part 1

HCM 380 Case Study Part 1

Trojan Memorial Hospital (TMH) is a large, inner-city hospital in San Antonio, Texas. You are the

hospital’s epidemiology team, and the Chief Executive Officer (CEO) wants you to make

recommendations regarding an ongoing outbreak of measles cases coming through the Emergency

Department (ER). Review the summary graph of your data (Figure 1) and the results of the interviews

you have conducted with the patients and their families (Table 1).

Figure 1. Graphic representation of the measles outbreak at Trojan Memorial Hospital

Table 1.

Compilation of Information Gathered from TMH Patients and Their Parents.

Patient Name Sex (1 = Woman, 2 = Man)

Age Age Vaccinated

Comments

1 (Day 1)

Sean 2 8 N/A Sean presented to the Trojan Pediatric Clinic (TPC) with a high fever (104o F), a sore throat, and a cough. He was tested for strep throat and the flu, but both of those tests were negative. He was given an intravenous antibiotic, Tylenol to reduce his fever, and a course of penicillin to begin taking when he

returned home. Sean was not tested for measles. Sean continued to run a high fever, and began to develop a rash, so his mother took him to the ER the day after his visit to TPC. The mother confirmed that Sean never was given the MMR vaccination, as she does not believe in vaccines.

2 (Day 8)

Estelle 1 43 4 Estelle is a nurse at TPC, and she was the primary care nurse for Sean, the index case patient. While she had been vaccinated, Estelle became ill, with several symptoms related to the measles. She drove herself to TMH and checked into the ER.

3 (Day 8)

Maria 1 3 1st dose at 16 months

Maria was a patient at TPC the same day that Sean was being seen. Their visits were concurrent, but they were never in the same room at the same time, including the waiting room, as Sean was taken back to the treatment area about five minutes before Maria arrived. Maria’s visit to TPC was for a well-check, as she was not sick.

4 (Day 9)

Emilio 2 2 N/A Emilio was seen at TPC the same day as Sean, but a bit later in the day. Emilio and his family just immigrated from Mexico. No one in Emilio’s family was vaccinated for MMR. Emilio was seen in the same patient room as Sean.

5 (Day 9)

Aranja 1 6 months N/A Aranja is Emilio’s younger sister. She was not at patient at TPC, but she was taken to the office as there was no one for her to stay home with.

6 (Day 9)

Juanita 1 27 N/A Juanita is Emilio and Aranja’s mother. She brought Emilio to TPC and was with him throughout his entire appointment.

7 (Day 10)

Emma 1 5 4 Emma is Maria’s neighbor. She and Maria had been playing together every day until Maria was taken to the ER. They played immediately after Maria returned from her appointment at TPC.

8 Willie

2 3 months N/A Willie is Sean’s cousin. Sean’s mother was babysitting Willie the day that

(Day 11)

Sean became sick. She took Willie to her parents’ house when she took Sean to TPC.

9 (Day 11)

Raphael 2 2 1st dose at 17 months

Raphael was seen at TPC just after Emilio, in the same room as both Sean and Emilio.

10 & 11 (Day 12)

Jaime and Isabel

2/1 11 months N/A Jaime and Isabel are Maria’s twin cousins. They came to visit Maria the day of Maria’s appointment and played with both Maria and Emma.

12 (Day 13)

Wanda 1 38 N/A Wanda is a nursing assistant in the ER at TMH. Wanda was not vaccinated as a child, as she grew up in Zambia. She should have been vaccinated when she joined the staff at TMH, but she was not.

13 (Day 14)

Jamile 2 3 months N/A Jamile is Wanda’s son. Wanda’s neighbor was watching Jamile when he broke out in a fever. The neighbor took Jamile to the hospital nine hours after Wanda was taken in.

14 (Day 15)

Jordyn 1 7 months N/A Jordyn was seen at TPC’s ER on Day 8 of the outbreak. She was on the same rotation as Estelle, and she had the same nurse and nursing assistants as Estelle.

15 (Day 17)

Robbie 2 21 months 1st dose at 15 months

Robbie is a readmit from Day 9. He was seen at TPC after hurting his head in a fall. Robbie sat next to Emilio is the ER on Day 9.

16 (Day 17)

Julia 1 3 1st dose at 17 months

Julia is Maria’s best friend at daycare. They play together daily and were playing when Maria started not feeling well.

17 (Day 17)

Tia 1 3 1st dose at 15 months

Tia is also in daycare with Maria and Julia. She had also played with Julia and Maria on Day 8 of the epidemic, before Maria became sick.

18 – 24 (Day 18)

Stephie, Shauna, Ronna, Maggie, Ava, Sonny, and Louis

6 X 1, 1 X 2

3 All received their first vaccines between 15 and 19 months

These seven patients are all classmates of Maria, Julia, and Tia. While they were not seen playing with Maria, Julia, or Tia, they were in the same room the day Maria became sick.

25 Wanda 1 38 N/A Wanda was a readmit from Day 13 of the outbreak. She was released from

(Day 19)

the hospital after two days, but she while she was stable at release, she developed encephalitis and was rushed back to the ER. Wanda fell into a deep coma and was admitted to ICU. She died on Day 22 of the epidemic.

26 (Day 19)

Esteban 2 3 1st dose at 16 months

Esteban is Raphael’s neighbor and friend. He had regular contact with Raphael up until he was taken to the ER, including the day Raphael was taken in.

27, 28, & 29 (Day 20)

Rosie, Clare, and Brady

2 X 1, 1 X 2

11, 9, and 11 months, respectively

N/A All classmates of Jaime and Isabel, these three are all too young to be vaccinated for MMR.

30 & 31 (Day 21)

Shawna and Yvette

2 X 1 8 and 20 months, respectively

Shawna is N/A, Yvette had 1st dose at 15 months

Shawna is a classmate of Jaime and Isabel, and Yvette is her older sister. Shawna and Yvette shared toys in the backseat of their mom’s SUV, heading home from daycare.

32 (Day 24)

Rosalyn 1 79 5 Rosalyn was in the ER 12 days ago (Day 12 of the outbreak), as she had missed her dialysis appointment and was rushed to the hospital when her kidneys had begun shutting down. Rosalyn was in the ER prior to Jaime and Isabel. She was attended to by Wanda. Rosalyn is the second fatality in this outbreak, dying of complications from pneumonia that caused a fatal heart attack, likely due to her poor overall physical health.

33 (Day 24)

Miguel 2 13 months N/A Miguel has no known affiliations with any of the other patients listed in this outbreak. He is kept at home with his mother, so he was not exposed to the outbreak at the daycare or at the hospital.

34 (Day 25)

Freddy 2 6 months N/A Like Miguel, Freddy has no known affiliations with any of the other patients, including Miguel. However, Freddy lives only 1.4 miles from Miguel’s home.

35 (Day 26)

José 2 3 N/A José is not a US citizen. He is on vacation, with his mother, visiting his

extended family, Miguel’s family. José is Miguel’s second cousin.

36 (Day 27)

Sara 1 7 N/A Sara was never vaccinated for MMR. She is homeschooled and has not come in contact with anyone on this list. Her family lives in the same neighborhood as Miguel and Freddy’s families.

37 (Day 27)

Mavis 1 2 1st dose at 18 months

Mavis also lives in this common neighborhood, and she does know Sara. She has not played with Sara in weeks, however, and has only seen Sara one time in the last month, having seen each other at Food Lion about 10 days ago.

38 (Day 27)

Zack 2 11 months N/A Zack has not come in contact with anyone on this list, nor does he know anyone on the list. Zack’s dad, however, is the produce manager at Food Lion, so he has briefly seen both Mavis and Sara and their families.

39 (Day 28)

Robyn 1 1 month N/A Robyn has no connection to any of the previous patients. She was seen at TPC on Day 19 of the outbreak, for a well-baby check-up. Robyn was not in any of the rooms that the previous patients had been in, except the waiting room, but after so many patients had become infected, the entire TPC facility was sanitized on Day 3 of the outbreak. There does not seem to be any link to Robyn and any of the known or possible cases or environments.

40 & 41 (Day 28)

Vickie & Vanessa

2 X 1 15 months N/A Vickie and Vanessa are twin girls who are do not know anyone on this list. They are not from this area, as they were just passing through on the interstate. They were rushed to TPC, as it was the closest hospital, when their parents noticed both were fussy and flushed looking.

42 (Day 29)

Fanny 1 13 months N/A Fanny is Mavis’ cousin. She had visited Mavis and played with her, as Mavis’ mom and Fanny’s mom were preparing dinner, on Day 17 of the

outbreak, but she has not seen her at any other time during this outbreak.

43 (Day 30)

Donnie 2 13 months N/A Donnie’s dad works for Rick, Zack’s dad, the produce manager at Food Lion. Donnie’s dad has worked every day for the past two weeks, as the department has been down an employee.

44 (Day 30)

Jessica 1 16 months 1st dose at 15 months

Jessica is Donnie’s classmate at daycare, which is the same daycare common to the children who had earlier contracted measles. Donnie and Jessica play together often, so they have been in regular, direct contact since the beginning of the outbreak.

After reviewing the cases above, please answer these questions. Each question is worth five (5) points.

1) Research measles and write a summary of the disease, including the symptoms, how it is spread,

the risks, seriousness, etc. You should consider the epidemiological triangle when writing this

summary.

2) After reviewing the case history, knowing the Sean was the index case, why do you think this

outbreak spread like it did? In other words, why do you think the disease continued to spread?

Were all the cases contracted at TPC or TMH? Explain any cases that do not seem to fit in line

with the rest of the cases.

3) Based on what you have observed from the cases, what do you think are the underlying

problems that allowed the disease to spread like it did? This is not a repeat of question 2. For

this question, please consider things like policy, procedure, processes, etc.