Friday, June 25, 2004

         This Week in the News

Foege, WH., et al., 
International Journal of Epidemiology
1976; 5:29-37

►Davis Productivity Award Winners Honored at Luncheon
The 18-member SARS Incident Command Team was among the honorees, and three members of that team were Bureau of Epidemiology staff. 
 

►Exercise Beleaguered Bus Rolls Through North Florida
This is no average bus ride, folks. And although their methods are a bit unconventional, a visit to your county is serious business.

A R T I C L E S

Three members of the Bureau of Epidemiology brought home a Davis Productivity Award for their work on the SARS Incident Command Team during Spring 2003. Don Ward, acting bureau chief, Melanie Black, professional training coordinator and Christie Luce, EpiCom marketing consultant, (who, at the time, was employed in Public Health Nursing) were selected to be involved in leadership roles in Florida at a time when the SARS virus was not fully understood and much of the country’s populace was frightened by the mysterious disease.  

The 18-member team, headed by Director of Public Health Nursing Karen Eaton, met daily to collect information and furnish it to medical entities across the state. It quickly established a SARS response line to assist physicians in making diagnoses; coordinated specimen collection and transportation with state labs; ensured follow-up counseling and exams for patient cases; hosted weekly teleconferences with hospitals, the tourism industry and concerned citizen groups; launched a database to track and analyze patient cases (Merlin), and a means of communication among Florida medical practitioners (EpiCom); and provided educational materials for public and professional consumption. Throughout the entire four-month period, members of the Incident Command Team made themselves available for consultation and provided dependable news updates through blast faxes, conference calls, e-mail and on-call rosters.  

Lt. Governor Toni Jennings presented their cash award and certificates of commendation at a June 8 luncheon at the Tallahassee Civic Center. She said in her keynote speech that, “We don’t thank state government workers enough…their foresight, insight and hard work make things better for us all.” 

We're proud of our colleagues for their dedication to mission and their fine achievements. Congratulations!
 

Case Definition: Anyone presenting with symptoms indicative of chickenpox (maculopapulovesicular rash without other apparent cause) regardless of vaccination history.

Chickenpox is caused by the varicella-zoster virus, a type of herpes virus. This virus is easily spread through direct contact with an infected individual and may occasionally occur by airborne spread from respiratory tract secretions. Transmission of the chickenpox virus may also result from contact with articles contaminated with an infected person’s secretions.

Outbreaks of chickenpox are common in late winter and early spring. In healthy children, chickenpox lasts two weeks or less and rarely causes complications. Infants, adolescents, adults, pregnant women, and persons with immune disease can have more severe symptoms and are at a higher risk of serious complications. These complications from chickenpox can result in hospitalization and can be life threatening. 

A chickenpox vaccine is available and does protect against the disease, and most people who get the vaccine will not get chickenpox. In the event that someone who has been vaccinated does get chickenpox, it is usually mild with fewer spots, a slight or no fever, and the recovery time is much shorter.

Methodology
An informative meeting was held between the Seminole County Health Department and school officials. Information provided by the school nurse included the name of each infected student, grade level, teacher, vaccination status, and days absent from school. In addition, emergency contact information was provided for each infected student. Information was provided on behalf of students from sensitive populations, such as those who were immune-compromised or exempt from the vaccine for religious reasons. Additionally, all pregnant staff members were identified.

All cases have been identified from March 10, 2004 to April 19, 2004. Suspect cases of chickenpox were either identified by the children’s parents or by the school nurse, as teachers sent any child with lesions to the school clinic for clearance to return to their classrooms. They were all confirmed once diagnosed by their private physicians. Chickenpox surveillance between the elementary school and the health department was implemented and tracked on a daily basis.

A line listing was developed in a Microsoft Excel spreadsheet. An epidemiological curve that examined the date of onset was designed. In addition, tables were created showing the cases by classroom, grade level, and vaccination status. Attack rates were calculated for each grade and for the school as a whole. 

Using the school’s Easy Call System, phone calls were made to each home to notify parents of chickenpox cases in the school. Information on what symptoms to look for and the health department’s contact information were provided. In addition, the Seminole County Health Department sent letters and fact sheets home by each child to their parents or guardians. A multidisciplinary health team visited the school and went to each classroom and performed education that focused on proper hand washing, symptoms of chickenpox, and when it is safe to return to school. Additionally, all workers attended a staff meeting where education was provided and questions were answered.

Disease control methods were recommended to school officials. School nurses were instructed to exclude all infected students from school until all lesions had crusted over. The parents of all immune-compromised children were contacted and told to consult their private physicians. Pregnant staff members were told to consult their OB/GYN doctors.

Results
From March 10 to April 19, 2004, twenty-eight students were infected with the varicella virus. The students’ ages ranged from 5 to 12 years of age with a mean of 8 years of age. Fifty-seven percent (16) were male students. Of the twelve students interviewed, 67% of the students reported fever, 83% reported itching, and 8% reported sore throat. The duration of illness for the unvaccinated students was 10 days. Among students who were vaccinated, the mean duration for illness was 6.9 days, with a range of 3-14 days. Figure 1 shows the number of chickenpox cases by date of onset. Although only 13 out of 28 students dates of onset were obtained, it was observed that a grade level would have a cluster of chickenpox cases and subsequently move on to the next grade level. There was a household contact observed in two cases. The epidemiological curve is indicative of person to person outbreak.

Below, Table 1 shows the attack rates by grade level. The school-wide attack rate was 3%, with the highest attack rate among 3^rd graders (9%) and 2^nd graders (5%). There were no cases among Kindergarteners and 4^th grade students.  Effective with the 2001-2002 school year, children entering, attending, or transferring to Florida public and private schools and preschools are required to have completed the varicella vaccine series for Preschool thru 2^nd grade students. Of the twenty-eight cases, 78.6% of the students were previously vaccinated. Table 2 shows the chickenpox cases by grade level and vaccination status.

Discussion
Of the 28 students with chickenpox, a total of 22 students received the varicella vaccine. Nine percent of the cases occurred in 3rd grade classrooms, which had the highest number of students who were unvaccinated (31%). Because the majority of students were vaccinated, most of the cases were less severe, with fewer lesions and a shorter duration of illness.

Of the 22 vaccinated students, 3 students were vaccinated within the last three years. Table 3 shows that 68% of the students were vaccinated over three years ago. There seems to be an issue of weakened immunity, and further study of the vaccine should be conducted to determine if boosters given 3 years post vaccination would supplement immunity.

Limitations
There were a few limitations with this study. Because most of the students were previously vaccinated against chickenpox, many physicians did not want to diagnose them as a positive chickenpox case. Some of the resulting diagnoses included scabies, eczema, flea bites, allergic reaction, and Fifth’s disease.

• In order for a child to be re-admitted to school, he/she must have either a doctor’s note or all lesions must be scabbed over. In some cases, because the child was previously vaccinated against chickenpox, a wrong diagnosis may have been made, resulting in an infectious child reentering or remaining in school.

• Each parent was contacted by phone and via mail. The resulting response rate was 46%, with 13 out of 28 parents interviewed. This lack of parental participation lends to reliability and validity issues.

• Recall bias could be a limitation to the study. From the investigation, immunity to chickenpox was reported primarily from parents.

The findings from this study show that the varicella vaccination is effective in preventing severe chickenpox cases. Results from an article published in the May 14, 2004 / Vol. 53 / No. 18 edition of MMWR show that vaccinations are 98% effective in preventing severe disease. Very similar to the MMWR study, it is possible that the school described here may not have recognized mild chickenpox cases as varicella before the detection of the outbreak. This may have played an important role in virus transmission. [Click here to view entire article with graphs.]

References
Barna D. Tugwell, MD, Lore E. Lee, MPH, Hilary Gillette, RN, MPH, Eileen M. Lorber, MD, Katrina Hedberg, MD, MPH and Paul R. Cieslak, MD.  Chickenpox Outbreak in a Highly Vaccinated School Population.  Pediatrics.  2004 Mar;113(3 Pt 1):455-9

CDC.  Outbreak of Varicella Among Vaccinated Children-Michigan, 2003.  MMWR 2004;53:389-392.             
 

We have now completed Beleaguered Bus Exercises in 8 of our 13 NFRDSTF counties. We will resume exercises in September for the five remaining counties. The exercises have been extraordinary learning experiences for all involved -- including our exercise team. 

The exercise is designed to be free-play. Once the initial 911 call is made, not even the exercise team knows how each county will respond. Although they may have used different approaches, and in most cases their assets were limited, we believe that all counties who have participated could respond to a real event by quickly containing the sudden introduction of a contagious disease into their communities.

Here is a summary of our observations and lessons learned to date:

Bus Riders. The number of bus riders varies from 25-35. The Capital Area Chapter of the American Red Cross volunteers provides us a core group of about 20 bus riders. We also have had bus riders join us from Department of Health, hospitals, Leon and other non-participating county health departments, and other regions. Among our distinguished riders was Dr. Bonnie Sorensen, the Deputy State Health Officer. Our riders are coached to present behavioral health challenges. They act frightened nearly to the point of panic and uncooperative nearly to the point of belligerence. 

Realism. We have made great efforts to allow the exercise to proceed as close to actual conditions as possible. One disease scenario involves a viral hemorrhagic fever. Our victims are moulaged with bruises, bleeding gums and noses, and have vomited into a small trash can on the bus. The vomitus consists of applesauce, oatmeal, creamed corn, and "vampire blood." The rest-room on the bus is filled with blood-soaked towels. In most cases, the victim has a sequestered plastic bag filled with "vomitus" that he/she spills out on the ground or on floor of the hospital emergency room while pretending to vomit. There is luggage in the compartment under the bus with items brought back from the host country. We have coordinated the exercise with the State Warning Point and the Epidemiology Hotline and encourage our county participants to make actual rather than simulated calls to obtain outside support.  

Safety. We present a safety briefing to our simulator team at the beginning of each bus ride.  Many of our volunteers are seniors and teens. We encourage them to stay out of direct sun, to drink plenty of water, and to stay away from response equipment. There are two safety officers for each bus. 

Scenario Variety. We recognize that health departments and other county agencies will talk to each other about the content of the exercises. This is expected, and we view it as good news. Therefore, we give each scenario a different twist. Besides varying the disease scenarios, twists have included having one victim die, separating a victim from a protective spouse, separating a 13 year old victim from a highly protective mother (this led to one of our most poignant and forceful bus rider demonstrations), and having people who actually lived in the exercise county driving home from the bus.

Incident Command. Whoever arrives at the scene first (typically EMS or Law Enforcement) has his or her hands full. In addition to triaging and transporting the victims, other passengers have gotten off the bus and gathered into small groups. Although they are very concerned about their fellow missionaries, they do not want to return to the bus. They complain about the smell of vomit and the possibility of being infected themselves. The counties that have been most successful in establishing quick control over the scene were those that immediately established incident command. In some cases we noted incident command change from law enforcement to health after initial control was established. One county had the incident commander don a vest so that he was clearly visible. Everyone who arrived at the scene was cleared and then directed to report to the IC.  

Law Enforcement. In many cases, sheriff's deputies and community police departments worked together to establish on-scene control. One county called in fire department support to assist in blocking of egress and ingress at the scene. When the decision was made to move asymptomatic but exposed passengers to quarantine, law enforcement provided escort for the bus and secured the quarantine site as well. 

EMS. Whether they arrived first on the scene or not, EMS nearly always made first entry onto the bus.  They were confronted by anxious passengers as well as symptomatic victims. They always found that they needed law enforcement backup. They stabilized the victims and in counties where there were hospitals, transported them. 

Emergency Management. Every county initiated at least partial activation of their Emergency Operation Center (EOC).  Most also had an emergency management representative at the scene.  Two counties began to establish a unified command within the EOC.

Hospitals. Gadsden Community Hospital, Weems Hospital (Franklin), and Trinity Hospital (Hamilton) actively participated in their county exercise. In addition, although it was located in Region I, Calhoun-Liberty Hospital received victims from Liberty County. Hospitals assessed incoming victims, placed them in isolation, developed a presumptive diagnosis (most times in coordination with the county health department), and initiated treatment. Our hospital evaluator from Tallahassee Memorial Hospital simulated exchange of information with EMS units that would have normally transported to TMH, and after a period of time called the county health department administrator with the results of blood tests and a presumptive diagnosis.

County Health Departments (CHD). CHDs have two roles in scenarios like those presented in the exercise -- establish quarantine and initiate the epidemiology investigation to determine the disease origins and degree of exposure. CHDs must work with hospitals to assist in the presumptive diagnosis. The disease used in the tabletop exercise was pneumonic plague. Many CHDs participating in the initial exercises remained convinced that the disease in the field exercise was also pneumonic plague in spite of markedly different symptoms. All CHDs acted promptly to establish quarantine and nearly all sent an epi-nurse to the hospital as a liaison. All CHDs also quickly initiated epi investigations at the quarantine site. The most effective CHDs were those where the administrator personally took charge of the scene and assumed the role of incident command.

Infection Control. In most counties, little attention was paid to the need to control blood and vomit as infectious waste. There were several instances where participants walked through the vomit on the ground. No one checked the bus rest-room for infectious waste. Two counties were concerned that luggage and souvenir rugs on the bus may be carrying vectors (e.g., infected fleas) and needed to be bagged for disposal. We noted that some CHD staff and responders need training in donning and fitting N-95 masks.

Debriefings.  A Hot Wash was held in each county immediately after exercise termination with representatives from each agency involved. A separate Hot Wash was held with bus passengers.  All were requested to complete a "Three Ups and Three Down" form listing three areas or issues that went well and three needing improvement. A representative from each agency was then asked to provide a brief summary of  impressions about the exercise, and exercise evaluators provided a summary of their observations. Each county agency will get a written copy of the evaluation report. 

Five counties are scheduled for September visits, including Leon. There will be an omnibus written and video report of the overall exercise when all are completed. Even now, it is obvious to the exercise team and participants that the arrival of a Beleaguered Bus has brought all an opportunity to improve their response skills and build confidence in their ability to control a public health emergency.
 

► Newest Member of the Epi Team to Market EpiCom

A year ago, Christie Luce was developing training materials and disaster manuals, designing online orientation modules for nursing staff, and coordinating a special needs shelter program. When the Office of Public Health Nursing made changes to its personnel structure, Christie was assigned the task of spearheading a marketing team to identify the mission of public health nursing and convey it to county health departments and children's medical service clinics throughout the state. Her responsibilities also entailed recruitment and retention, statistical analysis and, increasingly, marketing projects.

Marketing has been a good fit for this creative and energetic individual, although her degree from Florida State University is actually in the humanties. Her tenure as a state employee began in the early 1990s, when she worked part-time at the Office of Highway Safety while attending FSU. After a stint at the Department of Commerce giving tours of the Capitol (before the Bureau of Tourism was privatized to Visit Florida), she resumed working at the Office of Highway Safety as a full-time hearing officer.

Christie brings her workforce development and computer skills to the Bureau of Epidemiology with the primary goal of enhancing the EpiCom program. Her immediate aim is to create an EpiCom user manual and on-line tutorial. She will be attending conferences and seminars where there are potential EpiCom users, and working with hospitals to increase EpiCom enrollment and useage.

In her leisure time, she enjoys reading and riding bikes (Harleys, that is). Question: How many women at Lively Tech have graduated first in their class in motorcycle riding?  Answer: Only one!  To reach Christie, e-mail her at Christie_Luce@doh.state.fl.us or phone her at 445.4444, ext. 22450.
      

The Bureau of Epidemiology encourages Epi Update readers to not only register on the EpiCom system at https://www.epicomfl.net but to browse EpiCom frequently and contribute public health observations related to any suspicious or unusual occurrences or circumstances, as appropriate. EpiCom is the primary method of communication between the Bureau of Epidemiology and other state medical agencies during emergency situations.
 

West Nile (WN) Virus activity: One WN positive crow was reported in Hillsborough (6/21) County. So far this year, 21 counties have reported WN activity.

St. Louis Encephalitis (SLE) Virus activity: None this week. 

Eastern Equine Encephalomyelitis (EEE) Virus activity: There were three seroconversions to EEE virus in sentinel chickens from Alachua (6/14), Orange (6/14) and St. Johns (6/14) counties. Four horses, one from Jefferson (6/08), one from Marion (6/17), one from Osceola County (6/09) and one from Polk County (6/12) were reported with EEE infections. So far this year, 19 counties have reported EEE activity.

Highlands J (HJ) Virus activity: None this week.  

* Travel outside of state for most of the probable transmission period.

See the Web page for more information at www.MyFloridaEH.com.   
 

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