Utilizing the Incident Command System to Sucessfully Contain a Pertussis Outbreak

State: FL Type: Promising Practice Year: 2016

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In March of 2015, the Florida Department of Health in Broward County identified four (5) confirmed cases of pertussis, or whooping cough, involving three (3) adolescents, (1) toddler, and one (1) infant.  Pertussis is a highly contagious bacterial infection of the respiratory tract, and is a vaccine preventable disease.

The goal of the practice was to reduce the transmission of pertussis in Broward County.  The objectives were to coordinate the pertussis response activities of DOH Broward; minimize the spread of pertussis in the schools and day care centers, and provide the media and the public with accurate and timely information.

DOH Broward activated an Incident Command Team, utilizing the Incident Command System (ICS) and adhering to National Incident Management Standards (NIMS) to track and document progress for each of the goals/objectives identified in the Incident Action Plan (IAP).  A formalized epidemiological and communications response was initiated. 

Utilizing Incident Command to provide structure to a multi-disciplinary team was extremely effective in targeting, tracking and documenting progress in meeting all identified goals and objectives. Utilizing the Incident Command System, the multi-disciplinary incident management team was effective in targeting, tracking and documenting the course of the initial 5 cases of vaccine preventable pertussis and halting its spread to the community.

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Broward County Health Department
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Utilizing the Incident Command System to Sucessfully Contain a Pertussis Outbreak
Broward County is located in the southeastern portion of the State of Florida with Miami-Dade County to the south and Palm Beach County to the north.  Broward County’s 2014 population estimate of 1,869,235, represents 9% of the State’s population, and is the second most populous county of the 67 counties in the State of Florida and eighteenth most populous county in the United States (US Census).  Its diverse population includes residents representing more than 200 different countries and speaking more than 130 different languages.  31.5% of the residents are foreign-born.   Broward County is a minority/majority county demonstrated by its 2014 population by race (Black 28.8%, Asian 3.6%, Hispanic 27.4%, other races .5%, for a total of 60.3% and White 39.7%). In March of 2015, the Florida Department of Health in Broward County identified four (5) confirmed cases of pertussis, or whooping cough, involving three (3) adolescents, (1) toddler, and one (1) infant.  Pertussis is a highly contagious bacterial infection of the respiratory tract, and is a vaccine preventable disease.   The goal of the practice was to reduce the transmission of pertussis in Broward County.  The objectives were to coordinate the pertussis response activities of DOH-Broward; minimize the spread of pertussis in the schools and day care centers, and provide the media and the DOH Broward activated an Incident Command Team, utilizing the Incident Command System (ICS) and adhering to National Incident Management Standards (NIMS) to track and document progress for each of the goals/objectives identified in the Incident Action Plan (IAP).  A formalized epidemiological and communications response was initiated.  Utilizing Incident Command to provide structure to a multi-disciplinary team was extremely effective in targeting, tracking and documenting progress in meeting all identified goals and objectives.  Utilizing the Incident Command System, the multi-disciplinary incident management team was effective in targeting, tracking and documenting the course of the initial 5 cases of vaccine preventable pertussis and halting its spread to the community.   The Florida Department of Health in Broward County (DOH-Broward) is the official Public Health Agency in Broward County and has been operational since 1936. It is part of the Integrated Florida Department of Health (DOH) and operates in cooperation with the Broward County Commission under Florida Statute 154. DOH-Broward’s mission is “to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts”.  DOH-Broward is the lead agency providing core public health functions and essential services in the county as part of a complex public health system that includes hospitals, clinics, planning agencies, community-based organizations and others.  DOH-Broward provides population/community-based services to the county’s 1.8 million residents and over 10 million annual visitors, and is responsible for assessing, maintaining and improving health and safety within the county.  Website: http://broward.floridahealth.gov/
In March of 2015, the Florida Department of Health in Broward County (DOH-Broward) identified five (5) confirmed cases of pertussis, or whooping cough, involving three (3) adolescents, one (1) toddler, and one (1) infant.  Pertussis is a highly contagious bacterial infection of the respiratory tract.  The disease spreads easily from person to person; people get pertussis by breathing in droplets from an infected person’s cough or sneeze.  Transmission of the infection may also come through direct contact with droplets from an infected person’s cough.  Initial symptoms of pertussis are like those of a cold, including runny nose, sneezing, low-grade fever and a mild cough.  Within two weeks, the cough can become much worse.  Pertussis can infect people of all ages, yet most commonly affects infants and young children and can be fatal, especially in babies less than one year of age.  Children and the elderly with pertussis often have episodes of rapid, sporadic coughing followed by a characteristic intake of breath that sounds like a “whoop”.  These “whooping” coughing spells can make it hard for a child or older adult to eat, drink, or even breathe. The 5 cases of confirmed pertussis were identified as affecting two school, a daycare center and transitional housing site. The two schools have a combined student population of 2,331, the daycare has a capacity of 40 children, and the transitional housing site had a total of 20 persons in residence with one affected family of 4.  Health care providers and other first responders were also included in the target population for this practice. Contact investigation was utilized to define the affected population in Broward County.  The 2 affected area schools, daycare/aftercare center, and transitional housing sites were visited as part of the epidemiological field investigation.  DOH-Broward utilized its existing healthcare provider database to quickly transmit information regarding pertussis to Emergency Departments, Urgent Care Centers, Family Practitioners, Pediatricians, Internal Medicine Practitioners, Infection Control Practitioners, Infectious Disease Physicians, OB/GYNs and pulmonologists, day care centers, nursing homes, assisted living facilities, and EMS/Fire rescue.  Established community relationships and partnerships assisted in the accurate and timely exchange of necessary incident information.  Pertussis informational flyers were widely distributed at community meetings and to the community organizations including Emergency Support Function - 8 Health and Medical Work Group, Emergency Coordinating Council (Emergency Management Representatives from all 31 Broward County Municipalities), Family Central, Healthy Start, Me and My Dad event, Early Learning Coalition, WIC, and Health Mothers/Healthy Babies.  A pertussis press release was written and approved for release quickly by the Florida Department of Health Director of Communications and was transmitted to the media and posted to the DOH-Broward website and computer partner websites.  The multi-faceted social media campaign provided information to the 1.8 million residents in Broward County In the past response to pertussis outbreaks (outbreaks in general) were conducted as individual stand-alone programs with minimal coordination of activities across programs. Internal agency program coordination and integration provides a team approach to reaching clients, health care providers and the public to educate them on disease transmission and prevention and avert to further spread.  DOH-Broward utilized the Incident Command System (ICS), a component of the National Incident Management System, to provide organizational structure, meeting formats (Incident Action Plans (IAP) and Situation Reports) and After Action Planning to manage the response across multiple internal and external programs and entities.  The Incident Command System provided an effective structure to manage, track, document, and evaluate our response to a local health threat.  The integrated team formed for this response included the following programs:  Epidemiology, Emergency Preparedness, Provider/Commmunity Outreach, Public Information Officer, Planning, Pharmacy, Finance, School Health, Immunization, and WIC.  Meetings were held daily to coordinate an integrated plan in response to the outbreak. DOH-Broward utilized the Incident Command System (ICS), a component of the National Incident Management System, to provide organizational structure, meeting formats (Incident Action Plans (IAP) and Situation Reports) and After Action Planning to manage the response across multiple internal and external programs and entities. The practice was evidenced-based.  DOH-Broward utilized the Incident Command System and National Incident Management System to manage the response.  The Program Collaboration Service Integration Model (PCSI) and CDC guidelines regarding investigation and surveillance of communicable diseases, with a focus on the interruption of transmission guided the DOH-Broward response.   
Global Immunization
The goal of the practice was to reduce the transmission of pertussis in Broward County.  The objectives were to coordinate the pertussis response activities of DOH Broward; minimize the spread of pertussis in the schools and day care centers, and provide the media and the public with accurate and timely information.  ICS meetings were held from March 10, 2015 through March 16, 2015.  A total of five Situation Reports were developed.  An initial Incident Action Plan (IAP) was prepared on March 10, 2015, with a total of three IAP’s developed over the course of the event. The Incident Management Team was demobilized on March 16, 2015.  An After Action meeting was held on March 30, 2015 and was utilized to develop the After Action report.   DOH-Broward’s Epidemiology Department was notified of 5 confirmed cases via various methods including provider reporting, laboratory confirmation, ESSENCE, and the Broward County School Board.  Upon notification, DOH-Broward activated an Incident Command Team, and an epidemiological investigation was initiated with symptomatic students identified and parents contacted.  Contacts to the confirmed cases were also identified.  DOH-Broward staff visited each site, provided information about signs and symptoms, reviewed vaccination records, and obtained a list of non-immunized students and staff.  Staff also inquired about immunocompromised students and staff.  DOH-Broward staff reconciled the non-vaccination list from the schools with information in FL SHOTS.  A total of 385 records were reviewed in FL SHOTS.  At each Situation Meeting, DOH-Broward’s pharmacy reported on the current prophylaxis inventory on hand and maintained an adequate supply of adult and pediatric doses to meet community needs.  Contacts were notified to assess for vaccination, prophylaxis and/or treatment.  Prophylaxis was provided to those persons that were not immunized.  Teachers and students at the daycare were offered prophylaxis by DOH-Broward.  DOH-Broward’s pharmacy filled 49 prescriptions for 49 unduplicated patients.  Immunization Outreach was provided at the schools and daycare center for those students that were found to be unvaccinated.  DOH-Broward continued to review and monitor absenteeism, home room logs, and health room visits for symptoms of coughing at the affected facilities.  Broward County Schools sent pertussis information letters home to students at the school in three languages based on US Census data for the most popular languages spoken in Broward County (English, Spanish, Creole).   A letter was also sent to parents by the daycare.  New Incident Action Plans, updates to the Incident Command structure chart, and Situation Reports were available electronically to staff involved in the investigation.  Electronic documentation was also utilized to track and monitor activities of staff, the immunization status of contacts and whether they required and/or received prophylaxis.  DOH-Broward successfully developed and implemented targeted outreach efforts to providers, facilities and the communities within Broward County. Existing and trusted community relationships and partnerships were beneficial to initiating communication and assisted in the accurate and timely exchange of necessary incident information. DOH-Broward utilized its existing database to quickly transmit information regarding pertussis to Emergency Departments at the 17 Acute Care Hospitals, Urgent Care Centers, Family Practitioners, Pediatricians, Internal Medicine Practitioners, Infection Control Practitioners, Infectious Disease Physicians, OB/GYNs and pulmonologists, day care centers, nursing homes, assisted living facilities, and EMS/Fire rescue. The physician/provider letters were emailed to 1,400 recipients, 150 Urgent Care Center/Volunteer Clinics, and EMS/Fire and ESF 8.  Letters were also emailed to 840 day care centers and 65 nursing homes and assisted living facilities. Pertussis informational flyers were created and widely distributed at community meetings and to the community organizations including ESF-8 Work Group, Emergency Coordinating Council (Emergency Management Representatives from all 31 Broward County Municipalities), Family Central, Healthy Start, Me and My Dad event, Early Learning Coalition, WIC, and Health Mothers/Healthy Babies.  A total of 10,000 flyers were distributed in English, Spanish, and Creole languages.  The pertussis press release was approved quickly by the Florida Department of Health Director of Communications and was transmitted to the media and posted to the Florida Department of Health and DOH-Broward websites, as well as computer partner websites.  The multi-faceted social media campaign provided information to the 1.8 million residents in Broward County.  The time-frame for this practice was from March 10, 2015 through March 16, 2015. Broward County public and parochial schools sent letters, in three languages, home to the parents of students at the schools with pertussis cases.  The schools also provided information on the unvaccinated students, absenteeism and health room visits for cough to DOH-Broward.  The daycare provided information on the vaccination status of teachers and students at the day care.  Informational flyers were distributed to local community based organizations and were distributed and well as the WIC (Women, Infant Children) sites regarding pertussis. DOH-Broward has strong collaborative relationships with public and private health care providers, faith-based organizations, local governmental agencies, civic associations, the Miccosukee and Seminole tribal nations, and serve on many committees, Boards and provider networks.  Increased awareness and the mitigation of communicable diseases within our communities are more effectively achieved with these collaborative relationships. Start up costs were minimal due to use of existing DOH-Broward staff for the ICS. Costs of the vaccine is $35.00 per dose with a reimbursement of $52.50.
The after action report developed includes discussion of how each of the objectives in the Incident Action Plan were met during the activation of the multidisciplinary team.  The major strengths identified during this activation area as follows: All members of the incident management team had previous incident command experience which enabled the team to function smoothly with seamless adjustments being made in real-time. Lessons learned from prior incident command operations including the availability of electronic documentation created for the incident greatly improved the efficiency and effectiveness of the staff. The incident management team was activated immediately and included the subject matter expertise required to address the incident objectives. The meeting frequency was scaled in accordance with the needs of the incident. The epidemiology staff and school liaison staff successfully coordinated the review of health room logs and lists of unvaccinated and immunocompromised students to assess the need for vaccine, prophylaxis, and/or treatment The Logistics/Pharmacy staff quickly inventoried current prophylaxis on hand and maintained adequate inventory throughout the incident. DOH-Broward utilized its existing database to quickly transmit information regarding pertussis to Emergency Departments, Urgent Care Centers, Family Practitioners, Pediatricians, Internal Medicine Practitioners, Infectious Control Practitioners, ID physicians, OB/GYNs and pulmonologists, day care centers, nursing homes, assisted living facilities, and EMS/Fire rescue. Existing and trusted community relationships and partnerships assisted in the accurate and timely exchange of necessary incident information. Pertussis informational flyers were widely distributed at community meetings and to community organizations including ESF-8 Work Group, Emergency Coordinating Council (Emergency Management Representatives from all 31 Broward County Municipalities), Family Central, Healthy Start, Me and My Dad event, Early Learning Coalition, WIC, and Healthy Mothers/Healthy Babies. The pertussis press release was approved quickly by the Florida Department of Health Director of Communications and was transmitted to the media and posted to the DOH-Broward website and computer partner websites.  FloridaSHOTS (the State of Florida immunization registry) was utilized by DOH-Broward school health personnel to verify vaccine status of affected children. ESSENCE data system and reports from the schools indicated no new additional cases of pertussis. Based on this information, the actions taken mitigated additional spread of pertussis in the community. The after action report developed includes discussion of how each of the objectives in the Incident Action Plan were met during the activation of the multidisciplinary team.  The major strengths identified during this activation area as follows: All members of the incident management team had previous incident command experience which enabled the team to function smoothly with seamless adjustments being made in real-time. Lessons learned from prior incident command operations including the availability of electronic documentation created for the incident greatly improved the efficiency and effectiveness of the staff. The incident management team was activated immediately and included the subject matter expertise required to address the incident objectives. The meeting frequency was scaled in accordance with the needs of the incident. The epidemiology staff and school liaison staff successfully coordinated the review of health room logs and lists of unvaccinated and immunocompromised students to assess the need for vaccine, prophylaxis, and/or treatment. The Logistics/Pharmacy staff quickly inventoried current prophylaxis on hand and maintained adequate inventory throughout the incident. DOH-Broward utilized its existing database to quickly transmit information regarding pertussis to Emergency Departments, Urgent Care Centers, Family Practitioners, Pediatricians, Internal Medicine Practitioners, Infectious Control Practitioners, ID physicians, OB/GYNs and pulmonologists, day care centers, nursing homes, assisted living facilities, and EMS/Fire rescue.  Existing and trusted community relationships and partnerships assisted in the accurate and timely exchange of necessary incident information. Pertussis informational flyers were widely distributed at community meetings and to community organizations including ESF-8 Work Group, Emergency Coordinating Council (Emergency Management Representatives from all 31 Broward County Municipalities), Family Central, Healthy Start, Me and My Dad event, Early Learning Coalition, WIC, and Healthy Mothers/Healthy Babies.
Cross collaboration across programs is extremely important as well as continuing to foster existing relationships with Community Based Organizations, Schools and Child Care centers.  The development and use of the existing community wide data bases (physician, urgent care, etc.) continues to be invaluable in order to rapidly provide accurate and timely information to the community. Existing and trusted community relationships and partnerships assisted in the accurate and timely exchange of necessary incident information. The Florida Department of Health in Broward County will continue to use incident command for communicable disease outbreaks.  Incident command for outbreaks is scalable and assists in bringing staff from different departments together under a succinct structure with identifiable positions.  
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