School Rash Investigation Presented by Kristy M Bolen

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

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

Investigation Team n Little Sandy District Health Department ¨ Lloyd Miller, Director ¨ Heidi

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 ¨

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

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

Tri-State Preparedness Planners & Epidemiologists Group Ohio West Virginia

Carter County Demographics n Population ¨ 26, 889 n (2000 Census) County School system

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

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

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

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

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

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 ¨

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

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

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

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

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

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

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

Lessons Learned n Showed how beneficial regional epidemiologists are in an incident ¨ Team

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

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

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

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

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