Wisconsin Division of Public Health Disease Surveillance Manual

PURPOSE OF THIS MANUAL

The Division of Public Health, Bureau of Communicable Diseases and Preparedness, Communicable Diseases Epidemiology Section is the organizational unit within the Department of Health and Family Services charged with the responsibility of executing the statutory mandates regarding the reporting, surveillance and control of communicable diseases. These responsibilities are accomplished through the cooperative efforts of hospital infection control personnel, physicians and health care providers, local health departments, and the Wisconsin State Laboratory of Hygiene.

The purpose of this manual is to provide a comprehensive resource document to assist local health departments and other health care providers in clarifying their responsibilities for disease reporting, epidemiologic surveillance and outbreak investigations. This manual should answer most of the procedural questions related to these activities. Questions beyond the scope of the manual should be directed to the attention of the state epidemiologist or Communicable Disease Epidemiology Section staff.

 

I.   INTRODUCTION

A. List of Agency Acronyms:

BCDP Bureau of Communicable Diseases and Preparedness

BEOH Bureau of Environmental and Occupational Health

BLHS& EMS Bureau of Local Health Support & Emergency Medical Services

CDC Centers for Disease Control and Prevention

CDES Communicable Disease Epidemiology Section

DATCP Wisconsin Department of Agriculture, Trade and Consumer Protection

DHFS Department of Health and Family Services

DPH Wisconsin Division of Public Health

LHD Local Health Department

WSLH Wisconsin State Laboratory of Hygiene

B. Definition of Terms

"Bureau" is the Bureau of Communicable Diseases and Preparedness, Wisconsin Division of Public Health, Department of Health and Family Services.

"Case" is an illness or condition determined to be a communicable disease on the basis of clinical or laboratory criteria or both.

"Date of Onset" is the day on which a case or suspected case experienced the first sign or symptom of a communicable disease.

"Department" is the Department of Health and Family Services.

"Follow-up investigation" is the inquiry made by the LHD into the cause of illness in a particular case or cases and the control and prevention measures taken as a result of that inquiry.

"Follow-up report forms" are the forms provided by the DPH and/or CDC and completed by the LHD subsequent to the follow-up investigation.

"Food worker" is a person who handles food utensils or who prepares, processes, or serves food or beverages for people other than members of his or her immediate household.

"Health care facility" is a hospital, nursing home, home health agency or a provider of outpatient health care.

"High risk activities" are defined as food handling, patient care or child care occupations.

"Individual Case Report Form" is the form provided by the DPH for the purpose of reporting communicable

 "Laboratory" is any facility certified by the Department under Wisconsin State Statute 252.22, and Wisconsin Administrative Code HSS 165.02.

 "Local Health Officer" has the meaning prescribed in Wisconsin State Statute 251.06, and applies to the person who is designated as the local health officer for the place of residence of a case or suspected case of communicable disease.

"Local Health Department" is a county, city or village full-time health department.

"Morbidity Report" -- Same as "Acute and Communicable Diseases Case Report Form

"Outbreak" is the occurrence of unrelated cases of a communicable disease in a particular area and period of time that is in excess of the expected number of cases.

"Report Form" -- See "Acute and Communicable Diseases Case Report Form".

"Reporting" is the act of a health care provider (physician, infection control, etc.) notifying the LHD a communicable disease has occurred.

"Secretary" is the Secretary of the Department of Health and Family Services.

 "State Epidemiologist" is the person designated by the Secretary of DHFS as the person in charge of communicable disease control for the state.

"State Health Officer" has the meaning prescribed in Wisconsin State Statute 250.01, and applies to the person as appointed by the Secretary.

"Surveillance" is the comprehensive process by LHDs and the DPH of collecting initial and follow-up reports, consolidating of the information into meaningful graphs, tables and charts, interpretation of the data and distribution of the results.

"Suspected case" means a person thought to have a particular communicable disease on the basis of clinical or laboratory criteria or both.

C. Wisconsin Statutes Applicable to Communicable Disease

Chapter 250	Health; Administration and Supervision
	250.01		Definitions
	250.02		State health officials
	250.03		Public health system
	250.04		Powers and duties
	250.05		Sanitarians: qualifications, duties, registration
	250.06		Public health nurses
Chapter 251	Local Health Officials
	251.01		Definitions
	251.02		Local health department: establishment
	251.03		Local board of health: members
	251.05		Local health department: levels of service, duties
	251.06		Local health officer: qualifications, duties
	251.08		Jurisdiction of local health department
Chapter 252	Communicable Diseases
	252.01		Definitions
	252.02		Powers of department
	252.03		Duties of local health officers
	252.04		Immunization program
	252.05		Reports of cases
	252.06		Isolation and quarantine
	252.07		Tuberculosis
	252.1		Public health dispensaries
	252.11		Sexually transmitted disease
	252.18		Handling foods
	252.19		Communicable diseases: suspected cases, protection of public
	252.21		Communicable diseases; schools: duties of teachers, parents, officers
	252.22		Laboratories, approval of
	252.25		Violation of law relating to health

 

D. Wisconsin Statutes Related to Human Immunodeficiency Virus (HIV)

Chapter	48		Children’s Code
		48.371			Access to certain information by substitute care provider
Chapter	49		Public Assistance
		49.45			Medical assistance; administration
		(25)			Case management services
		49.686			AZT and pentamidine reimbursement program
Chapter	101		Department of Commerce – Regulation of Industry, Buildings and Safety
		101.02			Powers, duties and jurisdiction of department
		(19)			Form to document significant exposure
Chapter	102		Worker's Compensation
Chapter	103		Employment Regulations
		103.15			Restrictions on HIV related testing for purposes of employment
Chapter	115		State Superintendent; General Classifications and Definitions; Children with disabilities
		115.35			Health education program
Chapter	118			General School Operations
		118.25			Pupil records
		(1)			Definitions
		(2)			Confidentiality
		(3)			Maintenance of records
Chapter	146		Miscellaneous Health Provisions
		146.50			Emergency medical services personnel; licensure; certification; training
		(12)			Confidentiality of records
		146.81			Health care records: definitions
		146.82			Confidentiality of patient health care records
Chapter	149		Mandatory Health Insurance Risk-Sharing Plan
		149.10			Definitions
		149.12			Eligibility determination
Chapter	155		Power of Attorney for Health Care
		155.01			Definitions
		155.05			Power of attorney for health care
Chapter	250		Health, Administration and Supervision
		250.01			Definitions
		250.04			Powers and duties of the dependent
Chapter	252		Communicable Diseases
		252.01			Definitions
		252.02			Powers of department
		252.05			Report of Cases
		252.12			Services relating to acquired immunodeficiency syndrome
		(1)			Definitions
		(2)			Distribution of funds
		(3)			Confidentiality of information
		252.13			Blood tests for HIV
		252.14			Discrimination related to acquired immunodeficiency syndrome
		252.15			Restrictions on use of a test for HIV
		(1)			Definitions
		(2)			Informed consent for testing or disclosure
		(3)			Written consent to disclosure
		(4)			Record maintenance
		(5)			Confidentiality of test
		(5m)			Autopsies: Testing of certain corpses
		(5r)			Sale of tests without approval prohibited
		(6)			Expanded disclosure of test results prohibited
		(7)			Reporting of positive test results
		(8)			Civil liberty
		(9)			Criminal penalty
		252.16			Continuation coverage premium subsidies
		252.17			Medical leave premium subsidies
Chapter	609		Defined Network Plans
		609.81			Coverage related to HIV infection
Chapter	631		Insurance Contract Generally
		631.90			Restrictions on use of tests for HIV
		631.93			Prohibited provisions concerning HIV infection
Chapter	632		Insurance Contracts in Specific Lines
		632.68			Regulation of vertical settlement contracts
		6232.895			Mandatory coverage; drugs for treatment of HIV
Chapter	901		Evidence - General Provisions
		901.05			Admissibility of certain test results
Chapter	938		Juvenile Justice Code
		938.296			Testing for HIV infection and certain diseases
		938.346			Notice to victims of juveniles’ acts
		938.371			Access to certain information by substitute care provider
Chapter	939		Crimes – General Provisions
		939.622			Committing a serious sex crime while infected with acquired immunodeficiency syndrome, HIV or a sexually transmitted disease
Chapter	968		Commencement of Criminal Proceedings
		968.38			Testing for HIV infection and certain diseases

 

E. Administrative Codes Applicable to Communicable Disease

Chapter	HFS 138		Subsidy of Health Insurance Continuation Coverage Premiums for Persons with HIV Infection
		138.01		Authority and purpose
		138.02		Applicability
		138.03		Definitions
		138.04		Participation in the health insurance premium subsidy program
		138.05		Payment of health insurance premiums
Chapter	HFS 139		Qualifications for Public Health Professionals Serving Local Health Agencies
		139.03		Definitions
		139.04		General requirement
		139.05		Health officers
		139.06		Public health professionals serving as health officers for the purpose of communicable disease control
		139.07		Public health professionals who direct environmental health programs
		139.08		Public health nurses
Chapter	HFS 144		Immunization of Students
		144.02		Definitions
		144.03		Minimum immunization requirements
		144.04		Waiver for health reasons
		144.05		Waiver for reasons of religious or personnel conviction
		144.08		Responsibilities of local public health agencies
Chapter	HFS 145		Control of Communicable Diseases
	Subchapter I			General Provisions
	Subchapter II			Tuberculosis
	Subchapter III			Sexually Transmitted Diseases
Chapter	HFS 165		Laboratory Certification
Chapter	INS 3		Casualty Insurance
		3.53		HIV testing
		Appendix A		Wisconsin Notice and Consent for Human Immunodeficiency Testing
Chapter	INS 6		General Chapter
		6.67		Unfair discrimination in life and disability insurance

 

F. Regional Office Contacts

Regional Offices of the Division can provide assistance with accessing information and appropriate staff members of the Central Office contacts.

Southern
Mary Young
2817 International La. Suite 120
Madison, WI 53704
608-243-2351
608-243-2365 Fax

Southeastern
Robert Harris
819 N. 6th. St. Room 860
Milwaukee, WI 53203-1697
414-227-4860
414-227-2010 Fax

Northeastern
Dennis Hibray
200 N. Jefferson St. Suite 511
Green Bay, WI 54301
920-448-5220
920-448-5223 Fax

Western
Larry Gilbertson
610 Gibson St. Suite 3
Eau Claire, WI 54701-3679
715-836-5362
715-836-6686 Fax

Northern
Terri Timmers
1853 N. Stevens St.
Rhinelander, WI 54501
715-365-2700
715-365-2705 Fax

G. EPINET - Wisconsin Disease Surveillance Manual

All communicable disease case reports should be followed up for the purposes of prevention and control in a manner consistent with those methods listed in the most current edition of Control of Communicable Diseases Manual, Heymann DL, (ed), 18 th ed. 2004, Washington, D.C.

Disease follow-up investigation forms are included in this manual and found on the Wisconsin Health Alert Network (HAN)* and are a valuable tool for the investigator to interview a case or suspect case of disease. The follow-up investigation form outlines a minimum of demographic, clinical, epidemiologic and laboratory information needed to begin assessing public health implications of the case. Each follow-up report form provides a framework to determine the epidemiologic circumstances of the illness. Some follow-up forms have worksheets available to better assist the investigator.

In the United States , requirements for reporting diseases are mandated by state laws or regulations, and the list of reportable diseases in each state varies. In Wisconsin , Wisconsin State Statute 252.05 and Wisconsin Administrative Code HSS 145 require reporting of Communicable Diseases. The list of reportable diseases in Wisconsin appears on the back of the DPH 4151 and is included in this manual. Additionally, state health departments report cases of selected diseases (Table 1) to the Centers for Disease Control and Prevention (CDC) National Notifiable Disease Surveillance System (NNDSS), on a weekly basis. These data are published weekly in the Morbidity Mortality Weekly Report (MMWR) and an updated final report is published annually in the Summary of Notifiable Diseases.

With the EPINET manual, we have tried to adhere as closely as possible to the case definitions developed by the CDC and the Council of State and Territorial Epidemiologists (CSTE), published in “Case Definitions for Infectious Conditions Under Public Health Surveillance”, MMWR 1997; 46(RR-10). As uniform case definitions are adopted by the states, the incidence of reported diseases in different geographic areas may be more meaningfully compared at the local, state, and national levels.

* Many of the communicable diseases listed in this manual have follow-up forms or worksheets requested by either the Bureau of Communicable Diseases and Preparedness or the Centers for Disease Control and Prevention (CDC). All these report forms can now be found on the Wisconsin HEALTH ALERT NETWORK (HAN). After you login, go into TOPICS, click COMMUNICABLE, then under EPINET click on REPORT FORMS.

H. Report Forms

Please submit the appropriate follow-up form to the Division of Public Health (DPH) with the Acute and Communicable Disease Case Report Form (DPH 4151).

DISEASE	CDC	DPH	CDES
AIDS		4264
HIV INFECTION		4338
Pediatric Cases (< 13 years old) ONLY	50.42B
BABESIOSIS			101
BOTULISM, INFANT	52.73
CAT SCRATCH FEVER			102
CHANCROID		4243
CHLAMYDIA		4243
EHRLICHIOSIS	55.1
ENCEPHALITIS, ARBOVIRAL			103
GENITAL HERPES		4243
GONNORRHEA		4243
HEPATITIS A	53.1
HEPATITIS B	53.1
HEPATITIS C	53.1
HEPATITIS D	53.1
KAWASAKI SYNDROME	55.54
LEGIONELLA	52.56		105
LEPROSY	52.18	9077
LISTERIOSIS			106
LYME DISEASE			107
MALARIA	54.1
MEASLES		4077
PLEVIC INFLAMMATORY DISEASE (PID)		4243
PERTUSSIS		4236
PSITTACOSIS		9075
REYE SYNDROME	55.8
ROCK MOUNTAIN SPOTTED FEVER	55.1
RUBELLA, CONGENITAL SYNDROME	71.17
		4243
SYPHILIS		or
		4061
TETANUS	71.15
TOXIC SHOCK SYNDROME	52.3
TRICHINOSIS	54.7
		4000
TUBERCULOSIS
		42001
TYPHOID FEVER	52.5
WATERBORNE DISEASE OUTBREAKS	52.12

These forms can be found on the HAN. Login, then click on TOPICS, click COMMUNICABLE, then click EPINET and go into REPORT FORMS, another screen will appear and under Associated Links, click Report Forms and the table above will appear and click the appropriate disease form number.

I. Diseases Reportable at the State and National Level

1. Wisconsin Disease Surveillance Category I

The following diseases are of urgent health importance and shall be reported IMMEDIATELY by telephone to the patient’s local health officer upon identification of a case or a suspected case. Complete and mail an Acute and Communicable Diseases Case Report (DPH 4151) within 24 hours. Public health intervention is expected as indicated in the footnotes. See Wisconsin Administrative Code HSS 145.04 (3) (a).

Anthrax 1,4,5
Botulism 1,4
Botulism, Infant 1,2,4,5
Cholera 1,3,4,5
* Diphtheria 1,3,4,5
Foodborne or Waterborne Outbreaks 1,2,3,4
* Haemophilus influenzae invasive disease, (including epiglottitis) 1,2,3,5
Hantavirus 1,2,4,5
* Hepatitis A 1,2,3,4,5
* Measles 1,2,3,4,5
Meningococcal disease 1,2,3,4,5
Pertussis (“Whooping cough”) 1,2,3,4,5
Plague 1,4,5
* Poliomyelitis 1,4,5
Rabies (Human) 1,4,5
Ricin toxin 4,5
* Rubella 1,2,4,5
Rubella (Congenital syndrome) 1,2,5
Smallpox 1,4,5
Tuberculosis 1,2,3,4,5
Yellow Fever 1,4

2. Wisconsin Disease Surveillance Category II

The following diseases shall be reported to the local health officer on an Acute and Communicable Disease Case Report (DPH 4151) or other means within 72 hours of the identification of a case or suspect case. Public health intervention is expected. See Wisconsin Administrative Code HSS 145.04 (3) (b).

Amebiasis 1,3,
Arboviral infection (encephalitis / meningitis) 1,2,4
Babesiosis 2,4,5
Blastomycosis 2,4
Brucellosis 1,4
Campylobacter 3,4
Cat Scratch Disease (Bartonella species) 2,5
Cryptosporidiosis 1,2,3,4
Cyclosporiasis 1,4,5
E. coli 0157:H7 1,2,3,4
and other enterohemorhagic E. coli,
enteropathogenic E. coli,
enteroinvasive E. coli,
enterotoxigenic E. coli 1,2,3,4
Encephalitis, viral (other than arboviral)
Ehrlichiosis 1,2,5
Giardiasis 3,4
Hemolytic Uremic Syndrome 1,2,4
* Hepatitis B 1,2,3,4,5
Hepatitis C 1,2
Hepatitis D 2,3,4,5
Hepatitis E 3,4
Histoplasmosis 5
Kawasaki disease 2
Legionellosis 1,2,4
Leprosy 1,2,3,4,5
Leptospirosis 4
Listeriosis 2,4
Lyme disease 1,2
Malaria 1,2,4
Meningitis, bacterial (other than Haemophilus influenzae or
meningococcal disease) 2,5
Meningitis, viral (other than arboviral)
* Mumps 1,2, 4,5
Mycobacterial disease (nontuberculous)
Psittacosis 1,2,4
Q fever 2,4,5
Reye syndrome 2
Rheumatic fever (newly diagnosed and meeting the Jones criteria) 5
Rocky Mountain Spotted Fever 1,2,4,5
Salmonellosis 1,3,4
Sexually transmitted diseases:
Chancroid 1,2,4,5
Chlamydia trachomatis infection 1,2,4,5
Genital herpes infection (1 st episode identified by health provider) 2
Gonorrhea 1,2,4,5
Pelvic inflammatory disease 1,2,5
Syphilis 1,2,5
Trichomoniasis 2
Shigellosis 1,3,4
Streptococcus group A invasive disease 1,5
Streptococcus group B invasive disease 1,5
Streptococcus pneumoniae (pneumococcus) invasive disease 2
* Tetanus 1,2
Toxic shock syndrome 1,2 Toxic substance related diseases:
Infant methemoglobinemia
Lead intoxication (specify Pb levels)
Other metal and pesticide poisonings
Toxoplasmosis
Trichinosis 1,2,4
Tularemia 1,4
Typhoid fever 1,2,3,4
Typhus fever 4,5
Varicella (chickenpox) - reported by number of cases only
Yersiniosis 3,4

* For diseases proceeded by an asterisk (*) in Categories I and II give vaccination history.

3. Wisconsin Disease Surveillance Category III

The following diseases shall be reported to the state epidemiologist on an AIDS case report (DPH 4264) or a Wisconsin Human Immunodeficiency Virus (HIV) Infection Confidential Case Report (DPH 4338) or by other means within 72 hours after identification of a case or suspected case. See s.252.15 (7) (b), Stats., and s. HFS 145.04 (3) (b).

Acquired Immune Deficiency Syndrome (AIDS) 1,2,4
Human Immunodeficiency Virus (HIV) infection 2,4
CD4+ T-lymphocyte count <200 / m L, or CD4+ T-lymphocyte percentage of total lymphocytes of <14

Key:

1. Infectious diseases designated as notifiable at the national level.
2. Wisconsin or CDC follow-up form is required. LHDs have templates of these forms in the Epinet Manual and on the HAN.
3. High-risk assessment by LHD is needed to determine if patient or member of patient's household is employed as a food worker, day care or health care.
4. Source investigation by LHD is needed.
5. Immediate treatment is recommended, i.e., antibiotic or biologic for the patient or contact or both.

 

II. DISEASE SURVEILLANCE PROCEDURES AND RESPONSIBILITIES

A. Surveillance Procedures

Disease surveillance encompasses more than just reporting diseases and is an essential element in any disease prevention and control program. The CDES uses two approaches in disease surveillance:

1. Passive disease surveillance relies upon physicians and other health care providers to fulfill their statutory requirement of disease reporting.

2. Active disease surveillance is a more aggressive and labor intensive approach to identifying cases of disease. It involves the daily, weekly or monthly contacting of physicians, hospitals, schools, or other agencies to "actively" search for cases. This type of surveillance has defined objectives, and usually continues for a relatively short period until the objectives are met. Active disease surveillance coincides with periods of high disease frequency and usually yields a much higher percentage of actual identified cases. It is also used during an outbreak to find additional cases of disease.

The traditional sources of surveillance information are listed in Table A.

Table A

1. Morbidity Reports (Acute and Communicable Diseases Case Report)
2. Laboratory reports of infection
3. Outbreak investigation reports
4. Mortality reports (death certificates)
5. Active surveillance for specific diseases
6. Special surveys (i.e., hospital admissions, disease registers, serologic surveys)
7. Absentee data from school or work for selected diseases

Since most surveillance date are based on clinical cases, it is important to keep in mind the chain of events shown in Table B that must occur before a clinical case is confirmed.

Table B

Major Elements Needed for Surveillance of Clinical Illness:

1. Occurrence of clinical illness
2. Sufficient severity to seek medical care
3. Laboratory support of diagnosis
4. Reporting of the disease to the LHD
5. Collection and analysis of data by LHD or CDES
6. Reporting of the disease to the BCDP / CDES:

Physicians, clinics, hospitals, laboratories, or others aware of a person with an acute or communicable disease should notify the LHD using the Acute and Communicable Diseases Case Report

The LHD should collect missing data, initiate a disease specific epidemiologic follow-up investigation, assure that adequate prevention and control measures are taken and immediately notify the CDES and / or Regional Office.

For further information on the procedures for reporting, content of the report, urgency of the report, handling of reports by the local health officer, and categories of disease to b reported, please refer to Wisconsin Administrative Code HSS 145, Control of Communicable Diseases.

 

A. Surveillance Responsibilities

1. Local Health Department responsibilities:

Each LHD should maintain a surveillance system in its jurisdiction that is compatible with the statewide system.

The LHD is expected to:

1. Maintain a supply of communicable disease reporting forms for distribution to physicians, primary care practitioners, hospitals, clinics, schools, day care centers and/or others needing the forms.
   
2. Receive, evaluate and transmit completed reports to the state epidemiologist.
   
3. Investigate each communicable disease to gather epidemiologic and laboratory data for local, state and national surveillance.
   
4. Conduct a detailed follow-up to prevent future cases, identify the etiologic agent or agents, and identify the mode of transmission or risk factors associated with transmission.
   
5. Consult with the state epidemiologist or BCDP staff whenever any unusual circumstances occur regarding the disease.
   
6. Implement control measures for specific diseases consistent with Section 9, Methods of Control, contained in the latest edition of Control of Communicable Diseases Manual, or with specific measures issued by the state epidemiologist.

2. Local Health Support & Emergency Medical Services Regional Office responsibilities:

Professional and support staff assistance is available at the Local Health Support & Emergency Medical Services Regional Office. It is expected that:

1. Regional Program Consultants from the Immunization Program (IP) and Sexually Transmittable Diseases (STD) Program will respond to the majority of questions on immunizable diseases and STD surveillance for their respective geographic areas.
   
2. Regional Program Consultants will remain current on the BCDP surveillance activities and communicable disease guidelines. See Epinet Introduction: Regional Staff Contacts.
   
3. Nursing consultants will serve as a conduit of information from the LHD to the appropriate program staff in the region of the BCDP.
   
4. Regional support staff will:
   
   1. Provide storage, shipping and handling for immune globulin (IG) for viral hepatitis and handling of vaccine or other biologics;
   2. Maintain a limited supply of Acute and Communicable Diseases Case Report forms for provision to LHD on an emergency basis;
   3. Refer telephone and written correspondence to appropriate regional staff, or directly to the BCDP.

3. State Epidemiologist Responsibilities:

The state epidemiologist has overall responsibility for state disease surveillance activities and is expected to:

1. Provide consultation, technical assistance, and training regarding epidemiologic methods and disease control recommendations to LHDs.
   
2. Provide guidelines consistent with state and national objectives, policies and current medical literature.
   
3. Maintain a records system for receiving surveillance reports and consolidation of the information into meaningful tables, graphs and charts, provide analysis of the data, and prepare and disseminate summary reports.
   
4. Act as liaison with the CDC, WSLH, and other Wisconsin laboratories, the University of Wisconsin-Madison Medical School and the Medical College of Wisconsin to assure rapid and accurate flow of information regarding disease control and specimen collection of communicable diseases throughout Wisconsin .
   
5. Assign appropriate state staff to perform epidemiologic investigations where surveillance data indicate a suspected disease outbreak.
   
6. Assure that appropriate forms and information are supplied to LHDs as needed.
   

III. EPIDEMIOLOGIC INVESTIGATIONS

1. Disease Outbreaks

When foodborne or waterborne outbreaks occur it is the responsibility of the LHD or Regional Office to immediately notify the BCDP / CDES office. The LHD would then consult the FOODBORNE AND WATERBORNE DISEASE OUTBREAK INVESTIGATION MANUAL found on the Health Alert Network HAN).

2. Requesting Outbreak Assistance

There is no standard formula that will answer the question of when outbreak assistance should be requested.

As a general rule, the Division of Public Health does not provide on-site assistance to LHDs for routine communicable disease outbreaks. However, if an outbreak is suspected and the LHD needs technical, material or personnel assistance for an epidemiologic investigation, the health officer should contact the state epidemiologist. Consultation with the state epidemiologist should always be sought when: (1) the pattern of illness appears to be unusual, (2) the etiology of an unusual disease occurrence is not known, or (3) severe disabling (hospitalizations, death) consequences are occurring.