Transcript Managing a meningococcal infection outbreak An exercise in

Management of a Disease Outbreak
Meningococcal Infection at a High School
Luc Van Parijs, MD, MPH, DrPH
[email protected]
The author is a scholar
of the North East
Public Health
Leadership Institute,
Class of 2000.
• This lecture is one of series produced by the
Allegheny County Health Department (PA),
Bethlehem Health Bureau (PA) and the City
of Elizabeth Department of Health &
Human Services (NJ).
• The organizers of this project are scholars in
the Northeast Regional Public Health
Leadership Institute, Class of 2000. For
information contact:
[email protected]
Luc G Van Parijs, MD MPH DrPH
• Public health physician - till recently Director of the
Division of Communicable Disease Control of a local
health department - with strong interest in disease reporting
and the management of disease outbreaks. For 25 years
epidemiologist and manager of national and international
prevention programs (heart disease, cancer, STD and
leprosy). Extensive experience in teaching African and
Asian health care providers.
Learning Objectives
– Know clinical and epidemiological features of
meningococcal infection
– Know steps in outbreak control and required outcomes
– Appreciate need to work together with key persons
– Understand public perception/response to outbreak
– Understand relationship of leadership to success in
controling an outbreak
Performance Objectives
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list key features of meningococcal infection
articulate outcomes of a control strategy
discuss factors that influence control strategy
provide consistent response to questions about
meningococcal infection
– act timely and consistently in a crisis situation
INTRODUCTION
This lecture is an exercise in leadership analysis. It
provides a unique perspective of analyzing a disease
outbreak from the perspective of:
* Clinical & Epidemiological Factors
* Public Health Response
* Leadership
Leadership is often overlooked in successful disease
outbreak management. The lessons learned from this
case are applicable to other outbreak situations
Clinical and
Epidemiological
Features
Meningococcal infection -1
• Bacterial (pathogenic) agent
– Neisseria meningitidis with multiple
serogroups (A, B, C, Y, W…). In US mainly
B, C and Y ( ~ 30% each)
• Two clinical forms
– Meningitis, meningococcemia or combined
• Onset & Progression
– Abrupt, strikes healthy individuals without
warning
– Case fatality Rate (CFR): meningitis ~10%,
meningoccemia > 80%
Meningococcal Infection -2
• Incidence LOW, ~ 1 case
per 100,000 US population,
but public concern HIGH
• All ages affected. Highest
rates in < 5 yr; more cases
in winter/early spring
• Serotypes by age group:
B > in infants, C > in
young people/adults, Y
>in older people
• In outbreaks: usually
serogroup C
• 10-15 % carriage in
nose/throat of healthy
individuals (colonization
of mucosa). However,
unknown why a carrier
develops invasive disease
• Risk factors: crowding
(army barracks, college
dorms, parties), immune
disorders, smoking,
respiratory infections,
climate, poverty
Meningococcal Infection -3
• Prevention
• Treatment
(1) Chemoprophylax
(Rifampin/Ciprofloxacin)
close contacts exposed to
case; it clears pathogen in
24-48 hrs
(2) Vaccinate (Menomune)
people at high risk to
prevent spread of
infection; it induces active
immunity but with a lag
period of 10 days,
indicated if case rate
10/10,000 in < 3 months
in same setting
(1) Early Dx & prompt Rx of
case reduces CFR &
sequellae
(2) Intensive & supportive
hospital care, including
anti-microbial drugs
(3) Prompt reporting of case
to health department (HD)
(4) HD (and health care
provider) initiates
prevention
Public Health
Response
Main Events
• Two cases of meningococcal infection at a large
high school in three weeks
• First case (boy 17 yrs)
– survived
– close contacts prophylaxed
• Second case (girl 16 yrs)
– died
– close contacts prophylaxed
– students and staff of high school vaccinated (1 week
later)
– Intensive media coverage
Case 1: Chronology of Events
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3/9 (Thu) case reported ill at school & sent home
3/16 (Thu) onset symptoms & hospitalization
3/17 (Fri) case reported to health department (HD)
3/18 (Sa) laboratory confirmation of meningitis
3/19 (Su) serogroup C identified
3/19 (Su) school principal informed by HD and
HD establishes a preliminary list of close contacts
• 3/20 (Mo) case discharged with no sequelae
• 3/20 (Mo) HD staff meets with senior staff of high
school and hospital-based physician to review
situation & reach consensus on control strategy
Case 1: Control Strategy
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General meeting with staff and students
Prepare and send letter to parents
Start chemoprophylax of close contacts
Answer questions of parents, local
physicians and media at an evening town
hall meeting at school
Case 1: Expected Outcomes -1
• Accurate and timely information to alleviate fears,
and obtain compliance with control measures
– Audience: high school students, parents and staff;
health providers in local area; media
– Subjets: meningococcal disease, events at school and
control strategy
– Means: general meeting, town hall meeting, general
letter, response to phone calls
Case 1: Expected Outcomes - 2
• Composition of a “response” team with key
persons to initiate control measures
– Define tasks and responsibilities of school, health
department, and health care providers
– Assign a spokesperson(s) for consistency of messages
– Share resources (staff, rooms, medications, calls)
– Act quickly & decisively, but keep calm & in touch
with events
Case 2: Chronology of Events-1
• 4/8 (Sa): abrupt onset of disease, patient
hospitalized, rapid progression of disease, transfer
patient same day to tertiary facility but fatal
outcome (4/9) despite intensive medical efforts
• 4/8 (Sa): case reported to HD
• 4/8 (Sa): school principal informed by HD
• 4/9 (Su): list of possible close contacts composed
• 4/10(Mo): meeting HD staff with school staff &
hospital physician to review events & decide on
strategy
Case 2: Chronology of events-2
• 4/10 (Mo): info-meeting with school staff
and students
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4/10 (Mo-evening): town meeting with parents
4/11(Tu): start chemo prophylaxis of close
contacts at school (family contacts prophylaxed
at hospital on 4/8)
4/10 (Mo) and onwards: daily queries from
media; coverage of events on TV, radio and in
newspapers
Case 2: Chronology of Events -3
• 4/13 (Thu): confirmation of serogroup C
• 4/13 (Thu): communication HD with State HD
about outbreak criteria and advisability to initiate
vaccination of high school community
• 4/14 (Fri): telephone conference HD, State HD &
CDC to decide on vaccination
• 4/14 (Fri): meeting at high school to discuss
rationale for vaccination and develop a
vaccination plan.
• 4/14 (Fri): composition and diffusion of press
release by County Health Department
Case 2: Chronology of Events -4
• 4/15 (Sa): high school open for parents to obtain
vaccination consent forms & ask questions
• 4/16 (Su): town meeting to explain vaccination
(why, who, when) & answer questions/concerns
• 4/17 (Mo) through 4/19 (We): vaccination of
students and staff (n= 1,997) at cost of $ 134,000.
Some vaccinations by private physicians
• From 4/10 onwards active surveillance by HD to
detect possible meningococcal cases. No new
cases reported.
Case 2: Control Strategy -1
• Clarify scientific foundation of recommendation
to vaccinate
• Prevent panic and false rumors among students
and staff
– Timely informed by school principal who appealed to
calm despite tragic event & to positive attitude towards
preventive measures (prophylaxis and immunization)
• Deal with parental anxiety and obtain compliance
with vaccination effort
– Team presented facts and decisions at town meeting
with room for discussion of concerns and
disagreements
Case 2: Control Strategy -2
• Media
– Assigned same spokes-persons for media
queries and had key points prepared
– Assured that all staff adhered to the same key
messages when dealing with parents, students,
phone calls from the community
– Team showed attitude of cooperation with
media and stayed calm under intense scrutiny
Ingredients of a Public Health
Response
1. Adhere to scientific understanding of disease and
control measures
2. Compose a team with key leaders to deal with
crisis
3. Pay close attention to community and media
reactions
4. Plan chemoprophylaxis and vaccination and act
swiftly and decisively
5. Check for new cases. There was no third case
Leadership in
managing an outbreak
The situation
• Two meningitis cases occurred in a large,
prestigious high school
• The outbreak received high priority: staff and
resources were made available
• The school had dealt with crisis situations before
– There was a procedure to deal with a crisis
– Principal showed leadership
– Staff had the capacity to act at short notice. No time lost
in territorial fights
• People involved: staff of Health Department and
School, and hospital physician
Personal role in outbreak
• As Montgomery’s County Director of
Communicable Disease Control, had previous
experience in organizing a public health responses
to disease outbreaks
• Acted in this case according to best science and
public health practice, forged joint effort between
health department/high school/hospital, dealt with
community/media, briefed staff, consulted with
external resources, assumed full responsibility for
outbreak management
Expected Achievements
• Outcomes:
– Prophylax all close contacts and immunize high risk
group within time frame
– Maintain active surveillance of new cases
– Prevent rumors, alleviate fear, and educate community
about meningitis
• Selected strategy:
– Provide timely, accurate, consistent and people-oriented
information to parents, students, school staff and media
– Work as a team: HD, school, health care providers
Collaborative effort
• Representatives of the High school, the hospital
and the Health Department were experienced in
crisis situations, competent in their respective areas
and had a clear view of respective roles
• HD led the organization of a public health response
to the meningoccal cases
• The school led pro-active information efforts to
students, staff and parents
• A respected hospital physician assisted in defining
the response and liaised with medical community
• The response was perceived by the community as a
joint effort of county HD, high school, and local
Principles and Values Applied
• Show concern
– Acknowledge concerns of family, parents, staff and
students
– Act on people’s right to be kept informed of events
• Assume responsibility
– Take public health measures to prevent new case (s)
• Believe in positive outcome
– Communicate what each step is expected to achieve
– Keep composure in face of criticism and opposition
Recognition of successful
outcome
• Thank you letters to
– School principal and his staff
– Hospital physician
– Health department staff
• Should have been done
– Debriefing of HD staff and review of lessons learned
– Some form of celebration of a successful outcome
Lessons about leadership -1
1. Different leaders emerge at different times
The Communicable Disease Director of the HD was
placed in a leadership position to manage the different
phases of control and to act as central spokesperson,
yet other leaders emerged and were essential to
success:
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Superintendent: created supportive climate
School physician: was practical & effective with staff
Principal: had clear vision of image of school, acted swift and
decisively
Hospital physician: provided medical expertise and
credibility, offered resources
Lessons about leadership-2
2. The community expects an impeccable
performance of the HD but also wants to be heard.
This right should be recognized even if there are
dissenting voices
3. In a control strategy, a leader is responsible to
balance elements of science, team work,
community and media relationships, and the
organization of preventive work
4. You can do more and be more than you think