Ministry of Health, Government of Alberta December 2018 Alberta Outbreak Response Protocol ISBN 978-1-4601-4265-3 https://open.alberta.ca/publications/9781460142653 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without written permission of Alberta Health, Government of Alberta. Copyright of the Alberta Outbreak Response Protocol and its contents belongs to the Government of Alberta. For further information on the use of this protocol contact: Health.CD@gov.ab.ca Health and Wellness Promotion Branch Public Health and Compliance Branch Alberta Health Alberta Outbreak Response Protocol (AORP) December 2018 2
Table of Contents Acknowledgements... 4 List of Acronyms... 4 Purpose... 5 Scope... 5 Guiding Principles... 6 Legislated Mandate... 6 Response Protocol... 6 Unusual Outbreak Identification... 6 Notification to Partners and AB-OICC Assessment Call... 8 Activation and Composition of AB-OICC... 9 Outbreak Conclusion... 13 Submission of Final AORF... 13 Final Investigation Summary... 13 Post-Investigation Debrief... 13 References... 14 Appendix A: Roles and Responsibilities... 15 Alberta Health... 15 Alberta Health Services Population, Public and Indigenous Health... 16 Alberta Health Services ProvLab... 17 Indigenous Services Canada First Nations and Inuit Health Branch, Alberta Region (FNIHB-AB)... 18 Appendix B: Proposed OICC Agendas... 19 Appendix C: Proposed Template for AB-OICC Debrief... 20 Alberta Outbreak Response Protocol (AORP) December 2018 3
Acknowledgements The protocol was developed in a partnership and in collaboration with public health and laboratory experts from: Alberta Health; Alberta Health Services (AHS); Indigenous Services Canada, First Nations and Inuit Branch Alberta (FNIHB-AB); and AHS, Provincial Laboratory for Public Health (ProvLab). List of Acronyms AAF AORF CD CFIA CMOH EPH FNIHB-AB GOA IPC MOH OCMOH OHS AB-OICC PHA PHAC PPIH ProvLab Alberta Agriculture and Forestry Alberta Outbreak Reporting Form Communicable Disease Canadian Food Inspection Agency Chief Medical Officer of Health Environmental Public Health Indigenous Services Canada First Nations and Inuit Health Branch Government of Alberta Infection Prevention and Control Medical Officer of Health Office of the Chief Medical Officer of Health Occupational Health and Safety Alberta Outbreak Investigation Coordinating Committee Public Health Act (Alberta) Public Health Agency of Canada Population, Public and Indigenous Health (AHS) Provincial Laboratory for Public Health (AHS) Alberta Outbreak Response Protocol (AORP) December 2018 4
Purpose The purpose of the Alberta Outbreak Response Protocol (AORP) is to set out key guiding principles for the identification of, and coordinated response to, unusual outbreaks in Alberta in order to: outline roles and responsibilities of key partners (any agency with the responsibility to participate or respond to the unusual outbreak); enhance collaboration and coordination; establish clear lines of communication and information; and improve efficiency and effectiveness. Scope This protocol provides a framework for a coordinated response to unusual outbreaks of communicable diseases where other protocols are not already in place. In addition, this protocol supersedes the Alberta Communicable Disease Outbreak Roles and Responsibilities Manual from July 2013. An outbreak is: The occurrence of cases of disease in excess of what would normally be expected in a defined community, geographical area or season (World Health Organization, 2018). Unusual outbreaks have one or more of the following: A novel or emerging pathogen; Illness above expected amounts spread over more than one geographic jurisdiction; Severe illness or mortality among identified cases; A large number of unexplained illnesses involved; A rapidly expanding outbreak; An over-represented vulnerable population among cases (e.g., children, elderly) in the community; Multiple agencies managing the outbreak (e.g., Public Health, Agriculture, Emergency Management); and/or Significant media attention. This protocol should NOT be used where other protocols are already in place: The Alberta Foodborne Illness and Risk Investigation Protocol (FIRIP) should be used to guide outbreaks linked to food in Alberta. The Alberta Zoonotic Disease Investigation Protocol (ZIP) should be used to guide outbreaks linked to animals in Alberta. The Alberta Pandemic Influenza Plan should be used to guide pandemic influenza situations. Alberta Health Crisis Management Plan (Health EOC) and Alberta Emergency Plan (POC) should be used to guide public health emergencies, including epidemics/pandemics. - Partners may have operational plans for outbreak response (e.g., rare and emerging diseases); these will be considered when developing a Provincial response. Alberta Outbreak Response Protocol (AORP) December 2018 5
Guiding Principles Partners are encouraged to raise awareness of this protocol within their own organizations, including circulating the document to senior management. They are also encouraged to develop and participate in internal simulation exercises and training. When the AB-OICC convenes, it will serve as the main forum for information sharing, interpretation, clarification of roles and responsibilities, determination of response priorities and activities, and development of communication strategies. Legislated Mandate In Alberta, the requirements for reporting communicable diseases are mandated by the Communicable Diseases Regulation, under the Public Health Act (PHA). Alberta Health participates in the collection, analysis and interpretation of communicable disease data to assist the CMOH in fulfilling the duties prescribed in the PHA. Response Protocol Unusual Outbreak Identification An unusual outbreak may be identified from one or more of the following partners (See Appendix A: Roles and Responsibilities for more information): Alberta Health; AHS; ProvLab; FNIHB-AB; Other Provincial agencies (e.g., Covenant Health, Provincial Corrections); Other laboratories; Other Alberta government department(s) e.g., Office of the Chief Provincial Veterinarian at AAF; or National Agencies (e.g., PHAC). See Figure 1 Response to Unusual Outbreaks in Alberta (next page) for a general overview of Alberta s response to unusual outbreaks. Alberta Outbreak Response Protocol (AORP) December 2018 6
Figure 1 Response to Unusual Outbreaks in Alberta Unusual Outbreak Identified Initial Notification: Email to relevant partners Initial AB-OICC* Assessment Call Teleconference and review of information Identification of stakeholders Review Case Information Decision re: Activation of AB- OICC MONITOR Follow-up teleconference and review of new information YES Activation of AB-OICC NO Communication as needed Partners may continue their investigation AHS AH LABS AB-OICC Points of Collaboration Identify outbreak team Develop outbreak definition Review investigation findings Analysis Monitor outbreak and intervention Communicate findings Outbreak conclusion Outbreak debrief/review FNIHB PHAC ADHOC Stakeholders *Alberta Outbreak Investigation Coordination Committee Alberta Outbreak Response Protocol (AORP) December 2018 7
Notification to Partners and AB-OICC Assessment Call When a suspected unusual outbreak is detected or reported, an initial notification email to partners is made by the agency that detected the outbreak. If this occurs, an AB-OICC assessment call will be initiated by Alberta Health. The initial point of contact for the identifying partner at Alberta Health, during normal business hours, is the CD team nurse pager. After hours, the point of contact is the OCMOH answering service. Alberta Health will arrange and chair the initial teleconference (refer to Appendix A for proposed AB-OICC meeting agendas). The following partners, as applicable, will be invited to review information and conduct the initial assessment call for the unusual outbreak: Mandatory: OCMOH MOH: AHS, FNIHB CD: AHS, FNIHB, Alberta Health EPH: AHS, Alberta Health Surveillance: Alberta Health, AHS Optional: Disease/population-dependent (e.g. vaccine-preventable disease) EPH: FNIHB Surveillance: FNIHB Immunization: AHS, FNIHB, Alberta Health IPC: AHS, FNIHB, Alberta Health OHS: AHS, Covenant ProvLab and other laboratories Communications: AHS, FNIHB, Alberta Health Other agencies as required by AB-OICC NOTE: Alberta Health will maintain and update the AB-OICC Assessment Call Partner Contact List annually or as required. It is the responsibility of each partner to provide updates to Alberta Health. This list will be circulated annually or when required. Upon review of the information provided on the call, the partners will agree on one of the following: a) No further action. Communication as needed. If new information arises another AB-OICC assessment call can be initiated. b) Monitor the situation and reassess. Timeframe for follow-up meetings will be agreed upon by the partners. Chair will coordinate follow up meetings and distribute minutes/agenda. Relevant partners (e.g., AHS Surveillance) will present and update epidemiological data findings/interpretation and data analysis. At follow-up meeting, new information will be reviewed and reassessed to determine next steps. c) Activate the AB-OICC. The AB-OICC chairperson will be nominated and will be responsible for: - Scheduling subsequent meetings, - Creating agendas and documenting minutes, and - Chairing the meetings/teleconferences. Alberta Outbreak Response Protocol (AORP) December 2018 8
Activation and Composition of AB-OICC When the decision is made to activate the AB-OICC, the chairperson (nominated above) will arrange an initial meeting/teleconference with the following partners, as applicable, to initiate a coordinated outbreak response: OCMOH MOH: AHS, FNIHB CD: AHS, FNIHB, Alberta Health EPH: AHS, FNIHB, Alberta Health Immunization: AHS, FNIHB, Alberta Health IPC: AHS, FNIHB, Alberta Health, as required OHS: AHS, Covenant Surveillance: AHS, FNIHB, Alberta Health Communications: AHS, FNIHB, Alberta Health ProvLab and other laboratories, as required Other agencies (e.g., Agriculture & Forestry, Environment & Parks). Purpose of the AB-OICC The AB-OICC is responsible for: Coordinating a provincial outbreak response and investigation; Clarifying roles and responsibilities specific to this outbreak; Serving as a central point to share information from all sources and discuss findings, including results of centralized data analysis; Establishing priorities where critical resources are limited or constrained; Identifying resource needs and opportunities for sharing resources; Facilitating communication among participating partners; Developing comprehensive external communication strategies, ensuring consistent and complementary messages are released to the public and other stakeholders; Gaining consensus in resolving issues that emerge; Joint risk assessment and management; Joint decision-making; Scheduling a post-investigation debrief, and Dismantling of AB-OICC once no longer required. Alberta Outbreak Response Protocol (AORP) December 2018 9
Accountability For unusual outbreaks that are confined to one zone within Alberta, the zone MOH is considered the lead for that outbreak and the likely candidate to lead the AB-OICC, unless otherwise decided. For unusual outbreaks that are confined to more than one zone, Alberta Health is considered the lead for the outbreak, unless otherwise decided. AB-OICC versus EOC Activation The majority of unusual outbreaks in Alberta do not require the activation of a provincial EOC or ICS. However, if an outbreak becomes beyond the ability of the day-to-day operations to respond to it, the AB- OICC may find it necessary to do so. Partner agencies may elect to activate an EOC or ICS within their organization, regardless of whether a provincial EOC or ICS has been activated. Decision-Making and Resolving Differences The AB-OICC will strive to make consensus-based decisions on outbreak strategies, recognizing that partners have their own obligations, policies and mandates that must be respected. Decisions made by one partner pursuant to its obligations, but related to the purpose of the AB-OICC and the outbreak, should be communicated to all AB-OICC partners. Initial Meeting of AB-OICC The initial AB-OICC meeting should occur within one to three calendar days of initial notification. Refer to Appendix B for a proposed AB-OICC agenda outline. The AB-OICC will: a) Ensure the chairperson is kept up-to-date with information on the outbreak; b) Review outbreak findings to date; c) Determine what further investigation is required; d) Identify potential issues/concerns; e) Develop an action plan, designate working groups if needed and assign responsibilities; f) Determine need for an outbreak notification to CNPHI; g) Identifying need to contact PHAC or other agencies for assistance; h) Assign official communication leads; and i) Verify how urgent issues will be managed outside of business hours. Alberta Outbreak Response Protocol (AORP) December 2018 10
Coordinating On-going Outbreak 1. Investigation Activities Every effort should be made to standardize the information being collected and centralize the data analysis for the investigation. The AB-OICC will ensure the coordination of data collection and information sharing by agreeing to and sharing the following: a) Outbreak Case Definition An outbreak specific case definition, including case classification (i.e., confirmed, probable, suspect), will be determined by the AB-OICC. This may be the current Alberta case definition or a modification of it depending on the person, place, presentation and time factors of the unusual outbreak. b) Epidemiological Investigation An epidemiological investigation by one or more partners may already be underway when the AB-OICC is activated. The AB-OICC will work to coordinate the investigations and share findings among partners in a timely manner. The data from front-line source systems within AHS/FNIHB can provide epidemiological information in a timely and relatively simple manner electronically. In addition, the AB-OICC may request further epidemiological assistance from other agencies. Depending on the outbreak, Alberta Health may have reporting requirements with short timelines (e.g., to PHAC, the Minister, the CMOH). Options to deal with these requirements will be discussed with the AB-OICC should the need arise. When an unusual outbreak involves more than one province, coordination of the epidemiological information and guidance Alberta during national and international outbreaks will be led by Alberta Health. c) Laboratory Investigation The laboratory investigation should be led by the laboratory leadership in coordination with the AB-OICC to avoid gaps in reporting, prevent duplication, and discuss characterization (e.g., genotyping, serotyping, etc.) of the pathogen causing the outbreak. 2. Prevention and Control Strategies Prevention and control strategies may vary during an unusual outbreak depending on the severity and nature of the outbreak. The AB-OICC partners will develop appropriate prevention and control strategies. Working groups outside of the AB-OICC may be established to explore public health interventions and measures. These working groups will be expected to bring recommendations back to the AB-OICC for discussion and approval. Alberta Outbreak Response Protocol (AORP) December 2018 11
If manifests for international flights are required Alberta Health will be notified and take the lead. If manifests for domestic flights are required, Alberta Health will be notified and AHS will take the lead (support by Alberta Health will be provided as needed). Depending on the nature and magnitude of the unusual outbreak, other government departments (e.g., Agriculture), provinces or PHAC may be consulted and/or advised. Alberta Health will be responsible for this coordination. 3. Communication Strategy During unusual outbreaks, there may be a need to provide information and regular updates to the media, public, and other organizations (e.g. childcare facilities, schools, etc.). To ensure consistent and timely messaging the communication strategy will be a collaborative and coordinated effort. The AB-OICC will assess the need, content, timing, and appropriate activities for outbreak communication. Upon planning a communication strategy, the AB-OICC will designate one partner who will lead the coordination of the strategy, including the designation of a spokesperson(s). All communication teams involved in the AB-OICC must have the opportunity to review and approve communication products before they are finalized, recognizing compressed reviewing timelines. The communication lead will share final communication products with all AB-OICC partners prior to release. 4. Deactivation of AB-OICC The AB-OICC will determine when to scale back or deactivate. Deactivation should always occur once an outbreak is concluded. However, the AB-OICC can also choose to scale-back and/or deactivate prior to conclusion of an outbreak. Alberta Outbreak Response Protocol (AORP) December 2018 12
Outbreak Conclusion Submission of Final AORF When the unusual outbreak has concluded (the AB-OICC may already be deactivated), a final AORF should be submitted within 2 business days of closing the investigation as per usual reporting process. If this timeline cannot be met, an e-mail should be sent to OCMOH@gov.ab.ca and Health.CD@gov.ab.ca by the outbreak investigator outlining why the timeline cannot be met and an estimate of when the AORF will be sent in by. The final AORF, including the outbreak summary should be submitted no later than 30 days after closing the outbreak investigation. Final Investigation Summary Upon receipt of the final AORF, Alberta Health will prepare a final outbreak summary for OCMOH and key partners within two months for discussion at the post-investigation debrief. If communication with the public is considered at the conclusion of the outbreak, the messages should be coordinated between Alberta Health and relevant partners. Post-Investigation Debrief The AB-OICC chairperson will schedule a post-investigation debrief with members of AB-OICC within three (3) months of the closure of the outbreak. The Alberta Health summary report will be provided to all members in advance of the debrief. The goals of the post-outbreak debrief will include (see Appendix C for more details): Consensus on the source of the outbreak, if required; Effectiveness of public health actions and/or difficulties in their implementation; Evaluation of the collaborative response efforts, including communication and coordination; Discussion of any privacy and/or legal issues which may have arisen; Identification of immediate and/or long-term measures that require program and policy changes; Discussion on joint publication of outbreak findings in journals and/or presentations at conferences; Lessons learned; and Identification of improvements to the AORP. Alberta Outbreak Response Protocol (AORP) December 2018 13
References Canada-Alberta Partners in Food Safety (CAPiFS). Alberta Foodborne Illness and Risk Investigation Protocol (FIRIP). 2017. Available at: www1.agric.gov.ab.ca/$department/deptdocs.nsf/all/afs13869 Government of Canada. Foodborne Illness Outbreak Response Protocol (FIORP): A guide to multijurisdictional enteric outbreak response. 2017. Available at: www.canada.ca/en/publichealth/services/publications/health-risks-safety/canadas-foodborne-illness-outbreak-responseprotocol-fiorp-guide-multi-jurisdictional-enteric-outbreak-response.html World Health Organization. Disease Outbreaks. 2018. Available at: www.searo.who.int/topics/disease_outbreaks/en/ Alberta Outbreak Response Protocol (AORP) December 2018 14
Appendix A: Roles and Responsibilities Alberta Health Mandate Alberta Health is responsible for the health of Albertans and is responsible for developing and maintaining legislation, policies and guidelines that support the investigation of communicable diseases and outbreaks in Alberta. Legislation The PHA and associated regulations provide the legislative authority in Alberta to respond to outbreaks of communicable diseases. Role in Outbreaks The role of Alberta Health varies depending on the communicable disease and the size of the outbreak. Alberta Health works closely with AHS, FNIHB and other partners to ensure the response is adapted to the outbreak. The functions of Alberta Health may include: Coordinating outbreak-related legislative actions with other GOA ministries; Providing expert medical, epidemiological and public health advice and/or assistance to partners; Conducting provincial surveillance activities in collaboration with partners; Monitoring activities of key partners pertaining to outbreak investigation; Consulting with national and international public health experts and advisory bodies as required; Working in coordination with key partners to develop appropriate intervention strategies; Working in coordination with key partners to develop public health messaging; Working in coordination with key partners to conduct human health risk assessments; Leading and/or coordinating public communications provincially; and/or Sharing outbreak-related data and information with provincial and federal partners. Where appropriate, Alberta Health may provide guidance/direction to key partners with respect to certain aspects of the outbreak investigation. Alberta Outbreak Response Protocol (AORP) December 2018 15
Alberta Health Services Population, Public and Indigenous Health Mandate AHS public health staff, including the Medical Officers of Health (MOHs), Public Health Inspectors and Public Health Communicable Disease Nurses identify, investigate, manage and report notifiable diseases and communicable disease outbreaks in accordance with the PHA and pursuant regulations. In addition, AHS Public Health works to close gap in health outcomes for Indigenous people, advance health equity, and promote a public health approach within primary care. Role in Outbreaks AHS public health staff typically identify outbreaks in Alberta, through investigation of notifiable diseases and other reports of illness, and report these to Alberta Health. AHS will usually assume a leadership role in outbreak investigation and response, except on federal lands. AHS collaborates with internal and external partners as applicable. Depending on the type of outbreak, AHS public health outbreak roles include the following: Conduct investigations including inspections, sample collection and enforcement activities at facilities under their mandate; Collect, collate, analyze and interpret data from multiple sources (e.g. cases, environment; food specimens) to establish the epidemiology of the outbreak in order to determine the source of the outbreak; Recommend and/or implement outbreak control strategies in order to prevent further, transmission of disease, including provision of prophylaxis as required; Monitor outbreak activity through appropriate surveillance measures; Evaluate effectiveness of control measures; Report outbreak data to Alberta Health as per legislated reporting requirements; and/or Communicate to the public as appropriate in conjunction with AHS Communications. Alberta Outbreak Response Protocol (AORP) December 2018 16
Alberta Health Services ProvLab Mandate To provide public health microbiological testing in protecting the health of Albertans through leadership, partnership, innovation and excellence in surveillance, research, specialized laboratory testing for outbreak and emerging infectious disease responses. Role in Outbreaks Conduct provincial laboratory surveillance of communicable diseases; Provide laboratory testing expertise, consultation and leadership; Link clinical specimens associated with specific outbreaks using a web-based Exposure Investigation system where data can be disseminated in real time; Perform tests on submitted clinical, environmental and food samples to identify the pathogens; Assist with coordination of samples to be tested at other sites (e.g., AAF and CFIA); Use molecular typing to further determine the relatedness of the pathogens; Analyze and interpret laboratory data; Connect with PulseNet Canada, PHAC and other Canadian provinces, as required; and/or Report all outbreak data to Alberta Health and AHS as per legislated reporting requirements. Alberta Outbreak Response Protocol (AORP) December 2018 17
Indigenous Services Canada First Nations and Inuit Health Branch, Alberta Region (FNIHB-AB) Mandate (1) FNIHB-AB works collaboratively with First Nations and Inuit people, indigenous organizations, the federal health portfolio, other federal government departments, and provincial/territorial governments to: Improve the health outcomes among First Nations and Inuit peoples; Ensure the availability of, and access to, quality health services; Assist First Nations and Inuit communities in addressing health barriers, disease threats, and attaining health levels comparable to other Canadians living in similar locations; and Build strong partnerships with First Nations and Inuit to improve the health system. Role in Outbreaks Coordinates the investigation of outbreaks that occur in First Nations communities in Alberta; Reports all on-reserve outbreaks to Alberta Health; Coordinates case and contact investigations on reserve, in collaboration with public health staff in the community; Assists with the collection of samples on reserve, as appropriate, and the submissions of samples to the appropriate laboratory for analysis; Analyzes and interprets outbreak investigation data; Provides information and guidance to First Nations community leadership, physicians and public health staff working on reserve in community health centers/nursing stations, and operators of facilities on reserve that are experiencing an outbreak; and/or Provides public health messaging and education, as needed, in affected First Nations communities. (1) Government of Canada. 2012. First Nations and Inuit Health Branch: Mandate, Plans and Priorities. Available at: https://www.canada.ca/en/indigenous-services-canada/corporate/first-nations-inuit-health-branch/mandate-plans-priorities.html Alberta Outbreak Response Protocol (AORP) December 2018 18
Appendix B: Proposed OICC Agendas Proposed AB-OICC Assessment Call Agenda 1. Welcome and roll call 2. Provincial update a. Epidemiological b. Laboratory c. Partner updates 3. Communications 4. Next Steps AB-OICC Activation 5. Next Call (if applicable) 6. Adjournment Proposed AB-OICC Agenda 1. Welcome and roll call 2. Additions and approval of the agenda 3. Review of the minutes and action items (if applicable) 4. Provincial update d. Epidemiological e. Laboratory f. Partner updates 5. Communications 6. Next Steps 7. Next Call 8. Adjournment Alberta Outbreak Response Protocol (AORP) December 2018 19
Appendix C: Proposed Template for AB-OICC Debrief Step / Issue Comments Action Long-term Outcome Initial stage of the outbreak Outbreak detection and surveillance systems Verifying the diagnosis via laboratory analysis Case definitions Notification of partners and senior management Are there changes in this area that could be recommended for the next time? AB-OICC Initial Assessment Was enough notice given for initial assessment call? Activation Any issues around activation or how it occurred? OICC Call Did calls occur frequently enough? Were the agenda and calls well managed? Were the right participants on the call? Are there changes in this area that could be recommended for the next time? Epidemiological and Laboratory Investigations Were the epi summaries helpful and distributed in a timely manner? Was the line list easy to understand and complete? Are there changes within the Epi/Lab area that could be recommended for the next time? Communications Within OICC: Were updates via email sent frequently enough? Public communications Was decision-making around public communications handled well and in a timely manner? Are there changes in communication that could be recommended for the next time? Public Health Measures (what was done, implementation of control and prevention measures) What were the public health measures taken? Were they considered effective? What could be done differently next time? Are there other changes that could be recommended for the next time? Post-outbreak Debrief Any issues with how the outbreak was declared over and the AB-OICC was deactivated? How effective was the debrief session? Was it held in a timely manner following the outbreak? Other issues? Alberta Outbreak Response Protocol (AORP) December 2018 20