Objectives 3/3/2017. Disease Reporting in Georgia: The School Nurse s Role. Georgia Department of Public Health

Transcription

1 Disease Reporting in Georgia: The School Nurse s Role Presentation to: Georgia s School Nurses Presented by: Ebony S. Thomas, MPH Date: Friday, March 10, 2017 Objectives Describe the school nurse s role in disease reporting Identify who to report notifiable diseases to at the local, district and state level Recognize what information should be reported to public health when a suspect case is identified Outline control steps to take when a vaccinepreventable disease is identified in the school setting Georgia Department of Public Health 159 counties 18 public health districts 18 district epidemiologists 1 state public health department 1

2 Georgia Public Health Districts Epidemiology and Surveillance Epidemiology: The study of the distribution and determinants of health-related events in a population. Surveillance: Ongoing, systematic collection, analysis, and interpretation of health data, essential to the planning, implementation and evaluation of public health practice, closely integrated with the dissemination of these data to those who need to know and linked to prevention and control ( 03a3.htm) Disease/Outbreak Reporting Under Georgia law (O.C.G.A Code ), physicians, hospitals, nurses and laboratories are all required to report Ways to report Contact your district epidemiologist PUB-HLTH (24 hrs./7 days a week) State Public Health Office

3 Information to report Information to Report Who? Students, faculty, food workers, janitorial staff What? Type of illness Gastrointestinal Respiratory (pertussis) Rash (i.e. chickenpox, measles) Any parent reports of doctor s diagnoses or lab-confirmed conditions When? Dates of illness Did the person attend school while ill Where? Exposure setting Teacher and grade Extracurricular activities Assemblies Public Health Investigation Epidemiologist will: Request parent/guardian contact information Contact parents to learn more about symptoms, exposure history and make recommendations to stop the spread of disease. Provide recommendations to stop the spread of disease (how long to keep a child out, products to use to clean after vomit/diarrhea) Try to collect clinical specimens (stool, lesion, NP swab) from ill student or faculty for testing at the public health lab Assist with communicating with parents (i.e. letter) Epidemiologist cannot: Tell you when to close your school 3

4 Public Health Investigation Environmental Health might: Visit your kitchen for an inspection or assessment Require symptomatic food workers to stay home or change duties (per Food Code) Take samples of leftover foods from any implicated meals to hold and possibly test Environmental Health cannot: Clean your school Tell you when to close your school Public Health Investigation Epidemiologist will check-in throughout the incubation period to make sure no new cases are identified. Notify you of new cases identified at your school You are welcome to continue to contact public health with updates or concerns PERTUSSIS INVESTIGATION IN THE SCHOOL SETTING 4

5 Bordetella pertussis Fastidious, aerobic gram-negative, rod Produces multiple products: pertussis toxin, filamentous hemagglutinin, agglutinogens, adenylate cyclase, pertactin, and tracheal cytotoxin Responsible for the clinical features of pertussis disease An immune response to one or more produces immunity following infection Primarily a toxin-mediated disease Pertussis Clinical Features Mode of transmission: via respiratory droplets when an infected person coughs and/or sneezes Direct contact with secretions from respiratory tract of infectious person Incubation period: 7-10 days (range: 4-21 days; rarely may be as long as 42 days) Period of communicability: 1 to 2 weeks before cough onset (catarrhal stage) up to three weeks after cough onset Presents in three stages 1. Catarrhal 2. Paroxysmal 3. Convalescent Many cases go undiagnosed and unreported Pertussis Clinical Presentation 1. Catarrhal: 1-2 wks. Insidious onset of coryza (runny nose), sneezing, low grade fever, and a mild, occasional cough 2. Paroxysmal: 1-6 wks. Bursts of coughing with or without characteristic whoop Post-tussive vomiting May become cyanotic Do not appear ill between attacks 3. Convalescent: weeks to months Paroxysms gradually improve but recur with respiratory infection 5

6 Atypical Presentations of Pertussis Infants ( 6 months), adolescents and adults may have atypical presentations Young infants Cough minimal/absent Apnea, cyanosis poor feeding, gagging, vomiting No whoop Adolescents/adults Milder disease Hard to distinguish from other cough illness May transmit the disease to others Pertussis Complications Most common complication, and the cause of most pertussis-related deaths, is secondary bacterial pneumonia Young infants are at highest risk for acquiring pertussis-associated complications. Neurologic complications Seizures and encephalopathy Otitis media, anorexia and dehydration Medical Management Treatment of Case-Patient Primarily supportive Prevents further transmission May modify course if given early Erythromycin Azithromycin* Persons are infectious until 5 days of antibiotic treatment is complete and should remain out of school/work Exclude infectious patients from school, daycare, healthcare settings and contact with infants, pregnant women, and immunocompromised persons Post-exposure prophylaxis (PEP) Administer to all close contacts of case, regardless of age and vaccination status Bring close contacts up to date with pertussis vaccinations 6

7 ACIP Recommendations for the use of Pertussis Vaccine Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) 2,4,and 6 months of age, months, and 4-6 years Tetanus-diptheria-acellular pertussis vaccine (Tdap) Single dose in undervaccinated 7-10 years Single dose in age years of age Single dose in adults years of age in place of Td Single dose in persons in close contact with infants, including adults 65 y.o. Pregnant women during each pregnancy PERTUSSIS IN THE SCHOOL SETTING Pertussis Reporting School nurses play an integral role in disease surveillance Public health notifies the school when a new case is identified to offer guidance and conduct surveillance If you suspect a case of pertussis, the school nurse or school administrator should contact the local or district public health department immediately to report the case and for further guidance on pertussis control and prevention Do not await lab results 7

8 What should you do if a parent calls in saying their child has pertussis? Inform the parent that you are required to notify public health and that someone from public health will be contacting them to follow-up Call your local or district health department District public health will interview the student s parents and determine whether or not it is a true pertussis case-patient What information can you share with public health? Local, district and state public health are exempt from HIPPA Can obtain all personal information necessary to perform a public health investigation Public health will need: Student s full name and date of birth Parent s contact information Vaccination status What should you do once a single case of pertussis is confirmed in the school setting? A. Determine who may have been exposed to the ill student. Are any of the exposed individuals pregnant, immunocompromised, or inadequately immunized against pertussis? Contact them in-person and/or via phone to let them know of their exposure and signs/symptoms. Are any of the exposed individuals currently coughing? Refer them to their healthcare provider and recommend testing. B.If this is a case of pertussis, send out a letter and factsheet after consulting with public health Public health has standardized letters and fact sheets that they can provide to you. 8

9 What should you do once a case of pertussis is confirmed in the school setting? cont. C. Reinforce polices with staff on hand and respiratory hygiene and staying home while potentially infectious D. Conduct surveillance for symptomatic children, teachers and staff for 21 days after the last case s cough onset date Make sure teachers notify nurse of children with symptoms. Refer anyone with symptoms to a physician/pediatrician. Notify public health of symptomatic students, staff and/or teachers immediately. Recommend they get tested. E.Review immunization records of teachers and staff How do you identify exposed individuals? Household contacts (siblings, cousins, etc.) Same classroom, extracurricular activities, bus or carpool or socially Any direct face to face contact regardless of hours if they are close friends, boyfriend/girlfriend, sport teammates, or lunch partners Regardless of length of exposure, the following are high risk groups: Infants, Under-immunized young children Immmune-compromised individuals Pregnant women Who should receive the letter and fact sheet? Notify all exposed individuals (i.e. same classroom, extracurricular activities, bus route, etc.) High risk groups should be notified by phone and letter Consult with public health 9

10 Who should be excluded from school? Cases: should be exclude from school either (1) for 5 days after the start of antibiotics, or (2) when cough duration has been longer than 21 days Symptomatic contacts: Should be referred to their health care provider, and should be excluded using the same criteria as a case if pertussis is suspected Asymptomatic contacts: no exclusion is recommended Underimmunized/Unvaccinated individuals: no exclusion is recommended when a single case of pertussis is identified in the school The child returned back to school after 5 days of antibiotics, but is still coughing, what should I do? Pertussis was once referred to as the 100 days cough Antibiotic treatment is primarily supportive Does not make the cough go away Not infectious after 5-day course of appropriate antibiotic OR 21 days after cough onset Additional Action Steps to Consider Identify a room, separate from others, for a student exhibiting pertussis symptoms to wait in until a parent can pick them up from school. If there is not a separate room to have the student wait, keep facemasks on hand for the student to use until the parent can pick them up from school. Establish an easy to identify, public hand washing station. Review your school s current health policies to ensure they support deviation from day-to-day illness identification and exclusion guidelines during a pertussis outbreak. 10

11 PERTUSSIS OUTBREAKS IN THE SCHOOL SETTING Pertussis Outbreak Notify your district epidemiologist immediately when additional cases are suspected Determine if these cases are epidemiologically linked (i.e. same class, siblings, same bus, extracurriculars etc.) For each case, identify exposed contacts and treat as single case Pertussis Outbreak An outbreak will be confirmed if the number of epi-linked cases meet the outbreak definition, as determined by public health Requires laboratory confirmation Implement cough exclusion Exclude all individuals with cough-like illness Can not return to school without a signed release from a healthcare provider stating that pertussis is not suspected If pertussis is suspected then the individual needs to remain out of school until 5 days of antibiotics have been completed. Only when an outbreak is confirmed, will public health recommend exclusion of undervaccinated/unvaccinated students, teachers, and staff, immunocompromised individuals and pregnant women 11

12 Pertussis Outbreak Surveillance Cases will be considered part of the outbreak if they occur within one incubation period of the previous case (21 days) Active surveillance for additional cases should continue for 42 days after the onset of the last identified case (two incubation periods) Establish a regular reporting routine with your district health department for the duration of the outbreak You may be asked to keep/update a line list of symptomatic students, teachers and staff Contact Information Ebony S. Thomas, MPH Vaccine-Preventable Disease Epidemiologist Phone: Fax: Ebony.Thomas@dph.ga.gov Jessica Tuttle, MD Medical Epidemiologist Phone: Fax: Jessica.Tuttle@dph.ga.gov Questions? 12