Epi Teams Case Study



Case Study: Possible Measles Outbreak

FACILITATOR VERSION

Objectives

• List three (3) strategies for active case finding

• Describe outbreak control measures

• Prepare a statement for media during an outbreak situation

• Identify critical components of an outbreak investigation report

Instructions

Convene your local Epi Team, and provide each Epi Team member with a copy of the case study (participant version). Choose one person to act as the facilitator. This person should use the facilitator’s version of the case study.

Guidance for facilitating the case study can be found on the next page. The case study begins on page 3.

Time Allotted: 1.5 hours

Background Material

The following trainings, found at the North Carolina Center for Public Health Preparedness Training Web Site (), are recommended for Epi Team members without prior outbreak investigation experience. They can be viewed prior to completing the case study.

1. Embarking on an Outbreak Investigation (FOCUS on Field Epidemiology Volume 1, Issue 3)

2. Writing an Outbreak Report (I is for Investigation Session VI)

3. Risk and Crisis Communication (I is for Investigation Session VII)

Resources

CDC. Prevention of Specific Infectious Diseases: Measles. In CDC Health Information for International Travel 2008. Available at . Accessed on September 10, 2007.

WHO. Measles Fact Sheet. 2007. Available at . Accessed on September 10, 2007.

Guidance for Facilitators

Goal

The goal of working through a case study is active learning through engaged participation by each Epi Team member.

Role of Facilitator

As a facilitator, your job is to:

• Guide the Epi Team through the case study

• Involve every team member

• Moderate discussion drawing on the suggested answers to discussion questions

• Ensure key points are covered for each question

• Keep an eye on the clock

Active Participation

All team members should be involved in the discussion. One strategy for getting everyone involved is to have team members take turns reading aloud and attempting to answer questions. Facilitators should:

1. Ensure that the room set-up encourages group participation, ie. everyone seated around a table or chairs in a circle.

2. Select one team member to read aloud the first update and the first question.

3. Encourage that team member to attempt to answer the first question (regardless of his/her background).

4. Encourage other team members to add information and discuss the question.

5. Use the suggested answers to cover key point(s) that were not addressed during the discussion.

6. Have the next person read aloud the next update or question and begin an attempted answer as above – move in sequence to include everyone.

Follow this sequence until the scenario is completed, pacing discussion in order to finish the entire scenario.

Facilitation Tips

• Read the case study ahead of time so you are prepared for the discussion.

• Always remember the learning objectives for the case study.

• If one person is dominating the conversation, call on other team members.

• If someone in the group is not participating, ask his or her opinion.

• When someone asks a question, encourage other team members to provide the answer.

• Do not spend too much time providing the suggested answers to the group. Instead, encourage the team to share their opinions about possible responses to the given scenario.

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Question 1: What questions do you have for the nurse?

Suggested answer: During this initial phone call, you should try to gather as much information as possible. You want to ask questions about the patient including:

1) Clinical information about the patient (e.g. signs and symptoms, dates of onset, vaccination history, current health status of patient, whether patient is in airborne isolation room, pregnancy status of patient, records from Jan 20th visit, etc);

2) Laboratory tests and results;

3) Exposure information (e.g. possible sources of measles exposure, travel history);

4) Demographics (e.g. name, date of birth, address, occupation); and

5) Contacts (e.g. others who may be exposed, assuming patient has measles).

Much of the information you need to gather is included in the North Carolina Measles Surveillance Report, which is listed as the Measles Case Investigation Form on the Vaccine Preventable Disease Surveillance Web site ().

You will also want to ask whether any of the patient’s friends and family members have been ill, and whether the nurse has seen any patients with measles signs and symptoms. Finally, don’t forget to get the contact information for the nurse.

Question 2: Would you recommend that any laboratory tests be conducted at this point? If so, describe the test and the type of specimen that should be taken.

Suggested answer: Given the clinical picture, testing for measles IgM and IgG antibody is appropriate. This requires a blood sample. You should also obtain the results of any routine blood tests that may have already been conducted by the hospital.

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Question 3: Given the timeline of events, do you believe Pina contracted the disease in North Carolina or in India?

Suggested answer: You know that the incubation period for measles is 4 to 12 days, indicating that the patient most likely contracted measles while still in India, as opposed to North Carolina.

Question 4: Is it possible that Pina exposed others to measles? Consider the incubation period of measles, and the date of onset of her symptoms.

Suggested answer: Yes, it is possible that Pina exposed others to measles during her travel, since her symptoms began on January 17th. You know that measles is highly contagious, and can be transmitted from 1 day before prodromal symptoms (usually about 4 days prior to rash onset) through 4 days following rash onset. Since Pina’s first prodromal symptom (fever) began on January 17th, she was probably infectious beginning on January 16th, the day of the welcome party. For this reason, you will need to follow up with potentially exposed individuals (people in contact with Pina between January 16th-present), including Pina’s husband and child and individuals who attended the party.

Since the incubation period of measles is 4-12 days, although she probably contracted the disease in India, she was likely not contagious during her travel. The North Carolina Division of Public Health (DPH) should be consulted for advice about whether to trace her travel contacts. DPH may contact the Centers for Disease Control and Prevention.

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Question 5: Would you activate your Epi Team at this point? Why or why not? If so, which members of your Epi Team would be involved in this investigation?

Suggested answer: If you have not activated your Epi Team already, you would definitely want to activate the team upon receiving laboratory confirmation of measles. The team will be responsible for outbreak investigation activities and public health control measures, and should be convened as soon as possible.

The members of an Epi Team will vary depending on the local area and the size of the health department. Some members that might be involved include: health director, communicable disease nurse, epidemiologist, environmental health specialist, health educator, and nursing supervisor. Other team members to consider are a laboratorian or microbiologist, a public information officer, and an administrator.

Question 6: What public health agencies would you contact now?

Suggested Answer: If you have not done so already, this would be a good time to contact your Public Health Regional Surveillance Team (PHRST) and the Immunization Branch of the North Carolina Division of Public Health. The Immunization Branch will contact the Centers for Disease Control and Prevention (CDC) since measles is a nationally notifiable disease.

Question 7: You realize that Pina’s 5 month-old infant is at risk for contracting the disease, since the Measles, Mumps, and Rubella (MMR) vaccine is not usually given until 12 months of age. Should you provide the MMR vaccine to the infant?

Suggested answer: No, you should not provide the vaccine. The MMR vaccine is not given to infants under the age of 6 months since these infants are usually protected by antibodies from their mothers. However, in a situation such as this, when the mother is infected, the Advisory Committee on Immunization Practices (ACIP) recommends that unvaccinated children of all ages in the household who lack other evidence of measles immunity should receive immune globulin (IG).

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Question 8: What methods could you use to find additional cases?

Suggested answer: It is important to cast a wide net when looking for additional cases, and there are many ways to identify possible cases, depending on the particular situation. Your Epi Team will probably work together with the PHRST and the NC Immunization Branch or Communicable Disease Control Branch to find additional cases. Some possible case finding strategies include:

1) Contacting everyone who attended the welcome party. You may be able to get a list of names from the husband, or from the party organizers.

2) Getting a list of people (including patients, visitors, and staff) who were in the hospital emergency room during the times when Pina was there, and interviewing those people.

3) Alerting area hospitals and health care providers, either through phone calls, email, or fax, to look for and report possible cases of measles. It would be best to include a brief fact sheet about measles signs and symptoms and clinical diagnosis

4) Encouraging the general public to contact their health care provider if they have symptoms of measles. This can be done by holding a press conference and inviting the news media.

5) Issuing a HAN alert to notify public health officials in North Carolina. The State Epidemiologist may issue an Epi-X alert to notify public health officials throughout the country, if Pina may have exposed people from other states.

6) Contacting schools if there are any school-age contacts. Schools have vaccination records, which could help to identify students at risk of infection.

Question 9: What information should you collect when speaking with asymptomatic exposed individuals?

Suggested answer: You should collect:

1) Demographic and identifying information (e.g. name, address, phone number, date of birth, age, gender, race, occupation)

2) Exposure information (e.g. date of exposure, event/place of exposure, type of contact with case)

3) Clinical information (e.g. vaccination history, disease history, any laboratory documentation of measles immunity, any symptoms and dates of onset)

4) If reasonable, information about their potential contacts (e.g. names of daycares, schools, work sites). This information is gathered as a precaution, in case the person becomes ill and it is necessary to identify his or her contacts.

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Group Activity

Draft a message to share with the public based on what you know so far about the measles case and the potential for a larger outbreak. Keep in mind that you want the media to help you locate potential case-patients and provide information about the outbreak to the public in a way that does not cause alarm or fear.

Suggested answer: There are many ways that a press release could be written. Below is one example.

For Immediate Release

__________ County Health Department Media Relations

Potential Measles Outbreak

The _________ County Health Department is continuing the investigation of a possible measles outbreak. As of January 25th, the health department has documented one case of measles.

Measles is a highly contagious non-fatal disease, passed from person to person through casual contact. Individuals are encouraged to engage in proper hand washing techniques and sneeze or cough into a handkerchief or your elbow.

Symptoms of measles include fever that lasts at least 3 days, a rash, cough, runny nose, and red eyes. Many people have been vaccinated against measles, and therefore cannot become ill.

Individuals who may have been exposed to measles will be contacted by the health department. If you have symptoms of measles between January 15th and the present, please seek help immediately by calling your primary care physician, the Emergency Department at Community Hospital, or the number below.

For more information, call the 24-hour hotline at 919-123-4567 or visit

Question 10: What other media communication might be appropriate?

Suggested answers include: Regular news briefings on the status of the outbreak; a staffed hotline for community questions or concerns; information on the health department web site about measles, how it spreads, what the symptoms are, and how it is treated; educational flyers written in the various languages spoken by members of the community.

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Question 11: Should you offer Measles, Mumps, and Rubella (MMR) vaccine to exposed people?

Suggested answer: The official recommendation is to provide MMR vaccine within 72 hours of exposure to people without documentation of measles immunity. For people whose exposure was >72 hours ago, the Advisory Committee on Immunization Practices recommends offering immune globulin (IG).[1] In this situation, it is best to consult with the North Carolina Immunization Branch and the CDC for the most up-to-date recommendations.

Question 12: If you choose to offer MMR vaccine, describe how vaccine should be delivered. For example, will you hold a mass vaccination clinic? Do you have enough vaccine available at your health department, or will you need to order additional doses?

Suggested answer: Depending on the number of people who need to be vaccinated, it may be best to arrange individual appointments rather than holding a mass vaccination clinic to decrease the possibility of secondary transmission. However, a mass vaccination clinic may be the most efficient way to vaccinate a large number of contacts. Again, the local Epi Team should consult the North Carolina Immunization Branch for recommendations about the best strategy for vaccinating exposed persons.

The number of MMR doses maintained at the local health department will vary. Additional doses can be supplied from NCDPH within 24 hours.

Question 13: What kind of protection do you need to provide for your team members who are interviewing potentially exposed individuals? What about the community hospital staff who vaccinate potentially exposed individuals?

Suggested answer: In order to ensure staff safety for both the members of your team and the hospital staff, you should require documentation of measles immunity through one of the following: 1) documentation of 2 doses of MMR, 2) laboratory evidence of measles immunity, or 3) documentation of physician-diagnosed measles. Some states consider a person immune if they were born before 1957, but specific health-care facilities may require everyone to meet one of the 3 criteria above, regardless of age.

Standard infection control precautions should be followed when delivering vaccinations.

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Question 14: Since the outbreak appears to be under control, your health director suggests that the Epi Team write an outbreak report. What are some reasons for writing an outbreak report?

Suggested answer: Outbreak reports vary depending on the nature of the outbreak, but there are many good reasons to write a report including to:

• Document the actions that took place;

• Share new insights;

• Record performance;

• Substantiate recommendations;

• Prevent future outbreaks;

• Assist in investigation and control of similar incidents; and

• Provide documentation if needed for potential legal issues.

Activity

In small groups, draft an outline of an outbreak report listing all of the topics that should be included. Make sure to note the intended audience – your group should decide whether the outbreak report will be shared with 1) colleagues and superiors within your local health department, 2) other partners in the community, including the hospital, 3) the state health department, state laboratory, and public health regional surveillance team, and CDC, 4) the general public, and/or 5) other groups.

Suggested answer: An outbreak report can take many forms. One possible outline is included below.

I. Summary – a brief description of the outbreak and the major outcomes of the investigation

II. Background – information about the disease, including baseline rates in your area, past outbreaks, etc.

III. Outbreak Description – a fairly complete description of the outbreak situation, including the index case, dates of onset, date of report to LHD, steps taken to confirm the outbreak, number of ill persons, a description of who was involved in the investigation, a description of the location of the outbreak, etc.

IV. Methods and Results – a list of the methods used in the outbreak investigation, including the case definition, strategies used for case finding, case management, collection and analysis of laboratory specimens, public health control measures, and communication. A description of the results of these actions should follow the methods. Results may include a geographic representation of the cases, an epi curve, a risk factor analysis, and laboratory findings. This section will probably make up the bulk of the report.

V. Discussion – a brief description of the key aspects of the outbreak, including the hypothesis about the outbreak source

VI. Successes and Lessons Learned – an opportunity to identify areas where the investigation was successful, and areas where mistakes were made. Share lessons that can be applied to future outbreaks

VII. Recommendations – a list of recommendations for control of the current outbreak, prevention of future outbreaks, and outbreak investigations.

VIII. Acknowledgements – a list of the people involved in the outbreak investigation

The following indicators should be included in an outbreak report, if applicable. Since it is important to include the date of occurrence for these events, an outbreak timeline would be a good way to capture all of this information in one place.

1. First clinical observation of disease

2. Diagnosis of disease

3. Laboratory confirmation of disease

4. Identification of exposure source

5. Report to public health authority

6. Report to law enforcement authority

7. Initiation of emergency operation plan

8. Initiation of risk mitigation (i.e. disease control) activities

9. Initiation of post-exposure prophylaxis

10. Initiation of public education activities

11. Initiation of risk advice to healthcare workers

12. Last reported new case

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Group Brainstorm

Choose one member of the epi team to record responses on a flip chart. As a group, discuss one or more of the following questions.

• What aspects of the investigation were successful?

• All outbreaks present unique challenges. What characteristics of this outbreak made it challenging?

• What areas of the investigation could have been improved?

• If a similar outbreak occurred in your county, do you think that your epi team would be prepared to handle it?

• Did your Epi Team communicate effectively with a) the general public/media, b) hospital, c) state health department, and d) CDC?

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[1] Centers for Disease Control and Prevention. Measles, mumps and rubella – vaccine use and strategies for elimination of measles, rubella, and congenital rubella syndrome and control of mumps: recommendations of the Advisory Committee on Immunization Practices (ACIP). Morb Mortal Wkly Rep. 1998;47(No. RR-8):1-57.

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Background

It is Tuesday, January 23rd and you are an employee at a local health department. You are notified by the infection control nurse at the local community hospital that a patient at the hospital has been diagnosed with “possible measles.” The nurse tells you that the patient is a 23 year-old female from India. She first came to the hospital emergency room on January 20th with gastrointestinal symptoms and fever and returned to the hospital the next day with a rash which started on her face and progressed to cover most of her body. She was admitted that evening, and is still hospitalized.

Update 1

You recommend the patient be tested for measles antibodies (IgM and IgG) and that a blood sample be taken immediately to the NC State Laboratory of Public Health to conduct the tests. You also recommend starting appropriate isolation precautions (placing the patient in an airborne infection isolation room, equipping healthcare personnel with appropriate personal protective equipment, etc.) if these are not already in place. Because measles is highly contagious, you should proceed as if she does have the disease, even though confirmatory laboratory results are not yet available.

The infection control practitioner tells you more about the patient, Pina, who recently moved with her husband and infant daughter to the United States from India. She arrived in North Carolina on January 15th, and attended a welcome party on January 16th. Since the party, she has stayed at home with her 5 month old infant while her husband looks for work. Her fever began on January 17th.

Update 2: January 25th

You receive the results from the NC State Laboratory of Public Health. The patient tested positive for both IgG and IgM antibodies, confirming that she does have measles.

Update 3: January 26th

You call a meeting of your Epi Team, and identify the tasks that must be accomplished immediately. First, you decide to conduct active case finding to locate other potentially sick people in the community. You learn from the patient’s husband that there were about 45 people present at the welcome party on January 16th.

Update 4: January 26th

While you and your team are busy tracking down exposed individuals, a reporter from the local newspaper calls you and asks for a statement about the measles case. News about the case has spread, and people in the community are beginning to panic. At this point, there is only one sick individual, but potentially dozens of people who have been exposed to the disease.

Update 5: January 27th

Your Epi Team has been busy conducting interviews with the people who were in the hospital emergency room, and the 45 individuals present at the welcome party, including the patient’s husband and child. None of the people you have contacted so far are currently displaying symptoms.

Update 6: February 2nd

On January 28th, Pina’s 5 month-old daughter began exhibiting symptoms of measles, including a cough, fever and rash. The child was treated with Vitamin A supplements and kept in airborne isolation until yesterday. You followed up with the child’s contacts, but no other cases have been detected. Pina, the original patient, has recovered without any major complications.

Together with the hospital and members of your regional surveillance team, your Epi Team contacted 305 potentially exposed persons, and administered 165 MMR vaccinations.

Conclusion: February 8th

In all, there were only 2 cases of measles associated with this outbreak: Pina, the index case, and her 5-month old infant daughter. Both recovered without complications. Now your Epi Team is meeting to discuss the outbreak investigation.

Reminder

As the facilitator, you are the only team member with the suggested answers to discussion questions and activities. Other Epi Team members have only the scenario updates and questions.

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Patient diagnosed with possible measles. Case reported to health department

Index case returns with rash

Media contacts health department

Index case visits hospital

Index case arrives in US

Symptom onset for index case

Welcome party

Lab confirms measles

Patient diagnosed with possible measles. Case reported to health department

Daughter of index case develops symptoms

Lab confirms measles

Welcome party

Symptom onset for index case

Index case arrives in US

Patient diagnosed with possible measles. Case reported to health department

Index case visits hospital

Index case returns with rash

Lab confirms measles

Welcome party

Symptom onset for index case

Index case arrives in US

Patient diagnosed with possible measles. Case reported to health department

Index case visits hospital

Index case returns with rash

Media contacts health department

Media contacts health department

Welcome party

Patient diagnosed with possible measles. Case reported to health department

Lab confirms measles

Symptom onset for index case

Index case arrives in US

Index case visits hospital

Index case returns with rash

Epi team conducts interviews and provides vaccinations

Media contacts health department

Patient diagnosed with possible measles. Case reported to health department

Welcome party

Lab confirms measles

Symptom onset for index case

Index case arrives in US

Index case visits hospital

Index case returns with rash

Daughter of index case develops symptoms

Index case arrives in US

Symptom onset for index case

Welcome party

Epi team conducts interviews and provides vaccinations

Patient diagnosed with possible measles. Case reported to health department

Index case visits hospital

Index case returns with rash

Epi team conducts interviews and provides vaccinations

Media contacts health department

Patient diagnosed with possible measles. Case reported to health department

Welcome party

Lab confirms measles

Symptom onset for index case

Index case arrives in US

Index case visits hospital

Index case returns with rash

Patient diagnosed with possible measles. Case reported to health department

Index case visits hospital

Index case returns with rash

Welcome party

Lab confirms measles

Symptom onset for index case

Index case arrives in US

Index case visits hospital

Index case returns with rash

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