surveillance and monitoring of - neha cert · surveillance and monitoring of infectious diseases in...

Copyrighted Material ~ All Rights ReservedCourse Materials for NEHA-CERT Course EP0606

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Surveillance and Monitoring of Infectious Diseases in San Antonio

Shelters Following Hurricanes Katrina and Rita

Cherise J Rohr-Allegrini, Ph.D., M.P.H.

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• DSHS HSR 8 Epidemiology Response Team

• DSHS HSR 8 Public Health Preparedness Team

• John Herbold, DVM, MPH, PhD, DACVPM,FACE

• Students of University of Texas School of Public Health

– Cara Hausler• Students of University of Texas School

of Medicine• American Red Cross• Barrio Comprehensive Family Health

Care Center, Inc.• CentroMed• Comprehensive Health Services, Inc.• Texas MedClinic• University Health Services• “Green Pants”• Baptist Child and Family Services• COSA Department of Community

Initiatives

• San Antonio Metro Health District– Environmental Health Services Team

• Lori Calzoncit• Monty McGuffin• Terry Ricks

– Public Health Emergency Preparedness Team

• Roger Sanchez• Nancy Walea• Roger Pollok• Frank Chance

• CDC Hurricane Katrina Response Team– Melissa Marx– Doug Thoroughman– Alice Chapman– Mike Jhung– Jeff Hageman– Dan Jernigan– Robbie Gray– Robert Martin– Meri Pyle– Parmi Suchdev

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Katrina and Rita• 29 August 2005

– Hurricane Katrina struck the U.S. Gulf Coast forcing over 200,000 evacuees to shelters in 18 states

• 2 September 2005– ~12,700 evacuees began arriving in San

Antonio

• 6 September 2005– ~6000 Evacuees in 4 SA Area shelters

• 21 September 2005– Evacuees from Hurricane Rita

began arriving in San Antonio

– ~12,000 passed through area shelters between 21-28 September


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Daily Shelter CensusKelly 171, Kelly 1536, Windsor Park Mall, Levi Strauss

0

2000

4000

6000

8000

10000

12000

14000

9/2

9/4

9/6

9/8

9/10

9/12

9/14

9/16

9/18

9/20

9/22

9/24

9/26

9/28

9/30

10/2

10/4

10/6

10/8

10/1

010

/12

10/1

4

RITA

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Special Needs Shelter Daily Census

0

100

200

300

400

500

600

700

800

9/4

9/6

9/8

9/10

9/12

9/14

9/16

9/18

9/20

9/22

9/24

9/26

9/28

9/30

10/2

10/4

10/6

10/8

10/1

010

/12

# Ev

acue

es

RITA

Moved into Kelly 171


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San Antonio Hurricane Katrina Evacuees N=16,367MaleFemale

7

800 300 200 700

0 to 4

5 to 9

10 to 14

15 to 19

20 to 24

25 to 29

30 to 34

35 to 39

40 to 44

45 to 49

50 to 54

55 to 59

60 to 64

65 to 69

70 to 74

75 to 79

80 to 84

85+

City of San AntonioDepartment of Community InitiativesKatrina Emergency Aid Database (ClientTrack.NET)

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29 Aug3 Sept

21 Sept

24 Sept

30 Sept

17 Oct

23 Dec

10 Sept

Katrina hits Gulf CoastEvacuees arrive in SA

SAMHD turns Medical Services over to local health care organizations – Barrio Comprehensive, CentroMed, University Health Services

Rita Evacuees begin arriving in SA

Hurricane Rita hits Gulf Coast

Windsor Park Mall Shelter Closes

Shaw Group and Comprehensive Health Services take over

Shelters consolidated into Kelly 171, including Special Needs

Shelter closes

*DMAT began work Sept 3, opened Kelly 1536

American Red Cross provided First Aid Services in all non-Special Needs shelters from Day one until Oct 17

Special Needs shelters operated and staffed by Baptist Child and Family Services

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Epidemiology and Surveillance

• Medical Intake Surveys• Daily Surveillance • Laboratory Surveillance


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Medical Intake - Upon Arrival

• All evacuees offered Hepatitis A and Tetanus vaccinations– 6183 Hep A– 10,090 Td

• Evacuees asked to complete a screening tool to evaluate their current health status

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• Most evacuees came through Kelly 171– Few arrived independently at

• Kelly 1536• Levi Strauss• Windsor Park Mall

• Forms collected 9/1-9/6/05 as evacuees arrived • Form use inconsistent at shelters• Information was self-reported• N = 2556

Medical Intake Screening: Katrina

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Have seizures?

Have Asthma?CoughHow long?Do you smoke?Spitting up blood or mucus?

Are you running out of medication?

Take any medication?List:

Have high blood pressure?Severe Headache

Need a cane or walker?Wound, cut or scratchWhere?

Need a wheelchair?Stomach pain/cramps

Need Oxygen?Are you pregnant?DiarrheaHow long?

Use a glucose monitor?Have a history of Depression?VomitingHow long?

Have diabetes?Are you depressed?Watery, itchy eyes

Have an ostomy that needs care?Have hepatitis?

Have a wound that needs dressing?Experience incontinence?FeverHow long? What Temp?

Have any kind of catheter?Have tuberculosis?If yes, what medication?

Rash

Use baby formula?Have an ostomy?Insect Bite

Pregnant?Need dialysis?

Wear diapers?Have Diabetes?Take oral meds?Take Insulin shots?

Heart conditionChest painHow long?

Anyone in your family….Do you….Do you have any of the following?


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Medical Intake Results

0.0 5.0 10.0 15.0

Cardiac Conditions

Chest PainHeart Condition

% Evacuees

0 20 40 60

DialysisInsulin

Oral Meds

% of Diabetic Evacuees

Diabetes 14.2%

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0 1 2 3 4

Other Chronic ConditionsHIVTB

Hepatitis

% of Evacuees

OstomyIncontinence

% of Evacuees

0 2 4 6 8

Continence Conditions

0 20 40 60

Use Rx MedsRunning out of Meds

Rx Meds

% of Evacuees

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Acute Conditions

Itchy/watery eyes

Abdominal Pain/CrampsDiarrhea

FeverVomiting

Coughing Blood

Cough

% of Evacuees

1.37.37.3

131919

20.3

0 5 10 15 20 25

Insect biteRash

Wound

Skin Conditions

% Evacuees


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% of Evacuees

0 10 20 30

History of DepressionDepression

Anxiety/Nervousness

Mental Health initial survey

0 10 20 30 40

History of DepressionDepression

Anxiety/Nervousness

Mental Health 27 Oct N=47

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Medical Services• Each shelter maintained a

medical clinic • Sept 1-9

– San Antonio Metro Health District– Volunteers– DMAT

• Sept 9 – October 17– Kelly 1536: DMAT, then CentroMed– Kelly 171: Barrio Comprehensive and Red Cross– Windsor Park Mall: CentroMed (Shelter closed Sept 30)

and Red Cross– Levi Strauss – University Health Services

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Daily Syndromic Surveillance

Short Term Shelter5 Sept - 4 October 2005 (CDC and SAMHD)

Long Term Shelter18 October – 22 December 2005

(Shaw/Comprehensive Health Services and SAMHD)


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SAMHD Daily Surveillance Log for Evacuation Shelters

• Evacuees present to Shelter Clinic• Chief Complaint info obtained• Entered into Access Database file or

paper log• Electronic files submitted to

SAMHD/CDC daily• Analyzed in Microsoft Access

Database• Daily report generated

CommentTransfer?Chief Complaint

Zone/ Section

SexDOBLast Name

First Name

ID

Date __/__/__ Kelly 171 Kelly 1536 Levi WPM Special Needs__________

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___Lower respiratory tract illness (pneumonia; bronchiolitis/wheezing)

___Pertussis, suspected (whooping cough; chronic cough ≥ 2 weeks)

___Tuberculosis, suspected (cough >3 weeks, fever/chills, night sweats, recent weight loss)

___Upper respiratory or influenza-like illness (fever + either cough or sore throat)

___Respiratory illness

___Bloody Diarrhea, +/- vomiting

___Watery Diarrhea with NO vomiting

___ Watery Diarrhea (3 or more watery bowel movements per day) AND vomiting

___ Gastrointestinal-like Illness

___Fever >100.4° F (38° C) ALONE without localizing signs/ symptoms.

Epidemic Disease Potential# patients with conditionSyndrome Category

Surveillance Among Facilities Housing Hurricane Katrina Evacuees

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Epidemic Disease Potential

___ ___Other Illness (please specify): _________________________________

___ ___Lice___ ___Scabies

___ ___Suspect measles/rubella (maculopapularrash)

___ ___ Suspect chickenpox (vesicular rash)___ ___Rash-like Illness___ ___Conjunctivitis (red eyes, ocular discharge)___ ___Wound infections

___ ___Meningitis/encephalitis, suspected (fever, stiff neck, headache, mental status change)

___ ___Neurologic illness ___ ___Suspected Viral hepatitis ( jaundice, +/- fever)


22© ___ ___Dehydration___ ___High Blood Pressure and other Cardiovascular Diseases___ ___Asthma / COPD___ ___Diabetes Mellitus___ ___Heat related injury (not dehydration)___ ___Unintentional injury (accidents)___ ___Assault-related injury – Intentional (violence)___ ___Self-inflicted injury – Intentional (violence)___ ___Injury

Injury / Chronic Disease / Other___ ___Violent behavior___ ___Acute psychosis / Suicidal or Homicidal___ ___Disorientation / Confusion___ ___Substance abuse / withdrawal___ ___Anxiety / Depression / Insomnia___ ___Mental Health

Mental Health / Psychological Problems

# patients with conditionSyndrome Category

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Short Term ResidentsSept 5- Oct 11

N= 6879 visits

ColdThroat

RashFever

Flu-likeFever + Flu

DiarrheaVomiting

HeadacheMeningitisConjuntivitis

NauseaSkin

InfectionFever Only

GI

Epidemic Disease Potential

Other

Chronic/Injury (10%)

Mental (4%)

59%

28%

Respiratory 16%

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“Outbreaks”

I. GI illness in one Special Needs Shelter Sept 8-12

• 10 individuals – 1 hospitalized

• Investigation– Primary Sx: Vomiting and diarrhea– All age groups affected, 6 had children in diapers– Diapers were being changed on cots– UHS isolated Norovirus from hospitalized patient– Team educated residents and staff on hygiene,

recommended separate space for diaper changing


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“Outbreaks”II. GI Illness Kelly 1536• Sunday, Oct 2

– Report of “tons of people” with GI-like illness• 12 individuals overnight• Another 10 next day• Vomiting, diarrhea

– Interviewed 6 individuals• All ate different food, no common source

• Monday, Oct 3– Similar numbers sick, including “Green Pants” staff– Interviews with Green Pants, didn’t eat at facility, no common source– Reviewed hand washing, hygiene, SAMHD Sanitarians called for

inspections

• Tuesday, Oct 4– No new cases– Likely Norovirus

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Laboratory Surveillance

• Problematic: Medical area not conducive to obtaining samples at most shelters

• Laboratory surveillance based on residents transported to area hospitals– laboratories reported all findings from shelter

residents to SAMHD Epidemiology

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Long Term Shelter

• October 17 – The Shaw Group took over shelters from American Red Cross

• Consolidated all shelters into Kelly 171• Comprehensive Health Services provided

all medical care


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Long Term ShelterOctober 17- December 22

• Surveillance reports on paper, not electronic• Retrieved every 2-3 days, entered into Access

database• Daily phone/email contact between CHCS

and SAMHD to report any possible ‘events’ or concerns

• Flu Vaccine administered on Oct 28 to ~50% shelter residents

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Long Term ResidentsOctober 17- December 22

• >4000 visits• Approx 50% repeat visits

75%Acute

20% Epidemic Potential: GI and Respiratory

Chronic20%

Other/Mental Health

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Long Term Shelter Summary

• Repeat visits very common• Acute Illness visits, but no outbreaks• No significant GI illnesses

– Nausea, diarrhea usually self-limiting, rarely more than 24 hrs and never in clusters

How did we avoid any major problems?


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Food and Environmental HealthSAMHD

• First 2 weeks– 1-2 Sanitarians at each shelter 24/7– 8-10 hour shifts– Inspected:

• Food safety • Hand wash facilities• Toilets• Bedding• Common areas

• Continued weekly inspections until shelters closed on Dec 23

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Food Handling

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Problems Identified

• Early lack of adequate toilet facilities and hand-washing stations• Dirty clothes piled in a room• Hoarding food under cots• Lack of shower facilities upon first arrival• Lack of control of donated food items• Impromptu Day Care


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Shower Facilities

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Hand Washing Stations at 1536

Improved toilet and shower facilities at

1536

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• No real illness– Surveillance systems

effective– Education from Environmental

Health staff effective• Environmental health issues addressed • Continued education of shelter population• SAMHD Divisions worked together well• Staff stepped up to bigger roles

What Went Right?


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• SOPs• Improve Communication• Define Special Needs• Begin Epidemiology Surveillance earlier• Allow Environmental Health inspectors to

review shelters before setting up

What can we do better next time?

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