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Measles Mitigation - The Cornerstone of Public Health Practice – At Its Best
1. Communicable Disease Program
The Cornerstone of Public Health Practice – At Its Best
Dorothy MacEachern, Epidemiologist
Kim Papich, PIO
Susan Sjoberg, Emergency Response Coordinator
Measles Mitigation
2. Communicable Disease Program
Measles Mitigation
• Partnerships
• Internal and external
• Flexibility
• Backed by expertise and training
• Innovation
10. Communications
Communicable Disease/Epidemiology Investigation
Public Health Preparedness and Response
First Measles Case Confirmed
April 21, 2015
Spokane Declared Measles Free
June 5, 2015
Disneyland
Second Measles Case Confirmed
April 29, 2015
ProactiveMediaRelationships
Notification&Confirmation
13. Communications
Communicable Disease/Epidemiology Investigation
Public Health Preparedness and Response
First Measles Case Confirmed
April 21, 2015
Spokane Declared Measles Free
June 5, 2015
Disneyland
Second Measles Case Confirmed
April 29, 2015
ProactiveMediaRelationships
ICSActivationNotification&Confirmation
15. Communications
Communicable Disease/Epidemiology Investigation
Public Health Preparedness and Response
First Measles Case Confirmed
April 21, 2015
Spokane Declared Measles Free
June 5, 2015
Disneyland
Second Measles Case Confirmed
April 29, 2015
ProactiveMediaRelationships
Same-daypublicnotification
ICSActivationNotification&Confirmation
18. Communications
Communicable Disease/Epidemiology Investigation
Public Health Preparedness and Response
First Measles Case Confirmed
April 21, 2015
Spokane Declared Measles Free
June 5, 2015
Disneyland
Second Measles Case Confirmed
April 29, 2015
ProactiveMediaRelationships
Same-daypublicnotification
CaseInvestigation
ICSActivationNotification&Confirmation
22. Communicable Disease Program
Case Investigation
• Handling Exposures
• Mandatory vs. voluntary quarantine
(for exposed susceptibles)
• Issues Encountered
23.
24. Communications
Communicable Disease/Epidemiology Investigation
Public Health Preparedness and Response
First Measles Case Confirmed
April 21, 2015
Spokane Declared Measles Free
June 5, 2015
Disneyland
Second Measles Case Confirmed
April 29, 2015
ProactiveMediaRelationships
Same-daypublicnotification
CaseInvestigation
UtilizationofRECPlan
ICSActivationNotification&Confirmation
26. Communications
Communicable Disease/Epidemiology Investigation
Public Health Preparedness and Response
First Measles Case Confirmed
April 21, 2015
Spokane Declared Measles Free
June 5, 2015
Disneyland
Second Measles Case Confirmed
April 29, 2015
ProactiveMediaRelationships
Same-daypublicnotification
CaseInvestigation
UtilizationofRECPlan
ActionwithFlexibility
ICSActivationNotification&Confirmation
27. Communicable Disease Program
Action with Flexibility
• HELP!!!! – DOH Epi Strike Team to the
rescue!
• In-home testing services
• Existing contract → New partnership
• Phone interviews = internal partnerships
28. Communicable Disease Program
Action with Flexibility
Health Officer Order
• We’ve done this before but….
• Back-up legal?
• Who’s going to serve the order?
29. Communicable Disease Program
Action with Flexibility
On the phone and in the basement:
• Washington Poison Center
• Titer Clinics
• WA IIS look up
30.
31. Communications
Communicable Disease/Epidemiology Investigation
Public Health Preparedness and Response
First Measles Case Confirmed
April 21, 2015
Spokane Declared Measles Free
June 5, 2015
Disneyland
Second Measles Case Confirmed
April 29, 2015
ProactiveMediaRelationships
Same-daypublicnotification
CaseInvestigation
UtilizationofRECPlan
CycleofCommunications
ActionwithFlexibility
ICSActivationNotification&Confirmation
33. Communications
Communicable Disease/Epidemiology Investigation
Public Health Preparedness and Response
First Measles Case Confirmed
April 21, 2015
Spokane Declared Measles Free
June 5, 2015
Disneyland
Second Measles Case Confirmed
April 29, 2015
ProactiveMediaRelationships
Same-daypublicnotification
CaseInvestigation
UtilizationofRECPlan
CycleofCommunications
ActionwithFlexibility
ICSActivationNotification&Confirmation
ProactiveMediaRelationships
Publicnotification
CaseInvestigation
UtilizationofRECPlan
CycleofCommunications
ActionwithFlexibility
ICSActivationNotification&Confirmation
38. Communicable Disease Program
Lessons Learned
Communications
Communicable Disease/Epidemiology Investigation
Public Health Preparedness and Response
39. Communicable Disease Program
Future of Measles Control
Exposure definitions
Role clarification with hospital partners
Data Entry in WA IIS
• Titer results
• Immunity status verification
40. Communicable Disease Program
About SRHD
Mission
As a leader and partner in public health, we protect, improve and
promote the health and well-being of our communities.
Vision
Healthy Lives. Safe Environments. Thriving Communities.
Values
Integrity
Compassion
Respect
Equity
Collaboration
Innovation
Editor's Notes
Susan – introduce us and brief context
Susan – little more intro and delve into tie with conference
The theme of this year’s conference is Partnerships and Innovation: A Public Health Imperative. Our success in swift mitigation to the threat of measles exemplifies this theme. We already have a very strong and positive relationship with the Department of Health and their support in this measles response was amazing. We had to be flexible and shift gears a few times to meet the needs of the response, requiring us to build some new partnerships with local assets and with state level assets and we had to be super creative in finding families and measles immunity information.
Dorothy – start getting a little more technical
The last thing Dorothy can say should be around our three positions collaborating
The primary goal of measles outbreak response is to reduce morbidity and mortality by providing appropriate case management and vaccination.
Secondary goals are to:
limit the spread of the outbreak;
identify high-risk groups/areas for implementing strategies to improve vaccination coverage and other control measures;
assist in the identification and correction of weaknesses in immunization and surveillance;
raise awareness in the community about the disease and its prevention;
monitor the changing epidemiology of measles.
Susan:
At SRHD, by design and practice, these 3 program areas are closely linked with CD Epi and PHEPR under the same program manager and the communications/PIO through whom all media inquiries are funneled has created a habit of frequent and regular interactions and expectations. So the confluence of these three areas into one deep pool of response is worth shining a light into to show you why this measles mitigation effort succeeded AND where the boulders of opportunity to improve remain.
Dorothy slide
Dorothy slide:
Alerts to providers
Some dry runs (use of texting to evaluate rash)
Arrangements made for IG, if needed
Contract with visiting nurse association
Spokane Public Schools’ new policy
Immunization registry (IIS)
PIO, media spokespersons
ICS training
Conduit to DOH
Sort of thought we had something in place with TB with health officer orders
Preparation in the Face of Disneyland Outbreak
https://www.polleverywhere.com/multiple_choice_polls/2tk1JxLzAq2mei0
Here we go again!
A lot of the work I do in my job is ensuring that we have positive relationships with media and proactively securing coverage on a range of public health topics. Part of the reason we do this is to ensure that when a public health event like a confirmed measles case happens, reporters don’t just hear static when we tell them we have something that needs to be shared urgently.
Attempts to expand medical expertise specific to media opportunities, Ebola was our previous opportunity to growth depth in medical community.
A number of tools helps us to ensure these relationships are strong
Our Risk and Emergency Communications Plan has appendices that account for updated contact information for broad spectrum of media sources
Multiple ways that we communicate with media including IM, texting, social media and more traditional outlets (tools in place)
Recipricol relationships, we thank them and give them credit where credit is due, helps to elevate their status, brand (YouTube 700+ videos, news coverage clip embedded on our site can get upwards of 12,000 views between our agency and media)
The public has to trust us too
Brand awareness
Credible sources
Media training
Correction of misinformation, opportunity to piggyback on general matters of health concern
Dorothy slide
Stage Left Theatre
Spokane, WA
April 19, 2015 – 3pm
Call to duty officer line
Measles?
No case in Spokane County since 1994.
The same day as Washington was 42 days post a measles case.
Dorothy and Susan
Immediate request for assistance from Chas DeBolt (long history of DOH CD Epi support); work to get IG from Children’s in Seattle to bring with her on the plane….
What we knew about the patient, possible exposure locations
We swiftly moved from “hallway briefing” to all hands on deck.
Here we go again!
People, outside of the CD Epi team had been scattered with various activities throughout the day. We typically have hallway updates and briefings. When something is on the horizon that has the possibility of being “BIG” we often conduct an initial briefing but because this was so far outside the ordinary, we sat down together for the first time as we activated ICS.
INSERT structure, explain the basics of who was involved and why.
Internal staff relationship with Communications, understanding of protocols, etc.
Leaks and urgency to get public notified of locations
4:47 Personal phone call to each of the assignment editors or producers, press conference to make 6:00
Would like to put media clip here of Dr. Joel press conference
Notification to staff and partners
Tools available in REC plan for emerging messages, media contacts, press notifications, etc
Help Desk (a lot of the misinformation and confusion became evident) – hard to get someone to every station but worth it and only really in first 48 hours – deep in our media training
Opening of JIS (Wiggio) page out of Ebola playbook
Here we go again
Case Investigation
Decisions to keep personal information to a minimum, public’s concerns about it being a food service employee and risk not increased
qdoba did confirm, but we opted not to
75 healthcare providers – overwhelming majority had 2 documented MMRs, some had to have titers drawn
350 members of the public known to be exposed
36% documented vaccination
17% born prior to 1957
20% had + titer
= 27% unknown status or LTF
Exposure in public settings
Contact with employees/members through employers/owners
Contact for public through media outlets
Mandatory quarantine for 21 days after last contact:
household or close contacts of the case,
exposed healthcare providers*,
severely immune compromised persons, or children (birth through high school)
These individuals actively monitored by SRHD Epi for symptoms.
All others are advised to self –quarantine at home for 21 days after their last exposure. This is advised and is voluntary. No monitoring will be conducted.
Fractured families
Lack of health insurance
Verification of records (military & others)
Lack of English proficiency (chix pox)
Evasiveness of clients
Public vs HC settings (who’s responsible)
Identity of case
Family dynamics and recently-vaccinated teenager
Feb clinic when teen vaccinated vs. SPS blitz clinic and confusion that we “gave” community measles
SPS policy and the recent clinic
In the vein of universal access
(would like to show a few examples of tools we used from REC plan, i.e. urgent situational awareness template, media advisory and press conference planning, FAQs, utilization of Wiggio)
How LastPass allows multiple positions within ICS to access communcations tools
Process counts
Update regularly
Keeps everyone on track
Lists tasks
Key to avoiding public power struggles
Bones of your work
Here we go again!
425 potential exposures to document, follow up with and take action if needed. Cynthia Haggert and Azadeh Tesslimi were on the ground within about 36 hours to help us get organized and support our IC structure and then spent many long hours creating a line list to manage this.
During Disneyland, we had the forethought to beef up the contract we had with a local visiting nurse organization for the Trifecta of measles screening (NP swab, blood draw, urine sample). During our outbreak, this quickly became a stumbling block and we had to shift gears to another partner – PAML Mobile Services! They were amazing.
Dozens and dozens of people needed to be reinterviewed and followed up with. We had prioritized out the highest risk exposures that Epi were already working with but many many more individuals needed to be cleared either by positive titer results or immunization records.
The response in Clallam county and Chas DeBolts support there also paved the way for this response. The interview form we used for all of these potential exposures was created on the fly during Clallam county’s outbreak, just weeks before Spokane’s.
Susan Slide
This was all about partnerships.
Poison Center
Washington Poison Center (WPC) Support during Spokane Measles Outbreak: April-May 2015
Brief background (volume of exposures) and Purpose: (call center - SRHD, medical consulting need, etc.)
MOU (what does PC offer) and how activated:
DOH’s role:
Scripts and direct communications with WPC (modifications to the script on-going, electronic log and report to us each day, etc.):
Phone line logistics: (local number answered by WPC when activated, back to us when not)
How long to get up and running? And how many calls did WPC take?
Titer clinics, 4/24, 4/25, 4/28
Advertised through media, direct outreach
MRC assistance
Maxim meeting previous to first case, contract for trifecta of testing, then we needed services and fail, flexibility in finding other avenue
Speak to frazzled workers, beehive of activity
ICS protocols for checking in staff and well-being
Personal frazzle stories
Here we go again!
(KP to include visual here of cycle w/animation)
Feb clinic when teen vaccinated vs. SPS blitz clinic and confusion that we “gave” community measles
SPS policy and the recent clinic
Note to talk about reporters looking for new angles, tendency of our agency to say we’ve already shared everything we know. There is always a new angle to explore, keep topic fresh in minds, especially with concern that another case could appear.
Types of confusing information we had to clarify, misinformation generated by anti-vaccination crowd (vaccine-generated measles from recent school catch up clinic, patient zero was already sick at the point of vaccination clinic), important to update all channels with trending information, i.e. social media, FAQ, email when necessary to partners and reporters
Here we go again!
Dorothy Slide
2nd case – announced day after result –
controlled circumstance because quarantined close contact of first case (previous health officer orders)
Susan – make a tie with conference theme and innovation again
7 persons got IG (6 infants, 1 adult)
Dozens of persons titer tested
Hundreds of persons vaccinated
? Unknown number of persons came to believe in measles vaccination
Susan
3rd? case
Creativity in ruling out additional case with complex family situation
Dorothy’s
Cost of investigation
Susan
In the meantime, Chas has made her way back to the west side but is still in regular communication and trying to figure out the mystery of where this case came from
Dorothy: 42 days passed, out of nowhere
Likely someone who traveled through our community.
Kim
From a communications perspective, this helped substantiate our cases and non-relation to Disneyland or recently-vaccinated.
Kim
Technology constraints specific to website and uploading of information in timely manner
“You make the call” on second case and media’s want for first crack at coverage
Bloomsday implications, potential for signage, working with partners – sharing that race organizers concerned about publicity. Awareness of public events,
Dorothy or Susan - should public health be present as part of planning
Role clarification with hospitals and media expertise/willingness
Dorothy
Role clarification and confusion with hospital partners
Managing the line list, still requires some refinement
Helpful to pass ongoing work to DOH/other LHJs
HIPAA concerns and clarity beforehand on leaving messages and using text for diagnostics
Acquiring IG also somewhat related to hospital, even when we had IG, we had difficulty administering
Speak to Maxim vs. PAML, keeping your people happy at the lab, dropping off specimens after hours
Vouch for ICS (FINALLY!!!)
Susan last
Show of hands from audience, how many of you LHJ Immunization Policy/knowledge of immunity status of employees????
….documentation of SRHD staff immunity policy incomplete
New processes for 2-1-1 and Poison Control;
more comprehensive notification to internal partners (imms staff holding mobile clinic at time of media announcement of first case – ooopppps!)
Use of 201 and SharePoint log provided ease and simplification of ICS forms
Dorothy Change in exposure definition ala California? If a person has been in the military, they accept that has documented immunity – federal government, etc. requirements of service
Something more positive, actions we’re working on – pieces of our improvement plan
Process server and contract?
Exposure definitions
Roles and responsibilities (hospital partners)
Titer info and immunity status verification in IIS