Infectious Disease
Outbreak Investigation
on Campus:
Implications for Risk
Management
How it starts…
• 4:15 pm on a Friday before a holiday
weekend, you get called by (public
health? Residence life? The local ER?...)
notifying you that one of your students
has (fill in the blank) infectious disease..
• What do you do?
Steps for Outbreak Investigation
CDC Definition
But on campus…
1.
2.
1.
2.
3.
Prepare for field work
Establish the existence of an
outbreak
3. Verify the diagnosis
4. Define and identify cases
5. Describe and orient the data in
terms of time, place, and person
6. Develop hypotheses
7. Evaluate hypotheses
8. Refine hypotheses and carry out
additional studies
9. Implement control and
prevention measures
10. Communicate findings
4.
5.
6.
Establish the diagnosis
Assess susceptibility to infection
Identify the source of infection,
potential transmission and
identify contacts
Obtain specimens to allow for
laboratory confirmation
Collaborate with Public Health,
Campus EH&S, Residence life,
VCSA, Risk Management, Dean’s
office…
Communicate Findings
Step 1: Establish the Diagnosis
• Obtain additional clinical, laboratory
and/or radiologic studies to aid in
confirming the diagnosis
RISKS
• Incorrect diagnoses
• False positives—anxiety, wasted resources,
inappropriate and potentially harmful treatment
• False negatives– no/ineffective treatment and
worsening illness; exposure to others
Step 2: Assess Susceptibility to Infection
•
•
Obtain accurate, complete past medical and
surgical history, medications, immunization and
screening histories
Helps clarify WHY illness occurred in case, and
helps understand susceptibility of others
Risks
• Assuming vaccination = immunity; misdiagnose
• Failure to elicit relevant risk factors may impair
accurate understanding of mechanism of exposure
(i.e. partial treatment for TB resulting in MDR-TB)
Step 3: Identify the Source of Infection,
Transmission and Identify Possible Contacts
• Usually done in conjunction with Public Health, but will need
to coordinate and assist
Risks
• Sharing PHI; though important when public health threat (i.e.
active TB), often need to work with non-healthcare providers
to identify index case
• Over- or under-defining the “at risk” group; may create
unnecessary discomfort, anxiety and costs if net cast too
wide, or miss cases if failure to look for cases broadly enough
• Difficulty obtaining information about possible individual
“sources”, and often difficult to contact directly; leads to
delay in dx and treatment of “index” case and may expose
others to infection
Step 4: Obtain Specimens/Tests for
Laboratory Confirmation
• Usually considered “gold standard” for final
determination of “cases”
Risks
• No lab test has 100% sensitivity and specificity
therefore false positives and false negatives occur
and may lead to over and under diagnosis and
resulting risks (see prior slide)
• Costs and discomfort associated with testing
• Problems coordinating access to testing, or
perceived risk by students, may lead to low
screening or testing for illness amongst contacts
Step 5: Collaborate with…
• Public Health; may need to include state and federal, as well as
local
• College Deans
• Campus EH&S
• Risk Services—campus and UCOP
• Residence Life
• Athletics, Housing and Dining, CAPS, etc
***Important to begin this process immediately, and continue
throughout process
RISKS
• Playing “telephone game” where information may be distorted as
the number of involved parties grows
• Confusion regarding HIPAA, FERPA, and what information
can/should be shared, vs. what is private
• Failure to include some important entity
• Problems clarifying who is leading the efforts, and what to do when
“experts” are not in agreement
Step 6: Communicate Findings
•
•
Oral briefing for local campus and other health authorities
Written report that follows the usual scientific format
– By formally presenting recommendations, the report provides a
blueprint for action
– Serves as a record of performance, a document for potential
legal issues, and a reference if the health department
encounters a similar situation in the future.
Risks
• if unclear, may mislead efforts or create document for
assigning blame
• blueprint for action may need future modification, and may
create problems if contradicts written report
Summary
• These situations usually arise on a Friday at 4:30pm
• Never hesitate to call for help!!—County Health Dept,
local Infectious Disease experts, Campus EH&S, other
SHS Directors who’ve had similar experiences
• Be transparent, but don’t share information that has
not been confirmed
• Take time initially to review background data
regarding incidence of disease, risk factors, diagnosis
and treatment
• Save all notices and educational documents—may be
useful in future!
UC San Diego
Investigation of
Active Tuberculosis
UCSD Demographics 2013-2014
• 2013-2014 Total Enrollment: 30,310
• 23,805 undergraduates
•
2,881 (12%) international students
• 6505 graduate/medical/pharmacy students
• ~26% are international students
• 95 % of freshman live in on-campus housing
• 45% of undergraduates live in on-campus
housing
UCSD Active TB Cases
• Since 2009, we have had 10 cases of
active TB
• One case of multi-drug resistant TB (Feb
2010)
• This year we have had 3 cases of active
TB: 2 pleural TB, 1 cavitary pulmonary TB
Demographics of Active TB cases
• 4 cases were undergraduate students
• 1 case was a student who had been an
UCSD undergraduate but was diagnosed
just before she started medical school at
UCSD
• 5 cases were graduate students
• None of these cases were diagnosed from
the required TB screening program began
in 2011 for all incoming students.
Country of Origin of Active TB cases
• 3 from China
• 2 from South Korea
• 1 from Thailand, Vietnam, Macau,
Ethiopia, and Nicaragua
Case
• 21 yo F undergraduate from Macau with 3
mo. history of lump on right side of neck.
No cough, fatigue, fever or night sweats.
Had some weight loss over the past year
but recently gained 7 pounds. Had been
seen for allergies, a monospot done was
negative.
• Had BCG as child, no known TB exposure
Case (cont.)
Physical Exam
T 98.3, RR 16, weight 106, BMI 17.6
Exam notable for
OP: cobblestoning
neck: slightly tender lymph node on the
right posterior neck
pulm: CTA
Case (cont)
Work up for lymphadenopathy started
• CBC, metabolic panel, TSH- all normal
• Quantiferon- Positive
• Patient notified by secure message
Quantiferon test was positive and that she
needed to return for a CXR.
• Pt replied that day saying she would get CXR.
Case
• Patient returns to clinic 9 weeks later for
CXR.
• CXR shows 2.7 density in the right upper
lobe.
• Provider is not notified, sees the result the
following Monday. Patient brought in.
• Still no cough, night sweat, fatigue, weight
loss
• Exam notable for 1.5 cm mobile right
posterior lymph node. Lungs CTA
Case (cont.)
Chest CT done: 2.6 cm cavitary lesion in
apical segment of RLL, also several other
smaller opacities in RUL, RLL, lingula and R
cervical and subclavicular LN
Multiple attempts to contact patient: 3
phone calls, 1 secure message, 1 email- all
with no response. Finally texted patient on
her cell phone which she answered.
Case (cont.)
• Initially arranged to have patient in self
isolation at home and for sputum samples
to be done as outpatient.
• Consulted with pulmonary specialist who
decided to send patient to ED for
admission to ensure isolation and
expedite care.
Case (cont.)
• Patient was hospitalized for7 days.
• Started on RIPE
• Public Health determined that patient
could return to class after 5 days of RIPE
as she had no cough and AFB smears
were negative.
• Patient could return to her apartment as
her roommates had been advised or
tested.
Case (cont.)
• Patient completed 8 weeks induction
treatment of RIPE. TB cultures were pansensitive. Pt continue only on rifampin and
INH.
• Patient was followed by SD Public Healthtook DOT treatment via video chat.
• She finished 4 months of RI treatment.
• Repeat chest CT should improvement of RLL
cavitary lesions and all other pulmonary
nodules and lymphadenopathy.
Exposure screening
• SD Public Health determined who we
screened.
• We needed to screen 2 classes from the
second summer session and 3 classes
from the Fall 2013 quarter.
• 250 students and 5 professors notified
• 73 students came to the tuberculosis
screening clinics for testing.
• 3 known conversions.
Lessons in Risk Management
• Have a low index of suspicion in high risk
patients.
• Use reminder system to ensure that students
return for further testing sooner.
• Work with radiologists to improve
communications. There were delays in
diagnosis as the abnormal reading on the
chest xray and chest CT results were not
given to provider on the day of the readings.
Lessons in Risk Management
• Contact pulmonologist immediately to
determine plan of care (whether to workup as outpatient, direct admit, ED).
• Work with Public Health department to
determine who to screen.
• Coordinate with Department of Student
Affairs, Public Relations office to
determine how to contact students that
were exposed.
Lessons in Risk Management
• Work with Risk Management department
to identify funding for the cost of
screening and treating students that had
waived out of SHIP.
• Work with SD County Public Health to
facilitate screening of students exposed.
29
• Infectious Disease Outbreak
Investigation on Campus:
Implications for Risk
Management
• UC Berkeley
• Mumps
• 2011
30
Steps in Case Investigation
1. Establish the diagnosis
2. Assess susceptibility to
infection: obtain accurate,
complete immunization
histories
3. Identify the source of
Infection
4. Assess potential for
transmission and identify
contacts
5. Obtain specimens to allow
for laboratory confirmation
6. Collaborate with Public
Health
31
32
Good News
/
Bad News
• MUMPS CASES
• Mumps is no longer very
common in the US. Each year,
on average, a few hundred
people in the U.S. are reported
to have the disease.
• Before the U.S. Mumps
vaccination program started in
1967, about 186,000 cases were
reported each year. Since the
pre-vaccine era, there has been
a more than 99% decrease in
mumps cases in the united
states.
• Vaccination rates are suboptimal (MMR
•
•
•
•
autism concerns, waivers) and protection
is incomplete, affecting herd immunity.
YTD 2014: (January 1 to May 2): 464
reported mumps cases. Outbreaks in at
least two U.S. universities : Ohio State
and Fordham University in NY.
2011-2012 smaller outbreaks on college
campuses in California, Virginia, and
Maryland.
2009-2010: two large outbreaks, one
with 3,000 people. Index case recently
returned from UK where mumps
outbreak was occurring.
2006 multi state outbreak: >6,500 cases.
Predominantly affected college-age
students in midwest.
33
Mumps Outbreak
United States
May 2, 2006
3
55
1
257
22*
1609
248
279
1
499
101
2
34
Mumps at Berkeley (2011)
• 1. Establish Diagnosis
• Student newly arrived to
Conflicting
• Clinical case definition: illnesscampus.
characterized
by acutevaccine
onset of
history.
Recent
travel
to Europe
unilateral or bilateral self-limited
swelling
of the
parotid
or
later.and without
other salivary gland(s) lasting revealed
at least 2 days
apparent cause
• CC: onset of pain immediately
after biting down hard while
eating
• Average incubation period for mumps 16-18 days (range 12-25
• Initial impression was cellulitis
days)
• Developed testicular pain 6
days later
• Referred for testing for mumps,
but despite repeated requests
did not follow through
35
2. Obtain complete, accurate,
immunization history...but beware false
sense of security
•
•Roommate of the index case
came in 3 weeks later with
fatigue and swelling neck and
jaw. He had 2 documented doses
of MMR.
•Serologies: IgM negative/IgG
positive. No PCR done.
•Isolated for 5 days
•No public health notification
36
ACHA Guidelines
Recommendations for Institutional Prematriculation
Immunizations (April 2014)
• The ACHA “strongly supports the use of vaccines to protect the
health of our individual students and our campus
communities” and follows the CDC ADIP guidelines.
• In recognition of the “vital role of herd immunity” ACHA
discourages use of nonmedical exemptions to required
vaccines and advises counselling by a health services clinician
if exemptions are sought
• Consider exclusion of un-immunized students from school
during outbreaks of vaccine-preventable diseases
36
37
3. Identify the source of the Infection
• 29 cases identified (lab
confirmed or epi linked)
• 93% were students; one was
a public health staff
member that had assisted
during mumps vaccination
clinic!
• 76% had 2 doses of MMR ( =
fully vaccinated)
38
4. Assess Potential Transmission
and Identify Contacts
•Initial disclosure of
records to Public Health
was limited under FERPA
until the CDPH declared
the mumps outbreak an
emergency
•Collaborate with Public
Health
39
Family Educational Rights and Privacy Act
(FERPA) Statute: 20 U.S.C. § 1232g Regulations: 34 CFR Part 99
• FERPA is the Federal law that
protects the privacy of students’
education records.
• FERPA applies to educational
agencies and institutions that
receive funds under any program
administered by the Secretary of
Education.
• Medical or health related records
are “education records” subject
to FERPA.
• Exception: “a health or safety
emergency.”
39
•
An educational agency or institution
must record the following
information when it discloses PHI
under the health or safety
emergency exception in FERPA:
– The “articulable and significant
threat to the health or safety of
a student or other individuals”
that form the basis for the
disclosure; and
– The parties to whom the
institution disclosed the
information.
40
5. Obtain Specimens to allow for
Laboratory Confirmation
•
CDC
recommends
both be collected
from all patients
with clinical
features
compatible with
mumps, since
neither is
perfect:
• buccal or oral
swab specimen
(for PCR) and
• blood specimen
(for serologies)
41
Measures Taken
•Advisory to health care providers to be on the alert
for mumps, with guidelines for evaluation
•Advisory to campus including symptoms of mumps
and importance of urgent evaluation if any concern
•Isolation of all potential cases for 5 days
•Advised staff and students to review personal
immunization records and get updates as indicated.
•Provided MMR immunizations to 3,631 persons
within 1 month (1700 the first day)
•Reminders to campus community regarding cough
etiquette, respiratory and hand hygiene
42
43
Communicate Frequently
•
•
•
•
•
•
•
•
Mumps Outbreak
October 4, 2011
The UC Berkeley campus community is experiencing an outbreak of mumps. University Health Services and the City of Berkeley’s Public Health Division are working closely with the California
Department of Public Health to limit spread of the disease.
Mumps is a contagious viral infection that is spread by droplets of saliva or mucus, coming from the mouth, nose, or throat of an infected person. Most commonly symptoms develop 16-18 days
after exposure to the virus (range 14-25 days).Treatment for mumps consists of rest and fluids. Antibiotics are not useful.
To protect your health we urge you to do the following:
Review your vaccination records. We recommend vaccination for those who are not certain they have received 2 doses of MMR. There is good evidence that an additional (3rd) dose of MMR
provides increased protection from mumps in the setting of an outbreak such as this. We strongly encourage all UC students, faculty, and staff, regardless of vaccination status, to
receive an additional dose of MMR.
•
–
•
•
MMR Vaccine is available:
–
•
•
•
Note: MMR vaccine is not appropriate for pregnant women or for individuals with weakened immune systems.
Thursday, October 6th from noon- 6pm
Education Center at the Tang Center 2222 Bancroft Way, Berkeley. There is no charge for UC Berkeley students. No appointment is necessary.
Be alert for symptoms of mumps over the next 3-4 weeks: fever, headache, muscle aches, fatigue and loss of appetite, swollen or tender salivary glands under the ears, jaw or under the
tongue, on one or both sides of the face.
•
–
•
•
•
•
Stay home if you develop symptoms. Do not attend classes or work for 5 days after the onset of symptoms to help limit the spread of the disease to others.
Contact your healthcare provider. If you are a UCB student or established patient at Tang, please call our nurse advice line at 510-643-7197. We can collect a swab of your cheek to help
identify whether your symptoms are related to mumps.
Protect yourself: Wash your hands frequently or use a hand sanitizer. Cover your cough to reduce the spread of disease. Do not share eating utensils, drinking glasses, water bottles, etc.
Avoid close contact with those that are ill.
44
Welcome To Isolation
•
•
•
•
45
Lessons Learned
•Patients are infectious before onset of parotitis and
asymptomatic patients can transmit disease
•Even persons who have had two doses of MMR
might not be protected. Effectiveness of 2 doses of
vaccine estimated between 66-95% -- maintain
high level of clinical suspicion
•Documentation of immunization records facilitates
contact investigation
•Isolation is an important strategy but even strict
isolation is unlikely to completely interrupt disease
transmission and implementation can be difficult
46
Lessons Learned
•Communication to campus community important
initially and must be maintained in an ongoing
manner
•Disclosure requirements under FERPA can
complicate contact investigation
•More data is needed regarding the effectiveness of
a third dose of MMR in a mumps outbreak
•Prematriculation immunization requirements
useful in reducing incidence of outbreaks and
targeting immunization efforts if an outbreak
occurs.
47
Remember You are Not Alone.
48
Resources
49
Quick Sheets
50
Laboratory Testing Guidance
51
Other Resources
•CDC
•Campus Partners including PIO, Residential
Life etc
•Medical Reserve Core
•Staffing Agencies
•Other