A Multidisciplinary Approach to a Shigellosis Outbreak in Columbus, OH

State: OH Type: Model Practice Year: 2010

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In 2009, CPH sought to prevent the spread of disease and mobilize resources and community partnerships to resolve an outbreak of shigellosis. From 2003 through 2007, an average of 20 shigellosis cases was reported annually in Columbus. Beginning in June 2008 Columbus experienced concurrent outbreaks of both shigellosis and cryptosporidiosis. The shigellosis outbreak lasted for 15 months, with 519 cases in 2008 and 182 cases in 2009. Due to the unusually high incidence of shigellosis, our everyday infectious disease processes and resources became overwhelmed. This project sought to further control the spread of shigellosis and prevent new cases. This was an experimental method aimed at shortening the outbreak timeframe and lessening the burden on public health services and the community. The goal of this project was to reduce the incidence of shigellosis in Columbus to ≤ 3 cases per week sustained over eight weeks, the determined baseline marking the end of the 2008–2009 shigellosis outbreak.

Objective 1) Create a multi-disciplinary taskforce utilizing incident management principles as a new approach for collaboration, harnessing resources, and improving current public health processes for the control and prevention of infectious disease. Objective 2) Establish new processes for case investigation and data collection that improves disease tracking, obtains a more complete data set, and identifies case characteristics needed to form the design for more effective interventions.
Objective 3) Create an intervention to control the further spread of shigellosis and to prevent new cases, specifically in childcare centers involved in the 2008-2009 outbreak (with previously reported cases) and in those facilities identified in the target zip code areas not involved in the outbreak (with no cases reported).

Outcomes from this project strengthened our public health infrastructure capabilities to combat future outbreaks, such as the H1N1 Pandemic Influenza response. The creation of a task force comprised of multi-disciplinary public health staff using a three-tiered incident management style structure was innovative from past outbreak interventions. The creation of a new system for data collection and analysis facilitated the design of more effective interventions. Improvements were made to case investigation, completeness of data, determining means of transmission, mapping case concentrations, and determining when the outbreak had resolved. An intervention was designed for target audiences to control further spread and to prevent new cases of shigellosis in childcare centers, including outreach to childcare facilities with previously reported cases and those in target zip code areas with no cases yet reported. The educational interventions conducted to improve handwashing among the staff, children, and their families, as well as efforts to increase public awareness of this issue, was a coordinated effort. The resulting handwashing campaign can be used to control other infectious diseases through a variety of other programs.

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Columbiana County Health District
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A Multidisciplinary Approach to a Shigellosis Outbreak in Columbus, OH
In 2009, CPH sought to prevent the spread of disease and mobilize resources and community partnerships to resolve an outbreak of shigellosis. From 2003 through 2007, an average of 20 shigellosis cases was reported annually in Columbus. Beginning in June 2008 Columbus experienced concurrent outbreaks of both shigellosis and cryptosporidiosis. The shigellosis outbreak lasted for 15 months, with 519 cases in 2008 and 182 cases in 2009. Due to the unusually high incidence of shigellosis, our everyday infectious disease processes and resources became overwhelmed. This project sought to further control the spread of shigellosis and prevent new cases. This was an experimental method aimed at shortening the outbreak timeframe and lessening the burden on public health services and the community. The goal of this project was to reduce the incidence of shigellosis in Columbus to ≤ 3 cases per week sustained over eight weeks, the determined baseline marking the end of the 2008–2009 shigellosis outbreak. Objective 1) Create a multi-disciplinary taskforce utilizing incident management principles as a new approach for collaboration, harnessing resources, and improving current public health processes for the control and prevention of infectious disease. Objective 2) Establish new processes for case investigation and data collection that improves disease tracking, obtains a more complete data set, and identifies case characteristics needed to form the design for more effective interventions. Objective 3) Create an intervention to control the further spread of shigellosis and to prevent new cases, specifically in childcare centers involved in the 2008-2009 outbreak (with previously reported cases) and in those facilities identified in the target zip code areas not involved in the outbreak (with no cases reported). Outcomes from this project strengthened our public health infrastructure capabilities to combat future outbreaks, such as the H1N1 Pandemic Influenza response. The creation of a task force comprised of multi-disciplinary public health staff using a three-tiered incident management style structure was innovative from past outbreak interventions. The creation of a new system for data collection and analysis facilitated the design of more effective interventions. Improvements were made to case investigation, completeness of data, determining means of transmission, mapping case concentrations, and determining when the outbreak had resolved. An intervention was designed for target audiences to control further spread and to prevent new cases of shigellosis in childcare centers, including outreach to childcare facilities with previously reported cases and those in target zip code areas with no cases yet reported. The educational interventions conducted to improve handwashing among the staff, children, and their families, as well as efforts to increase public awareness of this issue, was a coordinated effort. The resulting handwashing campaign can be used to control other infectious diseases through a variety of other programs.
In 2009 CPH sought to prevent the spread of disease and mobilize resources and community partnerships to resolve an outbreak of shigellosis. From 2003 through 2007, an average of 20 shigellosis cases was reported annually in Columbus. Beginning in June 2008 Columbus experienced concurrent outbreaks of both shigellosis and cryptosporidiosis. The shigellosis outbreak lasted for 15 months, with 519 cases in 2008 and 182 cases in 2009. Due to the unusually high incidence of shigellosis, our everyday infectious disease processes and resources became overwhelmed. Shigellosis is a reportable infectious disease in Ohio. Shigella is a bacterium that causes diarrhea, fever and stomach cramps, is transmitted from person to person by contaminated hands or objects, and its symptoms can last five to seven days. Because the severity of diarrhea varies, it can be difficult to identify without testing. Columbus was experiencing 25 times more cases in 2008 than in previous years. Through case investigation and data mapping, we determined that 86% of cases were 17 years of age or younger, 47% of cases were related to a childcare facility and 57% of cases were African-American. Shigellosis is considered highly contagious and several factors were identified as barriers to controlling and preventing further spread. It is easily spread throughout households and showed increasing resistance to antibiotics. Inadequate handwashing, especially after using the bathroom or changing diapers was identified as the primary culprit of transmission. It was challenging working with parents, food handlers, and childcare operators around the exclusion of symptomatic individuals and cases from childcare facilities and licensed food establishments. Once diagnosed with shigellosis, a child is excluded from childcare for up to 10 days to several weeks, and until two negative stool samples are completed. This causes a potential hardship for both the family and childcare center for the child’s extended absence. Before the intervention, investigating nurses often found it difficult to reach the parents of children reported to be infected, found resistance from some childcare centers to make needed difficult changes to their environment and procedures that may spread infection, and challenges from healthcare providers less likely to test for and report the infection. We also discovered that families with children infected with shigellosis would move their child to another center once excluded from the first, thus further spreading the infection.Columbus had 519 cases of shigellosis reported in 2008, compared to just 10 in 2007. Because some cities have experienced outbreaks of shigellosis for as long as 18 months, a more intense intervention would be needed to try to limit its course for Columbus. While Shigella sonnei infection is not usually serious or life threatening, it can cause a significant impact on a community’s overall health and economic life. Every year, about 14,000 cases of shigellosis are reported in the United States. Because many milder cases are not diagnosed or reported, the actual number of infections may be twenty times greater. Children, especially toddlers aged two to four, are the most likely to get shigellosis. The spread of illness often occurs in childcare settings and in families with small children. Columbus’ cases were also concentrated in children younger than 17 who were in close proximity during the day, such as in childcare or school. Children missed an average of two to three weeks of school or childcare. This caused hardships for the children, their families, the childcare center or school, and possibly the worksites of family members. In addition to experiencing the illness itself, parents experienced lost wages (sometimes jobs) and children had long school absences. The childcare facilities experienced lost income, an increase in staff absenteeism, and additional costs associated.
Agency Community RolesThe local health department’s role in this practice is to be a leader in outbreak investigations and intervention in the community. Once a shigellosis case was reported to CPH the communicable disease nurses working under the Case Investigation Workgroup would follow up with the person having the known or suspected case to complete a questionnaire. The information was entered into the Ohio Disease Reporting System (ODRS) and a line list Excel spreadsheet and then analyzed by epidemiologists working under the Data Workgroup. The Data Workgroup created and facilitated a case investigation subcommittee which daily reviewed the case line list to ensure completeness of case investigation reports. The in-depth analysis of the raw data assisted in developing the intervention methods specific to age level, zip code, and ethnicity within the at risk populations. Once the communicable disease nurses had acquired the needed information from the patient and it was confirmed that the case involved a child attending a childcare center, community health nurses visited the center within one business day. Previous to the development of the Taskforce, these visits were conducted by communicable disease nurses. Using the community health nurses was a win-win in that they were already recognized by the community to educate on health interventions and it freed up the communicable disease nurses to concentrate on conducting the case investigations. The face-to-face visits to the childcare centers were conducted to share outbreak prevention and control interventions regarding shigellosis and other infectious diseases. The childcare centers received an educational packet full of age appropriate handouts, handwashing posters, form letters, and educational information on shigellosis. Should the childcare center be interested, the health department nurses conducted, with the center director, an environmental inspection to find ways to further reduce or eliminate any further spread of disease to the other children. These proactive measures broke down many barriers in that the childcare centers accepted the health department as a partner and not an enforcer. Another role of the health department is to provide up to date information to the healthcare community. The medical epidemiology subject matter expert was responsible for developing public health advisories for healthcare providers which included clinical guidance and treatment recommendations. A special page was created on the CPH and Communicable Disease Reporting System websites which provided current information to health care providers on the shigellosis outbreak. In addition the epidemiologists in the Data Workgroup created and maintained a GIS map to track case distribution in the community and wrote a weekly analysis update which was posted on our website and utilized by the Taskforce to create intervention strategies. It is the responsibility of the healthcare practitioners and laboratories in Columbus to report cases of communicable disease to the local health department as mandated by the Ohio Revised Code 3701. Shigellosis is a Class B(1) reportable disease of public health concern which needs timely response because of the potential for epidemic spread. This Class B(1) reportable disease should be reported to the health department by end of the next business day after the existence of a case, a suspected case, or a positive laboratory result is known. The reporting system used by Columbus is the Communicable Disease Reporting System (CDRS). CDRS is a joint reporting system with the Franklin County Board of Health to make the reporting, tracking, and investigation of communicable disease cases easier and more convenient. The face-to-face visits to the childcare centers by the communicable disease and community health nurses were conducted to share outbreak prevention and control interventions regarding shigellosis and other infectious diseases.  Costs and ExpendituresColumbus Public Health assembled a multi-disciplinary taskforce between February and May 2009 to focus on the 2008-2009 shigellosis outbreak in Columbus and to implement measures to control and prevent the spread of the disease. The taskforce was built on a three-tiered incident management style structure which included an advisory group, a core group and four workgroups. The advisory group consisted of the Medical Director, Director of Nursing, Director of the Office of Assessment and Surveillance, and the Communicable Disease Team Supervisor. The advisory group provided guidance to the core group on policy and administrative issues, as well as securing resources. The core group was led by a project manager who facilitated five CPH staff representing various public health specialties including nursing, epidemiology, environmental health, communications, health education, workforce development, emergency preparedness, community relations, and a medical epidemiology subject matter expert. The four workgroup function areas included case investigation, communication, data, and education and outreach. The core group met on a weekly basis and reported on the current situational analysis, planned and prioritized workgroup objectives for the upcoming week, shared ideas, and analyzed data. Separate meetings were held to discuss intersecting areas of the project with joint deliverables. For example, the Data Workgroup created and facilitated a case investigation subcommittee which reviewed daily a case line list to ensure completeness of case investigation reports. Innovative for CPH, this approach involved all taskforce specialty areas, including communicable disease nurses, epidemiologists, community health nurses, and the medical epidemiology expert. Members of the Core Group were temporarily released from their typical job responsibilities to work 32 hours per week on Shigella Taskforce activities. The medical epidemiology subject matter expert was hired as a paid temporary position to work exclusively on infectious disease investigations and to advise all workgroups. The workgroups consisted of eight staff members who remained in their normal positions, but worked exclusively on the shigellosis outbreak. Other staff members were utilized in-kind from other areas to assist with planning, outreach, and intervention methods such as health educators and environmental health sanitarians. Of those reporting their time and expenditures, the total amount of personnel costs attributed to this project is estimated at $117,513, mileage reported equaled $673.20, and materials purchased equaled $630.95. Materials contributed by other organizations as in-kind included: plastic pouches for childcare education kits, handwashing song CD with jewel cases, Communicable Disease Reporting System magnets, and communicable disease posters. The primary funding source used was an existing departmental account designated exclusively for the communicable disease prevention team. Some funds were also expended from a public health infrastructure grant and the environmental health general fund. The Taskforce utilized funds to print (black & white and color) handouts, coloring books, posters, and postcards, to produce stickers and decals, as well as to purchase books and county maps. Nearly 500 copies of a “Wash My Hands” Handwashing song were provided free from the City of Columbus Department of Development. The CD was distributed to all of the childcare centers that were visited by a communicable disease or community health nurse to promote proper handwashing techniques to reduce the spread of disease. The Taskforce tracked the salary and mileage for 14 CPH staff between February 6 and May 29, 2009. A total of $117,513 dollars were expended for staff salaries who worked 2,725 hours on the Taskforce and $673.20 in mileage for 1,224 miles driven in the community. ImplementationObjective 1) The Taskforce was built on a three-tiered incident management style structure which included an advisory group, a core group and four workgroups. The core group met on a weekly basis and reported on the current situational analysis, planned and prioritized workgroup objectives for the upcoming week, shared ideas, and analyzed data. The Workgroups held separate meetings to discuss intersecting areas of the project with joint deliverables. The overall process enabled the development of products and interventions that incorporated input from all workgroups, and integrated target audience characteristics, behaviors, barriers, and principles of health education and social marketing. Objective 2) A) Case Investigation and Data Workgroups - Collection: Conducted case investigations on all confirmed shigellosis cases within 24 hours of receiving a report. Provided educational information/resources to the infected person or the parent of an infected child within 48 hours of receiving a confirmed report of disease. Provided Shigella public health advisories monthly to healthcare providers throughout the outbreak which outlined outbreak status, disease symptoms, treatment and testing information. Initiated contact with childcare facilities with identified shigellosis cases within two days of receiving information. Provided stool specimen testing for appropriate at-risk contact and conducted needed cohort testing. This was ongoing during the project. B) Data Workgroup - Management and Reporting: Facilitated daily a meeting with communicable disease nurses, community health nurses, epidemiologists and medical epidemiology content expert to review case information and ensure completeness of data. Maintained daily an Excel spreadsheet line list of case data, obtaining guidance from subject matter expert on case investigation process, incorporating data from case questionnaire, and following up with cases when additional information was needed. Created and maintained a GIS map that tracked case distribution in the community and defining target zip codes for intervention. The timeframe was February 28 to October 9, 2009. Researched data from other Ohio cities with increased shigellosis cases. Contacted these cities to discuss epidemiologic data to find connections and discuss lessons learned. This was conducted in March, 2009. Provided analysis findings to assist with intervention strategies and distributed summary data reports and maps to Taskforce Advisory and Core Groups. Met weekly and discussed case characteristics and commonalities with those developing the intervention. Establish a shigellosis incidence baseline based on historical levels to determine when outbreak is over, collaborating with case investigation workgroup and content expert. This was completed March 27, 2009. Objective 3) A) Communication Workgroup - Components: Workgroups met to identify intervention audiences and settings, looking at related behaviors and possible barriers to behavior change. This was conducted in February, 2009. Researched existing related campaigns, defined audiences further, and prioritized behaviors impacting the spread of disease. This was conducted in February, 2009. Met with other programs and outside organizations working with identified audiences regarding behaviors, barriers to change and motivators. This was conducted in February, 2009. Defined set of key messages, materials and methods to be used and developed for the overall campaign design, colors, logo, and theme. This was completed in March, 2009. Material sets were developed for the following audiences: childcare (outbreak and non-outbreak); schools – K-12; pool facilities; healthcare providers; parents of young children; and the general public. We also selected existing materials from other organizations to save on costs and staff time. This took place in April and May, 2009. Web content was developed for specific audien
The goal of this project was to reduce the incidence of shigellosis in Columbus to ≤ 3 cases per week sustained over eight weeks, the determined baseline marking the end of the 2008-2009 shigellosis outbreak.Create a multi-disciplinary taskforce utilizing incident management principles as a new approach for collaboration, harnessing resources, and improving current public health processes for the control and prevention of infectious diseaseMeasureable incident objectives and strategies were developed for each of the four workgroups including the medical epidemiology expert. In addition tactics were developed with specific time deadlines that each workgroup was responsible for. Utilizing incident management style principles, the Project Manager created and maintained several forms to collect data to better manage the workgroups. These included a Shigella Team Information Form, a Shigella Time Sheet and a Shigella Taskforce – Core Team Time Off Matrix. The Core Team met on a weekly basis and was facilitated by the Project Manager who handled all business-related issues. A secure computer folder was also established on the department’s shared drive for all Shigella Taskforce members to share and download information. The Advisory Team provided feedback to the Core Group on a regular basis to ensure the tactics were on target with the goals. When the Taskforce disbanded a final review and after action meeting was facilitated by the Program Manager for all Taskforce members. Now that this model has been tested and evaluated to focus efforts entirely on an outbreak we have strengthened our ability to respond using a multi-disciplinary approach for future outbreaks. CPH realized the extent to which we were under-resourced in this mandated public health function. Establish new processes for case investigation and data collection that improves disease tracking, obtains a more complete data set, and identifies case characteristics needed to form the design for more effective interventions.In addition to the measurable incident objectives, strategies and tactics developed by both the Case Investigation and Data Workgroups a baseline of incidence was created to determine the end of the outbreak. The outbreak was considered resolved when the incidence dropped to ≤ 3 cases per week sustained over eight weeks. Once a case was reported to the health department the communicable disease nurses working under the Case Investigation Workgroup would follow up with the known or suspected case and complete a questionnaire. The information was entered into ODRS and a line list Excel spreadsheet and then analyzed by epidemiologists working under the Data Workgroup. The Data Workgroup created and facilitated a case investigation subcommittee which reviewed daily a case line list to ensure completeness of case investigation reports. Innovative for CPH, this approach involved all teams working with these cases, including communicable disease nurses, epidemiologists, community health nurses, and the medical epidemiology expert. The daily review of case investigations was extremely helpful to the epidemiologists, nurses, and medical epidemiology expert in helping to better understand where the cases were located, connections with family units or childcare centers, as well as a learning experience for those new to case investigations. The in depth analysis of the raw data assisted in developing the intervention methods specific to age level, zip code, ethnicity, and at risk populations. Improvements were made as to how soon data and case investigation staff should meet to discuss new cases. Create an intervention to control the further spread of shigellosis and to prevent new cases, specifically in childcare centers involved in the 2008-2009 outbreak (with previously reported cases) and in those facilities identified in the target zip code areas not involved in the outbreak (with no cases reported).Measureable incident objectives and strategi
Columbus Public Health has strengthened our ability to respond in kind to future outbreaks now that this model has been tested and evaluated. We have made strides in surmounting well engrained beliefs and practices that have hindered our ability to be a more effective public health department. An initial barrier was the silo mentality within programs. Working across teams and moving staff to areas of greatest need has not been an accepted practice. Labor contract issues were perceived to be an obstacle in areas such as work hours, seniority, and a perception that staff could not be reassigned to a different program. Managers expressed reluctance about different funding sources and skill sets between programs. The early transition was not always smooth behind the scenes yet we were successful in making the necessary reassignments without major disruption. Another barrier was based in part on the multi-disciplinary makeup of public health. One of our greatest strength’s is also a weakness because we don’t always value the contributions of other disciplines. Understanding each other’s knowledge base was key to moving this project forward. The growing pains resulted in a successful mission as well as a willingness to become involved in future approaches that were different from the norm. The successful use of a team approach was utilized to smoothly transition into the Spring 2009 H1N1 Pandemic Influenza public health response. The project has helped CPH to standardize and institutionalize some essential health education materials. Tools such as the development of a handwashing campaign were immediately distributed community wide for H1N1 prevention. CPH has continued to utilize the over 40 types of documents that were created including management tools, educational materials, and health care provider advisories. The face-to-face visits conducted by the community health nurses to share outbreak prevention and control interventions regarding shigellosis and other infectious diseases created new opportunities for childcare centers to see the health department as a partner rather than an enforcer. This has enabled CPH to strengthen our relationship with the childcare centers resulting in more requests for assistance and cooperation with exclusion rules. A series of extensive outbreaks including shigellosis and the abrupt onset of the H1N1 pandemic helped both our department and also other city departments realize the extent to which we were under-resourced in this mandated public health function. Following the work conducted by the Shigella Taskforce, CPH has already made the following changes. A full-time public health medical expert was hired to serve as a daily resource for communicable disease and epidemiology. The involvement of this position enables CPH to more proactively react and intervene at the earliest known onset of known or other potential outbreaks. Secondly, CPH reorganized several programs to be able to more fully respond to outbreaks and other public health issues that require a broader multi-disciplinary approach. This includes communicable disease which has been separated from immunizations and has a Program Manager that directly focuses on communicable disease issues with the full-time medical expert. The department has also refocused and realigned the communicable disease nurses and the community health nurses involved on the Taskforce to better be able to provide strategic assistance to control communicable diseases and provide outreach in the community. A major focus for the newly formed strategic nursing strike team is to advance our relationship with childcare centers. The department has applied for funds to develop educational programs and outreach to these centers and received favorable indication that funding will be approved in the spring of 2010. Lastly, in the midst of these tough economic times, CPH has successfully made the case with the City of Columbus ad
 
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