School Rash Investigation Presented by Kristy M Bolen

School Rash Investigation Presented by: Kristy M. Bolen, MPA Fivco Regional Epidemiologist

Investigation Team n Little Sandy District Health Department ¨ Lloyd Miller, Director ¨ Heidi Fosson, Preparedness Planner ¨ Henry Sturgill, Environmentalist ¨ Jeff Barker, Environmentalist ¨ Ellen Blevins, Nursing Supervisor ¨ Rita Sexton, School Nurse

Investigation Team n Regional Epidemiologist ¨ Kristy n Bolen Department of Public Health ¨ David Jones ¨ Dr. Nato Tarkhashvili ¨ Dr. Doug Thoroughman ¨ Colleen Kaelin

Map of Kentucky Counties and Area Development Districts BOONE LL BE MP CA N KENTO = Area Development District Boundaries IN T LLA PE N NDL GA ET GRANT R N OBE MASON RT SO IM TR CARROLL E BL OWEN HARRISON HENRY OLDHAM ON ST NG MARSHALL CARLISLE CLAY LAUREL TODD CALLOWAY PULASKI L SE S RU KNOX HARLAN LOGAN CUMBERLA ND SIMPSON HICKMAN LESLIE L BARREN METCALF WARREN TRIGG GRAVES KNOTT PERRY GREEN EDMONSON CALDWELL LYON PIKE OWSLEY ROCKCAST LE CASEY HART BUTLER CHRISTIAN FULTON JACKSON ADAIR KE Y I LIV Mc CR BALLARD N AC GRAYSON TAYLOR MUHLENBE RG FLOYD BREATHITT LINCOLN HOPKINS MARTIN MAGOFFIN LEE RD OHIO CRITTENDE N JOHNSON WOLFE ESTILL RA BOYLE MARION LARUE AN MORGAN AR WEBSTER MENIFEE POWELL MADISON UNION MC LE ER WASHINGT ON HARDIN OM TG MERCER LAWRENCE ON JESS A’’ MINE G DAVIESS ELLIOTT M NELSON BRECKINRID GE ROWAN CLARK RD ANDERSON BULLITT FAYETTE O DF HENDERSO N CK BOYD CARTER BATH O WO O FLEMING BOURBON HA NC GREENUP SCOTT FRANKLIN SPENCER MEADE LEWIS NICHOLAS SHELBY JEFFERSON BRACKEN O ALLEN MONROE CLINTON WAYNE WHITLEY Mc. CREARY BELL LETCHER

Tri-State Preparedness Planners & Epidemiologists Group Ohio West Virginia

Carter County Demographics n Population ¨ 26, 889 n (2000 Census) County School system ¨ Two Middle & High Schools ¨ Six Elementary Schools ¨ Total District Enrollment 4, 771 (2003 -2004)

Timeline of Investigation n January 5, 2005 ¨ Regional Epidemiologist is contacted by Little Sandy District Health Department (LSDHD) Four female students had left East Carter High School (ECHS) with a rash n One student had went to the Emergency Department with a severe reaction n Regional Epidemiologist planned to visit LSDHD and ECHS next morning to investigate n

Timeline of Investigation n January 6, 2005 ¨ Team from LSDHD & Epidemiologist visit ECHS Inspect classrooms & common areas n Talk to school nurse & office staff about students who left on the 5 th n Interview female student who comes in with rash while we are still in building n

Timeline of Investigation n January 6, 2005 ¨ Epidemiologist prepares questionnaire for distribution to students at ECHS with rash ¨ LSDHD calls later that afternoon to report 40 students have left ECHS with rash ¨ School officials cancel classes for Friday to “disinfect” the school ¨ Contact DPH, set up meeting for next morning

Timeline of Investigation n January 7, 2005 ¨ Epidemiologist meets with LSDHD & DPH team (David and Nato) ¨ Entire team visits ECHS to inspect building & talk to maintenance staff Asks about cleaning products used everyday & over Christmas break n Acquires MSDS sheets on products used regularly n Acquires Orkin’s number (sprayed over break) n Looked at heating/cooling system n

Timeline of Investigation n January 7, 2005 ¨ School nurse begins to report East Carter Middle School (ECMS) students are coming in with same rash ¨ Investigation team visits ECMS n Takes pictures & blood samples (from staff) ¨ Team finalizes questionnaire to distribute to students who’ve left with rash or students that leave Monday with rash

Timeline of Investigation n January 10, 2005 ¨ No cases reported over weekend ¨ By days end 100 students have checked out of both schools 29 students from ECHS n 71 students from ECMS n ¨ Regional Epidemiologist plans to return next day to enter completed questionnaires

Timeline of Investigation n January 11, 2005 ¨ By days end 49 students have checked out of five schools in the district 20 students from ECHS n 14 students from ECMS n 2 students from Upper Tygart Elementary n 11 students from West Carter High School n 2 students from West Carter Middle School n ¨ School officials decide to close schools until January 18 th

Timeline of Investigation n January 11, 2005 ¨ Media “blitz” begins n Calls received from local station & Lexington station n Regional Epidemiologist becomes PIO for case ¨ Phone conference with DPH officials n Dr. Kraig Humbaugh, Dr. Barry Wainscott, Dr. Doug Thoroughman, David & Nato n Set time for update next morning ¨ ECHS plays basketball game against another area high school n Creates an issue for media to focus on

Timeline of Investigation n January 12, 2005 ¨ Team creates Information sheet n Sheets sent to surrounding Regional Epidemiologists to distribute to their counties n Sheets also sent to area hospitals ¨ Completed questionnaires are entered & first “Epi. Curve” is produced ¨ During phone conference with DPH decide that Dr. Thoroughman, Colleen Kaelin, David and Nato will visit next day to meet with school officials & staff

Timeline of Investigation n January 13, 2005 ¨ Investigation team meets with school officials & staff n Assure school that it is safe to open on Tuesday ¨ Continue database to enter questionnaires into

Timeline of Investigation n January 14, 2005 ¨ Final n media interviews Assure public that its safe for children to return ¨ Decide not to call students that didn’t return questionnaire n Did not want to “stir-up” issue again

Timeline of Investigation n January 18, 2005 ¨ Students return to school 1 case at ECHS n 1 case at ECMS n 3 cases at three different elementary schools n n January 21, 2005 ¨ Investigation n is closed No definitive cause found Lack of questionnaires returned ¨ MMWR Article ¨

Lessons Learned n “In the midst of difficulty, lies opportunity. ” - Albert Einstein

Lessons Learned n Showed how beneficial regional epidemiologists are in an incident ¨ Team worked well together ¨ No territorial issues n Showed how beneficial partnerships are to an investigation ¨ West Virginia & Ohio partners ¨ DPH Partners

Lessons Learned n Misconception of our jobs ¨ Expectation versus reality ¨ Allowed community to see what our true function in an incident is n Communication is key ¨ With community (through media) ¨ With School officials (local and area wide) ¨ With DPH

Lessons Learned Need to delegate one or two people to answer phone questions from public n Contact notebook is a necessity n ¨ Didn’t have fax numbers for other Regional Epidemiologists or area physicians ¨ Didn’t have area school contact information ¨ Didn’t have media contact information

Lessons Learned n Need to contact media first ¨ Provide them with information sheet ¨ Don’t let them dictate the story n Data needs to be collected as soon as possible ¨ Lost chance to collect data when schools closed

Conclusion Even though a thorough investigation was conducted, no cause for the rash was discovered n Lessons learned helped with next investigation (February) n A good test of emergency plans & procedures n