Continuation Guidance -- Budget Year Five

Attachment I

EARLY WARNING INFECTIOUS DISEASE SURVEILLANCE

Guidance for Supplementary Activities in Support of the Early Warning
Infectious Disease Surveillance (EWIDS) Project

### Background

Terrorism is an ever-present threat in our times. Of special concern are
those forms of bio-terrorism that can inflict mass casualties. A
terrorist-induced outbreak of a dangerous and highly communicable
disease such as smallpox would require a concerted response by the
public health emergency response systems to prevent catastrophic
mortality and morbidity. Because pathogens do not recognize or respect
geopolitical boundaries and international travelers can spread a
contagious disease quickly to other nations, early warning surveillance
and prompt sharing of findings of concern among U.S. states, Mexican
states, and Canadian provinces along the borders and beyond is a public
health and national security imperative.

Funds provided by the Early Warning Infectious Disease Surveillance
(EWIDS) project, an activity led by the Office of the Assistant
Secretary for Public Health Emergency Preparedness, will enable the
enhancement of surveillance and epidemiological capabilities at the US
northern and southern borders, with emphasis on creating interoperable
systems with Canada and Mexico.

The EWIDS project will enable improvement of cross-border detection and
reporting of infectious disease outbreaks, epidemiological
investigations, surveillance-specific laboratory capabilities and
communications systems as well as surveillance and epidemiology related
training in states along the northern and southern borders of the United
States. The goal of EWIDS is to assist US border states, in coordination
with neighboring provinces/states in Canada and Mexico, to improve
surveillance capabilities at the state, local and tribal level to launch
an epidemiological investigation promptly, to share surveillance
(including laboratory) data and to provide for appropriately trained
public health personnel for these activities.

The key elements of an effective early warning infectious disease
surveillance system in support of public health preparedness response
consists of on-going surveillance to detect the outbreak, formulating
the appropriate response to and control of the outbreak through analysis
of the surveillance-based clinical and laboratory data, and planning/
implementing adequate health interventions.

The HHS-funded EWIDS project focuses **exclusively** on enhancing
infectious disease surveillance and epidemiology along the U.S. northern
and southern borders (in coordination with Canada and Mexico,
respectively) and the development of associated capabilities and
capacities within the 20 U.S. border states.

In accordance with the statutory language authorizing this project,
EWIDS funds are **NOT** intended to support non-surveillance-related,
broader border health activities in terrorism preparedness. Nor can
these funds be used to supplant other surveillance and/or
epidemiological activities already supported by the CDC Public Health
Preparedness Cooperative Agreements.

***Critical Capacities Relevant to Cross-Border Surveillance and
Epidemiology***

**Activities eligible for EWIDS funding are those in CDC's** **Focus
Areas B, C, E and G**. (Please note that, to be considered for EWIDS
support, proposed activities in Focus Areas E and G ***must*** be
surveillance and epidemiology related.) There are selected [Critical
Capacities]{.underline} (see below) within Focus Areas B, C, E and G
that represent the core expertise, capabilities and infrastructure that
are essential in responding to either a naturally occurring or a
terrorist generated infectious disease outbreak. Associated with these
selected Critical Capacities are [Activities That May be
Considered]{.underline}. Though not exhaustive, these lists provide
examples of related activities that recipients may propose to develop to
achieve the relevant Critical Capacities**.**

For each **Critical Capacity** that you plan to develop**,** the work
plan, must provide: (a) a brief description of the existing capacity in
your jurisdiction along the border, (b) an assessment of whether this
capacity is adequate, and (c) where you judge the capacity inadequate, a
proposal for effecting improvements during this budget
period\--including a timeline to guide implementation, measurable
milestones to facilitate accountability, and a proposed budget.

**I. SURVEILLANCE AND EPIDEMIOLOGIC CAPACITY**

A.  *Public Health Surveillance and Detection Capacity*

**Critical Capacity:** To rapidly detect a terrorist event along the
U.S. northern and southern borders through a highly functioning
mandatory reportable disease surveillance system, as evidenced by
ongoing timely and complete reporting by providers and laboratories,
especially of illnesses and conditions possibly resulting from
bioterrorism, other infectious disease outbreaks, and other public
health threats and emergencies.

**Activities That May be Considered:**

1.  Develop or enhance reporting protocols, procedures, surveillance
    activities, information dissemination, or analytic methods that
    improve the usefulness of the reportable disease system on both
    sides of the border. Develop or improve infectious disease
    surveillance along and across the international border by
    establishing a network of hospitals, clinics, epidemiologists and
    laboratories to conduct active sentinel surveillance for emerging
    infectious diseases and syndromes such as SARS, West Nile Virus, and
    fever and rash syndromes in a

> uniform manner. The long-term goal is to unify disease tracking for
> all illnesses and conditions possibly resulting from bioterrorism,
> other infectious disease outbreaks, and other public health threats
> and emergencies in the northern and southern border states.

2\. Develop and evaluate sentinel/syndromic surveillance programs in
border hospitals and clinics to rapidly detect (a) influenza-like
illness (ILI) and distinguish possible bioterrorism-caused illness from
other causes of ILI and (b) severe acute vesicular rash syndromes
resembling smallpox and other febrile exanthemas to distinguish possible
bioterrorism-caused illness from other causes and assist in case
definition through specific clinical entry criteria and differential
diagnosis.

3.  Communicate and provide feedback to reporting sources in your
    jurisdiction along the international border about notifiable
    diseases, conditions, syndromes and their clinical presentations,
    and reporting requirements and procedures, including those
    conditions and syndromes that could indicate a terrorist event.

4\. Assign a master's or doctoral trained or equivalent epidemiologist
(s) (bilingual, as appropriate) and/or public health nurse(s) to
cross-border infectious disease surveillance activities.

5\. Engage border counties and federally recognized tribes along the
border in your state to participate with public health officials in
cross-border collaborative activities through Mutual Aid Agreements,
Memoranda of Understanding, and/or contracts. Where appropriate, include
local binational health councils and/or Indian Tribes/Native American
organizations in bioterrorism surveillance activities.

B.  *Public Health Epidemiologic Investigation and Response Capacity*

**Critical Capacity**: To rapidly and effectively investigate and
respond to a potential terrorist event, as evidenced by ongoing
effective state and local responses to naturally occurring individual
cases of urgent public health importance or outbreaks of disease along
our international borders.

**Activities That May be Considered:**

1.  Collaborate with Canada or Mexico (as appropriate) to design,
    develop, and adopt a binational surveillance needs assessment tool
    to be used by public health officials on both sides of the border to
    identify gaps in the capacity of the state and local health
    departments to respond to bioterrorism event or infectious disease
    outbreak. Specific needs assessment studies may focus on
    epidemiology and surveillance functions and laboratory capacity to
    address cross-border epidemiological investigations and response
    needs.

2\. With local public health agencies, develop or enhance cross-border
surveillance protocols, response procedures, legal or regulatory
provisions affecting binational, cross-border public health activities,
or communication and information dissemination that improve the
effectiveness of the public health epidemiologic preparedness and
response, to include planning for surge capacity. Particular attention
should be paid to binational cooperation in border regions to facilitate
any necessary movement of funds, equipment, supplies, specialized
personnel, and/or sharing of surveillance data and diagnostic
specimens/biological samples.

3\. Convene binational surveillance and epidemiology planning workshops
to discuss and plan cross-border surveillance and/or epidemiology
related activities. Such activities could involve a collaborative and
regional approach with neighboring US border states as well as Mexico or
Canada (as appropriate).

**II. LABORATORY CAPACITY---BIOLOGIC AGENTS**

**Critical Capacity:** To develop and implement a program to provide
rapid and effective laboratory services in support of cross-border
infectious disease surveillance activities.

**Activities That May be Considered:**

1.  In coordination with your state public health laboratory, develop
    and implement a strategy to ensure laboratory testing (in clinical
    or public health laboratories) for rapid and specific confirmation
    of urgent case reports along the border region.

2\. Survey and assess the laboratory capacity on each side of the
international border and the connectivity among these laboratories with
a view towards (a) identifying and addressing needs or gaps with respect
to their consistency or uniformity of testing standards, notification
protocols, and laboratory-based surveillance data exchange practices and
(b) developing binational regional laboratory response capabilities.

**III. SURVEILLANCE-RELATED COMMUNICATIONS AND INFORMATION TECHNOLOGY**

**Critical Capacity:** To ensure electronic exchange of infectious
disease related information (that would include clinical, laboratory and
environmental data) in standard formats between the computer systems of
your public health department and those of your counterpart agency
across the international border.

**Activities That May be Considered:**

1.  

In coordination with local public health agencies on both sides of the
border, apply information technology to develop or enhance electronic
applications for reportable disease surveillance, including electronic
laboratory-based disease reporting from clinical and public health
laboratories and linkage of laboratory results to case report
information.

2.  Establish a secure, Web-based communications system that provides
    for rapid and accurate reporting and discussion of disease outbreaks
    and other acute health events that might suggest bioterrorism.
    Include provision for routine communications (e.g., Web, e-mail) and
    alert capacity for emergency notification (e.g., phone, pager) of
    key staff. Conduct cross-border technology assessments.

3.  Achieve an around-the-clock capacity for immediate response to
    reports of urgent cases, outbreaks, or other public health
    emergencies, including any events that suggest intentional release
    of a biologic agent by means of cross-border early warning
    infectious disease surveillance.

4.  Formulate, develop and, when feasible, test a binational 24/7
    infectious disease surveillance plan that uses the Health Alert
    Network as a basic structure and extends its coverage area to
    jurisdictions on both sides of the border.

**IV. EDUCATION AND TRAINING**

**Critical Capacity:** To provide ongoing specialized infectious disease
surveillance, epidemiologic and laboratory diagnostic training for
public health, clinical, and other healthcare professionals to develop
subject matter expertise within the public health system for
cross-border disease detection, diagnostics, contact tracing, and
outbreak analysis.

**Activities That May be Considered:**

1\. Conduct joint infectious disease surveillance training and exercise
session involving a broad range of appropriate participants from both
sides of the international border.

2\. Develop, train and exercise binational epidemiologic response teams
to conduct capable field epidemiologic investigations, rapid needs
assessments, exposure assessments, and response activities on both sides
of the border.

3\. Convene forums to discuss the planning and implementation of
cross-border surveillance and epidemiologic response activities. The US
border states (recipients of EWIDS funding) might consider using video
teleconferencing

> capabilities to the extent practical to facilitate the participation
> of their Canadian or Mexican counterparts in planning or follow-up
> sessions.

4\. Partner with Schools of Public Health and/or CDC's Centers for
Public Health Preparedness in developing training activities to enable
health professionals in Canadian border provinces and Mexican border
states to receive introductory or advanced training in epidemiological
surveillance, surveillance based laboratory methods and surveillance
related information technologies.

5.  Implement a program to enable epidemiologists, laboratorians and
    information technologists from Canada or Mexico (as appropriate) to
    perform on the job training and experiential learning field studies
    for a period of time in your state health department. Selection of
    "Visiting fellows" should be made based on the relative merits of
    candidates and matches the most meritorious candidates with
    previously identified needs within the border provinces/states.