Infectious Disease Outbreak Investigation on Campus: Implications for Risk Management

1. Infectious Disease Outbreak Investigation on Campus: Implications for Risk Management

2. 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?

3. Steps for Outbreak Investigation CDC Definition But on campus… 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 • Prepare for field work • Establish the existence of an outbreak • Verify the diagnosis • Define and identify cases • Describe and orient the data in terms of time, place, and person • Develop hypotheses • Evaluate hypotheses • Refine hypotheses and carry out additional studies • Implement control and prevention measures • Communicate findings

4. 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

5. 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)

6. 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

7. 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

8. 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

9. 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

10. 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!

12. UC San Diego Investigation of Active Tuberculosis

13. 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

14. 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

15. 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.

16. Country of Origin of Active TB cases 3 from China 2 from South Korea 1 from Thailand, Vietnam, Macau, Ethiopia, and Nicaragua

17. 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 monospotdone was negative. Had BCG as child, no known TB exposure

18. 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

19. 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.

20. 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

21. 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.

22. 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.

23. 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.

24. Case (cont.) Patient completed 8 weeks induction treatment of RIPE. TB cultures were pan-sensitive. Pt continue only on rifampin and INH. Patient was followed by SD Public Health-took 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.

25. 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.

26. 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.

27. Lessons in Risk Management Contact pulmonologist immediately to determine plan of care (whether to work-up 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.

28. 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. 29 • Infectious Disease Outbreak Investigation on Campus: Implications for Risk Management • UC Berkeley • Mumps • 2011

30. 30 Steps in Case Investigation • Establish the diagnosis • Assess susceptibility to infection: obtain accurate, complete immunization histories • Identify the source of Infection • Assess potential for transmission and identify contacts • Obtain specimens to allow for laboratory confirmation • Collaborate with Public Health

31. 31

32. 32 Good News / Bad News MUMPS OUTBREAKS • 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. 33 Mumps Outbreak United States May 2, 2006 3 55 1 257 22* 1609 248 279 1 101 499 2

34. 34 Mumps at Berkeley (2011) • 1. Establish Diagnosis • Clinical case definition: illness characterized by acute onset of unilateral or bilateral self-limited swelling of the parotid or other salivary gland(s) lasting at least 2 days and without apparent cause • Average incubation period for mumps 16-18 days (range 12-25 days) • Student newly arrived to campus. Conflicting vaccine history. Recent travel to Europe revealed later. • CC: onset of pain immediately after biting down hard while eating • Initial impression was cellulitis • Developed testicular pain 6 days later • Referred for testing for mumps, but despite repeated requests did not follow through

35. 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. 36 ACHA GuidelinesRecommendations 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

37. 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. 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. 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.” • 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. 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. 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

43. 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. • Note: MMR vaccine is not appropriate for pregnant women or for individuals with weakened immune systems. • MMR Vaccine is available: • 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. 44 Welcome To Isolation

45. 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. 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. 47 Remember You are Not Alone.

48. 48 Resources

49. 49 Quick Sheets

50. 50 Laboratory Testing Guidance