Student Aid for Field Epidemiology Response SAFER

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Student Aid for Field Epidemiology Response
(SAFER)

• Outbreak Response Training
• (AKA - Will I get to wear one of those cool
  hazard suits?)

Kristen Pogreba-Brown, MPH
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What is SAFER??

• A group of enthusiastic public health graduate
  students who are interested in learning more
  about how local health departments conduct
  outbreak investigations and who are available to
  take part in emerging and continuing disease
  investigations with public health professionals

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Background on the Team

• Needs assessment of local health departments
• Summary of interview findings
• Program development
• Pilot of course with student
• Establishment of an outbreak response course tied
  to team membership

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Program Synopsis

• Team membership
• Including eligibility criteria and an application
  process
• Required training on surveillance and outbreak
  response at ADHS
• Student participation in outbreak response class
• ICS 100 and ICS 700 training required
• Advisory group
• Steering committee with representatives from all
  partnering agencies
• Response Notification Systems
• Request for team participation from health
  departments
• Response from program coordinator to health
  departments
• Evaluations Systems
• Student training evaluations
• Agency evaluations of student participations
• Student evaluation of agency and experience
  following response

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Class Description

• Interactive seminars that bring in public health
  professionals to share their investigation
  experiences with the students
• Outbreak Activities
• Short-term projects for returning students
• Fun, Fun, Fun!

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Training Sessions

• Arizona Department of Health Services (Infectious
  Epidemiology Division)
• Students must complete a full day training
  session covering the basics of surveillance,
  reporting procedures and how different types of
  outbreak investigations are conducted
• Maricopa County Health Department
• Focuses on food borne outbreak investigations and
  interviewing skills
• Pima County Health Department
• Introduction to local health department,
  conducting interviews from a call center, and
  Incident Command structures and the EOC

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What would I do with SAFER?

• Interviews
• Helping to create questionnaires and conducting
  interviews either in person or over the phone
• Data Management
• Data entry, analysis and follow-up
• Communicating with the public
• Answering questions about the recent outbreak and
  public health in general
• Sample collection and transportation
• Conducting case-control studies
• Taking part in public health preparedness drills
• Become VERY comfortable discussing peoples
  bathroom experiences

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Activation of the Team
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What happens when the state calls?

• Email
• Calls
• Response

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What has SAFER done in the past?

• Pertussis outbreak in Pima County
• Norovirus outbreak at a local assisted care
  facility
• Case-Control of possible food borne outbreaks
  with Maricopa County Health Department
• Norovirus outbreak at the Grand Canyon
• Hepatitis A outbreak investigation with ADHS
• Mass vaccination drill with the University
  (upcoming)

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Can I Join?

• Do disease outbreaks interest you?
• Did you see Outbreak? Did you say Do scientists
  really chase monkeys like that?
• Do you ever wonder what actually takes place at a
  health department during an outbreak?
• Do you want to get some real world experience?
• Interviews
• Show your family one thing you could do with your
  future MPH
• Impress future dates (because, come on, who isnt
  turned on by learning all about a recent bout of
  Salmonella suffered by the masses)?

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What is required to join?

• Completion of Epi(a) and Biostats(a)
• OR the permission of the instructor
• Training sessions at ADHS, Maricopa and Pima
  Counties

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Details

• If youre interested for next semester
• We will be having two training sessions a year so
  anyone that would like to join next semester is
  welcome to come then
• The team will be more formally linked to a 1 unit
  class (tentatively called Public Health
  Experience) so keep your eyes open on your email
• The first class will be September 8th from 10-12
  (room A122)!

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QUESTIONS???

• Kristen Pogreba-Brown
• kpogreba_at_email.arizona.edu
• Dr. Robin Harris
• rharris_at_azcc.arizona.edu

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Norovirus Investigations with Maricopa County
Health Department
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3 Separate Outbreaks

• Assisted Care Facility X
• Assisted Care Facility Y
• School Z

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Assisted Care Facility X

• In late May of 2005 the doctor on call was paged
  by a local fire department who reported
  transporting three ill residents from a senior
  apartment complex to the local hospital. They
  reported that other residents at the complex were
  ill with the same gastrointestinal symptoms.
• An investigation was initiated, and the apartment
  manager was contacted. A line list of ill
  residents was provided by the facility two days
  later and interviews were conducted by
  Epidemiology staff as well as students from the
  Student Epidemiology Response Team. Over the
  course of the outbreak, 58 residents and 2 staff
  members were reported ill.

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Assisted Care Facility X

• Cases (15 Interviews)
• 5 Confirmed
• 15 Probable
• 42 Suspect
• 10 of the cases were hospitalized with no deaths
• Demographics
• Age Range 18-97 (Median 80 years old)
• 27 Male/73 Female

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Outbreak Details

• Attack Rate 52 (62/120)
• Illness Duration
• Median 30 hours
• Mean 47 hours
• Range 2-184 hours
• Symptoms
• Diarrhea, cramps, vomiting, malaise, nausea,
  chills, body aches, weakness, fever, headache,
  anorexia

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What SAFER did?

• Conducted a case-control study
• Interviewed cases
• Interviewed controls
• We were able to make phone calls from Tucson,
  which made responding to the outbreak much easier
• Lots of faxes!

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What happened next?

• The infection control practitioner (ICP) at the
  local hospital was contacted and provided
  information on the residents seen in the
  emergency department (ED) and admitted to the
  hospital. A total of ten residents were admitted
  to the hospital during the outbreak, another
  three residents were seen in the ED.
• Environmental Services (ES) inspected the complex
  kitchen. They noted that at that time the dining
  room had been closed and all meals were being
  delivered to residents in their rooms. ES
  advised that all kitchen and dining room contact
  services be sanitized with bleach solution, this
  was done. The inspector was also informed that
  the head chef had been ill with gastrointestinal
  symptoms on the day before the outbreak and one
  server had called into work ill on the same day
  with similar symptoms. The chef did come to
  work, but was restricted to doing paperwork that
  day and did not handle any food in the kitchen.

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Conclusions

• The outbreak was attributed to Norovirus
  (laboratory confirmed with 5/9 samples sent to
  state lab)
• Exact route of transmission could not be
  determined from the available data
• Kitchen staff were reported ill the day before
  the residents became ill, but person-to-person
  transmission among the residents can not be ruled
  out.

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Assisted Care Facility Y

• Three days before the earlier outbreak at
  Facility X, a social worker from the local
  hospital reported that eight residents of a
  senior living apartment complex were seen at the
  emergency department (ED) for gastrointestinal
  illness. The manager of the apartment complex
  was contacted by Epidemiology staff who
  discovered that the facility was an independent
  senior apartment complex that had an on-site
  dining room and an activities area.

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Investigation continues

• The staff stated they had surveyed the complex
  (n197 apartments) and identified eight residents
  with gastrointestinal illness, of those, four
  were seen at the local ED and one had been
  admitted.
• The dining room had been closed to be thoroughly
  cleaned and sanitized meanwhile all meals were to
  be delivered to residents rooms. The complex
  initiated the meal deliveries before being
  contacted by Epidemiology staff. Activities were
  also temporarily suspended, with staff instructed
  to clean and sanitize all common areas. Ill
  residents were instructed to remain in their
  rooms.
• The next day, a line listing was provided from
  the facility with 31 residents and 3 staff
  reported ill. This line list was faxed to the
  University of Arizona where Student Epidemiology
  Response Team and team members interviewed 14
  cases and 11 controls. The team also requested
  stool specimens from cases interviewed, but none
  were obtained.
• Residents from both facilities were known to
  interact with one another.

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Assisted Care Facility X

• Cases (14 Interviews)
• 0 Confirmed
• 14 Probable (7 went to ED, 1 hospitalized)
• 43 Suspect
• 1 of the cases were hospitalized with no deaths
• Demographics
• Age Range 74-94 (Median 85 years old)
• 43 Male/57 Female

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Conclusions

• Case control was done, however no food was able
  to be isolated as the causative agent
• The etiology of the outbreak was not confirmed
  because no stool samples were collected, however,
  the transmission and symptoms were consistent
  with Norovirus.

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School Z

• Again, in late May 2005 a report was received
  from a Gilbert school nurse who reported an
  outbreak of gastrointestinal illness among a
  group of 6th grade children who had taken an
  overnight field trip to a science camp in
  Prescott.
• A line listing of the ill children was received
  and the school nurse stated that all ill children
  would be excluded from school for at least 24
  hours. One child was reportedly ill almost as
  soon as the camp was reached and the other
  children became ill the next day.
• A total of 32 children were reported ill.
• Yavapai county Environmental Services (ES) was
  notified, and they inspected the camp. No other
  illnesses had been reported at the camp. The
  camp provided food, however the parent/chaperones
  were in charge of preparing the meals. The
  Student Epidemiology Response Team was contacted
  and conducted interviews with a sample of the ill
  childrens parents.
• In all fifteen questionnaires were completed.

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School Z

• Cases (15 Interviews)
• 1 Confirmed
• 15 Probable
• 13 Suspect
• Demographics
• Age Range 11-13 (Median 12 years old)
• 66 Male/34 Female

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Conclusions

• Three stool specimens were sent to the state lab
  for analysis. Two were negative but one was
  positive for Norovirus, Miami Beach strain.
• One child was sick upon reaching the camp and it
  is highly likely that the illness was spread
  person-to-person.