Measles Mitigation - The Cornerstone of Public Health Practice – At Its Best

PowerPoint Presentation

The Cornerstone of Public Health Practice At Its Best

Dorothy MacEachern, EpidemiologistKim Papich, PIOSusan Sjoberg, Emergency Response Coordinator

Measles Mitigation

Communicable Disease Program

Communicable Disease ProgramSusan introduce us and brief context

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Measles MitigationPartnerships Internal and externalFlexibility Backed by expertise and trainingInnovation


Communicable Disease ProgramSusan little more intro and delve into tie with conference

The theme of this years 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.

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COMMUNICABLE DISEASE/EPIDEMIOLOGY INVESTIGATION

PUBLIC HEALTH EMERGENCY PREPAREDNESS AND RESPONSECOMMUNICATIONS

Communicable Disease ProgramSusan:

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.3


CommunicationsCommunicable Disease/Epidemiology InvestigationPublic Health Preparedness and ResponseFirst Measles Case ConfirmedApril 21, 2015Spokane Declared Measles FreeJune 5, 2015DisneylandSecond Measles Case ConfirmedApril 29, 2015

Communicable Disease ProgramDorothy slide5

In Place at SRHD

Communicable Disease ProgramDorothy slide:

Alerts to providersSome dry runs (use of texting to evaluate rash)Arrangements made for IG, if neededContract with visiting nurse associationSpokane Public Schools new policyImmunization registry (IIS)PIO, media spokespersonsICS training Conduit to DOH

Sort of thought we had something in place with TB with health officer orders

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Communicable Disease ProgramPreparation in the Face of Disneyland Outbreakhttps://www.polleverywhere.com/multiple_choice_polls/2tk1JxLzAq2mei0

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CommunicationsCommunicable Disease/Epidemiology InvestigationPublic Health Preparedness and ResponseFirst Measles Case ConfirmedApril 21, 2015Spokane Declared Measles FreeJune 5, 2015DisneylandSecond Measles Case ConfirmedApril 29, 2015Proactive Media Relationships

Communicable Disease ProgramHere we go again!8

Good communication with the public is a necessity, not a luxury!

Proactive Media Relationships


Communicable Disease ProgramA 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 dont 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 strongOur Risk and Emergency Communications Plan has appendices that account for updated contact information for broad spectrum of media sourcesMultiple 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 tooBrand awarenessCredible sourcesMedia trainingCorrection of misinformation, opportunity to piggyback on general matters of health concern

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CommunicationsCommunicable Disease/Epidemiology InvestigationPublic Health Preparedness and ResponseFirst Measles Case ConfirmedApril 21, 2015Spokane Declared Measles FreeJune 5, 2015DisneylandSecond Measles Case ConfirmedApril 29, 2015Proactive Media RelationshipsNotification & Confirmation

Communicable Disease ProgramDorothy slide10

Communicable Disease ProgramStage Left TheatreSpokane, WA

April 19, 2015 3pmCall to duty officer lineMeasles?

No case in Spokane County since 1994.The same day as Washington was 42 days post a measles case.

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Confirmation of 1st Case


Communicable Disease ProgramDorothy and Susan

Immediate request for assistance from Chas DeBolt (long history of DOH CD Epi support); work to get IG from Childrens 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. 12

CommunicationsCommunicable Disease/Epidemiology InvestigationPublic Health Preparedness and ResponseFirst Measles Case ConfirmedApril 21, 2015Spokane Declared Measles FreeJune 5, 2015DisneylandSecond Measles Case ConfirmedApril 29, 2015Proactive Media RelationshipsICS ActivationNotification & Confirmation


Initial Briefing to Activation

ICS Activation


Communicable Disease ProgramPeople, 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.14

CommunicationsCommunicable Disease/Epidemiology InvestigationPublic Health Preparedness and ResponseFirst Measles Case ConfirmedApril 21, 2015Spokane Declared Measles FreeJune 5, 2015DisneylandSecond Measles Case ConfirmedApril 29, 2015Proactive Media RelationshipsSame-day public notificationICS ActivationNotification & Confirmation


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Same-Day Public Notification


Communicable Disease ProgramInternal 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 6:0016

Same-Day Public Notification


Communicable Disease ProgramWould 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

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CommunicationsCommunicable Disease/Epidemiology InvestigationPublic Health Preparedness and ResponseFirst Measles Case ConfirmedApril 21, 2015Spokane Declared Measles FreeJune 5, 2015DisneylandSecond Measles Case ConfirmedApril 29, 2015Proactive Media RelationshipsSame-day public notificationCase InvestigationICS ActivationNotification & Confirmation

Communicable Disease ProgramHere we go again

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Communicable Disease ProgramCase Investigation

Decisions to keep personal information to a minimum, publics concerns about it being a food service employee and risk not increased

qdoba did confirm, but we opted not to

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Case Investigation75Health Care Providers


Communicable Disease Program75 healthcare providers overwhelming majority had 2 documented MMRs, some had to have titers drawn

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Case Investigation350Exposed Members of the Public


Communicable Disease Program350 members of the public known to be exposed

36% documented vaccination17% born prior to 195720% had + titer=27% unknown status or LTF

Exposure in public settingsContact with employees/members through employers/ownersContact for public through media outlets

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Case InvestigationHandling ExposuresMandatory vs. voluntary quarantine(for exposed susceptibles)Issues Encountered


Communicable Disease ProgramMandatory 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 familiesLack of health insuranceVerification of records (military & others)Lack of English proficiency (chix pox)Evasiveness of clientsPublic vs HC settings (whos responsible)Identity of case

Family dynamics and recently-vaccinated teenagerFeb clinic when teen vaccinated vs. SPS blitz clinic and confusion that we gave community measlesSPS policy and the recent clinic

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Communicable Disease ProgramQuarantine Protocolshttps://www.polleverywhere.com/multiple_choice_polls/oyY5BwR6qVQWRKx

Dorothy

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CommunicationsCommunicable Disease/Epidemiology InvestigationPublic Health Preparedness and ResponseFirst Measles Case ConfirmedApril 21, 2015Spokane Declared Measles FreeJune 5, 2015DisneylandSecond Measles Case ConfirmedApril 29, 2015Proactive Media RelationshipsSame-day public notificationCase InvestigationUtilization of REC PlanICS ActivationNotification & Confirmation


Utilization of REC Plan


Communicable Disease ProgramIn 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 countsUpdate regularlyKeeps everyone on trackLists tasksKey to avoiding public power strugglesBones of your work

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CommunicationsCommunicable Disease/Epidemiology InvestigationPublic Health Preparedness and ResponseFirst Measles Case ConfirmedApril 21, 2015Spokane Declared Measles FreeJune 5, 2015DisneylandSecond Measles Case ConfirmedApril 29, 2015Proactive Media RelationshipsSame-day public notificationCase InvestigationUtilization of REC PlanAction with FlexibilityICS ActivationNotification & Confirmation


Action with FlexibilityHELP!!!! DOH Epi Strike Team to the rescue!In-home testing servicesExisting contract New partnershipPhone interviews = internal partnerships


Communicable Disease Program425 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 countys outbreak, just weeks before Spokanes. 27

Action with FlexibilityHealth Officer OrderWeve done this before but.Back-up legal?Whos going to serve the order?



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Action with FlexibilityOn the phone and in the basement:Washington Poison CenterTiter ClinicsWA IIS look up


Communicable Disease ProgramSusan Slide

This was all about partnerships. Poison Center

Washington Poison Center (WPC) Support during Spokane Measles Outbreak: April-May 2015Brief background (volume of exposures) and Purpose: (call center - SRHD, medical consulting need, etc.)MOU (what does PC offer) and how activated:DOHs 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 outreachMRC assistance

Maxim meeting previous to first case, contract for trifecta of testing, then we needed services and fail, flexibility in finding other avenue

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Communicable Disease ProgramSpeak to frazzled workers, beehive of activity

ICS protocols for checking in staff and well-being

Personal frazzle stories30

CommunicationsCommunicable Disease/Epidemiology InvestigationPublic Health Preparedness and ResponseFirst Measles Case ConfirmedApril 21, 2015Spokane Declared Measles FreeJune 5, 2015DisneylandSecond Measles Case ConfirmedApril 29, 2015Proactive Media RelationshipsSame-day public notificationCase InvestigationUtilization of REC PlanCycle of CommunicationsAction with FlexibilityICS ActivationNotification & Confirmation


Cycle of Communications


Communicable Disease Program(KP to include visual here of cycle w/animation)

Feb clinic when teen vaccinated vs. SPS blitz clinic and confusion that we gave community measlesSPS policy and the recent clinic

Note to talk about reporters looking for new angles, tendency of our agency to say weve 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 reporters32

CommunicationsCommunicable Disease/Epidemiology InvestigationPublic Health Preparedness and ResponseFirst Measles Case ConfirmedApril 21, 2015Spokane Declared Measles FreeJune 5, 2015DisneylandSecond Measles Case ConfirmedApril 29, 2015Proactive Media RelationshipsSame-day public notificationCase InvestigationUtilization of REC PlanCycle of CommunicationsAction with FlexibilityICS ActivationNotification & ConfirmationProactive Media RelationshipsPublic notificationCase InvestigationUtilization of REC PlanCycle of CommunicationsAction with FlexibilityICS ActivationNotification & Confirmation


2nd Case Confirmed


Communicable Disease ProgramDorothy 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

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2nd Case Interventions6Infants


Communicable Disease Program7 persons got IG (6 infants, 1 adult)Dozens of persons titer testedHundreds of persons vaccinated? Unknown number of persons came to believe in measles vaccination

Susan3rd? caseCreativity in ruling out additional case with complex family situation

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AftermathCost to SRHD-OnlyCost of Vaccine for Two$75K$100


Communicable Disease ProgramDorothys

Cost of investigation36

A Dash of Innovation.


Communicable Disease ProgramSusanIn 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.

KimFrom a communications perspective, this helped substantiate our cases and non-relation to Disneyland or recently-vaccinated. 37

Lessons Learned

CommunicationsCommunicable Disease/Epidemiology Investigation

Public Health Preparedness and Response


Communicable Disease ProgramKimTechnology constraints specific to website and uploading of information in timely mannerYou make the call on second case and medias want for first crack at coverageBloomsday 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

DorothyRole clarification and confusion with hospital partnersManaging the line list, still requires some refinementHelpful to pass ongoing work to DOH/other LHJsHIPAA concerns and clarity beforehand on leaving messages and using text for diagnosticsAcquiring IG also somewhat related to hospital, even when we had IG, we had difficulty administeringSpeak to Maxim vs. PAML, keeping your people happy at the lab, dropping off specimens after hoursVouch for ICS (FINALLY!!!)

Susan lastShow of hands from audience, how many of you LHJ Immunization Policy/knowledge of immunity status of employees???? .documentation of SRHD staff immunity policy incompleteNew 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

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Future of Measles ControlExposure definitionsRole clarification with hospital partnersData Entry in WA IISTiter resultsImmunity status verification


Communicable Disease ProgramDorothy 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 were working on pieces of our improvement plan

Process server and contract?

Exposure definitionsRoles and responsibilities (hospital partners)Titer info and immunity status verification in IIS39

About SRHDMission As a leader and partner in public health, we protect, improve and promote the health and well-being of our communities.

VisionHealthy Lives. Safe Environments. Thriving Communities.

Values Integrity Compassion Respect Equity Collaboration Innovation



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Measles Mitigation - The Cornerstone of Public Health Practice – At Its Best

Health & Medicine

Transcript of Measles Mitigation - The Cornerstone of Public Health Practice – At Its Best