Management of a Disease Outbreak Meningococcal Infection at a High School

1
Management of a Disease Outbreak Meningococcal
Infection at a High School

• Luc Van Parijs, MD, MPH, DrPH
• Lgvanparijs_at_cs.com
• The author is a scholar
• of the North East
• Public Health
• Leadership Institute,
• Class of 2000.

2

• 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 dcw01_at_health.state.ny.us

3
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.

4
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

5
Performance Objectives

• 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

6
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
7
Clinical and Epidemiological Features
8
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 gt 80

9
Meningococcal Infection -2

• Incidence LOW, 1 case per 100,000 US
  population, but public concern HIGH
• All ages affected. Highest rates in lt 5 yr more
  cases in winter/early spring
• Serotypes by age group B gt in infants, C gt in
  young people/adults, Y gtin 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

10
Meningococcal Infection -3

• Prevention
• (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 lt 3 months in
  same setting

• Treatment
• (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

11
Public Health Response
12
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

13
Case 1 Chronology of Events

• 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

14
Case 1 Control Strategy

• 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

15
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

16
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

17
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

18
Case 2 Chronology of events-2

• 4/10 (Mo) info-meeting with school staff and
  students
• 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

19
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

20
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.

21
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
• Vaccination criteria articulated by a unified
  team
• Team firm and consistent on who should be
  vaccinated

22
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

23
Ingredients of a Public Health Response

• Adhere to scientific understanding of disease and
  control measures
• Compose a team with key leaders to deal with
  crisis
• Pay close attention to community and media
  reactions
• Plan chemoprophylaxis and vaccination and act
  swiftly and decisively
• Check for new cases. There was no third case

24
Leadership in managing an outbreak
25
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

26
Personal role in outbreak

• As Montgomerys 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

27
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

28
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
  area hospital

29
Principles and Values Applied

• Show concern
• Acknowledge concerns of family, parents, staff
  and students
• Act on peoples 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

30
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

31
Lessons about leadership -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
• 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

32
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