1. Health Surveillance in Shelters
Shelter Surveillance Work Group
January 21, 2014
MMRS

2. Objectives
Describe how surveillance can be conducted in an emergency shelter to increase situational awareness of disease and illness during disasters.
Describe how shelter surveillance has been used in national disasters, such as the response to Hurricane Sandy.
Explain protocol and process for conducting surveillance in emergency shelters and gain knowledge in preventing and managing outbreak situations in shelters.
Understand how facility-specific environmental health and safety assessments are performed at emergency shelters during disasters.
Demonstrate the use of the shelter surveillance forms by reviewing case studies.

3. How do you know when you have a health problem in your shelter?

4. Eric Noji, book editor – The Public Health Consequences of Disasters
“Disasters are defined by what they do to people. Otherwise, they are simply interesting geological or meteorological phenomena.”
Eric Noji, book editor – The Public Health Consequences of Disasters

5. Public Health Capability – Mass Care
Function 4: Monitor mass care population health.
Task 2: During an incident, conduct surveillance at congregate locations to identify cases of illness, injury, and exposure within mass care populations.

6. Shelter Syndromic Surveillance – Hurricane Katrina
Aug 29, shelters established in Georgia
Data collected:
Census data
Symptoms consistent with outbreak potential
Chronic conditions
Injuries
Medical referrals
Single day maximum residents - 1,504 persons; average of 122 people
Source: Advances in Disease Surveillance 2007: 2:148.

7. Hurricane Katrina 13 shelters assessed over a 21-day period
Norovirus outbreak in 1 shelter
Hypertension (33 cases/1,000 resident-days)
Diarrhea (9 cases/1,000 resident-days)
Cough (9 cases/1,000 resident-days)
Skin infections (8 cases/1,000 resident-days)

8. It’s getting closer…Hurricane Sandy
NY Response & Shelter Surveillance
Most common reason for visits were follow-up care, mental health and exacerbation of chronic conditions
NJ Response
Field team focused on largest shelters, those expecting to remain open the longest and those with Red Cross Health Services (21 shelters)
About 50% presented with acute symptoms; 33% follow-up care

10. What is health surveillance in shelters?
Collecting health information on illness and injury to monitor the health of individuals in an emergency shelter
Goals:
Prevent outbreaks or implement infection control measures at the onset of an outbreak
Prevent the spread of communicable diseases
Implement measures to prevent injuries

11. Benefits
Preventing….

12. Conducting Health Surveillance
Recommended that it starts within 24 hours of shelter activation
Request for assistance can be made to the State Emergency Operations Center (SEOC) Emergency Support Function (ESF) 8 Desk
Three forms to assist with surveillance

13. Prevention Measures Triage Encourage hand hygiene and cough etiquette
Give symptomatic evacuees with a cough a mask and direct to the Medical Unit or a separate area for registration
Encourage hand hygiene and cough etiquette
Place hand sanitizer by the food, make sure there is soap in the restrooms
Place posters and educational materials in high traffic areas

14. Prevention Measures
Provide personal protective equipment (e.g. gloves, masks) to shelter workers when in contact with sick residents or in contact with bodily fluids

15. Illness and Outbreaks in a Shelter
Signs and symptoms associated with communicable diseases:
Vomiting, fever, diarrhea, cough, sore throat, rash, stiff/sore neck
When illness is suspected:
Escort the resident to the Medical Unit or notify the unit and stay with the resident/worker until medical support arrives
Call 911 if it is an emergency

16. Illness and Outbreaks in a Shelter
If a resident or worker is suspected to have a communicable disease of concern (e.g. cough with blood) or there are 3 or more residents/workers with similar symptoms within a 24 hour period:
Document incident in the Medical Unit Activity Log and the Medical Unit Leader should consult with the Shelter Manager
Shelter Manager contacts NH Division of Public Health Services by phone and works with them to implement control measures

17. Guidance for Medical Unit
A table from the “Infection Prevention and Control for Shelters During Disasters” is included
Provides recommendations for isolation and contact precautions

18. Infection Control Triage Individual Placement/
Symptoms/Syndrome
Isolation
Precaution
Category1
Individual Placement/
Separation
Requires
medical
professional
assessment
Respiratory
Cough, runny nose, watery eyes
Standard
None No
Fever (Temp > 100F*) & cough in
adults
Droplet
Cohorting;
Spatial distancing2
Yes
Fever (Temp > 100 F*) & cough in
children
Contact
Fever (Temp > 100F*), cough
with bloody sputum, and weight loss
Airborne3
AIIR^ or negative
pressure area/room;
Diarrhea or Vomiting
Vomiting
Social distancing3
Loose or unformed stools
Watery or explosive stools, with or
without blood

19. Conducting Health Surveillance
Forms
Natural Disaster Morbidity Surveillance “Individual Form”
Natural Disaster Morbidity Surveillance “Summary Report”
Environmental Health Assessment Form
Forms were developed by the Centers for Disease Control and Prevention

20. Environmental Health Assessment Form
Completed each operational period by the municipal Health Officer or other designated Environmental Health Specialist and submitted to the shelter manager for review
Does not need to be sent to the SEOC, for local/regional use for environmental assessments

21. Pass out form. Talk through the form, noting each section
Pass out form. Talk through the form, noting each section. Address any specific question. Mention that in NH, shelter manager or health officer typically completes form BEFORE shelter opens. Highlight benefits of conducting assessment before opening, and its relationship to infection prevention. Discuss Red Cross variation of using Environmental assessment form, including fact that ARC volunteer may be both shelter manager and running health station.

22. “Individual Form”
Completed for each individual that visits the Medical Unit of First Aid Station by the staff
Considered a confidential document
Can be attached or included with the narrative or notes on the patient visit
Do not post to WebEOC and do not send to the SEOC

23. Pass out form.

24. “Summary Report”
Completed using the information from the “Individual Forms” by the Medical Unit Leader or designee
Submitted each operational period to the SEOC ESF 8 desk by phone or HAM radio
Not a confidential document because it does not contain personal identifiers and is aggregate data

25. Pass out form. Keep description brief- we will return to this after individual case studies.

26. Case Study #1
A 29 yo female shows up at the registration desk with red, watery eyes and states that she has some muscle aches
She has 3 children, the youngest is a 9 mo who is breast feeding and has loose stools
This person is referred from registration to the medical station

27. Case Study #1 Cont.
At the medical station the 29 yo is found to have a semi productive cough and a fever of 100.4F.
The 9 mo year old is afebrile and has no other symptoms

28. Questions What type of precautions should be taken for the mom?
What type of precautions should be taken for the baby?
Where should they be housed within the shelter?
What type of education is needed for the family?

29. Answers
The mom is given a mask to wear and encouraged to call her doctor
Make sure the mom has enough diapering supplies for the night
The family is given their own room to stay in
Educate the mom on hand hygiene and cough etiquette

30. Filling out the individual form – 29 year old mom
Walk through ALL FIELDS including demographic information, city, etc. Note the star notations and their instructions at bottom of form.

33. Filling out the individual form – 9 month old

35. Filling out the summary form
2 patients seen at the Medical Unit on 10/4/2013
29 yo female
9 mo

36. 1 2

37. Case 2
A 12 yo comes in to the medical station with a diffuse rash and an oral temp of 99.9F
Rash is itching and started 2 days prior to coming to the shelter

38. Questions What precautions should you take for the 12 yo?
Does he need to be separated from others in the shelter?

39. Answers
This person is monitored by shelter medical staff, and they are encouraged to return to the medical station if symptoms change

41. Case 3
A 68 year old male using portable oxygen arrives at the medical station complaining of a cough and runny nose
He has a productive cough and is short of breath, unable to complete whole sentences

42. Questions
What immediate actions need to be taken with this shelter resident?
How should this be documented?
Who should be notified about this incident?

43. Answers
The breathing issue is priority over the infectious disease symptoms, call 911
The client is encouraged to sit down and is monitored continuously by medical staff until EMS arrives
The shelter manager is made aware that 911 has been called
A shelter volunteer is sent to the parking lot to receive EMS and direct responders to the patient

46. Case 4 The first lunch is being served since the shelter opened
It is hamburgers and salad
The hamburger is properly cooked, but the lettuce is packaged
About 48 hours after this lunch, 4 shelter residents start complaining of nausea, vomiting and diarrhea

47. Questions What actions should be taken with the food staff?
What actions should be taken in the kitchen/ food prep area?
What precautions should be taken for the 4 ill shelter residents?
Who should you notify about this incident?

48. Answers
Check to see if any of the food handlers and ill and if they are, ask them to stop handling and working with food
Make sure workers aren’t touching ready made food with their bare hands
Make sure the food prep area is cleaned and proper food handling procedures are being followed
Send the 4 residents to the Medical Unit and isolate them into classrooms or a separate area of the shelter; ideally, give them a separate bathroom to use from the general shelter residents
Educate the residents on hand hygiene
Since more than 3 shelter residents with similar symptoms in a 24 hour period, the shelter manager calls NH DPHS

50. Filling out the Summary Report for Cases 1-4

52. Resources CDC – Forms APIC Document
APIC Document

53. Acknowledgements Shelter Surveillance Work Group
Phil Alexakos
Ashley Conley
Mary Cook
Ken Dufault
Ian Dyar
Michelle McFadden
Darlene Morse
Deb Perkins
Carole Totzkay
Emergency Services Unit
NH DHHS
NH HSEM

54. Contact Information
Darlene Morse
NH DHHS
Ashley Conley
City of Nashua, Division of Public Health and Community Services