DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT
Disease Control and Environmental Epidemiology Division
6 CCR 1009-5
STATE BOARD OF HEALTH
RULES AND REGULATIONS PERTAINING TO PREPARATIONS FOR A BIOTERRORIST EVENT, PANDEMIC INFLUENZA, OR AN OUTBREAK BY A NOVEL AND HIGHLY FATAL INFECTIOUS AGENT OR BIOLOGICAL TOXIN
In Section 24-32-2103, C.R.S., emergency epidemic is defined as cases of an illness or condition, communicable or noncommunicable, caused by bioterrorism, pandemic influenza, or novel and highly fatal infectious agents or biological toxins.
Regulation 1.  Preparations by Local Public Health Agencies for an Emergency Epidemic
1.	Each county and district public health department and public health nursing service in this state subject to Section 25-1-501and section 25-1-106 et seq., C.R.S., is required to maintain an up-to-date notification list for an emergency epidemic.  The list shall include at a minimum general or critical access hospitals, regional emergency medical and trauma advisory councils, rural health or community health centers and the local emergency management agencies within the jurisdiction of the local public health agency.  The local public health agency is required to conduct notification tests by a broadcast fax or another communications method for rapid notification at least twice per year.
2.	Each county and district public health department in this state subject to Section 25-1-501 et seq., C.R.S., was required to sign a uniform mutual aid agreement in 2001 with all other county and district public health departments subject to Section 25-1-501 et seq., C.R.S., that obligates the county or district public health department to render aid during an emergency epidemic unless the county or district public health department needs to withhold resources necessary to provide reasonable protection for its own jurisdiction.  If not already done, each public health nursing service and county and district public health department subject to section 25-1-601 et seq., C.R.S., must sign by December 31, 2007 a uniform mutual aid agreement with all other county and district public health departments and public health nursing services subject to section 25-1-501 and 25-1-601 et seq., C.R.S., that obligates the county or district public health department or county health nursing service to render aid during an emergency epidemic unless the county or district public health department or public health nursing service needs to withhold resources necessary to provide reasonable protection for its own jurisdiction.
3.	Each county and district public local health department subject to Section 25-1-501 et seq., C.R.S., shall maintain an agency response plan and associated emergency support function #8 – health and medical annex to the local emergency operations plan that mirrors the national response plan that the agency will implement when the governor declares a disaster emergency that is the result of an occurrence or imminent threat of an emergency epidemic.  The plan, and associated annex, shall be reviewed and updated annually.  Each county and district public health department shall submit the plan (or revised plan) to the Colorado Department of Public Health and Environment, the Colorado Board of Health and local board of health, if applicable, by July 31 of each year.  Each public health nursing service subject to 25-1-601 et seq., C.R.S., shall prepare a plan and associated emergency support function #8 – health and medical annex and the local emergency operations plan that the agency will implement when the governor declares a disaster emergency that is the result of an occurrence or imminent threat of an emergency epidemic.  The plan and associated annex shall be reviewed and updated annually.  Each public health nursing service shall submit the plan to the Colorado Department of Public Health and Environment (CDPHE), the Colorado Board of Health and local board of health and/or local county commissioners, if applicable, a revised plan by July 31 of each year.  In addition, the county or district public health department or the public health nursing service shall provide a copy of the annual revision submitted pursuant to these regulations to the its jurisdiction’s local offices of emergency management, to all general or critical access hospitals, (or, in the absence of a hospital, rural health or community health centers) and to all regional emergency medical and trauma services advisory councils within the jurisdiction of the local public health agency by July 31 of each year.  Each county or district public health department or the public health nursing service shall conduct at least one annual exercise of its plan that incorporates at least four of the areas listed below.  Each county or district public health department shall complete an after-action report and improvement matrix within 60 days of exercise completion.
The plan shall address the following areas:
A)	Organization and assignment of all employees of the agency to work on controlling the emergency epidemic using the National Incident Management System;
B)	Having sufficient supplies and a process for the provision of personal protective equipment against bacterial and viral infections to employees who are assigned to work in areas where they may be exposed to ill and contagious persons or to infectious agents and waste; personal protective equipment shall, at a minimum, be the equipment and supplies used to achieve standard precautions;
C)	Procurement and storage of at least five days supply of doxycycline or other antibiotic, as determined by the Colorado Department of Public Health and Environment, to be used as prophylaxis for all employees.  The plan shall include procurement of another antibiotic for a small number of employees who may be unable to take doxycycline;
D)	An emergency, after-hours call-down list of persons who may be needed to organize and respond to an emergency epidemic; such list shall include persons with experience and training in communicable disease epidemiology and incident management;
E)	Creation of an agency operations center within the agency or participation in a local emergency operations center for the purpose of (i) centralizing telephone, radio, and other electronic communications; (ii) compiling surveillance data; and (iii) maintaining a log of operations, decisions, resources, and orders necessary to control the epidemic; (iv) responding to executive orders of the governor regarding the emergency epidemic and (v) managing mass dispensing and vaccination activities;
F)	Creation of teams to: (i) monitor the situation, including infection control, in each hospital within the agency’s jurisdiction, doing this on-site as necessary and with assistance from the Colorado Department of Public Health and Environment as appropriate; (ii) assess and manage infection control in the community outside of the hospital; and (iii) assess and manage, in coordination with hospitals and the county coroner, the disposal of human corpses in accordance with emergency support function #8 – health and medical, (iv) manage and dispense pharmaceuticals to the public;
G)	Organization, receipt, staffing, security, and logistics of the distribution and delivery of antibiotics, antiviral medications, vaccines, or other medications and supplies needed in an emergency epidemic following the provisions of Emergency Support Function #8 health and medical;
H)	Identification of at least two public spokespersons who will coordinate public information with the Colorado Department of Public Health and Environment and are responsible for providing information to the citizens of their jurisdiction about how to protect themselves, what actions are being taken to control the epidemic, and when the epidemic is over; and
I)	Implementation of a back-up communications system, such as 800 megahertz radios or amateur radio emergency services, that will be used to communicate with local emergency management agencies if and when telephone communications are disabled or not functioning;
Regulation 2.	Preparations by General or Critical Access Hospitals for an Emergency Epidemic
1.	Each general or critical access hospital in this state is required to maintain an up-to-date notification list for an emergency epidemic.  The list shall include any satellite clinics; acute care facilities, or trauma centers operated by the hospital; offices of physicians and health care providers on the staff of the hospital, as available; and the local public health agency and local emergency management office serving the county in which the hospital is located.  The hospital is required to conduct notification tests by a broadcast fax or by another communications method for rapid notification at least twice per year.
2.	Each general or critical access hospital in this state shall MAINTAIN a plan that the hospital will implement when the governor declares a disaster emergency that is the result of an occurrence or imminent threat of an emergency epidemic.  The plan shall be reviewed and updated annually and each general or critical access hospital in this state shall submit to the Colorado Board of Health a revised plan by July 31 of each year.  In addition, the general or critical access hospital shall provide a copy of the annual revision submitted pursuant to these regulations to the local public health agency, the local office of emergency management, and the regional emergency medical and trauma services advisory council in the region in which the hospital is located by July 31 of each year.  Each general or critical access hospital in this state shall conduct at least one annual exercise of its plan that incorporates at least four of the areas listed below.
The plan shall address the following areas:
A)	Organization: using National Incident Management System principles, assignment, reassignment, and alteration of normal work schedules of all medical staff and all employees of the hospital who may be called on to work during an emergency epidemic;
B)	Having sufficient supplies and a process for the provision of personal protective equipment against bacterial and viral infections to all staff and employees who are assigned to work in areas where they may be exposed to ill and contagious persons or to infectious agents and waste; personal protective equipment shall, at a minimum, be the equipment and supplies used to achieve standard precautions;
C)	Procurement and storage of at least five days supply of doxycycline or other antibiotic, as determined by the Colorado Department of Public Health and Environment, to be used as prophylaxis for all employees.  The plan shall include procurement of another antibiotic for a small number of employees who may be unable to take doxycycline;
D)	An emergency call-down list of off-duty or retired health care providers who may be asked to work or volunteer as needed to respond to an emergency epidemic;
E)	Creation of a facility operations center within the hospital for the purposes of: (i) centralizing telephone, radio, and other electronic communications; (ii) compiling morbidity and mortality data including the number of patients, number of available beds, and number of working staff and employees; (iii) receiving and responding to executive orders of the governor regarding the emergency epidemic; and (iv) maintaining a log of operations, decisions, and resources necessary to maintain operations during the epidemic;
F)	Creation of teams to assess and manage: (i) infection control within the hospital; and (ii) in coordination with local public health departments and the county coroner, the disposal of human corpses;
G)	Security of the hospital facility necessary to control large and unruly crowds;
H)	Rapid transport of human diagnostic specimens to the state laboratory or as otherwise directed by the Colorado Department of Public Health and Environment;
I)	Prevention of the spread of the epidemic disease within the hospital from persons ill with the condition causing the emergency epidemic to staff, employees, and other patients of the hospital; and
J)	Coordination and communication with other hospitals and pre-hospital care agencies to assure that patients with extreme, life-threatening, or emergency medical or traumatic conditions are not unnecessarily diverted from the hospital; and
K)	Triaging all persons during an emergency epidemic in a manner that protects the facility, staff, and public and routing these persons to the appropriate facility based on their medical status.
Regulation 3.	Preparations by Managed Care Organizations, Rural Health and Community Health for an Emergency Epidemic
1.	Each managed care organization, rural health and community health center licensed in this state by the division of insurance and that operates medical facilities or pharmacies is required to maintain an up-to-date notification list for an emergency epidemic.  The list shall include any satellite clinics, acute care facilities, or trauma centers operated by the organization, as well as offices of physicians and health care providers working as full-time contractors or staff of the organization.  The organization is required to conduct notification tests by a broadcast fax or another communications method for rapid notification at least twice per year.
2.	Each managed care organization, rural health and community health center operating medical facilities or pharmacies in this state shall prepare a plan that the organization would implement when the governor declares a disaster emergency that is the result of an occurrence or imminent threat of an emergency epidemic.  The plan shall be submitted to the Colorado Board of Health by December 31, 2007.  The plan shall be reviewed and updated annually thereafter and each managed care organization in this state shall submit to the Colorado Board of Health, local board of health, and local county commissioners, if applicable, a revised plan.  Each managed care organization; rural health and community health center in this state shall conduct at least one annual exercise of their plan that incorporates at least two of the areas listed below.
The plan shall address the following areas:
A)	Rapid transport of human diagnostic specimens to the state laboratory or as otherwise directed by the Colorado Department of Public Health and Environment from facilities that are operated by the organization;
B)	A rapid method of determining the inventory of broad spectrum antibiotics in facilities and pharmacies that are operated by the organization, including pill counts of doxycycline or other antibiotic, as determined by Colorado Department of Public Health and Environment;
C)	A rapid method of securing and protecting antibiotics, antiviral medications, vaccines, and personal protective equipment within facilities and pharmacies that are operated by the organization; personal protective equipment shall, at a minimum, be the equipment and supplies used to achieve standard precautions; and
D)	Delivery or transfer of the supplies listed in paragraph C to authorized personnel as directed by executive orders of the governor.
Regulation 4.	Preparations by Regional Emergency Medical and Trauma Services Advisory Councils for an Emergency Epidemic
1.	Each regional emergency medical and trauma services advisory council in this state is required to maintain an up-to-date notification list of organizations for an emergency epidemic. The list shall include all pre-hospital care organizations within the jurisdiction of the regional emergency medical and trauma services advisory council.  The council is required to conduct notification tests by a broadcast fax or by another communications method for rapid notification of these organizations at least twice per year.
2.	Each regional emergency medical and trauma services advisory council shall advise the pre-hospital care organizations within its jurisdiction to develop a plan that the organization would implement when the governor declares a disaster emergency that is the result of an occurrence or imminent threat of an emergency epidemic.  The organizations shall be advised that the plan should address the following areas:
A)	Organization: using the National Incident Management System, assignment, reassignment, and alteration of normal work schedules of all staff and all employees of the organization who may be called on to work during an emergency epidemic;
B)	Having sufficient supplies and a process for the provision of personal protective equipment against bacterial and viral infections to all staff and employees who are assigned to work in areas where they may be exposed to ill and contagious persons or to infectious agents and waste; personal protective equipment shall, at a minimum, be the equipment and supplies used to achieve standard precautions;
C)	Procurement and storage of at least five days supply of doxycycline or other antibiotic, as determined by Colorado Department of Public Health and Environment to be used as prophylaxis for all employees.  The plan should include procurement of another antibiotic for a small number of employees who may be unable to take doxycycline;
D)	An emergency call-down list of off-duty or retired emergency medical service providers who may be asked to work or volunteer as needed to respond to an emergency epidemic.
Regulation 5. 	Preparations by the Colorado Department of Public Health and Environment for an Emergency Epidemic
1.	The Colorado Department of Public Health and Environment is required to maintain an up-to-date notification list for an emergency epidemic.  The list shall include the Governor’s Office, members of the Governor’s Expert Emergency Epidemic Response Committee, general or critical access hospitals, county and district public health departments, regional emergency medical and trauma services advisory councils, and the state Division of Emergency Management.  The Colorado Department of Public Health and Environment is required to conduct notification tests by a broadcast fax or by another communications system for rapid notification of these contacts at least twice per year.
2.	The Colorado Department of Public Health and Environment shall prepare an internal response plan and associated Emergency Support Function #8 health and medical annex to the state emergency operations plan that mirrors the National Response Plan (NRP) that The Colorado Department of Public Health and Environment will implement when there is an occurrence or imminent threat of an emergency epidemic.  The plan shall be reviewed and updated annually and shall be submitted to the Colorado Board of Health with the revisions by July 31 of each year, and shall provide the revised plan to local public health agencies.  The Colorado Department of Public Health and Environment will submit the revised Emergency Support Function #8 health and medical annex to the Division of Emergency Management by July 31 of each year.  The Colorado Department of Public Health and Environment shall conduct at least one annual exercise of the plan that incorporates at least four of the areas listed below.
The plan shall address the following areas:
A)	Organization: using the National Incident Management System and assignment of potentially all employees of The Colorado Department of Public Health and Environment to work on controlling the emergency epidemic;
B)	Having sufficient supplies and a process for the provision of personal protective equipment against bacterial and viral infections to employees who are assigned to work in areas where they may be exposed to ill and contagious persons or to infectious agents and waste; personal protective equipment shall, at a minimum, be the equipment and supplies used to achieve standard precautions;
C)	Procurement and storage of at least five days supply of doxycycline or other antibiotic, as determined by The Colorado Department of Public Health and Environment, to be used as prophylaxis for all employees.  The plan shall include procurement of another antibiotic for a small number of employees who may be unable to take doxycycline;
D)	An emergency, after-hours call-down list of persons who may be needed to organize and respond to an emergency epidemic; such list shall include persons with experience and training in communicable disease epidemiology and incident management;
E)	Maintenance of an agency department operations center within the Colorado Department of Public Health and Environment for the purpose of (i) centralizing telephone, radio, and other electronic communications; (ii) compiling surveillance data; (iii) maintaining a log of operations, decisions, resources, and orders necessary to control the epidemic; and (iv) apportionment of pharmaceuticals;
F)	Creation of teams to assist local public health agencies to: (i) monitor the situation in each hospital where the emergency epidemic is occurring; (ii) assess and manage infection control in the community outside of the hospital; and (iii) assess and manage, in coordination with hospitals and the county coroner, the disposal of human corpses in accordance with Emergency Support Function #8 – health and medical;
G)	Assurance of the appropriate distribution and delivery of antibiotics, antiviral medications, vaccines, or other medications needed in an emergency epidemic to locations determined by local public health agencies or local emergency management agencies;
H)	Identification of at least two public spokespersons responsible for providing information to the citizens of the state about how to protect themselves, what actions are being taken to control the epidemic, and when the epidemic is over; and
I)	Implementation of a back-up communications system, such as 800 megahertz radios or amateur radio emergency services, that will be used to communicate with the state office of emergency management and local public health agencies if and when telephone communications are disabled or not functioning; and maintenance of a rapid notification system.
3.	The Colorado Department of Public Health and Environment shall provide to each county and district local public health department subject to Section 25-1-501 et seq., C.R.S., and to the state Division of Emergency Management a copy of the plan submitted pursuant to these regulations.  The plan shall be provided upon request to general and critical access hospitals, managed care organizations, regional emergency medical and trauma services advisory councils, and local offices of emergency management.
Regulation 6. 	Assessing Compliance with these Regulations
For the purposes of determining eligibility for the protections of section 24-32-2111.5, C.R.S., the Colorado Department of Public Health and Environment shall review plans submitted to the Colorado Board of Health pursuant to Regulations Two through Four, may examine exercise evaluations and may examine and inspect faxes transmitted or documentation of other communications methods used for rapid notification of contacts and agencies pursuant to Regulations Two through Four.