2. Infectious Diseases and the Impact on Our Schools Mary G. McIntyre, MD, MPH State Epidemiologist Assistant State Health Officer for Disease Control and Prevention

3. OBJECTIVES  Define “the Public Health System”?  “What we do?”  Review of Disease Control and Prevention’s Structure  What is your role?  Examples  Questions

6. Mission Statement for Bureau of Communicable Disease The mission of the Bureau of Communicable Disease (BCD) is to prevent and control designated communicable diseases and illness in Alabama.

7. Bureau of Communicable Diseases Epidemiology HIV/AIDS Immunization Sexually-transmitted Diseases Tuberculosis 6

8. Epidemiology Mission Statement To protect the residents of Alabama through constant monitoring of the incidence and prevalence of communicable, zoonotic, and environmentally-related human disease. 7

9. Epidemiology Division Branches Analysis and Reporting Infection Control –Healthcare-associated Infections* –Infected Healthcare Workers Program* Surveillance Toxicology Zoonotic 8 *Call 1-800-338-8374 and ask for Infection Control

10. Mission Statement for Bureau of Clinical Laboratories The mission of the BCL is to give laboratory support for public health programs and make policy decisions that protect and promote the health of the citizens of Alabama.

11. BCL Locations and Branches Montgomery Clinical Chemistry Metabolic Microbiology Respiratory Sanitary Bacteriology/Media Serology Mobile Clinical Environmental 10 www.adph.org/bcl

12. HIPAA ADPH is a public health authority as defined by the Health Insurance Portability and Accountability Act (HIPAA) to collect or receive protected health information (PHI) for the purpose of surveillance, investigations, and interventions of notifiable diseases, without authorization of the patient. 11 http://www.cdc.gov/mmwr/preview/mmw rhtml/m2e411a1.htm

13. Outbreaks An outbreak is defined as illness in 2 or more people, from separate households, with a common exposure. “An outbreak” can occur in any of the BCD divisions (STD, HIV, TB, STD, IMM or EPI) Most often occurs in EPI due to the number of potential diseases falling under this area 12

14. Notifiable Diseases/Conditions Purpose of Notifiable Diseases ADPH administrative code authorizes and requires reporting, http://www.alabamaadministrativecode.state.al.us/docs/hlth/index.html http://www.alabamaadministrativecode.state.al.us/docs/hlth/index.html ADPH is exempt from HIPAA Privacy Rules, http://www.cdc.gov/mmwr/pdf/other/m2e411.pdf http://www.cdc.gov/mmwr/pdf/other/m2e411.pdf 13

15. Surveillance Pyramid 14

16. Immunization The goal of the Immunization Division is to stop the spread of diseases that are vaccine preventable by providing vaccine to the citizens of Alabama, educating the medical personnel and the public on the importance of vaccinations, and ensuring that children who are in day care, Head Start, and school are adequately immunized against diseases that are harmful and sometimes deadly.

17. Tuberculosis The ultimate goal for the Division of Tuberculosis (TB) Control is the elimination of tuberculosis in Alabama. Until that goal is reached, the Division strives to reduce the annual burden of disease, limit transmission and prevent future cases through the provision of diagnostic, treatment, and case management activities. The Division of TB Control provides these services to all persons in Alabama, regardless of the ability to pay. This commitment to the citizens of Alabama has contributed to historic declines in TB morbidity and mortality.

18. STD The Division of STD Prevention and Control is charged with identifying populations at increased risk for infection in order to reduce their chances of developing a sexually transmitted disease (STD), transmitting it to others, and/or developing related complications. Statewide disease intervention staff provide screening, diagnostic, education, treatment, partner notification, and referral services in every county of Alabama.

19. HIV The mission of the Division of HIV/AIDS Prevention and Control, in collaboration with community partners, is to reduce the incidence of HIV infections, to increase life expectancy for those infected, and to improve the quality of life for persons living with or affected by HIV. The charge of the Division is to: –monitor the epidemic –improve public understanding of HIV –prevent or reduce behaviors that transmit HIV –increase individual knowledge of HIV serostatus –strengthen systems for referral to appropriate prevention and treatment services

20. Who Must Report Physicians Dentists Nurses Medical Examiners Hospital Administrators Nursing Home Administrators Laboratory Directors

21. Who Must Report School Principals Day Care Center Directors –We expect and want multiple reports

22. EXAMPLE 1 FOODBORNE ILLNESSES

24. What is Foodborne Illness?

25. Foodborne Illness AKA – foodborne disease What is it? –illness resulting from the consumption of food –commonly known as food poisoning, –can be caused by consuming a food contaminated with a chemical or natural toxin, or pathogens (bacteria, viruses, parasites) –contamination can occur before, during, and after food preparation

26. These are symptoms of a FOODBORNE ILLNESS Stomach Pain Diarrhea Vomiting Not the flu!?

27. Did you know? According to the Center for Disease Control: 76 million become ill due to food / year 325,000 hospitalized 5000 die / year

28. How Many Are There? There are more than 250 known foodborne illnesses.

29. What Foods Are Most Likely to be Contaminated? raw meat and poultry raw eggs (even in uncooked brownie, cake, or cookie dough) unpasteurized milk raw shellfish unwashed raw fruits and vegetables unpasteurized fruit juice

30. How Do You Know If You Have Foodborne Illness? Onset of symptoms can occur in hours to days of food consumption –known as the incubation period Symptoms vary –mild to severe ( requiring hospitalization ) Common symptoms include: –diarrhea, abdominal cramps, and nausea

31. Am I at Risk? YES –76 million cases of foodborne illness occur each year in the U.S. –pregnant women, infants, the elderly, and those weakened immune systems are at greater risk for foodborne illness

32. What Can I Do? Follow these simple guidelines: –CLEAN –COOK –CHILL –LEFTOVERS

33. Food Poisoning and Foodborne Illness  BACTERIA  VIRUS  TOXINS  CHEMICALS Can be caused by eating food contaminated with:

34. What Are the Most Common Causes of Foodborne Illness? Those caused by the bacteria: –Campylobacter –Salmonella –E. coli O157:H7 Those caused by a group of viruses: –Norwalk and Norwalk-like viruses

35. Campylobacter Found in the intestinal tract of birds, sheep, cattle and on the surface of raw poultry.

36. Campylobacter Causes abdominal cramps, diarrhea and fever Onset is 2-5 days Lasts 7-10 days

37. Salmonella Found in the intestines of birds, reptiles, & mammals.

38. Salmonella Causes fever, diarrhea & abdominal cramps. Can cause severe dehydration in infants and elderly. Onset is 6 hours - 2 days Lasts 1- 3 days.

39. E-coli 0157:h7 Lives in cattle & other similar animals. Found in raw meat, non-pasteurized milk, apple cider, sprouts.

40. E-coli 0157:h7 Causes severe bloody diarrhea & cramps. Causes hemolytic uremic syndrome (HUS). Kidneys fail Red blood cells are destroyed Onset of illness 2-5 days. Lasts 5-10 days.

41. Influenz

42. Norovirus The cause of HALF of all foodborne illness. Spread by hand contact with food food placed on a surface that is contaminated by the virus or when virus is airborne. Cold foods such as sandwiches & salads are often associated with Norovirus.

43. Norovirus Starts suddenly. Causes diarrhea, vomiting, abdominal cramps, headache, low-grade fever, chills & muscle aches. Often called the flu. Symptoms begin 12 to 48 hours after ingestion of the virus. Recovery in 2-3 days but may remain ill for up to 2 weeks.

44. HEPATITIS A VIRUS

45. Another Foodborne Illness Virus Possible sources include by shellfish, salads, deli meats fruits, milk and milk products Symptoms include sudden onset of fever, general discomfort, fatigue, headache, nausea, loss of appetite, vomiting, abdominal pain & jaundice after several days. Lasts 1 to 2 weeks (severe cases up to several months).

47. Biological Toxins Biological Toxins are produced by some pathogens found in food contamination. They could also come from a plant or animal.

48. Bacterial Toxins Some bacteria produce poisons or toxins that cause: FOODBORNE ILLNESS (sometimes intentional)

49. Staphylococcus aureus Commonly associated with food service.

50. If toxin - onset of illness is as quickly as 30 minutes If infectious - onset can take 6 hours or longer to appear. Staphylococcus Aureus

51. produces a toxin that causes serious vomiting and stomach cramps. Staphylococcus Aureus

52. Clostridium Botulinum Toxin producing bacteria Causes botulism Symptoms are nerve related and can cause muscle paralysis Symptoms typically occur 8 to 36 hours after or as late as 10 days Lasts several days to 1year

54. CHEMICAL POISONING Careless or improper storage of chemicals Improper use of chemicals Improper labeling Sometimes intentional addition of poison

55. CHEMICAL POISONING Always store cleaners and chemicals below your food or food surfaces. Choose pesticides that are approved for use in the kitchen.

57. What Can I Do? Follow these simple guidelines: –CLEAN –COOK –CHILL LEFTOVERS

58. CHILL OUT……… Bacteria grows quickly at room temperature, so refrigerate leftover foods within 2 hours. Food will cool more quickly if divided into several shallow containers for refrigeration. Refrigerate leftovers promptly:

60. WASH YOUR HANDS OFTEN Especially: When preparing food. After using the bathroom. Avoid direct contact with public restroom doorknobs. (use paper towel to open door)

61. WHEN WASHING YOUR HANDS Use warm, soapy running water. Rub your hands thoroughly, scrubbing between fingers, and nails for: 10–15 SECONDS.

62. Safe Preparation of Fruits & Vegetables Clean any items that come into contact with fresh foods: knives cutting boards hands

63. Do wash your hands with soap and water before preparing food. Do rinse fresh fruits & vegetables with cold water. Do refrigerate at a temperature of 40 o F or less. Do throw away items that have come into contact with raw meat or chemicals. Do not prepare food for others if you yourself have diarrhea. Do not use bleach or soap on fruits & vegetables. Do NOT eat fresh cut items left un-refrigerated for > 2 hours. Do not eat bruised or damaged fruits & vegetables. Fruits & Vegetables Do’s & Don’ts

64. Safe Preparation of Raw Meats A few simple precautions can reduce the risk of foodborne diseases: COOK SEPARATE CHILL REPORT

65. It’s Getting Hot in here…. COOK: Meat, poultry, and eggs thoroughly. Use a thermometer to measure the internal temperature of meat to be sure that it is cooked sufficiently to kill bacteria. For example: Ground beef should be cooked to an internal temperature of 160 o F. Eggs should be cooked until the yolk is firm.

66. SEPARATE: Put cooked meat on a clean platter rather than back on one that held the raw meat. Don't cross- contaminate one food with another. Avoid cross-contaminating foods by washing hands, utensils, and cutting boards after they have been in contact with raw meat or poultry.

67. If in doubt as to the safety of your food, THROW IT OUT!!

68. I’m Telling…. REPORT: Foodborne illnesses to your LOCAL HEALTH DEPARTMENT. Your local health department works hard to track down the causes of the foodborne illness.

69. Prevent Food Poisoning The Bottom Line Keep Hot Food Hot Cold Food Cold Keep Everything Clean Especially: Wash Your Hands Don’t go to work sick.

70. Assemble a Team Everyone Has a Role in the Safety of Food

71. National Coalition for Food Safe Schools Action Guide and Tool Kit www.foodsafeschools.org www.neha.org www.foodsafeschools.org www.neha.org

72. This Children's Environmental Health presentation was made possible through a grant from The Dow Chemical Company Foundation

73. Credits Charles Lichon, R.S., M.P.H., Creator of Children’s EH Program, Midland County Health Department (CHD) Michigan Nancy Atwood, M.S., Midland CHD (MI) Sanitarian Christine Rogers, Meth Response Coordinator, Kalamazoo CHD, MI Gayle Blues, Midland CHD, layout and design Robert Wolfe, R.S., Midland CHD (MI) Sanitarian John Demerjian and Linda Van Orden, Wayne CHD, MI, Body Art National Environmental Health Association (NEHA.org) for website storage and oversight. NOTE: Permission to use this and all Children’s EH Power Point presentations is granted thru NEHA, however, all grant and credit notices & informational slides must be used during each presentation.

74. EXAMPLE 2 TUBERCULOSIS

75. Basic TB Facts Tuberculosis (TB) is caused by a bacterium called Mycobacterium tuberculosis. –the bacteria usually attack the lungs, but TB bacteria can attack any part of the body such as the kidney, spine, and brain –if not treated properly, TB disease can be fatal –in the past, TB was the leading cause of death in the United States –today, TB is still a leading cause of death across the globe

76. How TB Spreads TB is spread through the air from one person to another –the TB bacteria are expelled when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings –people sitting or working nearby may breathe in these bacteria and become infected Do you know the guy in the next slide?

77. How TB is Controlled Public health interventions are designed to interrupt TB transmission How do we accomplish that task? –identify and treat-to-cure those with active TB disease, and – identify, evaluate, and preventively treat contacts through disciplined use of public health tools and methodologies

78. Concentric Circle Approach (an important methodology in contact follow up) Household Leisure Work / School INDEX PATIENT Close Contacts Other-than-Close Contacts

79. TB is NOT spread by: Shaking someone’s hand Sharing food or drink Touching bed linens or toilet seats Sharing toothbrushes Kissing

80. TB Infection TB bacteria can live in the body without making you sick - this state is called TB infection Most people who breathe in TB bacteria and become infected are able to fight and contain the bacteria to stop them from multiplying People with TB infection do not feel sick and do not have any symptoms People with TB infection are not infectious and cannot spread TB bacteria to others.

81. TB Disease Also called “active TB disease” because the body’s immune system can't stop the bacteria from “actively replicating” or multiplying People with TB disease are sick and will likely have symptoms –persons with pulmonary or airway disease may be capable of spreading the bacteria to other people they spend time with every day

82. Symptoms of TB Disease Bad cough that lasts 3 weeks or longer Chest pain Coughing up blood or sputum Weakness or fatigue Weight loss / Loss of appetite Fever / Chills Night sweats

83. Infection vs. Disease Positive TB Skin Test Normal Chest X- Ray No symptoms Cannot transmit to others May be treated preventively Positive TB Skin Test Abnormal Chest X-Ray Has symptoms May transmit to others May be treated and cured

84. Testing for TB Infection There are two kinds of tests that are used to detect TB bacteria in the body: the tuberculin skin test (TST) and TB blood tests. These tests can be accessed through your health care provider or, in certain cases, through TB staff in your public health area. If you have a positive reaction to either of the tests, a chest X-ray is indicated to see if you have TB disease.

85. Treatment for TB Infection If your chest X-ray is clear and TB disease is ruled out, we may want to treat you to keep you from developing TB disease Treatment of TB infection is often called “preventive therapy” because it reduces the risk that TB infection will progress to active TB disease in the future

86. How TB Control is Organized in Alabama Each Public Health Area has a TB team: this team may include a Manager, a Nurse, a Disease Intervention Specialist, and an Administrative Support Assistant This team is responsible for executing the TB Protocol and the provision of TB control services in their respective area One important take away point is that your local TB expert is just a phone call away!

87. Take away points… TB is an infectious disease that touches the lives of hundreds of Alabamians each year. TB cases and their contacts receive expert care at no cost from dedicated public health physicians, nurses and staff. TB control efforts have been successful, but continued vigilance and response capacity is required to protect the public health.

88. Take away points… TB screening for school employees should be reserved for new hires with risk factors for tuberculosis Contact your local TB expert if anyone (i.e., student, faculty, or other staff) exhibit symptoms of active TB disease.

89. DISCUSSION AND QUESTIONS