EMERGING AND RE-EMERGING INFECTIOUS DISEASES

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16.1 Summary

Infectious diseases have posed threats to communities for centuries, including the appearance of new infectious disease threats. Diseases that were once major threats, but had declined in prevalence, are re-emerging as significant concerns. Despite advances in technology to prevent, detect, and treat infectious diseases, the ease of global travel and interconnectedness across continents adds new dimensions to disease control. Coronavirus Disease 2019 (COVID-19), Ebola Virus Disease (EVD), and measles are three examples of infectious diseases of concern in the modern era, although other diseases such as chikungunya, pertussis, avian influenza, and polio are also concerning. Disease reporting and surveillance are vitally important to prevent outbreaks of emerging and re-emerging disease.

16.2 Definitions

16.2.1    Emerging Infectious Diseases 

Emerging infectious diseases are diseases that have not occurred in humans before, have occurred previously but affected only small numbers of people in isolated places, or have occurred throughout human history but have only recently been recognized as distinct diseases due to an infectious agent. See National Institutes of Health Understanding Emerging and Re-emerging Infectious Diseases. Examples of emerging diseases include Coronavirus Disease 2019 (COVID-19), Ebola Virus Disease (EVD), avian influenza, chikungunya, Zika, severe acute respiratory syndrome (SARS), and Middle East respiratory syndrome (MERS).

Disease reporting, surveillance, and contact tracing are key components to preventing, detecting, and treating emerging and re-emerging diseases. It may be necessary to detain individuals to prevent the spread of disease or declare public health emergencies, and mass fatalities may occur. See sections 4.0, 7.0, 8.0, 12.0 and 17.0 of the Manual for more information about these critical topics.

There are certain restrictions related to travel within, and entry into ,the U.S. with respect to particular diseases. See sections 17.5, 17.6, and 17.7 of the Manual for more information.

16.2.2    Re-emerging Infectious Diseases 

Re-emerging infectious diseases are diseases that once were major health problems globally or in a particular country, but then declined dramatically, and are again becoming health problems for a significant proportion of the population. See National Institutes of Health Understanding Emerging and Re-emerging Infectious Diseases. Examples of re-emerging diseases include measles and tuberculosis.

Due to the complex and dynamic nature of many infectious diseases, the distinction between “emerging” and “re-emerging” can be difficult to determine, which can lead to different classifications by infectious disease experts. See Emerging Infectious Diseases: Threats to Human Health and Global Stability.

16.3 Factors Influencing Emergence and Re-emergence

World Health Organization (WHO) warned in a 2007 report that infectious diseases are emerging at an unprecedented rate. Since the 1970s, approximately 40 infectious diseases have been discovered, including COVID-19, SARS, MERS, EVD, avian and swine influenza, and Zika. As the world becomes more interconnected through globalization and increased travel over longer distances, the potential for novel diseases to emerge or old diseases to re-emerge increases dramatically. In addition, increased population density exacerbates this concern.

Many factors are associated with the emergence of new infectious diseases or the re-emergence of an old one. Such factors include:

  • The evolution of pathogens over time;
  • Change in human migration;
  • Population growth and expansion into new geographic areas;
  • Climate change;
  • Wars and conflict;
  • Antimicrobial resistance;
  • Decline in vaccination coverage;
  • Destruction of the environment;
  • Increased contact with wild animals;
  • Increased travel;
  • Weak health systems;
  • Delayed emergency response; and
  • Inadequate public health infrastructure. 

See Baylor College of Medicine Emerging infectious Diseases.

As the nation’s capital, the District is a hub of international travel and often hosts international summits, conferences, and meetings; thus, emerging and re-emerging diseases are of particular concern to the District.

16.4 Coronavirus Disease 2019

As the new decade began, a novel coronavirus spread around the globe, originating in Wuhan, China. Extraordinary public health measures were employed by governments across the world, including stay-at-home orders and closure of schools and non-essential businesses; still, by May 8, 2020, nearly 4 million cases were reported by global authorities, with approximately 276,000 deaths worldwide. As of May 28, 2020, there were more than 100,000 COVID-19 related deaths in the U.S.

The COVID-19 pandemic offers a prime illustration of the importance of all facets of preparedness. Here we include a brief overview of the disease caused by the novel coronavirus, how the pandemic unfolded, and legal aspects of the public health emergency response at the federal and District levels as of May 13, 2020.

As the situation was unfolding at the time of this writing, it is critical to ensure that information regarding governmental legal actions and guidance related to COVID-19 are the most up to date.

Information about the District’s response to the COVID-19 pandemic can be found at https://coronavirus.dc.gov/. The Centers for Disease Control and Prevention (CDC) provides a comprehensive website related to the COVID-19 pandemic at www.cdc.gov/coronavirus/2019-ncov/index.html.

16.4.1    Transmission

Coronaviruses are a large family of viruses, some causing illness in people and others circulating among animals, including camels, cats, and bats. Rarely, animal coronaviruses can spread to people. SARS-CoV-2, the virus that causes COVID-19, is the seventh coronavirus known to infect humans. Three (SARS-CoV, MERS-CoV and SARS-CoV-2) can cause severe respiratory illness and can be fatal; the other four produce mild, cold-like symptoms. SARS-CoV-2 likely originated in an animal and spread to humans, with bats currently thought to be the most likely reservoir host of the progenitor virus. See The proximal origin of SARS-CoV-2.

COVID-19 is spread person to person, between people who are in close contact with one another (within about 6 feet). It is transmitted through respiratory droplets produced when an infected person coughs or sneezes. These droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into the lungs. It may be possible that a person can get COVID-19 by touching a surface or object that has the virus on it and then touching their own mouth, nose, or possibly their eyes, but this is not thought to be the primary mode of transmission. Coronaviruses on surfaces and objects naturally die within hours to days. Warmer temperatures and exposure to sunlight may reduce the time the virus survives on surfaces and objects. Emerging science suggests that aerosolized virus may also be transmissible, although this route of infection requires further study. See Aerodynamic analysis of SARS-CoV-2 in two Wuhan hospitals; Reopening Guidance for Cleaning and Disinfecting Public Spaces, Workplaces, Businesses, Schools, and Homes.

COVID-19 seems to be spreading easily and sustainably in the community in affected areas. Community spread means people have been infected with the virus in a geographic area, including some who are not sure how or where they became infected. COVID-19 appears to spread more easily than influenza but is less contagious than measles. See Centers for Disease Control and Prevention How COVID-19 Spreads.

16.4.2    Symptoms

The incubation period of COVID-19 is 2-14 days, with the median time of 4-5 days from exposure to onset of symptoms. Individuals with COVID-19 report a wide range of symptoms. The most prevalent symptoms are cough and shortness of breath or difficulty breathing. People also report a combination of the following: fever, chills, repeated shaking with chills, muscle pain, headache, sore throat, and loss of taste or smell. Other less common symptoms that have been reported include gastrointestinal symptoms like nausea, vomiting, or diarrhea. Reported illnesses have ranged from people with no or mild symptoms to people being severely ill with pneumonia and other complications. People are thought to be most contagious when they are most symptomatic (i.e., the sickest), although there have been reports of transmission before an infected person has symptoms and by infected individuals with no symptoms. See Centers for Disease Control and Prevention Symptoms of Coronavirus; Centers for Disease Control and Prevention Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease.

Children infected by COVID-19 generally experience milder illness than adults: relatively few are hospitalized and they experience fever, cough, or shortness of breath less frequently than adults. However, severe outcomes, including three deaths as of April 2, 2020, have been reported among pediatric COVID-19 case in the U.S. See Centers for Disease Control and Prevention Coronavirus Disease 2019 in Children — United States, February 12–April 2, 2020. On April 27, 2020, an alert circulated from the United Kingdom about an emerging COVID-19-related syndrome in children, now being called “Pediatric Multi-System Inflammatory Syndrome Potentially Associated with COVID-19.” Temporally associated with COVID-19, the rare syndrome is characterized by persistent fever and features of Kawasaki disease and/or toxic shock syndrome, with abdominal symptoms being common. To date, most infected children have recovered. See COVID-19 and a serious inflammatory syndrome in children: Unpacking recent warnings.

Cases of this rare syndrome have been reported in children in Europe and the U.S.; as of May 11, 2020, 93 cases have been reported in New York State, 39 of which were in New York City (NYC), with at least three deaths believed to have been linked to the emerging syndrome. See Coronavirus News: 93 children in NY diagnosed with inflammatory syndrome possibly linked to COVID-19.

Based on currently available information and clinical expertise, older adults and people of any age who have serious underlying medical conditions may be at higher risk for severe illness from COVID-19. Based on age and living arrangements, individuals aged 65 years and older and people who live in a nursing home or long-term care facility are at increased risk. Medical conditions that may increase the risk of COVID-19 include: individuals with chronic lung disease or moderate to severe asthma, serious heart conditions, or a compromised immune system (e.g., due to cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled Human Immunodeficiency Virus (HIV), and prolonged use of immune-weakening medications). People of any age with severe obesity (BMI>40) or underlying, poorly controlled medical conditions, such as diabetes, renal failure, or liver disease, might also be at higher risk. See Centers for Disease Control and Prevention People Who Are at Higher Risk for Severe Illness.

Based on current science, pregnant women seem to have the same risk of COVID-19 as those who are not pregnant. Because pregnancy causes changes in their bodies that may increase the risk of some infections, it is always important for pregnant women to try to protect themselves from illness whenever possible, including potential exposure to COVID-19. See Centers for Disease Control and Prevention Pregnancy and Breastfeeding.

16.4.3    Testing

Although there is currently no United States Food and Drug Administration (FDA)-approved test for SARS-CoV-2, the FDA has issued several emergency use authorizations (EUAs) related to testing. There are two types of tests: molecular and antibody. The molecular tests are nucleic acid amplification tests that detect the genetic material of the virus. Molecular tests analyze the virus in respiratory samples typically collected from the nose or throat with a special swab. They determine whether an individual is currently infected and can be used to directly diagnose COVID-19. The FDA has issued numerous EUAs for molecular tests, which are thought to be highly accurate.

Antibody tests are serology tests to detect the body’s immune response to the infection; they do not detect the actual virus but rather antibodies in the blood with which the body is fighting the infection. However, antibodies may not be detected in the early days of an infection, causing the test to be a false negative. Antibody tests can also give a false positive if a person has antibodies from a previous infection by a different coronavirus. Therefore, antibody tests cannot be used in isolation to diagnose COVID-19. The FDA has also issued EUAs for antibody tests. The evidence regarding the effectiveness of antibody testing is evolving, so their accuracy or utility has not yet been definitively established. See United States Food and Drug Administration Medical Devices Including Tests for COVID-19; Centers for Disease Control and Prevention Testing for COVID-19.

See section 5.7 of the Manual and United States Food and Drug Administration Emergency Use Authorizations for more information about EUAs.

COVID-19 testing differs by location. CDC has issued guidance for who should be tested; however, decisions about testing are made by state and local health departments or healthcare providers. As of May 8, 2020 the total number of public health laboratories (PHL) that have completed verification and are offering testing is 97 – at least one PHL in all fifty states plus the District, Guam, Puerto Rico, and the U.S. Virgin Islands. The majority of testing, however, is being done by the private sector. See Centers for Disease Control and Prevention U.S. Viral Testing Data; The Association of Public Health Laboratories.

In the U.S., CDC is typically the first developer of a diagnostic test to be distributed to their national network of public health labs for used in the U.S. to combat an emerging health threat. See United States Food and Drug Administration Coronavirus (COVID-19) Update: FDA expedites review of diagnostic tests to combat COVID-19. Therefore, despite WHO having listed two COVID-19 diagnostic tests for emergency use, CDC developed its own test that could identify COVID-19 and related viruses. See Centers for Disease Control and Prevention Lab Advisory: Reminder: COVID-19 Diagnostic Testing. Issues with false positive tests by, and potential contamination of, test kits distributed by CDC, compounded by the lack of a national strategy, caused a delay in distribution of test kits and limited access to testing across the U.S. Adequate access to testing has yet to be resolved. See Key Missteps at the CDC Have Set Back Its Ability to Detect the Potential Spread of Coronavirus; Officials Say C.D.C. Errors Caused Testing Delays; Contamination at CDC lab delayed rollout of coronavirus tests; Thousands of coronavirus tests are going unused in US labs; Contamination at CDC lab delayed rollout of coronavirus tests.

CDC recommends that clinicians use their judgment to determine if a patient has signs and symptoms compatible with COVID-19 and whether the patient should be tested. Because there is a national shortage of testing supplies and reagents, CDC has developed suggested priorities for who should be tested. High priority individuals include hospitalized patients with symptoms, workers in healthcare facilities or congregate living setting and first responders with symptoms, and residents in long-term care facilities or other congregate living situations, such as prisons and shelters, with symptoms. Priority individuals for testing include persons with symptoms of potential COVID-19 infection and persons without symptoms who are prioritized by health departments or clinicians for any reason. See Centers for Disease Control and Prevention Evaluating and Testing Persons for Coronavirus Disease 2019.

In the District, testing is available through the District PHL, commercial labs, and some hospital-based clinical labs. DC Health has established its own testing prioritization scheme, most recently updated on May 7, 2020. COVID-19 testing priorities in D.C. are as follows:

  • High Priority: Symptomatic hospitalized patients; workers in healthcare facilities, congregate living settings, and first responders with symptoms or history of close contact exposure; residents in long-term care facilities or other congregate living settings with symptoms or history of close contact exposure.
  • Priority: Persons with symptoms of potential COVID-19 infections, including fever, cough, shortness of breath, chills, muscle pain, loss of taste or smell, vomiting or diarrhea, and/or sore throat; asymptomatic persons who are greater than age 65, have underlying conditions, or are critical infrastructure workers; household contacts of laboratory-confirmed COVID-19 patients.
  • Non-Priority: Individuals without symptoms not listed above.

See DC Health, Health Notice for District of Columbia Health Care Providers.

Testing requirements and procedures continue to be modified based on additional availability of resources, as well as the evolution of our understanding of SARS-CoV-2 and COVID-19.

DC Health has also issued guidance on infection control and specimen collection, including conservation of Personal Protective Equipment (PPE) and practices specific to skilled nursing facilities. See DC Health, Health Notices; DC Health March 26, 2020 - COVID-19 DC Health Guidance for Conservation of Personal Protective Equipment; DC Health March 13, 2020 - DC Health Infection Control Recommendations for Preparedness & Management of COVID-19 in Skilled Nursing Facilities; DC Health Health Notice for District of Columbia Healthcare Providers Coronavirus (COVID-19): Updated Priorities for Testing Patients with Suspected COVID-19 Infection and Updated Prioritization of Contact Tracing by DC Health.

On April 21, 2020 the FDA authorized the first diagnostic test for home collection of COVID-19 testing specimens under an EUA. The re-issued EUA permits testing of samples self-collected outside of clinical settings using the LabCorp COVID-19 RT-PCR test, which are then mailed to the laboratory. Home-collection kits are only authorized for this specific lab and test and are not yet publicly available. See United States Food and Drug Administration Coronavirus (COVID-19) Update: FDA Authorizes First Test for Patient At-Home Sample Collection.

16.4.4    Contact Tracing 

Contact tracing is a core disease control measure utilized by health departments in any outbreak investigation. After defining a “case” based on what is known about the disease, infected individuals are interviewed to determine all individuals with whom they had contact during the period in which they were likely to have been infectious. Public health officials then educate all of the potentially exposed persons about their risk of infection (without revealing the personal information of the initially infected person), what they should do to separate themselves from others who are not exposed, how to monitor themselves for illness, and the possibility that they could spread the infection to others even if they themselves do not feel ill.

In the case of COVID-19, contacts are encouraged to stay at home and practice social distancing from others (at least 6 feet) until 14 days after their last exposure. They are advised to monitor themselves by checking their temperature twice daily and watching for cough or shortness of breath. The extent of contract tracing and follow-up being done by health departments varies, depending on case load and capacity. To the extent possible, public health staff check in with contacts to make sure they are self-monitoring and have not developed symptoms. Contacts who develop symptoms should immediately isolate themselves and contact their healthcare provider. If they develop severe symptoms, such as trouble breathing, they should get emergency medical care immediately. See Centers for Disease Control and Prevention Contact Tracing; Part of a Multipronged Approach to Fight the COVID-19 Pandemic.

Due to the community spread of COVID-19 in the District, DC Health has been conducting contact tracing in specific situations, e.g., outbreaks or persons working in occupations at high risk for spreading COVID-19. Therefore, DC Health recommends that clinicians who order COVID-19 tests be prepared to advise patients on home-quarantine while test results are pending and home-isolation when a patient’s tests are positive. DC Health provides additional guidance for persons who test positive, their contacts and household members. See DC Health March 19, 2020 - Guidance for Persons who Tested Positive for COVID-19; DC Health March 19, 2020 - Guidance for Contacts of a Person Confirmed to have COVID-19DC Health March 19, 2020 - Guidelines for Household Members, Intimate Partners, and Caregivers (in a Non-healthcare Setting) of a Person Confirmed to have COVID-19; DC Health, Health Notice for District of Columbia Healthcare Providers Coronavirus (COVID-19): Updated Priorities for Testing Patients with Suspected COVID-19 Infection and Updated Prioritization of Contact Tracing by DC Health.

As the District reopens, contact tracing requirements and procedures continue to be modified based on additional availability of resources, as well as the evolution of our understanding of SARS-CoV-2 and COVID-19.

16.4.5    Treatment and Vaccines

Currently, there are no FDA-approved drugs to treat COVID-19. Several dozen potential treatments are now in development, some utilizing existing medications for other diseases and conditions and others that are newly developed medications. On May 1, 2020, the FDA issued its first EUA for the antiviral drug remdesivir for the treatment of confirmed or suspected cases in adults or children. It is administered intravenously by healthcare providers to patients hospitalized with severe disease. See United States Food and Drug Administration Coronavirus (COVID-19) Update: FDA Issues Emergency Use Authorization for Potential COVID-19 Treatment.

On May 9, 2020 the United States Department of Health and Human Services (HHS) announced an allocation plan for remdesivir donated by Gilead Sciences, Inc., to the U.S. for use in areas of the country most impacted by the pandemic. Cases containing 40 vials of the drug were sent to seven states for distribution by their state health department: Indiana (38), Massachusetts (117), New Jersey (94), New York (565), Rhode Island (30), Tennessee (7), and Virginia (33). A second allocation went to Connecticut (30 cases), Illinois (140), Iowa (10), Maryland (30), Michigan (40), and New Jersey (110). See United States Department of Health and Human Services HHS announces shipments of donated remdesivir for hospitalized patients with COVID-19. Other allocations have been distributed since, including to the District.

On May 1, 2020 the FDA issued guidance for healthcare providers and investigators on the administration and study of investigational convalescent plasma collected from individuals who have recovered from COVID-19. Because COVID-19 convalescent plasma is not yet FDA-approved, its use is restricted to clinical trials, expanded access treatment protocols, and single patient emergency use investigational new drug applications. Patient eligibility criteria include laboratory confirmation of COVID-19, severe or immediately life-threatening disease, and informed consent. See United States Food and Drug Administration Recommendations for Investigational COVID-19 Convalescent Plasma.

Non-experimental treatment is largely symptomatic. Many persons with mild to moderate symptoms do not require hospitalization and can manage their illness at home. Persons with more severe symptoms may require hospitalization. Treatment of hospitalized patients involves supportive management of the most common complications of COVID-19, including pneumonia or other respiratory illness, organ failure, and secondary infections. See Centers for Disease Control and Prevention Interim Clinical Guidance for Management of Patients with Confirmed Coronavirus Disease (COVID-19).

As of May 2020, there is no FDA-approved vaccine to prevent COVID-19. Multiple human clinical trials are currently underway around the world. The first National Institutes of Health (NIH)-funded, phase one trial in the U.S. started on March 19, 2020 at Kaiser Permanente Washington Health Research Institute using the experimental vaccine mRNA-1273. Researchers at Oxford University estimate that the vaccine being tested in their clinical trial, ChAdOx1 nCoV-19, could be available as early as fall, 2020. However, Dr. Anthony Fauci, Director of the NIH National Institute of Allergy and Infectious Disease, has told reporters that summer 2021 was his prediction on the availability of a vaccine, as it would take 12-18 months, to develop, test, and approve a vaccine for public use. See United States Food and Drug Administration Vaccines, Biologics, Human Tissues, and Blood ProductsNational Institutes of Health NIH clinical trial of investigational vaccine for COVID-19 begins; Oxford University’s timeline for a COVID-19 vaccine is shorter than previous estimates; When will a COVID-19 vaccine be ready?.

16.4.6    Prevention

The best way to prevent becoming infected with COVID-19 is to avoid being exposed to the virus. CDC recommends actions individuals should take to protect themselves and others. Self-protection includes activities such as regular handwashing, use of hand sanitizer containing at least 60 percent alcohol, avoiding touching one’s eyes, nose, or mouth with unwashed hands, and avoiding close contact with others (i.e., social distancing). Actions that individuals can take to protect others include staying home when sick (except to seek medical care), covering coughs and sneezes, mask usage when around others, especially in public spaces, and regular cleaning and disinfection of surfaces. See Centers for Disease Control and Prevention Prevent Getting Sick.

16.4.7    Centers for Disease Control and Prevention Guidance for United States Hospitals

CDC has issued specific guidance for infection control and use of PPE for direct healthcare providers, first responders, and healthcare facilities, as well as a Comprehensive Hospital Preparedness Checklist for COVID-19. The checklist advises that all hospitals should be prepared to deal with COVID-19 patients and ensure that their staff are trained, equipped, and capable of practices needed to prevent the spread of disease, identify and isolate potential COVID-19 patients and inform appropriate authorities, provide care for infected patients as part of routine operations, be prepared to expand capacity in the event of disease outbreaks while maintaining care for non-COVID-19 patients, monitor and manage exposed healthcare personnel, and communicate effectively within the facility and externally about COVID-19. 

16.4.8    Select Global Timeline of the COVID-19 Pandemic

On December 31, 2019, WHO was informed of a pneumonia of unknown cause, detected in the city of Wuhan in Hubei province, China, appearing to originate from the Huanan Seafood Market. On January 7, 2020, Chinese authorities identified the causative agent to be a novel coronavirus, one not previously identified as causing disease in humans, which was named SARS-CoV-2. China recorded its first death from SARS-CoV-2 on January 11, 2020. The first case outside of China was confirmed on January 13, 2020 in Thailand. The first case in the U.S. was reported on January 20, 2020 in a 35-year-old man in Snohomish County, Washington, who had recently returned from Wuhan. On January 20, 2020, Wuhan was placed under quarantine, with the entirety of Hubei province under quarantine within a few days. On January 24, 2020, the first cases were reported in Europe. WHO declared a Public Health Emergency of International Concern (PHEIC) on January 30, 2020. On January 31, 2020, President Trump banned foreign nationals from entering the U.S. if they had been in China within the prior two weeks.

The first death outside China was recorded in the Philippines on February 2, 2020. The death toll in China surpassed that of the 2002-2003 SARS epidemic on February 9, 2020, with 811 deaths recorded. WHO announced that the disease caused by SARS-CoV-2 would be named Coronavirus Disease 2019, or COVID-19, on February 11, 2020. South Korea saw a spike of COVID-19 cases in mid-February, reporting its first death on February 20, 2020. Iran reported its first cases on February 19, 2020, with Italy following on February 21, 2020. California reported the first case in the U.S. with no clear source of exposure, indicating community spread, on February 26, 2020. The U.S. reported its first death on February 29, 2020.

The Spanish outbreak began on March 3, 2020. The District announced its first case of COVID-19 on March 7, 2020. On March 8, 2020, Italy placed all 60 million residents on lockdown. WHO declared the outbreak a pandemic on March 11, 2020; President Trump banned all travel from 26 European countries on the same day. A national emergency was declared in the U.S. on March 13, 2020. On March 19, 2020, China reported no new locally spread infections for the first time since the pandemic began. The District announced its first COVID-19 death on March 20, 2020. NYC confirmed 21,000 COVID-19 cases on March 23, 2020, making it the largest epicenter of the outbreak in the U.S. On March 26, 2020, the total confirmed cases in the U.S. reached 82,404, the highest in the world, surpassing both China and Italy. That same day, the G20 Extraordinary Virtual Leaders’ Summit on COVID-19 was held to advance a coordinated global response to the COVID-19 pandemic and its human and economic implications. By the end of March, more than one-third of humankind was under some form of lockdown.

One million COVID-19 cases were reported around the world by April 2, 2020; the global death toll surpassed 100,000 on April 10, 2020. By April 15, 2020, the global number of COVID-19 cases surpassed two million. On April 21, 2020, California officials announced that a person had died from COVID-19 on February 6, 2020, three weeks earlier than what authorities had thought had been the first U.S. COVID-19 death. On April 22, 2020, the U.S. reported the highest single-day death toll for any country, more than 2,600.

The pandemic's epicenter moved to South America by May 2020. By May 8, 2020, nearly 4 million cases were reported by global authorities, with approximately 276,000 deaths worldwide. As of May 28, 2020, there were more than 100,000 COVID-19 related deaths in the U.S.

See World Health Organization Coronavirus disease (COVID-19) Pandemic;   Centers for Disease Control and Prevention Coronavirus (COVID-19); Johns Hopkins University & Medicine Coronavirus Resource Center; New York Times.

16.4.9    Select Federal Response Actions to the COVID-19 Pandemic 

The Centers for Medicare and Medicaid Services (CMS) issued a number of waivers and guidance documents in response to the COVID-19 pandemic. See Centers for Medicare and Medicaid Services Coronavirus Waivers & Flexibilities for more information.

The HHS Office for Civil Rights (HHS OCR) provided Bulletins, Notifications of Enforcement Discretion, Guidance, and Resources to help explain how patient health information may be used and disclosed in response to the COVID-19 nationwide public health emergency. See United States Department of Health and Human Services HIPAA and COVID-19.

CDC issued interim final rules and took other actions related to its isolation and quarantine authority in response to the COVID-19 pandemic. See https://www.cdc.gov/quarantine/aboutlawsregulationsquarantineisolation.html for more information.

The FDA took a number of actions in response to the COVID-19 pandemic. See https://www.fda.gov/emergency-preparedness-and-response/counterterrorism-and-emerging-threats/coronavirus-disease-2019-covid-19 for more information.

  1. Emergency Declarations 

On January 31, 2020, United States Secretary of Health and Human Services (HHS Secretary) Azar declared that a public health emergency under section 319 of the Public Health Service Act existed nationwide since January 27, 2020 due to COVID-19. The declaration of public health emergency was renewed on April 21, 2020.

President Trump declared dual emergencies, effective March 1, 2020, on March 13, 2020 under the National Emergencies Act (NEA) and section 501(b) the Robert T. Stafford Disaster Relief and Emergency Assistance Act of 1988 (Stafford Act), which allows the federal government to declare an emergency without a governor’s request. See Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak.

All 50 states, the District of Columbia, and four territories were approved for major disaster declarations to assist with additional needs identified under the nationwide emergency declaration for COVID-19. See Federal Emergency Management Agency COVID-19 Disaster Declarations.

On March 10, 2020, HHS Secretary Azar issued a declaration under the Public Readiness and Emergency Preparedness Act (PREP Act) to provide liability immunity for activities related to medical countermeasures against COVID–19. This declaration was amended, effective March 27, 2020, to extend liability immunity to covered countermeasures authorized under the Coronavirus Aid, Relief, and Economic Security Act (CARES Act).

See section 4.2 of the Manual for more information about federal declarations, section 5.8 of the Manual for more information about the PREP Act, and section 16.4.9 E of the Manual for more information about the CARES Act.

The Office of the General Counsel of HHS (HHS OGC) issued an omnibus advisory opinion on April 17, 2020, and modified on May 19, 2020, to address questions and concerns raised about the scope of PREP Act immunity during the COVID-19 pandemic. This advisory opinion set forth the current views of the HHS OGC. It was not a final agency action or a final order, does not bind HHS or the federal courts, and does not have the force or effect of law.

  1. Section 1135 Waivers

On March 13, 2020, HHS Secretary Azar issued a section 1135 waiver with a retroactive effective date of March 1, 2020, regarding:

  • Emergency Medical Treatment and Active Labor Act (EMTALA) sanctions for patient relocation purposes;
  • Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule regulations (for limited duration);
  • In-state licensure requirements for healthcare workers;
  • Participation restrictions on Medicare, Medicaid, & the Children’s Health Insurance Program (CHIP);
  • Medicare Advantage payment limitations; and
  • Sanctions under section 1877(g) (the Physician Self-Referral Law or the Stark Law).

See section 4.3 of the Manual for more information about section 1135 waivers.

See Section 1135 Waivers and COVID-19: An Overview for more information regarding section 1135 waivers during the COVID-19 pandemic.

See Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19 for more information on approved Medicaid emergency authorities to address the COVID-19 pandemic.

  1. Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020

The Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, which passed with near unanimous support in both the House and Senate, was signed on March 6, 2020. The bill provided $8.3 billion in emergency funding for federal agencies to respond to the coronavirus outbreak, both domestically and globally.

See The U.S. Response to Coronavirus: Summary of the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020 for more information.

  1. Families First Coronavirus Response Act

The Families First Coronavirus Response Act (FFCRA) was signed on March 18, 2020. This Act addressed the domestic outbreak, including paid sick leave, insurance coverage of coronavirus testing, nutrition assistance, and unemployment benefits.

See The Families First Coronavirus Response Act: Summary of Key Provisions for a summary of key provisions of the FFCRA.

  1. Coronavirus Aid, Relief, and Economic Security Act

The CARES Act, which was signed on March 27, 2020, provided $2.2 trillion in economic stimulus funds relief to individuals and businesses suffering losses from the COVID-19 pandemic.

See The Coronavirus Aid, Relief, and Economic Security Act: Summary of Key Health Provisions for a summary of key health provisions of the CARES Act.

The CARES Act created a new category of covered countermeasures eligible for liability immunity under the PREP Act: respiratory protective devices approved by the National Institute for Occupational Safety and Health (NIOSH) that the HHS Secretary determines to be a priority for use during a declared public health emergency. See section 5.8 of the Manual for more information about the PREP Act.

  1. Paycheck Protection Program and Health Care Enhancement Act 

The Paycheck Protection Program and Health Care Enhancement Act was signed on April 24, 2020. This Act provided $484 billion in additional funding to replenish and supplement key programs under the CARES Act, including the Paycheck Protection Program (PPP), small business disaster loans and grants, hospitals and healthcare providers, and testing.

See The Paycheck Protection Program and Health Care Enhancement Act: Summary of Key Health Provisions for a summary of key health provisions of this act.

16.4.10    Select State Response Actions to the COVID-19 Pandemic

States took varying legal actions to prevent the spread of COVID-19 and mitigate the impact of the pandemic on the U.S. public health and healthcare systems. Using executive authority, governors, mayors, and state agencies issued executive orders, emergency proclamations, and emergency rulemakings to institute social distancing measures, including stay-at-home and shelter-in-place orders, travel restrictions, curfews, mandatory quarantine periods for travelers, mask-wearing requirements, business and school closures, and bans on gatherings of various sizes. States also restricted elective medical procedures and appointments, commandeered medical supplies, and ordered healthcare facilities to increase their capacity. Some states preempted local government efforts to enact localized mitigations measures; other states expressly permitted local government action. States also took various approaches to reopening, with some states reopening before COVID-19 cases dropped for 14 days, which was one of the criteria contained in White House guidance on reopening.

Virginia declared a state of emergency due to the COVID-19 pandemic on March 12, 2020 and a public health emergency on March 20, 2020. Virginia’s stay-at-home order was originally issued on March 30, 2020. An amended order was issued on May 4, 2020. As of May 12, 2020, there were 25,800 COVID-19 cases and 891 COVID-19 deaths in Virginia. Virginia began reopening on May 15, 2020. 

Maryland declared a state of emergency and a catastrophic health emergency due to the COVID-19 pandemic on March 5, 2020. The declaration was renewed on May 6, 2020. Maryland issued a series of prohibitions on mass gatherings as well as stay-at-home orders on March 12, 2020; the most recent order was issued on May 6, 2020. As of May 12, 2020, there were 33,373 COVID-19 cases and 1,573 COVID-19 deaths in Maryland. Maryland began reopening on May 15, 2020.

See the following for more information about state and local government actions to address COVID-19:
• State Data and Policy Actions to Address Coronavirus
                 • National Conference of State Legislatures State Action on Coronavirus (COVID-19)  
                 • National Governors Association What Steps Have States Taken To Address Coronavirus?
                 • Association of State and Territorial Health Officials Coronavirus Disease 2019 (COVID-19) Response Hub
                 • National Association of County & City Health Officials Coronavirus Resources for Local Health

16.4.11    Select District of Columbia Response Actions to the COVID-19 Pandemic

See Appendix 7.0 for a timeline of the events described below.

See section 4.5 of the Manual for more information about mayoral authority to declare emergencies in the District.

On February 28, 2020, District Mayor Bowser issued Mayor's Order 2020-035 to prepare District government agencies for the potential impacts of COVID-19 on the District’s residents, businesses, and visitors, and on the operations of the District government. The Mayor declared both a public emergency (Mayor's Order 2020-045) and a public health emergency (Mayor's Order 2020-046) due to the COVID-19 pandemic on March 11, 2020.

DC Health took a number of actions on March 13, 2020, including issuing two administrative orders as well as issuing emergency rulemaking. Administrative Order 2020-01 sets forth certain authorities of DC Health necessary to address COVID-19. The DC Health Director may:

  • Coordinate emergency response activities with local, regional, or federal agencies, the private sector, and non-governmental organizations; 
  • Order an individual or groups of individuals to submit to quarantine, isolation, and/or medical treatment (collectively referred to as “detention”) when there is probable cause to believe that the individual or group is likely to be affected with or a carrier of a communicable disease and the presence of the individual or group is likely to cause death or seriously impair the health of others;
  • Waive any licensing, registration, or certification requirements, permits, or fees otherwise required by District law or regulations to allow healthcare providers from other jurisdictions appointed as temporary agents to respond to the public health emergency, provided that the temporary agents are licensed, registered, or certified and in good standing in their home jurisdictions in their fields of expertise and meet the District’s suitability requirements;
  • Register and appoint licensed, registered, and certified healthcare providers, either from the District or from other jurisdictions, as temporary agents of the District without compensation, provided that the temporary agents are licensed, registered, or certified and in good standing in their home jurisdictions in their fields of expertise and meet the District’s suitability requirements;
  • Register and appoint lay volunteers to support the efforts of the District’s medical response to COVID-19;
  • Exempt licensed healthcare providers, either from the District or from other jurisdictions, from civil liability for damages for any actions taken within the scope of the provider’s paid or unpaid service, except in instances of gross negligence for actions taken during the state of emergency;
  • Authorize the use of crisis standards of care or modified means of delivery of healthcare services in scarce resource situations;
  • Authorize DC Health to coordinate healthcare delivery for first aid within the limits of individual licensure in shelters or facilities provided in plans and protocols published by DC Health, as determined expedient by the DC Health Director;
  • Modify the scope of practice for certain licensed, registered, and certified healthcare providers as required, including authorizing certified paramedics to administer vaccines;
  • Modify DC Health operational processes and procedures as needed to ensure more efficient use of DC Health staff during the COVID-19 response;
  • Implement plans and protocols to address medical surge, including coordination of health and medical resources, disposal of hazardous waste, and other plans and protocols, as needed; and
  • Procure materiel, human capital, and other goods and services as needed to support the health and medical response to COVID-19.

Administrative Order 2020-02 set forth requirements under which licensure, certification, or registration requirements, permits, and/or fees were waived for healthcare practitioners appointed as temporary agents of the District in order to respond to the COVID-19 public health emergency. The DC Health Director issued an emergency rulemaking that prohibits certain mass gatherings of 250 or more persons at the same time in a single room or other single confined or enclosed space to reduce the spread of COVID-19. In addition, gatherings of more than 10 individuals organized by an organization that is not a hospital, nursing home, assisted living facility, or other medical facility, that primarily serves or targets persons of 60 or older years of age, persons who have serious medical conditions (including heart disease, diabetes, lung disease, asthma, or chronic pulmonary obstructive disease), or persons who are immunocompromised, were also prohibited.

On March 14, 2020, the District of Columbia Department of Health Care Finance announced emergency and proposed rulemaking for Medicaid providers who could now deliver in-home healthcare services via telemedicine. This policy change allowed Medicaid beneficiaries to receive telemedicine services at their home and required Medicaid telemedicine providers to ensure that any technology used met the standards of care when the beneficiary received telemedicine services at their home. The rule will remain in effect for 120 days or until July 10, 2020, unless superseded by publication of a Notice of Final Rulemaking in the D.C. Register.

Mayor’s Order 2020-048, issued on March 16, 2020, prohibited mass gatherings of more than 50 persons at the same time in a single room or other single confined or enclosed space to reduce the spread of COVID-19. In addition, gatherings of more than 10 individuals organized by an organization that is not a hospital, nursing home, assisted living facility, or other medical facility, that primarily serves or targets persons of 60 or older years of age, persons who have serious medical conditions (including heart disease, diabetes, lung disease, asthma, or chronic pulmonary obstructive disease), or persons who are immunocompromised, continued to be prohibited. Restaurants and taverns were required to suspend table seating and could operate only delivery and grab-and-go services as of March 16, 2020. Night clubs, multi-purpose facilities, health clubs, health spas, massage establishments, and theatres were required to suspend operations on March 17, 2020.

The COVID-19 Response Emergency Amendment Act of 2020 (D.C. Act 23-247) became effective on March 17, 2020. This expansive act provided the Mayor with additional authority and addressed critical needs of District residents and businesses during the COVID-19 declared public health emergency, including wage replacement, business relief, and additional authorities and exemptions regarding health, public safety, consumer protection, and government operation. For example, this act created a new category of leave available under the District’s Family and Medical Leave Act, declaration of emergency leave, and temporarily eased certain eligibility requirements for unemployment insurance compensation and other public benefit programs. The act also prohibited the disconnection of electric, water, and gas services, as well as evictions during a public health emergency.

Mayor’s Order 2020-049, issued on March 19, 2020, stated that exemptions could be granted for overweight, over width, registration, licensing, and hours of service to all motor carriers and drivers transporting emergency relief supplies or otherwise providing direct assistance in support of emergency relief efforts to, through, and from any area of the District. This authorization applied to water, food, medical supplies and equipment, supplies and equipment necessary for community safety, sanitation, and prevention of COVID-19, supplies and equipment necessary to establish and manage temporary facilities in response to COVID-19, heating oil, motor fuels, and propane, agricultural products and supplies, equipment and supplies necessary to restore utilities, removal of waste, and any other equipment, services, supplies, and persons transported to support the COVID-19 response and recovery, regardless of their point of origin or destination.  The order also delegated authority to the District of Columbia Department of Transportation to issue temporary waivers of registration and licensing requirements for motor carriers and drivers and temporary waivers of normal weight and width restrictions on roads controlled by the District in order to ensure that these services, supplies, equipment, and persons reach impacted areas in a timely fashion.

On March 20, 2020, under Mayor’s Order 2020-050, the Mayor extended the declarations of public emergency and public health emergency until April 24, 2020 and incorporated the emergency measures included in Mayor’s Order 2020-045 and Mayor’s Order 2020-046. Also, on March 20, 2020, Mayor’s Order 2020-051 was issued, which continued the prohibition on mass gatherings of more than 50 persons at the same time in a single room or other single confined or enclosed space to reduce the spread of COVID-19. The prohibition of table service and service to standing customers at restaurants, bars, taverns, and multi-purpose facilities in the District, including seated, fast food, and fast casual, continued. Such businesses could operate take out, grab-and-go, and delivery operations only. The suspension of operations for nightclubs, multi-purpose facilities, health clubs, health spas, massage establishments, and theatres that began March 17, 2020 was continued. In addition, all of Department of Parks and Recreation’s facilities, including playgrounds, parks, and athletic fields, were closed to the public and no member of the public allowed to enter upon or into such facilities.

On March 23, 2020, pursuant to Mayor’s Order 2020-052, the Mayor delegated authority in order to execute actions required under the COVID-19 Response Emergency Amendment Act of 2020.

Mayor’s Order 2020-053, issued on March 24, 2020, and based on guidance provided by the United States Department of Homeland Security’s Cybersecurity and Infrastructure Security Agency (CISA), ordered the temporary closure of all non-essential businesses. In addition, essential businesses that remained open were required to comply with social distancing requirements. Both essential and non-essential businesses were required to take reasonable steps to allow employees to work remotely.

All businesses with a facility in the District (except essential businesses as defined in the order) were required to cease all activity. Minimum basic operations were still permitted, defined as the minimum necessary activities to: maintain inventory, ensure security, process payroll/employee benefits, facilitate working remotely/teleworking, clean/disinfect facilities, and provide supervision of contractors and provide essential maintenance.

Essential businesses were defined as:

  • Healthcare and public health operations pursuant to the guidelines from the CISA;
  • Veterinary care;
  • Essential infrastructure – public works and utilities;
  • Food and household products and services – establishments engaged in the sale/distribution of food products, alcohol, and any other household consumer products:
    • Laundry service providers;
    • Medical marijuana cultivation centers;
    • Stores that sell products necessary to maintain safety, sanitation, and operation of residences; and
    • Restaurants or facilities that prepare/serve food must be take-out or deliver only.
  • Social services providing the necessities of life (food and shelter);
  • Communications and information technology;
  • Energy and automotive services (e.g., gas stations, auto repair shops, and auto supply stores;
  • Financial services;
  • Educational institutions for the sole purpose of facilitating distance learning or modifying facilities/providing support;
  • Transportation and logistics (e.g., delivering/shipping goods, taxis and ride-share, mailing and shipping services, and bicycle shops);
  • Construction and building trades;
  • Housing and living facilities;
  • Professional services, including legal, insurance, notary, and accounting services, but only to assist in compliance with legally mandated activities, essential businesses, or essential government functions; and
  • Childcare facilities, with priority given for the children of essential employees.

Any business that did not fall within a category listed as essential businesses in the order, but which provided goods or services necessary to maintain operations at an essential business, could apply for a waiver, processed through the District of Columbia Homeland Security and Emergency Management Agency (HSEMA).

Essential government functions included first responders, police, fire and emergency medical services, emergency management, 311/911 call center, law enforcement functions, services needed to ensure the continued operation of the government agencies (local and federal) or their contractors and provide for the health, safety, and welfare of the public, District of Columbia Courts, inter‐governmental commissions, and entities performing such functions, including judicial and election functions.

Social distancing requirements included maintaining at least 6 feet of distance from another individual, washing hands with soap and water for at least 20 seconds or using hand sanitizer frequently or after contact with potentially‐infected surfaces, covering coughs or sneezes preferably with a tissue immediately disposed of, or into the elbow or sleeve (not with hands), and regularly cleaning high‐touch surfaces and not shaking hands.

On March 27, 2020, DC Health issued Administrative Order 2020-03. Under the order, COVID-19 was added to the list of notifiable diseases and conditions for the duration of the public health emergency. In addition, all public health and commercial labs were required to share data on notifiable diseases or conditions with the District of Columbia Health Information Exchange (D.C. HIE) and DC Health for the duration of the public health emergency. The D.C. HIE was authorized, for the duration of the public health emergency, to provide notification of positive test results to District of Columbia Fire and Emergency Medical Services providers in the event of their exposure to COVID-19.

The Mayor issued a stay-at-home order on March 30, 2020 under Mayor’s Order 2020-054, which required all individuals in the District to stay in their residences except to perform essential activities, engage in essential business, provide or obtain essential government services, or engage in certain authorized recreational activities not involving close contact with others. Individuals experiencing homelessness were exempt, but were strongly urged to obtain shelter, with District agencies making such shelter available as soon as possible and to the extent practicable, using COVID-19 risk mitigation practices in their operations. Additional limitations were placed on individuals and businesses.

Also on March 30, 2020, DC Health issued Administrative Order 2020-04, which provided that emergency medical services (EMS) agencies that were awarded Certificate of Need (CON) or CON exemption, either permanent or temporary, be offered a streamlined process and application for a provisional D.C. EMS Agency certification for the duration of the declared emergency plus 30 days thereafter. In addition, pursuant to 29 DCMR section 562, the DC Health Director was permitted authorize “Community Paramedicine” as a pilot project to improve patient care services. All other EMS certification requirements and/or fees were waived for healthcare practitioners for the duration of declared emergency.

On March 31, 2020, effective immediately, DC Health issued a Notice of Emergency Rulemaking to amend DCMR Title 22, Subtitle B, Chapter 2, to require individuals living in the District to stay at their place of residence, with certain exceptions, to reduce the community transmission of SARS-CoV-2.

DC Health issued Administrative Order 2020-05 on April 2, 2020, to authorize the use of crisis standards of care by healthcare facilities during the COVID-19 declared emergency. Healthcare facilities were required to have invoked their emergency operations plans in order to implement their crisis standards of care plans. Each facility’s crisis standards of care were deemed approved by the District, to be executed by health and allied professionals, or other licensed, registered, or certified professionals providing services in a healthcare facility or a District approved alternate care site facility in response to the District’s COVID-19 declared public health emergency. For the duration of the declared emergency, these crisis standards of care served as the standards of care and the degree of care owed to patients by licensed, registered, or certified healthcare professionals as set forth in each healthcare facility’s respective emergency plan.

All healthcare professionals and their assisting personnel executing the crisis standards of care plan were required to do so in good faith, ethically, fairly, and equitably without regard to the patient’s disability, insurance status, or ability to pay.

See section 11.4 of the Manual for more information on crisis standards of care and section 16.4.12 of the Manual for more information about equity concerns during the COVID-19 pandemic.

Also on April 2, 2020, DC Health issued a Notice of Emergency and Proposed Rulemaking, effective immediately, to amend Chapter 13 (Prescriptions and Distribution) of Title 22, Subtitle B of the DCMR. This emergency rulemaking was deemed necessary to protect the health, safety, and welfare of the District’s residents by ensuring the continued availability of hydroxychloroquine, chloroquine, and azithromycin to patients who rely on these prescription medications for treatment of FDA-approved medical conditions and diseases to avoid disability, illness, and early death. The purpose of this rulemaking was to require that pharmacists only dispense hydroxychloroquine, chloroquine, and azithromycin for FDA-approved conditions and treatment or pursuant to the exceptions set forth in this rulemaking. The emergency rule expired 120 days from the date of adoption, July 31, 2020, or upon publication of a Notice of Final Rulemaking in the D.C. Register, whichever occured first.

Mayor’s Order 2020-057, issued on April 6, 2020, placed restrictions on certain personnel, travel, and training due to the impacts of COVID-19 on District government finances and revenue shortfall.

Mayor’s Order 2020-058, issued on April 8, 2020, required the implementation of social distancing protocols at indoor retail food sellers and declared that farmers’ markets and the Municipal Fish Market were no longer deemed “essential businesses,” meaning they could not operate without first obtaining a waiver. Furthermore, tennis and golf were removed from the definition of “allowable recreational activity” and individuals utilizing rooftop or courtyard spaces could only do so with members of their household and while practicing social distancing.

On April 10, 2020, D.C. Act 23-286 “COVID-19 Response Supplemental Emergency Amendment Act of 2020” was enacted. This expansive act provided the Mayor with additional authority and addressed critical needs of District residents and businesses during the COVID-19 declared public health emergency, including wage replacement, business relief, and additional authorities and exemptions regarding health, public safety, consumer protection, and government operation, as well as authorized and provided for the issuance of certain District notes and bonds. For example, the Act amended the District Accrued Sick and Safe Leave Act (ASSLA) to create a new category of paid leave called “declared emergency leave;” employers were required to provide paid leave to employees for any covered reason provided by the FFCRA. The Act also required mortgage servicers to create a deferment program for residential and commercial mortgages during a declared public health emergency and 60 days thereafter.

Also on April 10, 2020, pursuant to Mayor’s Order 2020-059, the Mayor delegated authority in order to execute actions required under the COVID-19 Response Supplemental Emergency Amendment Act of 2020.

Mayor’s Order 2020-060, issued on April 13, 2020, delegated authority to the Director of the Department of General Services to procure goods and services for emergency medical facilities related to the COVID-19 public health emergency.

On April 14, 2020, DC Health issued a Notice of Emergency Rulemaking to amend DCMR Title 22, Subtitle C, Chapter 57, which allowed District residents registered as qualifying patients to obtain medical marijuana from dispensaries registered in the District through delivery, curbside pickup, and at-the-door pickup options.

Mayor’s Order 2020-063, issued on April 15, 2020, extended the public health emergency and public health emergency in the District through May 15, 2020. The order also designated individuals who perform direct support services within certain residences and facilities (e.g., community living residences and facilities for individuals with medical, physical, or other healthcare conditions that are funded in whole or part by the District, nursing homes and assisted living facilities, low-barrier and emergency shelters for individuals, families, or youth experiencing homelessness or fleeing domestic violence, psychiatric hospitals, and certain correctional and youth rehabilitation facilities) as essential healthcare providers necessary for the District’s COVID-19 public health emergency response. Protocols were required at these facilities for the safety of employees and residents, including the exclusion of visitors and non-essential personnel, screening of all individuals entering the facility for COVID-19 symptoms, social distancing measures, and the cancellation of group activities. Policies and procedures to address anticipated staff shortage and fast-tracking employment at these facilities were also included. In addition, the Department of Health Care Finance was ordered to review its claims data for 2019 and 2020 to identify beneficiaries who may have underlying health conditions that make them more vulnerable to severe illness or death from COVID-19, as well as conduct outreach activities to the identified individuals.

DC Health issued Administrative Order 2020-06 on April 20, 2020, which provided liability protections for persons providing services to the District during the COVID-19 public health emergency declaration. Under this administrative order, any person, employee of the District not otherwise exempt under existing law, or contractor providing services under the direction of DC Health arising out of the COVID-19 response efforts, is exempt from civil liability for damages for actions taken while acting within the scope of their employment, voluntary service, or scope of work to prevent or control the spread of COVID-19, except in instances of gross negligence or intentional act or omission during the period of the declared public health emergency.

See section 5.8 of the Manual for more information about liability protection.

See https://www.dccourts.gov/coronavirus for more information about the operation of District of Columbia Courts during the COVID-19 pandemic.

Mayor’s Order 2020-065, issued on May 9, 2020, provided technology guidelines for virtual meetings and delegated authority to the Chief Procurement Officer to exempt any contractor providing services arising out of a contract with the District government from civil liability for damages for actions taken while acting within the scope of services of their contract, except in instances of gross negligence, and solely for actions taken during the public health emergency.

In preparation for medical surge in the District, local hospitals were directed to increase their bed capacity to accommodate as much as 125% of their licensed capacity. The District’s Alternate Care Site (ACS), a temporary hospital, was built to accept patients once hospitals exceed their capacity.  Designed and constructed in 22 days within the Walter E. Washington Convention Center and ready for operation as of May 12, 2020, the ACS had the ability to provide acute and non-acute care for mildly symptomatic COVID-19 patients referred from other licensed hospitals within the District. Coordinated by local and federal agencies, the ACS could accommodate 437 patients in fully equipped individual patient rooms, and provide a complete range of clinical and non-clinical providers, as well as support functions like radiology, laboratory, and pharmacy. The ACS was designed to expand to accommodate up to 1,900 beds, if needed.

See https://www.cdc.gov/coronavirus/2019-ncov/hcp/alternative-care-sites.html and  https://asprtracie.hhs.gov/technical-resources/111/covid-19-alternate-care-site-resources/99 for more information and resources related to alternate care sites.

On May 13, 2020, District Mayor Bowser issued Mayor’s Order 2020-066, which extended the District’s public emergency and public health emergency declarations until June 8, 2020. This order also outlined mask requirements and the District’s preparations for reopening.

The ReOpen D.C. Advisory Group issued recommendations to Mayor Bowser regarding how to reopen the District safely via a phased reopening strategy with mitigation guidelines under sector on May 21, 2020. The ReOpen D.C. Advisory Group recommended a four-phase approach to reopening businesses, government operations, services, and activities in the District, with each phase reducing restrictions and moving toward Phase Four, when District restrictions based on protecting public health would lift.

On May 27, 2020, District Mayor Bowser issued Mayor’s Order 2020-067, which declared that the District was in Phase One of reopening. The order established the applicable standards for reopening, lifted restrictions under the “Stay-at-Home” Order, and allowed certain businesses to reopen on May 29, 2020, under specified conditions. Large gatherings of more than 10 individuals continued to be banned. Healthcare providers were permitted to continue to offer, or resume offering, services, including outpatient or other surgical procedures in the District that would not unduly burden hospital capacity or COVID-19 related resources. Conditions were set for food establishments and taverns, nightclubs and other mixed-use facilities that offer food, to open for outdoor dining. Parks, dog parks, tennis courts, tracks, and fields could reopen; however, playgrounds, public pools, recreation centers, and indoor facilities were to remain closed. The District’s public emergency and public health emergency declarations were extended until July 24, 2020.

16.4.12    Equity Concerns Raised by the COVID-19 Pandemic 

See section 14.0 of the Manual for more information regarding at-risk populations.

The COVID-19 pandemic shined a spotlight on existing health inequities in the United States. African Americans, Latinx, and Native American communities were disproportionately impacted by both the disease and its accompanying economic devastation. Individuals experiencing homelessness had no home in which to shelter or access to sanitation facilities to wash their hands. Older adults and individuals with disabilities became concerned that policies regarding the allocation of scarce resources (e.g., ventilators and intensive care unit beds) would result in scoring systems that would put them at lower priority to receive such resources. Individuals from Asia and Asian Americans experienced increased racism and stigmatization for being responsible for the “Chinese virus.” The environments of nursing homes, residential facilities, and correctional facilities led to significant outbreaks of COVID-19, putting older adults, individuals with disabilities, and incarcerated persons, at risk. Families who relied on schools to provide their children with food were faced with sudden food insecurity, as were those who relied on federal nutrition assistance programs.

The United States District Court for the District of Columbia issued a nationwide preliminary injunction on March 13, 2020, to halt a federal rule that would remove an estimated 700,000 individuals from the Supplemental Nutrition Assistance Program (SNAP) by limiting a state’s ability to request a waiver of SNAP work requirements for certain adults without dependents. The United States Department of Agriculture (USDA) may not enforce the regulation while the court considers the legality of the challenged rule. The court reasoned that the plaintiffs were likely to win on the merits of the case because aspects of the rule are “likely unlawful because they are arbitrary and capricious.” The court also held that the injunction was needed to prevent irreparable harm to multiple states, nonprofits, and SNAP recipients. The court highlighted SNAP’s importance to national pandemic response efforts “[e]specially now, as a global pandemic poses widespread health risks, guaranteeing that government officials at both the federal and state levels have flexibility to address the nutritional needs of residents and ensure their well-being through programs like SNAP, is essential."

HHS OCR issued a bulletin on March 28, 2020, designed to ensure that entities covered by civil rights authorities keep in mind their obligations under laws and regulations that prohibit discrimination on the basis of race, color, national origin, disability, age, sex, and exercise of conscience and religion in HHS-funded programs. See United States Department of Health and Human Services Office for Civil Rights in Action Bulletin: Civil Rights, HIPAA, and the Coronavirus Disease 2019 (COVID-19). This bulletin was released after several disability rights organizations filed complaints with HHS OCR regarding state protocols regarding treatment and the allocation of scarce resources during the COVID-19 pandemic. See HHS-OCR Complaints Re COVID-19 Treatment Rationing.

For more information about equity issues and the COVID-19 pandemic, please see the following:
• State Policies May Send People with Disabilities to the Back of the Line for Ventilators
                  • Ten Equity Implications of the Coronavirus COVID-19 Outbreak in the United States
                  • American Medical Association COVID-19 health equity resources
                  • American Public Health Association COVID-19 and Equity
                  • Centers for Disease Control and Prevention Interim Guidance for Homeless Service Providers to Plan and Respond to Coronavirus Disease 2019 (COVID-19)
                  • COVID-19 and Health Equity Resources  

16.5 Ebola

The Ebola virus causes an acute, serious illness that is often fatal if left untreated. EVD was first discovered in 1976 in two consecutive outbreaks in different parts of Central Africa. The first one occurred near the Ebola River in what is now the Democratic Republic of the Congo (DRC), giving the virus its name. See Centers for Disease Control and Prevention Ebola (Ebola Virus Disease) History of Ebola Virus Disease. Since that time, periodic outbreaks have occurred in several African countries. The 2014-2016 outbreak in West Africa was the largest and most complex outbreak, with more cases and deaths in this outbreak than all others combined spread across several countries. See World Health Organization Ebola Virus Disease. In 2018, the DRC declared its ninth and tenth outbreaks of EVD, the latter of which is still ongoing. See European Medicines Agency Ebola. This is considered to be the second largest Ebola outbreak.

DC Health has an Ebola information page: https://dchealth.dc.gov/page/ebola-information.

16.5.1    Transmission 

The natural wildlife host of Ebola virus has not been definitely identified but African fruit bats may be the reservoir. The virus is introduced into the human population through close contact with the blood, secretions, organs, or other bodily fluids of infected animals like chimpanzees, monkeys, gorillas, and fruit bats. EVD is then spread from human to human via direct contact with the blood, secretions, organs, or other bodily fluids of infected individuals, and with surfaces and materials contaminated with these fluids like bedding or clothing.

Healthcare workers who have close contact with patients with suspected or confirmed EVD have frequently become infected when infection control precautions are inadequate and PPE is not available. EVD may also be transmitted through traditional burial ceremonies that involve direct contact with the deceased individual. Pregnant women infected with EVD may transmit the virus via breastmilk or pregnancy-related fluids and tissue. EVD transmission may occur from semen from a man who recovered from EVD, but has not been shown to be transmitted through vaginal fluids from a woman.

See Overview, Control Strategies, and Lessons Learned in the Centers for Disease Control and Prevention (CDC) Response to the 2014-2016 Ebola Epidemic.

16.5.2    Symptoms 

The incubation period of EVD is 2-21 days; symptoms usually appear within 8-10 days after exposure. First symptoms include the sudden onset of fever, fatigue, muscle pain, headache, and sore throat; these symptoms are similar to other infectious diseases such as malaria and Lassa fever, making diagnosis difficult. Initial symptoms are followed by vomiting, diarrhea, rash, and in some cases, both internal and external bleeding. In severe cases, multi-organ dysfunction such as kidney and liver failure can develop. An infected person becomes contagious once symptoms appear.

See Overview, Control Strategies, and Lessons Learned in the CDC Response to the 2014-2016 Ebola Epidemic.

16.5.3    Treatment and Vaccines 

Currently, there are no anti-viral drugs approved by the FDA. Two of the four investigational treatments utilized in the 2018 DRC outbreak that demonstrated higher survival rates, regenerin (REGN-EB3) and mAb114, are currently being used to treat confirmed cases of EVD. See Centers for Disease Control and Prevention Ebola (Ebola Virus Disease). Symptomatic treatment, early supportive care with intravenous hydration and supplemental oxygen, and treatment of co-infections improve the likelihood of survival.

On November 11, 2019, a vaccine, Ervebo (Ebola Zaire Vaccine [rVSV∆G-ZEBOV-GP, live]) was granted EU-wide conditional marketing authorization, following a recommendation by the European Medicines Agency (EMA). See European Medicines Agency Ebola. On November 19, 2019, WHO prequalified Ervebo, fast-tracking its licensing, access, and rollout in countries at highest risk. See WHO prequalifies Ebola vaccine, paving the way for its use in high-risk countries. On December 19, 2019, Ervebo became the first FDA-approved vaccine for the prevention of EVD. Prior to licensure, it was used during the 2018 outbreak in the DRC as an investigational vaccine under the FDA’s Expanded Access Program to protect persons at highest risk of the Ebola outbreak under a “ring vaccination” strategy that continues today. This strategy tracks the epidemic, recruiting individuals at increased risk of infection due to their connection to a patient confirmed with EVD. See World Health Organization Uganda’s groundwork in preparedness bodes well for stopping Ebola’s spread within its borders.

16.5.4    2014-2016 Ebola Virus Disease Outbreak: West Africa

The first reported cases in the 2014-2016 Ebola outbreak in West Africa were reported to WHO on March 23, 2014 in the forested rural region of southeastern Guinea bordering Liberia and Sierra Leone. The lack of public health infrastructure, including the absence of adequate surveillance capabilities, impeded a rapid and effective response in the affected countries. The outbreak spread to urban areas and exploded into an epidemic, overwhelming the isolation, laboratory testing, and treatment capacities of the three countries. The epidemic was further exacerbated by poor infection control in healthcare facilities as well as the high mobility and intermixing of populations. By late summer 2014, EVD had reached the densely populated capitals of all three countries. On August 8, 2014, WHO declared the situation a PHEIC.

CDC Emergency Operations Center (EOC) was activated from July 9, 2014 until March 31, 2016. CDC’s response was the agency’s largest emergency response in its history. Approximately 4,000 CDC staff directly participated in the response, with 1,897 deployed in Guinea, Sierra Leone, Liberia, and other African countries affected to provide surveillance, contact tracing, data management, laboratory testing, and health education.

Airport screenings were required for travelers leaving West Africa to prevent the spread of EVD to other countries. CDC trained over 24,000 healthcare workers in West Africa on infection prevention and control. By the end of 2015, laboratory capacity was expanded in Guinea, Sierra Leone, and Liberia, to 24 laboratories able to test for EVD. See Overview, Control Strategies, and Lessons Learned in the CDC Response to the 2014-2016 Ebola Epidemic.

WHO lifted the PHEIC status for the West Africa Ebola crisis on March 29, 2016. During the outbreak 28,616 cases of EVD and 11,310 deaths were reported in Guinea, Sierra Leone, and Liberia. See 2014-2016 Ebola Outbreak in West Africa.

16.5.5    2014-2016 Ebola Virus Disease Outbreak: United States 

During the 2014-2016 Ebola outbreak, 11 individuals were treated for EVD in the U.S. On September 30, 2014, CDC confirmed the first travel-associated case of EVD diagnosed in the U.S. in a patient who traveled from West Africa to Dallas, Texas. The patient died on October 8, 2014. Two nurses who provided care for the patient became infected with EVD, were hospitalized, and recovered. A fourth case was confirmed in a healthcare worker who volunteered in Guinea and returned to NYC in October 2014; the individual was hospitalized there and recovered. An additional seven individuals with EVD symptoms were transported by charter aircraft from West Africa for treatment at U.S. hospitals; six of these patients recovered. See, e.g., 2014-2016 Ebola Outbreak in West Africa.

After her return to the U.S. after caring for EVD patients in West Africa, nurse Kaci Hickox was asked by Maine public health officials to quarantine herself in her home for the 21-day EVD incubation period, receive direct active monitoring from a public health nurse, and restrict her movements to avoid contact with others. While Hickox agreed to participate in direct active monitoring, she refused to self-quarantine or restrict her movements absent the onset of symptoms. Under Maine law, Maine public health officials are required to request court intervention to effectuate their detention order, which will be issued if the court finds by clear and convincing evidence that a public health threat exists. See ME Rev Stat Ann tit 22, § 805 and ME Rev Stat Ann tit 22, § 812. Maine public health officials filed such a petition. A Maine court ruled that while Hickox was required to comply with direct active monitoring and other steps, the state had not shown by clear and convincing evidence that restricting Hickox’s movements was necessary to protect public health, as Hickox did not have EVD symptoms and was therefore not infectious. See Mayhew v. Hickox, No. CV-2014-36 (Me Dist Ct, Fort Kent, October 31, 2014).

16.5.6    2018-2019 Ebola Virus Disease Outbreak: Democratic Republic of the Congo 

A new outbreak of EVD was declared by the Ministry of Health of the DRC in North Kivu Province on August 1, 2018 and is still ongoing. As of May 3, 2020, 3,462 EVD cases and 2,243 deaths were reported, with an overall case fatality ratio of 65%. See World Health Organization Ebola virus disease – DRC. Four EVD cases were reported in Uganda in June 2019, three in June and one in August. All four patients had recently traveled to the DRC and died from EVD. In response, the Ugandan Health Ministry registered 108 of their contacts for follow-up. There have been no reports of non-travel related cases of EVD in Uganda. See U.S. Food and Drug Administration First FDA-approved vaccine for the prevention of Ebola virus disease, marking a critical milestone in public health preparedness and response.

On July 17, 2019, WHO declared that the EVD outbreak in the DRC was a PHEIC. The declaration followed a meeting of the International Health Regulations Emergency Committee for EVD in the DRC. The Committee cited recent developments in the outbreak in making its recommendation, including the first confirmed case in Goma, a city of almost two million people on the border with Rwanda, and the gateway to the rest of DRC and the world.

16.5.7    CDC Guidance for United States Hospitals 

To facilitate a coordinated response to a suspected or confirmed case of EVD in the U.S., in 2014 CDC issued the Interim Guidance for U.S. Hospital Preparedness for Patients Under Investigation (PUIs) or with Confirmed EVD: A Framework for a Tiered Approach. Under this framework, state and local health officials, in consultation with hospital officials, urgent/emergency care settings, and emergency medical services providers in each state were advised to develop a concept of operations plan that described a networked approach to the evaluation, care, and testing of PUIs and the transfer and treatment of patients with confirmed EVD. To create a coordinated, networked approach, state and local health officials, in collaboration with hospital executives, designated acute healthcare facilities to serve in one of three roles:

  • Frontline healthcare facilities;
  • Ebola assessment hospitals; and
  • Ebola treatment centers.

While states were not required to adopt a three-tiered approach, CDC strongly encouraged all states to identify Ebola assessment hospitals that could effectively manage PUIs until the diagnosis of EVD was confirmed or ruled out. This was especially important in states where there was not expected to be an Ebola treatment center. As of July 2012, 55 hospitals in 17 states and D.C. had established Ebola treatment centers. See Centers for Disease Control and Prevention Overview, Control Strategies, and Lessons Learned in the CDC Response to the 2014–2016 Ebola Epidemic.

CDC also worked with the United State Department of Homeland Security, United State Customs and Border Control, and health departments to institute a process for screening and monitoring travelers returning from West African countries with EVD outbreaks. After being screened at one of five designated airports, these returning travelers were monitored by their state or local health department for Ebola symptoms over the 21-day incubation period. From October 2014 through December 2015, roughly 29,000 individuals were monitored. See Centers for Disease Control and Prevention Overview, Control Strategies, and Lessons Learned in the CDC Response to the 2014–2016 Ebola Epidemic.

Although the CDC has stopped issuing EVD guidance, current information is available at: https://www.cdc.gov/vhf/ebola/index.html.

16.5.8    Interstate Transportation 

An infectious substance is regulated as a hazardous material under the United States Department of Transportation's (U.S. DOT) Hazardous Materials Regulations (HMR). The HMR apply to any material U.S. DOT determines is capable of posing an unreasonable risk to health, safety, and property when transported in commerce. An infectious substance must conform to all applicable HMR requirements when being transported.

Solid materials contaminated with the Ebola virus are classified as Category A infectious substances according to the HMR and may only be transported in two scenarios:

  • In full compliance with classification and packaging requirements of the HMR; or
  • Under the terms of a special permit.

The U.S. DOT has additional information regarding transporting infectious substances available at https://www.phmsa.dot.gov/transporting-infectious-substances/transporting-infectious-substances-overview.

A patient died of Ebola in Texas in 2014. Six truckloads of Ebola-contaminated waste were removed from his apartment after his death. The U.S. DOT granted an emergency special permit authorizing a waste removal company to transport this Ebola-contaminated waste for autoclaving or incineration. The waste was incinerated in Texas, with the ashes to be transported out-of-state to Louisiana to be buried in a landfill. Louisiana took legal action to prevent the ashes from entering the state and was ultimately successful.

16.6 Measles

Measles is a serious, and sometimes fatal disease caused by a virus in the paramyxovirus family. It is typically transmitted through direct contact and through airborne droplets. The virus infects the respiratory tract, then spreads throughout the body. Measles is not spread by animals. Before the introduction of measles vaccine in 1963 and widespread uptake in vaccinations, major epidemics occurred approximately every 2–3 years, causing an estimated 2.6 million deaths each year. More than 140,000 people died from measles worldwide in 2018, mostly children under the age of 5 years, despite the availability of a safe and effective vaccine. See World Health Organization Measles.

On March 26, 2019, the DC Health Division of Epidemiology-Disease Surveillance and Investigation (DE-DSI) issued a health notice for District of Columbia Healthcare Providers regarding guidance on measles testing and control measures. DC Health urges healthcare providers to maintain an increased index of suspicion for measles in patients with clinically compatible symptoms, and ensure that all patients are up to date on measles, mumps, rubella (MMR) vaccine, including before international travel.

16.6.1    Transmission 

Measles is a highly contagious virus that lives in the nose and throat mucus of an infected person. It can spread to others through coughing and sneezing. The measles virus can live for up to two hours in an airspace where the infected person coughed or sneezed. Measles is so contagious that if one person is infected, up to 90% of the people close to that person who are not immune will also become infected. Infected people can spread measles to others four days before the rash appears and remain contagious for four days after the rash presents. See Centers for Disease Control and Prevention Measles (Rubeola) Transmission.

16.6.2    Symptoms 

Measles symptoms include high fever, cough, runny nose, and red, watery eyes. Symptoms appear 7-14 days after exposure. Measles rash appears 3-5 days after the first symptoms appear. The rash usually begins as flat red spots that appear on the face at the hairline and spread downward to the neck, trunk, arms, legs, and feet. Small raised bumps may also appear on top of the flat red spots. The spots may become joined together as they spread from the head to the rest of the body. When the rash appears, a person’s fever may spike to more than 104° Fahrenheit. See Centers for Disease Control and Prevention Measles (Rubeola) Signs and Symptoms.

16.6.3    Complications and Vaccines 

Common complications from measles include otitis media, bronchopneumonia, laryngotracheobronchitis, and diarrhea. Even in previously healthy children, measles may cause serious illness requiring hospitalization.

  • One of every 1,000 measles cases will develop acute encephalitis, which often results in permanent brain damage.
  • One to three of every 1,000 children who become infected with measles will die from respiratory and neurologic complications.
  • Subacute sclerosing panencephalitis (SSPE) is a rare, but fatal degenerative disease of the central nervous system characterized by behavioral and intellectual deterioration and seizures that generally develops 7 to 10 years after measles infection.

People at high risk for severe illness and complications from measles include:

  • Infants and children under 5 years old;
  • Adults over 20 years old;
  • Pregnant women; and
  • People with compromised immune systems, such as from leukemia and HIV infection.

See Centers for Disease Control and Prevention Measles (Rubeola) for Healthcare Professionals.

Measles can be prevented with an MMR vaccine. The vaccine protects against three diseases: measles, mumps, and rubella. MMR vaccine is given later than some other childhood vaccines because antibodies transferred from the mother to the baby may provide some protection from disease and make the MMR vaccine less effective until about 1 year of age. Two doses of MMR vaccine are 97% effective at preventing measles; one dose is approximately 93% effective. See Centers for Disease Control and Prevention Measles (Rubeola) Vaccine for Measles.

16.6.4    Measles History in the United States 

In 1912, measles became a nationally notifiable disease in the U.S. Before the vaccine was available, nearly all children got measles by the time they were 15 years of age. The measles vaccination program started in 1963; prior to this, an estimated 3 to 4 million people got measles each year in the U.S. Approximately 500,000 cases were reported each year to CDC; of these, 400 to 500 people died, 48,000 were hospitalized, and 1,000 developed encephalitis (inflammation of the brain) from measles. See Centers for Disease Control and Prevention Measles (Rubeola) Vaccine for Measles.

In 1978, CDC sought to eliminate measles in the U.S. by 1982. Although this goal was not met, by 1981, the number of reported measles cases was 80% fewer than the previous year. A 1989 measles outbreak among vaccinated school-aged children prompted the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), and the American Academy of Family Physicians (AAFP) to recommend a second dose of MMR vaccine for all children. Following widespread implementation of this recommendation and improvements in first-dose MMR vaccine coverage, reported measles cases declined even more. Measles was declared eliminated (absence of continuous disease transmission for greater than 12 months) from the U.S. in 2000. See Centers for Disease Control and Prevention Measles (Rubeola) History of Measles.

16.6.5    Cases and Outbreaks 

As vaccination rates began decreasing in the U.S., cases and outbreaks of measles became more frequent. In addition, travelers bring measles into the U.S. from countries where the disease still occurs or where outbreaks are occurring. See Centers for Disease Control and Prevention Measles (Rubeola) Questions About Measles. In 2014, Disneyland California experienced an outbreak during which at least 131 California residents, as well as residents from six other states, Mexico, and Canada, were infected with measles. See California Department of Public Health Immunization Branch Measles.

The U.S. experienced a significant measles outbreak in 2019: 2019, 1,282 individual cases of measles were confirmed in 31 states, the greatest number of cases reported in the U.S. since measles was declared eliminated in 2000. In 2020, as of April 5, 12 cases in seven jurisdictions have been reported. See Centers for Disease Control and Prevention Measles (Rubeola) Cases and Outbreaks.

  1. Washington State – On January 25, 2019, Washington State Governor Jay Inslee declared a state of emergency for all counties in the state due to measles outbreaks. At the time of the declaration, there were 25 confirmed measles cases in Clark County and one confirmed case in King County. Another outbreak began on May 9 in three Puget Sound counties. As of July 16, 2019, there were a total of 85 confirmed measles cases in the state. See Washington State Department of Health Measles 2019.
     
  2. New York City – A significant measles outbreak began in NYC in late 2018 centered in regions with a large Orthodox Jewish population. On April 9, 2019, the NYC Health Commissioner declared a public health emergency and ordered every adult and child who lives, works or resides in certain zip codes in NYC to be vaccinated. On April 17, 2019, the NYC Board of Health voted unanimously to adopt a resolution supporting the Commissioner's order and the vaccination requirement. People who are immune to measles or have a medical condition that prevents them from receiving the vaccine are exempt. Noncompliant individuals can be fined $1,000. As of July 15, 2019, 31,299 doses of the MMR vaccine have been administered to people who are under 19 years old in these areas. From September 2018 to July 15, 2019, there have been 623 confirmed measles cases in NYC. See NYC Health Measles.

    Parents of unvaccinated children challenged the NYC order, claiming it was disproportionate to the circumstances and failed to use the least restrictive means to control measles while protecting individual autonomy, informed consent, and free exercise of religion. The order was upheld by a New York state court on April 18, 2019, which held that the petitioners had not offered a demonstrably better, safer, or more efficient alternative to support their argument that the mandatory vaccination fails the “least restrictive means” standard. The court dismissed religious objections because the petitioners did not offer affidavits of a religious official or other doctrinal documentation to support their claim of religious exemption. Finally, with respect to informed consent, the issue was inappropriately raised in the context of a measles outbreak: “A fireman need not obtain the informed consent of the owner before extinguishing a house fire. Vaccination is known to extinguish the fire of contagion.” See C.F. v New York City Dept. of Health and Mental Hygiene, 2019 NY Slip Op 31047(U) (April 18, 2019).
     

  3. Rockland County, New York – On March 26, 2019, Rockland County, a suburb outside of NYC, declared a state of emergency due to a measles outbreak. As part of the declaration, unvaccinated individuals under the age of 18 were prohibited from being in public places, including restaurants, civic centers, houses of worship, shopping malls and schools. At the time of the declaration, there were more than 150 confirmed cases of measles in the county, the majority of whom had not received the MMR vaccine. See Rockland County Measles Information.
    Parents of unvaccinated children sued Rockland County, arguing that the county executive overstepped his powers because the current measles outbreak did not qualify as an emergency. On April 5, 2019, a New York State court ruled that the number of measles cases did not rise to an epidemic or constitute a disaster, thereby not meeting the requirements of Executive Law section 24.

The judge who upheld NYC’s mandatory vaccination order disagreed with the judge who overturned the Rockland County public health emergency/quarantine order on the basis of the definition of the word “epidemic.” While the Rockland County judge looked at the percentage of the overall population affected to determine whether there is an epidemic, the judge in the NYC case stated that the appropriate measure is the sudden percentage rise in infection experience by the subject population. “If one were to wait till a significant percentage of overall population were infected, disaster would inevitably ensue.” See C.F. v New York City Dept. of Health and Mental Hygiene, 2019 NY Slip Op 31047(U) (April 18, 2019).

After an appellate panel upheld judge’s order, the Rockland County Department of Health (RCDOH) Commissioner issued a Communicable Disease & Exposure Exclusion Order, which has three components:

  1. Any person diagnosed with the measles or exposed to a person diagnosed with the measles as evidenced by laboratory evidence or a measles tracing investigation conducted by RCDOH must be excluded from indoor and outdoor places of public assembly located in Rockland County for a period of up to 21 days.
  2. The individual is prohibited from going to or being present at any place of public assembly for any period of time with exceptions for medical care, emergency situations and court appointments.
  3. Individuals are required to cooperate with RCDOH public health authorities by providing information regarding details of one's illness, exposures and contacts.

Failure to comply can result in a $2,000 fine per violation per day. 

16.7 Other Emerging and Re-emerging Diseases

EVD and measles are just two of the many emerging and re-emerging diseases of concern. Other infectious diseases of concern include whooping cough, polio, chikungunya, and avian influenza. Most of these diseases are reportable under District law.

See section 7.0 and Appendix 5.0 of the Manual for more information about notifiable diseases.

CDC developed A CDC Framework for Preventing Infectious Diseases: Sustaining the Essentials and Innovating for the Future (CDC’s ID Framework) to provide a roadmap for improving the U.S.’s ability to prevent known infectious diseases and to recognize and control rare, highly dangerous, and newly emerging threats through a strengthened, adaptable, and multi‐purpose U.S. public health system. While the primary purpose of CDC’s ID Framework is to guide CDC’s infectious disease activities, the document also seeks to advance collective action to prevent and control infectious diseases, recognizing the realities of the current fiscal climate and our changing public health and healthcare environments.



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