Dueling Infectious Disease Outbreaks

Editor's Note: Roger Racine is the Region 7 Healthcare Coalition Epidemiologist at the Grand Traverse County Health Department. He was recently featured in the February 2015 publication of The Guardian of Public Health sent out by the Office of Public Health Preparedness (Lansing, MI). The following is his report on "Dueling Infectious Disease Outbreaks" in the state of Michigan.
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Dueling Infectious Disease Outbreaks
Submitted by Roger Racine, Region 7 Epidemiologist

The autumn of 2014 was an unusual time for many health departments in Michigan as they wrestled with policies for monitoring travelers from West Africa for early symptoms of Ebola infections. Grand Traverse County Health Department (GTCHD) was no different, but they had the added demands of a Pertussis outbreak (Whooping Cough) in a large school that would later grow to involve schools throughout the area. The “cherry on top” was the surprising presentation of the first Measles cases in Michigan for 2014.

The first cases of Pertussis were limited to a couple of students and a teacher in one classroom. At this point, cases are easily treated with antibiotics (Pertussis is a bacterium, not a virus) and the health department provided extra prescriptions for other potentially exposed students and staff. It later became known that some families in the classroom declined their prescriptions due to personal concerns of antibiotic overuse. At least one such family had also previously declined the standard recommended vaccinations for their children. Within a couple of weeks, new cases were reported from other classrooms throughout the school. Despite a last-ditch effort from school administration to close the school and provide antibiotics to everyone, the outbreak escaped containment and spread to the schools throughout the community.  

Just in time for Thanksgiving, a pair of (unvaccinated) world travelers returned to Traverse City from a trip to the Philippines. They brought home more than just souvenirs and luggage - they also brought home the highly-infectious Measles virus. The average incubation period is fairly long for Measles, about 10 days before the fever and 14 days before the tell-tale rash. In fact, these two cases were initially reported as suspect Salmonella Typhi (Typhoid Fever) illnesses.

After a labor intensive effort to track-down all potentially exposed people to ensure that everyone had received the critically-important vaccination or other illness-preventing treatments, only 3 new cases were ever reported (5 in total). The limited number of locally acquired cases was a tremendous success from the early and strong, public health response. Part of what helped the cause was the Ebola monitoring in place at the area urgent cares and hospital. This pair had visited both during their infectious period (prior to being diagnosed) but were the last patients at the end of the day at the urgent care and at the ER. They were each immediately masked and whisked away to an isolation room due to answering “yes” to travel and “yes” to the flu-like symptoms, questions being asked of all patients to screen for possible Ebola infections.

Internally, the county health department established a hot-line to provide protective treatments for families exposed to Pertussis and rearranged non-essential service staff schedules to cover the hotline daily for 8 weeks. In total, the hotline processed 4,380 phone calls and facilitated 1,450 prescriptions. Additionally, staff conducted 90 case investigations, provided antibiotics to one entire K-12 school, and 15 other classrooms throughout the county and on average to 15 close contacts for every reported case. The Health Officer and Emergency Preparedness Coordinator (EPC) conducted 55 TV/Radio interviews, 111 Media phone call/e-mail updates, 12 physician health alerts and 10 press releases. The burden of the two outbreaks resulted in almost every other health department clinical service needing to be scaled back for lack of staff.

GTCHD worked closely with the Michigan Department of Community Health and availed themselves of their Regional Epidemiologist for support. They also quickly implemented their incident command structure for outbreak response and essential services.  Additionally, they implemented a novel management technique of forming two-separated Communicable Disease (CD) Response Units within their one traditional CD section. One unit focused on Pertussis surveillance and response and managing the raging demands of the media and general public; while the other conducted intensive Measles case interviews and directed testing and treatments while keeping watch for any potential new cases. GTCHD worked collaboratively and cooperatively with the Benzie- Leelanau District Health Department on both outbreaks crossing jurisdictional lines in both measles and pertussis.

While the newly re-emerging vaccine-preventable illnesses threaten the fabric of our society, efforts like adding new counseling requirements for parents seeking vaccine waivers for children in school hopes to increase our vaccination rates once again and may well succeed in curbing future outbreaks. The silver lining of these outbreaks is that the community dialogue on vaccines has been renewed and the silent supporters of vaccinations have again found their voices. Community forums are currently being organized for public discussions on vaccination in Grand Traverse County.