Management of a Disease Outbreak Meningococcal Infection at a High School

1. Management of a Disease OutbreakMeningococcal Infection at a High School Luc Van Parijs, MD, MPH, DrPH Lgvanparijs@cs.com The author is a scholar of the North East Public Health Leadership Institute, Class of 2000.

2. This lecture is one of series produced by the Allegheny County Health Department (PA), Bethlehem Health Bureau (PA) and the City of Elizabeth Department of Health & Human Services (NJ). • The organizers of this project are scholars in the Northeast Regional Public Health Leadership Institute, Class of 2000. For information contact: dcw01@health.state.ny.us

3. Luc G Van Parijs, MD MPH DrPH • Public health physician - till recently Director of the Division of Communicable Disease Control of a local health department - with strong interest in disease reporting and the management of disease outbreaks. For 25 years epidemiologist and manager of national and international prevention programs (heart disease, cancer, STD and leprosy). Extensive experience in teaching African and Asian health care providers.

4. Learning Objectives • Know clinical and epidemiological features of meningococcal infection • Know steps in outbreak control and required outcomes • Appreciate need to work together with key persons • Understand public perception/response to outbreak • Understand relationship of leadership to success in controling an outbreak

5. Performance Objectives • list key features of meningococcal infection • articulate outcomes of a control strategy • discuss factors that influence control strategy • provide consistent response to questions about meningococcal infection • act timely and consistently in a crisis situation

6. INTRODUCTION This lecture is an exercise in leadership analysis. It provides a unique perspective of analyzing a disease outbreak from the perspective of: * Clinical & Epidemiological Factors * Public Health Response * Leadership Leadership is often overlooked in successful disease outbreak management. The lessons learned from this case are applicable to other outbreak situations

7. Clinical and Epidemiological Features

8. Meningococcal infection -1 • Bacterial (pathogenic) agent • Neisseria meningitidis with multiple serogroups (A, B, C, Y, W…). In US mainly B, C and Y ( ~ 30% each) • Two clinical forms • Meningitis, meningococcemia or combined • Onset & Progression • Abrupt, strikes healthy individuals without warning • Case fatality Rate (CFR): meningitis ~10%, meningoccemia > 80%

9. Incidence LOW, ~ 1 case per 100,000 US population, but public concern HIGH All ages affected. Highest rates in < 5 yr; more cases in winter/early spring Serotypes by age group: B > in infants, C > in young people/adults, Y >in older people In outbreaks: usually serogroup C 10-15 % carriage in nose/throat of healthy individuals (colonization of mucosa). However, unknown why a carrier develops invasive disease Risk factors: crowding (army barracks, college dorms, parties), immune disorders, smoking, respiratory infections, climate, poverty Meningococcal Infection -2

10. Treatment (1) Early Dx & prompt Rx of case reduces CFR & sequellae (2) Intensive & supportive hospital care, including anti-microbial drugs (3) Prompt reporting of case to health department (HD) (4) HD (and health care provider) initiates prevention Meningococcal Infection -3 • Prevention (1) Chemoprophylax (Rifampin/Ciprofloxacin) close contacts exposed to case; it clears pathogen in 24-48 hrs (2) Vaccinate (Menomune) people at high risk to prevent spread of infection; it induces active immunity but with a lag period of 10 days, indicated if case rate 10/10,000 in < 3 months in same setting

11. Public Health Response

12. Main Events • Two cases of meningococcal infection at a large high school in three weeks • First case (boy 17 yrs) • survived • close contacts prophylaxed • Second case (girl 16 yrs) • died • close contacts prophylaxed • students and staff of high school vaccinated (1 week later) • Intensive media coverage

13. Case 1: Chronology of Events • 3/9 (Thu) case reported ill at school & sent home • 3/16 (Thu) onset symptoms & hospitalization • 3/17 (Fri) case reported to health department (HD) • 3/18 (Sa) laboratory confirmation of meningitis • 3/19 (Su) serogroup C identified • 3/19 (Su) school principal informed by HD and HD establishes a preliminary list of close contacts • 3/20 (Mo) case discharged with no sequelae • 3/20 (Mo) HD staff meets with senior staff of high school and hospital-based physician to review situation & reach consensus on control strategy

14. Case 1: Control Strategy • General meeting with staff and students • Prepare and send letter to parents • Start chemoprophylax of close contacts • Answer questions of parents, local physicians and media at an evening town hall meeting at school

15. Case 1: Expected Outcomes -1 • Accurate and timely information to alleviate fears, and obtain compliance with control measures • Audience: high school students, parents and staff; health providers in local area; media • Subjets: meningococcal disease, events at school and control strategy • Means: general meeting, town hall meeting, general letter, response to phone calls

16. Case 1: Expected Outcomes - 2 • Composition of a “response” team with key persons to initiate control measures • Define tasks and responsibilities of school, health department, and health care providers • Assign a spokesperson(s) for consistency of messages • Share resources (staff, rooms, medications, calls) • Act quickly & decisively, but keep calm & in touch with events

17. Case 2: Chronology of Events-1 • 4/8 (Sa): abrupt onset of disease, patient hospitalized, rapid progression of disease, transfer patient same day to tertiary facility but fatal outcome (4/9) despite intensive medical efforts • 4/8 (Sa): case reported to HD • 4/8 (Sa): school principal informed by HD • 4/9 (Su): list of possible close contacts composed • 4/10(Mo): meeting HD staff with school staff & hospital physician to review events & decide on strategy

18. Case 2: Chronology of events-2 • 4/10 (Mo): info-meeting with school staff and students • 4/10 (Mo-evening): town meeting with parents • 4/11(Tu): start chemo prophylaxis of close contacts at school (family contacts prophylaxed at hospital on 4/8) • 4/10 (Mo) and onwards: daily queries from media; coverage of events on TV, radio and in newspapers

19. Case 2: Chronology of Events -3 • 4/13 (Thu): confirmation of serogroup C • 4/13 (Thu): communication HD with State HD about outbreak criteria and advisability to initiate vaccination of high school community • 4/14 (Fri): telephone conference HD, State HD & CDC to decide on vaccination • 4/14 (Fri): meeting at high school to discuss rationale for vaccination and develop a vaccination plan. • 4/14 (Fri): composition and diffusion of press release by County Health Department

20. Case 2: Chronology of Events -4 • 4/15 (Sa): high school open for parents to obtain vaccination consent forms & ask questions • 4/16 (Su): town meeting to explain vaccination (why, who, when) & answer questions/concerns • 4/17 (Mo) through 4/19 (We): vaccination of students and staff (n= 1,997) at cost of $ 134,000. Some vaccinations by private physicians • From 4/10 onwards active surveillance by HD to detect possible meningococcal cases. No new cases reported.

21. Case 2: Control Strategy -1 • Clarify scientific foundation of recommendation to vaccinate • Prevent panic and false rumors among students and staff • Timely informed by school principal who appealed to calm despite tragic event & to positive attitude towards preventive measures (prophylaxis and immunization) • Deal with parental anxiety and obtain compliance with vaccination effort • Team presented facts and decisions at town meeting with room for discussion of concerns and disagreements • Vaccination criteria articulated by a “unified” team • Team firm and consistent on who should be vaccinated

22. Case 2: Control Strategy -2 • Media • Assigned same spokes-persons for media queries and had key points prepared • Assured that all staff adhered to the same key messages when dealing with parents, students, phone calls from the community • Team showed attitude of cooperation with media and stayed calm under intense scrutiny

23. Ingredients of a Public Health Response • Adhere to scientific understanding of disease and control measures • Compose a team with key leaders to deal with crisis • Pay close attention to community and media reactions • Plan chemoprophylaxis and vaccination and act swiftly and decisively • Check for new cases. There was no third case

24. Leadership in managing an outbreak

25. The situation • Two meningitis cases occurred in a large, prestigious high school • The outbreak received high priority: staff and resources were made available • The school had dealt with crisis situations before • There was a procedure to deal with a crisis • Principal showed leadership • Staff had the capacity to act at short notice. No time lost in territorial fights • People involved: staff of Health Department and School, and hospital physician

26. Personal role in outbreak • As Montgomery’s County Director of Communicable Disease Control, had previous experience in organizing a public health responses to disease outbreaks • Acted in this case according to best science and public health practice, forged joint effort between health department/high school/hospital, dealt with community/media, briefed staff, consulted with external resources, assumed full responsibility for outbreak management

27. Expected Achievements • Outcomes: • Prophylax all close contacts and immunize high risk group within time frame • Maintain active surveillance of new cases • Prevent rumors, alleviate fear, and educate community about meningitis • Selected strategy: • Provide timely, accurate, consistent and people-oriented information to parents, students, school staff and media • Work as a team: HD, school, health care providers

28. Collaborative effort • Representatives of the High school, the hospital and the Health Department were experienced in crisis situations, competent in their respective areas and had a clear view of respective roles • HD led the organization of a public health response to the meningoccal cases • The school led pro-active information efforts to students, staff and parents • A respected hospital physician assisted in defining the response and liaised with medical community • The response was perceived by the community as a joint effort of county HD, high school, and local area hospital

29. Principles and Values Applied • Show concern • Acknowledge concerns of family, parents, staff and students • Act on people’s right to be kept informed of events • Assume responsibility • Take public health measures to prevent new case (s) • Believe in positive outcome • Communicate what each step is expected to achieve • Keep composure in face of criticism and opposition

30. Recognition of successful outcome • Thank you letters to • School principal and his staff • Hospital physician • Health department staff • Should have been done • Debriefing of HD staff and review of lessons learned • Some form of celebration of a successful outcome

31. Lessons about leadership -1 • Different leaders emerge at different times The Communicable Disease Director of the HD was placed in a leadership position to manage the different phases of control and to act as central spokesperson, yet other leaders emerged and were essential to success: • Superintendent: created supportive climate • School physician: was practical & effective with staff • Principal: had clear vision of image of school, acted swift and decisively • Hospital physician: provided medical expertise and credibility, offered resources

32. Lessons about leadership-2 2. The community expects an impeccable performance of the HD but also wants to be heard. This right should be recognized even if there are dissenting voices 3. In a control strategy, a leader is responsible to balance elements of science, team work, community and media relationships, and the organization of preventive work 4. You can do more and be more than you think