Assigment .Apa seven . All instructions attached.

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Case Study 1: Acute Respiratory Disease Outbreak in a

Hurricane Evacuation Center Session Overview

Instructions For this exercise, you will be asked to work in groups to participate in an investigation of an outbreak of respiratory disease. Information regarding the scenario will be provided to you in parts, each of which will be followed by related discussion questions. Choose one group member to read each segment of information aloud to the rest of the group. After receiving the information, work as a team to formulate answers to each discussion question. Intended Audience All public health, medical, veterinary, pharmacy, emergency management, hospital, and other professionals interested in public health preparedness and field epidemiology. Time Required (estimated) 90 minutes Learning Objectives

 Identify challenges associated with the public health response to a complex emergency, such as a natural disaster combined with a potential outbreak of infectious disease

 Describe public health responsibilities to displaced persons during an emergency  List the steps of an outbreak investigation and describe how to implement them

as an outbreak investigation team  Identify public health legal powers available for management of a complex public

health emergency

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Case Study 1: Acute Respiratory Disease Outbreak in a

Hurricane Evacuation Center

Pre-Test

1. Which of the following describe active public health surveillance in a shelter? a. Provide information about the occurrence of infectious diseases b. Identify health-related topics about which to educate shelter residents c. Monitor sanitation and determine the availability of shelter facilities such

as water, toilets, electricity, and medical care d. A and B only e. All of the above

2. True or False: Public health departments can conduct medical screening before admitting any new people arriving to a shelter.

3. An epidemic curve can be used to provide information on a potential outbreak’s: a. Pattern of spread b. Magnitude c. Time (exposure and/or disease incubation period) d. All of the above

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Case Study 1: Acute Respiratory Disease Outbreak in a

Hurricane Evacuation Center Student Guide

Situation

September 14th: A Category 3 hurricane with 125 mile per hour winds is approaching the coast. As the Beach County Health Director, you are using your phone tree to call nurses to staff the shelters that the Division of Emergency Management authorities have opened under a mandatory evacuation order. Shelters are located in schools, churches, and community centers across the county and can safely house up to a total of 10,000 people – about 20% of your county’s population – for a few days. This will cover most residents who live in mobile homes or other substandard housing, as well as those who live in storm surge or flood-prone low lying areas. Your county also has a mutual aid agreement with Island County to take any residents who can’t be served by their limited local shelters. Based on experience, you know that most tourists have already gone home, and that many residents will prefer to stay in a hotel or with friends or family if possible. In your last Community Health Assessment survey, your health department found that 13% of residents said they would not evacuate if authorities announced a mandatory evacuation, so you are aware that some residents will choose to try to ride out the storm in their homes. In setting up the shelters, you need to meet residents’ basic needs for food and water. You also want to ensure that basic sanitary conditions will be met and that you have a system in place to cover basic medical care if needed and monitor for possible disease outbreaks. You also have a plan for documenting the names and addresses of each person staying at a shelter.

1. Consider what you know about the baseline rates of communicable diseases in your

community based on regular reporting and surveillance activities. How would your knowledge of these baseline rates be applicable to the situation in the shelter?

2. As a health director concerned with the potential for disease outbreaks in an

evacuation center, what would be your primary goals for establishing surveillance in the evacuation centers?

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Update 1: Day 1

September 15th: The storm hit your community hard overnight and the impact on your county’s infrastructure has turned out to be far worse than expected. Almost all of the nearly 50,000 county residents have no power. The municipal water system is not able to provide safe water, and a boil water order is in effect. Trees and power lines are blocking a number of county roads and communication is spotty. The local hospital is running on generator power, but the main roads leading to the hospital have been flooded. Hospital staff are unable to get into work, so only those who stayed at the hospital overnight are able to provide assistance to the few people who can reach the facility. Some residents with severe injuries are being flown by helicopter to the hospital, but it is basically impossible for community residents to reach the hospital for treatment. One of your shelters begins to receive a large number of people who did not evacuate prior to landfall, including members of the small homeless population who have been camping at a nearby vacant lot. Other residents are arriving who have walked through floodwaters to get to the shelter. Many who are arriving have minor injuries related to blowing debris and other hazards.

3. Because people arriving at the shelter may have communicable diseases, injuries,

storm-related illnesses, or unmet chronic medical needs (e.g. oxygen, dialysis, prescription refills) that you are not equipped to provide assistance for, would you consider starting a medical screening program before admitting any new people to the shelter?

4. If you decide to use public health legal powers to isolate a portion of the shelter

population based on medical screening, what must you legally provide to them?

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Update 2: Day 2

September 16th: There are now about 750 people at the shelter. A large number of people are reporting respiratory symptoms to shelter staff and volunteers. Community members continue to arrive, including non-evacuees who can no longer stay at their homes and evacuees who initially went to other shelters who are now looking for friends and family from Island County who may have evacuated to Beach County. You’re concerned that these new arrivals may be exposed to ill individuals at the shelter or that they may be ill themselves already. In addition, you are concerned about stress among members of your community. Emergency management is not allowing citizens to go back to their homes because crews are working hard to open roads and repair power lines. People are starting to experience high stress levels wondering about the status of their homes and possessions.

5. What steps would you take to address potential mental health effects of the disaster?

Update 3: Day 2

Evening of September 16th: A growing number of people in the shelter are reporting worsening respiratory symptoms, including coughing, tight chest, and fatigue. You consider conducting a cot survey to determine the health status of everyone staying in the shelter, but wonder how your staff would be able to develop the questionnaire and perform the interviews in addition to all their other responsibilities. You decide that you should first try to identify and define the cases to determine if this is really an outbreak or just a usual spike in non-specific respiratory symptoms that is often seen in shelters.

6. What basic steps of an outbreak investigation might you undertake at this time? 7. How would you assess the potential of a respiratory disease outbreak in the shelter? 8. How would you decide whether people are suffering from a respiratory illness

contracted before they arrived at the shelter or an illness contracted during an outbreak at the shelter?

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9. Discuss the elements of an epidemiologic curve or “epi curve” that you might be able

to draw based on the results of your cot survey. Below you see two sample epi curves; on the left is an example of a point source epi curve (Fig. 1) and on the right is an example of a person-to-person epi curve (Fig. 2).

Figure 1. Point Source Epi Curve

Update 4: Day 3

Morning of September 17th: Your hardworking staff and several volunteers are finishing a cot survey of a sample of the shelter residents. Based on this data, it seems that many respiratory symptoms have cleared up due to isolation, infection control practices, hand-washing, and other steps you implemented earlier. Then your staff comes across a person with a productive and persistent cough, chest pain, fatigue, and lack of appetite. This person reports that he’s been sick like this for at least 2-4 weeks but was fine before then. He had a chest x-ray about 1 week ago, but never heard from the clinic what the results were due to the storm coming. Your staff is concerned that this person may be the cause of the outbreak of respiratory illness.

11. What further information should you obtain from this person?

Figure 2. Person-to-Person Epi Curve

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Update 5: Day 3

Afternoon of September 17th: While you are discussing whether it may be advisable to isolate this person from others in the shelter to prevent transmission of whatever illness he may have, one of your public health nurses realizes that the Beach County Health Department has a non-compliant TB patient with a name similar to the one of your ill shelter resident. She wonders if it is possible that this is the same person, or if he may have given a false name for fear of not being allowed into the shelter or being turned in to the authorities.

12. Even though you don’t know if this is the same person, would you implement

isolation of this person? 13. You know something about infection with TB, transmissibility, and TB disease

because of the growing number of cases that you have been seeing in your health department. Is it appropriate to consider person-to-person transmission of TB in the shelter?

14. Some of the people staying in the shelter are recent immigrants to your community.

Should you consider the possibility of reactivation of long-latent TB among these new migrants? How might isolation of suspected cases impact the future willingness of immigrants to come to shelter?

Update 6: Day 4 September 18th: The people staying in the shelter are getting more and more anxious to go see their homes. Emergency management officials have said that they may allow citizens back into the community by this afternoon, but just to look at their houses and pick up some possessions. They will not be able to spend the night in their homes and a curfew will be in place at dusk. However, you can’t guarantee that all those currently in the shelter will come back; some may leave the shelter to stay with family or friends outside the county.

15. How will you track everyone who leaves the shelter to update them on the diagnosis

of the respiratory disease they may have been exposed to at the shelter and get them tested if necessary? Should you consider testing people at the shelter for TB?

16. What are your legal powers and responsibilities to protect the community? Can you

keep people at the shelter until you can confirm the diagnosis of TB?

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Conclusion

Most people left the shelter as soon as emergency management allowed. Only 25% returned to the shelter after going to survey damage to their property. Because of your suspicions about this potential case of TB, you confirmed contact information from everyone in the shelter so that you could contact them if they needed to be tested for TB. The next day, the hospital admitted the man you suspected of having TB. A chest x-ray and other tests revealed that he was suffering from lung cancer (which, of course, would not be transmissible to others in your shelter or community). Several weeks later, you were relieved to be signing letters to all those who stayed in the shelter letting them know that they were not in danger of having contracted TB at the shelter.

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References Torok M. Epidemiologic Curves Ahead. FOCUS on Field Epidemiology Vol 1, Iss 5. MacDonald PDM, ed-in-chief; Alexander LA, Mejia GC, eds. Available at: https://nciph.sph.unc.edu/focus/vol1/issue5/1-5EpiCurves_issue.pdf. Accessed April 6, 2016. Matthews GW, Abbott EB, Hoffman RE, et al. Legal Authorities for Interventions in Public Health Emergencies in Law in Public Health Practice. Goodman RA, ed. New York: Oxford University Press: 2007. Infectious Disease and Dermatologic Conditions in Evacuees and Rescue Workers After Hurricane Katrina—Multiple States, August–September, 2005. MMWR Morb Mortal Wkly Rep. September 2005;54:961-964. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5438a6.htm. Accessed April 6, 2016. Epidemiologic Notes and Reports Surveillance of Shelters After Hurricane Hugo— Puerto Rico. MMWR Morb Mortal Wkly Rep. 1990; 39:41-42, 47. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/00001545.htm. Accessed April 6, 2016. N.C. Division of Public Health. Outbreak Investigations: Outbreak Steps. In: North Carolina Communicable Disease Control Manual. 2012. Available at: http://epi.publichealth.nc.gov/cd/lhds/manuals/cd/toc.html. Accessed April 6, 2016.