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What is Eastern equine encephalitis (EEE)?

EEE is a rare disease that is caused by a virus spread by infected mosquitoes.  EEE virus (EEEV) is one of a group of mosquito-transmitted viruses that can cause inflammation of the brain (encephalitis).  Tn the United States, approximately 5-10 EEE cases are reported annually.

How do people get infected with EENV?

EEEV is transmitted through the bite of an infected mosquito.  Disease transmission does not occur directly from person to person.

Where and when have most cases of EEE occurred?

Most cases of EEE have been reported from Atlantic and Gulf Coast states.  Cases have also been reported from the Great Lakes region.  EEE cases occur primarily from late spring through early fall, but is subtropical endemic areas (e.g., the Gulf States), rare cases can occur in winter.

Who is at risk for infection with EEEV?

Anyone in an area where the virus is circulating can get infected with EEEV.  The risk is highest for people who live in or visit woodland habitats, and people who work outside or participate in outdoor recreational activities, because of greater exposure to potentially infected mosquitoes.

How soon do people get sick after getting bitten by an infected mosquito?

It takes 4-to 10 days after the bite of an infected mosquito to develop symptoms of EEE.

What are the symptoms of EEV disease?

Severe cases of EEV infection (EEE, involvin encephalitis, an inflammation of the brain) begin with the sudden onset of headache, high fever, chills, and vomiting.  The illness may then progress into disorientation, seiures, and coma.  Approximately a third of patients who develop EEE die, and many of those who survive have mild to severe brain damage.

How is EEE diagnosed?

Diagnosis is based on tests of blood or spinal fluid.  These tests typically look for antibodies that the body makes against the viral infection.

What is the treatment for EEE?

There is no specific treatment for EEE.  Antibiotics are not effective against viruses, and no effective anti-viral drugs have been discovered.  Severe illnesses are treated by supportive therapy which may include hospitalization, respiratory support, IV fluids, and prevention of other infections.

How can people reduce the chance of getting infected with EEEV?

Prevent mosquito bites.  There is no vaccine or preventive drug.

• Use insect repellent containing DEET, picaridin, IR3535 or oil of lemon eucalyptus on exposed skin and/or clothing.  The repellent/insecticide permethrin can be used on clothing to protect through several washes.  Always follow the directions on the package.
• Wear long sleeves and pants when weather permits.
• Have secure, intact screens on windows and doors to keep mosquitoes out.
• Eliminate mosquito breeding sites by emptying standing water from flower pots, buckets, barrels, and other containers.  Drill holes in tire swings so water drains out.  Keep children’s wading pools empty and on their sides when they aren’t being used.

Waht should I do if I think a family member might have EEE?

Consult your healthcare provider for proper diagnosis.

Reference: www.cdc.gov/EasternEquineEncephalitis/gen/qa.html

 Authority

Section 1135 of the Social Security Act [42 USC §1320b–5] permits the Secretary of Health and Human Services to waive certain regulatory requirements for healthcare facilities in response to emergencies.  Two conditions must be met for the Secretary to be able to issue such “1135 waivers”:  first, the Secretary must have declared a Public Health Emergency; second, the President must have declared a National Emergency either through a Stafford Act Declaration or National Emergencies act Declaration.  If these conditions are met, then healthcare facilities may petition for 1135 waivers in response to particular needs, and only within the geographic and temporal limits of the emergency declarations.

Under Section 1135:

The Secretary may tailor authorities granted under Section 1135 waivers to match the specific situational needs, but the requirements that may be waived include those related to Medicare, Medicaid or the Children’s Health Insurance Program (CHIP), the Emergency Medical Treatment and Active Labor Act (EMTALA), and the Health Insurance Portability and Accountability Act (HIPAA).  These requirements provide important protections for patients during normal day-to-day operations, but they may impede the ability of healthcare facilities to fully implement disaster operations plans that enable appropriate care during emergencies.  For example, requirements under the Emergency Medical Treatment and Active Labor Act (EMTALA) would prohibit hospitals from certain rapid triage or sorting activities and prevent the establishment of off-site, alternate care facilities that could off-load emergency department demand.

• Waivers are permitted only to the extent they ensure that sufficient health care items and services are available to meet the needs of Medicare, Medicaid, and CHIP beneficiaries in the emergency area during the emergency period.  The “emergency area” and the “emergency period” are the geographic area, in which, and the time period, during which, the dual declarations exist. 
• Permitted actions include the waiver or modification of conditions of participation, other certification requirements, program participation requirements, pre-approval requirements for health care providers; waiver of sanctions for certain directions or relocations and transfers that otherwise would violate the Emergency Medical Treatment and Labor Act (EMTALA); waiver of sanctions related to Stark self-referral prohibitions; modifications to deadlines and timetables for the performance of required activities; and waiver of sanctions and penalties arising from noncompliance with certain Health Insurance Portability and Accountability Act (HIPAA) privacy regulations.

Examples of use of waivers:

• Hospitals request to set up an alternative screening location for patients away from the hospital’s main campus (requiring waiver of the Emergency Medical Treatment and Labor Act-EMTALA)
• Hospitals request to facilitate transfer of patients between ERs and inpatient wards between hospitals (requiring waiver of both EMTALA and HIPAA regulations)
• Critical Access Hospitals requesting waiver of 42 CFR 485.620, which requires a 25-bed limit and average patient stays less than 96 hours
• Skilled Nursing Facilities requesting a waiver of 42 CFR 483.5, which requires CMS approval prior to increasing the number of certified beds in a distinct part

Past instances where authority to grant Section 1135 waivers was enabled for recent disaster events include

• Hurricane Katrina (2005)
• 56th Presidential Inauguration (2009)
• Hurricanes Ike and Gustav (2008)
• North Dakota flooding (2009)

Q:  Why do this now; why can’t we wait until a hospital or region needs these 1135 Waivers?

            A:  The H1N1 epidemic is moving rapidly.  By the time regions or healthcare systems recognize they are becoming overburdened, they need to implement disaster plans quickly.  1135 Waivers still require specific requests be submitted to HHS and processed, and some State laws may need to be addressed as well.  Adding a potential delay while waiting for a National Emergency Declaration is not in the best interest of the public, particularly if this step can be done proactively as the President has done today. 

Q:  Has the authority to grant 1135 waivers been granted before?

            A:  Yes, there are several instances where 1135 Waiver authority has been granted under the Stafford Disaster Relief and Emergency Assistance Act (vice National Emergencies Act) to help healthcare facilities cope with large patient burdens.  Recent examples include Hurricane Katrina (2005), Hurricanes Ike and Gustav (2008), and the North Dakota flooding (2009).  In addition, 1135 waiver authority has been granted previously as a precautionary measure, as in the case of the recent 56th Presidential Inauguration (2009).

Q:  Specifically, what will this NEA Declaration enable and what will this allow hospitals to do, if a waiver is requested and granted?

            A:  An NEA Declaration fulfills the second of the two conditions required for the Secretary of HHS to be able to grant 1135 waivers.  If requested, and HHS grants an 1135 waiver, healthcare facilities will be able to utilize alternate care sites, modified patient triage protocols, patient transfer procedures, and other actions that occur when they fully implement disaster operations plans.

Q:  Is the HIPAA Privacy Rule suspended during a national or public health emergency?

            A (from the HHS Office for Civil Rights website):  No; however, the Secretary of HHS may waive certain provisions of the Rule under the Project Bioshield Act of 2004 (PL 108-276) and section 1135(b)(7) of the Social Security Act.

What provisions may be waived

If the President declares an emergency or disaster and the Secretary declares a public health emergency, the Secretary may waive sanctions and penalties against a covered hospital that does not comply with certain provisions of the HIPAA Privacy Rule:

1. the requirements to obtain a patient’s agreement to speak with family members or friends involved in the patient’s care (45 CFR 164.510(b))
2. the requirement to honor a request to opt out of the facility directory (45 CFR 164.510(a))
3. the requirement to distribute a notice of privacy practices (45 CFR 164.520)
4. the patient’s right to request privacy restrictions (45 CFR 164.522(a))
5. the patient’s right to request confidential communications (45 CFR 164.522(b))

When and to what entities does the waiver apply

If the Secretary issues such a waiver, it only applies:

   1. In the emergency area and for the emergency period identified in the public health emergency declaration.

   2. To hospitals that have instituted a disaster protocol.  The waiver would apply to all patients at such hospitals.

   3. For up to 72 hours from the time the hospital implements its disaster protocol.

When the Presidential or Secretarial declaration terminates, a hospital must then comply with all the requirements of the Privacy Rule for any patient still under its care, even if 72 hours has not elapsed since implementation of its disaster protocol. 

Regardless of the activation of an emergency waiver, the HIPAA Privacy Rule permits disclosures for treatment purposes and certain disclosures to disaster relief organizations. For instance, the Privacy Rule allows covered entities to share patient information with the American Red Cross so it can notify family members of the patient’s location.  See 45 CFR 164.510(b)(4).

Learn More:  * See http://www.hhs.gov/ocr/privacy/hipaa/understanding/special/emergency/katrinanhipaa.pdf for information on sharing information in emergency situations.

CDC is currently investigating cases of respiratory illnesses in the states of California and Texas.  The individuals who have become ill are between the ages of 7 and 55.  63% of the cases are male.  Treatment for anyone suspected of having this illness (swine influenza) are oseltamivir and zanamivr.  Symptoms of the illness include cold symptoms, fatigue, loss of appetite and fever.  Individuals should see their physician to have a nasal culture tested for influenza and stay at home until symptoms have passed, usually 5-7 days.  Travel to the affected areas in Mexico is being discouraged.

16oo cases of swine flu reported in Mexico with 103 deaths.  Cases reported in the US include 7 in California, 2 in Kansas, 1 in Ohio, 8 in NYC (among a group of students who recently returned from Mexico), 2 in Texas.  Cases have also been reported in Canada, British Columbia, Nov Scotia, France, Spain, Scotland, and Israel.

Protecting yourself and your family:  Stay away from large groups of people.  Stay at least 6 feet away from individuals who have a respiratory tract infection.  Wear a mask if you have to be close to someone with a respiratory tract infection including someone who is living in your house.  If you are experiencing a fever greater than 100 try to get an influenza culture done and take antiviral medication within 48 hours of onset of symptoms.  Antivirals may not help if not started within 48 hour of onset of illness.

Person infected with the swine flu should be considered infectious up to 7 days after onset of symptoms.  People who are continue to be sick after 7 days should be considered infectious.  Especially children.