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Reporting Outbreaks, Epidemics or Unusual Occurrences of Communicable Diseases

Public Health Service
Health Services and Mental Health Administration
Indian Health Service
Silver Spring, Maryland


Effective Date:  March 17, 1969


    1. To establish requirements and procedures for reporting outbreaks, epidemics or unusual occurrences of communicable diseases affecting Indians and Alaska Natives served by the Indian Health Service.
    2. To prompt assistance, if needed, to the Service Units in supplies, drugs, biologicals and/or manpower.
    3. To enable Service Unit staff to receive advice, guidance and epidemiological assistance from Area, Headquarters, or other agencies, in the treatment of cases, control of epidemics and tracing the origin and mode of the spread of the disease.

  2. GENERAL.  It is essential for the Headquarters and Area Offices to be informed promptly and adequately of outbreaks, epidemics or unusual occurrences of communicable diseases, to assure that appropriate action is being taken and to alert the Surgeon General and other responsible officers in view of public interest in such matters.

    1. All cases of cholera, plague, louse-borne relapsing fever, smallpox, louse-borne typhus fever and yellow fever.
    2. All cases of tick-borne relapsing fever, flea-borne typhus fever, anthrax, botulism, psittacosis, typhoid fever, diphtheria, poliomyelitis and human rabies.
    3. All outbreaks, regardless of their etiology, occurring in hospitals, schools, dormitories or any other institution.
    4. All outbreaks of diarrhea of the newborn occurring in hospitals.
    5. All outbreaks, regardless of their etiology or place of occurrence, in which water or food is suspected or found to be the vehicle of the infection.
    6. High incidence of respiratory diseases, particularly during periods when influenza is likely to occur.
    7. "Micro-epidemics" of tuberculosis in a community or institution, e.g., school.
    8. Outbreaks or unusual high incidence over the endemic pattern for the locality of gastrointestinal infectious diseases, especially infectious hepatitis, salmonellosis, shigellosis and gastroenteritis.
    9. Multiple cases of undiagnosed diseases or diseases new or infrequent in the locality, i.e., meningococcal meningitis.  A single case of a communicable disease long absent from a population, or first invasion of a disease not previously recognized in that locality, is to be considered as a potential epidemic and meeting the requirements in respect to reporting of epidemics.
    10. Multiple group of cases of a disease occurring under unusual circumstances, such as uncommon mode of spread, a relatively high case fatality rate or a high incidence of diseases "out of season."
    11. Unusual occurrence of syphilis.
    12. Unusual occurrence of high mortality episodes, particularly among children, when an infectious etiology is confirmed or suspected.
    13. Unusual occurrence in animals, of rabies, anthrax, psittacosis, plague, Q fever, tularemia, brucelosis, equine and St. Louis types of encephalomyelitis and leptospirosis, since these diseases may spread to man.


    1. Preliminary Report.  As soon as information of any of the occurrences mentioned in 3 above is available, the Service Unit Director or officer in charge of the field facility shall notify the Area Director by telephone or telegram.  The Area Director should see that consultative services are provided, if appropriate, as well as any assistance the Service Unit may need.  Upon receiving the notification, the Area Director, utilizing telephone or telegram, shall notify the Chief, Office of Program Services, Indian Health Service.  The Chief, Office of Program Services will furnish a copy of the notification to the Chief, Program Analysis and Statistics Branch.  This preliminary report should include the location, the general nature or type of outbreak, apparent mode of spread, and the extent or approximate number of cases.  Diseases included in categories A and B in 3 above will be reported by the case, with the name, sex, age and address of the patient(s).  Outbreaks of other diseases included in 3 will be reported by the number of cases, except when requested otherwise by the Area or the Indian Health Service Headquarters.  The occurrence of cases of diseases included in category A in 3 above will be reported, by the case, by telephone or telegram to the Chief, Foreign Quarantine Program, Atlanta, by the Director of the Indian Health Service or his designate.

    2. Progress Report.  The preliminary notification will be confirmed by mail.  The Service Unit Director or the officer in charge of the facility will submit in triplicate, following the preliminary report in A above, a written report of the occurrence with whatever additional information is available and measures taken or planned to be taken to cope with the situation.  The Area Director will forward the original and one copy of this report, with comments if necessary, to Indian Health Service Headquarters, Attention:  Chief, Office of Program Services.  The Chief, Office of Program Services will forward one Copy to the Chief, Program Analysis and Statistics Branch.

    3. Final Report.  When the investigation has been completed, a written report, utilizing Form HSM-133, Report of Disease Outbreak, (formerly PHS-767) shall be prepared by the Service Unit Director or officer in charge of the facility, and forwarded to the Area Director in triplicate.  One copy shall be retained by the Area and the original and one copy forwarded to Headquarters, Attention:  Chief, Office of Program Services.  The Chief, Office of Program Services will forward one copy to the Chief, Program Analysis and Statistics Branch.

  5. FILING THE REPORTS.  The Program Analysis and Statistics Branch, Office of Program Planning and Evaluation, will organize a file by disease to keep annually the copies of the Preliminary, Progress and Final reports referred to in 4 A, B, and C above.

  6. INSTRUCTIONS FOR PREPARING REPORTS.  Report of epidemiological investigations of single cases or outbreaks of diseases included in 3A and 3B above should be submitted with all pertinent details, including place of occurrence, name, age and sex of the person(s) involved, source of infection, length of the incubation period, a short description of the symptoms and of similar cases in the community, results of laboratory tests used to confirm the diagnosis and the previous immunization history if applicable.

    When preparing a final report of an epidemic, the number of cases should be estimated when an accurate count is not possible.  The number of exposed persons should also be estimated.  It is important that the length of the incubation period be stated as accurately as possible, that symptoms exhibited by a majority of the cases be described briefly and that the location of the outbreak or place of exposure be given.  Special efforts should always be made to include reports of laboratory examinations of specimens from persons who were ill or of samples of suspected vehicles of infection (food, water, etc.).  The number of cases confirmed by laboratory tests should be given, especially in outbreaks of diphtheria, meningitis, typhoid fever, salmonellosis and shigellosis.

  7. OTHER REPORTING REQUIREMENTS.  The submission of the preliminary, progress or final reports referred to in this circular does not affect the requirement for reporting notifiable diseases as prescribed in Indian Health Circular No. 61-12, Monthly Report of New Cases of Notifiable Diseases, Form HSM-134, (formerly PHS-2692).

    It does not affect either the submission to the State or the local Health Department of the reports concerning cases or outbreaks of communicable diseases as required by the corresponding State and local Health Departments.  All Indian Health Area Directors will keep themselves informed of and conform with State and local Health Departments or other agencies' requirements for reporting the occurrence of communicable diseases in humans or animals.  Each Area Director will keep his Service Unit Directors and/or Officers in Charge of facilities informed of the current established State and local Health Departments reporting procedures, and will take the necessary steps to assure their compliance.

  8. SUPPLY FOR FORMS.  Forms will be furnished systematically on the basis of periodic reports of planned requirements, in accordance with DHEW Forms Management Manual, Chapter PHS: 2-35.

  9. SUPERSESSION.  This Circular supersedes DIH Circular No. 67-2,"Reporting Outbreaks, Epidemics or Unusual Occurrences of Communicable Diseases," dated January 24, 1967.

/E.S. Rabeau, M.D./
E.S. Rabeau, M.D.
Assistant Surgeon General
Director, Indian Health Service

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