Infectious Disease Outbreak Investigation on Campus: Implications for Risk Management. How it starts… .
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4:15 pm on a Friday before a holiday weekend, you get called by (public health? Residence life? The local ER?...) notifying you that one of your students has (fill in the blank) infectious disease..
What do you do?
But on campus…
Establish the diagnosis
Assess susceptibility to infection
Identify the source of infection, potential transmission and identify contacts
Obtain specimens to allow for laboratory confirmation
Collaborate with Public Health, Campus EH&S, Residence life, VCSA, Risk Management, Dean’s office…
Obtain accurate, complete past medical and surgical history, medications, immunization and screening histories
Helps clarify WHY illness occurred in case, and helps understand susceptibility of others
Assuming vaccination = immunity; misdiagnose
Failure to elicit relevant risk factors may impair accurate understanding of mechanism of exposure (i.e. partial treatment for TB resulting in MDR-TB)
Usually done in conjunction with Public Health, but will need to coordinate and assist
Sharing PHI; though important when public health threat (i.e. active TB), often need to work with non-healthcare providers to identify index case
Over- or under-defining the “at risk” group; may create unnecessary discomfort, anxiety and costs if net cast too wide, or miss cases if failure to look for cases broadly enough
Difficulty obtaining information about possible individual “sources”, and often difficult to contact directly; leads to delay in dx and treatment of “index” case and may expose others to infection
Usually considered “gold standard” for final determination of “cases”
No lab test has 100% sensitivity and specificity therefore false positives and false negatives occur and may lead to over and under diagnosis and resulting risks (see prior slide)
Costs and discomfort associated with testing
Problems coordinating access to testing, or perceived risk by students, may lead to low screening or testing for illness amongst contacts
Public Health; may need to include state and federal, as well as local
Risk Services—campus and UCOP
Athletics, Housing and Dining, CAPS, etc
***Important to begin this process immediately, and continue throughout process
Playing “telephone game” where information may be distorted as the number of involved parties grows
Confusion regarding HIPAA, FERPA, and what information can/should be shared, vs. what is private
Failure to include some important entity
Problems clarifying who is leading the efforts, and what to do when “experts” are not in agreement
These situations usually arise on a Friday at 4:30pm
Never hesitate to call for help!!—County Health Dept, local Infectious Disease experts, Campus EH&S, other SHS Directors who’ve had similar experiences
Be transparent, but don’t share information that has not been confirmed
Take time initially to review background data regarding incidence of disease, risk factors, diagnosis and treatment
Save all notices and educational documents—may be useful in future!
Since 2009, we have had 10 cases of active TB
One case of multi-drug resistant TB (Feb 2010)
This year we have had 3 cases of active TB: 2 pleural TB, 1 cavitary pulmonary TB
4 cases were undergraduate students
1 case was a student who had been an UCSD undergraduate but was diagnosed just before she started medical school at UCSD
5 cases were graduate students
None of these cases were diagnosed from the required TB screening program began in 2011 for all incoming students.
3 from China
2 from South Korea
1 from Thailand, Vietnam, Macau, Ethiopia, and Nicaragua
21 yo F undergraduate from Macau with 3 mo. history of lump on right side of neck. No cough, fatigue, fever or night sweats. Had some weight loss over the past year but recently gained 7 pounds. Had been seen for allergies, a monospotdone was negative.
Had BCG as child, no known TB exposure
T 98.3, RR 16, weight 106, BMI 17.6
Exam notable for
neck: slightly tender lymph node on the right posterior neck
Work up for lymphadenopathy started
CBC, metabolic panel, TSH- all normal
Patient notified by secure message Quantiferon test was positive and that she needed to return for a CXR.
Pt replied that day saying she would get CXR.
Patient returns to clinic 9 weeks later for CXR.
CXR shows 2.7 density in the right upper lobe.
Provider is not notified, sees the result the following Monday. Patient brought in.
Still no cough, night sweat, fatigue, weight loss
Exam notable for 1.5 cm mobile right posterior lymph node. Lungs CTA
Chest CT done: 2.6 cm cavitary lesion in apical segment of RLL, also several other smaller opacities in RUL, RLL, lingula and R cervical and subclavicular LN
Multiple attempts to contact patient: 3 phone calls, 1 secure message, 1 email- all with no response. Finally texted patient on her cell phone which she answered.
Initially arranged to have patient in self isolation at home and for sputum samples to be done as outpatient.
Consulted with pulmonary specialist who decided to send patient to ED for admission to ensure isolation and expedite care.
Patient was hospitalized for7 days.
Started on RIPE
Public Health determined that patient could return to class after 5 days of RIPE as she had no cough and AFB smears were negative.
Patient could return to her apartment as her roommates had been advised or tested.
Patient completed 8 weeks induction treatment of RIPE. TB cultures were pan-sensitive. Pt continue only on rifampin and INH.
Patient was followed by SD Public Health-took DOT treatment via video chat.
She finished 4 months of RI treatment.
Repeat chest CT should improvement of RLL cavitary lesions and all other pulmonary nodules and lymphadenopathy.
SD Public Health determined who we screened.
We needed to screen 2 classes from the second summer session and 3 classes from the Fall 2013 quarter.
250 students and 5 professors notified
73 students came to the tuberculosis screening clinics for testing.
3 known conversions.
Have a low index of suspicion in high risk patients.
Use reminder system to ensure that students return for further testing sooner.
Work with radiologists to improve communications. There were delays in diagnosis as the abnormal reading on the chest xray and chest CT results were not given to provider on the day of the readings.
Contact pulmonologist immediately to determine plan of care (whether to work-up as outpatient, direct admit, ED).
Work with Public Health department to determine who to screen.
Coordinate with Department of Student Affairs, Public Relations office to determine how to contact students that were exposed.
Work with Risk Management department to identify funding for the cost of screening and treating students that had waived out of SHIP.
Work with SD County Public Health to facilitate screening of students exposed.
29 Identify Possible Contacts
30 Identify Possible ContactsSteps in Case Investigation
31 Identify Possible Contacts
32 Identify Possible ContactsGood News / Bad News
33 Identify Possible Contacts
Mumps Outbreak United States
May 2, 2006
34 Identify Possible ContactsMumps at Berkeley (2011)
35 Identify Possible Contacts2. Obtain complete, accurate, immunization history...but beware false sense of security
36 Identify Possible ContactsACHA GuidelinesRecommendations for Institutional Prematriculation Immunizations (April 2014)
37 Identify Possible Contacts3. Identify the source of the Infection
38 Identify Possible Contacts4. Assess Potential Transmission and Identify Contacts
39 Identify Possible ContactsFamily Educational Rights and Privacy Act (FERPA)Statute: 20 U.S.C. § 1232g Regulations: 34 CFR Part 99
40 Identify Possible Contacts5. Obtain Specimens to allow for Laboratory Confirmation
41 Identify Possible ContactsMeasures Taken
43 Identify Possible ContactsCommunicate Frequently
44 Identify Possible ContactsWelcome To Isolation
45 Identify Possible ContactsLessons Learned
46 Identify Possible ContactsLessons Learned
47 Identify Possible ContactsRemember You are Not Alone.
48 Identify Possible ContactsResources
49 Identify Possible ContactsQuick Sheets
50 Identify Possible ContactsLaboratory Testing Guidance
51 Identify Possible ContactsOther Resources
Pam Cameron FNP, Anna Harte MD – UC Berkeley University Health Services