Case Study 1: Acute Respiratory Disease Outbreak in a Hurricane Evacuation Center Session Overview | Homework Solution

Case Study 1: Acute Respiratory Disease Outbreak in a Hurricane Evacuation Center Session Overview

Instructions

For this exercise, you will be asked to work in groups to participate in an investigation of an outbreak of respiratory disease. Information regarding the scenario will be provided to you in parts, each of which will be followed by related discussion questions.

Choose one group member to read each segment of information aloud to the rest of the group. After receiving the information, work as a team to formulate answers to each discussion question.

Intended Audience

All public health, medical, veterinary, pharmacy, emergency management, hospital, and other professionals interested in public health preparedness and field epidemiology.

Time Required (estimated)

90 minutes

Learning Objectives

• Identify challenges associated with the public health response to a complex emergency, such as a natural disaster combined with a potential outbreak of infectious disease Acute Respiratory Disease Outbreak
• Describe public health responsibilities to displaced persons during an emergency
• List the steps of an outbreak investigation and describe how to implement them as an outbreak investigation team
• Identify public health legal powers available for management of a complex public health emergency

Case Study 1: Acute Respiratory Disease Outbreak in a Hurricane Evacuation Center

Pre-Test

2. Which of the following describe active public health surveillance in a shelter?
   1. Provide information about the occurrence of infectious diseases
   2. Identify health-related topics about which to educate shelter residents
   3. Monitor sanitation and determine the availability of shelter facilities such as water, toilets, electricity, and medical care Acute Respiratory Disease Outbreak
   4. A and B only
   5. All of the above
3. True or False: Public health departments can conduct medical screening before admitting any new people arriving to a
4. An epidemic curve can be used to provide information on a potential outbreak’s:
   1. Pattern of spread
   2. Magnitude
   3. Time (exposure and/or disease incubation period)
   4. All of the above

Case Study 1: Acute Respiratory Disease Outbreak in a Hurricane Evacuation Center Student Guide

Situation

September 14th:  A Category 3 hurricane with 125 mile per hour winds is approaching the coast. As the Beach County Health Director, you are using your phone tree to call nurses to staff the shelters that the Division of Emergency Management authorities have opened under a mandatory evacuation order. Shelters are located in schools, churches, and community centers across the county and can safely house up to a total of 10,000 people – about 20% of your county’s population – for a few days. Acute Respiratory Disease Outbreak This will cover most residents who live in mobile homes or other substandard housing, as well as those who live in storm surge or flood-prone low lying areas.

Your county also has a mutual aid agreement with Island County to take any residents who can’t be served by their limited local shelters. Based on experience, you know that most tourists have already gone home, and that many residents will prefer to stay in a hotel or with friends or family if possible. In your last Community Health Assessment survey, your health department found that 13% of residents said they would not evacuate if authorities announced a mandatory evacuation, so you are aware that some residents will choose to try to ride out the storm in their homes.

In setting up the shelters, you need to meet residents’ basic needs for food and water. You also want to ensure that basic sanitary conditions will be met and that you have a system in place to cover basic medical care if needed and monitor for possible disease outbreaks. Acute Respiratory Disease Outbreak You also have a plan for documenting the names and addresses of each person staying at a shelter.

1. Consider what you know about the baseline rates of communicable diseases in your community based on regular reporting and surveillance activities. How would your knowledge of these baseline rates be applicable to the situation in the shelter?
2. As a health director concerned with the potential for disease outbreaks in an evacuation center, what would be your primary goals for establishing surveillance in the evacuation centers?

Update 1: Day 1

September 15th: The storm hit your community hard overnight and the impact on your county’s infrastructure has turned out to be far worse than expected. Almost all of the nearly 50,000 county residents have no power. The municipal water system is not able to provide safe water, and a boil water order is in effect. Acute Respiratory Disease Outbreak Trees and power lines are blocking a number of county roads and communication is spotty.

The local hospital is running on generator power, but the main roads leading to the hospital have been flooded. Hospital staff are unable to get into work, so only those who stayed at the hospital overnight are able to provide assistance to the few people who can reach the facility. Some residents with severe injuries are being flown by helicopter to the hospital, but it is basically impossible for community residents to reach the hospital for treatment.

One of your shelters begins to receive a large number of people who did not evacuate prior to landfall, including members of the small homeless population who have been camping at a nearby vacant lot. Other residents are arriving who have walked through floodwaters to get to the shelter. Many who are arriving have minor injuries related to blowing debris and other hazards.

3. Because people arriving at the shelter may have communicable diseases, injuries, storm-related illnesses, or unmet chronic medical needs Acute Respiratory Disease Outbreak (e.g. oxygen, dialysis, prescription refills) that you are not equipped to provide assistance for, would you consider starting a medical screening program before admitting any new people to the shelter?
4. If you decide to use public health legal powers to isolate a portion of the shelter population based on medical screening, what must you legally provide to them?
5. What steps would you take to address potential mental health effects of the disaster?
6. What basic steps of an outbreak investigation might you undertake at this time?
7. How would you assess the potential of a respiratory disease outbreak in the shelter?
8. How would you decide whether people are suffering from a respiratory illness contracted before they arrived at the shelter or an illness contracted during an outbreak at the shelter? Acute Respiratory Disease Outbreak
9. Discuss the elements of an epidemiologic curve or “epi curve” that you might be able to draw based on the results of your cot survey. Below you see two sample epi curves; on the left is an example of a point source epi curve (Fig. 1) and on the right is an example of a person-to-person epi curve (Fig. 2).

Figure 1. Point Source Epi Curve                                 Figure 2. Person-to-Person Epi Curve

11. What further information should you obtain from this person? Acute Respiratory Disease Outbreak
12. Even though you don’t know if this is the same person, would you implement isolation of this person?
13. You know something about infection with TB, transmissibility, and TB disease because of the growing number of cases that you have been seeing in your health Is it appropriate to consider person-to-person transmission of TB in the shelter?
14. Some of the people staying in the shelter are recent immigrants to your community. Should you consider the possibility of reactivation of long-latent TB among these new migrants? How might isolation of suspected cases impact the future willingness of immigrants to come to shelter? Acute Respiratory Disease Outbreak
15. How will you track everyone who leaves the shelter to update them on the diagnosis of the respiratory disease they may have been exposed to at the shelter and get them tested if necessary? Should you consider testing people at the shelter for TB?
16. What are your legal powers and responsibilities to protect the community? Can you keep people at the shelter until you can confirm the diagnosis of TB?

References

Torok M. Epidemiologic Curves Ahead. FOCUS on Field Epidemiology Vol 1, Iss 5. MacDonald PDM, ed-in-chief; Alexander LA, Mejia GC, eds. Acute Respiratory Disease Outbreak Available at: https://nciph.sph.unc.edu/focus/vol1/issue5/1-5EpiCurves_issue.pdf. Accessed April 6, 2016.

Matthews GW, Abbott EB, Hoffman RE, et al. Legal Authorities for Interventions in Public Health Emergencies in Law in Public Health Practice. Goodman RA, ed. New York: Oxford University Press: 2007.

Infectious Disease and Dermatologic Conditions in Evacuees and Rescue Workers After Hurricane Katrina—Multiple States, August–September, 2005. MMWR Morb Mortal Wkly Rep. September 2005;54:961-964. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5438a6.htm. Accessed April 6, 2016.

Epidemiologic Notes and Reports Surveillance of Shelters After Hurricane Hugo— Puerto Rico. MMWR Morb Mortal Wkly Rep. 1990; 39:41-42, 47. Available at: Acute Respiratory Disease Outbreak http://www.cdc.gov/mmwr/preview/mmwrhtml/00001545.htm. Accessed April 6, 2016.

N.C. Division of Public Health. Outbreak Investigations: Outbreak Steps. In: North Carolina Communicable Disease Control Manual. 2012. Acute Respiratory Disease Outbreak Available at: http://epi.publichealth.nc.gov/cd/lhds/manuals/cd/toc.html. Accessed April 6, 2016.