy decisions for control measures and prevention strategies. These data from communicable disease reports are tabulated, analyzed and can be used to guide public health policy decisions for control measures and prevention strategies.

38. Public Health Use of Surveillance Data Time: Monitor temporal trends of disease Identify unexpected increases Assess effectiveness of prevention and control measures Person: Examine demographic information Identify risk factors for disease Target prevention messages Place: Identify clusters of cases by location Identify risk factors, vehicles or vectors for disease Target control measures

39. Clinical Uses for Surveillance Data Time: In May, would you suspect influenza in a patient with a cough and fever?

40. Influenza ActivityNC, 2003-2007

41. Clinical Uses for Surveillance Data Person: In an adult with a fever and rash, would you suspect a case of Rubella?

42. Rubella NC, 1987-2003

43. Clinical Uses for Surveillance Data Place: In Chapel Hill, would you suspect a patient with encephalitis to be infected with La Crosse Virus, a mosquito-borne virus?

44. LaCrosse Encephalitis NC, 1997-2002

45. Today, in NC, there are over 60 diseases that are reportable by law to the health department. If you have a patient with a reportable communicable disease, you should complete a report card (like this one).Today, in NC, there are over 60 diseases that are reportable by law to the health department. If you have a patient with a reportable communicable disease, you should complete a report card (like this one).

46. Questions? For assistance with or questions regarding communicable disease reporting or control, call Hospital Epidemiology 966-1638 Thank you! Thank you again, and please call me in Hospital Epidemiology if you need assistance or have any questions regarding communicable disease reporting or control measures.Thank you again, and please call me in Hospital Epidemiology if you need assistance or have any questions regarding communicable disease reporting or control measures.