University of Illinois at Chicago, School of Public Health
Karyn M. Warsow, MS, MPH, University
of Illinois at Chicago, School of Public Health
Kuntal A. Rana, MPH, University of Illinois at Chicago, School of Public
Health
Yewande Morgan, MPH, University of Illinois at Chicago, School of Public
Health
Roman Golash, MA, MBA, Special Bacteriology/Bioterrorism Unit, Illinois
Dept of Public Health
Adapted from Leadership in Public Health 2002;6(1):39-48
On July 10, 2002, the County Health Department was contacted to investigate a suspected case of smallpox in a patient admitted to a local hospital complaining of acute flu-like symptoms since 7/1/02. As a result 240 cases were investigated.
The State Department of Public Health assisted by the Center for Disease Control and Prevention (CDC) confirmed 21 case of active smallpox and 219 possible cases pending PCR (polymerase chain reaction) and morphogolic identification. The suspected epidemiologic path of transmission was traced to a college demonstration opposing the war in Afghanistan. The origin of infection is yet to be determined.
The Neisseria State Department of Public Health was created in 1877 to regulate medical practitioners and to promote sanitation. Today, it is responsible for protecting the state's 12.4 million residents, as well as countless visitors, through the prevention and control of disease and injury. The Department's nearly 200 programs touch virtually every age, aspect and cycle of life.
The State of Neisseria is divided into counties with all but four counties served by a local health department; those counties utilize the State Health Department. Local Health Departments review the frequency and source of institutional calls regarding suspected disease patterns and are ultimately responsible for contacting the State to request an evaluation. The current system is set-up discordantly, in which community-based civilian hospitals lack an effective mode of communication between each other and, as a result, are unaware of each other in terms of outbreaks and the incidence of disease. However, the division of Infectious Disease at each hospital is responsible for continuous review and follow-up of all patients diagnosed with community-based and nosocomial active infections. This includes identification of pathogens, but excludes colonization of the common organisms. However, microorganisms resistant to antimicrobial therapy (Minimum Inhibitory Concentration (MIC) >1) and colonized are reported. A structure is in place to reflect reporting of communicable diseases mandated for entry into the State database that oversees incidence and disease patterns. A deficiency is seen in the time lag between diagnosis and time of reporting from the health care provider and/or health care facility.
The Neissaria State Laboratory is designed by the CDC as a level B (+), due to quality control and monitoring required to maintain confidentiality of specimen processing and testing protocols for pathogen identification. The State is not allowed to work with hospital laboratories (Level A). The Neisseria State Laboratory is equipped with sophisticated instrumentation to improve the accuracy of pathogen identification including PCR and immuno-antigen testing. Specimens are sent to a level C and D (CDC and Fort Detrick) for further animal and molecular investigation and confirmation.
The Coli County Health Department was established in 1956 by referendum as a state-certified pubic health department. The department consists of primarily five divisions: administrative services, behavioral health services, community health services, environmental health services and primary health services. They have a budget of $37 million which supports 60 separately funded programs and more than 850 professionals comprise their staff. The county has 644,000 residents, 67,000 uninsured residents, and 75,000 underinsured residents with a disproportionate amount of underserved populations in various cities.
Coli County Hospital is located in Neisseria's northern suburbs and is an academic healthcare system comprised of six entities. The system includes three hospitals, Aureus, Proteus and Tropicalus Hospital. As an integrated health care delivery system, the Corporation also includes a Medical Group, Home Services and Research Institute. For seven consecutive years Aureus and Proteus Hospitals have been named among the Top 100 nationally and among the Top 15 Major Teaching Hospitals.
Coli County Hospital is committed to preserving the overall health of the surrounding communities and has implemented a syndromic surveillance system to detect signs and symptoms of communicable disease without any obvious mode of exposure. This program, conducted in partnership with the Coli County Health Department, is based on an intensive educational program aimed at increasing awareness of the medical staff to enable accurate detection of the differences between diseases that have a similar clinical presentation.
A 30-year old black female was admitted to Coli County Hospital with a suspected diagnosis of chickenpox and a 5-day history of fever, vomiting, headache, backache and lethargy. The patient reported acne like pustules that began to appear on the extremities, specifically soles of the feet and palms of her hands. The lesions progressed to form a scab, which would eventually fall off. Specimens of the purulent fluid were taken for culture and sensitivity. Comfort measures were instituted including hydration and antimicrobial therapy. However, after a long and complicated hospital course involving temperature spikes of 105-106 degrees Fahrenheit, a number of nosocomial infections and hypovolemic shock, the patient expired 3 weeks post admission due to multisystem organ failure secondary to sepsis.
In the hospital laboratory, designated as Level A for specimen processing, the microbiology technician, Serratia Bug-Me, receives a culture identified as: Purulent Drainage/Extremity Lesions/Suspected Chickenpox. He is careful to follow standard operating procedures for specimen processing and maintains Universal Precautions by wearing latex gloves, a coat and respiratory mask while preparing the culture medium and specimen material under a BSL3 workstation (designated area equipped with airflow suction on the ceiling and hooded ventilation). The culture is left to incubate for 24 hours. The next day Serratia checks the culture's rate of growth under the electron microscope and notices an unusual pattern of the vegetative cells. The morphology of the cells is unlike anything the technician has ever seen in his 20 years of practical experience.
Out of curiosity, the technician makes a call to a representative of the Special Bacteriology Unit at the Neisseria State Department of Public Health. After a brief consultation, Serratia is advised to send an isolate of the infectious material to the State Laboratory, designated Level B, for further morphological identification of the pathogen taken from the patients' alleged Chickenpox lesion. Serratia is very careful to prepare the specimen for transport as a biohazardous infectious agent. While dividing the sample into the second petri dish under the BSL3 workstation, he takes off his mask to sneeze. The probe with the vegetative cells, still in his hands is brought away from the workstation. Unconsciously, Serratia breathes in deeply and wipes his eyes with his free hand. He looks down and realizes that the specimen held in his other hand is not contained.
Concurrently, Epidemiology/Infectious Disease Nurse, Variola Exudate, is reviewing the hospital admissions from the past 2 weeks, and notices that 7 patients had been diagnosed with adult Chickenpox. As part of her job description, it is Ms. Exudates responsibility to follow up on all cases involving communicable disease. She discovers that 6 of the patients were treated and sent home and one patient died a couple days ago. She goes to Medical Records to make a request to review the charts of all 7 patients. The chart of the patient that had expired was still being assembled in Correspondence, so Ms. Exudate took the 6 available charts to dictation. After careful analysis, there appeared to be no real difference between the cases in terms of their physical examination or recommended treatment by the attending staff physician. The gram stain and culture results were still pending, which seemed a little strange, but Ms. Exudate failed to call microbiology for verification. The discharge summary indicated that each patient was instructed to return to the outpatient clinic if signs and symptoms persisted.
Ms. Exudate called the Coli County Local Health Department to inquire whether or not any other cases of adult onset Chickenpox had been reported. The Epidemiologist at the local health department was busy and said that she would get back to the nurse within 24 hours after checking the database, but to her knowledge, there had been no other reports. Ms. Exudate hung up the telephone and sat in the dictation room thinking. She decided to call up to the clinic to see if anyone could check the admission log for return visits of the patients she was investigating. She picked up the telephone and dialed. There was no answer. She tried again. No answer. Frustrated, she walked up to the clinic. As she entered the waiting area, the clinic staff soliciting her for assistance overwhelmed her. The waiting area was filled with at least 20 people including members of the medical staff who were seriously ill with an alleged diagnosis of adult onset chickenpox.
The Board of Governors, advised by the Chief Medical Director of Coli County Hospital, called a code gray and disaster measures were initiated. Morphological confirmation of Variola virus from the Neisseria State Department of Public Health was pending, but would be available within 24 hours. All hospital admissions involving infectious type lesions were quarantined. At the Children's Hospital, 23 new cases of Chickenpox were diagnosed in the emergency room.
Independently, the Coli County Health Department initiated bacteriologic emergency protocols based only on hospital microbiology reports of a possible Variola virus isolated from culture. They had no other choice. There was no preparation made for a massive viral crisis. In their omnipotence, Coli County Health Department chose to act immediately instead of waiting for the results of an extensive morphological work-up that was being conducted at the Neisseria State Laboratory to determine the species of the pathogen.
The decision was made not to alarm the community. It was for their own good. Representatives from the Coli County Health Department and hospital administrators called a public meeting involving the media to assure the citizens that the situation was under control. The anxiety and fears of the people were nonchalantly dismissed and regarded as an overreaction. There was hysteria in the community. People fled to their homes, ignoring the community officials. They gathered their belongings and loved ones to escape the blight using any mode of transportation available.
Coli County Health Department immediately contacted the Neisseria State Department of Public Health. Additional specimens from two different hospitals were sent for processing and identified as the Variola virus. The State contacted the Center for Disease Control and Prevention (CDC). An alert was faxed immediately to all surrounding hospitals indicating the correlation of signs and symptoms between the smallpox and chickenpox. Daily progress reports were made to the Neisseria State Health Department regarding the patients' status, prognosis and diagnosis of new cases.
The most important part of containing the spread of the smallpox virus was to locate the host. After an intense investigation that required the assistance of local law enforcement, the FBI and CDC, it was determined that the host was in fact the patient who had expired. Further epidemiologic investigation discovered that the patient had attended a college demonstration opposing the bombing of Afghanistan and was suspected of volunteering for a suicide mission. Fifty-four of the cases were identified as having attended a college rally. Two cases were indigent persons who were seen in the emergency room and released. Local law enforcement were called to check out the homeless shelters and the parks for these individuals since no locator information was available at this time. This is not just a health concern, but also involves the well-being of the entire community in terms of safety, environment, economics and legalities.
It is also theorized and investigation continues to uncover evidence to confirm that the Smallpox virus was housed in a SS18 bomblet warhead and released near the college. This release of the aerosol, taking into consideration the regions wind currents, would elicit a massive epidemic. Due to the pending threat, the following organizations have been called into action to assist the local authorities: military, Secret Service, ATF (Alcohol Tobacco and Firearms) and the State Police.
Merely disseminating information without regard for communicating the complexities and uncertainties of risk does not necessarily ensure effective risk communication. Well-managed efforts ensure that the messages are constructively formulated, transmitted and received and that they result in meaningful actions. The goal is to produce an informed public, not to defuse public concerns or replace actions. Through a partnership between the State and Local Health Departments, it was agreed upon to implement a proposed plan based on the guidelines established by the Agency for Toxic Substances and Disease Registry (ATSDR) for risk communication.
With the proposed risk communication in place, the State and County Health Departments made the decision to go public with the outbreak when the CDC had confirmed the identity of the specimens and the potential for secondary spread had significantly increased due to the number of personal contacts reported by each victim.
The Executive Director of the Neisseria State Health Department and the Director of the Coli Community Health Division were chosen for their ability to keep the message focused and to minimize any discrepancies in the information given. It is important that the public receive accurate information from credible sources in order to minimize the amount of false phone calls that the Health Department might receive. This enabled public health officials to focus time and energy in the right direction so that all secondary infections could be identified and treated and so that the scope of the outbreak could be narrowed.
Public communications with coworkers took place through news releases and fact sheets, site tours, meetings to address questions and concerns, hotlines, and unit newspaper articles. Public communications with area residents took place through community meetings, newspaper articles and ads, radio and TV talk shows, fliers, films, videos and other materials at libraries, and direct mailings. Public communications with elected officials, opinion leaders and environmental activists took place through frequent telephone calls, fact sheets, personal visits, invitations to community meetings, news releases, and advance notices. Communications with the media took place through news releases that focused on the message, clear, informative fact sheets, site visits, and news conferences.
Through effective risk communication, information was disseminated to the public in an attempt to diminish secondary spread. The State and County Health Department understand that they cannot always prevent outbreaks, but they do have a duty to minimize the risk.
The coalition formed was composed of the director of the Coli County Health Department, Neisseria State Health Department, chairmen of the teaching hospitals, directors of various community-based organizations and directors of the state and local laboratories. The goal was to determine what resources were available and what would be required to handle a future epidemic of Smallpox or other contagion. Through the negotiation process, it was agreed that each organization would ensure that its staff was knowledgeable concerning the accurate diagnosis of Smallpox as compared to Chickenpox, procedures for treatment and quarantine of suspected cases, as well as reporting cases to the State for entry into the database. The database system would be utilized to identify similarities between reported cases and to confirm whether personal contacts of the victims had been identified. In addition, it was determined that all the hospitals would establish an effective and efficient system of syndromic surveillance. Should it be necessary to quarantine large areas, restrictions would be followed to set boundaries beginning at the neighborhood level and progressing, if necessary, to county levels. Laboratory staff would be properly trained and required to adhere to standard operating procedures (SOP) regarding specimen processing and employee safety.
Alliances were also formed between community-based organizations, law enforcement agencies and the media. These alliances would serve to provide information to the communities regarding infectious diseases, quarantine procedures, measures for preventing and controlling an outbreak.
The Coli County Health Department and the Neisseria State Department of Public Health initially were neither effective nor efficient in handling the Smallpox outbreak. Several lapses of communication, lack of proper education of the health care professional, poor surveillance and deficient policy development identified in the scenario resulted in the delay of successful management of the Smallpox epidemic. However, there is always some good that comes from the threat of evil. Through intensive strategic planning and negotiation, a cohesive program was designed and implemented to anticipate the occurrence of unexpected events that could threaten the health of the community.
Pox Case Study last revised July 06, 2006 (csong)