Case Study: Possible Measles Outbreak PARTICIPANT VERSION Objectives • • • • List three (3) strategies for active case finding Describe outbreak control measures Prepare a statement for media during an outbreak situation Identify critical components of an outbreak investigation report Instructions 1. Complete each question in the case study. It is recommended to answer each question in sequential order since you are performing an outbreak investigation. 2. You can use classroom or online resources to answer the questions, such as CDC or local health departments. 3. You can answer the questions directly in the Word Document. Please save your file as LastName_FirstName_PBHE426_Case Study 1. 4. Please put your name in the document header. 5. Submit your completed assignment in the Classroom Assignment – Case Study One. 6. This assignment is to be completed individually. The assignment will have “group” or “team” activities. You need to complete all questions in the case study, but you can exclude the in-class portions, such as writing responses on flip-charts. Resources Centers for Disease Control and Prevention. Measles (Rubeola). 2018. Available at https://www.cdc.gov/measles/index.html World Health Organization. Measles Fact Sheet. 2018. Available at http://www.who.int/mediacentre/factsheets/fs286/en/. 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Index case returns with rash Index case visits hospital Patient diagnosed with possible measles. Case reported to health department Background It is Tuesday, January 23rd and you are an employee at a local health department. You are notified by the infection control nurse at the local community hospital that a patient at the hospital has been diagnosed with “possible measles.” The nurse tells you that the patient is a 23 year-old female from India. She first came to the hospital emergency room on January 20th with gastrointestinal symptoms and fever and returned to the hospital the next day with a rash which started on her face and progressed to cover most of her body. She was admitted that evening, and is still hospitalized. Question 1: What questions do you have for the nurse? Question 2: Would you recommend that any laboratory tests be conducted at this point? If so, describe the test and the type of specimen that should be taken. 15 16 17 Index case arrives in US 18 19 Symptom onset for index case Welcome party 20 21 22 23 24 25 26 27 28 29 30 Index case returns with rash Index case visits hospital Patient diagnosed with possible measles. Case reported to health department Update 1 You recommend the patient be tested for measles antibodies (IgM and IgG) and that a blood sample be taken immediately to the NC State Laboratory of Public Health to conduct the tests. You also recommend starting appropriate isolation precautions (placing the patient in an airborne infection isolation room, equipping healthcare personnel with appropriate personal protective equipment, etc.) if these are not already in place. Because measles is highly contagious, you should proceed as if she does have the disease, even though confirmatory laboratory results are not yet available. The infection control practitioner tells you more about the patient, Pina, who recently moved with her husband and infant daughter to the United States from India. She arrived in North Carolina on January 15th, and attended a welcome party on January 16th. Since the party, she has stayed at home with her 5 month old infant while her husband looks for work. Her fever began on January 17th. Question 3: Given the timeline of events, do you believe Pina contracted the disease in North Carolina or in India? Question 4: Is it possible that Pina exposed others to measles? Consider the incubation period of measles, and the date of onset of her symptoms. 3 15 16 17 Index case arrives in US 18 19 Symptom onset for index case Welcome party 20 21 22 Index case returns with rash Index case visits hospital 23 24 25 26 27 28 29 30 Lab confirms measles Patient diagnosed with possible measles. Case reported to health department Update 2: January 25th You receive the results from the NC State Laboratory of Public Health. The patient tested positive for both IgG and IgM antibodies, confirming that she does have measles. Question 5: Would you activate your Epi Team at this point? Why or why not? If so, which members of your Epi Team would be involved in this investigation? Question 6: What public health agencies would you contact now? Question 7: You realize that Pina’s 5 month-old infant is at risk for contracting the disease, since the Measles, Mumps, and Rubella (MMR) vaccine is not usually given until 12 months of age. Should you provide the MMR vaccine to the infant? 4 15 16 17 Index case arrives in US 18 19 Symptom onset for index case Welcome party 20 21 22 Index case returns with rash Index case visits hospital 23 24 25 26 27 28 29 30 Lab confirms measles Patient diagnosed with possible measles. Case reported to health department Update 3: January 26th You call a meeting of your Epi Team, and identify the tasks that must be accomplished immediately. First, you decide to conduct active case finding to locate other potentially sick people in the community. You learn from the patient’s husband that there were about 45 people present at the welcome party on January 16th. Question 8: What methods could you use to find additional cases? Question 9: What information should you collect when speaking with asymptomatic exposed individuals? 5 15 16 17 Index case arrives in US 18 19 20 Symptom onset for index case Welcome party Index case visits hospital 21 22 Index case returns with rash 23 24 25 26 27 28 29 30 Lab confirms Media contacts measles health department Patient diagnosed with possible measles. Case reported to health department Update 4: January 26th While you and your team are busy tracking down exposed individuals, a reporter from the local newspaper calls you and asks for a statement about the measles case. News about the case has spread, and people in the community are beginning to panic. At this point, there is only one sick individual, but potentially dozens of people who have been exposed to the disease. Group Activity Draft a message to share with the public based on what you know so far about the measles case and the potential for a larger outbreak. Keep in mind that you want the media to help you locate potential case-patients and provide information about the outbreak to the public in a way that does not cause alarm or fear. Question 10: What other media communication might be appropriate? 6 15 16 17 Index case arrives in US Welcome party 18 19 Symptom onset for index case 20 21 22 Index case returns with rash Index case visits hospital 23 24 25 26 27 28 29 30 Lab confirms Media contacts measles health department Patient diagnosed with possible measles. Case reported to health department Epi team conducts interviews and provides vaccinations Update 5: January 27th Your Epi Team has been busy conducting interviews with the people who were in the hospital emergency room, and the 45 individuals present at the welcome party, including the patient’s husband and child. None of the people you have contacted so far are currently displaying symptoms. Question 11: Should you offer Measles, Mumps, and Rubella (MMR) vaccine to exposed people? Question 12: If you choose to offer MMR vaccine, describe how vaccine should be delivered. For example, will you hold a mass vaccination clinic? Do you have enough vaccine available at your health department, or will you need to order additional doses? Question 13: What kind of protection do you need to provide for your team members who are interviewing potentially exposed individuals? What about the community hospital staff who vaccinate potentially exposed individuals? 7 15 16 17 Index case arrives in US Welcome party 18 19 Symptom onset for index case 20 21 22 Index case returns with rash Index case visits hospital 23 24 25 26 27 Lab confirms measles Media contacts health department Patient diagnosed with possible measles. Case reported to health department 28 … 2 Daughter of index case develops symptoms Epi team conducts interviews and provides vaccinations Update 6: February 2nd On January 28th, Pina’s 5 month-old daughter began exhibiting symptoms of measles, including a cough, fever and rash. The child was treated with Vitamin A supplements and kept in airborne isolation until yesterday. You followed up with the child’s contacts, but no other cases have been detected. Pina, the original patient, has recovered without any major complications. Together with the hospital and members of your regional surveillance team, your Epi Team contacted 305 potentially exposed persons, and administered 165 MMR vaccinations. Question 14: Since the outbreak appears to be under control, your health director suggests that the Epi Team write an outbreak report. What are some reasons for writing an outbreak report? Activity In small groups, draft an outline of an outbreak report listing all of the topics that should be included. Make sure to note the intended audience – your group should decide whether the outbreak report will be shared with 1) colleagues and superiors within your local health department, 2) other partners in the community, including the hospital, 3) the state health department, state laboratory, and public health regional surveillance team, and CDC, 4) the general public, and/or 5) other groups. 8 15 16 17 Index case arrives in US 18 19 Symptom onset for index case Welcome party 20 21 22 Index case returns with rash Index case visits hospital 23 24 25 26 27 28 29 Lab confirms Media contacts measles health department Patient diagnosed with possible measles. Case reported to health department 30 Daughter of index case develops symptoms Epi team conducts interviews and provides vaccinations Conclusion: February 8th In all, there were only 2 cases of measles associated with this outbreak: Pina, the index case, and her 5-month old infant daughter. Both recovered without complications. Now your Epi Team is meeting to discuss the outbreak investigation. Group Brainstorm Choose one member of the epi team to record responses on a flip chart. As a group, discuss one or more of the following questions. • What aspects of the investigation were successful? • All outbreaks present unique challenges. What characteristics of this outbreak made it challenging? • What areas of the investigation could have been improved? • If a similar outbreak occurred in your county, do you think that your epi team would be prepared to handle it? • Did your Epi Team communicate effectively with a) the general public/media, b) hospital, c) state health department, and d) CDC? 9
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