Communicable Disease Outbreak Investigation

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Communicable Disease Outbreak
Investigation
OVERVIEW
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Health Departments

• Why do they do what they do?

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WI State Statute 251.05 A local health department
shall provide at least

• surveillance, investigation, control and
  prevention of communicable diseases,
• other disease prevention,
• health promotion
• human health hazard control

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WI State Statute 251.03 Local Board of Health

• A local Board of Health shall consist of not more
  than 9 members. At least 3 of these members
  shall be persons who are not elected officials.
• Good faith effort to appoint a registered nurse
  and a physician

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Duties of Local Board of Health

• Assess public health needs and advocate for the
  provision of reasonable and necessary public
  health services
• Assure the enforcement of state public health
  statutes and public health rules
• May adopt local regulations that it considers
  necessary to protect and improve public health.

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Duties of Local Board of Health

• Develop policy and provide leadership that
  advocates for equitable distribution of public
  health resources
• Assure that measures are taken to provide an
  environment in which individuals can be healthy

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Duties of Local Health Officer

• Enforce local and state public health statutes
  and rules
• Promote the spread of information as to the
  causes, nature and prevention of prevalent
  diseases and the preservation and improvement of
  health

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Duties of Local Health Officer

• Investigate the appearance of any communicable
  disease
• Do what is reasonable and necessary for the
  prevention and suppression of disease may forbid
  public gatherings may require isolation of the
  patient, quarantine of contacts

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What is a Public Health System?

• Not just the local health department
• Is a dynamic partnership comprised of government,
  individuals, and the public, private, nonprofit,
  and voluntary sectors.

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What Are the Shared, Essential Services of the
Public Health System?
1. Monitor health status to identify community
health strengths and current and emerging issues
and problems. 2. Identify, investigate, control,
and prevent health problems/hazards. 3. Educate
the public. 4. Promote community partnerships to
identify and solve problems. 5. Create policies
and plans to support individual/community
health. 6. Enforce laws and regulations to
protect health/insure safety.
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What Are the Shared, Essential Services of the
Public Health System?
7. Link people to needed health
services. 8. Assure a diverse, adequate, and
competent public health workforce. 9. Evaluate
the effectiveness, accessibility, and quality of
personal and population-based health
services. 10. Conduct research to seek new
knowledge, insights, and innovative
solutions. 11. Assure access to primary health
care for all. 12. Foster understanding and
promotion of social and economic conditions that
support good health.
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WI Statute 252.05 require reporting of
communicable diseases

• Persons required to report include any person
  licensed under ch. 441 and 448 or any other
  person having knowledge that a person has a
  communicable disease such as laboratory
  directors, school nurses day care staff,
  infection control staff

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Reportable Disease Categories

• Category 1
• Report immediately upon case identification or
  suspected case.
• Category 2
• Report within 72 hours of case identification or
  suspected case
• Category 3
• Report within 72 hours after case identification
  or suspected case directly to state
  epidemiologist

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Outbreak Investigations can be challenging

• Time urgency /public pressure
• Early media report may create public panic
• May overwhelm healthcare delivery system, large
  number of symptomatic individuals, worried well
• Legal liability/ financial interests
• If delayed, may be difficult to collect clinical
  and environmental samples

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How are Outbreaks Recognized?

• Astute health care provider, infection
  preventionist and/or laboratory worker
• Public health surveillance data
• Concerned patient/ families
• Media

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Why do Outbreak Investigation?

• Stop outbreak/ prevent new cases
• Interrupt transmission/ implement controls
• Develop prevention strategies for the future
• Discover new diseases or new presentations of
  old diseases
• Address public concern

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What is Role of Private Provider?

• Identify first case(s)
• May be the first to recognize outbreak
• Assist in identifying additional cases
• Obtain clinical specimens

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What is Role of Public Health?

• Define outbreak, onset, symptoms, potential
  exposure and possible causative agent if unknown
• Determine clinical specimens to collect
• Develop working case definition
• Recommend control measures
• Conduct case interviews
• Descriptive epi (line lists/analysis)
• Hypothesis/theory generation
• Case finding/hypothesis testing
• Conduct or coordinate environmental investigation

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Successful outbreak investigation requires
collaboration between

• Infection Preventionist
• Local physicians
• Schools/school nurses
• Veterinarians
• Daycares
• Media

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Communicable Disease Tools

• Heymann Control of Communicable Diseases Book
• WDPH Disease Fact sheets
• WDPH/ Regional
• Consultation

• Epinet
• 4151,4243
• AAP Redbook
• CDC

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3 Main Component Areas of Most Outbreak
Investigations

• Epidemiological investigation
• Environmental investigation
• Interaction with the public, press and legal
  system

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Outbreak Control Measures?

• Should be driven by results of epidemiologic,
  laboratory, and environmental investigations
• Delicate balance between waiting for
  confirmation of theories and preventing more
  cases
• Sensitive to the fact that not sure what you are
  looking at
• Control measures may change as investigation
  continues

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Examples of Control Measures

• Case identification
• Treatment / isolation
• Infection control practices
• Exclusion guidelines
• Environmental cleaning
• Contact tracing

• Vaccines
• PPE
• Quarantine of exposed
• Therapeutic prophylaxis
• Community containment measures
• Recalls/Closures

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How to Interact with Public and Press?

• Media can be helpful in soliciting cases and for
  the dissemination of information to the public
  about recalls/ other control measures.
• Media can also create public panic and possible
  bias in investigations.
• Media should ideally be handled by designated PIO
  (Public Information Officer) or JIC (Joint
  Information Center)

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Fond du Lac County Shigellosis

• July 07 6 confirmed cases, 1 suspect, linked to
  1 facility
• August None
• Sept 2 cases at 2 different elementary schools,
  1 suspect case at a different elementary school

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Shigellosis Historical Data

• Jan. 06 1 case
• May 06 1 case
• Nov. 06 1 case

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Shigellosis Control MeasuresSchools/Daycares

• Regimented handwashing
• Increased bathroom cleaning
• School absence surveillance
• Identify links among cases

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Shigellosis- Healthcare Providers

• Test all symptomatic individuals
• Fax positive stool test results immediately
• Biograms and sensitivity patterns to identify
  antibiotic resistance

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Shigellosis- Community Awareness

• Multiple local media releases
• Signs and symptoms
• Access to testing
• Remain home if symptomatic
• Handwashing handwashing handwashing

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Shigellosis 6 months later

• 49 confirmed, 6 suspect cases involved
• 5 elementary schools
• 7 daycares
• 5 healthcare workers from 5 different employers
• 1 restaurant employee

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Pertussis Disease in Fond du Lac County 2003-04

• 212 PCR/culture confirmed cases of pertussis
  disease in 2003
• 100 probable pertussis disease cases in 2003
• 61 PCR/culture confirmed and probable cases of
  pertussis disease in 2004

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Pertussis Disease in Fond du Lac County before
2003

• 1 to 2 reported cases of Pertussis Disease
  annually with many years of no reported cases

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PCR/Culture Confirmed Pertussis in Fond du Lac
County 2003
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Control Measures

• Alerts sent to all Health providers, Nursing
  Homes, and Daycare providers, highlighting number
  of cases, where they were occurring, along with
  disease signs and symptoms, isolation, testing
  and treatment recommendations
• Press releases to the print, radio and TV media
  distributed jointly from Public Health and the
  major Healthcare Providers in the area
• Implementation of respiratory etiquette
  procedures (asking individuals to mask upon
  entering a health care facility/clinic if
  experiencing respiratory symptoms)
• School nurses actively assessed students for s/s
  of disease and monitored for isolation compliance
• Adoption of accelerated DTaP immunization
  schedule for all infants during epidemic

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Individuals Tested/Treated

• 3000 individuals had NP swabs between October
  2003 and January 2004
• 5000 individuals were treated for pertussis
  disease due to s/s or as a close contact

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Agnesian HealthCare System

• 220 staff tested
• 137 employees had URI and cough symptoms,
  tested started on antibiotics and were furloughed
• 12 employees had rhinitis (no cough) and were
  tested, started on antibiotics and could work
  with a mask
• 8 employees were assessed by their own
  healthcare providers
• 59 employees were started on antibiotics due to
  confirmed exposure to close contact with known
  pertussis

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Major Challenges

• Physician standardization of pertussis diagnosis,
  treatment and isolation
• Identification of close contacts outside of the
  traditional family contacts
• Staffing for health care institutions during
  aggressive case finding
• Public and staff relations for health care
  institutions

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Pertussis Epidemic in Fond du Lac County

• 70 of confirmed disease occurred in middle and
  high school aged children
• 3 infants (under 8 weeks of age) were
  hospitalized in 2003. No hospitalizations in
  2004.
• No lab confirmed disease in nursing homes, group
  day care settings, or hospital employees/clinic
  staff.
• No deaths reported in Fond du Lac County from
  pertussis disease

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Financial Impact- Fond du Lac County Health
Department

• 900 hours of staff time estimated 36,000
• Medication Health Department paid for 5,000

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Financial Impact toAgnesian HealthCare

• Cost of
• Medication 13,000.00
• Lab Testing 11,000.00
• Visits to ER/UC 1200.00
• Sick Leave 49,450.00
• This does not include the cost of
• replacement staff and personal protective
  equipment

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2009 Pertussis Case

• One young adult
• Treated but not isolated
• Exposed 65 coworkers and 1 newborn
• 13 symptomatic people tested
• Institutional memory-none

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Fond du Lac - Initial Response

• Team effort
• FdL HD
• WDPH
• Local Physicians
• Hospital Infection Preventionist
• Hospital Public Relations

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Public Health/ Healthcare Response - Issues

• Information from all health care partners
• Credible
• Accurate
• Consistent
• Standardized assessment tool
• Determine risk of exposure
• Recommendation for post-exposure prophylaxis
  (PEP)
• Rabies immune globulin (RIG) and PEP availability
• Media coverage - intense due to rare event

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Control Measures

• Rabies fact sheet distributed
• Information released to media coordinated
• Hot line was established at hospital
• Number released to radio media
• Staffed by Hospital and FdL HD
• FdL HD phone number given for general rabies
  questions
• Screening clinic established to determine
  exposure and need for PEP
• News conference- Hospital PR staff facilitated

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Communicable Disease Control Resources

• Local Health Department
• Control of Communicable Disease in Man, Heymann
• Department of Health website http//dhs.wisconsi
  n.gov/communicable/diseasereporting
• http//hanplus.wisc.edu/EPINET
• CDC website www.cdc.gov

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Questions????Diane CappozzoFond du Lac County
Health Officer920-929-3085diane.cappozzo_at_fdlco.w
i.gov