Inform & Involve State Health Department. Health Department Notifies CDC. Conduct Investigation.

Inform & Involve State Health Department and Conduct Investigation. For situations that suggest the possibility of bioterrorism, it is important that local public health officials notify their counterparts in their state health department. State health departments should identify a state public health official in charge of the response. This person should be available 24 hours per day, seven days a week, via a telephone number or other means of electronic communication provided to all local health departments.

Preliminary investigation: Local health departments, in concert with their state health department, should perform a preliminary investigation of a cluster of patients presenting with the following characteristics:

1. Large numbers of ill persons with similar disease or syndrome
2. Large numbers of unexplained disease, syndrome or deaths
3. Unusual illness in a selected population (e.g. outbreak of severe rash illness affecting adults)
4. Higher morbidity and mortality associated with usual disease or syndrome
5. Endemic disease with unexplained increased incidence (e.g. tularemia, plague)

Full investigation: Local health departments should immediately notify the state health department, for investigation of:

1. a cluster of patients [as defined above] that is unexplained after a preliminary investigation.
2. one or more cases of disease in a community in which the disease does not normally occur (e.g., tularemia in New York City, or plague in North Carolina).
3. a cluster of patients presenting with the following unusual characteristics:
   1. Endemic disease in non-endemic area, or in an area without a vector/host for zoonotic disease (e.g., tularemia, plague).
   2. Multiple disease entities in the same patient.
   3. Illness in an unusual geographic distribution (e.g., ‘downwind’ in an aerosol release)
   4. Simultaneous clusters of similar illness in non-geographic areas, domestic or foreign
   5. Unusual, atypical, or antiquated strain of agent (including antibiotic resistance pattern)

At such time as a bioterrorist incident is confirmed or thought to be probable, local and state health officials should immediately notify the FBI. This notification may be appropriate immediately following the preliminary investigation.