12/05/2001
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New Hanover County Health Department
Revenue and Expenditure Summaries for October 2001
Revenues
CumulatIve \I
33.32%
Month Reported
Mon4of12
Ocl-O
ypeof
evenue
Budgeted
Amount
Current Year
Revenue Balance
Earned Remainln
rSo./fV
$ 168i04 $ 1,112,330
$ 184,945 $ 348,099
$ 265,183 $ 696,751
$/~...71'} $
$ "AO,273 $
$ 48,772 $
415842 $
Prior Yeaf
Revenue Balance
Earned Remalnln
\I
\I
BUdgeted
Amount
302.967
179,829
66,378
1,088,996
343,215
875,522
Expenditures
ypeof
Ex enditure
Budgeted
Amount
Expended
Amount
Balance
Remainin
\I
Budgeted
Amount
Expended
Amount
Balance
Remainin
\I
Summary
BUdgeted Actual
FY 01-02 FY 01-02
Expenditures:
Salaries & Fringe $8,779,646 $2,584,429
Operating Expenses $1,569,300 $488,270
Capital Outlay $126,307 $34,755
Total Expenditures $10,475,253 $3,107,454
Revenue: $4,525,224 $1,163,819
%
29.66%
Net County $$
25.72%
$5,950,029 $1,943,635 32. % '3 J ro
I ~';).3~"
-Pre~PT MAi ~ ~ {
",tf1/ ~'1
Revenue and Expenditure Summary
For the Month of OCTOBER 2001
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NEW HANOVER COUNTY HEALTH DEPARTMENT
BOARD OF HEALTH (BOH) APPROVED
GRANT APPLICATION STATUS
Date (BOH) Grant Requested Pending Received Denied
Youth Tobacco Prevention Project- Robert
10/3/01 Woods Johnson Youth Center $11,800 $11,800 $0
Teens Against Tobacco Use (TATU)-Health
Action Council of NC $350 $350 $0
Healthy Carolinians- NC DHHS $10,000 $10,000
Family Assessment Coordination- March
9/5/01 of Dimes $16,500 $16,500
Folic Acid Project- March of Dimes $16,618 $16,618
Safe Kids Coalition- Stale Farm"Good
Neighbo~' $500 $500
TB Elimination and Prevention - CDC,
8/1/01 NCDHHD, DPH, TB Control Program $10,000 $ 9,200 $800
Teen Aids Prevention (TAP)- CFMF $45,500 $25,000 $20,500
Diabetes Today - Diabetes Prevention & Control $/fJ,ocO
7/11/01 Unit, NCDHHS $10,000 $10,000
Lose Weight Wilmington - Cape Fear Memorial
Foundation $75,000 $75,000
.
Diabetic Care for Prenatal Patients-NC Medical
6/6/01 Society Foundation $25,050 $25,050 $0
Healthy Homes- Asthma Program - Partnership
for Children (Smart Start) $28,060 $26,000 $2,060
No activity to report for May 2001
Maternity Care Coordination Expansion Grant
4/4/01 NC DHHS $15,000 $15,000
Wilmington Housing Authority- Ross Grant -
TAP & Alternative HIV Test Sites for 3 year
funding $192,221 $192,221
Safe Kids Trailer-Safe Kids Safe Communities-
NC Govemo(s Highway Safety $8,740 $8,480 $260
No activity to report for Jan, Feb and Mar 2001
Intensive Home Visitation Program Expansion
12/6/00 Grant - Smart Start $100,000 $96,000 $4,000
Childhood Asthma Management & Control
Interventions- NC Department of Health &
Human Services, Division of Public Health, WCH
11/1/00 Section $23,000 $10,285 $12,715
.:
Cape Fear Memorial Foundation-Lice
Eradication Program $5,000 $5,000 $0
Healthy Carollnlans- Office of Healthy
Carolinians, Division of Public Health, North
10/4/00 Carolina Dept of Health & Human Services $10,000 $10,000 $0
March of Dimes- March of Dimes Birth Defects
Foundation Eastem Carolina Chapter $10,000 $8,250 $1,750
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As of 11/19101
. NOTE: Notification received since last report.
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NEW HANOVER COUNTY HEALTH DEPARTMENT
BOARD OF HEALTH (BOH) APPROVED
r.RANT APPLICATION l:TATIIS
Enhanced Counseling Program for HIV / AIDS
9/6/00 Elton John Aids Foundation $48,000 $48,000
Smart Start applying for Cape Fear Memorial
812/00 Foundation Grant (MOW) $52,000 $50,000 $2,000
Enhanced Counseling Program- Z. Smith
Reynolds Foundation $48,000 $48,000
Teen Aids Prevention- Z. Smith Reynolds
Foundation $59,000 $59,000
7/12/00 March Toward TB Elimination- NC DHHS $10,000 $7,200 $2,800
Cape Fear Memorial Foundation IT AP
Pr09ram)2 year request $55,000 per year $55,000 $35,000 $20,000
Diabetes Today - DHHS DDPH $10,000 $10,000 $0
Totals $895,339 $53,618 $337,615 $504,106
5.99%
Pending Grants 5 19%
Funded Total Request 6 22%
Partially Funded 10 37%
Denied Total Request 6 22%
Number of Grants Applied For 27 100%
As of 11/19/01
. NOTE: Notification received since last report.
37,71%
56.30%
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David E Rice
11 /20/0 1 07 :24 AM
To: bjones@nhcgov.com@NHC, Ismith@nhcgov.com@NHC
cc:
Subject: Re: TB Budget Ammendment Request[lli
Please prepare budget amendment for the NHCBH Executive Committee agenda for November
27
Beth Jones
Beth Jones
11/19/01 03:55 PM
To: David E Rice/NHC@NHC
cc: Lynda Smith/NHC@NHC, Cindy Hewett/NHC@NHC, Kim
RoaneINHC@NHC
Subject: TB Budget Ammendment Request
Request approval to prepare budget amendment using revenues generated by charging for PPO's
to purchase the Purified Protein Oerivative to administer The need to do this came to us by way
of a State memo that effective in January, the TB program will not provide PPO except for high
risk and contact investigations for a TB case. We give many PPO's for employment screenings
and charge to do those.
n. Forwarded by Beth Jones/NHC on 11/19/2001 03:49 PM .....
,
..Kim Roane
.... 11/16/2001 03:48
PM
To: Beth JonesINHC@NHC
cc:
Subject: TB Budget Ammendment Request
The State has notified us that effective January, 2002, they will no longer provide PPO for routine
Tuberculin skin tests. There were no funds budgeted in the 5152 budget to pay for the PPO's,
since the State has always provided local Health Oepartments PPO's free of charge.
Fortunately, our Health Fee revenues are far exceeding our projections in the 5152 budget,
primarily due to increasing numbers of PPO's being administered. For this current budget year,
our revenue budget is $14,000. For the first 4 months of the year we have already earned
$10,044 in Health Fees. Based on these actual amounts, we can project we will exceed our
budgeted revenues by $16,000. I believe we need to request a budget ammendment to increase
our revenues for 5152.4118 from $14,000 to $27,000, and to add $13,000 to the expenditure
budget for 5152.4210. This is a conservative increase, but will be sufficient to purchase PPO's
and other clinic supplies.
13
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NEW HANOVER COUNTY BOARD OF OOMMI66IQrJt:HS
REQUEST FOR BOARD ACTION
Meeting Date: 12/"/01
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Department: Health Presenter: Lynda Smith, Assistant Health Director
Contact: Lynda Smith-343-6592
SUBJECT:
Cape Fear Memorial Foundation for Diabetes Education, Management and
Prevention
($60,000)
BRIEF SUMMARY:
We are requesting approval to submit a Letter of Intent to apply for a $60,000 Cape Fear Memorial
Foundation grant. The grant is for The Diabetes Education, Management and Preventon Program. The
program will offer the Diabetes Self-Management Education Curriculum developed by the North Carolina
Diabetes Advisory council. In cooperation with the School of Nursing at Cape Fear Community College,
these classes will respond to the lack of education and
and information available for persons with Type 2 diabetes and their families. The classes will be offered
at little or no cost at least three times per year
To increase the percentage of persons with diabetes receiving the recommended foot exams, eye exams,
flu vaccines and pneumonia vaccines, The Diabetes Education, Management and Prevention Program will
sponsor outreach activities to include foot checks by podiatrist; eye exams by optometrists; and
inoculations by registered nurses.
To promote wellness, physical activity, weight control, and blood pressure control for persons with, and at
risk for diabetes, three B-week wellness programs will be offered. In addition to nutrition seminars and
wellness talks, exercise specialist will offer structured and supervised physical activity
Funding will be linked with additional resources to offer a valuable and much needed service to the
uninsured, underinsured, high risk, and unserved populations in our community
RECOMMENDED MOTION AND REQUESTED ACTIONS:
Approval to submit Letter of Intent, approval of grant application, and approval of budget amendment for
$60,000 if award granted.
FUNDING SOURCE:
Cape Fear Memorial Foundation ($60,000)
ATTACHMENTS:
yes-2page letter of intent to apply for Cape Fear Memorial Grant for $60,000
16
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NEW HANOVER COUNTY
HEALTH DEPARTMENT
2029 SOUTH 17TH STREET
WILMINGTON, NC 28401-4946
TELEPHONE (910) 343-6500, FAX (910) 341-4146
I e~
Everywbere. Everyday. Everybocty.
DAVID E. RICE, M.P.H., M.A.
Health Director
LYNDA F. SMITH, M.P.A.
Assistant Health Director
Garry Garris, President
Cape Fear Memorial Foundation
2508 Independence Blvd., Suite 200
Wilmington, NC 28412
Dear Mr. Garris,
The New Hanover County Health Department wishes to apply for a grant in the amount
of$60,000 to establish a Diabetes Education, Management and Prevention program for
New Hanover County.
e
Diabetes has increased by 40% in the United State in the last ten years, but the disease is
even IIlOre pronounced in southeastern North Carolina Nearly 10% (9.9%) ofaduhs in
our region indicated that they have diabetes, according to the 1999 Health and Human
Services Needs Assessment of the Southeast Region. That is nearly twice the 5.4% found
nationally. The problem is compounded by the alarming fact that I in 3 of those with
diabetes do not know it.
Many complications are associated with this disease including cardiovascular disease,
end stage renal disease, blindness and lower extremity amputations. Diabetes is more
common among African Americans, women, older adults and persons oflower education
and income categories. Fortunately, much can be done to prevent diabetes and improve
the heahh and quality oflife of those who have diabetes. Unfortunately, few services
exist in New Hanover County. New Hanover Regional Medical Center's Coastal
Diabetes Center closed as the hospital moved away from its mission that included
wellness; funding for the New Hanover County Diabetes Today Coalition was cut from
the state budget.
.
The Diabetes Education, Management and Prevention Program will offer the Diabetes
Self-Management Education Curriculum developed by the North Carolina Diabetes
Advisory Council. In cooperation with the School of Nursing at Cape Fear Community
College, these classes will respond to the lack of education and information available for
persons with Type 2 diabetes and their families. Because education is a key component in
successful diabetes management, these 9 module classes will be offered at little or no cost
at least three times per year.
/I ?jour .JJeafth _ Our Priorit'j II
17
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To increase the percentage of persons with diabetes who receive the recommended foot
and eye exams, and flu and pneumonia vaccines, the Diabetes Education, Management
and Prevention Program will sponsor outreach activities to include foot checks by
podiatrists; eye exams by optometrists; and inoculations by registered nurses.
To promote wellness, physical activity, and weight and blood pressure control for persons
with and at risk for diabetes, three 8-week wellness programs will be offered at little or
no cost to participants. In addition to nutrition seminars and wellness talks, exercise
specialists will offer structured and supervised physical activity.
The New Hanover County Diabetes Today Coalition has laid the groundwork to give the
Diabetes Education, Management and Prevention Program great capacity to succeed.
Based at the Health Department for the last two years, the Coalition has sponsored
numerous outreach and awareness programs. Strong networking links include: UNCW
School of Nursing and Cape Fear Community College; the Lions Club; health care
specialists including endocrinologists, cardiologists, podiatrists, optometrists, diabetes
educators and dietitians; Bristol-Myers Squibb pharmaceutical company; NC Diabetes
Advisory Council and the Coalition's member agencies including the Department of
Aging, Community Health Center, New Hanover Heahh Network, Department of Social
Services, Healthy Carolinians, and Cooperative Extension Service.
funding from Cape Fear Memorial Foundation will be linked with additional resources to
offer a valuable and much needed service to the uninsured, underinsured, high risk and
unserved populations in our community.
~~~our consideration.
~~.Rice
lIealth Director
18
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It NEW HANOVER COUNTY BOARD OF HEALTH
2002 Executive Committee Meeting Dates
. January 29, 2002
. February 26, 2002
. March 26, 2002
. April 23, 2002
. May 28, 2002
. June 25, 2002
-
. July 30, 2002
. August 27,2002
. September 24, 2002
. October 29, 2002
. November 26,2002
. December 17, 2002
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NEW HANOVER COUNTY BOARD OF HEALTH
2002 Meeting Dates
. January 2, 2002
. February 6, 2002
. March 6, 2002
. April 3, 2002
. April 11 , 2002 - Staff Appreciation Luncheon
. May 1, 2002
.
. June 5, 2002
. July 3, 2002
. August 7,2002
. September 4, 2002
. October 2, 2002
. November 6, 2002
. December 4, 2002
. December 12, 2002 - Holiday Celebration
.
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NORTH CAROLINA PUBLIC HEALTH.
Bioterrorism Risk Reduction and Response
November 15, 2001
Backl!:round
Attached is the information developed for Governor Easley's Terrorism Task Force as it
pertains to public health preparedness and response to bioterrorism in North Carolina
This was developed under specific guidance as critical steps the state should undertake as
soon as possible. It is not intended to be a comprehensive plan for the long term needs of
all public health. It is also important to know that this proposal represents a scaled down
version of what was first proposed for public health. The Governor used this information
to demonstrate the type of expenditures he wanted to make immediately as justification
for House Bill 1471 that gives him the authority to spend up to $30 million from the
State's "Rainy Day Fund" in the current biennium budget cycle (2001-2003). The actual
budget and subsequent expenditures must be approved through the Govemor's Office and
may vary from the figures shown in this proposal.
21
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NORTH CAROLINA PUBLIC HEALTH
.
Bioterrorism Risk Reduction and Response
October 30, 2001
Potential Risks of Bioterrorism
The current spread of anthrax through the rnail system in this country marks a new era in the
nation and in the public health efforts required to protect the public. Bioterrorism is no longer a
theory or a tabletop exercise--it is reality. It is critical that this bioterrorism event not be
considered a one-time disaster that is not likely to reoccur. Rather the nation and this state must
prepare to live on a daily basis with the threat ofbioterrorism. It is critical for government to
redesign and strengthen its capacity to protect the public's health in a time where biological
agents are being deployed against the people of this nation and potentially in our own state.
North Carolina rnust prepare to detect the release of a bioterrorism agent as early as possible and
take aggressive control measures to prevent the spread of deadly infections or chemical
exposures. As in the current bioterrorism acts with anthrax, the release of such an infectious
agent into the public will most likely occur through covert action and would only be detected
through the heightened surveillance of a strong public health system working on a daily basis in a
communities all across North Carolina. .
The biological or chemical agents that have the greatest potential to be used in bioterrorism
activity include:
Anthrax
Botulism
Brucellosis
Cholera
Plague
Q Fever
Ricin
Smallpox
Staphylococcal Enterotoxin B Disease
Triothecene Mycotoxicosis
Tularemia
Venezuelan Equine Encephalitis
Viral Hemorragic Fever (Ebola, Marburg)
Four agents of greatest concern because of their contagiousness, their ability to be aerosolized
and their high mortality rates are small pox, plague, anthrax and botulism.
Smallpox: The smallpox virus has claimed more lives than any other disease in history. A
worldwide immunization campaign eliminated smallpox in 1978 and immunizations in this
country were stopped in 1972. The population in the United States is uniformly unprotected
from smallpox since the vaccination protection expired after approximately 10 years. While the
only two official repositories of smallpox are held at the Centers for Disease Control in Atlanta
and in Russia, there is speculation that smallpox virus is also held by other unidentified
potentially hostile countries. There are only 15 million vaccine doses available in this country
and the United States is seeking to secure additional vaccine. There is no proven treatment for
.
11/15/01
22
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smallpox. Smallpox spreads easily via respiratory droplets and through direct contact with
contaminated clothing or bed linens. It is highly contagious and an infected person may be
asymptomatic but spreading the virus to others for 2 weeks before they are identified.
Approximately 5-20 secondary cases can be expected per case; 24-40% of those people who
come in contact with a person with smallpox will contract the illness themselves, The mortality
rate is 30%.
Plague: While there are three types of plague---all of which could be used in bioterrorism---the
most deadly and most likely form to be used would be in an aerosolized release causing
pneumonic plague. This form of the plague is highly contagious from person to person and has
an incubation period of I-I 0 days. Antibiotics are effective treatment and need to be given within
18-24 hours of the onset of symptoms. The overall mortality rate is 57% but without treatment
the mortality rate if 100%. There is no vaccine available for pneumonic plague.
Anthrax: The most lethal form of anthrax is inhalation anthrax, which has a mortality rate of
86-100% within three days if treatment is not begun before the onset of symptoms. This is
considered to be the most likely type of the disease to occur in a bioterrorism incident due to its
relative ease to produce and disperse. It is not contagious person to person but can be
aerosolized to have multiple persons exposed in a single incident. No vaccine is available to the
general public at this time due to complications with the vaccine as well as due to the current
limited supply.
Botulism Toxin: Botulism toxin is one of the most poisonous substances known. It is a
neurotoxin that is produced by a bacteria and is sometimes found in canned foods or the spore
form of the organism may enter the body through wounds, germinate in the body and produce
toxin. In a bioterrorism event, this toxin could be aerosolized and breathed into the lungs or it
could be used to contaminate food supplies. The diagnosis would be made clinically; there are
no specific laboratory findings. Death comes from respiratory failure. An antitoxin is available
through the Centers for Disease Control and should be administered as soon as possible.
Recommendations to Protect Against Bioterrorism and Its Impact on the Public
North Carolina's best defense against bioterrorism is detecting the release of an agent of
bioterrorism as early as possible and taking aggressive action to prevent deaths. The following
three recommendations will help North Carolina achieve this goal:
(1) Creation of Seven Bioterrorism Teams in Seven Lead Local Health Departments for
Regional Protection
The intentional release of a biological or chemical agent into the population in a bioterrorim act
will begin in local communities. The control measures to prevent illness and deaths must also be
aggressively undertaken at the local level. The lead agency that will be on the front line in the
release of a bioterrorism agent into a commllnity will be the local health department.
There are 100 counties in North Carolina that are served by 87 local health departments. These
agencies have the responsibility for detecting and implementing control measures for 61
11/15/01
23
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communicable diseases and conditions that are reportable. In this work, the local health
department provides the leadership for the entire medical community (private doctors, hospitals,
laboratories) finding out through intense epidemiologic investigation answers to these types of
questions:
"
Who is sick?
From what illness?
How did it happen?
Are there other cases that we don't know about yet?
How do we determine if there are other cases?
Who are the other people these cases might have come in contact with and exposed?
How do we find these individuals?
What treatments are recommended for the individuals who are sick or exposed-- drugs?
vaccines?
What treatments or safety measures are recommended for the general public--drugs?
vaccines? isolation? quarantine measures?
How and when should information be communicated to the public at large to control
infection and/or fear?
Numerous other questions arise in investigating and controlling a disease outbreak. These are
just a sample of the more typical issues that must be addressed. While this disease identification
and control activity occurs 7 days a week, 24 hours a day, the capacity to detect early and a
respond aggressively is stronger in some county health departments than in others. In EVERY .
County, the communicable disease staff dedicated to this effort are stretched very thin.
The need for laboratory analysis of unknown substances has grown exponentially since the
recent anthrax attacks in this country. The ongoing demand for this kind of work is likely to
decrease somewhat over time as new safety measures are implemented but the level of suspicion
and the realty of this threat is forever changed. This will certainly result in the need for increased
capacity for laboratory analysis on an ongoing basis. The State Laboratory of Public Health is
the CDC designated network lab for certified testing of biologic agents.
In the current environment where bioterrorism has become a reality, it is critical to strengthen the
ability of the local health departments to detect the release of a biological agent as early as
possible and respond to the spread of disease. It is not affordable to provide additional resources
in today's economic environment to every local health department. Therefore a regional
approach working through local lead health departments located in strategic locations across the
state is recommended.
Specifically, the recommendation is to create seven Bioterrorism Teams to be co-located to the
greatest extent possible with the Emergency Regional Response Teams that are currently
operating in the state. These Bioterrorism Teams would be composed of medical and disease
investigation staff. Each Bioterrorism Team would be responsible for a 14-16 county area.
Their sole responsibilities will be the following:
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11/15/01
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1. Detecting as early as possible, any potential bioterrorim release of an infectious or chemical
agent.
2. Rapidly and thoroughly investigating any possible bioterrorism release and confirming that a
release has occurred.
3. Aggressively screening other people who may have been exposed.
4. Determining rapidly the course of treatment or vaccination as needed for individuals at risk.
5. Guiding the medical community in recommending treatment of their patients and families.
6. Communicating the risks to other counties in their catchment area and to the NC Division of
Public Health.
7. Providing surge capacity to help other Bioterrorism Teams respond when a bioterrorism
release occurs in other parts of the state outside of their Team area.
8. Providing quality, timely and accurate information to the public at large. In the current
environment, fear is contagious and the public has a tremendons need for information that is
vital not only to their physical health but to their mental health as well.
In order to contain costs yet maximize the necessary medical and disease investigation expertise
that is needed to provide effective statewide coverage against bioterrorism, the Bioterrorism
Teams will be multi-disciplinary. All seven Bioterrorism Teams will include a physician
epidemiologist, a laboratory technician, a disease investigator and a support person to blanket
each 14-16 county area with added ability to detect early and investigate any unusual illness or
deaths. The roles and responsibilities of these positions are outlined below:
PhysicianlEpidemiologists (7): The physician epidemiologist will on a daily basis be studying
and evaluating multiple electronically integrated disease data sets coming from hospitals,
pharmacies, physician offices, local health departments, laboratories, third party payors and other
sources seeking to identify any possible emerging unusual illness or deaths that might indicate a
bioterrorism release of an infectious or chemical agent has occurred in a community. The
physician epidemiolgist will deploy the disease investigators on the seven teams as needed to
investigate an emerging threat or occurrence. The physician epidemiologist will be a critical
resource for the medical community in communicating recommendations on treatment, isolation
or immunization of sick or exposed persons. In addition, the physician epidemiologist will work
closely with a laboratory person to rule out, on an ongoing basis, pathogens related to a
bioterrorism threat from tissue cultures. This physician epidemiologist will also be able to
answer numerous questions from fearful or concerned members of the public and the media.
Laboratory Technicians (7): The laboratory technician will be responsible for ruling out
suspicious agents in clinical specimens ofsick or exposed persons in the 14-16 county catchment
area. This laboratory person would work closely with the State Laboratory of Public Health in
transmitting those specimens that could not be ruled out and would require further testing. The
laboratory person would provide direction on how samples should be taken (both clinical and
environmental) and how to transport them to the appropriate follow-up lab. This person would
be trained in how to handle highly infectious agents that might be used in a bioterrorism act. This
position would provide linkages to local law enforcement agencies handling potentially
dangerous items.
11I15/01
25
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Disease Investigation Specialists (7): The primary responsibility of these professionals would
be to follow-up sick piltients or deaths to determine the specific details of a potential exposure to
a bioterrorism release. The potential exposure of others would be determined by this person in
consultation with the physician epidemiologist. The plan of action for treatment, prophylaxis,
immunization, isolation or quarantine would be coordinated by this person working with the
local health departments in the Team's catchment area. This rapid and coordinated response
would prevent unnecessary illness and death. These professionals spend much of their time in
the field interviewing potential contacts, reviewing medical records, and investigating sites.
"
Management Support (7): Each Bioterrorism Team would require ongoing administrative
support to receive reports, manage information, and assist with communication issues from the
public and the media. Organized information and coordination of teleconferencing to assure
effective communication in a bioterrorism outbreak will be critical to mounting an effective
effort to reduce illness and death. It is necessary to have a well trained person answering the
phone calls to make certain important information is captured and to direct calls appropriately.
(2.) Creation of a State Level Bioterrorism Team
The seven local health department Bioterrorism Teams will be supported by a state level
Bioterrorism Team. This team will be composed of a medical expert in the field ofbioterrorism, e
a lead laboratory scientist, two medical laboratory technologists, and a support person. The roles
and responsibilities of these positions are outlined below:
Bioterrorism Physician Expert (1): The State's Bioterrorism Team will be lead by a physician
who has expertise in infectious disease and bioterrorism. This expert will coordinate the work of
the State Bioterorism Team as well as the seven local health department Bioterrorism Teams
across the multiple county catchment areas. The Bioterrorism Physician Expert will be a
bioterrorism link to NC Emergency Management, the Centers for Disease Control, the FBI, SBI,
all 87 health departments, medical facilities, academic research institutions and military
instalhnents in North Carolina. This expert will convene a Core Team of infectious disease
experts in academics, the military and the private sector that could be leveraged as necessary to
mount a major, sustained response to the release of a highly infectious agent in North Carolina
with widespread impact.
Laboratory Scientist (1): This laboratory scientist will work closely with the Bioterrorism
Expert in developing the most effective laboratory for the state on biological and chemical
bioterrorism. The capacity of the State Public Health Laboratory to sustain a major effort in the
event that a highly contagious infectious agent is released is not adequate at this time. This
scientist would not only provide added capacity but would also seek to leverage additional
capacity working with other labs in academics, research and agriculture. In addition, this
laboratory scientist would be responsible for the statewide registry of potential bioterrorism
agents in laboratories across North Carolina. This laboratory scientist would be the key linkage
to law enforcement in maintaining the chain of custody as bioterrorism acts are criminally
investigated.
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Medical Laboratory Technologist n (2): These laboratory technicians are necessary to respond
to the increased demand for microbiologic testing of unknown substances. The State Laboratory
of Public Health is part of the bioterrorism lab network and currently the only CDC authorized
lab for biologic testing. These samples require very careful and complicated laboratory analysis
while maintaining the law enforcement chain of custody necessary for the criminal aspects of the
investigation. These positions would be dedicated to this work. Whereas the current staffing
level requires "borrowing" from other work areas within the lab to meet the demands for this
type of testing but this could not be sustained over time.
Management Support (1): This position is necessary to provide the ongoing office support for
the professional stafi"in the Bioterrorism Team. This position would coordinate the
communications coming from the Team in every aspect from professional conferencing, to
handling telephone calls from the media and the public to preparing correspondence and
maintaining accurate reports and files.
(3.) Public Health Electronic Communication and Surveillance System
The surveillance system to collect, analyze, and report disease information is not adequate to
detect bioterrorism attacks early. The existing system has three significant weaknesses putting
our citizens at risk. 1) It is not electronic and therefore it is slow, cumbersome, and prone to
errors. 2) It is not integrated. North Carolina currently utilizes more than 15 distinctly different
public health iwormation systems for collecting, analyzing and reporting information vital to
public health. 3) It does not capture the information necessary to detect disease and infections
soon enough. Many of these data elements are not currently reportable. For example, the signs
and symptoms of anthrax disease are non-specific flu-like symptoms and not always reportable.
An increase in these symptoms may be the first indication of an attack. Re-engineering these
diverse systems into an enterprise, web-enabled, public health system is essential to
accomplishing State objectives to better identify public health risks and take prompt public
health action to protect health. An integrated public health iwormation system that efficiently
collects and manages public health data in a secure environment is critical to the core public
health function of disease reporting and surveillance in this State. The functional components of
this electronic system include:
. Health Alert Network (IIAN) - A Virtual Private Network (VPN) running on the state's
Wide Area Network at 56Kbs with continuous access to connect local health departments,
hospitals, laboratories, private providers, and other healthcare partners as necessary for both
detecting a biologic attack and responding to it. Many areas of the state lack this essential
electronic connectivity. The RAN will have sophisticated messaging capacity to alert key
players when unusual or emergency events occur according to a pre-determined emergency
operations plan. The RAN will be developed with local municipal and county government
agencies to take full advantage of existing informatiol, technology infrastructures to avoid
duplication.
. National Electronic Disease SurveiIlance System (NEDSS) - The existing disease
surveillance system relies primarily on hand written disease report cards mailed to the state.
11/15/01
27
Electronic reporting is faster and easier therefore more reliable. It will also create a new
surveillance database with analytical capacity that can be merged with other critical data
systems to detect potential bioterrorism events early The new electronic disease surveillance
system can be used to report early signs and symptoms of disease, which are not currently
collected or reported. This information will be essential to detecting a biologic attack. This
system will also report information as necessary to the National Electronic Disease
Surveillance System.
. Public Health Laboratory Information Management System (LIMS) - This internet
based laboratory specimen submission and reporting system is linked to the disease
surveillance system for lab results with critical relevance for identifying emerging disease
trends or unusual disease events. The LIMS will utilize the same secure electronic backbone
of connectivity being developed with the Health Alert Network.
11/15/01
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NORTH CAROLINA PUBLIC HEALTH
Bioterrorism Risk Reduction and Response
BUDGET
Recommendation #1 - Creation of Seven Bioterrorism Teams in Seven Lead Local
Health Departments
EpidemiologistJMD (7 FTE's @$150,000)
Disease Investigation Specialist (7 FTE's @ $50,000)
Support Staff (7 FTE's @ $30,000)
Lab Technician (7 FTE's @ $50,000)
Lab Equipment and Supplies
Operating expenses
Rent, phone, facility expense
Office Set-up (computer, furniture, files)
Subtotal
Annualized
$1,050,000
350,000
210,000
350,000
87,500
140,000
105,000
$2,292,500
Recommendation #2 - Creation of a State Bioterrorism Team
Annualized
$225,000
50,000
80,000
100,000
*Bioterrorism Expert M.D. (salary & fringe)
Support Staff & Operating
Laboratory Scientist
Medical Lab Technician (2 FTE's @ $50,000)
Laboratory Equipment and Installation
Laboratory Supplies
Office Set-up (computer, furniture, files)
Subtotal
75,000
$530,000
One Time
$105,000
175,000
$280,000
One Time
$250,000
50.000
$300,000
Recommendation #3 - Create a Bioterrorism Electronic Communication and
Surveillance System
Annualized
Central ODerations (State)
Application Development Project Supervisor (1 FTE)
Computer Systems Analyst 11 (1 FTE)
Operating, Training, and Travel
Messaging Alert Software: Develop and Install
Maintenance
Data Modeling Software: Purchase and Install
Maintenance
Verisign Certificate Security
$ 95,000
65,000
20,000
25,000
2,000
15.000
$ 222,000
Subtotal
11/15/01
One Time
$ 300,000
20,000
$ 320,000
29
Local Health Deoartment Ooerations
. Counties that DO NOT meet the minimum Connectivity Requirement (42)
Annualized One Time
$ 1,500
T1 Connection:
Installation
Maintenance and Operating (12 mos.)
Router
PIX Firewall 515 Protection:
Installation
Subtotal
Subtotal (42 counties)
. Counties requiring Local Area Networks (12)
Wiring and Installation of LAN
CISCO switch (24 ports)
LAN Server and Operating System
Workstations (5-20)
Subtotal
Subtotal (11 counties)
$ 15,000
$ 15,000
$ 630,000
4,000
5,000
$ 10,500
$ 441,000
$ 3,000
2,500
5,000
20,000
$ 30,000
$ 366,000
. Counties with Existing IT Infrastructure that meets the Standard (58)
PIX Firewall 515 Protection: Installation $ 5,000
Subtotal $ 5,000
Subtotal (58 counties)
Total Surveillance
GRAND TOTAL
$ 832,000
$3.674.500
*This level of salary & fringes will be required to recruit and retain such an expert.
11115/01
$ 290,000
$1,417,000
$1.997.000
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NORm CAROLINA PUBLIC BEALm
Bioterrorism Risk Reduction and Response
November 5, 2001
Laboratory Response Network
Since September 11, 2001, the demand for public health laboratory testing of unknown or
suspicious substances has escalated to a whole new level. While it is reasonable to expect the
current level of concern over potential anthrax exposures will subside, it is clear that it will not
go away and that new threats are inevitable. This will result in a new ongoing need for increased
public health laboratory services. Additional resources are required to meet these baseline needs
in addition to a plan to response to the event specific needs that accompany an actual
bioterrorism event in NC or other states. The current workload in the State Laboratory of Public
Health (SLPH) force complex analysis of unknown substances has increased twenty fold and that
is in the absence of any confirmed cases of anthrax exposure in NC.
To meet the needs set forth by the Centers for Disease Control and Prevention (CDe) for
a national Laboratory Response Network, the NC State Laboratory of Public Health proposes
enhancing the core capacity of the SLPH in three critical ways:
1) Increased Core Capacity of the SLPH - Double the core capacity of the SLPH to perform
high-level microbiologic laboratory analysis (BSL-3) in two ways: I) Minor renovations to
the existing BSL-3 lab to make it more efficient including a new larger autoclave, a new
larger biologic safety hood, and three new dedicated laboratory tecImicians and 2)
Establishment of an additional BSL-3 laboratory with the purchase and installation of a
stand-alone self-contained BSL-3 laboratory to be located adjacent to the current SLPH.
2) Establish Regional SLPH Capacity -Establish four regional public health labs in lead local
health departments as an extension of the SLPH. These regional public health laboratories
would be trained and equipped to perform first order testing on clinical and environmental
samples. County sites being considered include Buncombe, Cumberland, Mecklenburg and
Pitt public health centers which also coincide with the counties with existing Emergency
Management Haz Mat Response Teams. These regional centers would be under the direction
of the State Laboratory of Public Health Director and provide enhanced regional laboratory
capacity for bioterrorism and disease surveillance. Start-up costs would vary from site to site
but is estimated to average $150,000 per site.
3) Develop Surge Laboratory Capacity - The SLPH will enter into mutual aid agreements
with a limited number of high level laboratories in the state's major medical centers and
university centers to assist with surge capacity during a full-scale bioterrorism event. In this
way the SLPH will have a mechanism to increase capacity as required by the specific event
without overbuilding capacity that might go unused during normal operations.
11/15/01
31
Other state operated laboratories, such as the DENR and Agriculture laboratories, have special
testing niches to fill in the response to acts ofbioterrorism. DENR laboratories can respond to
the need for testing for chemical agents and the Agriculture laboratories can test for the zoonotic
diseases in livestock and wildlife, such as foot and mouth disease, equine encephalitis and West
Nile Virus.
Laboratory Response Network
(Additional Costs Not Included in the Original Budget Submitted for lIB 1471)
BUDGET
Recommendation #1 - Increased Core Capacity of the SLPH
2001-02
$ 72,667
500,000
11,600
30.000
$614,267
Lab Equipment and Supplies
Stand-alone BSL-3 Lab
Operating expenses
Office Set-up (computer, furniture, files)
Subtotal
Recommendation #2 - Establish Rel!ional SLPH Capacity
2001-02
$116,000
134,800
23,200
30.000
$304,000
Lab Technician (4 FTE's @ $50,000)
Lab Equipment and Supplies (4 sites)
Operating expenses (4 sites)
Office Set-up (computer, furniture, files)
Subtotal
Recommendation #3 - Develop Surl!e Laboratory Capacity
2001-02
Negotiate Mutual Aid Agreements $0
2002-03
$20,000
$20,000
2002-03
$200,000
60,000
40,000
$300,000
2002-03
$0
Note: In the event of a declared bioterrorism emergency, the Governor will have emergency
powers to redirect resources to secure additional laboratory services as needed.
Total
$918,267
11/15/01
$320,000
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New Hanover County Board of Health
2001 Accomplishments
January Access to Dental Care meetings
Board of Health Committee Appointments
Family Planning Title X - 30m Anniversary
Wilmington International Airport - 100% Smoke Free Establishment
NC State Health Director's Conference
Association of NC Boards of Health Annual Meeting
February Super Staff Award Recepient Patricia Johnson
FY 2001-2002 Budget Request approved
Jail Medical Program - Nationally Accredited
Folic Acid Grant received
Improving the Vision of Students in New Hanover County:
Lenscrafters Foundation Mobile Van
NHCHD - NHC alternate Emergency Operations Center
Rats in Wilmington
March Public Health Leadership Videoconference - Betrayal of Trust
West Nile Virus campaign
Changes in OSHA Blood Borne Pathogen Standard
Commit to Quit Celebration
Revisions to Fee Policy
Priority List of Health Department Programs and Services
Performance Evaluation of Health Director
UNC-SPH Public Health Workforce Preparedness
April Ninth Annual Staff Appreciation Luncheon
New Hanover County Asthma Task Force
Resolution in Support of Programming and Actions to Reduce
Motor Vehicle Crashes Related to Driver Distraction
Legal Duties to Clients with Limited English Proficiency
May Management Academy for Public Health Teams
Annual Pet Adoptathon
Senior Links Health Fair 2001
Camp Notaweezie
Reclassification of Information Systems Support Specialist
Motorcycle Helmet Law Response
NHCHD Roof floods
June NHCHD Web Site expanded
Rotary Immunization Collaboration
Cape Fear Memorial Foundation - Lice Grant
Board of Health presentation of FY2001-02 Budget to Board of
County Commissioners
Revisions to Fee Policy
July Organizational Capacity Update - AEIOU Team
Super Staff Award Recepient Judy Evonko
Wheel Chairs donated by Rotary to Emergency Shelters
Public Health Foundation of New Hanover County Bylaws
1
New Hanover County Board of Health
2001 Accomplishments
August Public Health Foundation of New Hanover County approved by
Board of County Commissioners
Senior Smile 2001
Reorganization - Senior Environmental Health Program Specialists
NC Medical Society Grant - Pregnant Women with Diabetes
Certificates for Mother-Friendly Businesses
Additional School Nurse positions
September 9/11 Terrorism Events
Interim Recommended Notification Procedures for Local and State
Health Department Leaders in the Event of a Bioterrorism Incident
61St Positive Rabies Case
Snow's Cut Vector Control Project
Health Insurance Portability and Accountability Act presentation
NCPHA Annual Educational Conference - NHCHD Award received
October Bioterrorism Events in New Hanover County
Regional Bioterrorism Training
NC Bicycle Helmet Law
Appointment of Nominating Committee
November Dr Frank R. Reynolds Clinic Dedication
Teen AIDS Prevention Program - Youth Leadership Award
Public Health Foundation of New Hanover County Articles of
Incorporation
December HOLA 2001 Latino Achievement Award
North Carolina Public Health Bioterrorism Risk Reduction and
Response
2
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NEW HANOVER COUNTY
HEALTH DEPARTMENT
2029 SOUTH 171H STREET
WILMINGTON, NC 28401-4946
TELEPHONE (910) 343-6500, FAX (910) 341-4146
Everywhere. Everydly. Everybody.
DAVID E. RICE, M.P.H., M.A.
Health Director
LYNDA F. SMITH, M.P.A.
Assistant Health Director
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Memorandum
To: NHCBH Members
From: Gela N. Hunter, RN, FNP, Chairman
Date: December 5, 2001
Re: Committee Assignment Preferences for 2002
Please review the following list of NHCBH Committees and mark your
preferences. Return your list to me in the self-addressed envelope
provided.
Committee Check If interested
Executive Committee
Environmental Health Committee
Personal Health Committee
Animal Control Services Adviso Board
Association of North Carolina Boards of Health
nJ.mt. Bi"_ _ _ .
Administration
Animal Control Services
Child Health
Communicable Disease
Communi Health
Dental Health
Environmental Health
Laborato
Nutrition
Women's Health Care
(Committee assignments for 2001 are on the reverse side of this
memorandum.)
/I Your .J.Ieahk - Our priori!,! /I
NEW HANOVER COUNTY BOARD OF HEALTH
Committee Assignments
2001
-
Executive Committee:
Dr Wilson O'Kelly Jewell, Chairman
Mrs. Gela N. Hunter, Vice-Chairman
Mr. Henry V. Estep
Mr W Edwin Link
Mr. William T Steuer
Bud!!et Committee:
Member Division
Mr. William T. Steuer, Chairman Administration
Mrs. Anne Braswell Rowe Animal Control Services
Mrs. Gela N. Hunter Child Health Services
Dr. Melodv C. Sneck Communicable Disease
Dr. PhiliD Palmer Smith, Sr. CommutrltVHealth
Dr. Wilson O'Kellv Jewell Dental Health
Mr. W. Edwin Link Environmental Health
Mrs. Estelle G. Whitted Laboratorv
Dr. Michael E. Goins Nutrition
Mr. Henrv V. Esten Women's Health Care
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Environmental Health Committee:
Mr. W Edwin Link, Chairman
Dr. Michael E. Goins
Mrs. Gela N. Hunter
Dr. Philip Palmer Smith, Sr
Mr. William T. Steuer
Persoual Health Committee:
Mr. Henry V. Estep, Chairman
Mrs. Anne Braswell Rowe
Dr. Philip Palmer Smith, Sr.
Dr. MelodyC. Speck
Mrs. Estelle G. Whitted
Animal Control Services Advisory Committee
Dr. Melody C. Speck
Association of NC Boards of Health
Dr. Michael E. Goins
e
BOARD OF DIRECTORS
.. SworI,-
~-ComItyI'8rlllriip
For CbildnD, N!D'R:
3001 W.........A_
WiImiDIJoo, NC 28403
911).S21).S244
_V~Ib_
AlI-"""""""
m5.KarA...,..,SaiI<F
WiImiDIJoo, NC 28401
911).792-9989
/aDd McCludlee, T.-
__eo_1lqlI
202981"51
WiIIIiIIfoa. NC28401
911).34l-6SS9
Solly. JIIII,&lnOo7
Tdomoo CmporotioD
80S N. _.....
P.O. Box 1626
WhiIeWIe, NC 28472
9100642-8229
Mull... de a-JwDp
4411 CIsde I!oyDc Rood
CallIe IIayDe, NC 28429
911)._9949
Father Plol BnDt, SJ
_0. Box 13784
Ban, NC 28S61
2-63s-9429
y......~
CadIoIicIlociol_
401l6_PIocenM
WiImiDIJoo, NC 2840S
91I).ZSI.aI30
RI10 Anal RompbaI
Bnmswick Coammity CoIk:&o
P.O. Box30
SUpply, NC 28462
911).7_ Oll. 387
,.-
r-S<nicesCooidiDllm'
320 ClIesbI.. 8~ Sail< S02
WiImiDllloa. NC 28401
911).341-7184
11m So_
1022 Ccm:us F"'l' Rood
~ NC 28443
910.962-3422
-MqllIs
LcpI Scrvioes of 1.-- Cope Fmr
POBOXBl4
WibJiD&Iaa, NC 28402
911).763-6207
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"0" 'A'
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'Il"I; '"
"Hel/Jil1f! ()ur hI/in Americans"
November 19,2001
New Hanover County Health Department
2029 S. 1 Th Street
Wilmington, NC 28401
Attention: Dr. David Rice, Director
The Board of Directors of HOLA is pleased to announce that the New
Hanover County Health Department has been nominated and selected to be
recognized for one of this year's Latino Achievement Awards. The
nomination reads, ''The New Hanover County Health Department provides
services equally to English speaking and non-English speaking patients in all
areas of the agency."
For all your efforts in community support HOLA would like to
recognize your exemplary efforts. We will be having a smaIl recognition
program at the next HOLA Educational Forum on December 4111 from 12 noon
till 2 p.rn. at the Canterbury Annex. We request your presence for this event.
There will be lunch provided.
We look forward to seeing you there.
Sincerely
~FcS'-
Alan F. Swart
HOLA President
PO Box 483 Wilminw.cn, North Carolina 28402
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STRATEGIC PLANNING PRIORITIES
November 27,2001 Update
I. Access to health care
(Issues #7, 11 & 5)
-+ The annual Inner City Rabies Clinic was held on November 10, 2001, at Five Points
Community Center The clinic has been in operation for nearly a decade to enable pet owners
in this area access to rabies vaccinations for their animals.(a lower number of vaccinations (34)
than last year)
-+ Weekly fluoride mouth rinse continues this year in the New Hanover County Schools. 7652
kindergarten through fifth grade students are participating in this excellent preventive program.
-+
II. Preventive services & lifestyle-related risks
(Issues #12 & 15)
-+ Car Seat Checks: Event to be held on Saturday November 10 at Monkey Junction WalMart
in conjunction with Kure Beach Police Department and the New Hanover County Injury
Prevention Coalition.
-+ Influenza Vaccine Campaign: Excellent response from public - vaccine supply adequate.
A flu clinic is scheduled on November 27 at Carolina Beach Presbyterian Church.
-+ Tuberculosis Elimination Funds: $9,200 was awarded to NHCHD Communicable Disease
Division.
-+ Influenza Vaccine Campaign: Excellent response from public - vaccine supply adequate.
3,041 doses given October 29 through November 9 (1,751 first week, 1290 second week). Many
positive comments have been made by public and staff regarding the smoothness of the
process.
-+ Community Health nurses administered flu vaccine in 3 clinic sites and are administering it
to homebou nd patients
-+ The first annual Public Health Conference was held on October 11, 2001, at the ACS
shelter The conference focused on staff procedures and rabies issues as a means of educating
area veterinarians and developing community ties with representatives from their hospitals.
-+ Carolinas Poison Center for North Carolina: Complimentary poison prevention brochures,
magnets, and stickers received and given to the Child Health Division for inclusion in the Poison
Control packets.
-+
III. Communication, education & marketing (promotion)
(Issue #1 & 4 in part)
-+ Reynolds Tribute: A portrait and a plaque will be placed in the Dr Frank R. Reynolds Clinic
by the end of this week. Thanks to Lynda Smith and Frances DeVane for their special efforts in
making the Tribute a success!
-+ Website: Medical/Health information in Spanish. http://www.graciasdoctor.com
-+ Let's Talk Month: Halloween distribution of parent/child information was a success with over
1,000 messages delivered.
-+ Annual Report: Will be presented to the NHCBH on November 7 The report will be available
on our Web Site. Limited copies will be available upon request.
-+ The Women's Health Care Division participated in the following outreach efforts during the
month of October, 2001
-+ Let's Talk Month - distributed packets of information and resources to area churches,
distributed communication messages attached to lollipops to be handed out as Halloween
treats, distributed communication messages to New Hanover County employees through email
-+ Breast Cancer Awareness Month - Conducted two (2) radio interviews, participated with four
1
health fairs, participated with "Cut for the Cure"
-+ Brett Schoen, our Family Assessment Coordinator presented our "universal screening
process" at a statewide Intensive Home Visiting meeting on November 9, 2001 We have
developed a comprehensive system to survey and assess the needs of new parents, during
pregnancy and at delivery Resources are supplied based on the needs identified, referrals are
made, and follow up provided.
-+ Jean McNeil taught a second class for Dr Bob Weedon's UNCW Honors students regarding
proper pet care and ACS responsibility in the community
-+ Nancy Ryan became a member of DOVIA, an organization of volunteers, to promote
increased helpers at the shelter In addition, ACS was featured in the neighbors section of the
Star News requesting volunteers, and Jean McNeil spoke on WAAV radio with a plea to fill
staffing voids with community partners
-+ "Making a Difference in Diabetes" Magazine: Tenth edition of this diabetes newsmagazine
from the North Carolina Diabetes Advisory Council, Diabetes Prevention and Control Program
and the Herald Sun was distributed to Team.
-+ Newspaper Article "A Mother's Gift'" This family is followed by the New Hanover County
Health Department Maternal Public Health Staff.
-+ Flu Vaccine News Release-11/26/02: Supplies adequate to offer immunizations to everyone
wanting protection from flu.
-+
IV. Facility utilization & Information technology
(Issues #6 & 4 in part)
-+ ACS staff now accesses GIS mapping available on the county web-site. Areas that are not
on current maps can be located utilizing this tool.
-+ Bids received for barcoding project for medical records
-+ Mail Handling Procedures: Mike Winebar (NHC Safety Officer) is scheduled to provide
training to mail handlers on Wednesday, November 28,2001 at 9:00am. He is scheduled at
9:30am on the same day, to provide training to staff handling "State Courier" As soon as
training is received, all mail coming to the health department through the postal service will be
opened by the one person responsible for mail opening. This will include PERSONAL and
Confidential items. Please do not schedule personal or confidential mail which is not business
related to be delivered at the Health Department.
-+
V. Water quality, storm water management & drainage; & Air
quality (Issues #3 & 8)
-+
VI. Emerging health risks
(Issue #13)
-+ Bioterrorism: NHCHD BTL (Bioterrorism Leadership) Team continues to meet each
Tuesday A draft of the policies and procedures has been prepared and will be revised by the
BTL Team.
-+ The BTL Team met twice with NHHN and SEMH Staff. The purpose of the meetings is to
find common ground and to collaborate on areas related to bioterrorism. CDC conducted a video
conference (November 16) on "CDC Responds: Bioterrorism and the Infection Control
Community NACCHO conducted a Bioterrorism Conference Call on November 16.
-+ NCDHHS-DPH released the "North Carolina Public Health: Bioterrorism Risk Reduction and
Response" document on November 15. HB 1471 as signed by Governor Easley, creates 7
Bioterrorism Teams in 7 Lead Local Health Departments for Regional Protection (NHCHD is one
of seven), creates a State Level Bioterrorism Team, and enhances the public health
communication and surveillance system (Health Alert Network, National Electronic Disease
Surveillance System, and Public Health Laboratory Information Management System).
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~ CDC conducted a Laboratory teleconference on November 9. "Protecting the Homefront"
was televised on NHCTV and WECT on November 10. The Medical Society met on November
12 to discuss the medical response to bioterrorism. NHCHD/NHHN weekly meetings begin
today NHC Emergency Manangement Response Team members meet today to discuss field
testing for anthrax and storage issues. The IC3 Meeting is scheduled for today NHCHD will
continue to attend LEPC (Local Emergency Planning Committee) and the Emergency Services
Forum meetings. On November 16, a teleconference "CDC Responds: Bioterrorism and the
Infection Control Community" and a NACCHO Bioterrorism Conference Call will be held.
~ NHCHD has created a Bioterrorism Information Line at 343-6602 (Public can record a
message for nurses).
~ Two videos are available from Pat Johnson: "CDC Broadcast: Anthrax, What Every
Clinician Should Know" and "NHCHD Bioterrorism Exercise and Information Session -
10/25/01 " Health Director gave the "Public Health Response to Bioterrorism" presentation to the
Board of County Commissioners last night. A copy of the presentation was given to the
Management Team. A community forum, "Protecting the Homefront" will be televised on NHCTV
and WECT on November 10 at 6:30 pm.
~ Beth Jones is working on public health guidelines for law enforcement dealing with
suspicious packages.
~ Governor Easley proposed $13.6 million to better prepare NC for terrorist attacks. This
includes establishing seven regional public health bioterrorism teams. NHCHD is one of the
proposed sites.
~ Responding to threats of bioterrorism. Developed written materials for staff and public to
assist in providing education. Attending meetings related to public health role in response.
~ Salmonella: Investigation show cases seem to be linked to a common source.
~ Suspected Foodborne IIness: Being investigated involving some catered meals to several
retailers on Friday after Thanksgiving.
~ TB Contact Investigation: Large TB contact investigation continues related to a new case of
TB.
~
VII. Population growth & diversity
(Issue #2)
~ HOLA Educational Meeting: Next meeting is December 4,2001 from 12:00 noon-2:00pm at
Canterbury Annex. There will be a lunch for $5, a speaker, and presentation of awards.
~
VIII. Discontinued services picked up by Health Department
(Issue #9)
~
IX. Staff Development & continuing education
(Issue # 14)
~ Management Academy for Public Health: Two NHCHD Teams will attend the second round
of classes in Durham. Child Health Team (Janet McCumbee, Alicia Pickett, Kim Roane, Janet
Nelson, and Pat Melvin) will attend on November 7-9 Animal Control Services Team (Jean
McNeil, Daisy Brown, David Howard, Barbara McClure, and Dr Robert Weedon) will attend on
November 14-16.
~ Management Academy for Public Health: The Child Health Team (Janet McCumbee, Alicia
Pickett, Kim Roane, Janet Nelson, and Pat Melvin) attended on November 7-9. Their "Hand in
Hand for Healthier Children" presentation was a success.
~ Management Academy for Public Health: The Animal Control Services Team (Jean McNeil,
Daisy Brown, Barbara McClure, David Howard, and Dr Bob Weeden) attended on November
14-16. Their Spay/Neuter Clinic Project won the green ribbon for the most fundable project.
~ Janet McCumbee reported on several items from MAPH: password protection, analyzing
3
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agency culture, and the "Health Care Criteria for Performance Excellence."
-+ Sarah Smith from ACS attended the GIS training class and came back to train staff on its
use for locating unlisted map locations. Other ACS staff attended HR training courses and
updates.
-+ Staff meeting to address bioterrorism on October 18,
-+ Panel Discussion on Eating Disorders: 8pm tonight at Level 5 @ Citystage (Downtown
Wilmington N. Front Street) free of charge.
-+ CPR Training: For Health Department Staff Thursday 11/29/01 and Friday 11/30/01
-+ STD Clinic Preceptor Site: STD Clinic will be a site for Registered Nurses to receive
precepting for pelvic exams as part of State sponsored Sexual Assault Training.
-+
X. Evaluation of services
(Issue #16)
-+ Mail Handling Procedures: NHC Safety Officer plans to limit the list of current mail handlers
in the County Lynda Smith and Frances DeVane will address the Health Department process,
Our plans should be completed next week.
-+ Temporary Food Facility Rules: Environmental Health Staff will meet with the County
Attorney this afternoon to review the impact of changes to NC General Statutes on exemption
status.
-+ Performance Appraisals Process: Pertormance Appraisals Process Team presented their
recommendations to the Management Team on October 30. The Management Team discussed
the recommendations on November 6 and will continue its review on November 13, Today the
Performance Appraisal Process Policy and Job Performance Definitions were approved, and the
Performance Appraisal Guidelines were revised.
-+ NHC Goals and Departmental Programmatic Policy Goals: Division Directors will submit
suggestions to Lynda Smith by November 26.
-+ Ground Rules: The Management Team received a copy of the ground rules from the Team
Handbook, The Management Team will have a discussion on setting meeting ground rules on
November 27
-+ NHC Administrative Policies and Procedures Manual: Revised sections were distributed to
the Division Directors and will be available in the break rooms.
-+ WIC Federal Budget: Passed by increasing funding of $211 M. Hope to get an additional
$39M from Economic Stimulus Legislation.
-+ Pre-CPT Billing: Is anticipated the first week in December Billing will go back to January
1999.
-+ Medicaid Cost Analysis: Scheduled for January 2002,
-+ HIPAA. Still waiting for GAP analysis. Cindy Hewett has received a summary of
assessments submitted.
-+ The eighth Animal Control Officer position was eliminated due to county downsizing. One
schedule rotation that allowed for greater evening and/or weekend coverage has been removed
due to the loss of the position, Staff continues to evaluate services as attempts are made to
meet the needs of the community efficiently
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AEIOU (Assessing, Evaluating, Improving, Our Opportunities are
Unlimited) Team Minutes
November 19, 2001
Attendance: Carol Bottoms, Mamie Carlos, Beth Jones, Mary Jo Newton, Susan O'Brien, Dave Rice,
Lynda Smith, Marcy Smith
New Business
Dave Rice announced the resignation of Avery Rollinson due to a staff shortage in the Family Planning
Clinic. He suggested that the non-supervisory members compile a list of names of possible
replacements. Since a great deal of time and energy has been devoted to dealing with the events of
September 11 and since the two groups are working on similar issues, blending the AEIOU Team
function in the Board of Health strategic planning process is being considered. Should the team finalize
and wrap up its subcommittee work, table the AEIOU Team, and reconvene the team when the new
organizational capacity tool being developed is available? Dave Rice polled the members present who all
favored this suggestion provided that all subcommittee work had been satisfactorily completed. Dave
said he would poll the team members not present at the meeting.
Reports
e Community Health Assessment
. The Health Department lacks a standard ongoing process to examine internal and ex1ernal trends, to
make forecasts, and to systematically develop long term plans for its future. The Health Department
should conduct or support periodic risk factor surveys to identify community risk factors, their
prevalence, and interrelationships.
. Bobby Waters; Mitzi Chappell; Beth Jones; Mary Jo Newton; Dr Kate Bruce, UNCW, Psychology
Dept., Barbara Shell, Cape Fear Healthy Carolinians; and Dr Steve Meinhold, UNCW Associate
Professor
Beth Jones reported that the CHA team met on October 18. She felt that the goal of the subcommittee is
how to institutionalize or allow an on-going standardized community health needs assessment process.
Funding is critical; possible sources are the newly formed Public Health Foundation (funding not expected
to be available for at least a year according to Bobby) or corporate sponsors provided it could be
guaranteed that money is spent on a health needs assessment.
The state is considering changing the Community Health Assessment cycle to four years. In year one
25% of the counties would report, in year two another 25% of the counties would report, and in year three
and four the remaining 50% of the counties would report.
According to Beth, what is most important is what happens after a community health assessment is
completed; it must be implemented. Implementation could be accomplished if it could go through the
Board of Health of Health strategic planning process,
Access to Care
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. The Health Department seeks to assure that all citizens receive personal health services regardless
of their ability to pay
. Carol; Avery Rollinson; Mamie Carlos; Dianne Harvell; Joyce Hatem; Wendell Hansley, Good
Shepherd House; Regina James; and Mary Piner
.
Mamie Carlos reported that the subcommittee met on August 20. Funding and staffing still limit access to
health care. She pointed out that access to care is also a top priority in the Board of Health strategic
planning process. The subcommittee discussed the need to increase school-based health clinics to get
health care and information to students. A possible solution would be to have a Health Department
representative on the Board of Education Steering Committee to promote the importance of providing
increased health care access to students,
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Mamie indicated that there were no new issues discussed regarding access to transportation. She felt
that the subcommittee has wrapped up its work.
Public Policies/Health Priorities
. The Health Department and the community need to set priorities for addressing health problems
based on the results of the community health assessment.
. Andrea Carson, Susan O'Brien, Lynda Smith, Marcy Smith, Elisabeth Constandy, B, J. Stallings,
Vivian Mears, and Janet McCumbee
The Health Priorities team met on November 15 and formulated a list of recommendations to present to
the AEIOU Team.
1) The Health Director should continue to present Board of Health and/or other public health
information summaries at Health Department monthly staff meetings as appropriate. Dave and Lynda
pointed out that health information is posted on the Health Department Web page.
2) The Health Director should continue to post the Board of Health strategic planning update reports
to Health Department staff via Lotus Notes. _
3) The Board of Health focals should be presented at the Health Department monthly staff meetings, .,
as the Health Director thinks appropriate.
4) Every two years the Board of Health/Management Team should update the strategic plan, which
could be modeled after the October 2000 retreat.
5) Information on health needs could be gathered from the Community Health Assessment and
compiled into a report to use as a resource at the retreat.
The AEIOU Team approved all five recommendations. Dave Rice commented that there was no
indication that the Board of Health would not want to repeat the strategic planning process in 2002,
The final item of business for the Health Priorities subcommittee is to prepare a letter to stakeholders
outlining results of the survey
The nex1 AEIOU meeting is scheduled for January 14, 2002 in the Thomas Fanning Wood Conference
Room, The meeting was adjourned at 4 p.m.
Respectfully submitted,
Marcy Smith
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NORTH CAROUNA DEPARTMENT OF
.. ENVIRONMENT AND NATURAL RESOURCES
.. DIVISION OF ENVIRONMENTAL HEALTH
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MICHAEL F EASLEY, GOVERNOR
WILLIAM G. ROSSI JR., SECRETARY
LINDA. C. SEWALL. DIRECTOR
MICHAEL U. RHODES. SECTION CHIEF
&~:~A
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NCDENR
November 21, 2001
To:
All Environmental Health Personnel
From:
Michael U. Rhodes, Chief
Environmental Health Services Section
DEH, NCDENR
UPDATE
Restaurant Grading Pilot Project
Refereoce:
The Restaurant Grading Pilot Project recently had activity that may be of interest to you.
During the summer of2001 a meeting was held with representatives from each of the seven Pilot Project Counties.
The Pilot Project Counties are Burke, Cabarrus, Catawba, Macon, Mecklenbnrg, New Hanover, and Wllson.
Also represented at the meeting were representatives from the North Carolina Environmental Health Supervisors
Association and the Environmental Health Section of the North Carolina Public Health Association. The purpose of
the meeting was to discuss the types of information to be gathered from the Restaurant Grading Pilot Project Survey
data and Health Services Information System (HSIS) database inquiries.
Attached to this messal!e are the three surveys develooed from innut at the above meetinl! and the State
Center for Health Statistics.
Linda Sewall has told me that at the last Environmental Health Supervisor's Association meeting in Winston Salem
there was a discussion of a possible third option on the part of the survey where
the responder was asked which grade card option was preferred. The possible third option that
was discussed at several stakeholders group meetings was a card with both a large and
prominent letter grade and nwnerical score. We discussed this option with the folks at the State Center
for Health Statistics. The State Center for Health Statistics recommended restricting the survey to the two options
currently being used.
The attached surveys are currently being administered in all Pilot Project Counties and Survey Control Counties.
Also during the above stake holders meeting it was discussed that additional counties should have input into the
survey process. The concept of adding counties to the survey process that were not currently involved in the Pilot
Project was discussed at length. It was determined that Control Counties that were of similar size to the Pilot Project
Counties would be solicited to participate in the survey activity. Five Counties agreed to participate in the survey as
Control Counties. The Survey Control Counties are Cleveland, Lincoln, Onslow, Robeson and Wake. Including
Pilot Project Counties and Survey Control Counties there are 12 Counties participating in the Restaurant Grading
Pilot Project Survey.
Another point of interest is the inclusion of the University of North Carolina at Greensboro, School of Public Health
Education. UNCG will be collecting all Restaurant Grading Pilot Project Survey data. UNCG has agreed to collect
the survey data and develop the report from the data This third party participation will help increase the validity of
the statistical report generated from the survey data.
It is anticipated that all infunnation concerning the Restaurant Grading Pilot Project will be presented to the North
Carolina Commission for Health services at the February, 2002 Commission meeting. Upon presentation of all
statistical data and comments the Commission for Health Services may determine the continued direction for the
Restaurant Grading Pilot Project.
ENVIRONMENTAL HEALTH SERVICES SECTION -
1632 MAIL SERVICE CENTER, RAlEIGH, NoRTH CARoUNA 27699-1 632 TELEPHONE 919-733 2894 FAX 919-7154739
AN EQUAL OPPOR'lUNrTY / AFFIRMA'J'JVE ACTION EMPLDYER
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2001 REHS & ENVIRONMENTAL HEALTH STAFF SURVEYS
1. How long have you been authorized in Food & Lodging?
o Less than 5 years 0 5-10 years 0 More than 10 years
2. Are you currently involved in Food & Lodging? 0 Yes 0 No END OF SURVEY
3. Which card do you think will be most helpful to the public for evaluating the cleanliness of a
restaurant?
A.O
{,
B.O
{,
SANITATION s~
95.0
SANI1A1l0N GRADE
. A
lf~l...t.C,,"I.__~...
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1JJlsiJ""CIJlfli'_....~_-.;.
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4 On a scale of 1 to 5, to what extent do you support the new sanitation score card? Circle one.
1 2 3 4 5
(Not at aD) (A lot)
5. What direction do you think this program should go? Check one response.
o
o
o
Stop, go back to original ABC grade statewide
Expand numeric score card statewide
Other
6. Are you currently working or have you previously worked in a restaurant grading pilot project
county?
o Yes 0 No END OF SURVEY
7. When posting an 88 as opposed to a Grade B, are the restauranteurs more receptive to
suggestions for improvement and education? 0 Yes 0 No
8. Since the beginning of this program do you think the sanitation of establishments in your
county has improved? 0 Yes 0 No 0 Do Not Know
9. Do you think using the new sanitation score card has improved your relationship with the
restauranteurs? 0 Yes 0 Stayed the same 0 Declined
10. Are you spending more time, less time, or about the same amount of time on an inspection?
o More time 0 Less time 0 About the same amount of time
REHS & EHS Survey (Revised May 2001)
2001REHS_EHS _Survey _ DRFT3
I County
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2001 CUSTOMER SURVEY
2.
Do you check sanitation cards? 0 Yes 0 No
Are you a resident of this county? 0 Yes 0 No
3.
As a consumer what type of sanitation grade card do you prefer.
A.O
{,
B.O
{,
C. 0 No Preference
SANXTATION SCORE
95.0
SANJ'OO'ION GRADE
A:
.._..'."C....l._....._~..
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fi!;}:-=:":::::::'~':":::
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4.
When dining out, what is the lowest numeric sanitation score you
would consider acceptable?
o 95 - 102
o 90-94.5
o 85 - 89.5
080-84.5
o 70-79.5
5. Are you aware that a new sanitation score card has been used in a
limited number of North Carolina counties since 1998?
o Yes 0 No
6. When dining out, what is the lowest sanitation grade you would
consider acceptable?
o Grade A 0 Grade B 0 Grade C
County
Rest. ill
Customer Survey (Revised May 2001)
200]_ Customer Survey_Drft3
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2001 RESTAURANTEUR SURVEY
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1.
How long have you been a restauranteur in NC?
o Less than 5 years 0 5-10 years 0 More than 10 years
2. As a restaurant owner what type of sanitation grade card do you prefer?
A. 0 B. 0 C. 0 No Preference
-1.. -1..
SANIDTION SCOBE
95.0
SANroo'lON GRADE
A
..'......c.ml.____
___- __1 ,"",_
~.'""'":::"=.:::::.:::._,,::
:~ -.-'--'-...
-."' ----
. ~b.C~~.....__- ;.-=..-=-
---~- .
,.
;~~--
3. Are you currently receiving 2 point educational credit on your sanitation score?
DYes 0 No
4. What direction do you think this program should go? Check one response.
o Stop, go back to original ABC grade statewide
o Expand numeric score card statewide
o Other
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5. Are you currently operating a restaurant in a county using the new score card?
DYes 0 No End ofsurvey
,,',
6. Do you think using the new sanitation score card has improved your relationship with the
Environmental Health Specialist?
o Yes 0 Stayed the same 0 Declined
7. Have you made any significant changes, physical or operational to improve your numeric
sanitation score?
o
Yes 0
No
8. Did posting the numeric score encourage or motivate you to take educational training?
DYes 0 No
County
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Restauranteur Survey (Revised May 2001)
200] Reslauranteur Survey_DRFf3
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Resolution
OF THE
NEW HANOVER COUNTY BOARD OF COMMISSIONERS
Urging Priority Support For The United States Senate Bill 1486
'Biological and Chemical Weapons Preparedness Act of 2001'
WHEREAS, terrorists may threaten to use, or attempt to use, a biological or chemical weapon
against the United States; and
WHEREAS, with respect to bioterrorism, State and Local first-responder, public health, and
medical communities stand directly on the front lines. How well the United States responds to such
a threat or attack will depend on the preparedness of State and Local communities; and
WHEREAS, State and Local first-responder units lack the basic training and equipment needed to
effectively counter the bioterrorism threats; and
WHEREAS, there continues to be insufficient capital funding by private and public sources of
hospitals, laboratories, clinics, information networks, and other necessary elements to ensure the
provision of public health services in the event of a bioterrorism attack; and
WHEREAS, the terrorism threat extends well beyond traditional methods of attack. Common
everyday agricultural products such as foods, fertilizers, pesticides and even certain animals can be
transformed into devastating weapons that threaten economic well-being as well as public health.
The ability of the United States to diagnose, contain, and treat plant and animal diseases is hampered
by lack of coordination, training, and testing facilities; and
WHEREAS, the common good of resisting bioterrorism through immediate first response and solid
medical and public health infrastructure depends upon a sustained, consistent Federal, State, and
Local focus and resource commitment; and
NOW, THEREFORE BE IT RESOLVED that The New Hanover County Commissioners will
work with Senator John Edwards in support of the'Biological and Chemical Weapons Preparedness
Act of2001'.
Adopted this the _ day of
,2001
Ted Davis, Jr., Chairman
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Public Health History in New Hanover Countv
Some Considerations (Benefits to the Community)
. Community presentations on the uniquc situation of New Hanovcr as a public hcalth
community.
. Aliicles on specific public health events in New Hanover (Newspaper; HistOlical
Socicty; Medical Journals, etc.)
. A monograph on the history of the New Hanover Health Depaliment.
. An improvement in archival resources, catalogues, and resourccs on issues related to
public health in New Hanover County
. Such research and interest would bring the various medical communities in the
county into close communication and it should heighten relationships.
. Should create more interest in the community regarding public health and public
health history
. An oral history collection from former health department employees, physicians, and
others that will be a resource for future researchers and health historians.
. Archival photographs, articles, posters, and other materjals related to public health in
New Hanover County.
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;' -- The.University, of. No'rth Carolina 'at Chapel HiII:~ '.. . ',: '. , " "
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HEALTH LAW
Number 78 October 2001
RESPONDING TO BIOLOGICAL THREATS: THE
PuBLIC HEALTH SYSTEM'S COMMUNICABLE
DISEASE CONTROL AUTHORITY
. Jill Moore
For the past several years, public health officials at the national, state, and local levels have
been concerned about the possibility that individuals or groups might use disease-causing
biological agents in acts of terrorism. Articles have been written on the subject, conferences
held, and preparedness plans developed. I The subject probably was not foremost in the minds
of the general public, however, and even those involved in writing the articles or developing
the plans may have thought it unlikely thaI large-scale acts of bioterrorism would be directed al
civilians in the United States. But in the immediate aftermath of the terrorist attacks of
September II, 2001, concerns about the possibility ofbioterrorism began to surface in the
popular media.2 Shortly thereafter, those same media outlets covered the story as the possibility
unfolded into reality.
It started in the early days of October, when the first case of inhalation anthrax to occur in
the United States in more than Iwenly years claimed the life of a Florida man.3 Within a week,
it was discovered that two of the deceased man's co-workers had been exposed to anthrax and
the exposures were tentatively linked to a letter sent 10 the man's Florida office. Less than a
week after that, another case of anthrax-also associated with a letter-was confirmed in New
York, reports of anthrax-contaminated letters in Nevada and the United States Capitol were
The author is an Institule of Government faculty member who specializes in public health law.
I. See, e.g.. C. Gregory Smith el aI., Bioterrorism: A New Threat with. Psychological and Social
Sequelae, 61 N,C, MEDtCALJOURNAL ISO (2000); N,C. Dept. of Health and Human Services, North
Carolina Public Health Bioterrorism Preparedness and Response Plan: Draft (June 26, 2001) (on file
with author).
2. See, e.g., John Fialka el aI.. Are We Prepared for the Unthinkable?, Wall St. Journal, Sept. 18,
2001, at B1, Sheryl Gay Stolberg, Some See U.S. as Vulnerable in GertnAttack, N.Y Times, Sept. 3D,
2001.
3. Centers for Disease Control and Prevention. Update: Investigation of Anthrax Associated with
Intentional Exposure and Interim Public Health Guidelines, October 200/,50 MORBIDITY & MORTAllTY
WEEKLVREPORT 889, 890 (Oct. 19,2(01).
Health Law Bulletin No, 78
confirmed, and testing of suspicious lellers was under-
way in locations throughout the United States, including
North Carolina. As this bulletin goes to press, there
have been eleven confirmed cases of anthrax, all asso-
ciated with the mail. Three of the cases have been
fatal. 4
Bioterroristthreats or actions require the coordi-
nated response of numerous public agencies and offi-
cials at all levels of government. The federal Centers
for Disease Control and Prevention (CDC) has identi-
fied five key focus areas for bioterrorism response:
I preparedness for bioterrorist acts,
2. disease detection and surveillance,
3. diagnosis and characterization of biological
agents,
4. response to bioterrorist threats and actions, and
5. the development of systems to support
communications among official responders and
communications to the general public.5
The public health system will be a critically important
component of any response plan or effort, as its day-to-
day work involves many of those activities.
In North Carolina, the legal authority for public
health officials to engage in many of the activities re-
quired for bioterrorism response comes from our
state's communicable disease control laws. Those laws
give state and local public health officials numerous
powers and duties that enable them to control the
spread of diseases caused by biological agents. Among
other things, public health officials receive reports of
communicable diseases and conditions from physicians
and other parties, investigate individual cases of com-
municable diseases and disease outbreaks, conduct
disease surveillance activities, provide certain clinical
and laboratory services, educate the public about com-
municable diseases and conditions, and allempt to
ensure that individuals comply with communicable
disease control measures.6 Those powers and duties
apply to the communicable diseases that local health
departments deal with every day, such as sexually
4. News Release, Centers for Disease Control and
Prevention. CDC Summary of Confirmed Cases of Anthrax
and Background Information (Oct. 23, 2001), available on
the Internet at http://www.bt.cdc.govlDocumentsApp
I Anthraxll 023200 I PM/I 023200 I PM.asp.
5. Centers for Disease Control and Prevention, Biologi-
cal and Chemical Terrorism: Strategic Plan/or Prepared-
ness and Response, 49 MORBIDITY & MORTALITY WEEKLY
REPORT 1,8-11 (April 21, 2(00) (hereafter CDC Strategic
Plan).
6. N.C. GEN. STAT ~ l30A-I44 (hereafterG.S.).
.
.
October 2001
h
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transmitted diseases and tuberculosis. But they also .
extend. to all of the biological agents that the CDC has
designated as Category A (or highest priority) agents
for bioterrorism preparedness planning (see Table I).
Table 1. Category A Biological Agents
Category A 7 agents are those that may be used by
terrorists and that pose a particular risk to national
security because they are easily disseminated or easily
transmitted from person-to-person, have high mortality
rates and a high potential for significant public health
impact, and might cause widespread panic or social
disruption. They are:
Anthrax (Bacillus anthracis)
Botulism (Closrridium botulinum toxin)
Plague (Yersinia pestis)
. Smallpox (Variola major)
. Tularemia (Francisella tularensis)
Certain viral hemorrhagic fevers, including
Ebola hemorrhagic fever, Marburg hemorrhagic
fever, Lassa fever, Argentine hemorrhagic fever,
and related viruses.
All of the Category A agents are covered by North
Carolina's communicable disease control laws.
This bulletin reviews the general law of communi- .
cable disease control in North Carolina. It then exam-
ines each of the CDC's Category A agents in turn and
analyzes in greater detail how the communicable dis-
ease statutes and rules would apply to an event involv-
ing a particular agent.
Law of Communicable Disease
Control
In our day-to-day communications, we may use the
term "communicable disease" to refer only to illnesses
that are contagious from person to person. North
Carolina has a legal definition of communicable
disease that includes those illnesses and goes further to
pick up a number of illnesses that cannot be transmilled
from one person to another. ''Communicable disease"
is defined by law in North Carolina as an illness caused
by an infectious agent-usually a virus or bacterium-
7 CDC Strategic Plan, supra note 5, at 5; see also the
CDC's bioterrorism Web page, http://www.bt.cdc.gov The
CDC has designated several chemical agents, such as the
nerve gas sarin. as high.priority chemical agents. Chemical .
agents are not subject to communicable disease control laws
and are not considered further in this bulletin.
2
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October 2001
that can be transmitted from person to person, from an
animal to a person, through an intermediate host or
vector, or through the inanimate environment. S A
person has a "communicable condition" if the person
has been infected with a communicable agent but does
not have symptoms of disease.9 North Carolina's
communicable disease laws apply to both communica-
ble diseases and communicable conditions. All of the
Category A biologic agents discussed in this bulletin
are captured by North Carolina's legal definitions of
communicable disease and communicable condition.
Responsibility for communicable disease control
in North Carolina is shared by state and local public
health officials. At the state level, the Commission for
Health Services promulgates communicable disease
control rules. 10 The state health director has the
authority to examine patient records pertaining to
communicable diseases II and to order isolation or
quarantine in appropriate circurnstances.12 The Divi-
sion of Public Health, within the state Department of
Health and Human Services, has many communicable
disease responsibilities: The Division's Epidemiology
Section receives reports of cases of communicable
diseases,13 coordinates and conducts disease sur-
veillance and disease investigation activities, provides
public information about communicable diseases, and
provides support and assistance to local public health
agencies in their response to communicable disease.
The Division's State Laboratory of Public Health
provides laboratory services that support the diagnosis
of communicable diseases and conditions.
At the local level, the directors of public health
departments must receive reports of communicable
diseases and conditions, t4 investigate reported cases, I 5
ensure that communicable disease control measures
prescribed by the Commission for Health Services have
been explained to the appropriate parties,I6 dis-
seminate public health information,17 and advise local
health officials ahout public health matters. IS Local
health directors also are empowered to examine patient
8. G.S. 130A-133(\).
9. G.S. 130A-133(S).
10. G.S. 130A-147
II. G.S. 130A-I44(b).
12. G.S. 130A-14S.
13. ISA N.C. ADMIN. CODE 19A.0101.
14. G.S. 130A-13S through 130A.139.
IS. G.S. 130A-I44(f); 130A-4I(b)(3).
16. G.S. 130A-I44(e).
17 G.S. 130A-4I(b)(S).
18. G.S. 130A-4I(b)(6).
Health Law Bulletin No. 78
records pertaining to communicable disease 19 and to
exercise quarantine and isolation authority.20
Required Reporting of Communicable
Diseases
Some communicable diseases and conditions are
designated as "reportable," meaning that physicians
and certain others must make a report to public health
officials when they know or suspect that a person has
the disease or condition. Individuals who are required
by law to make reports are listed in Table 2. The law
also authorizes, but does not require, medical facilities
to make a report to the local health director when there
is a patient in the facility who is reasonably suspected
of having a reportable communicable disease or
condition.21
The list of reportable communicable diseases and
conditions is established by the North Carolina Com-
mission for Health Services22 and currently includes
sixty-one diseases and conditions.23 Reports must be
made within time frames prescribed by the Commis-
sion for Health Services. Some diseases-including
those that are highly infectious or cause high mortality,
such as those on the Category A list-must be reported
within twenty-four hours by telephone and in written
form within seven days. Reports must include the name
and address of the patient and the disease diagnosis,
among other things.24
The required reports involve the disclosure of
health information that is ordinarily considered confi-
dential; however, there are specific exceptions to
medical confidentiality laws for required communi-
cable disease reporting. There are two principal confi-
dentiality laws to consider in detennining whether
health care providers may disclose communicable
disease information: the federal medical privacy rule
(also known as the HIPAA25 privacy rule), and a state
statute that addresses the confidentiality of
communicable disease information.
19. G.S. 130A-I44(b).
20. G.S. 130A-14S: 130A-4l(b)(4).
21. G.S. 130A-137
22. G.S. 130A-I34.
23. 15A N.C. ADMIN. CODE 19A.0101.
24. ISA N.C. ADMIN. CODE 19A.0102.
25. H\PAA stands for the Health Insurance Portability
and Accountability Act of 1996, Pub. L. No. 104-191.
Among other things, HIPAA authorized the federal Depan-
ment of Health and Human Services to promulgate a medical
privacy rule. Id. ~ 264.
3
Health Law Bulletin No. 78
October 2001
Table 2. Individuals Required by Law to Report Communicable Diseases and Conditions
.
Reporter What to report To whom to report N.C.G.S.
Physicians Any instance in which the physician has reason to Local health director 130A-135
suspect that a person about whom the physician
has been professionally consulted has a reponable
communicable disease or condition
School principals Any instance in which the principal or operator Local health director 130A-136
and operators of has reason to suspect that a person in the school
child day care or child care facility has a reponable
facilities communicable disease or condition
Operators of Known or suspected outbreaks of food-borne Local health director 130A-138
restaurants and illnesses among customers or employees, and
other food/drink known or suspected food-borne illnesses in food
establishments handlers
Persons in charge Positive tests for certain communicable diseases Local or state public health 130A-139
of laboratories (specified in 15A N.C. Admin. Code officials
19A.OIOI(c))
Local health Communicable diseases, conditions, and positive N.C. Department of Health 130A-140
directors laboratory findings that are reported to the local and Human Services; in
health director some instances, other local
health directors
The federal medical privacy rule applies to enti- these exceptions, the privacy rule does not prevent a
ties covered by HIP AA, which includes most health health care provider from sharing information with
'd 26 I . hi' public health officials investigating and controlling
care provl ers. n most Instances. t e ru e reqUires
health care providers to obtain a patient's pennission communicable diseases.
before disclosing individually identifiable health in- Information about reponable communicable dis-
formation. However, there are broad exceptions to eases is also subject to a strict state confidentiality
that requirement for disclosures made to public health law. The state's communicable disease confidentiality
officials for public health surveillance. investigation, statute requires any person or entity-whether public
and intervention; disclosures that are necessary to or private-to keep confidential all information or
avert serious threats to health or safett; and records that identify a person with a reponable
disclosures that are required by law.2 Because of communicable disease or condition.28 The statute
provides some exceptions to confidentiality, however,
26. HIP AA applies to health plans, health care including several exceptions that specifically pennit
the release of information or records for purposes of
clearinghouses, and health care providers who transmit complying with communicable disease reporting.
health infonnation electronically in connection with a investigations, and enforcement activities.29 A
transaction covered by H\P AA. 45 C.F.R. t 160.102.
27 45 C.F.R. t 164.512(b) (authorizing disclosures to
public health officials for the purpose of preventing or 28. G.S. 130A-143.
controlling diseases, for the conduct of public health 29. G.S. 130A-143(4) (allowing releases of inform-
investigations or surveillance. or other specified public ation that are necessary to protect the public health and are
health activities); 45 C.F.R. t l64.S12(j) (authorizing made in accordance with the Commission for Health
disclosures that are necessary to prevent or lessen a serious Services' rules); G.S. 130A-143(5) (allowing releases that
and imminent threat to the safety of a person or the public, are made pursuant to the communicable disease laws); G.S.
when those disclosures are made in good faith and 130A-143(6) (allowing the Depanment of Health and
consistent with professional and ethical standards); Human Services or a local health depanmentto release
45 C.F.R. t l64.512(a) (authorizing disclosures that are infonnation in order to enforce the communicable disease
required by law). control laws); G.S. 130A-143(8) (allowing the Depanment
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October 2001
separate state law provides immunity from civil or
criminal liability for individuals who report commu-
nicable diseases pursuant to the reporting laws.30
Anthrax, botulism, plague, and tularemia all are
on the Commission for Health Services' list of
reportable communicable diseases and conditions] I
Smallpox and the major viral hemorrhagic fevers are
not. This means only that no one is required by law to
report those illnesses to public health officials. It does
not mean that those illnesses should not be reported,
nor does it mean that the illnesses are exempt from
the remainder of communicable disease control law.
Smallpox and the viral hemorrhagic fevers meet the
legal definition of "communicable disease" and are
therefore governed by all of the communicable dis-
ease control laws except for the ones that by their
terms apply only to reportable diseases and
conditions-that is, the laws governing reporting and
confidentiality of communicable disease
information. J2
Even though they are not reportable illnesses,
health care providers who know or suspect smallpox
or a viral hemorrhagic fever in a patient should make
an immediate report to public health officials and
should not be deterred from making a report by con-
cerns about patient confidentiality The state commu-
nicable disease confidentiality law does not apply to
these diseases since they are not reportable. The fed-
eral medical privacy rule does apply in this case,
however. Under the federal rule, health care providers
may disclose confidential medical information to
public health officials with the permission of the
patient or the patient's legal representative, or without
permission when the disclosure is necessary to pre-
vent or lessen a serious and imminent threat to the
public health.33 Although providers may prefer to
obtain permission before making a report, it is
extremely important to the public health that the
report not be delayed by attempts to obtain permis-
of Health and Human Services and local health
departments to release information for lIle purpose of
preventing or controlling the spread of a communicable
disease or condition); G.S. 130A-143(lO) (authorizing
releases made pursuant 10 G.S. 130A-I44(b), which
requires physicians. persons in charge of medical facilities.
and persons in charge of laboratories to permit a local
health director or the state health director to examine,
review. and copy records for communicable disease control
purposes).
30. G.S. 130A-142.
31. 15A N.C. ADMIN. CODE 19A.0101.
32. G.S. 130A-134 through 130A-143.
33.45 C.F.R. g 164.512(j).
Health Law Bulletin No. 78
sion. The provider will not violate the federal privacy
rule by disclosing confidential medical information
without permission if the provider in good faith
believed that the disclosure was necessary to prevent
a serious and imminent threat to the public's health.
Disease Investigation
Local health directors in North Carolina are
required by law to investigate cases and outbreaks of
communicable diseases and conditions.34 They are
assisted in this effort by state and regional public
health officials. Among other things, the director's
investigation must determine the identity of all per-
sons for whom control measures are required. If con-
trol measures are required, the director must ensure
that the measures are explained to the proper parties
and that the parties comply.35
In the course of a disease investigation, public
health officials will obtain information from a number
of sources, including but not limited to the infected
person, if possible; other exposed persons, if they are
known; and health care providers involved in the
diagnosis and treatment of the infected persons.
Physicians, persons in charge of medical facilities,
and persons in charge of laboratories are required by
law to permit a local health director or the state health
director to examine, review, and obtain a copy of
medical records pertaining to the diagnosis, treat-
ment, or prevention of conununicable diseases or
conditions.36 The law grants immunity from liability
to physicians and persons in charge of medical facili-
ties or laboratories who make their records available
in accordance with this law.37
Communicable Disease Control Measures
The North Carolina Commission for Health
Services is required by law to adopt rules prescribing
communicable disease control measures.38 The Com-
mission has adopted specific control measures for
HN, Hepatitis B, sexually transmined diseases, and
tuberculosis.39 The control measures for most other
communicable diseases and conditions are contained
in the American Public Health Association's Control
34. G.S. 130A-I44(a); 15A N.C. ADMIN. CODE
19A.0103(a) and (b).
35. 15A N.C. ADMIN. CODE 19A.0103.
36. G.S. 130A-I44(b).
37 G.S. 130A-I44(c).
38. G.S. 130A-I44(g).
39. 15A N.C. ADMIN. CODE 19A.0202through .0205.
5
Health Law Bulletin No. 78
of Communicable Diseases Manual (hereafter
Communicable Diseases Manual),40 which is
incorporated by reference in the communicable
disease control rules.4t The Communicable Diseases
Manual contains control measures for all of the Cate-
gory A biologic agents except for smallpox, which
was certified as eradicated by the World Health
Organization in 1980.
The Commission also has prescribed general
principles to be followed in applying the manual's
control measures, and in devising control measures
for communicable diseases and conditions for which
there are no specific control measures. Among other
things, those principles state that control measures
must be reasonably expected to decrease the risk of
transmission and must be consistent with recent sci-
entific and public health information. For diseases
that are transmiued by the airborne route-which
includes several of the Category A agents-the
control measures must require physical isolation of
the person for the duration of infectivity 42
All persons are required by law to comply with
the communicable disease control measures estab-
lished by the Commission.43 Failure to comply is a
misdemeanor punishable by a sentence of up to two
years.44
Isolation and Quarantine
In North Carolina, isolation and quarantine
authority may be exercised by a local health director
or the state health director.4S Isolation and quarantine
authority are both legally defined as the authority to
limit the freedom of movement or action of persons
or animals in order to prevent the spread of commu.
nicable diseases or conditions. The distinction
between the terms is subtle and not necessarily in
accord with their common meanings; isolation applies
to persons who actually have a communicable disease
or condition, while quarantine applies to persons who
40. Abram S. Benenson ed.. Control of
Communicable Diseases Manual. 16th ed. (American
Public Health Association, 1995) (hereafter Communicable
Diseases Manual). The manual may be purchased from the
American Public Health Association through its
Publication Sales Department. P.O. Box 753, Waldorf, MD
20604; or on the Association's Web site. www.apha.org.
41. 15A N.C. ADMIN. CODE 19A.0201(a).
42. ISA N.C. ADMIN. CODE 19A.0201(b).
43. G.S. 130A-I44(O.
44. G.S. l30A-25.
4S. G.S. 130A-145.
October 2001
have been, or are reasonably suspected of having .
been, exposed to a communicable disease or condi-
tion.46 In either case, the local or state health director
may limit the freedom of movement of the person.
Isolation or quarantine authority may only be exer-
cised when and for so long as the public health is en-
dangered, and only when all other reasonable means
for correcting the problem have been exhausted and
no less restrictive alternative exists.47
Duties of Physicians
While most of North Carolina's communicable
disease control law addresses the authorities and
responsibilities of the public health system, portions
of the law create legal obligations for private parties
as well. In particular, physicians have several impor-
tant duties under the communicable disease control
law. Physicians must;
. Report communicable diseases and conditions
to the local health director, as described earlier
in this bulletin.48
Instruct individuals with communicable
diseases and conditions in the disease control
measures that are required by law.49
. Cooperate with communicable disease investi- .
gations by making records and information
available to public health officials who pro-
perly request them. so
46. a.s. 130A-133(2) and (4). Quarantine authority
also applies to individuals wbo have not received legally
required immunizations. with the limitation that those
individuals may only be quarantined when there is an
outbreak. of the disease for which they have not been
immunized and the local health direclOr has determined
that immunizations are required to control the outbreak.
47 G.S. 130A-145. The Commission for Health
Services has imposed further restrictions on isolation and
quarantine orders "for communicable diseases and
communicable conditions for which control measures have
been established." 15A N.C. ADMIN. CODE 19A.0201(d). It
is unclear what this phrase means, but in the context of the
communicable disease control rules as a whole, it seems
likely that it means only those diseases and conditions that
have specific control measures in the rules-i.e., HIV,
Hepatitis B, sexually transmitted diseases, and tuberculosis.
For those diseases and conditions, isolation and quarantine
orders may be no more restrictive than the applicable
control measures.
48. G.S. 130A-135. .
49 l5A N.C. ADMIN. CODE 19A.021O.
50. G.S. 130A.I44(b).
6
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October 2001
Application of Communicable
Disease Laws to Category A
Biological Agents
Anthrax
Anthrax is an acute infection caused by a spore-
fonning bacterium. It occurs primarily in hoofed
animals-such as goats, pigs, and cattle-and only
rarely in humans. It is not spread from person to per-
son but through contact with the spores. Anthrax can
infect the skin (cutaneous anthrax), the intestinal
tract, or the respiratory system (inhalation anthrax).
Symptoms usually appear within seven days after
exposure.5t
Anthrax is a reportable communicable disease in
North Carolina.52 Physicians who know or suspect
that a patient has anthrax must make a report to the
local health director within twenty-four hours. An
initial report must be made by telephone and followed
by a written report within seven days.53A person in
charge of a laboratory must report any lab findings
that indicate anthrax to the state's Division of Public
Health, General Communicable Disease Control
Branch, within twenty-four hours.54 A medical facil-
ity in which a patient has known or suspected anthrax
is authorized by law to make a report to the local
health department. 55
The control measures for anthrax are set forth in
the Communicable Diseases Manual. Among other
things, the control measures require that reports be
made to local health authorities and that contacts and
the source of the infection be investigated. 56 Immuni-
zation of contacts is not required and is not available
to the general public. Antibiotic therapy can prevent
illness in persons exposed to anthrax. 57
Many of the control measures that appear in the
Communicable Diseases Manual appear to assume
that the anthrax infection will have occurred from an
51. Communicable Diseases Manual, supra note 40.
at 18-20.
52. 15A N.C. ADMIN. CODE 19A.0101(2).
53. ISA N.C. ADMIN. CODE 19A.0102(a).
54. 15A N.C. ADMIN. CODE 19A.0101(c)(I)(B),
.0102(d)(3).
55. G.S. 130A-137
56. Communicable Diseases Manual, supra note 40,
at 21-22.
57 Centers for Disease Control and Prevention. Facts
About Anthrax, Botulism, Plague. and Smallpox. available
on the Internet at http://www.bt.cdc.govlDocumentsApp
lFactsAboul!FactsAbout.asp (hereafter. CDC Fact Shee.).
Health Law Bulletin No. 78
occupational or other exposure to raw animal materi-
als. Anthrax infections that are caused through
terrorist acts may ultimately require the application of
additional or different control measures. North
Carolina's communicable disease rules acknowledge
that public health officials may need to devise control
measures for diseases for which specific control
measures are not contained in the state rules and
require that any such measures be consistent with
recent scientific and public health infonnation.58 This
would appear to authorize public health officials to
devise control measures that are specific to containing
anthrax caused by bioterrorism, provided that those
measures are consistent with recent scientific and
public health information.
Botulism
Botulism causes weakness and paralysis of the
muscles. It can cause death by paralyzing the breath-
ing muscles. There are three main forms of
botulism-foodborne botulism, infant botulism, and
wound botulism. Foodborne botulism is caused by the
ingestion of botulinum toxin in contaminated foods.
Infant botulism occurs in infants who harbor the
clostridium botulinum bacterium in their intestines.
Wound botulism can occur when wounds become
infected with the bacterium. Botulism is not conta-
gious from person to person. Botulism caused by
terrorism would most likely be of the foodborne
variety The symptoms of foodborne botulism usually
appear twelve to thirty-six hours after exposure. 59
Botulism is a reportable communicable disease in
North Carolina.60 Physicians who know or suspect
that a patient has botulism must make a report to the
local health director within twenty-four hours. An
initial report must be made by telephone and followed
by a written report within seven days.61 A person in
charge of a laboratory must report any lab findings
that indicate botulism to the state's Division of Public
Health, General Communicable Disease Control
Branch, within twenty-four hours.62 An operator of a
restaurant or other food and drink establishment must
report known or suspected outbreaks of botulism
among customers or employees to the local health
58. lSA N.C. ADMIN. CODE 19A.0202(b).
59. Communicable Diseases Manual. supra note 40,
at ~9; CDC Fact Sheet. supra note 57
60. lSA N.C. ADMIN. CODE 19A.0101(3).
61. lSA N.C. ADMIN. CODE 19A.0102(a).
62. lSA N.C. ADMIN. CODE 19A.0101(c)(1)(F).
.0102(d)(3).
7
Health Law Bulletin No. 78
director within twenty-four hours.63 A medical facil-
ity in which a patient has known or suspected botu-
lism is authorized by law to make a report to the local
health department.64
The control measures for botulism are set forth in
the Communicable Diseases Manual. Among other
things, the control measures require that reports be
made to local health authorities, and that contacts and
the source of the infection be investigated.65 There is
no vaccination available to prevent botulism; how-
ever, the CDC maintains a supply of botulism anti-
toxin that can reduce the severity of botulism symp-
toms if it is administered early in the course of the
disease.66
Plague
Plague is caused by a bacterium that is found in
rodents in many areas of the world. It is usually
transmitted to humans through an intermediate host,
typically a flea. Naturally occurring plague usually
begins with a localized abscess followed by the
enlargement of the lymph nodes. The enlarged nodes
are known as buboes (hence the name. bubonic
plague). However, plague can also infect the lungs to
create a lethal infection called pneumonic plague,
which can be spread from person to person. Symp-
toms of pneumonic plague usually appear two to four
days after exposure.67
Plague is a reportable communicable disease in
North Carolina.68 Physicians who know or suspect
that a patient has plague must make a report to the
local health director within twenty-four hours. A.n
initial report must be made by telephone and followed
by a written report within seven days.69 A person in
charge of a laboratory must report any lab findings
that indicate plague to the state's Division of Public
Health, General Communicable Disease Control
Branch, within twenty-four hours.70 A medical facil-
ity in which a patient has known or suspected plague
63. I5A N.C. ADMIN. CODE 19A.0102(b) and (c).
64. G.S. 130A-137
65. Communicable Diseases Manual, supra note 40.
at 69-70.
66. eve Fact Sheet, supra note 57
67 Communicable Diseases Manual, supra note 40,
at 353-54; eve Facl Sheet, supra note 57
68. l5A N.C. ADMIN. CODE 19A.0101(37).
69. t5A N.C. ADMIN. CODE 19A.OI02(a).
70. 15A N.C. ADMIN. CODE 19A.0101(c)(l)(Y).
.0102Id)(3).
.
.
October 2001
is authorized by law to make a report to the local .
health department.71
The control measures for plague are set forth in
the Communicable Diseases Manual. The control
measures require the isolation of patients with pneu-
monic plague until forty-eight hours of appropriate
antibiotic therapy have been completed and the
patient has demonstrated a favorable clinical
response. Persons who have been in face-to-face
contact with pneumonic plague patients or who live in
a patient's household should receive prophylactic
antibiotics and be placed under surveillance for seven
days. If an exposed person refuses the antibiotic
therapy, he or she must be isolated and placed under
surveillance for seven days. Additional control meas-
ures call for ridding patients' possessions and house-
holds of fleas and rodents, reports to local health
authorities, and the investigation of contacts and the
source of the infection.72 There is no vaccine against
pneumonic plague.73
Smallpox
The eradication of smallpox is considered one of
the great public health triumphs of our time. The last
case of naturally occurring smallpox was in Somalia .
in 1977 In 1980, the World Health Organization cer-
tified that smallpox had been eradicated. At that time,
all known samples of the variola major virus, which
causes smallpox, were held in tight security by the
United States or the Soviet Union.74 Today, those
remain the only official stores of virus. However,
there have been reports that other parties-including
the governments of North Korea and Iraq-have sup-
plies of the virus.75
Meanwhile. in the years since eradication, rou-
tine vaccination against smallpox has ceased. Small-
pox is no longer a reportable communicable disease
in most jurisdictions, including North Carolina, and
specific control measures for smallpox are no longer
contained in the Communicable Diseases Manual.
Smallpox nevertheless is within the reach of North
Carolina's communicable disease control laws,
71. G.S. 130A-137
72. Communicable Diseases Manual, supra note 40.
at 356-57
73. eve Fact Sheet. supra note 57
74. eve Facl Sheet, supra note 57; eommunicable
Diseases Manual, supra note 40. at 425.
75. E.g., William l. Broad. U.S. Acls 10 Make .
Vaccines and Drugs Against Smallpox, N.Y limes, Oct. 9.
2001.
8
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October 2001
because it meets the statutory definition of a commu-
nicable disease.76
Smallpox begins with high fever and body aches
that are followed within days by a skin rash. The rash
begins with flat red lesions that become pus-filled and
then crust over. Smallpox is highly contagious and is
fatal in about 30 percent of cases. Routine vaccina-
tion against smallpox ended in the United States in
1972, and it is unknown whether the immunity pro-
vided by vaccinations administered before that date is
still effective. It is therefore assumed that all persons
in the United States, including those who were vacci-
nated, are susceptible to smallpox infection.77
Because it is highly contagious and vaccine-
created immunity may no longer be effective, a single
case of smallpox constitutes a public health
emergency 78 Because naturally occurring smallpox
has been eradicated, a single case also raises a strong
suspicion of bioterrorism. Therefore, although small-
pox is no longer on Nonh Carolina's list of reponable
communicable diseases, health care providers who
know or suspect that a person has smallpox should
make an immediate repon to the local health depan-
ment. Health care providers may make the repon with
or without the patient's permission.79
When public health officials receive a repon of
smallpox, they must immediately initiate a disease
investigation and implement disease control meas-
ures. Local health officials should also immediately
contact appropriate state and federal public health
and law enforcement officials. There are no specific
control measures for smallpox in the Nonh Carolina
communicable disease rules or the Communicable
Diseases Manual; therefore, public health officials
must devise appropriate measures. Those measures
may include isolation or quarantine of infected and
exposed persons.80 Vaccination against smallpox can
prevent or lessen the severity of illness in persons
exposed to smallpox if it is given promptly Smallpox
vaccine is not ordinarily available, but the United
States maintains an emergency supply 81
76. G.S. 130A-133(l).
77 CDC Facl Sheet, supra note 57
78. See Communicable Diseases Manual. supra note
40, at 425 ("Should a smallpox-like case occur,
IMMEDIATE telephonic communication with health
authorities is obligatory.").
79.45 C.F.R. ~ 164.512(j).
80. See CDC Facl Sheet, supra note 57; 15A N.C.
ADMIN. CODE 19A.0201(b)(2) (requiring isolation for
diseases transmitted by the airborne route).
81. CDC Facl Sheet, supra note 57
Health Law Bulletin No. 78
Tularemia
Tularemia is a bacterial infection that is usually
caused by tick or deerfly bites, or by contact with
infected rabbits, muskrats, and squirrels. It is not
transmitted from person to person. Naturally acquired
tularemia usually affects the lymph nodes, but it may
also take a pneumonic form, infecting the lungs.
Symptoms usually appear three to five days after
exposure.82
Tularemia is a reponable communicable disease
in Nonh Carolina.83 Physicians who know or suspect
that a patient has tularemia must make a repon to the
local health director within twenty-four hours. An
initial repon must be made by telephone and followed
by a written repon within seven days.84A person in
charge of a laboratory must repon any lab findings
that indicate tularemia to the state's Division of
Public Health, General Communicable Disease
Control Branch, within twenty-four hours.85 A medi-
cal facility in which a patient has known or suspected
tularemia is authorized by law to make a repon to the
local health depanment.86
The control measures for tularemia are set fonh
in the Communicable Diseases Manual. Among other
things, the control measures require repons to local
health authorities and the investigation of contacts
and the source of the infection.87 Tularemia vaccina-
tion ordinarily is not available, but an investigational
vaccine is maintained by the U.S. Army Medical
Research Institute of Infectious Diseases.88
Many of the control measures that appear in the
Communicable Diseases Manual appear to assume
that the tularemia infection will have occurred from a
natural source. Tularemia infections that are caused
through terrorist acts may ultimately require the
application of additional or different control meas-
ures. Nonh Carolina's communicable disease rules
acknowledge that public health officials may need to
devise control measures for diseases for which
specific control measures are not contained in the
state rules, and require that any such measures be
consistent with recent scientific and public health
82. Communicable Diseases Manual. supra note 40.
at 499-500.
83. 15A N.C. ADMIN. CODE 19A.0101(54).
84. 15A N.C. ADMIN. CODE 19A.0102(a).
85. 15A N.C. ADMIN. CODE 19A.010I(c)(l)(N),
.0102(d)(3).
86. G.S. 130A-137,
87 Communicable Diseases Manual, supra note 40,
at 501-02.
88. CDC Facl Sheet, supra note 57
9
Health Law Bulletin No. 78
information.89 This would appear to authorize public
health officials to devise control measures that are
specific to containing tularemia caused by bioterror-
ism, provided that those measures are consistent with
recent scientific and public health information.
Viral Hemorrhagic Fevers
The CDC's Category A list of biological agents
includes the general category of viral hemorrhagic
fevers-illnesses that are caused by viruses such as
Ebola. These viruses cause high fevers and hemor-
rhaging throughout the body The hemorrhaging can
lead to shock, multiple system failure, and death.90
The illnesses are contagious from person to person.
They are known to be spread through contact with
infected persons' body fluids, and they may be spread
through the airbome route as well.
None of the viral hemorrhagic fevers is repon-
able in North Carolina. However, a single case of a
viral hemorrhagic fever is an important public health
event and may create the suspicion that a bioterrorist
act has occurred. Therefore, health care providers
who know or suspect that a person has a viral hemor-
rhagic fever should make an immediate repon to the
local health department. Health care providers may
make the repon with or without the patient's
perrnission91
Control measures for the viral hemorrhagic
fevers are found in the Communicable Diseases
Manual. Infected persons must be isolated. Persons
who have been in contact with the infected persons
are not required to be quarantined, but they should be
placed under surveillance.
REC~IVED"
NOV 0 7 2001
N.H. CO. HEALTH DEPT.
89. 15A N.C. ADMIN. CODE 19A.0202(b).
90. E.g., Communicable Diseases Manual, supra note
40, at 159 (Ebola-Marburg Viral diseases).
91. 45 C.P.R. ~ 164.512(j).
October 2001
Conclusion
Terrorist acts involving the use of biological
agents require the coordinated response of numerous
public and private actors, including-but not limited
to-public health officials, law enforcement officials,
emergency responders, and health care providers.
North Carolina's communicable disease control laws
are an important tool in the response to bioterrorism,
but they are only one of many tools that are needed.
This bulletin therefore provides only one piece of the
legal information that readers may need. Moreover,
as this goes to press, our understanding of the attack
involving anthrax is still developing. For the most
recent updates and additional information about
responding to bioterrorist events, readers should
consult the CDC's bioterrorism Web page at
hllp://www.bt.cdc.gov and the North Carolina Divi-
sion of Public Health's Web site at htlp:l/www.dhhs
state.nc.usldphl.
This Bulletin is published by the Institute of Government to
address issues of interest to local and state government employees
and officials. Public officials may photocopy the Bulletin under
the following conditions: (1) it is copied in its entirety; (2) it is
copied solely for distribution to other public officials. employees,
or staff members; and (3) copies are not sold or used for
commercial purposes.
Additional copies of this Bulletin may be purchased from the
Institute of Government. To place an order or to request a catalog
of Institute of Government publications. please conlact the
Publications Sales Office. Institute of Government. C8# 3330
Knapp Building, UNC-CH, Chapel HiD, NC 27599-3330;
lelephone (919) 966-4119: fax (919) %2-2707; e-mail
sales@iogmail.iog.unc.edu;orvisit the Institute's Web site at
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The Institute of Government of 1bc: University of North Caro-
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iC2001
Institute of Government. The University of North Carolina at
Chapel HiD
Printed in the United States of America
This publication is printed on pennanent, acid-free paper in .
compliance with the North Carolina General Statutes
10
~.
,\
~
Novemb~i' 2001
New Hanover County Health Department
Betsy Summey, FNP, 343-6531
Phys~c~an Role CrU;~cal ~n
PubUc Health Response to B~oterror~sm
The events of September II, 200 I
raised the level of concern for our
country's vulnerability to acts of
terrorism. VYhen inhalational anthrax
was diagnosed on October 3, an
already anxious public recognized
bioterrorism as a real threat.
The Centers for Disease Control and
Prevention (CDq established a
Bioterrorism Office in 1998 to
prepare for the critical role public
- health would play. The CDC received
... funding for preparedness at national,
., state, and local levels; created the
national pharmaceutical stockpile to
ensure availability of pharmaceuticals,
supplies, and equipment; intensified
research into potential bioterrorism
agents; enhanced laboratories and
communication systems; and provided
training to improve capacity for
surveillance and response. The plan,
while a work in progress, has been
tested over the last two months.
Public health is a critical player in the
response to this new national threat.
National rt~sources were immediately
available and tons of medical supplies
reached New York City within seven
hours of deployment after attacks on
the World Trade Center. VYhen
anthrax cases were identified, the
CDC activated the national stockpile
and investigation teams to assist with
surveillance, investigation and control
at multiple sites in the country. The
role of public health was headline
... news as the CDC provided national
.. leadership.
On October 8 events in our
community moved bioterrorism from
a theoretical discussion to
implementation of a response plan.
Bioterrorism has been on the training
and preparedness agenda for three
years In New Hanover County.
Systems are in place for physicians to
report 61 reportable illnesses. In
addition, the reporting system
requests physicians to report any
unusual disease patterns or
unexplained illness to assist in
identifying emerging diseases not yet
identified as reportable. This includes
suspicion of a biological terrorist
incident. Public health is required to
report these to the state and the FBI.
Public health has a responsibility to
prepare for a rapid response and to
provide leadership should a
bioterrorist incident occur
Public Health Goals
+ Increase ability to detect
bioterrorist attack
'11Tq)I'OYe capacity to rapidly
respond
. Reduce severity and extent of
injuries or a_e
+Reduce loss of life
The role of the medical provider is
crucial since an index case may seek
medical care. The first identification of
a suspicious bioterrorist attack will
likely come from an alert clinician.
There may be symptomatic individuals
with no identified exposure who seek
care. Shortly after that information
reaches the news media, there may be
many asymptomatic individuals seeking
care who are concerned about
exposure. A clinician's individual
judgement along with consultation
with colleagues will be helpful.
However, the local public health
department is the central source of
information for surveillance of illness
and death in the community. Public
health surveillance assimilates and
analyzes disease reports, identifies
disease clusters, and develops
intervention strategies necessary for
outbreak control.
The confirmation of a. diagnosis,
laboratory testing, deployment of
professionals to conduct large
investigations, availability of supplies
and technical advice, and
recommendations for treatment and
prevention are services provided by
the CDC and accessed through the
local health department. It begins with
the initial report from the clinician.
Public Health Strategies
'Early Identification and
treatment
. Prompt reporting
+.Epldemlologlc investigation
. Education
+ Preventive medications
.Outbreak controIllMaures
+lsoIation/quarantine a
Since October 8, New Hanover
County Health Department (NHCHD)
has issued public health advisories on
the handling of mail and encourages
911 notification of any suspicious mail
that may pose a threat. There have been
hundreds of phone calls from concerned
citizens. For example. when anthrax was
identified in other parts of the country,
there were calls to physicians and
NHCHD about possible exposures in
those locations and post-exposure
prophylaxis. Law enforcement, Hazmat
response teams, and emergency
management respond to 91 i calls and
conduct threat analyses and determine
when samples are submitted for testing.
Thus far, all samples tested from New
Hanover County have been negative for
anthrax. Anthrax is not
the only biological
agent with weapon
potential.
Biological Agents
with Weapon Potential
Of Highest eoo-n:
- Anthrax (_)
- PIaguo<-l
. lloIuIism (tcocIn)
. Smallpax-varlcla
(vlNS)
. Inhalation Tulanmla
(->
. IlemonhagIc Fever
(vlNS)
Based on:
-/Easeof _nation
or ba._.iwIon
"_formajor
publlc_~
(~and
mortllIlty)
.'_ for public
panic and social
dlsrupllon
Case definitions for heightened alert will
be developed based on the biological
agent suspected. In the absence of
specifics, clinicians are being asked to be
alert for anything unusual.
VIIhat to Report
+ Unusual tenlpOl'8l or geographic
clustering
. Unusual age alStribution for
common diseases
. Other deviations from nonnaI
dl_ patterns
~ Unusuai number of unexplained
deaths In otherwise healthy
populations
POINTS TO REMEMBER
I) First responders must be
protected, and that includes
clinicians.
2) Communication is essential.
NHCHD has a 24-hour reportable
line that pages a communicable
disease nurse upon leaving a report.
The number is 343-6682.
3) E-mail capacity greatly enhances
our ability to share critical health
information rapidly. If you would
like to receive e-mail alerts, send a
request to be added to the
physician list-serve to bjones@nhc.
BlllI'.
4) A vital concern is to provide
appropriate information while not
creating unnecessary alarm or
panic.
New Hanover County has been selected
as one of seven regional sites to receive
funding for a medical epidemiologist an~
support activities as a result of North_
Carolina legislation, which passed with
very impressive speed.
A wall chart is available at www unc.edul
deptslspiceJbioterrorism.html to assist in
early identification of symptoms
consistent with biological agents. The
CDC Web site at www.bt.cdc.gov
contains MMWR articles and clinical
information for preparedness and
response and general information for the
public. Up-to-the-minute information is
available.
VVhile we can expect state and federal
assistance, our community will look to us
to protect it and provide care.
Coordinating with physicians, law
enforcement, emergency management,
first response teams, and hospitals is
essential. Strong ~lationships among key
responders will strengthen our
preparedness. Surveillance starts on the
front line in a local community. The
better reporting and surveillance system_
we have in place, the better our outcome.
will be. Our community expects that.
Now is the time to make it happen.
Communicable Disease Statistics
New Hanover County
July 1, 2001 - October 31, 2001
AIDS............................ 8
HIV Infection................... 16
Lyme Disease ................... 0
Campylobacter ........... 8
Chlamydia ............... 125
E.Coli 0157:H7 ............0
Gonorrhea............... 114
Hepatitis A.................. 2
Hepatitis B (acute) ..... 3
Hepatitis B (carrier).... 6
Hepatitis C (acute) ..... 1
Pertussis........................... 0
Rky. Ml Spotted Fever....3
Salmonellosis................. 58
Shigellosis ........................ 3
Strep, Group A Invasive ..1
Syphilis ...........................12
Tuberculosis ....................5