Measles Mitigation - The Cornerstone of Public Health Practice – At Its Best
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This document discusses Spokane Regional Health District's response to a measles outbreak in 2015. It summarizes the key activities including confirming two measles cases, notifying over 75 health care providers and 350 exposed individuals, conducting case investigations, utilizing their emergency response plan, maintaining communication through public notifications and media relationships, and implementing control measures with flexibility. Lessons learned highlighted the importance of communication, clarifying roles with partners, and improving data systems for monitoring immunity status.
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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
- 5. 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
- 6. In Place at SRHD
- 8. 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
- 9. Communicable Disease Program “Good communication with the public is a necessity, not a luxury!” Proactive Media Relationships
- 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
- 12. Communicable Disease Program Confirmation of 1st Case
- 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
- 14. Communicable Disease Program Initial Briefing to Activation ICS Activation
- 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
- 16. Communicable Disease Program Same-Day Public Notification
- 17. Communicable Disease Program Same-Day Public Notification
- 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
- 20. Communicable Disease Program Case Investigation 75 Health Care Providers
- 21. Communicable Disease Program Case Investigation 350 Exposed Members of the Public
- 22. Communicable Disease Program Case Investigation • Handling Exposures • Mandatory vs. voluntary quarantine (for exposed susceptibles) • Issues Encountered
- 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
- 25. Communicable Disease Program Utilization of REC Plan
- 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
- 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
- 32. Communicable Disease Program Cycle of Communications
- 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
- 34. Communicable Disease Program 2nd Case Confirmed
- 35. Communicable Disease Program 2nd Case Interventions 6 Infants
- 36. Communicable Disease Program Aftermath Cost to SRHD-Only Cost of Vaccine for Two
- 37. Communicable Disease Program A Dash of Innovation….
- 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
- Quarantine Protocols https://www.polleverywhere.com/multiple_choice_polls/oyY5BwR6qVQWRKx Dorothy
- Here we go again!
- 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