Use of Incident Command Structure (ICS) in the Public Health Response to a Human Rabies Case

1. Use of Incident Command Structure (ICS) in the Public Health Response to a Human Rabies Case Diseases in Nature Conference June 11, 2007 Cindy Kilborn, MPH, M(ASCP) Chief Epidemiologist

2. Objectives • Describe: • Investigation of case • Recognition of magnitude of response required • Decision to utilize ICS • Discussion of action taken

3. Overview of the Disease • Fatal viral infection of the Central Nervous System • Reservoir • Raccoons, skunks, bats, foxes and coyotes • Usual mode of transmission • Bite (or exposure to saliva) of infected mammal • Other: mucous membranes, aerosol, corneal transplant, etc. • Incubation period • several weeks -10 yr or longer • Characteristic symptoms • Fever and malaise, insomnia • Anxiety and confusion, abnormal behavior • Agitation progressing to delirium and hallucinations

4. Case Report-May 2006 • 16 yr old male • May 4-complained of hypersensitivity and fear of swallowing • May 5-symptoms worsened • Tremors, involuntary movement of extremities, 4+ anxiety • Hx of no food, water or sleeping for 24 hrs • Lucid, oriented, answered questions appropriately • Community hospital emergency department • Initial clinical assessment-”altered mental status” • Transferred to tertiary care hospital • Low suspicion of infection • Jerking motions exacerbated by touch • Clinical impression-”anxiety attack”

5. Case Report-May 2006, cont. • Transferred to area psychiatric facility • Developed fever, headache, projectile vomiting • Decision to transfer back to tertiary hospital • Condition worsened • Diverted to original hospital for intubation/stabilization • May 6-Admitted to tertiary hospital • Incoherent, could not recognize parents • CSF-no organisms seen • Dark brown emesis • “glassy eyed” • Steady deterioration

6. Case Report-May 2006, cont. • 2nd tertiary hospital visit-parents mention possible bat exposure • Approximately 4 weeks prior to onset • Felt rustling on cheek while napping • Found bat in room (window open/no screen) • Informed parent • Bat caught with towel and discarded • Not reported to physician or health dept.

7. Case Report-May 2006, cont. • May 6-Infectious Disease physician called DSHS and CDC • Information on submitting specimens • Specimens submitted on May 8; result positive May 9 • Feasibility of implementing treatment protocol used successfully in Wisconsin 2004 • Not implemented • May 12-case expired • 1st human rabies death in Texas since 1997

8. Initial Public Health Response • May 8-HCPHES Epidemiology received possible rabies case • Info from DSHS 6/5S Zoonosis Control staff • Son in same school as case • Call from school district health coordinator • Also reporting a possible rabies case in a student • Immediately contacted DSHS Infectious Disease Control Unit (IDCU) • Did not know of the possible case

9. Initial Public Health Response, cont. • Initiated internal notification tree • Began investigation to verify case • Description of symptoms accurate • Rabies was included in differential diagnosis • Began identification of contacts • Immediate family members • Close friends • Healthcare workers (HCWs) • Possible contacts at school

10. Initial Public Health Response, cont. • Customized existing assessment tools for identified risk groups • Info used from additional tools • DHSH 6/5S Zoonosis Control • Healthcare workers • CDC Viral and Rickettsial Zoonoses Branch • Family and other social contacts • Continued identification of all HCWs • Distributed HCW assessment to all hospital and ambulance transport staff involved • Finalized other assessment forms for family/social contacts for later use

11. Initial Public Health Response, cont. • Epi staff continued investigation • Conference call held with DSHS & CDC • Parents difficult to reach • Animal exposure not mentioned in MR • Confirmed by interview with neighbor • HCPHES activates ICS

12. Incident Command Structure • Modeled after NIMS • Areas to address • Epidemiology & surveillance • Crisis communication for public & media • Veterinary response • Treatment guidelines for medical community • Command structure established • Incident Commander-Medical Epidemiology physician • Operations Chief-Chief Epidemiologist • Planning Chief-Senior Epidemiologist • Logistics Chief-staff Epidemiologist • Finance Chief-Administrative Services Director

13. Incident Command Structure, cont. • ICS Chief assignments re-evaluated • Epi staff needed “in the field” • Not able to manage both roles • ICS positions reassigned • Public Health Preparedness Division • Operations, Planning, Logistics • Incident Commander not reassigned

14. Public Health Operation • Phone bank established-12 hr/day • Up-to-date rabies info posted on web • Contact investigations • Evaluation of risk • Recommendation of PEP

15. Public Health Operation • Phone Bank Operations • Set up 10 phone lines • Identified a phone bank coordinator • Provided “just in time” training for staff • Not widely publicized to general public • Calls requiring exposure assessment referred to Epidemiology • Calls with additional concerns about bats and rabies referred to Veterinary Public Health • In operation 5/10 – 5/17; 140 calls received

16. Exposure Assessment at School • Identified the potential students at risk (~250 classmates, team mates and friends) • Identified an area at the school to hold interviews • Assembled HCPHES staff for “on site” activities • Rabies overview presenter • Individual interviewers • Data entry clerks and coordinator • May 11-Rabies exposure assessment at school

17. Exposure Assessment at School, cont. • Students divided into groups of about 75 • Presentation given on rabies and its transmission • Students self-selected if they still considered themselves at risk • Those students were individually interviewed • Information from assessment entered into laptops on site • Public Health physician evaluated all assessments • PEP recommended for students meeting criteria • Epidemiologists and nurses inform parents

18. Session for parents at school • HCPHES Executive Director presented • Other HCPHES also in attendance to assist with questions • Deputy Director • Director of Veterinary Public Health • Public Information staff • Epidemiology staff

19. Additional Exposures Identified • Case was a swimming instructor for pre-K kids • Swimming team requested an on site educational program – May 13 • Utilized PHP Van for transport • Interviewers available for individual assessment • After presentation, no parents felt child at risk

20. Assessing Risk • Public Health physicians assessed all forms • Identified additional potential risks • “Gleeking” • Chocolate fountain • Recommendations based on CDC Guidelines • 142 people assessed (HCW-42; CC-100) • 53 were recommended PEP (HCW-17; CC-36 • Several “not at risk” people obtained PEP privately • Parents of 3 children recommended for PEP declined

21. Veterinary Public Health Operations • Conducted environmental assessment of the home • 2 story home in wooded residential area • Case’s room had several windows but no screens • Several areas around home suitable bat habitat • No evidence of bat colonies or activity

22. Veterinary Public Health Operations, cont. • Bat rabies in Harris County is enzootic • 2004 - 48 positive bats • 2005 – 30 positive bats • 2006 – 12 positive bats prior to May 9 • Closest identified positive bat had been 16 miles west of home

23. Veterinary Public Health Operations, cont. • Publicity of case raised level of awareness • Veterinary Public Health activity increased • On average-35 animals submitted/mo. • In May 135 submitted; 96 were bats • On average-115 bite cases reported/mo • In May 193 cases reported • VPH staff managed increased phone calls • Developed screening questionnaire • Counseled callers on risk • Facilitated testing of bats • Referred calls to private physician for PEP

24. Public Information Operations • HCPHES Office of Public Information • Acted as point of contact for all public health aspects • Sent media advisories • Arrange press conference and media packet • Info on rabies prevention • Attended by TV, radio and print media • English, Spanish and Vietnamese • Coordinated visual demo of safe bat capture • Compiled Incident Activity Binder • Historical documentation • Reference tool for future use

25. After Action Review • HCPHES Office of Public Health Preparedness • Held review for overall Human Rabies Response • Shared experiences • Discussed successes and challenges • Identified areas for improvement • Applicable to other public health emergencies