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Practice Type: Model
Program Name: A Multidisciplinary Approach to a Shigellosis Outbreak in Columbus, OH
Organization: Columbus Public Health
Web site: publichealth.columbus.gov
Overview: 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.
Year Submitted: 2010
Responsiveness and Innovation: 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 with purchasing needed supplies. An outbreak of this magnitude also seriously impacted CPH’s ongoing ability to respond to and control other outbreaks of disease. Columbus Public Health saw this as an opportunity to explore a new approach to controlling and preventing future outbreaks. The multi-disciplinary, cross-departmental team approach, utilizing incident management principles, could be used to develop new methods of interventions to prevent future outbreaks. The handwashing campaign was also developed to be used with many other infectious diseases and by any program. Lastly, public health nurses had experienced barriers to reaching parents and childcare staff utilizing investigation and education methods and materials. This was an excellent opportunity to strengthen our relationships with childcare centers and schools, and to show to parents, with their assistance, what public’s health role is in the community. The childcare centers especially learned that this role includes being a partner in infectious disease investigations and not an enforcer.The multi-disciplinary taskforce sought to reduce the incidence of shigellosis by developing new measures to control and prevent the spread of disease and also to help curb the number of new infections among individuals and facilities not yet affected by the outbreak. Specific interventions to reach these designated target populations included developing and disseminating appropriate health education materials and utilizing community health nurses already recognized by the community to educate on health interventions. Concentrated intervention efforts were conducted with vulnerable populations within the community most affected and at highest risk as identified through epidemiologic incidence analysis and geocoding. As the intervention methods and efforts shifted from response to prevention, we successfully trained community health nurses who had not participated in outbreak response and interventions previously. The efforts of the Task Force reaffirmed the role of public health as a leader in outbreak investigations and intervention in the community and strengthened interdepartmental relationships that were not formerly utilized. We are pleased to report that in October 2009 the number of shigellosis cases returned to baseline. It was an innovative approach at CPH to dedicate six staff to concentrate the majority of their work efforts on this project. We learned however, that through this type of effort, we will be better able to handle future emerging issues with limited resources. Tools such as the development of a handwashing campaign and the use of a team approach were utilized to smoothly transition into the spring 2009 H1N1 Pandemic Influenza public health response efforts. Over 40 types of documents were created to be inclusive of our target audiences and were incorporated into specific audience kits and distributed through childcare centers (outbreak and non-outbreak centers), parents, healthcare providers, pool operators, and schools. Materials created included management tools, educational materials, awareness campaign pieces, form letters, and health care provider advisories. Educational materials were also created and specifically written for vulnerable populations, including the Hispanic and Somali communities. The face-to-face visits conducted by the community health nurses to share outbreak prevention and control messages regarding shigellosis and other infectious diseases was a successful intervention method. These visits helped to break down many barriers experienced by communicable disease case investigators prior to the project. Childcare center staff was more responsive to public health staff and more readily accepted the health department as a partner, not an enforcer. In addition, health care provider advisories were written and shared with the healthcare community providing clinical guidance to heighten awareness of the outbreak and to encourage testing among patients, as well as treatment with effective antibiotics. Many of these resources were posted online on our CPH website and were made available to everyone. To reduce the incidence of shigellosis CPH initiated the concept of developing a taskforce made up of staff with program expertise in different fields. This was the first time CPH had created such a taskforce to work exclusively to implement measures to control and prevent the spread of disease. The taskforce was modeled using incident management principles to incorporate standardized incident tools to meet the demands of a community-wide enteric outbreak. The Incident Command System (ICS), a key feature of the National Incident Management System, is applicable for use in any type of small or large emergency or nonemergency situation. The Taskforce consisted of an Advisory Group, a Core Group and four Workgroups. In keeping with ICS principles, the Taskforce was kept interdisciplinary but small in order to maintain communications and accuracy of information. Overall this design using ICS principles was very successful because there was an enhanced line of communication between the advisory group, the core group and the workgroups, as well as between the program manager and the content expert. The roles were clearly defined yet flexible to meet the needs of the outbreak. It was also a good method of integrating multi-disciplinary staff members who had never worked together before to remain engaged, stay committed to the process and feel like they were a making a contribution to meet the goals and objectives established for the Taskforce. In the developing stages of the task force, CPH contacted other local health departments to inquire about their approaches to shigellosis outbreak response. Both the Marion County Health Department in Indiana and Milwaukee Health Department in Wisconsin had recently also experienced large, prolonged outbreaks of shigellosis. Resources shared with CPH included: outbreak response interventions and evaluation; timeline of events; outbreak summary reports; lessons learned; healthcare provider, childcare center and school letters; and press releases. A literature search was conducted via PubMed and the Centers for Disease Control and Prevention to elucidate existing approaches to shigellosis outbreak response and interventions by local health departments. Articles reviewed include: Sharing Shigella: Risk Factors for a Multicommunity Outbreak of Shigellosis Shane, AL, Tucker NA, Crump, JA, Mintz ED, Painter JA. Arch Pediatr Adolesc Med. 2003 Jun;157(6):601-3. Communitywide shigellosis: Control of an Outbreak and Risk Factors in Child Day-Care Centers Mohle-Boetani JC, Stapleton M, Finger R, Bean NH, Poundstone J, Blake PA, Griffin PM. Am J Public Health. 1995 Jun;85(6):812-6. Outbreaks of Multidrug-Resistant Shigella sonnei Gastroenteritis Associated with Day Care Centers – Kansas, Kentucky and Missouri MMWR. October 6, 2006;55(39);1068-1071. Current Trends Community Outbreaks of Shigellosis – United States MMWR. August 3, 1990;39(30);509-513,519. The Marion County Health Department in Indianapolis also implemented ICS in response to their 2007–2008 shigellosis outbreak. Lessons learned from Indianapolis were incorporated into the response to the outbreak in Columbus. Key enhancements to the CPH response included: a multi-disciplinary, collaborative team approach; designation of staff to focus the majority of their efforts on the outbreak response; chain of command; unity of command; and manageable span of control. The incident management principles the CPH Shigella Taskforce utilized from ICS included management by objectives, chain of command, unity of command, manageable span of control, and resource management. Management by objectives includes establishing overarching objectives and directing efforts to attain the established objectives. The Program Manager worked with each of the workgroups to establish incident objectives, strategies and tactics they were responsible for completing within a specific time period. The Core Group met weekly to provide tactical updates, to problem solve, and establish new time sensitive tactics for the following week. Chain of command refers to the orderly line of authority within the ranks of the incident management organization. The Taskforce model included the Advisory Group, the Core Group and the Workgroups. The Advisory Group, made up of senior-level departmental staff that like the policy makers in an emergency operations center, made coordination decisions on policies and negotiated with key community partners. The Core Group consisted of an interconnected circle with the Program Manager in the center and a second circle tying the Medical Epidemiology Content Expert in with all of the Workgroup Leaders. In ICS, Unity of Command means that every individual has a designated supervisor to whom he or she reports. The Program Manager reported to the Advisory Group. The four workgroups and the subject matter expert reported to the Program Manager. This was challenging at first as Taskforce members had to get used to reporting to someone else other than their regular day-to-day supervisor. In addition, the staff in the Workgroups all reported to a Workgroup Leader, which is similar to the ICS function of Sections. The Taskforce diagram clearly showed that everyone was to communicate with each other. Manageable Span of Control, a key to effectively and efficiently manage an incident, means that a supervisor should only manage one to seven individuals. Within our Taskforce we were careful to not overwhelm one individual, therefore we ensured the Program Manager and every Workgroup Leader only supervised one to six employees. Finally Resource Management includes processes for categorizing, ordering, and tracking resources. It was the responsibility of the Program Manager to track all Taskforce expenses, manage requests for time off to ensure staff coverage, and to track staff time and mileage. The collaboration CPH has with our community shareholders is always a key component of our everyday work, and was duly important to the Shigella Taskforce. A 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 CDRS websites which provided current information to healthcare 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 the CPH website and utilized by the Taskforce to create intervention strategies. The healthcare provider community found this information to be very timely and important in providing proper health services to their patients. In addition CPH manages an eHealth Alert program on our department’s website. All residents of Columbus, including community shareholders are encouraged to sign up for eHealth alert on the home page of our website. Those who sign up receive health alert notifications to the email address of their choice on such topics as high ozone alerts, reminders on how to prepare food safely during the holidays, and updated information on H1N1. Although the capabilities were not available when the Shigella Taskforce was active, the health department now utilizes social marketing techniques such as Twitter and Facebook. These forms of communication were very helpful during the fall H1N1 public health response and have become a valuable tool with CPH’s outreach to community partners and the public in general. In implementing intervention techniques, the Shigella Taskforce created over 40 types of documents including management tools, educational materials, and health care provider advisories. Many of the materials were created as templates that could be used or adapted easily by a childcare center or school. Educational materials were also created and specifically written for vulnerable populations within our community, including the Hispanic and Somali communities.Adding the Advisory Team to the Taskforce was beneficial for working on our relationships within the community so that the Core Group could concentrate on the outbreak and incorporate intervention methods into the community. These senior level administrators included the Medical Director, Director of Nursing, the Director of the Office of Assessment & Surveillance and the Communicable Disease Team Supervisor. Through their role as policy decision makers they negotiated with community partners such as the Ohio Department of Health, Ohio Department of Job and Family Services (ODJFS), Action for Children, and Nationwide Children’s Hospital. In Columbus two agencies have direct involvement with all child care centers, the Ohio Department of Job and Family Services (ODJFS) and Action for Children. ODJFS is the agency responsible for licensing, accrediting, training, and providing direction to childcare centers throughout the state. Founded in 1972, Action for Children is the source for child care and early learning services in central Ohio. With the assistance of the Taskforce Advisory Team, meetings were scheduled with these agencies to improve our understanding of their role with childcare centers and to find ways where we could all work more collaboratively. We often found that their rules did not directly meet the recommendations from the health department regarding health issues. Both agencies also provide through their websites lists of currently licensed childcare centers, which assisted us in assessing which childcare centers are in which zip codes. In the future we plan to follow up with ODJFS to establish a memorandum of understanding for outbreaks, all hazard communication, and general policies in order to work with them quickly in an emergency. We are also planning to have several of our nurses complete the 6-hour Train the Trainer Childcare Provider course and possibly provide the training to childcare centers within the Columbus community. The work of the Taskforce strengthened many relationships. For example we worked very closely with the Columbus City Schools and the City of Worthington Schools to provide information on shigellosis, other enteric diseases, and general cleaning guidelines. We found that the schools prefer the information be sent to one central location and they will disseminate the information into the schools, normally through the school nurses. The school nurses are an integral part of assisting the health department spread the word on such issues as proper handwashing and maintaining clean surfaces. The schools were very interested in any information we could provide them to assist with reducing or eliminating the spread of disease. Having information posted on our website was also helpful to the schools, as well as other community partners, because it was easy to access in order to make copies and laminate, if needed.
Agency and Community Roles: The 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. It was our hope that the childcare centers would utilize the information we provided them and correct the issues found during the informal environmental inspections. We depended on the childcare centers to educate the parents by insisting that a sick child remain at home and upholding the exclusion policy until the child was well enough to return to childcare. The Taskforce worked with the CPH Division of Environmental Health to provide information for our Sanitarians to carry with them during their routine school inspections. Handouts, age appropriate signs and handwashing posters were created to educate the schools about proper handwashing, keeping surfaces cleaned and sanitized, and enforcing the stay home if you are sick rule. This type of information was indeed helpful to the school nurses as a proactive way of educating the schools, as well as providing immediate reinforcement to those schools having students with active shigellosis cases. The Taskforce also worked with the CPH Division of Environmental Health to provide resources for pools on handwashing, excluding patrons with diarrhea, as well as cleaning and sanitizing surfaces. Handouts were provided at the annual Pool Operators Class and enteric diseases, such as shigellosis and cryptosporidiosis, were highlighted during the PowerPoint presentation. Additional partners assisted with specific goals for messaging to the general public. Local media outlets NBC 4, 10TV and ABC 6, were instrumental in promoting messages about the outbreak, methods of transmission and prevention. Pool operators participated in media interviews and posted messages around their facilities. Local print news contained articles released by CPH, including The Columbus Dispatch, Fronteras, Call & Post, Columbus Post, and Columbus Parent.
Costs and Expenditures: Columbus 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.
Implementation: 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 with purchasing needed supplies. An outbreak of this magnitude also seriously impacted CPH’s ongoing ability to respond to and control other outbreaks of disease. Columbus Public Health saw this as an opportunity to explore a new approach to controlling and preventing future outbreaks. The multi-disciplinary, cross-departmental team approach, utilizing incident management principles, could be used to develop new methods of interventions to prevent future outbreaks. The handwashing campaign was also developed to be used with many other infectious diseases and by any program. Lastly, public health nurses had experienced barriers to reaching parents and childcare staff utilizing investigation and education methods and materials. This was an excellent opportunity to strengthen our relationships with childcare centers and schools, and to show to parents, with their assistance, what public’s health role is in the community. The childcare centers especially learned that this role includes being a partner in infectious disease investigations and not an enforcer.The multi-disciplinary taskforce sought to reduce the incidence of shigellosis by developing new measures to control and prevent the spread of disease and also to help curb the number of new infections among individuals and facilities not yet affected by the outbreak. Specific interventions to reach these designated target populations included developing and disseminating appropriate health education materials and utilizing community health nurses already recognized by the community to educate on health interventions. Concentrated intervention efforts were conducted with vulnerable populations within the community most affected and at highest risk as identified through epidemiologic incidence analysis and geocoding. As the intervention methods and efforts shifted from response to prevention, we successfully trained community health nurses who had not participated in outbreak response and interventions previously. The efforts of the Task Force reaffirmed the role of public health as a leader in outbreak investigations and intervention in the community and strengthened interdepartmental relationships that were not formerly utilized. We are pleased to report that in October 2009 the number of shigellosis cases returned to baseline. It was an innovative approach at CPH to dedicate six staff to concentrate the majority of their work efforts on this project. We learned however, that through this type of effort, we will be better able to handle future emerging issues with limited resources. Tools such as the development of a handwashing campaign and the use of a team approach were utilized to smoothly transition into the spring 2009 H1N1 Pandemic Influenza public health response efforts. Over 40 types of documents were created to be inclusive of our target audiences and were incorporated into specific audience kits and distributed through childcare centers (outbreak and non-outbreak centers), parents, healthcare providers, pool operators, and schools. Materials created included management tools, educational materials, awareness campaign pieces, form letters, and health care provider advisories. Educational materials were also created and specifically written for vulnerable populations, including the Hispanic and Somali communities. The face-to-face visits conducted by the community health nurses to share outbreak prevention and control messages regarding shigellosis and other infectious diseases was a successful intervention method. These visits helped to break down many barriers experienced by communicable disease case investigators prior to the project. Childcare center staff was more responsive to public health staff and more readily accepted the health department as a partner, not an enforcer. In addition, health care provider advisories were written and shared with the healthcare community providing clinical guidance to heighten awareness of the outbreak and to encourage testing among patients, as well as treatment with effective antibiotics. Many of these resources were posted online on our CPH website and were made available to everyone. To reduce the incidence of shigellosis CPH initiated the concept of developing a taskforce made up of staff with program expertise in different fields. This was the first time CPH had created such a taskforce to work exclusively to implement measures to control and prevent the spread of disease. The taskforce was modeled using incident management principles to incorporate standardized incident tools to meet the demands of a community-wide enteric outbreak. The Incident Command System (ICS), a key feature of the National Incident Management System, is applicable for use in any type of small or large emergency or nonemergency situation. The Taskforce consisted of an Advisory Group, a Core Group and four Workgroups. In keeping with ICS principles, the Taskforce was kept interdisciplinary but small in order to maintain communications and accuracy of information. Overall this design using ICS principles was very successful because there was an enhanced line of communication between the advisory group, the core group and the workgroups, as well as between the program manager and the content expert. The roles were clearly defined yet flexible to meet the needs of the outbreak. It was also a good method of integrating multi-disciplinary staff members who had never worked together before to remain engaged, stay committed to the process and feel like they were a making a contribution to meet the goals and objectives established for the Taskforce. In the developing stages of the task force, CPH contacted other local health departments to inquire about their approaches to shigellosis outbreak response. Both the Marion County Health Department in Indiana and Milwaukee Health Department in Wisconsin had recently also experienced large, prolonged outbreaks of shigellosis. Resources shared with CPH included: outbreak response interventions and evaluation; timeline of events; outbreak summary reports; lessons learned; healthcare provider, childcare center and school letters; and press releases. A literature search was conducted via PubMed and the Centers for Disease Control and Prevention to elucidate existing approaches to shigellosis outbreak response and interventions by local health departments. Articles reviewed include: Sharing Shigella: Risk Factors for a Multicommunity Outbreak of Shigellosis Shane, AL, Tucker NA, Crump, JA, Mintz ED, Painter JA. Arch Pediatr Adolesc Med. 2003 Jun;157(6):601-3. Communitywide shigellosis: Control of an Outbreak and Risk Factors in Child Day-Care Centers Mohle-Boetani JC, Stapleton M, Finger R, Bean NH, Poundstone J, Blake PA, Griffin PM. Am J Public Health. 1995 Jun;85(6):812-6. Outbreaks of Multidrug-Resistant Shigella sonnei Gastroenteritis Associated with Day Care Centers – Kansas, Kentucky and Missouri MMWR. October 6, 2006;55(39);1068-1071. Current Trends Community Outbreaks of Shigellosis – United States MMWR. August 3, 1990;39(30);509-513,519. The Marion County Health Department in Indianapolis also implemented ICS in response to their 2007–2008 shigellosis outbreak. Lessons learned from Indianapolis were incorporated into the response to the outbreak in Columbus. Key enhancements to the CPH response included: a multi-disciplinary, collaborative team approach; designation of staff to focus the majority of their efforts on the outbreak response; chain of command; unity of command; and manageable span of control. The incident management principles the CPH Shigella Taskforce utilized from ICS included management by objectives, chain of command, unity of command, manageable span of control, and resource management. Management by objectives includes establishing overarching objectives and directing efforts to attain the established objectives. The Program Manager worked with each of the workgroups to establish incident objectives, strategies and tactics they were responsible for completing within a specific time period. The Core Group met weekly to provide tactical updates, to problem solve, and establish new time sensitive tactics for the following week. Chain of command refers to the orderly line of authority within the ranks of the incident management organization. The Taskforce model included the Advisory Group, the Core Group and the Workgroups. The Advisory Group, made up of senior-level departmental staff that like the policy makers in an emergency operations center, made coordination decisions on policies and negotiated with key community partners. The Core Group consisted of an interconnected circle with the Program Manager in the center and a second circle tying the Medical Epidemiology Content Expert in with all of the Workgroup Leaders. In ICS, Unity of Command means that every individual has a designated supervisor to whom he or she reports. The Program Manager reported to the Advisory Group. The four workgroups and the subject matter expert reported to the Program Manager. This was challenging at first as Taskforce members had to get used to reporting to someone else other than their regular day-to-day supervisor. In addition, the staff in the Workgroups all reported to a Workgroup Leader, which is similar to the ICS function of Sections. The Taskforce diagram clearly showed that everyone was to communicate with each other. Manageable Span of Control, a key to effectively and efficiently manage an incident, means that a supervisor should only manage one to seven individuals. Within our Taskforce we were careful to not overwhelm one individual, therefore we ensured the Program Manager and every Workgroup Leader only supervised one to six employees. Finally Resource Management includes processes for categorizing, ordering, and tracking resources. It was the responsibility of the Program Manager to track all Taskforce expenses, manage requests for time off to ensure staff coverage, and to track staff time and mileage. The collaboration CPH has with our community shareholders is always a key component of our everyday work, and was duly important to the Shigella Taskforce. A 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 CDRS websites which provided current information to healthcare 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 the CPH website and utilized by the Taskforce to create intervention strategies. The healthcare provider community found this information to be very timely and important in providing proper health services to their patients. In addition CPH manages an eHealth Alert program on our department’s website. All residents of Columbus, including community shareholders are encouraged to sign up for eHealth alert on the home page of our website. Those who sign up receive health alert notifications to the email address of their choice on such topics as high ozone alerts, reminders on how to prepare food safely during the holidays, and updated information on H1N1. Although the capabilities were not available when the Shigella Taskforce was active, the health department now utilizes social marketing techniques such as Twitter and Facebook. These forms of communication were very helpful during the fall H1N1 public health response and have become a valuable tool with CPH’s outreach to community partners and the public in general. In implementing intervention techniques, the Shigella Taskforce created over 40 types of documents including management tools, educational materials, and health care provider advisories. Many of the materials were created as templates that could be used or adapted easily by a childcare center or school. Educational materials were also created and specifically written for vulnerable populations within our community, including the Hispanic and Somali communities.Adding the Advisory Team to the Taskforce was beneficial for working on our relationships within the community so that the Core Group could concentrate on the outbreak and incorporate intervention methods into the community. These senior level administrators included the Medical Director, Director of Nursing, the Director of the Office of Assessment & Surveillance and the Communicable Disease Team Supervisor. Through their role as policy decision makers they negotiated with community partners such as the Ohio Department of Health, Ohio Department of Job and Family Services (ODJFS), Action for Children, and Nationwide Children’s Hospital. In Columbus two agencies have direct involvement with all child care centers, the Ohio Department of Job and Family Services (ODJFS) and Action for Children. ODJFS is the agency responsible for licensing, accrediting, training, and providing direction to childcare centers throughout the state. Founded in 1972, Action for Children is the source for child care and early learning services in central Ohio. With the assistance of the Taskforce Advisory Team, meetings were scheduled with these agencies to improve our understanding of their role with childcare centers and to find ways where we could all work more collaboratively. We often found that their rules did not directly meet the recommendations from the health department regarding health issues. Both agencies also provide through their websites lists of currently licensed childcare centers, which assisted us in assessing which childcare centers are in which zip codes. In the future we plan to follow up with ODJFS to establish a memorandum of understanding for outbreaks, all hazard communication, and general policies in order to work with them quickly in an emergency. We are also planning to have several of our nurses complete the 6-hour Train the Trainer Childcare Provider course and possibly provide the training to childcare centers within the Columbus community. The work of the Taskforce strengthened many relationships. For example we worked very closely with the Columbus City Schools and the City of Worthington Schools to provide information on shigellosis, other enteric diseases, and general cleaning guidelines. We found that the schools prefer the information be sent to one central location and they will disseminate the information into the schools, normally through the school nurses. The school nurses are an integral part of assisting the health department spread the word on such issues as proper handwashing and maintaining clean surfaces. The schools were very interested in any information we could provide them to assist with reducing or eliminating the spread of disease. Having information posted on our website was also helpful to the schools, as well as other community partners, because it was easy to access in order to make copies and laminate, if needed.
Sustainability: 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 administration for a budget expansion and the need for more epidemiology staff support in which the hiring process has been initiated.
Lessons Learned:

 

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