HSEEP AAR-IP Template



City and County of Alamosa Salmonella Outbreak

Colorado Department of Public Health and Environment

After Action Report

March – April 2008

CONTENTS

EXECUTIVE SUMMARY 2

Event Overview 2

Background 2

Participating Agencies 3

Response Overview 3

Analysis of Response 12

Strengths 12

Areas for Improvement 16

Conclusion 18

Appendix A: Timeline of Events 19

Appendix B: Business and Community Partner Contributors 20

EXECUTIVE SUMMARY

IN MARCH 2008, ALAMOSA, COLORADO EXPERIENCED A SUDDEN OUTBREAK OF SALMONELLA DUE TO A CONTAMINATED MUNICIPAL WATER SYSTEM. THIS EVENT TESTED THE STATE’S ABILITY TO MANAGE AN EPIDEMIC AND QUICKLY MOBILIZE KEY RESOURCES.

The City and County of Alamosa, located in southern Colorado, declared a state of emergency after at least 52 people became ill from Salmonella typhimurium. Laboratory tests confirmed what local public health officials had suspected: the bacteria were being introduced via the city’s water distribution system. A bottled water order was in effect for nearly three weeks as officials set to work disinfecting the well-water system with high levels of chlorine. A total of 425 people became ill and one death was associated with this outbreak by the end of April 2008.

Efficient communication and high levels of cooperation among various response partners are credited with significantly limiting the number of illnesses. The purpose of this report is to analyze the activities that took place during the response in order to identify strengths and areas for further improvement for the Colorado Department of Public Health and Environment.

Event Overview

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2 BACKGROUND

Salmonella contamination in municipal water is very uncommon. According the U.S. Centers for Disease Control, there have been only five reported instances of waterborne salmonella outbreaks in the past 20 years.[1] In 1993, a water storage tower in Gideon, Missouri, inadequately protected from bird feces is believed to have been responsible for a salmonella outbreak that killed seven people and led to at least 15 people being hospitalized after an estimated 625 people drank the municipal water and became ill.1

Like many rural communities throughout Colorado, Alamosa (pop. 8,682) does not have an organized local health department and relies heavily on the Colorado Department of Public Health and Environment (CDPHE) to provide many of the county’s environmental health services.

Cases of salmonella in Alamosa County and the surrounding San Luis Valley Region are also rare. The following table shows the total number of cases of Salmonellosis diagnosed in the San Luis Valley over a ten-year period (01/01/1998 to 12/31/2007) by County:

|Alamosa |Conejos |Costilla |Mineral |Rio Grande |Saguache |Total |

|18 |12 |3 |1 |18 |2 |54 |

Alamosa relies on a series of deep artesian wells for its municipal water. The Colorado Department of Public Health and Environment (CDPHE) required a waiver for the use of untreated municipal water, including monthly water quality testing conducted by the CDPHE Water Quality Control Division.

Alamosa City water is stored at the surface in a ground level reservoir and two storage tanks (water towers). These towers are located in an area of town that is also a desirable habitat for birds and wild mammals, preferred hosts for Salmonella serogroup Typhimurium.

The City of Alamosa experienced an unusually cold winter throughout the end of 2007 and into the spring of 2008. The city experienced a deep frost level with frozen water lines and underground meters at private residences. In addition, citywide street construction was conducted throughout this same time of year.

Participating Agencies

The following governmental / non-governmental agencies that were involved in the response and recovery operations for this event:

Alamosa County and City Management

Alamosa County Nursing

Alamosa County Office of Emergency Management

Alamosa County Road and Bridge

Alamosa County Sheriff’s Office

Alamosa Fire Department

Alamosa Police Department

Alamosa Water Department

American Red Cross

City of Durango

City of Fort Collins

Colorado Department of Agriculture

Colorado Department of Corrections

Colorado Department of Human Services- Mental Health

Colorado Department of Public Health and Environment

Colorado Department of Transportation

Colorado Information Analysis Center

Colorado National Guard

Colorado Rural Water Association

Colorado Veterinary Medical Foundation

Colorado Volunteers Active in Disaster (COVOAD)

Congressman John Salazar's Office

Costilla County

Denver Environmental Health

Division of Emergency Management

Division of Fire Safety

Division of Local Government

Eastern Colorado Incident Management Team

FEMA Region VIII

Governor Ritter’s Office

Governor’s Office of Economic Development

Governor’s Office of Homeland Security

Jefferson County Incident Management Team

Local Public Health Agencies

Northwest Colorado Incident Management Team

Rio Grande County

Rocky Mountain Poison and Drug Center (COHELP)

Saguache County

Salvation Army

San Luis Valley Mental Health

San Luis Valley Regional EMS/RETAC

Small Business Administration

U.S. Centers for Disease Control and Prevention (CDC)

U.S. Department of Health and Human Services

U.S. Food and Drug Administration 

U.S. Forest Service

U.S. Senator Ken Salazar's Office

1 Response Overview

The first Alamosa resident to become ill with salmonella was an 18-year-old student who worked in a local-area restaurant. When hospital lab reports detected salmonella in her stool culture on March 12, the Alamosa County Nursing Service immediately contacted county officials and began investigations.

The local public health nursing service reported the outbreak to the Colorado Department of Public Health and Environment (CDPHE) on March 14 and quickly united with other local-area first responders to establish an Emergency Operation Center (EOC) in Alamosa.

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3 By March 17, Alamosa County had at least 18 culture confirmed cases of salmonella illness and dozens of reports from local providers that children were suffering from bloody diarrhea and fevers. County and State health officials continued to work closely with area healthcare providers to identify and investigate cases.

While caseworkers first suspected undercooked chicken from the restaurant where the index case worked (15 of the first 20 cases interviewed consumed food from this restaurant), 10 more local-area residents – including four infants under the age of 11 months who were only consuming formula mixed with tap water – also tested positive for salmonella two days later. No other common food sources, animals, child care or contact with non-household cases were identified, and the majority of those who were ill either lived or worked within the Alamosa city limits. This led investigators to identify the Alamosa Water District as the source of the bacteria.

Water samples were collected and cases were interviewed for detailed water consumption and exposure histories. 12/12 cases consumed Alamosa water including 5/5 infants on formula. Laboratory data was limited at this time; however, epidemiological data strongly suggested that the municipal water system was the source of the outbreak.

On March 19, CDPHE issued a bottled water order to the city of Alamosa. CDPHE water quality officials decided to issue a bottled water order, rather than a boil order, due to the high levels of arsenic and other heavy metals naturally found in Alamosa’s water supply. Due to concerns that boiling the water could concentrate the already high levels of arsenic, CDPHE officials issued the bottled water order to avoid additional health concerns.

The City and County of Alamosa signed an emergency declaration on the evening of March 19.

At this time the Alamosa EOC was fully operational.

Initial laboratory findings determined that while the groundwater itself was not contaminated, salmonella was present in the water distribution system. The exact source of the contamination remains unknown, yet officials suspect that cracks in the aging pipe system may be to blame. Three theories evolved as to the source of the contamination in the water distribution system:

1. Cross contamination in the system;

2. A crack in the line allowing contamination to enter during low pressure; and

3. Contamination of the water storage site. It was later determined that East Alamosa water was not contaminated.

An investigation of the municipal water system reported cracks in wall of ground level reservoir, a layer of sludge in the reservoir, plenty of deer scat on the ground around the reservoir. The storage tank (water tower) had cracks in the roof and plenty of bird feces on top. No evidence of animals was found inside the reservoir or tanks (such as remains, feathers, nests, etc.).

The objectives for State and local public health officials were to:

1. Enforce the bottled water order for customers who pay water bill to the City of Alamosa (East Alamosa Water was not affected)

2. Assist city in draining and patching the holding tank

3. Decontaminate (super-chlorinate) tanks and water distribution system

4. Test water for chlorine levels during super-chlorination

5. Test water for bacteria and arsenic/heavy metal levels

6. Continue to monitor illness patterns and provide public information on how to stop the spread

7. Assist businesses, food facilities, schools, daycare facilities to follow water use guidelines

CDPHE Response

Nine divisions within CDPHE were called upon to support the environmental, epidemiological, risk communication and water quality activities involved with investigating and monitoring the outbreak. Additional assistance was provided by the U.S. Department of Health and Human Services.

The objectives for all nine of the CDPHE divisions are listed below:

Consumer Protection Division

• Provide guidance/assistance to restaurants, food manufacturers, childcare centers, and schools

• Conduct inspections of restaurants, food manufacturers, childcare centers, and schools

• Track facility closures for restaurants, schools and daycare centers 

Disease Control and Environmental Epidemiology Division

• Provide assistance in conducting disease surveillance, including conducting case interviews and a community phone survey

• Track and document number of cases and hospitalizations

• Provide guidance to Infection Control Practitioners (ICPs) and regional/local epidemiologists

Emergency Preparedness and Response Division

• Coordinate information and response activities from CDPHE divisions

• Monitor and provide staffing replacements for local/state public health staff   

• Update messages on COHELP hotline and on CDPHE website 

• Track COHELP reports, including homebound residents

• Track KRONOS records and other CDPHE fiscal costs related to the incident

• Provide ESF #8 support to Colorado Division of Emergency Management (CDEM)

• Assist Colorado Division of Emergency Management (CDEM) in getting water, personnel, equipment and other resources to Alamosa as needed

Health Facilities and Emergency Medical Services Division

• Contact/provide assistance to hospitals, clinics, and long-term care facilities

Laboratory Services Division

• Perform laboratory testing to confirm the presence of salmonella, total coliform and heavy metals

Office of Communications

• Work with local and other state joint information center (JIC) partners and CDPHE divisions to draft public communications, including press releases, flyers and messages for COHAN and reverse 911, as needed 

Prevention Services Division

• Provide assistance to Alamosa WIC Director to find supplies of “ready to feed” formula

1 Hazardous Materials and Waste Management Division- Sustainability Program

• Ensure recycling facilities in Alamosa were ramped up to accept additional plastic water containers

Water Quality Control Division

• Coordinate with city to develop and implement plan for flushing city municipal water system          

• Conduct water sampling for bacteria and heavy metals before/during/after flush         

• Activate and coordinate COWARN members to provide personnel and equipment mutual aid resources to Alamosa

• Provide guidance for water use during each stage during system flush     

       

Colorado Water/Wastewater Agency Response Network (CoWARN)

On March 19, CDPHE issued an urgent request for assistance over the Colorado Water/Wastewater Agency Response Network (CoWARN). This was the first activation of the CDPHE sponsored web-based mutual aid network, which was launched in September 2007. Currently, it involves 47 public and private water and wastewater utilities, industry support organizations and government members whose mission is to provide immediate assistance to members in emergency. Participation in this network is purely voluntary and Colorado is one of only six states in the country that has established a mutual aid network for water experts. Within two hours, three of the 47 CoWARN members were readying personnel and equipment to send to Alamosa. (Denver Water, Aurora Water, and Fort Collins Utilities had crews, equipment, water containers and a tanker truck immediately available for deployment). CoWARN coordinators from CDPHE, Denver Water and Aurora Water operated from the CDPHE Departmental Operations Center (DOC) and managed and tracked supplies and assistance donated through the network. Throughout the duration of the event, 23 CoWARN water and wastewater utilities and industry support members, including the State of Nebraska, lent technical expertise, equipment and supplies to Alamosa.

Colorado Health Emergency Line for the Public (COHELP)

Once CDPHE officials decided to draft the bottled water order for the City of Alamosa, EPRD staff informed their contacts at the Rocky Mountain Poison and Drug Center (RMPDC) to activate the Colorado Health Emergency Line for the Public (COHELP), a toll-free public information hotline that provides consistent, accurate, and up-to-date information to the public on health issues of concern. Within three hours, COHELP was staffed and ready to deliver standardized information to the citizens of Alamosa on Salmonella and precautions regarding the use of their municipal water.

3 The COHELP system has the capability to take up to 1,000 calls per hour through telephony, integrated voice response unit, and web-based technology. Individuals have the option to listen to a voice recording or speak to a live person. English and Spanish operators were on hand to answer questions about the salmonella outbreak from 7 a.m. to 11 p.m. daily. Over a two-week period, they received 2,544 calls – including a peak volume of 486 calls in one single day. RMPDC reported information to CDPHE on a daily basis, including call volume, top five frequency asked questions, a geo-coded call trend analysis based on zip code as well as real-time reporting of emergency requests. Service hours were adjusted to meet the public’s need, for example, when the nursing staff in Alamosa needed to take a break over the weekend, coverage was provided by registered nurses at RMPDC for medical support.

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5 Public Information and Communications

Even before the bottled water order was sent to the city on March 19, local communication efforts were in full gear. Public awareness announcements were sent to the public on issues such as hand washing, food safety and other important hygiene tips as the source of the outbreak was still unknown at the time. The information was primarily shared via four local radio stations and two local newspapers, the Alamosa Valley Courier and The Pueblo Chieftain. The local public health nursing service also worked with Adams State College in Alamosa to send text message “blasts” over the college’s cell phone system, and alerted the San Luis Valley Regional Medical Center and local-area child care providers.

An emergency Joint Information Center (JIC) was established as part of the EOC to conduct all communication functions from a single location in Alamosa. CDPHE as well as other State agencies, including the Colorado Division of Emergency Management (CDEM), provided technical guidance and assisted in developing fact sheets and press releases in partnership with the local JIC. It was determined early in the event that the local JIC representatives would be the one and only point of contact for the media – this helped to ensure that accurate, consistent information was provided and that rumors were controlled. Information was provided to the public in both English and Spanish by various means including press releases to the media (television, local radio and print), local cable channel 10, the county website (), the state public health website (cdphe.state.co.us/epr/Alamosa.html), flyers delivered door-to-door, and via the COHELP Line. In addition to issuing flyers, fact sheets, press releases and a reverse 911 system, the JIC conducted daily team briefings and utilized an online situational awareness tool that provided real-time status updates and the ability to share information among responders.

Public information officers faced some formidable challenges when communicating to residents about the outbreak. Alamosa County is a largely rural, isolated community with few mass media outlets. The county also has a high percentage of Spanish-speaking residents with relatively low literacy rates. Lastly, city officials were reticent to believe that salmonella could be in the municipal water supply – even after testing came back positive – and did not fully support county and state efforts to communicate to the public about the outbreak.

Online Situational Awareness Tool (SATool)

The CDPHE Emergency Preparedness and Response Division (EPRD) was in the process of creating a new online situational awareness tool (SATool) when the salmonella outbreak occurred. EPRD decided to use this event as a means of testing this new online system. All Federal, State and local members of the Alamosa response were invited to use the secure, web-based system to share critical information specific to the incident. The system listed key, real-time information, including conference call numbers, key contact information, and incident status updates. Users could also share information via the document library, where all Incident Action Plans (IAPs), daily Situational Reports (SitRps), epidemiological data, press releases, official orders, pictures, maps, and other key documents were stored and shared with response partners throughout the state. The tool also contained a media-tracking tool that searched media and blog postings to assist the JIC with media monitoring, tracking public concerns and rumor control.

Emergency Management and Water Distribution to the Public

Other state agencies were also called upon to respond, therefore, the State Emergency Operations Center (SEOC) was activated. The key objectives of the SEOC were to:

1. Determine the source of the contamination

2. Inform the public of the on-going situation

3. Establish a logistical system for the distribution of clean water to those who could pick up the water and to those who were either home-bound or institutionalized

4. Remove the contamination from the system

The Colorado Division of Emergency Management (CDEM) assisted with the distribution of donated water. Multiple commercial entities donated water, along with other products and services, throughout the incident. A list of business and community partners who donated goods can be found in Appendix B.

On March 20, two bulk water distribution points were operational for three hours each distributing a cumulative total of 6-8,000 gallons. Additional points were opened on March 21. An initial needs-assessment was conducted by the local jurisdiction and determined an estimated need of 40,000 gallons of water per day once the water system flushing and decontamination began. Flushing was expected to commence once:

1. The appropriate equipment was in place

2. Sufficient bulk/bottled water was in place during the flushing

3. A public information plan was established to notify the residents of the flushing and the associated actions to be taken.

On March 21, Colorado Governor Bill Ritter declared a State Public Health emergency (Executive Order D 006 08)[2] enabling assistance from the Colorado National Guard. Alamosa residents were able to retrieve free bottled water or fill up their own containers with fresh water provided at the bulk water distribution sites. Officials from CDPHE and CDEM worked with seven commercial water bottlers and suppliers to provide the community with at least 53,000 gallons of donated bottled water, worth an estimated $75,000.

On Sunday, March 23, more than 200 volunteers from the American Red Cross and local-area businesses and organizations came together to help responders distribute hundreds of free bottles of water, hand sanitizer and Pedialyte, as well as informational flyers, across the community.

Flushing the Distribution System

On March 20, City officials, the CDPHE Water Quality Control Division (WQCD), and Denver Water developed a plan for the flushing of the entire water system. As seen on the map on page 9, Alamosa was divided into three sectors - the flushing moved from north (sector 1) to south (sector 3).

On March 24, Alamosa water samples test positive for salmonella. Tests of the non-chlorinated artesian well, which feeds the district, were not contaminated; however, the distribution system was positive. State laboratory testing for human specimens included serotyping, PFGE and PulseNet. All initial samples were positive for Salmonella serotype Typhimurium. Environmental specimens conducted were culture, PCR (5/5+ Salmonella by PCR), and serotyping/PFGE (community water tested 4/5+ Salmonella Typhimurium 00-E). Meanwhile, the county’s small two-person microbiology lab was quickly overwhelmed by the number of stool samples needing cultures and received assistance from CDPHE and the CDC. This was the first time that the state public health laboratory had had to conduct PCR testing on water samples before waiting for the cultures to grow out.

At this time, a formal request to HHS is made by the Governor to provide assistance for this response. Federal experts in epidemiology, public information and from the U.S. Food and Drug Administration were requested and sent to Colorado to assist.

On March 25, the super-chlorination of the water system began. Members of the CDPHE Water Quality Control Division and other CoWARN members, began to flush extremely high levels of chlorine into approximately 50 miles of water pipe – and then proceeded to flush it back out. Volunteers distributed flyers to all residents informing them of this action. For the next 18 days, the system was flushed and tested.

A three-stage process was developed by the City of Alamosa to inform the public of actions to be taken during the water system flushing. The JIC notified the public of the new water-use guidelines during each stage of the flushing process via the media, flyers and reverse 911. Definitions for each stage are listed below:

STAGE 1 – Red: High concentration of chlorine - 25 parts per million (ppm); Can not use water for anything other than flushing toilets; Possible skin, eye, or other irritation from water exposure. City officials will notify each neighborhood before the process begins. In Stage 1, citizens may experience skin, eye, or other irritation from exposure to the highly concentrated chlorinated water. If signs of irritation occur, immediately rinse irritated areas with bottled water. If the irritation continues or spreads, contact your health care provider for follow up care. At the end of Stage 1, residents will be notified as the concentration of chlorine decreases to Stage 2 levels and additional uses of the water become possible.

STAGE 2 – Yellow: Chlorine decreases to 10 ppm (slightly above swimming pool); Water can be used to bathe and wash laundry; Can not consume water. This is 2 to 3 times greater than the maximum level acceptable for drinking water. At this time, residents should run their bathtub faucet - 5 minutes on hot, then 5 minutes on cold, or until they smell chlorine. Some people may experience skin, eye or nose irritation from chlorine at this level, but may bathe with caution. Tap water should not be consumed or used to brush teeth. This stage is expected to last up to 10 days, but may last longer depending on results of the flush.

STAGE 3 – Green: Chlorine decreases to 1-2mg per liter; Normal drinking, bathing, and other water uses can be resumed. At this time, residents should run all taps in their homes for at least two minutes to charge their system with drinkable, chlorinated water. Normal drinking, bathing, and other water uses can be resumed at this stage.

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City of Alamosa – Sectors 1-3 During the Municipal Water System Flushing Process

Throughout the “Red” and “Yellow” phases of system flushing, disinfection, and water sampling, CoWARN crews worked 12 hour shifts. CoWARN members provided technical expertise, equipment and supplies to Alamosa that were critical to proper system disinfection and water sampling throughout the flushing events and into system recovery. As the “Red” and “Yellow” phases of flushing commenced, additional technical resources, including certified professionals, equipment and supplies, were provided to support staff at the City’s wastewater treatment plant as well.

CoWARN members directly involved in this incident included:

Aurora Water

Canon City

City of Boulder

City of Golden

City of Greeley

City of Longmont

City of Pueblo Wastewater

City of Thornton

Colorado Springs Utilities

Denver Water

East Alamosa

East Cherry Creek Valley Water and Sanitation District

Fort Collins Utilities

Fremont Sanitation District

Littleton /Englewood Wastewater Treatment Plant

Metro Wastewater Reclamation District

Parker Water and Sanitation District

Pinery Water and Wastewater District

Prospect Mountain Water Company

Pueblo Board of Water Works

South Adams County Water and Sanitation District

Town of Castle Rock

Town of Erie

Town of Monument

Ute Water

Colorado Rural Water Association

Rural Community Assistance Partnership

Frequent water samples showed that the high levels of chlorination were not causing a significant increase in the amount of heavy metals in the city’s water, therefore, on April 3; CDPHE issued a boil water order for the City of Alamosa.

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2 Ongoing Surveillance Activities

Surveillance included proactive outreach to daycare centers, schools, assisted living facilities, hospitals and more, with assistance from the U.S. Centers for Disease Control (CDC) and local and regional epidemiologists.

CDPHE conducted a community telephone survey using 2,238 random telephone numbers over a two-week period to provide further surveillance. 541 households were reached with a total of 1,377 individuals contacted. Over 70 interviewers participated. Well persons were used as age-matched controls, ascertained by subset of interviewers and approximately 14 percent of individuals reported gastrointestinal illness.

Officials from the CDPHE Consumer Protection Division, with assistance from the CDC and the U.S. Food and Drug Administration (FDA), handled the task of going door-to-door, contacting every restaurant, hotel, food manufacturer, food storage facility, grocery store, school and child care center in the area to help ensure that the public was no longer being exposed to municipal water. The state and federal consumer protection teams conducted more than 225 in-person site visits during the event and provided a series of written guidelines specific to each stage of the emergency in addition to face-to-face assistance.

Daily calls were made to the two nursing homes; one assisted living center, and one hospital that receive their water from the affected distribution system. CDPHE’s Health Facilities Division provided guidance for cleaning and disinfecting of equipment and bathing of sensitive patients during the system flushing. No healthcare associated salmonellosis cases were identified during the outbreak.

The school nurse, in partnership with members from the CDPHE Disease Control Division and the Alamosa Nursing Service, conducted enhanced passive surveillance throughout the Alamosa School District. Isolated cases were identified, excluded and referred to a healthcare provider. Schools were closed for two weeks during the initial outbreak period (spring break plus one extra week due to water restrictions).

A childcare surveillance system was developed by the CDC EIS officer and was maintained by CDPHE and the local nursing service. Daily calls were made to all licensed daycare centers, and although no outbreaks were identified, this provided a good opportunity for public health to provide childcare providers with intensive education on infection control during the citywide water restrictions.

Recovery

On April 11, CDPHE rescinded the boil water order, approving the Alamosa water supply to be safe for general consumption. One death has been attributed to the outbreak, which infected an estimated 425 people in total. As of June 11, 2008, 24 people in Alamosa County remained hospitalized after the outbreak.

Forty-nine miles of water distribution lines were flushed and disinfected in just seven days as opposed to the original estimate of three months.

More than 1,030 individuals volunteered during the incident, including staff from more than 30 local-area businesses, donating more than 4,500 hours in time and labor. Incident management teams from all over the state of Colorado traveled to Alamosa to support and relieve the local team during the three-week period.

Before the outbreak occurred, Alamosa was scheduled to switch over to a new water-treatment plant in June 2008. To date, the city has repaired one water tank and taken a ground-level reservoir offline since the outbreak. By state order, it has also kept the chlorine level in the municipal water supply at 1.7 milligrams per liter and continues to test for both bacteria contamination and adequate chlorine levels.

This event has also spurred CDPHE to investigate the need to increase regulation of other rural, un-chlorinated water systems throughout the state.

Another adverse effect of this event was the economic impact upon local businesses. The community did qualify for Small Business Administration loans with the assistance of CDEM. No other federal financial assistance was available. While the state of Colorado provided $300,000 to help fund emergency response efforts, officials estimate that the outbreak likely cost upwards of $1 million.

Overall, $69,646 from CDC Public Health Preparedness funds were returned to CDPHE from local public health departments throughout Colorado to assist with this response. In addition, CDPHE received $50,000 from the Colorado Health Foundation. The state controller helped process fiscal requests in timely fashion and funds were used to assist with funding the COHELP hotline, local and state laboratory expenditures, public health staffing needs, hotel accommodations and equipment purchases.

Reported Cases of Salmonella in Alamosa as of April 30, 2008

Total Cases = 425

Culture Confirmed Cases = 117 (27.6% of cases)

Median Age = 12.5 years old

Age Range = 3 weeks to 94 years

Gender = 49% Female

Hospitalizations = 22

Death = 1

43% of residents made some contact with a healthcare provider

34% of residents visited or consulted with their primary care physician

10% of residents visited the emergency room

2% of residents were hospitalized

Analysis of Response

THE FOLLOWING SECTION OF THIS REPORT IDENTIFIES SOME OF THE COMMONLY IDENTIFIED STRENGTHS AND AREAS FOR IMPROVEMENT FOR THE COLORADO DEPARTMENT OF PUBLIC HEALTH AND ENVIRONMENT AS OBSERVED DURING THIS EVENT.

Strengths

3 Item: COHELP

Discussion: Although CDPHE has been using COHELP since 2003, the hotline had never been used for an emergency event of this magnitude. Without the assistance of COHELP, the Alamosa EOC would have been overwhelmed (and possibly debilitated) with calls from the public. COHELP has also proven to be an effective tool to support surveillance activities, both during the outbreak in Alamosa and with other public health events around the state. COHELP, however, is a relatively expensive resource, costing the state approximately $40,000 over the three-week incident in Alamosa.

Recommendations: Investigate ways to make COHELP more affordable during public health crises, including adding e-mail functionality. Inquire about the possibility of other CDPHE division’s sharing the cost of the annual COHELP contract. Try to limit the number of revisions made per day to information posted on the website and to COHELP.

4 Item: Use of the Joint Information Center (JIC) and Public Information

Discussion: The JIC was extremely effective in communicating timely, consistent information not only to responders but also to the media. The JIC was established early and control was maintained at local level and supported by the state. One lesson taken from this high-profile incident is to ensure that top priority is given to local media outlets. When state and national media arrived on the scene, local media were often pushed to the back during press briefings.

Recommendations: Continue to engage and inform local media as an essential partner during crises.

Get information translated into Spanish as soon as possible.

Item: Volunteers

Discussion: County and state officials were extremely pleased with the level of volunteerism that took place over the course of the event. This incident demonstrated that when a community is in crisis, volunteers will come forward to assist (over 200 volunteers showed up to pass out flyers on Easter Sunday alone). Moreover, the event underscored the importance of having a credentialed volunteer system in place. In 2007, the Colorado Volunteer Mobilizer (CVM) System was created to organize and provide training to public health and medical professionals, as well as support personnel, to ensure that trained volunteers can be called up quickly to respond to any disaster. In Alamosa, the CVM system was still being populated, so volunteers were assembled using local media, church groups and word-of-mouth within the community. Volunteers were tasked with handing out flyers and bottled water; however, other emergencies may require more complex tasks and technical expertise. It is imperative that public health and medical professionals be credentialed to serve as trained volunteers prior to an event.

Locals expressed extreme gratitude for the local Red Cross chapter. With such short staffing, Alamosa did not have someone identified to coordinate volunteers. The Red Cross volunteer coordinator agreed to coordinate community volunteers along with their own staff - if it was not for this coordinator, they would not have been able to coordinate such a large response. Other private organizations also assisted with the volunteer effort, such as transportation companies volunteering their vehicles and staff to transport volunteers throughout the community.

Recommendations: A volunteer coordinator position needs to be pre-identified and situated within the EOC to manage and accommodate volunteers. Continue to assist Alamosa in promoting and using the CVM in exercises, drills and real events.

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6 Item: Incident Command

Discussion: Once the decision was made to send the official bottled water order to the City and County of Alamosa, CDPHE activated the CDPHE Department Operations Center (DOC). All Federal, State and local partners agreed that the activation of the CPDHE DOC to coordinate public and environmental health activities was of great benefit and necessity. The DOC was activated quickly and regularly scheduled meetings and conference calls were held with all participating response agencies. All response agencies utilized the Incident Command System (ICS) to respond to the event. The use of ICS was flexible; staff fulfilled the duties necessary to respond to the event and the necessary documentation was maintained and shared with all partner agencies as needed and requested. CDPHE division staff learned that DOC operations do not need to be stringent, but their involvement can flexible within this structure. Several Federal, State and local partners commented on how impressed they were with Colorado’s knowledge and use of ICS. The local nursing service has funded the majority of the ICS training opportunities provided in the San Luis Valley Region using CDC Public Health Preparedness funds. The fact that Alamosa County staff had received incident command system training prior to the outbreak was critical to the success of the response. Local nursing service staff noted that if it were not for their knowledge and use of ICS, the event most likely would have taken a drastic turn for worse. At a statewide conference of county commissioners in June 2008, Alamosa’s county commissioner, Darius Allen, told an audience that he had never understood why his staff was spending so much time and money on trainings – but now, after the outbreak, he clearly sees the value in preparedness education.

Some state epidemiologists provided critiques about the use of ICS during this response. The state epidemiologist in charge in Alamosa was often not informed of staff or structure changes. Before the ICS structure was fully operational under the Incident Management Teams, CDPHE disease control staff were working in parallel to the local ICS structure, not within it. The daily culture for CDPHE disease control staff is to put out fires and respond to events without using ICS- it was difficult for them to transition into, and work, within this framework.

7 Recommendations: EPRD to meet with DCEED staff to discuss improved uses of ICS for epidemiological investigations – encourage DCEED staff to implement the use of ICS in daily tasks. Continue to train new public health workforce in ICS, NIMS and EOC operations. Work with CDPHE divisions to ensure that all management and leadership staff are familiar with internal protocols for emergency activation and operations within the CDPHE Department Operations Center.

8 Continue to identify EPR staff skills sets and train them on various position duties so they can be quickly plugged into positions within the DOC.

9

10 Item: Incident Management Teams

Discussion: This was the first time that all three certified Incident Management Teams (IMTs) in the State of Colorado were deployed to the same incident. This incident gave the IMTs a chance to practice and improve their team transitions and sharing of documentation with each other as they assumed and renounced authority of the event. Although the local nursing service director described the transition from a local public health event to the IMT as a “a little traumatic” at first, all Federal, State and local partners agreed that the IMT staff were critical to organizing and implementing a solid incident command response structure within the City and County of Alamosa. IMTs helped to alleviate exhaustion of limited staff at the local level by augmenting personnel needs with experienced staff from outside agencies. The IMTs also assisted local and State responders in the use of ICS to meet the needs of this complex incident.

Recommendation: Incorporate public health into IMT concept; encourage state, regional and local public health staff to join IMTs within their communities if possible.

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12 Item: Dedicated State and Local Public Health Staff

Discussion: Local nursing service staff members were overwhelmed very early in the response. Local staff members were working 12-20 hour shifts for weeks conducting case investigations, developing information for local media and answering questions and participating in meetings with local elected officials. CDPHE sent subject matter experts from water quality, disease control, consumer protection, emergency preparedness and public information to assist in the response. Disease control conducted hundreds of case investigations and over 70 people volunteered to do phone interviews. State and Federal consumer protection teams conducted more than 225 in-person site visits during the event and provided a series of written guidelines specific to each stage of the flushing process, in addition to face-to-face assistance. There was also an amazing collaboration between staff from various divisions within CDPHE. Flexibility of staff was key. Staff pulled together as a team and locals stated that assistance from state was very helpful and greatly appreciated.

Recommendation: Continue to provide ways for staff from various divisions within CDPHE to work together and practice skills required during emergency response. Some additional recommendations were made for internal communications within CDPHE for future events:

1. Improve communication with staff who are not directly involved in the response – let them know who to check in with for availability, let them know that they too can monitor the SATool and forward SITREP to these individuals.

2. Be sure to update call down lists quarterly at a minimum.

3. Identify a more coordinated, streamlined process for collecting information from all divisions in-between daily briefings

Item: CoWARN

Discussion: This was the first employment of the CoWARN system. Members were organized and deployed very quickly. Throughout planning and the “Red” and “Yellow” phases of system flushing, disinfection, and water sampling, CoWARN crews worked 12 hour shifts, around the clock, side by side with Alamosa and CDPHE personnel to get the job done. The entire 49 miles of water distribution lines were disinfected and flushed in just 7 days instead of original estimate of 3 months due to their hard work and dedication. CoWARN members provided technical expertise, equipment and supplies to Alamosa that were critical to proper system disinfection and water sampling throughout the flushing events and into system recovery.

Recommendations: Continue to expand the role and capabilities of this mutual aid network

16 Item: Public-Private Partnerships

Discussion: This event highlighted the value and importance of forming private-public partnerships for emergency response. Within hours of the decision to send the official bottled water order, CDPHE staff had agreements from several local area and national businesses willing to donate bottled and bulk water to the city of Alamosa. This included a direct call to Wal-Mart headquarters as CDPHE had just recently completed a preparedness campaign with the international big-box store. Businesses delivered drinking water in short notice, often for free. CDEM coordinated the donation and delivery of water throughout the event, and staff from more than 30 local-area businesses, donated more than 4,500 hours in time and labor. Some local hotel owners offered hotel rooms to responders at reduced costs and those hotels that did not receive their water from the affected distribution lines provided showers for free to the public.

Recommendations: Continue to develop private-public partnerships.

17 Item: Special Needs

Discussion: State and local public health officials agreed that the response to special needs populations was handled well. Hearing impaired and other special-needs individuals had been previously identified and mapped in the Alamosa County Nursing Services emergency plans. All public information was translated into Spanish and local responders addressed Spanish dialect issues well. COHELP was used to develop a list of homebound individuals (an ad was put in the local paper asking for people with needs to call COHELP if they needed assistance) and the county sheriff’s office and the Alamosa Fire Department delivered two-day water supplies to these homebound individuals every other day. Local responders also developed an inclusive list of home bound with home health, long-term care, and meals on wheels recipients. A local woman came forward volunteering to assist with the deaf community. Other special-needs organizations throughout the state of Colorado also pitched in, providing bottled water, risk communication and other services to these groups.

Recommendations: In the future, all emergency communication plans need to reflect the special needs of the local community’s at-risk populations. For instance, CDPHE believed that written information could be provided to Alamosa’s deaf community – but later learned that some members of that population could not read. Similarly, Alamosa’s large Guatemalan population speaks Q’anjob’al, a Mayan dialect, and not Spanish. CDPHE needed assistance during the emergency to quickly translate public information into Q’anjob’al for this group.

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20 Item: Federal Assistance

Discussion: State and local public health staff found the assistance of our Region VIII representative to be extremely valuable. The federal staff members that were sent to assist were also greatly appreciated. HHS and FDA staff assisted the Consumer Protection Division in developing a system to inventory restaurants, hotels, food manufacturers, food storage facilities, grocery stores, schools and child care centers in the area using lessons learned from Hurricane Katrina. CDC staff were also helpful in assisting with disease surveillance activities. Later in the response, CDPHE experienced a great deal of frustration with the CDC laboratory. Information was not being shared with the state, laboratory results were withheld, and CDC did not utilize the Incident Command System with external partners.

Recommendations: During events requiring the partnership between CDC and State and local public health, ensure that CDC is integrated into the State ICS structure and frequently communicate with CDC to ensure that information, including laboratory results, are being shared with all appropriate partners in a timely fashion.

21 Item: CDPHE Laboratory Capabilities

Discussion: Both State and local public health staff praised the CDPHE Laboratory Services Division for their dedication and hard work during this outbreak. The lab conducted multiple tests after hours and on weekends throughout the three-week outbreak to determine the source and to confirm that the water system was free of bacteria once the system flushing had been completed. The local laboratory in Alamosa became overwhelmed very quickly and the State lab was able to assist in confirming new cases. Sample results were provided as quickly as possible. Although laboratory staff have developed and exercised plans for testing infectious agents, they never had to combine environmental samples with human disease samples – they did not have prior experience exercising a large-scale environmental outbreak. This event gave laboratory staff the opportunity to integrate various components of services and personnel working together instead of independently.

Recommendations: This event highlighted the laboratory’s need for a higher level of capability for parasitic capabilities for large volumes of water or food samples.

23 Item: Emergency Response Communication and Coordination Systems

Discussion: The various IT systems used by state and local public health preparedness staff were instrumental to ensuring an effective and efficient response to this event. The Colorado Health Alert Network (COHAN) was used to send notifications to local public health agencies, infection control practitioners, emergency rooms, and other healthcare providers and response personnel throughout the affected region and the state. The new situational awareness tool, SATool, ensured that staff and partners in the field stayed connected and always had one place they could go to find situational reports, contact information, conference call dial in instructions, and other documentation such as epidemiological data, to effectively do their jobs. The ability to post documents on the website also improved DOC staff transitions, ensuring that everyone had access to key files since they were not housed on one person’s computer. A total of 119 documents were posted on the SATool during the Alamosa event. HCStandard was also a new system that was used to respond to this event. HCStandard is a resource-tracking tool that was in the process of being populated with hospital data, but for this event, it was used to track staffing. HCStandard alleviated early issues with tracking staff and other resources deployed to Alamosa from CDPHE. 800 MHz radios were provided to all responders who went into the field and this enabled them to communicate with the Alamosa EOC and the CDPHE DOC to provide real-time updates about the status of the water distribution system.

Recommendations: Continue to maintain systems and ensure that the public health and response partner workforce has the training needed to use these IT systems. Continue to use and test systems during drills and real events. Continue to promote the use of HCStandard as a tracking mechanism for resource requests. Ensure that all appropriate agencies have access to, and training on, HCStandard and SATool.

Areas for Improvement

Issue: Staff Safety

Discussion: When CDPHE staff members were deployed to Alamosa, staff in the DOC knew who was deployed, but there was no check in/check out process for staff once they arrived. CDPHE staff members were not involved in the security briefings conducted in the EOC prior to the arrival of the IMTs. No staff safety issues arose during this event, but EPRD staff recognize the importance of tracking staff, providing staff with safety briefings each day and having access to contact information for all staff in the field in the event that another emergency, such as a natural disaster, were to occur.

Recommendations: In the future, ensure that all deployed staff check-in to the EOC or to a designated Incident Command Post. For every event, assign a Safety Officer in the DOC that is responsible for providing CDPHE staff updates to the Safety Officer at the local EOC, SEOC, etc.

Issue: CDPHE Coordination with Emergency Management

Discussion: This event generated a lot of respect for the value and complexity that public health brings to emergency response. An IMT Operations Section Chief stated, "What I've learned from this incident is that almost every All Hazards Incident I can think of is really going to have to include Public Health as a key Operations piece." However, local response partners, as well as some state DEM members have minimal knowledge of public health.

During the initial stages of this event, local response partners, such as fire and police, as well as state emergency management partners, did not know why public health was so operational. They did not understand CDPHE’s role in disease investigation or that all of the county’s environmental services, including water inspection and consumer protection, were the responsibility of the state (as this local jurisdiction does not have its own environmental health services).

During this incident the State Emergency Operations Center (SEOC) [managed by the Colorado Division of Emergency Management (CDEM] used a modified version of an Incident Action Plan (IAP) for the first time, including the use of the ICS 204 (Assignment List) to gain input from their Emergency Support Functions and the ICS 213RR (Resource Request Message), which helped track resources and expenditures. The process for collecting information from various Emergency Support Functions (ESFs) was new, and on a few occasions, the information provided to SEOC from CDPHE was not included or was incorrectly added to the IAP. In addition, CDEM attempted to create their own epidemiological graphs - they were informed that CDPHE staff had the expertise to provide this information. There was also some confusion over CDEM’s role in providing resource assistance for obtaining water and paper goods for the community. At the local level, CDPHE and local public health staff had to meet several times with county commissioners, the city council and other elected officials and first responders to explain to them why public health was mandating that people no longer consume the city’s tap water. There was a great deal of value in meeting one on one with city managers and city council members to educate them on public health issues and to dispel rumors.

Recommendation: Continue to educate emergency response partners on public health’s roles and responsibilities. Create a summary sheet on what we do, including links to public information fact sheets to help a JIC create messages. Be more assertive and educate people upfront on public heath’s roles, responsibilities and authority.

Issue: Use of Official Orders Within the Local Joint Information Center (JIC)

Discussion: The JIC worked best under local control, however, there was some confusion over the official orders issued by CDPHE for the City and County of Alamosa. The JIC did not understand that the official orders coming from CDPHE were issued to City/County officials and were only being provided to the JIC as a courtesy. The JIC attempted to change the wording in official orders for use in press releases and other forms of communication. At one point, City officials and local JIC staff decided to change CDPHE’s message to boil water for 15 seconds to 1 minute. Local officials made this change due to fear that 15 seconds did not sound like enough time to kill bacteria present in tap water. This fear was not scientifically based and CDPHE had to call all restaurants and other facilities back with the city’s new message to ensure that they were complying with requirements and that they were not confused by the last-minute change in messaging. CDPHE did inform JIC staff that they did not have the authority or expertise to change these orders and CDPHE also ensured that City officials were aware of their legal responsibility to follow official orders as presented by the State.

Recommendation: During future events, ensure that the local JIC staff understand the guidance provided by CPDHE staff and that messages from official orders should never be changed.

24 Issue: Mutual Aid and Resource Coordination

Discussion: This event highlighted the importance of mutual aid agreements during an emergency. Most mutual aid networks and partnerships worked very well, however, some resource requests were filled in a piecemeal fashion, with CDPHE officials picking up the phone and calling other agencies or relying on word of mouth. One example of this was with the Mid America Alliance (MAA), a mutual aid network between public health agencies within FEMA Regions VII and VIII. This event provided the MAA with a good opportunity to conduct a mutual aid drill for neighboring states, however, these states provided feedback to Colorado that we needed to better define what skills/experience we needed when making personnel requests– resource typing would assist in this effort. National efforts at resource typing, specifically for public health, have been slowed in recent years, but more can be done on the state level to ensure emergency managers have access to the information they need to request and receive appropriate resources during a disaster.

Recommendation: Continue to follow national efforts for public health resource typing. Ensure emergency managers have access to public health resources available to assist during an emergency event.

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3 Issue: Communication Between Local EOC and State EOC/CDPHE DOC

Discussion: During any event, communication is always an area that can be improved. After the IMT transitions, it was difficult for CDPHE staff to determine who was in charge. New staff contacts were not always communicated to all partners and the staff turnover impacted contacts in the JIC and in the field. Having CDPHE representatives in the local EOC was very helpful for members of Disease Control, Water Quality, and Public Information. During the first week of the response, CDPHE was under the impression that the city water utility representative was on the phone during the daily conference calls with the local EOC. It was often difficult to know who was present during these calls, even with the use of roll call prior to the start of the meeting. CDPHE staff members were providing updates and direction for city water officials, but they were rarely, if ever, on these conference calls. There was also confusion early in the event because staff members from CDPHE were not physically in the EOC to translate information and explain the current situation from a scientific perspective. More communication was also needed from the field; members of the local EOC were asking for information from CDPHE, but CDPHE did not get status updates from the local EOC early during the event. As the event progressed, CDPHE found great benefit to having a representative from Disease Control and Water Quality physically present in the EOC to answer questions and to ensure that guidance was being followed. It was also helpful to have a regional public health staff member be a member of the IMT to act as a liaison between State and local public health staff and other responders in Alamosa.

Recommendations: During conference calls, do a better job of identifying who is on the phone and what their roles are. In the future have at least one CDPHE representative, physically present in the local EOC, especially for complex public health events requiring expertise from multiple divisions. Incorporate State and regional public health emergency preparedness staff in IMTs.

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5 Issue: Staff Cross-Training

Discussion: Several CDPHE divisions identified the need to cross-train staff from other divisions and programs within the department. Disease Control expressed an interest in quickly training people with a background in epidemiology on how to do case interviews for specific events – they had a large number of people volunteer to assist them in performing the telephone survey, however, due to the lack of experience of many of these volunteers, much of the data collected was not followed up on as it would have been by an experienced, well-trained epidemiologist. Consumer Protection also provided another example of the need to cross-train staff. As Consumer Protection is a small division, many staff members from EPRD traveled to Alamosa to assist with the large number of daily restaurant, childcare, and other inspections and consultations. Although these staff members provided a great deal of assistance, many of them lacked the appropriate level of environmental knowledge needed to assist with many tasks.

CDPHE divisions were open to providing non-essential staff with cross training on key areas and opportunities to shadow other division employees to get a better understanding of the tasks that they perform on a daily basis. The end goal is to develop a core group of staff members that have the necessary skills and training to assist specific divisions during a large-scale event.

This model was used during the Alamosa event. Additional people were needed to man the call center at COHELP. Individuals were selected from EPRD, trained, and were sent to the call center to answer questions from the public. Now, CDPHE has access to an additional 5 people that can perform this role.

Cross training will also help to alleviate some of the issues that were identified in the local EOC. Various divisions sent staff to Alamosa to perform specific technical skills in the field, but they also found that they needed at least one full time person with this technical knowledge to be sitting in the EOC communicating with incident command at all times. This was difficult, often impossible, due to a lack of staff with this specific technical knowledge in various areas of public and environmental health.

By cross training key staff, individuals can be selected to communicate with incident management in the EOC while the subject matter experts are in the field, doing what they do best, while the status of their activities is being effectively communicated back to decision makers in the EOC.

Recommendation: Implement training/shadowing for other divisions – increase staff with skills to conduct case interviews, assist with restaurant, childcare and healthcare facility inspection/education, and other relevant and appropriate tasks during an event.

Ensure that all division’s receive more information and training on the importance of personal preparedness – many staff needed to be deployed quickly and their deployment was delayed in some cases due to a lack of family planning and access to key items in the work place.

Train more staff on how to post information to the EPR website.

Conclusion

FAST ACTION, EFFICIENT COMMUNICATION AND THE HIGH LEVEL OF COOPERATION AMONG VARIOUS AGENCIES ARE ALL CREDITED WITH SIGNIFICANTLY LIMITING THE NUMBER OF ILLNESSES IN ALAMOSA. WHILE A BOOST IN FEDERAL FUNDING IN RECENT YEARS HAS ALLOWED COLORADO TO ESTABLISH A STATEWIDE INFRASTRUCTURE TO EFFECTIVELY RESPOND TO SUCH DISASTERS, THE EVENT IN ALAMOSA UNDERSCORES THE IMPORTANCE OF CONTINUED FUNDING FOR EMERGENCY PREPAREDNESS AND THE NEED TO INTEGRATE PUBLIC HEALTH ACTIVITIES WITH EMERGENCY MANAGEMENT.

It is widely acknowledged that federal funding for public health preparedness in Colorado in recent years made a significant impact in the response efforts. For instance, state and local public health emergency preparedness personnel, including epidemiologists, planners and trainers, equipment in the state public health laboratory, and technology systems including the Colorado Volunteer Mobilizer (CVM), and a notification system known as the Colorado Health Alert Network (COHAN), as well as the COHELP hotline are all products of federal public health cooperative agreement funding provided by the CDC.

Federal funds are quickly dwindling; in 2008, Colorado alone received a 23 percent cut in public health preparedness funding. Nationwide, such federal funds are expected to steadily decrease over the next several years. As the event in Alamosa demonstrated, local, on-the-ground expertise of city and county officials is critical during a public health emergency. But such local efforts need to be supported by the state. Without annual, consistent state funding, local public health preparedness and response activities will become increasingly disparate and fragmented.

In Colorado, a new Senate bill (SB 08-194) is expected to facilitate more mutual aid agreements among local health departments and help further integrate public health services into emergency management. Passed with overwhelming legislative support and backed by a broad range of public and private organizations, this bill will establish a system of coordinated, consistent public health care across the state while still allowing individual counties and districts to determine the services that will best meet their local public health needs.

Appendix A: Timeline of Events

Mar 6, 2008 First case of salmonella reported in Alamosa

Mar 14, 2008 Salmonella reported to CDPHE

Mar 17, 2008 Alamosa County Emergency Operations Center activated

Mar 18, 2008 52 cases of suspected salmonella reports

SEOC activated at Level II

Mar 19, 2008 CDPHE issues bottle water order for the City

COHELP line (1-877-452-2911) activated

CDPHE CoWARN (mutual aid) network activated

Denver Water and CDPHE Water Quality personnel arrive in Alamosa

Mar 20, 2008 Three water distribution points established

CoWARN meeting takes place at CDPHE to plot strategy

Mar 21, 2008 City of Alamosa signs CoWARN mutual aid agreement

Governor declares Public Health emergency (Executive Order D 006 08)[3]

Colorado National Guard deploys

Mar 22, 2008 Governor and US Senator Salazar tours City

Mar 23, 2008 Jefferson County Incident Management team (IMT) arrives

Volunteers distribute approximately 5,000 flyers

Mar 24, 2008 Alamosa water samples test positive for salmonella

Local press conference occurs

Additional CoWARN requests occur

Formal request to HHS is made by the Governor

Mar 25, 2008 Alamosa public schools are closed

Governor issues Executive Order D 007 08, amending D 006 08

Mar 26, 2008 City placed in “Red” status

CDC personnel arrive

Mayor begins daily televised statements on Channel 10

CoWARN partners from Pueblo Board of Water Works, Colorado Rural Water Association, and the State of Nebraska arrive on scene

Mar 27, 2008 Salvation Army provides vouchers for paper products

Northwest IMT relieves Jefferson County IMT

Mar 28, 2008 “Red” phase is completed, City moved to “Yellow”

89% of all regulated food service/institutional facilities remain open. CDPHE Consumer Protection Division contacts all

SEOC deactivated

Mar 29, 2008 CoWARN partners from City of Boulder and East Cherry Creek Valley water and Sanitation District arrive on scene

Mar 30, 2008 Transition plan to go “Green” is issued

Mar 31, 2008 Schools are reopened

Eastern Colorado IMT relieves Northwest IMT

Apr 01, 2008 CoWARN crews demobilized

Apr 03, 2008 CDPHE boil water order is issued

Apr 08, 2008 Water sample shows the presence of Giardia[4] and Cryptosporidium[5] (samples taken prior to flush)

Apr 09, 2008 Post-flush samples shows the absence of Giardia and Cryptosporidium

Apr 10, 2008 Total number of cases reported = 399, hospitalizations = 16

Apr 11, 2008 Boil water order is rescinded, water can be consumed by residents

Apr 18, 2008 Only death related to salmonella incident is reported

May 29, 2008 A Colorado Open Records Act request is submitted to DOLA and CDPHE

Appendix B: Businesses and Community Partner Contributors

A-1 Discount Water

Advantage Water

Albertson's Grocery

All American Moving

Anheuser-Busch/Coors

Arrowhead subsidiary

Bulk Water Runner

Center for Disability

City Market/King Soopers

Clorox

Colorado Pure

Coors

Costco/Nestle

Deep Rock

El Dorado Water

Germ-X

HealthOne

Highland Water

Huggies (Kimberley-Clark)

Indian Springs

Jack's Market

Johnson & Johnson

LDS Church

Lysol

Memorial Hospital (Colorado Springs)

Mile Hi Culligan Water

Mile Hi Water

My Medical Solutions

Nestle/Costco

Pampers

Pepsi

Playtex

Pure Water To Go

Purell

Rocky Mountain Bottled Water

Safetec of America, Inc

Safeway

Sierra Springs Water

Simpler Life Emergencies

Swift Trans

Up the Creek Water Works

US Foods

Valley Water Service

Walgreens

Wal-Mart/Sam's Club

Water Runner

Water to Go

DS Waters

Whole Foods

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1 CDC, “Surveillance for Waterborne-Disease Outbreaks – United States, 1993-1994,” Morbidity and Mortality Weekly Report, April 16, 1996, 45(SS-1); 1-33.

[1] This Executive Order: (1) activated the State Emergency Operations Plan; (2) when necessary, utilizes assets from the Colorado National Guard; (3) releases funding for authorized expenditures (up to $300,000) from the State Disaster Fund; and (4) Colorado Department of Transportation is authorized to waive selected fees/restrictions that may impede rapid support to the City of Alamosa.

[2] This Executive Order: (1) activated the State Emergency Operations Plan; (2) when necessary, utilizes assets from the Colorado National Guard; (3) releases funding for authorized expenditures (up to $300,000) from the State Disaster Fund; and (4) Colorado Department of Transportation is authorized to waive selected fees/restrictions that may impede rapid support to the City of Alamosa.

[3] Giardiasis is an infection of the intestines caused by the parasite Giardia lamblia.

[4] Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). An infection may be caused by bacteria or parasites in spoiled food or unclean water.

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