Head to Toe 19 2015 Annual Conference THE ABCs OF COMMUNICABLE DISEASES IN SCHOOL JOAN BAUMBACH, MD, MPH, MS DEANDRA J. INGRAM, MPH NEW MEXICO DEPARTMENT OF HEALTH
Session Objectives Identify select reportable communicable diseases that occur in the school setting Identify when to notify the NM Dept. of Health Epidemiology & Response Division Describe school-based response to communicable diseases & potential outbreaks
Importance of School Health Research shows that students learn best when they are healthy, safe, & feel connected to their school A healthy school community promotes student success Infectious diseases account for millions of school days lost k-12 yearly in U.S. public school students Group setting of schools foster person-to-person transmission of infections Close contact Shared supplies & equipment
Common Infectious Diseases in Students Foodborne illness Noroviruses Salmonellosis Shigellosis Respiratory illness Common cold Influenza Young children are among the populations at greatest risk for serious flu complications Too few are vaccinated Too few receive antivirals Pertussis Pneumonia
Less Common Illnesses MRSA (Methicillin-Resistant Staphylococcus aureus) Colonization requires no school action Active disease requires no skin-to-skin contact Meningococcal disease Transmission through direct contact with secretions of the nose and throat of an infected person (usually household) School settings if close prolonged physical contact Kissing, sharing food/beverages/toothbrushes/cigarettes Plague School nurse saved the day!
Schools Keep Communities Healthy Encourage sick students & staff to stay home & get medical attention for severe illness Supply adequate soap & paper towels Teach good hand hygiene practices Clean & disinfect classroom materials & surfaces Provide messages about preventing infectious disease Adopt healthy practices Safe food handling Standard precautions when handling body fluids & excretions Up-to-date vaccines, including annual influenza vaccination of students & staff
When to Wash How to Wash Before eating Before, during, & after handling or preparing food After contact with blood or body fluids After changing a diaper After using the bathroom After handling animals After touching something that could be contaminated Before dressing a wound, giving medicine, inserting contact lenses More often when someone near you is sick Whenever hands look dirty Wet your hands, apply soap Rub hands together vigorously to make a lather & scrub all surfaces Continue for 20 seconds Need a timer? Imagine singing Happy Birthday all the way through twice Rinse hands well under running water Dry hands using a paper towel or air dryer If possible, use your paper towel to turn off the faucet If soap & water not available, use an alcohol-based wipe or hand gel if hands not visibly soiled
Epidemiology Epidemiology The study of the distribution & determinants of health-related states or events in specified populations, & its application to the control of health problems Scientific discipline Field epidemiology Uses the tools of epidemiology to design, evaluate, or improve interventions to protect or improve public health Generates new knowledge & evidence for decision making
Field Epidemiology Communicable disease surveillance systems Design, operation, evaluation Field research Risk factors Distribution of disease Outbreak investigations Often urgent need to find out about risk factors, risk groups, best ways to intervene Time pressure, media attention, public anxiety Need for ad hoc teams to help with investigations School personnel often key members of these teams
Notifiable Conditions in New Mexico Mandated by state regulation Developed & updated by NMDOH List of diseases/conditions that are tracked statewide Communicable diseases: human and animal Occupational injury and illness Environmental exposures & injuries Adverse vaccine reactions Healthcare-associated infections Cancer Human papilloma virus Birth defects Genetic & congenital hearing screening
Notifiable Diseases or Conditions in New Mexico Routine Emergency Reporting of Infectious Diseases in Humans Anthrax* Avian or novel influenza* Bordetella species* Botulism (any type)* Cholera* Diphtheria* Haemophilus influenzae invasive infections* Measles Meningococcal infections, invasive* Plague* Poliomyelitis, paralytic & non-paralytic Rabies Rubella (including congenital) Severe Acute Respiratory Syndrome (SARS)* Smallpox* Tularemia* Typhoid fever* Yellow fever Note: Laboratory or clinical samples for conditions marked with [*] are required to be sent to the Scientific Laboratory Division.
Notifiable Diseases or Conditions in New Mexico Routine Reporting of Infectious Diseases in Humans Brucellosis Hepatitis A, Campylobacter infections* Coccidioidomycosis Colorado tick fever, Cryptosporidiosis Cyclosporiasis Cysticercosis Dengue E. coli 0157:H7 infections* E. coli shiga-toxin producing (STEC) infections* Giardiasis Group A streptococcal invasive infections* Group B streptococcal invasive infections* Hantavirus pulmonary syndrome Hemolytic uremic syndrome, post diarrheal Hepatitis A, acute; hepatitis B & C, acute or chronic, hepatitis E, acute Influenza, lab-confirmed hospitalization Legionnaires disease Leprosy Leptospirosis Listeriosis* Lyme disease Malaria Mumps Necrotizing fasciitis* Psittacosis Q fever Relapsing fever Rocky Mountain spotted fever Salmonellosis* Shigellosis* St. Louis encephalitis infections Streptococcus pneumoniae invasive infections* Tetanus Trichinosis Toxic shock syndrome Varicella Vibrio infections* West Nile Virus infections Western equine encephalitis infections Yersinia infections*
Outbreak Investigation Steps Prepare for field work Verify the diagnosis & confirm the outbreak Define a case and conduct case finding Obtain data: time, place, person Take immediate control measures Formulate & test hypotheses Plan & execute additional studies Implement & evaluate control measures Communicate findings
Outbreak Detection & Response Delay in outbreak detection & inadequate response can lead to Increased numbers of cases Increased duration of transmission & outbreaks Excess morbidity & even mortality Preparing for, investigating, & responding to priority communicable diseases Critical to reduce morbidity & mortality Needed to contribute to improved health status
School Case & Outbreak Investigations NMDOH & schools frequently collaborate on case & cluster investigations Varicella Pertussis NMDOH & schools frequently collaborate on outbreaks Norovirus Influenza
Conducting Investigations in Schools Usually requires formation of team/s Teams can include o School personnel School Nurses Teachers Administrators Others (e.g., maintenance personnel, students, parents) Department of Health personnel o Epidemiologists o Public Health Nurses o Others (e.g., trainees of various kinds)
Public Health Associate Program (PHAP) A competitive, 2-year, paid training program with the Centers for Disease Control and Prevention (CDC) Assigned to New Mexico Department of Health (NMDOH) in 2013 from an applicant pool of over 4,400 Current surveillance officer with the Infectious Disease Epidemiology Bureau Primary responsibilities are supporting statewide communicable disease reporting, control & public health preparedness initiatives
Relevant Terminology for Investigations Index Case: the first case of a condition or syndrome ( patient zero ) Case Definition: includes criteria for person, place, time, & clinical features Case Investigation: standardized investigation of a single case of a specified condition Case Management: following a case for a period of time to ensure proper diagnostic testing, treatment &/or prophylaxis Contact Prophylaxis: measures taken to prevent disease in contacts of an identified case
Communicable Disease Reporting Responsibilities Healthcare providers, laboratories, & others with knowledge of a notifiable condition report to the New Mexico Department of Health (NMDOH) o New Mexico Administrative Code 7.4.3.13 o Can report to central or local NMDOH, or NMDOH designees From NMDOH public health offices o Public Health Nurses may generate investigations in the NM Electronic Disease Surveillance System (NM-EDSS) & conduct investigations independently or with Central Epi On-call epidemiologist available for consultation & response to emergency conditions 24/7/365 at (505)827-0006
School Nurses Notify NMDOH Ill child presents to school nurse & his/her illness is assessed for likelihood of communicable disease Case is assigned to appropriate jurisdiction for investigation & follow-up Nurse contacts health department for direction regarding suspected notifiable condition & may express desire for testing On-call epi encourages identification of high risk contacts of index case (e.g., pregnant &/or immunocompromised staff and/or students) and enters case into NM-EDSS Infectious Disease Epidemiology Bureau is notified when the nurse contacts the on-call epidemiologist, the student(s) lab report is received electronically or via fax
Role of School Nurses in Case Investigation Assess risk of transmission from index case to others Active surveillance Provide education on reducing risk of infection Identify extent of exposure Who has class with index patient 0 What is the makeup of patient 0 s household? What is their vaccination status? Identify potential sources of ongoing transmission and/or presence of a cluster/outbreak Help to characterize the epidemiology of an infectious condition Is it spread through direct contact? Air?
NMDOH Notifies Nurses of Illness in their School NMDOH receives a result of a notifiable condition on a school-aged child via electronic lab report (ELR), fax, or call Epidemiology and Response Division personnel assign case for investigation to public health nurse in appropriate jurisdiction after obtaining necessary demographic information Public Health Nurse contacts school nurse where case attends & a patient interview is conducted to determine whether student is currently ill or still within the infectious period of the illness Based on results of patient interview, child may be treated & excluded, & contact tracing may be necessary
Case Study 8 adolescents Acute chest pain in all, gastrointestinal illness in some Varying dates of onset Q1.How would you proceed with this information? Q2. Do you need more information? If so, then what?
What do we need to know? School Nurses What grades are the students in? Do they attend the same school? Do they share common activities? What are their clinical signs & symptoms? When were onsets of illnesses & how long did they last? Did they see outside healthcare providers, were they hospitalized? Epidemiology and Response Division Are the symptoms suggestive of common illness? o Case definition Are there any laboratory test results associated with their illnesses? Do the students spend time in close contact with each other? What is the vaccination status or other underlying features of the students?
Investigating an Illness of Unknown Etiology Develop a case definition What do each of the cases have in common? Develop a questionnaire for investigation What should we ask to try & uncover a common exposure? Designate a lead for the investigation School nurse? Central Epi? Make a plan for specimen collection if needed Arrange laboratory/confirmatory testing
Case Study: Suspect Pericarditis Cluster MD called with suspicion of cluster of pericarditis in adolescents Ultimately 7 males & 1 female were identified (ages 13-18 years) All involved in athletic teams (football, basketball, &/or track) The 7 high school students spent time together regularly outside of sports, and 1 middle school student did not Medical records & electrocardiograms were requested & reviewed by their team physician, NMDOH epidemiologists, and a UNM pediatric cardiologist Findings were inconsistent with original suspicion of pericarditis & did not meet the CDC case definition of the condition Students parents were encouraged to consult their primary care providers for questions regarding fitness for resuming physical activity
Routine Cluster and Outbreak-Specific Response in Schools Complete patient interviews among contacts of the index case Determine need for testing of symptomatic contacts Specimen collection, transport, & testing must be arranged in order to confirm a diagnosis Ill persons should be identified & monitored using a line list Determine need for prophylaxis of close asymptomatic contacts
Importance of Line Lists
Nurse Epi Go Kits Designed to support enteric specimen collection on 5-10 patients Sterile Cups Stool C&S/O&P medium Includes lab submission forms Specimen bags Writing Utensils Tourniquets Tubes Personal Protective Equipment (PPE) (gowns, gloves, and masks) for up to 5 people AND MORE!
Case Management and Follow-Up Sometimes there is need to notify the parents of cases, clusters, or outbreaks via letters home More broad communication to community may be necessary o Community meetings to discuss the concerns of parents of students in the affected school o Press releases Checking in with school nurses to assess the progress on clearing an illness in their school Continuing to collect line lists & reporting results of any testing to necessary parties
Epidemic Curve
We Could Not Do It Without You! You contribution is essential & appreciated We try to make it as easy as possible for you Your suggestions for improvement are welcome Call us as needed 505-827-0006 24/7/365 Joan Baumbach 505-827-0011 joan.baumbach@state.nm.us Deandra J. Ingram 505-827-0099 deandra.ingram@state.nm.us