[Update 2: See my October 31 post for information about the law of isolation and quarantine in North Carolina, and for resources for more information about the 2014 Ebola epidemic.]
[Update: On September 30, the CDC announced that a case of Ebola had been diagnosed in the United States. The CDC’s statement is here. This post initially stated that a State Health Director’s temporary order to report had been issued for enterovirus D68. In fact, the temporary order required reports of middle eastern respiratory syndrome (MERS), not enterovirus. There have been no cases of MERS in North Carolina. The author regrets the error and has corrected the post.]
Earlier this month, I attended the North Carolina Public Health Association’s annual fall conference and had the opportunity to hear a panel address the 2014 Ebola virus epidemic. The panel featured state epidemiologist Megan Davies and several local health directors who, while focusing on Ebola, spoke about many aspects of core public health infrastructure—including the capacity of North Carolina’s public health system to detect and respond to communicable disease outbreaks.
As Dr. Davies was quick to point out, the present Ebola epidemic is still confined to west Africa. [Update 9/30: On September 30, the CDC reported that a case had been diagnosed in Texas.–JM] While the global public health community is appropriately concerned with containing this outbreak—the worst on record—it isn’t something that we should feel imminently threatened by here in North Carolina. Any epidemic may be worthy of our attention, as North Carolinians may work, study, volunteer, or travel almost anywhere in the world. But Ebola has characteristics that make it easier to contain than other outbreaks that readers of this blog may recall. Unlike SARS or H1N1 flu, it is not an airborne illness—Ebola is spread by contact with the body fluids of an infected person. It is a zoonotic disease, meaning it can be transmitted to humans from infected animals, but the animals that are its natural hosts are not native to North America. Also, the outbreaks of Ebola that have occurred periodically since the 1970s have unfortunately and tragically been facilitated by inadequate health care facilities and supplies in the countries where the disease originated. Even the health care workers who cannot avoid dealing with patients’ body fluids can be kept healthy with infection control methods and supplies that are routine in US health care facilities. [Update 10/31: The preceding statement reflected the views of public health officials at the time. After two health care workers became infected in Dallas, the CDC revised its infection control guidance. As I noted below and repeated in my October 31 post, control measures sometimes change as new knowledge is acquired. I did not expect to provide an example in my posts, but there you have it.–JM]
In other words, there is no need to panic about Ebola in North Carolina. However, this has also been the summer of enterovirus D68 and chikungunya, and those diseases have appeared in our state. Plus, some communicable diseases are endemic in North Carolina, meaning that they have not been eradicated and can be expected to appear from time to time. I hope you’ll agree, that makes this a good time to write about the laws that North Carolina has in place to detect and respond to communicable diseases.
Detecting Communicable Disease in North Carolina
Public health officials employ a variety of strategies to detect cases or outbreaks of communicable diseases. Two that are particularly important and in use in North Carolina are disease surveillance systems, and laws that require certain diseases or conditions to be reported to public health officials.
North Carolina conducts statewide public health surveillance via a data collection system called NC DETECT (North Carolina Disease Event Tracking and Epidemiologic Collection Tool). This system receives data daily from North Carolina hospitals and allows public health officials to identify public health threats rapidly.
Disease reporting is separate from surveillance but also critical to rapid detection. North Carolina law provides for both mandatory and voluntary communicable disease reporting, and both routine and non-routine reporting occasions. State laws require physicians and certain others to routinely report more than 70 communicable diseases and conditions. The list of reportable communicable diseases is adopted as a rule by the Commission for Public Health and is published in the NC Administrative Code. The types of diseases on the list include those with public health significance such as tuberculosis, HIV, the various forms of hepatitis, most of the vaccine-preventable diseases, sexually transmitted diseases, illnesses caused by contaminated food or water, mosquito-borne illnesses, novel influenza viruses, and assorted others (including hemorrhagic viruses such as Ebola). A table listing the relevant statutes and describing who is required to report what, when, and to whom is available here.
In addition to this routine reporting of diseases on the list, some health care professionals have a legal duty to report other diseases or conditions when the State Health Director orders it. A state law, G.S. 130A-141.1, allows the State Health Director to issue a temporary order requiring health care providers to make certain kinds of reports. Such an order might require reporting a particular disease, or it might require reporting certain kinds of symptoms, trends in prescribing, or other uses of health care services. This law was adopted to address emerging illnesses, because there might be a period of time during a new outbreak when public health officials know that something is going on but aren’t sure what it is yet and want to monitor symptoms while the knowledge foundation is developing. Or sometimes a new disease first appears somewhere other than North Carolina, and our state’s public health officials want to ensure early notification if and when it arrives here. Just this past summer, this authority was used twice to require reports related to the emerging illnesses of chikungunya (a mosquito-borne illness) and middle eastern respiratory syndrome (MERS). Chikungunya has since been documented in North Carolina.
In addition to routine and non-routine mandatory reports, state law allows for some voluntary reporting. For example, G.S. 130A-137 allows (but does not require) health care facilities to make reports of the diseases designated reportable. This is an intentional redundancy because any physicians who work in the facilities are already required to make reports, but this provides another route to get the information in if for some reason a physician’s report is not made. Another state law, G.S. 130A-476(a), allows voluntary reports of symptoms and other facts that are not ordinarily reportable but may indicate a health threat caused by bioterrorism. Why have laws authorizing voluntary reporting? Both of these laws serve the very important purpose of allowing reporters to disclose information to public health officials without violating confidentiality laws.
Indeed, health care providers sometimes worry that communicable disease reporting violates confidentiality or the federal HIPAA privacy rule, even when the report is required rather than voluntary. However, HIPAA specifically allows reports to public health officials when a state law either requires or permits it (see 45 CFR 164.512(b)), and all of the reports described in this post are required or permitted by a state law. The specific state laws that require the reports also provide immunity from liability under state law for disclosures of information that are made in accordance with the reporting requirement. Finally, a state communicable disease confidentiality law (G.S. 130A-143) limits public health officials’ redisclosure of information that is reported, which provides additional confidentiality protection for communicable disease information. This doesn’t mean public health officials can’t redisclose the information — they can, but they have to follow state laws and rules that ensure the information is used for public health purposes, treatment purposes, and a few other things that are spelled out in the statute.
Controlling Communicable Disease in North Carolina
G.S. 130A-144 authorizes the Commission for Public Health to adopt rules prescribing communicable disease control measures, and requires all persons to comply with them. The Commission’s rules are published in Title 10A, Subchapter 41A of the NC Administrative Code. The term “communicable disease control measures” is not defined in state law, but it has the meaning common sense would suggest: measures or steps that are taken to control the spread of a communicable disease. Local health directors are responsible for ensuring that communicable disease measures are given. In practice this often simply means ensuring that people who may spread the disease are informed about the required control measures, but it could also mean instructing other persons to take steps to prevent the spread of disease.
The Commission for Public Health has adopted rules specifying the communicable disease control measures for only a few diseases and conditions: HIV, hepatitis B and C, sexually transmitted diseases, tuberculosis, smallpox/vaccinia, and SARS. For other communicable diseases, the required control measures are those that are specified in guidelines and recommended actions published by the federal Centers for Disease Control and Prevention (CDC), or if no such materials are available, from the guidelines and recommendations in the Control of Communicable Diseases Manual, a publication of the American Public Health Association (APHA). Both the CDC documents and the APHA manual are incorporated by reference into the Commission’s rules.
Emerging illness is a term that is used to describe two different types of diseases: those that are entirely new to a population, as HIV was in the early 1980s, or known diseases that begin to rapidly increase in frequency or geographic spread, as West Nile virus was in the early 2000s. In recent years, CDC has been quick to develop and publish guidelines and recommended actions for emerging illnesses. However, this gets complicated. With emerging illnesses, there are often many unknowns: In what ways does the disease spread, and how readily? How severe is it? Are existing treatments effective, or is something new required? Are certain people more susceptible than others? The answers to all these questions are relevant to developing appropriate control measures, but those answers may also be emerging or evolving as knowledge develops. When this happens, CDC may change its guidelines and recommended actions.
By incorporating the CDC materials into North Carolina’s communicable disease rules, the Commission for Public Health has attempted to ensure that the control measures required by state law are aligned with up-to-date scientific understanding about emerging illnesses. On the other hand, by adopting potentially changing guidelines as the required control measures, the Commission has handed public health officials a challenge: keeping up with changes in control measures and communicating those changes effectively to the public. For example, at the outset of the 2009 H1N1 outbreak CDC guidance advised school closure if any student or staff member developed the flu. But very shortly thereafter, CDC rescinded that guidance and replaced it with recommendations for schools that did not contemplate closure in most circumstances. This created confusion and posed a significant communication challenge for public health and school officials throughout the United States, including in North Carolina, where a school closure occurred right before the guidance changed.
Public health officials also must keep people who are subject to control measures apprised of any changes. I have advised public health officials who give control measures to keep a record of what those control measures are on the day they are given. CDC guidance is usually electronic, and may be drawn from a CDC website that could change if the guidance is updated. If a public health official must give control measures based on CDC electronic guidance, I recommend saving or printing a copy of the guidance document, dating it, and keeping careful records that clearly identify the date of the CDC document the official relied on when the control measures were given. This could be important if the official later must explain why he or she ordered X when the CDC later decided that Y was the more appropriate control measure.
Conclusion and Resources for More Information
At the beginning of this post, I referred to public health infrastructure. The laws I have described are part of the infrastructure that allows public health to detect and respond to communicable diseases in North Carolina. Surveillance, detection and response are essential public health activities that are carried out routinely in our state, though in the absence of a current outbreak they may be “under the radar.” For more information about communicable disease control in North Carolina, visit the communicable disease page on the state Division of Public Health’s website.
If you’d like to know more about the emerging illnesses mentioned in this post, here’s where to go for information:
- Enterovirus D68 – Information from the CDC is available here. The NC Division of Public Health also has information, including a memo with recommendations for NC health care providers, available here.
- Chikungunya — The CDC’s information on this disease is here. Information about the disease in North Carolina is presently on the NC Division for Public Health’s home page.
- Ebola – The World Health Organization is tracking the 2014 outbreak and making information available here. The CDC’s information on the current outbreak is here and general information about the virus is here. Information from the NC Division of Public Health, including information about the uninfected volunteers who returned to North Carolina from west Africa in August, is available on the Division’s home page.