Public Health Department Policy & Procedure Manual Example


High Risk Exposure – Resource for Clinicians



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High Risk Exposure – Resource for Clinicians

In the event that an exposure is determined to be high risk by a clinician, he/she can call the CDC Hotline for Occupational Bloodborne Exposures at 888-HIV-4911. Overuse of HIV prophylaxis in the occupational setting is a significant issue. All prophylactic medications have great potential for serious adverse reactions. Explain the situation to the hotline’s clinical specialist and they will make recommendations regarding prophylaxis.

Refusal of Blood Test by Exposed Individual


Any individual who has been exposed to blood, body fluids, or other potentially infectious material and refuses any follow-up testing and evaluation must sign the Blood Test Declination for Employees Exposed to Potentially Infections Material.

EVALUATION:
Any exposure to blood, body fluids, or other potentially infectious material will be immediately reported to the health department director. Evaluation of each exposure incident shall be consistent with the Exposure Control Plan, using the Employee Bloodborne Incident Report. The health department director or his/her designee will assist the exposed individual in setting up an appointment with a health care provider within 24 hours. Utilizing Aspirus Occupational Health will be strongly encouraged to assure that rapid HIV antibody testing can be done. Hepatitis C and HIV testing may also be conducted through the health department. The health department director will assure that current CDC recommendations are followed.

REFERENCES/LEGAL AUTHORITY:


  • Infection Control Manual
  • EpiNet Manual, State of Wisconsin, Department of Health and Family Services, EpiNet guidelines can be found under “Information for Health Professionals” on each disease page listed at the Communicable Disease Subject A-Z Index at: http://www.dhs.wisconsin.gov/communicable/index.htm


  • MMWR, June 29, 2001, Volume 50, No. RR-11: Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis

  • Wiscsonsin Administrative Code Chapter 145

  • Chapter 252 Wisconsin Statutes

POLICY TITLE: Rabies Prevention and Control



EFFECTIVE DATE: 1/5/10

DATE REVIEWED/REVISED: 7/2/12

AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
PURPOSE STATEMENT:
To protect Pepin County residents from exposure to rabies; to investigate all occurrences with possible human exposure to rabies and facilitate proper response (medical care, prophylactic rabies treatment; quarantine, euthanization, etc.).
POLICY:
Pepin County Health Department will coordinate an effective rabies control response to all suspect human exposures.

PROCEDURE:
Physicians and Medical Community:

  • Administer treatment to bite victims. Exposure is defined in rabies flowchart found here: http://www.dhs.wisconsin.gov/communicable/rabies/RabiesAlgorithm/Index.htm.

  • Determine if rabies post-exposure prophylaxis is recommended.

  • Contact the appropriate county dispatch as soon as possible after a potential rabies exposure.

  • If you treat the bite victim or submit animal for testing, notify the bite victim of the animal testing results.


Pepin County Dispatch:
  • Contact law enforcement for bite complaints via phone or fax and provide details of the bite incident reported



Law Enforcement Officer:

  • Conduct initial investigation of all animal bites and complaints.

  • Complete order of quarantine, including date of final examination at the end of quarantine. See Health Officer for order of quarantine forms.

  • Issue rabies control report and ensure quarantine compliance and veterinary care within 24 hours of incident or notification of incident.

  • If owner is noncompliant, take measures to ensure compliance.

  • Consult with health department for fee-exempt testing.

  • Consult with veterinarians and physicians.

  • Provide education on animal bites, rabies and quarantines to animal owner.

  • Assist in animal euthanasia when necessary.

  • Transport animals to quarantine facility as necessary.

Owner of animal (defined as any person who owns, harbors, keeps or controls and animal.)



  • Immunize all animals as appropriate and keep a valid vaccination certificate.

  • License animals

  • Deliver animal to quarantine facility if required by order of quarantine

  • Pay for fees associated with, but not limited to, treatment or examination by veterinarian, quarantine in isolation facility, euthanasia fees and preparation of specimens for testing

  • Comply with quarantine order issued by law enforcement officer.



Quarantine Facility:

  • House quarantined animals in a segregated area during observation period

  • Prevent animal contact with the general public during quarantine period

  • Ensure veterinary observations are completed as appropriate

  • Bill animal owners for quarantine costs
  • Euthanize animals as appropriate



Veterinarians:

  • Vaccinate and maintain vaccination records for individual animals and respond to inquiries from public health, humane officers or law enforcement about vaccination status of a particular animal

  • If an owner presents an animal that has bitten a person, contact the appropriate county dispatch as soon as possible. Do not vaccinate or euthanize until the quarantine period expires.

  • Examine animal and quarantine as necessary.

  • Consult with Health Department and county humane officers as necessary.

  • If animal is to be euthanized for rabies testing, request fee-exempt testing from the health department using fee-exempt status form, or by telephone contact. Fee-exempt testing may be granted if the animal is severely injured or extraordinarily vicious, and owner consents to euthanize the animal for the test.

  • Prepare and submit specimens to the State of Lab Hygiene.

  • Examine quarantined animal three times (or fewer as appropriate), sign rabies control report certifying that the animal exhibited no signs of rabies and forward to issuing officer.

  • Notify the legal authority that issued the rabies control report immediately if animal owner does not report to the obligatory second and third animal examinations.

  • Return signed rabies control report forms to the health department within 2 days of the final examination

  • Upon completion of quarantine, vaccinate animal if necessary

  • Notify the bite victim of the lab results if you submit an animal to the State Lab of Hygiene for rabies testing


Health Department:

  • Receive order of quarantine and incident report from law enforcement
  • Conduct initial public health investigation of all animal bits and complaints


  • Consult with bite victims, veterinarians, physicians and law enforcement officers

  • Provide education on animal bites, rabies and quarantines to animal owners

  • Approve fee-exempt testing at State of Lab Hygiene (WSLH), consult with WSLH and Division of Health (DOH) personnel

  • If owner is noncompliant, take measures to ensure compliance

  • Maintain a list of contacts at WSLH, DPH, and other local health departments

  • Complete and enter rabies control reports into database, retain and file hard copies


Corporation Counsel/District Attorney:

  • Prosecute non-compliance with enforcement orders issued by humane officers as per Ch.95.21.

  • Ensure appropriate use of dog license fund

  • Initiate legal action against animal owners who fail to reimburse county for expenses paid to keep the animal in an isolation facility, supervision and examination ad the fee for the laboratory examination


County Clerk:

  • When an animal involved in a bite incident has no owner, pay from the dog license fund expenses incurred in connection with keeping the animal in an isolation facility, supervision and examination of the animal by a veterinarian, preparation of the carcasses for laboratory examination and the fee for the laboratory examination

Note: Owners of animals are responsible for all expenses incurred during quarantine according to Chapter 95 (Section 95.21, 2h) of the Wisconsin Statutes. This is true even if the victim was on the owner’s property when bitten. If the animal involved has no owner, the fees will be paid from the dog license fund. Non-compliance will be entered by the Pepin County Corporation Counsel/District Attorney. Legal action will be initiated against animal owners who fail to pay fees related to Order of Quarantine.

WSLH rabies requisition sheet can be found here:


http://www.slh.wisc.edu/home/images/rabiesrequisitionsheet.pdf
More information on rabies can be found here:

http://www.dhs.wisconsin.gov/communicable/rabies/index.htm
A link with further information at the CDC morbidity and mortality weekly report can be located at:

http://www.cdc.gov/mmwr/

EVALUATION:
Rabies partners will be updated annually on rabies prevention protocols, roles and responsibilities. A meeting will be convened if there are changes to protocols.
REFERENCES/LEGAL AUTHORITY:


  • Ch. 94.21 Stats. – Animal Health

  • Ch 254.51(5) Stats. – Environmental Health: Powers and Duties

  • Ch. 59.23 Stats – Counties: Clerk

  • Ch. 173 Stats. – Animals: Humane Officers

  • Ch. 174 Stats. – Dogs

  • Ch. ATCP 13 – Local Rabies Control Programs

POLICY TITLE: TB – Accessing Services

EFFECTIVE DATE: 3/30/09

DATE REVIEWED/REVISED: 7/16/12

AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
PURPOSE STATEMENT:


  1. To ensure accurate and timely reporting of TB suspects and cases of active disease.

  2. To ensure that all persons affected by tuberculosis receive the services they need.

  3. To prevent the spread of TB.


POLICY:

The Pepin County Health Department will assure immediate reporting of all suspect and active cases of tuberculosis according to Wisconsin Statute 252.07 and Wisconsin Administrative Code HFS 145.04. Public health staff will assure that case finding, diagnosis, and treatment of suspect or confirmed active tuberculosis disease are carried out according to protocols established by the Centers for Disease Control and Prevention and the State TB Program. Pepin County Health Department will promote accurate identification and treatment of latent tuberculosis infection, and will foster accessibility to all services and resources for those who are affected by tuberculosis.

PROCEDURE:

Persons with Suspect or Confirmed Active TB Disease


  1. Reporting a person who is a suspect or confirmed case of active TB disease:

  1. a. Refer to other agency policies regarding the need for isolation or

  2. confinement, and for source case investigation instructions.

b. Evaluate all data elements when a DPH 4151 (Acute and Communicable

Disease Report) is received from a health care provider. Complete any

missing data.

c. Complete a DPH 44151 when a verbal/phone report of a person with

suspect or active TB disease is received.

d. Access and document all available information regarding the person and

report the case to the state TB program immediately (608-266-9692).

e. Send the DPH 44151 within 24 hours to the state TB program. It can be

faxed instead to (608) 266-0049. Faxing the form will satisfy the immediate

reporting requirement and the 44151 mailing requirement. If TB is later

ruled out, communicate that fact to the state TB program. The case should also be entered into Wisconsin Electronic Disease Surveillance System (WEDSS), and paper forms can be scanned into the electronic filing cabinet for the case in WEDSS.

f. All forms required for reporting and documentation can be found at:

www.dhfs.state.wi.us/dph_bcd/TB.

  1. Ordering medications for persons who are suspects or confirmed cases, contacts to an active case, a child age four or under, or a youth age five or older that a physician has placed on window prophylaxis:


  1. Facilitate a medial evaluation for the client. If the attending health care provider does not have the most current information on treating active disease, provide resources. Contact the state TB program (608-266-9692) if the health care provider could benefit from consultation.

  2. Fax the blank DHP 44000 (attached) to the health care provider if they do not have one, and provide any necessary instructions. Medication protocols approved by the American Thoracic Society are printed on page two of the DPH 44000. Pages three and four provide instructions.

  3. Obtain prescription and take the following actions:

  • Compare the regimen prescribed to the approved regimens and

note any variations.

  • Review the DPH 44000 and address any discrepancies.

  • Contact the health care provider as needed to clarify orders.

  • Phone the TB program at (608) 266-9692 with any questions.

  1. Fax page one of the completed DPH 44000 with the signed prescriptions on it to the state TB program (608-266-0049), and alert the TB program staff by phone (608-266-9692) that you are sending a request.

  2. In special circumstances, medications can be filled locally in order to secure them more quickly. These circumstances include the following:

  • A close contact to an active case with a newly positive TB skin test

who also has a high-risk medical condition.

  • A contact to a case who is a young child or is HIV positive or has

another high-risk medical condition that results in being

immunosuppressed, regardless of their skin test results.


  • A contact who is five or older but a physician has made a medical

determination that window prophylaxis is needed.

  1. The state TB program will send a fax providing a client identification number and authorizing pharmacy billing and TB program payment for the medications.

  2. Supply the local pharmacy with the prescriptions. Also provide them with the TB Program authorization with the client ID number and billing instructions (attached).




  1. Receiving and picking up medications:

  1. Go to the pharmacy and pick up the medications dispensed for the client, acting as an agent of the client.

  2. Deliver medications to the client, assessing the client according to the “Tuberculosis Screening and Follow Up” policy/procedure.

  3. Educate the client/family regarding TB and the importance of adherence and completion of therapy.

  4. Assess for the need for directly observed therapy (DOT).

  5. Assess all clients throughout therapy for: risk factors for adverse reactions, occurrence of adverse reactions, medication efficacy, side effects, adherence to regimen, and overall effect of treatment on the individual and family.

  6. If medications are obtained through a local pharmacy, arrange for monthly refills throughout therapy.

  7. Inform the state TB program of any changes in the client’s medication therapy.




  1. Closing out a suspect of active disease after disease is ruled out:

  1. Notify the TB program by phone (608-266-9692) when a suspect of active disease is confirmed as not having TB disease.
  2. Continue the procedure for treating persons with LTBI for the suspect who turns out to have infection. Submit the DPH 44125 Follow Up on Therapy (attached) when this person has completed therapy, transferred out of state, etc. or complete the TB Med Follow-up tab for this case in WEDSS See the “Tuberculosis Screening and Follow Up” policy/procedure for forms.





  1. Notify the TB program by phone (608-266-9692) as soon as you learn that any person with active TB or LTBI is moving out of your jurisdiction.

  1. Report the following information:

  1. Receive name, address, and phone number of appropriate new health department for that address from the TB program.

  2. Refer client for continuing care.

  3. Gather relevant documentation to forward to the new health department, such as:

  • Culture results

  • Physician’s notes

  • Chest x-ray impression, skin test dates, and results

  • Sensitivity results

  1. Write a summary letter to mail or fax to the new health department, along with the following:

  • Demographic data and any “tips” needed to locate the person;

  • Things that have worked well for the person;

  • Information about treatment adherence, culture, family,

psychosocial issues;

  • Side effects or adverse reactions;

  • Follow up medical appointments.

  1. Phone the new health department and provide verbal referral.

  2. Handle medications that have not yet been administered or delivered according to the following criteria:

Within the State of Wisconsin:

  • Patient may take the bottle they are currently using.

  • Send any undelivered bottles to the new health department.

To other states and international locations:


  • Patient may take the bottle they are currently using and one additional

bottle.

  • Do NOT send any medications out of the state of Wisconsin.

Document handling of medications in the client’s record.

  1. Provide the patient with copies of information forwarded to the new health department.

  2. Instruct the patient to make contact with the new health department upon arrival and provide him/her with the name and phone number of the person to contact.

  3. For persons moving out of state, phone the TB program to facilitate a smooth transition and use the following criteria:
Persons with active disease

  • Request that the TB program do an interstate transfer.

  • Send a copy of a summary letter addressed to the receiving health

department to the TB program. Keep a copy for our records.
Persons with LTBI

medication handling, as well as calling and sending (or faxing) the

clinical information. Complete documentation in WEDSS.



  • Complete and submit a DOH 4125, Follow Up on Therapy form to the

state TB program or complete the TB Med Follow-up Tab in WEDSS.

  1. Phone the TB program for guidance with referring persons with active disease or LTBI for continuing care if they are migrating from state to state within the U.S. or to and from Mexico.

  2. For persons moving out of the U.S., phone the TB program to facilitate a smooth transition.

Persons with Latent TB Infection (LTBI)

1. Reporting:


  1. Persons who have LTBI and are not at high risk for suddenly breaking down with disease are not ordinarily a threat to the public. They do not need to be reported to the public health department.

  2. Ensure that a chest x-ray is obtained for clients you become aware of with a positive skin test so TB can be ruled out promptly. Call the TB program at 608-266-9692 if there are funding issues.

  3. Advocate for the client with the health care provider if treatment for LTBI is appropriate.



  1. Initiating services and ordering medications for a person with LTBI:

  1. Facilitate a medical evaluation and a prescription from a health care provider to begin medication therapy. Provide resources as needed. Contact the state TB program (608-266-9692) if the health care provider wishes to consult with another medical provider regarding treatment decisions.

  2. Fax the DPH 44000 (attached) to the health care provider if needed and provide any needed instructions. Approved medication protocols are on page two of the DPH 44000.

  3. Have the health care provider complete and fax the DPH 44000 to the state TB program. The health care provider could simply fax the prescriptions to the TB program while public health staff completes the DPH 44000.

  4. Be sure all data elements of the DPH 44000 are completed.

  5. Fax page one of the DPH 44000 to the state TB program (608-266-0049). A fax of the original signature is equivalent to an original signature.
  6. The state TB program will start a case in WEDSS indicating that the DPH 44000 has been processed and the medications are on their way to the health department.


  7. Medications will be received 1-2 weeks after the TB program receives the request.

  • If the medications do not arrive promptly, check with the TB

program to be sure all needed information has been received and

processed.



  1. A local pharmacy may be used for medications for treatment of LTBI.

  2. Place all medications in a locked cabinet and deliver to the client as scheduled.

  3. Arrange for medication refills throughout therapy. Order medication refills from the state TB program by completing the refill request form (DOH 44126) at least one month in advance or request refills using the preferred method of WEDSS, by completing the TB Med Refill tab on the case incident in WEDSS.




  1. Establishing care and monitoring for the client with LTBI:

  1. See “Tuberculosis Screening and Follow-Up” policy/procedure.




  1. Closing out the case of the person with LTBI with the TB program:

  1. Submit the DPH 44125 when therapy is complete or use the preferred method of completing the TB Med Follow-up tab in the case incident in WEDSS. See “Tuberculosis Screening and Follow-Up” policy/procedure.


Persons with special reporting requirements and needs (e.g. immigrants, refugees, K1 fiancés, etc.)

  1. These individuals require prompt follow up because:

  1. The overseas chest x-ray, sputum evaluation, and decision about their possibility of being infectious may have been done quite a while ago and may no longer reflect their current tuberculosis status.
  2. There is great potential for persons to become infectious during their travels, even though they may have been considered non-infectious when they were evaluated in their home country. The process of coming to the United States may have been long, stressful, and unhealthy and medication therapy may not have been taken even if it was prescribed/indicated.


  3. No skin testing is done during the process of coming to the United States.




  1. The health department may receive information about an immigrant or refugee with tuberculosis disease or infection in one of the following common manners:

  1. A letter or new WEDSS incident from the state TB program arrives with enclosed information from the CDC Division of Quarantine or another state’s health department. This letter describes the role of the health department with emphasis on:

  • Securing the medical evaluation for the client to rule out active

disease and/or begin treatment for disease or infection, and

  • Returning the Report on Alien with Tuberculosis, CDC 75.17 form,

to the state TB program to complete the reporting requirements.

  1. A client may walk into the health department with a need for follow up related to TB infection or disease.




  1. Classifications of immigrants and refugees related to their TB evaluations prior to coming to the U.S.:

  • The primary role of the health department with each of these categories of persons is to apply and read a TB skin test and facilitate prompt medical evaluation.

  1. Locate the client on the table on the following page when you receive a Report on Alien with Tuberculosis form (B1 or B2 “yellow form”) and the packet of information from the TB program. It is possible that the person may have become infectious between the time they left their home country and the time they arrived in Wisconsin.

  2. Secure interpreters when needed.
  3. Provide a TB skin test and facilitate a medical evaluation as soon as possible.


  4. Facilitate application for medical assistance for those believed to be eligible. See attached “Medical Assistance Benefits for Persons with Tuberculosis” for more information. Migrant workers have the same right to MA as all U.S. citizens.

Those ineligible for TB MA, may qualify for the Pepin County TB Dispensary Services


EVALUATION:


REFERENCES/LEGAL AUTHORITY:



  • Wisconsin Statutes 252.07(8) and 252.07(9)

  • Wisconsin Administrative Code HFS 145.05.

  • Tuberculosis Screening and Follow Up

- Conducting a Comprehensive Contact and Source Case Investigation

- Confinement

- Isolation

- Directly Observed Therapy



POLICY TITLE: TB – Confinement

EFFECTIVE DATE: 3/30/09

DATE REVIEWED/REVISED: 7/16/12

AUTHORIZED BY: Heidi Stewart, BSN, Health Officer / Director
PURPOSE STATEMENT:


  1. To provide for the legal confinement of persons who are known or thought to have infectious or high-risk tuberculosis who do not voluntarily adhere to isolation/airborne precautions, refuse medical evaluation, or refuse to follow a medical treatment regimen and pose a substantial threat or potential threat to themselves or others.

  2. To prevent or suppress the spread of TB.



POLICY:



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