1. Feburary 3, 2005P. Brumund, Chesapeake HD1 Epidemiology Tools Used at the Local Level Common and uncommon tools used in investigations and response How partnerships enhance outcomes - Within Public Health - Outside Public health

2. Feburary 3, 2005P. Brumund, Chesapeake HD2 Investigation 1 Tuberculosis

3. Feburary 3, 2005P. Brumund, Chesapeake HD3 TB Exposure Investigation Background Hospital Nurse with active TB died Unknown duration of infectiousness Unknown number of patients exposed Unknown number of hospital visitors exposed or their identity No base-line data to compare screening findings

4. Feburary 3, 2005P. Brumund, Chesapeake HD4 TB- Tools to Answer the Unknowns Need strong relationships & diplomacy –Hospital staff (clinical & administration) –Neighboring health districts –State health department –Laboratory –Media –Community –Local health department staff

5. Feburary 3, 2005P. Brumund, Chesapeake HD5 TB – Game Plan Create a team (ICS)

6. Feburary 3, 2005P. Brumund, Chesapeake HD6 TB – Investigation & Response Social & Professional Contacts –Coordinating three districts –Hospital employee and staff screening Screening and testing patients and visitors –Approx. 900 patients –Approx. 1500 visitors Outside help needed

7. Feburary 3, 2005P. Brumund, Chesapeake HD7 TB- Evidence Based Decisions Time to answer the unknowns –Period of infectiousness Patient Reaction Rates over time of exposure –What patients were exposed? Social & Professions infection rates Do we expand time of exposure period?

8. Feburary 3, 2005P. Brumund, Chesapeake HD8 TB - Outcomes 2500 people screened –2300 TSTs 2100 (92%) read –128 positive TST –> 350 x-rays 120+ hours of clinic time New TB testing policy and employee illness monitoring at the hospital

9. Feburary 3, 2005P. Brumund, Chesapeake HD9 Investigation 2 Foodborne Outbreak

10. Feburary 3, 2005P. Brumund, Chesapeake HD10 Foodborne Outbreak (FBO) Background 200 bed residential facility Unknown cause of 30 GI illness complaints Mentally handicapped population

11. Feburary 3, 2005P. Brumund, Chesapeake HD11 FBO – Tools Required Relationships –Facility staff –Laboratory –Media –Medical Examiner –Environmental Health program

12. Feburary 3, 2005P. Brumund, Chesapeake HD12 FBO – Tools Required Dedicated & Knowledgeable Epidemiology Response Team Interviewing skills Outbreak Investigation techniques Analytic skills Reliable references Diplomacy & Advocacy

13. Feburary 3, 2005P. Brumund, Chesapeake HD13 FBO - Results Cause of illness – Clostridium perfringens 30 ill residents, 1 associated death Improved food preparation and monitoring Additional staff Legislative measures for more funding Eat Chopped Pork BBQIll Not IllTotal Yes (exposed)302858 No (not exposed)11112 Total313970 AR = 51.7; RR = 6.2069; p = 0.000587

14. Feburary 3, 2005P. Brumund, Chesapeake HD14 Investigation 3 Severe Acute Respiratory Syndrome (SARS)

15. Feburary 3, 2005P. Brumund, Chesapeake HD15 Severe Acute Respiratory Syndrome (SARS) Background March 2003 E.D. patient has flu- like symptoms ED physician recognizes travel history New Disease = lack of information, diagnostics Concerned about exposure: –Hospital staff –Community –Family

16. Feburary 3, 2005P. Brumund, Chesapeake HD16 SARS – Tools Used Relationships Hospital –Infection Control –Emergency Department –Administration –Public Relations Attending Physician Media Community Patient & Family Date: 10 Feb 2003 From: Stephen O. Cunnion, MD, PhD, MPH This morning I received this e-mail and then searched your archives and found nothing that pertained to it. Does anyone know anything about this problem? Have you heard of an epidemic in Guangzhou? “An acquaintance of mine from a teacher's chat room lives there and reports that the hospitals there have been closed and people are dying.“ A ProMED-mail post

17. Feburary 3, 2005P. Brumund, Chesapeake HD17 SARS – Tools cont’d Communication –Hot line –Mass communication –Internet / email –Pro-Med email Public Health Regulations –Isolation & Quarantine –Reportable condition Tools Not Available –Diagnostic to confirm illness –Reference materials and investigation tools –Confidence infection control is working Additional surveillance required

18. Feburary 3, 2005P. Brumund, Chesapeake HD18 SARS - Results Patient survived –One of nine confirmed US cases Source patient survived –Other exposed contacts died Tools for future use –CDC Studies Employee exposure Household contacts Long-term effects of SARS

19. Feburary 3, 2005P. Brumund, Chesapeake HD19 Common Toolbox Items Control of Communicable Disease Manual VDH Communicable Disease Manual VDH Epidemiology web site www.vdh.state.va.us/epi/regs.asp www.vdh.state.va.us/epi/regs.asp www.vdh.state.va.us/epi/bulletin.asp CDC web site www.cdc.gov www.cdc.gov World Health Organization www.who.int/en/ www.who.int/en/ Pro-Med Mail www.promedmail.org www.promedmail.org And of course, paper & pen

20. Feburary 3, 2005P. Brumund, Chesapeake HD20 QUESTIONS ? Paul Brumund Epidemiologist Chesapeake Health Department 757-382-8642 Paul.brumund@vdh.Virginia.gov