Measles Outbreak Exercise Notes

Introductions and Roles

  • Frank Balik: Regional emergency preparedness response coordinator for public health at Central Valley Health in Jamestown.
  • Works with the EPR section at Health and Human Services.
  • Beth Schwartz: Regional public information officer for emergency preparedness from Central Valley.
  • Dylan Parno: Works in environmental health at Central Valley Health, adjacent to EPR.
  • Participant roles:
    • Players: Everyone present.
    • Observers: Sherry (though participation is welcome).
    • Facilitator: Frank Balik (to steer the exercise).
    • Evaluators: Everyone (to take notes for the after-action report).

Exercise Structure

  • Three modules:
    • Patient zero.
    • Isolation and quarantine.
    • Expanding cases.
  • A reduced version of the state's exercise, with modifications for long-term care.

Exercise Guidelines

  • Open, low-stress environment.
  • Varying viewpoints and disagreements are expected.
  • Use current plans, capabilities, and training insights to respond to the scenario.
  • Decisions are not precedent-setting and may not reflect the organization's final position.
  • The exercise is an opportunity to discuss multiple options and solutions.
  • Focus on problem-solving efforts and recommended actions.
  • Assumptions and artificialities are inherent in the exercise and should be accepted.
  • Low-fault learning environment.
  • The scenario is plausible, and events occur as presented.
  • All players receive the information simultaneously.

Exercise Evaluation

  • Everyone takes notes for the after-action report.
  • Online feedback form (QR code and web link on the back of the planning document).
  • Feedback will be included in the after-action report.

Objectives

  • Familiarity with isolation and quarantine plans.
  • Familiarity with Sentry Code regarding isolation and quarantine.
  • Understanding of requirements for isolation and quarantine.
  • Understanding what causes people to be subject to isolation and quarantine.
  • Understanding PPE requirements for measles.

Patient Zero: Initial Scenario (June 24 - Corrected to June 9)

  • A 21-year-old female traveled to Williston for Memorial Day weekend.
  • Returned to her apartment on Monday evening, May 27, and to work on Tuesday, May 28.
  • Worked various shifts as a certified medication aide through Sunday, June 8.
  • Socialized at numerous bars in Jamestown during evenings.
  • Called off sick today, presenting at Sanford Clinic with:
    • Sudden onset high fever.
    • Rash.
    • Conjunctivitis.
    • Coryza.
    • Malaise.
  • The physician suspects measles and:
    • Contacts local public health.
    • Sends a sample to the state lab for testing.
  • Patient told to isolate until measles test results return.
  • Patient has not been vaccinated for measles.

Questions and Discussion: Patient Zero

  • Should measles be suspected in this case? Incubation period of measles: approximately 21 days.

  • Besides public health, who else should be notified of a suspected measles case? The employee's workplace should be notified if the employee is getting tested for measles.

  • Would contact tracing be started at this time (suspect case)? No, contact tracing is initiated by the state only after confirmation.

  • Should any information be released to the public, staff, or resident families at this time? The answer is no. Even if the employee posts on social media they are being tested.

    • Response to inquiries: "We cannot confirm or deny; we don't have enough information at this time."
    • Acknowledge awareness of the situation.

  • Does Eventide notify staff and/or next of kin of a possible exposure at this time? No.

    • If yes, ReadyCall for families and the EKG system for staff.
    • Keep information updated.

Confirmed Case: June 26

  • Testing confirms the original case is measles.
  • Contact tracing begins by the state.
  • Health and Human Services issues a news release.
  • Contact tracing continues; most agree with voluntary quarantine.
  • Several visitors to Eventide may be affected (ranging from pre-K to adults).

Questions and Discussion: Confirmed Case

  • Should this patient be isolated or quarantined?
    • Isolation: Separating someone with the disease.
    • Quarantine: Separating someone potentially exposed to the disease before confirmation.
  • Types of isolation and quarantine:
    • Voluntary: Agreement to abide by the requirements.
    • Involuntary: Ordered under Sentry Code.
      • Local health officers are authorized to place people in involuntary isolation and quarantine.
      • Law enforcement can support the order.
      • Judicial process: consultation with the state's attorney and court.
  • Public health responsibilities for involuntary isolation and quarantine:
    • Ensuring access to medications and food.
  • Enforcement:
    • Prosecution under Sentry Code.
    • Dependence on local law enforcement and the state's attorney.

Support and Monitoring

  • Supplies and equipment:
    • Leverage local resources or the medical cache.
  • Monitoring:
    • One or two calls per day to check for symptoms and temperature.
    • Recording all information.

Additional News Releases and Media Inquiries

  • Generally, no additional local news releases.
  • Responses to media inquiries:
    • Coordinate with the vice president of marketing or corporate office.
  • Agencies involved in press releases:
    • Coordination between local entities and corporate.
  • Responsibility for notifying residents, staff, and families:
    • Local decision-making.

Vaccination Considerations

  • Should any unvaccinated contacts be vaccinated? Yes.

  • Vaccination window: Within 72 hours of exposure.

    • 93% effective if given within this window (after one dose).
    • Two weeks for full protection.
    • Twenty-eight days between the two doses.

  • Vaccination outside the 72-hour window:

    • Does not negate the need for isolation and quarantine.
    • Still beneficial.

  • Clarification:

    • Unvaccinated, exposed individuals vaccinated within 72 hours still require monitoring.
    • Symptoms or positive test results necessitate quarantine.
    • After 72 hours, quarantine for 21 days.

Public Health Support and Contact Tracing

  • Potential need for vaccine support.
  • Smaller agencies may need medical reserve corps for vaccination clinics or contact tracing assistance.
  • Public health role in providing assistance for contact tracing:
    • Possibility of assigning nurses.
    • Local response, unlike COVID (no funding).

Vaccination List and Employee Status

  • No specific list of MMR-vaccinated or unvaccinated residents and staff.
  • Ability to access employee vaccination status.
  • Explicit permission may be needed, depending on state laws and onboarding documentation.
  • Employees born before 1957 are considered immune due to natural exposure.
  • If no records exist for those born after 1957, vaccination is generally recommended.

Staff Exclusion Policy

  • No specific policy for excluding staff unvaccinated for measles following known exposure.
  • Consider leave and health insurance coverage for employees excluded from work during isolation/quarantine (21 days).
  • Example: Covering health insurance and charging the employee back.

Refusal to Isolate or Quarantine

  • What happens if an exposed, unvaccinated employee refuses to isolate or quarantine and continues to report to work?
    • Consistent communication about the need to quarantine for 21 days.

Staffing and Operational Considerations

  • The impact of staff absences on daily operations.
  • Maintaining minimum care ratios.
  • Challenges with residents in isolation or quarantine:
    • HEPA filters and potential leaks.
    • Handling of shared items between resident rooms.
    • Ability to move unvaccinated residents to isolated rooms (no negative pressure rooms).

Expanding Cases: Module 3

  • 25-year-old disabled male resident starts experiencing measles symptoms.
    • Not vaccinated due to childhood cancer and ongoing treatment.
    • Sample sent to the state lab.
  • 3-year-old male starts experiencing measles symptoms.
    • Exposed to the initial patient while visiting his grandparent.
    • Attends pre-K and daycare.
    • Had one dose of MMR vaccine.
    • Parent has had both doses of MMR and no symptoms.
    • Sample sent to the state lab.

Confirmed Cases: July 5

  • The 3-year-old and 25-year-old are confirmed to have measles.
  • Three active cases in Jamestown.
  • All childcare facilities in Jamestown exclude unvaccinated children.
  • Several staff with infants under six months have no access to childcare.

Media and Communication (Expanding Cases)

  • The home office would handle media inquiries.
  • Public health will conduct media briefings in conjunction with the state.
  • Coordination if anything is tied to Eventide's facility.

Childcare Support

  • Does Eventide provide any support to these employees to continue working? No formal process. Flexible shift changes.
  • Infants cannot receive the measles vaccine until six months old.
  • If there's a community outbreak and infants are under a year old, they can get the MMR dose early but will need to repeat the dose at one year of age.

Eventide's Staff and Family Picnic

  • Scheduled for June 24 (date inconsistency).
  • Decision: Postpone, cancel, or continue as scheduled?
  • Messaging to families if proceeding:
    • Acknowledgement of community illness and identified cases may prompt postponement.

Vaccination Clinics

  • Should vaccination clinics be set up for the public?
    • Depends on demand and increasing cases.
  • Precautions:
    • Airborne precautions.
    • Screening everyone.
    • Drive-through clinics to avoid contaminating the building.
  • Potential locations:
    • Civic Center.
    • Fairgrounds.

Hot Wash: What Went Well?

  • Thought-provoking aspects.
  • Consideration of daycare closures.
  • Leveraging COVID staffing work and applying it to this situation.

Hot Wash: What Did Not Go So Well/Identified Gaps?

  • Lack of a policy.
  • Corporate vs. local decision-making.

Additional Gaps

  • Staffing challenges due to long quarantine periods (21 days) and potential re-exposure.
  • Whether staff PTO would cover such a long quarantine.
  • Difficulty in determining vaccination history.
  • Employee access to vaccination records: Is it automatic, or is permission needed?

Improvements for Next Time

  • Stories or scenarios to add:
    • The 25-year-old could be one of our employees.
    • Family member comes and visits.