Case Study 10 What did you learn about preparing for and responding to the initial outbreak of a communicable disease in Part 1? how did your response change based on the information and developments in Part 2?What recommendation would you give to the mayor about holding the annual conference?   PEER REVIEWED JOURNAL IF POSSIBLE   This exercise, developed by the Northwest Center for Public Health Practice,* is designed as an opportunity for public health personnel and their local emergency counterparts to gain skills and knowledge in preparing for and responding to a large-scale communicable disease event

Subject:NursingPrice: Bought3

Share With

Case Study 10

What did you learn about preparing for and responding to the initial outbreak of a communicable disease in Part 1? how did your response change based on the information and developments in Part 2?What recommendation would you give to the mayor about holding the annual conference?

 

PEER REVIEWED JOURNAL IF POSSIBLE

 

This exercise, developed by the Northwest Center for Public Health Practice,* is designed as an opportunity for public health personnel and their local emergency counterparts to gain skills and knowledge in preparing for and responding to a large-scale communicable disease event. Participants address a hypothetical bioterrorism incident in the form of an infectious disease outbreak to acquire this learning. The exercise enables participants to identify the communication, resources, data, coordination, and organizational elements associated with an emergency response.

 

Introduction

The goal of this exercise is to identify the policy questions that must be considered in responding to a bioterrorism event. The depicted exercise scenario will enable participants to understand and experience the shortcomings or gaps in their ability to identify and respond to policy issues (as opposed to operational procedures). Participants will be required to state policy questions such as these: Who should be responsible? What information is needed? When is public information given out? In essence, participants will be identifying what is required in responding to an incident and not necessarily how an agency will actually respond. It is important that the exercise identify policies required to respond effectively to the scenario rather than using only those policies that currently exist. Addressing those policies that need clarification or development will be helpful in eventually strengthening the overall response system and will identify areas in operational policies and procedures that need refinement.

Part 1

Storyboard 1

This incident affects four counties: Cedar, Dogwood, Pine, and Maple. The incident begins in Cedar County in the month of August.

Cedar County

• Total population: 150,000 residents.
• The major city, Watertown, has a population of 40,000 residents.
• There are two area hospitals; one is a children's hospital.
• There are numerous nursing homes and daycare centers.
• International trade, tourism, agricultural products, and lumbering are the major industries.
• An economic trade group conference is scheduled to be held in Watertown in 3 weeks. About 100 members will be attending, including foreign economic officials.
• Residents are all served by a regional public water supply system.
• The Cedar County health department has a staff of 70 employees. The department has a full-time director of public health and a full-time health officer (MD). A full range of public health services, including environmental health, community health nursing, laboratory, and clinical public health services, are provided.

Dogwood County

• Located directly to the north of Cedar County.
• Total population: 35,000 residents.
• Noted for its numerous water recreational areas.
• About 10,000 residents are served by small or individual water supply systems.
• The Dogwood County health department has 25 total staff, including environmental health specialists and community health nurses. A health officer (MD) is part time.

Pine County

• Located directly to the south of Cedar County.
• Total population: 15,000 residents.
• Serves as a bedroom community to Cedar County. Many Pine County residents commute to work in Cedar County's major city.
• Residents receive public water supplied by Cedar County Regional Water Utility.
• The Pine County health department has a total of 14 staff members (five are part time). Two are environmental health specialists and 10 are public health nurses. The remaining staff members provide administrative support. A health officer is a contract physician from the community.

The state health department is located in Maple County, 140 miles to the east of Cedar County. The state health department's public health laboratory and the state's university are also located in Maple County. The population of Maple County is 1 million.

Event 1

Day 1, Friday

People with gastrointestinal illness are beginning to contact their medical care providers through the nurse hotline and patient consultation lines. Individuals with gastrointestinal problems are calling or visiting area emergency rooms and urgent care centers on Friday afternoon and evening. The hospital's patient consultation line is experiencing an increased number of callers with symptoms, including severe diarrhea, fever, chills, headache, nausea, vomiting, abdominal pain, and possibly bloody stools. All cases describe diarrhea as a symptom. Almost all report at least two or more of the additional symptoms. Illnesses have lasted 1 to 2 days without improvement. Most patients are middle-aged adults, but approximately 10% are over the age of 65. A total of 30 people are seen in hospital emergency rooms and urgent care centers by late Friday evening. (This means that a total of 400 individuals may be exhibiting similar symptoms but are not seeking medical care. The 30 cases, or 7.5% of the 400, visit a medical care provider for symptoms.) Stool samples are taken for six of the affected cases seen by a physician. Three individuals are hospitalized for dehydration or other gastrointestinal complications.

Day 2, Saturday Morning

Patients are still being seen in the emergency room and urgent care centers. By 10:00 AM, the number of patients exhibiting similar symptoms is up to 45. The decision is made to notify the health department. There is some concern about the capacity of the clinics to handle the increasing number of patients seeking treatment.

 

Event 2

Day 2, Saturday Noon

By noon, the patient count is up to 60. The local health officer decides to convene a meeting to discuss next steps. A local pharmacist calls the local hospital to ask what is happening. The pharmacist reports that the store is almost out of antidiarrheal medicine because of heavy demand.

 

Event 3

Day 2, Saturday Evening

The health department decides to begin interviewing cases.

 

Event 4

Day 2, Saturday Evening

Medical care providers from Dogwood and Pine Counties are reporting a high number of patients complaining about severe gastrointestinal problems. By 5:00 PM, the total patient count from all three counties is 75. Seventeen stool specimens have been taken. Six people have now been hospitalized.

 

Event 5

Day 2, Saturday Evening

Hospital personnel have confirmed to the news media a large number of people being seen with some type of "intestinal illness" but refer callers to the health department.

 

Event 6

Day 2, Saturday Evening

At 5:00 PM, a member of a tour group visiting the county reports to the health department that 35 of 50 members have become ill with severe diarrhea, vomiting, and nausea. None have seen a doctor. All ate at local restaurants in the area for the past week. The group is primarily non-English speaking tourists from Southeast Asia.

 

Part 2

Storyboard 2

The focus of attention is being directed toward food service establishments in the three counties as a result of patient interview data. Numerous establishments are being identified as places where interviewed patients have eaten or have purchased foods in the past week. Many are restaurants; however, specialty grocery stores are also being frequently mentioned.

Twelve identified restaurants are in Cedar County. One is in Dogwood County. All restaurants serve a high volume and variety of customers. They range from well known, moderately priced, national chain restaurants to popular, high-scale dining establishments. Company executives, business leaders, attorneys, and government officials often eat at the affected city establishments. All are popular with tourists visiting both counties. Four establishments serve ethnic foods. Two are Mexican. The other two are Asian. Three affected restaurants have a history of poor food handling practices, particularly handwashing and temperature violations. None of the establishments have had violations of foods from unapproved sources.

The three specialty grocery stores are highly popular and have a high turnover of food inventory. All are owned and operated by the same company. Two of the specialty stores are in Cedar County. The third is located in Dogwood County. All food service establishments are served by public water but from different water utilities.

Event 7

Day 3, Sunday Morning

Health department personnel interviewing cases are hearing about 12 restaurants being repeatedly named in Cedar County and one in Dogwood County. Three of the restaurants in Cedar County have had a history of food service violations. Several people becoming ill, however, have not eaten at any of the 13 named restaurants. Laboratory results on patients will not be available until the next day.

 

Event 8

Day 3, Sunday Morning

Many ill patients have not eaten at a restaurant in the past week; however, food items being commonly named include fresh salsa, pesto dishes, pizzas, Asian soups, and gourmet salads.

 

Event 9

Day 3, Sunday Morning

Remember that there is a large economic trade group conference scheduled in Watertown (Cedar County) in 3 weeks, as mentioned in Storyboard 1.

Hospital emergency rooms and medical clinics in the county are becoming overwhelmed with patients. Medical facilities are short staffed because many medical personnel are home ill with "gastrointestinal upset." There is concern among medical staff about spread of the illness within the hospital and the urgent care clinics.

 

Event 10

Day 3, Sunday Evening

The patient count is up to 250 after news reports on the disease outbreak. The source is not yet determined, but food is highly suspected, with attention focusing on fresh herbs. Most cases are middle-aged adults. The age range of cases is from 5 to 82 years.

 

Event 11

Day 3, Sunday Evening

Early results of diagnostic tests indicate that Shigella sonnei is the causative agent.

 

Shigellosis Fact Sheet

• Typical symptoms of Shigellosis include severe diarrhea often accompanied by fever, chills, headache, nausea, vomiting, abdominal pain, and possibly bloody stools. The incubation period is 1 to 7 days (usually 1 to 3 days). Fewer than 10% of cases seek medical care, and fewer have confirmatory stool cultures performed. Complications such as dehydration may result in hospitalization, but deaths are rare.

Event 12

Day 3, Sunday Evening

The city's mayor receives a message from an extremist group taking credit for "contaminating the food supply with an infectious bacterial agent." The group threatens to continue to do so unless the upcoming conference of economic trade group representatives is canceled. The mayor shares the message with the health department director and the chief of police.

 

Event 13

Day 3, Sunday Evening

An anonymous person calls the local newspaper and says she represents a group that wishes to take credit for "making people sick with food contaminated with botulism."

 

Events 14 and 15

Day 3, Sunday Evening

The health officer declares a public health emergency. The phone lines are jammed.

 

Event 16

Day 4, Monday Morning

The reported patient count is now more than 400. Eighty percent of cases are from the largest county. The remaining 20% come from the two adjacent counties. Thirty cases are restaurant workers. Affected cases range in age from 4 to 87 years. Thirty cases are hospitalized. Five are in serious condition.

 

Event 17

Day 4, Monday Morning

The state university microbiology laboratory located in another part of the state reports to the university campus security that numerous vials of Shigella sonnei are missing from the laboratory. The vials were last seen 7 days ago. A few vials from the original batch of the culture are still available. Campus security contacts the county sheriff. The county sheriff contacts its local health department (Maple County).

Part 3

Storyboard 3

A terrorist group possesses 2 gallons of a liquid broth containing high concentrations of a disease-causing bacterial agent. The cultures of the bacterial agent have been secretly manufactured using stolen vials from a university laboratory. The infectious broth was surreptitiously sprayed onto produce at a food distribution warehouse in Cedar County over a 2-day period. The contaminated produce was then distributed to affected food establishments (13 restaurants and three specialty grocery stores): 12 local restaurants and two specialty grocery stores in Cedar County and one restaurant and a specialty grocery store in Dogwood County. Pine County food establishments were not affected. The produce was used for garnish and seasonings in a variety of dishes at the restaurants. The contaminated dishes were consumed in all 13 restaurants on Tuesday evening and Wednesday lunch and dinner. The produce was also purchased directly by consumers at the three local specialty grocery stores on Tuesday and Wednesday. Residents in all three counties became ill by consuming the contaminated products. Not all of the sick people have visited their medical care provider.

Event 18

Day 4, Monday Evening

Business at area food establishments is decreasing significantly.

 

Event 19

Day 4, Monday Evening

News media from other states are calling for interviews or information.

 

Event 20

Day 4, Monday Evening

Reinterviewing of cases and working closely with restaurants to identify common ingredients indicates cilantro and basil as the most likely contaminated products.

 

Event 21

Day 4, Monday Evening

An 86-year-old woman dies from complications resulting from Shigellosis. Her family threatens a lawsuit against the responsible agency.

 

Event 22

Day 14, Friday—Recovery Period

Nothing more was ever heard from the extremists. No new infections are attributed to the identified food source; however, secondary cases continue to occur, including outbreaks in three daycare centers. Public alarm has decreased, but people are still calling about food safety and concerned by the cases that continue to occur—the public does not understand the meaning of "secondary cases." The trade conference is still scheduled for 1 week from today.

 

*Northwest Center for Public Health Practice, University of Washington, in conjunction with the Washington State Department of Health. Originally titled, "Hands-on Training for Public Health Emergencies" and developed through funding from the Health Alert Network and Bioterrorism Preparedness and Response Program at the Centers for Disease Control and Prevention (CDC).