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Outbreak Scenario Outbre tbreak ak Scenario enario Based d on an outbrea eak k that occurred rred in the Nether erla lands ds Objecti ectives ves Section 1 Logistics Identify the initial steps and sequence of events of an

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SLIDE 1

Outbreak Scenario

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SLIDE 2

Background Scenario Investigation

Section 1

Response

Outbre tbreak ak Scenario enario

Based d on an outbrea eak k that occurred rred in the Nether erla lands ds

Objecti ectives ves

 Identify the initial steps and sequence of events of an outbreak investigation and response to a disease of unknown origin in a local community  Recognize the professionals and organizations involved during an interprofessional and multiagency outbreak investigation and response involving a potential zoonotic disease of agricultural

  • rigin

 Identify the different mechanisms of disease transmission that could allow a zoonotic pathogen of agricultural origin to reach a community  Ascertain the potential impact on human health (as well as agriculture) that an outbreak like this could have  Recognize One Health principles to manage and prevent the zoonotic transmission of agricultural related agents to the community

Logistics

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SLIDE 3

Background Scenario Investigation

Section 1

Response

Outbre tbreak ak Scenario enario

Based d on an outbrea eak k that occurred rred in the Nether erla lands ds

Dynamic amics: s:

  • Information will be shared with you in as the
  • utbreak progesses
  • At several intervals, questions will be presented and

you will have 5 minutes to discuss them at your table

  • Moderators at each table will keep the conversation

moving and provide necessary background information

  • Select a spokesperson at each table, as random

tables will be asked to present their conclusions Logistics

= question slide to be discussed

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SLIDE 4

Scenario Investigation Logistics Response

Outbre tbreak ak Scenario enario

You u are a public lic healt alth h offic ficial ial worki rking ng for r Bucke ckeye ye Count unty y Healt alth h Distr strict ict (BCHD CHD).. )...

Background

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SLIDE 5

You are a public health

Background Situation Investigation Logistics Response

Outbre tbreak ak Scenario enario

Scenario  Since May 16, 40 students and 5 staff members have been absent due to flu-like symptoms at Northside Elementary School

  • Two staff members

were hospitalized with pneumonia

Friday, day, May 18 - 9:30am 0am

School Nurse Call to BCHD

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SLIDE 6

You are a public health

Background Situation Investigation Logistics Response

Outbre tbreak ak Scenario enario

Scenario Last three days: have seen 7 patients complaining of:

  • Fever, Cough, & Chest pain
  • Severe headache (retrobulbar)

Diagnosis:

  • Community Acquired Pneumonia
  • 2 patients hospitalized & not

improving

  • Patients seen this morning are

worsening Tests:

  • Influenza virus – Neg.
  • Sputum & blood cultures - Neg. for

common causes of pneumonia

Friday, day, May 18 - 11:00 00 AM

Call to BCHD

Ruby Dolor

Infection Preventionist at Smallville Hospital
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SLIDE 7

You are a public health

Background Situation Investigation Logistics Response

Outbre tbreak ak Scenario enario

Scenario May 16:

  • 2 residents developed pneumonia

May 17:

  • 3 residents developed pneumonia
  • All cases being managed in-house

Tests:

  • Influenza virus – Neg.
  • Sputum & blood cultures – Neg. for

common causes of pneumonia

  • Legionella urine antigen test – Neg.

Friday, day, May 18 - 2:30 0 PM

Call to BCHD

Greis Nursing Home

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SLIDE 8

Outbre tbreak ak Scenario enario

Northside Elementary Greis Nursing Home Greis Nursing Home is located a few blocks from the Northside Elementary School

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SLIDE 9

IS THIS S A PUBLIC IC HEALTH LTH CONCERN CERN THAT T REQUIRE UIRES S FURTHER THER ATTENTI ENTION? ON? WHY OR WHY NOT?

You have 5 minutes to discuss among your table…

Outbre tbreak ak Scenario enario

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SLIDE 10

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 11

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 12

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 13

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 14

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 15

YES! S!

In many states, any unexpected pattern of suspected/ confirmed cases, deaths or increased incidence of any

  • ther unknown disease of major public health concern

should be reported. In our current scenario the combined calls received by this local health department represent an increased incidence in an unidentified illness and therefore reportable, requiring an action by the LHD. The number of similar cases reported from these locations represent an increased incidence of an unidentified illness

Outbre tbreak ak Scenario enario

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SLIDE 16

AT THIS S POINT T IN TIME, E, WHAT T WOULD LD BE THE APPROPR ROPRIATE ATE RESPONS PONSE E FOR THE LOCAL L HEALTH LTH DEPAR ARTMENT? TMENT?

You have 5 minutes to discuss among your table…

Outbre tbreak ak Scenario enario

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SLIDE 17

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 18

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 19

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 20

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 21

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 22

Outbre tbreak ak Scenario enario

Case Distribution Infection Control

Contact Info Report to State

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SLIDE 23

Outbre tbreak ak Scenario enario

An Any y pr priv ivacy acy co conc ncerns erns wh when en co coll llecting ecting th this is in info formation? rmation?

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SLIDE 24

Outbre tbreak ak Scenario enario

Except under the following circumstances

  • School officials with legitimate educational interests
  • Other schools to which a student is transferring
  • Specified officials for audit or evaluation purposes
  • Others, but at the discretion of school officials

Federal Educational Rights and Privacy Act (FERPA)

This law prohibits release of student’s records without written parental consent except under certain circumstances

Health Insurance Portability and Accountability Act (HIPPA)

This law protects individual identifiable health information while permitting the disclosure of information needed for direct patient care HIPAA recognizes the legitimate need for those ensuring public health and safety to have access to this information to carry out their public health mission

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SLIDE 25

You are a public health

Background Scenario Logistics Response

Outbre tbreak ak Scenario enario

Investigation

  • A suspect case definition is

established and an outbreak investigation begins

  • A Public Information Officer

(PIO) has been designated and preliminary information is being compiled to distribute to community stakeholders

  • You prepare to continue

interviews and staff phone lines

  • ver the weekend if necessary

Friday, day, May 18 - 4:30 0 PM

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SLIDE 26

What t kinds ds of informa

  • rmation

tion will l you request uest from the patient ients s during ing your r intervi erviews? ews? What t questio stions ns will l you ask to find d the cause e of the symptom ptoms? s?

You have 5 minutes to discuss among your table…

Outbre tbreak ak Scenario enario

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SLIDE 27

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 28

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 29

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 30

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 31

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 32

Outbre tbreak ak Scenario enario

  • Demographic questions (age, gender, race)
  • Other health conditions
  • Places visited (work, school, shops, library, etc.)
  • Symptoms--types, onset date, duration
  • Vaccination history
  • Occupational exposure
  • Contact with people who are ill
  • Animal/Livestock exposure
  • Any recent travel (national, international)

Qu Ques estions tions to to As Ask

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SLIDE 33 Initial calls to LHD about
  • utbreak of
respiratory disease of unknown cause

May 20

Onset of symptoms for first cases More cases
  • reported. Initial
interviews reveal all cases localized to the school, nursing home and surrounding area Press Release

May 22

Investigators report results of initial interviews and request further tests Sample submission

Timeline meline of Even vents ts

May 18 May 16 May 21

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SLIDE 34

You are a public health

Background Scenario Logistics Response

Outbre tbreak ak Scenario enario

Investigation Typical pathogens that cause Community Acquired Pneumonia (CAP)

  • Bacterial (85% of CAP): Streptococcus pneumoniae,

Haemophilus influenzae, Moraxella catarrhalis

  • Viruses: Influenza A and B, parainfluenza viruses,

respiratory syncytial virus, adenovirus

  • Pneumonia not caused by one of these bacteria or

viruses is considered atypical and usually caused by: Chlamydia pneumoniae, Legionella pneumophila, Histoplasma capsulatum, Mycoplasma pneumoniae

Tests ts

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SLIDE 35

You are a public health

Background Scenario Logistics Response

Outbre tbreak ak Scenario enario

Investigation In cases where tests for all these pathogens are negative, less common cause of pneumonia include Q fever (C. burnetti), Hantavirus, Tularemia (Francisella tularensis) and endemic fungi among others should be investigated.

Tests ts

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SLIDE 36

You are a public health

Background Scenario Logistics Response

Outbre tbreak ak Scenario enario

Investigation

Coxiella Burnetti (Q-Fever)

  • Bacterial zoonotic disease

Transmission from livestock

  • Inhalation, ingestion, exposure to

broken skin or mucus membranes

  • Found in birth associated fluids and

tissues, unpasteurized milk products, contaminated soil and bedding

  • Human to human transmission unlikely

Clinical signs

  • Fever, muscle pain, malaise, headaches,

atypical pneumonia, hepatitis, or meningoencephalitis

  • 40% of exposed will develop signs

Samples ples Positive tive for C. . burnett netti

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SLIDE 37

What t informa

  • rmation

tion would ld you want t to provide vide to the public lic about ut the situati uation

  • n at this

s point nt and their ir chance nce of getting ing sick? k?

You have 5 minutes to discuss among your table…

Outbre tbreak ak Scenario enario

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SLIDE 38

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 39

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 40

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 41

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 42

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 43

Outbre tbreak ak Scenario enario

What is going on?

  • An outbreak of pneumonia

caused by Q fever has occurred at Northside Elementary School and Greis Nursing Home in Smallsville What is Public Health doing?

  • Continuing the investigation
  • Identified the cause
  • Working to determine the source
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SLIDE 44

Outbre tbreak ak Scenario enario

What is my risk?

  • Most commonly contracted from contact with

infected livestock, consumption of unpasteurized milk or milk products, or exposure to contaminated dust

  • Unlikely to be transferred human to human

What should I do?

  • Anyone with symptoms should contact their family

physician to determine if they should be tested Make sure you are consistent and clear with messages to the public — designate a spokesperson!

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SLIDE 45

You are a public health

Background Scenario Logistics Response

Outbre tbreak ak Scenario enario

Investigation

Q-Fever is a Class B Bioterrorism agent and is also zoonotic Class B Bioterrorism Agent:

  • Second highest priority
  • Moderately easy to disseminate
  • Result in moderate morbidity rates and low mortality

rates

  • Require specific enhancements of CDC’s diagnostic

capacity and enhanced disease surveillance

Class ss B Bioterro errorism rism Agent nt

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SLIDE 46

As this s is a z zoonoti notic c bioterr terroris

  • rism

m agent, nt, what t agencie ncies s should uld be include luded d to the investi estigati gation

  • n team?

m?

You have 5 minutes to discuss among your table…

Outbre tbreak ak Scenario enario

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SLIDE 47

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 48

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 49

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 50

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 51

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 52

Outbre tbreak ak Scenario enario

  • Local law enforcement/ FBI to initiate a Threat

Credibility Evaluation

  • BCHD/SDH to investigate potential food borne and
  • ther sources of infection
  • SAHO/USDA should be contacted to investigate

possible animal exposure

  • Schedule a conference call with BCDH, SDH, CDC,

FBI, SAHO, USDA-APHIS-VS

Agency ncy Invol

  • lvement

vement

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SLIDE 53

You are a public health

Background Scenario Logistics Response

Outbre tbreak ak Scenario enario

Investigation Conference call with:

  • BCDH: Buckeye County Department of Health
  • SHD: State Health Department
  • CDC: Centers for Disease Control and Prevention
  • FBI: Federal Bureau of Investigation
  • SAHO: State Animal Health Office
  • USDA-APHIS-VS: United States Department of

Agriculture - Animal and Plant Health Inspection Service - Veterinary Services

Who are these e Agenc ncie ies?

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SLIDE 54

You are a public health

Background Scenario Logistics Response

Outbre tbreak ak Scenario enario

Investigation

  • Are there known groups displaying behavior indicating a

motive or resolve to carry out an attack?

  • Do the operational aspects of the attack make it possible?
  • Do the technical aspects make an attack feasible?

FBI FBI - Threat eat Credibi dibility lity Evaluat luation ion

These cases were not consistent with bioterrorism

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SLIDE 55

You are a public health

Background Scenario Logistics Response

Outbre tbreak ak Scenario enario

Investigation

  • Revise case definition based on new information
  • Revise questionnaire with more details about potential

source exposures such as livestock and raw milk product consumption

  • Re-interview all cases

Public lic Healt lth h – Source rce Investi estigati gation

  • n

Public Health found no evidence of a food borne source

  • r direct contact with livestock animals or their products
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SLIDE 56

What t steps ps should ld SAHO/US O/USDA DA take e to investi estigate gate this s outbrea break? k?

You have 5 minutes to discuss among your table…

Outbre tbreak ak Scenario enario

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SLIDE 57

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 58

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 59

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 60

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 61

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 62

Outbre tbreak ak Scenario enario|Based on Real Events

  • Examine records at their diagnostic lab – have there

been cases of Q fever diagnosed in the previous 6 months?

  • Contact local veterinarians – any increase in Q fever

cases in livestock in previous months?

  • Identify farms within a few miles of the cases and ask

farmers about herd health, reproductive problems, and manure handling practices

  • Identify environments that could be contaminated

with the pathogen

SAHO/ O/US USDA DA-An Animal imal Source rce Investi estigati gation

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SLIDE 63

You are a public health

Background Scenario Logistics Response

Outbre tbreak ak Scenario enario

Investigation

How did this happen? pen?

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SLIDE 64 Initial calls to LHD about
  • utbreak of
respiratory disease of unknown cause

May 20

Apr 30

Farmer A spreads manure on fields. Weather has been dry for the last two
  • weeks. Today is
windy. Onset of symptoms for first cases

Feb- Mar

Farm A experience problems with high rate of abortion in sheep flock More cases
  • reported. Initial
interviews reveal all cases localized to the school, nursing home and surrounding area Press Release

May 22

Investigators report results of initial interviews and request further tests Sample submission Samples positive for Q fever Conference call with BCDH, SDH, CDC, FBI, SAHO, USDA- APHIS-VS SAHO begins site visits at farms visited by patients and farms with 3 miles of the
  • utbreak location . Discovers
events at Farm A Press issued. Public Information Officer appointed to handle public inquires Q fever confirmed in sheep from Farm A Cooperating agencies meet to discuss findings.

Timeline meline of Even vents ts

May 23 May 18 May 16 May 21 May 25 May 27

Human – Public Health Response Animal – Agricultural Response

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SLIDE 65

Outbre tbreak ak Scenario enario

Northside Elementary Greis Nursing Home

5 10 15 20 25 5/16/2012 5/17/2012 5/18/2012 5/19/2012 5/20/2012 5/21/2012 5/22/2012 5/23/2012 5/24/2012 5/25/2012 5/26/2012 5/27/2012 5/28/2012 5/29/2012 5/30/2012 5/31/2012 6/1/2012 6/2/2012 Number of Cases Date Of Symptom Onset Distribution of Cases by Date of Symptom Onset

Farm A

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SLIDE 66

What t prevent vention ion and control trol measure sures would ld you recommen mmend d (human man and animal)? mal)?

You have 5 minutes to discuss among your table…

Outbre tbreak ak Scenario enario

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SLIDE 67

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 68

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 69

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 70

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 71

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 72

Outbre tbreak ak Scenario enario

Prevent vention ion and Control trol Measure sures

  • Public Health and prevention messaging
  • Continue surveillance of human cases
  • Agricultural Response
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SLIDE 73

You are a public health

Background Scenario Investigation Logistics Response

Outbre tbreak ak Scenario enario

Response

  • Provide frequent updates to the media on the

current investigation and disease prevention

  • Raise awareness through outreach to local

partners

  • Local physicians and veterinarians
  • Extension agents, 4-H groups
  • Farm Bureau
  • Provide fact sheets on Q fever and other easily

accessible information on websites, social media, via stakeholders Public lic Healt lth h and Prevent vention ion Messagi saging ng

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SLIDE 74

You are a public health

Background Scenario Investigation Logistics Response

Outbre tbreak ak Scenario enario

Response

  • Identify and investigate new cases
  • Discover past cases which meet the case definition for this
  • utbreak, with specific emphasis on trying to identify Chronic

Q-Fever

  • Summarize the outbreak and make recommendations to

prevent future outbreaks

Continu tinue e Human n Disease ease Surveil veillanc lance

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SLIDE 75

You are a public health

Background Scenario Investigation Logistics Response

Outbre tbreak ak Scenario enario

Response

Contact livestock producers to provide education on Q fever and prevention of transmission to humans. Special focus on:

  • Composted manure, birthing material and carcasses
  • If composting is not possible:
  • Cover manure when transported
  • Only spread on non‐windy days
  • Immediately plow into soil
  • Follow local regulations in regards to spraying manure
  • Additional recommendations are provided in the

NASPHV Q-Fever compendium

Agricul icultura tural Respons ponse

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SLIDE 76

You are a public health

Background Scenario Logistics Response

Outbre tbreak ak Scenario enario

Investigation

  • Q fever can’t be effectively treated in animals
  • Most do not show signs
  • The pathogen is ubiquitous and persistent in the

environment

  • SAHO might have the authority to quarantine animals

when he/she believes there is a dangerously contagious or infectious disease present

  • It is incredibly unlikely that a SAHO would quarantine a

farm for Q fever, because such quarantine could not be lifted as the disease cannot feasibly be eliminated from the farm

How do we Manage ge the Infecte ected d Animal mals

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SLIDE 77

What t did you learn rn from m this s scenari nario

  • about

ut invest estigat igation ion of a zoonoti notic c disease ease outbreak reak?

You have 5 minutes to discuss among your table…

Outbre tbreak ak Scenario enario

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SLIDE 78

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 79

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 80

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 81

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 82

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Countdown Clock By Dr. Jeff Ertzberger
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SLIDE 83

Outbreak Scenario

  • Many emerging infectious diseases are zoonotic
  • Potential for bioterrorism attack using zoonotic agent
  • Importance of communicating across disciplines
  • Cooperation between human public health officials and veterinary

public health officials!

  • Importance of being familiar with steps in outbreak investigation

Key Points from the Scenario

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SLIDE 84

Outbreak in the Netherlands

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SLIDE 85

Outbre tbreak ak Scenario enario

Armando E. Hoet, Joanne Midla, Jeanette O’Quin, Jason Stull, Suzanne Tomasi, Wendy Lehman, and the Ohio One Health Alliance working group

Developmen velopment t Team eam

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SLIDE 86

Outbreak Scenario

Questions?