For this exercise, you will be asked to work in groups to participate in an outbreak investigation in a school setting.

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Case Study 5: Outbreak in a School Setting

Session Overview Instructions For this exercise, you will be asked to work in groups to participate in an outbreak investigation in a school setting. Information regarding the scenario will be provided in parts, each of which will be followed by related discussion questions. Choose one group member to read each segment of information aloud to the rest of the group. After receiving the information, work as a team to answer each discussion question.

Intended Audience All public health, medical, veterinary, pharmacy, emergency management, hospital, and other professionals interested in public health preparedness and field epidemiology.

Time Required (estimated) 90 minutes

Learning Objectives

 Describe the school nurse’s role in responding to and managing an infectious disease outbreak

 List the steps of outbreak investigation in a school setting  Discuss ways that schools can work with local public health authorities for

effective outbreak response  Create a case definition  Write main points for a letter to parents about a school outbreak

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Case Study 5: Outbreak in a School Setting

Pre-Test

1. True or False: A school nurse is not required to report an outbreak to the local health department.

2. What data can be used to determine whether an outbreak is occurring in a school

setting? a. Comparison of current rates of disease observed among the population

with baseline rates in the same group b. Comparisons of the current absenteeism rate with baseline rates c. Interviews with students and/or their parents on their condition and

possible exposures d. All of the above e. A and C only

3. True or False: Once case definitions for probable and confirmed cases are developed, they cannot be changed.

4. Which of the following information would NOT be included in a message to parents about a school outbreak?

a. A summary of the outbreak to date b. A list of control measures c. Signs and symptoms of the disease d. Instructions on proper hygiene practices e. Information about treatment f. Indicators of severe illness requiring hospitalization g. Contact information for the school nurse h. All of the above information should be provided

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Case Study 5: Outbreak in a School Setting

Student Guide

Update 1: January 10th You are a school nurse at Oak Ridge Elementary School. It is January 10th, and students returned from winter break last week. Today, 14 children came to your office complaining of symptoms including vomiting, nausea, and diarrhea. Two students also had a low-grade fever. The number of students with these gastrointestinal symptoms seems higher than usual (which would indicate and outbreak), although not alarmingly so. Unfortunately, you rotate schools throughout the week and are not at this school on a daily basis to determine whether these reports of illness are definitely an outbreak.

1. What control measures (if any) would you take at this point? 2. As a school nurse, are you required to report certain diseases or outbreaks to your

local public health department? Should you report anything at this time? Who is the point of contact at your local health department?

Update 2: January 12th Over the next few days, more students become ill with gastrointestinal symptoms, and absenteeism at your school increases markedly above the usual rates of 5-6% for this time of year to a rate of 15% among students. Staff absenteeism also increases above usual rates. Given the high absenteeism and common symptoms, you suspect an outbreak may be happening. You decide to gather more information and notify the local health department.

3. What information should you gather to determine whether an outbreak is occurring? 4. Group Brainstorm: Have one member of the group write ideas on the

flip chart. When you call the local health department to report the potential outbreak, what information should you be prepared to provide?

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Update 3: January 13th One ill student has been hospitalized for dehydration due to vomiting and diarrhea. This afternoon, you receive a call from a nurse at the health department that the student has tested positive for norovirus. Although not a reportable disease by law, norovirus is highly contagious and contributes to over 50,000 hospitalizations and between 570-800 deaths each year in the U.S. It causes outbreaks in a variety of settings, including health care facilities, restaurants, cruise ships, schools, prisons, and other institutional settings. Because of its transmissibility and potential for large outbreaks, the nurse, Jeremy, recommends that you work together with him to conduct a full outbreak investigation at the school, with the health department as the lead.

5. What are the steps of an outbreak investigation? Are there additional considerations

when the investigation is conducted in a school setting? 6. As a school nurse, would you be responsible for working with the local public

authority to investigate and respond to this outbreak? If not, who would serve as the main liaison from the school to the health department? What are some of the responsibilities of the school liaison to the health department?

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Update 4: January 13th Below is a line listing of the possible cases to date (Table 1). Some information is incomplete since you have not been able to interview everyone yet.

Table 1. Possible Cases as of January 13

First Name

Last Name

Sex Age Symptoms Date of Onset

Laboratory Testing

Notes

Juan Ramirez M 8 D,V,N 1/10 none

Madison Hooper F 10 D,V 1/9 None

Noah Price M 9 D,V,F,M 1/9 Positive – norovirus

Trey Milton M 11 D,N,F 1/11 None

Hannah Nicholson F 10 D,V,N 1/10 None

Isabel Johnson F 6 D,V No interview

Katherine Atwood F 7 D,? No interview

Miguel Santos M 8 V No interview

Harper Burke F 10 D,V No interview

Bella Lucas F 11 D,V,? No interview

Raymond Ross M 9 D,V,F,N 1/9 None

Jacob Hall M 9 D,V,? No interview

Julie Brentwood F 39 D,V,N,M 1/11 None

Monica Hardesty F 25 D,V,N,F,M 1/10 None

Katie Volksman F 32 D,V No interview

* D = diarrhea; V = vomiting; F = fever; N = nausea; C = abdominal cramps; M = muscle aches

7. Based on the information provided, write case definitions for probable and

confirmed cases. (Hint: Case definitions determine who is counted as a “case” in an outbreak. They should always include criteria for person, place, time, and clinical features).

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Update 5: January 13th Jeremy, the health department nurse, recommends the following control measures: more thorough handwashing and bleach cleaning of shared environmental surfaces, especially high-traffic areas such as hand rails and door handles. You make a note to meet with the custodial staff to discuss cleaning and disinfecting procedures. Jeremy also notifies you that environmental health specialists plan to visit tomorrow to collect specimens. You know that norovirus can persist on surfaces and continue to infect people for days or weeks. In addition, he suggests conducting an epidemiologic study as a method to identify the cause of the outbreak. Jeremy asks you whether it is practical to conduct a cohort study, or whether it is more realistic to conduct a case-control study. He is willing to write a draft questionnaire and then send it to you for review.

8. What types of environmental samples should be collected? Which laboratory tests

will be conducted to determine if norovirus is present in the samples? 9. What is the difference between a cohort study and a case-control study? Which study

design would be best in this situation?

Update 6: January 14th Information and rumors about the norovirus outbreak spread throughout the school and the local community. Worried parents are calling the school asking whether schools will close. Staff members are asking how they can protect themselves and their students from becoming ill. Students with chronic illness and/or immune suppression require special consideration in order to meet their health and educational needs. You will need to assess the plan for this population in more detail with guidance from the local health director. So far those students have not shown symptoms of norovirus infection. Since it is Friday, it would be ideal to send a letter home with students this afternoon.

10. Group Activity: Have one member of the group write ideas on a white

board or flip chart. What do you communicate to parents at this point? As a group, draft 3-4 key points to include in a letter to parents (do not spend time on fine details, think about the major points you would cover).

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Update 7: January 14th Today you received a phone call from the parent of one ill student who is concerned about the privacy of her daughter’s personally identifiable health information. The call prompts you to review what you know about data confidentiality, particularly the intersection of the Health Insurance Portability and Accountability Act (HIPAA) and the Family Educational Rights and Privacy Act (FERPA) during a school-associated disease outbreak.

11. Are student health records covered by HIPAA and/or FERPA? Are you (as a school

nurse) permitted to release personally identifiable information (PII) or protected health information (PHI) to the health department without written parental consent?

Update 8: January 17th After consulting with the principal, you decided to conduct a cohort study using a web- based questionnaire for parents and staff. For families without at-home Internet access, a paper questionnaire was sent home with students before the weekend. The questionnaire included a 3-day food history. Of the 314 students and 66 staff members in the school, 207 (66%) students and 59 (89%) staff members participated in the study. Initial descriptive analysis of the interview data is useful. Among the 266 respondents, 85 (32%) met the probable case definition for norovirus. There were no differences in illness based on age or gender. None of the cafeteria staff members was ill, and no food item was significantly associated with illness. However, there were two factors that were significantly associated with illness in bivariate and multivariate analysis: being in a classroom along the kindergarten hallway (attack rate = 71%; relative risk [RR] = 1.9; 95% confidence interval [CI] = 1.3–2.8) and having contact with an ill individual (AR = 38%; RR = 1.8; CI = 1.2–2.7).

12. Based on these results, what control measures do you recommend? Does the lack of

association with a specific food rule out the possibility that this was a foodborne outbreak?

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Update 9: January 19th The outbreak has subsided, and school attendance is back to normal levels. You have found that the outbreak gave you an opportunity to promote the importance of proper hand hygiene, and students and staff have been receptive. You also conducted an interactive lesson with the food service staff about food safety.

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References

Association of State and Territorial Health Officials. Comparison of FERPA and HIPAA privacy rule for accessing student health data. http://www.astho.org/programs/preparedness/public-health-emergency-law/public- health-and-schools-toolkit/comparison-of-ferpa-and-hipaa-privacy-rule/. Accessed April 6, 2016. Centers for Disease Control and Prevention. Norovirus website. http://www.cdc.gov/norovirus/index.html. Updated December 30, 2014. Accessed April 6, 2016. Centers for Disease Control and Prevention. Norovirus outbreak in an elementary school – District of Columbia, February 2007. Morb Mortal Wkly Rep. 2008;56(51):1340-1343. Centers for Disease Control and Prevention. Updated norovirus outbreak management and disease prevention guidelines. MMWR Rec Rep. 2011;60(RR03):1-15. Minnesota Department of Health. Checklist for schools when outbreaks of gastroenteritis are suspected. http://www.health.state.mn.us/divs/idepc/dtopics/foodborne/outbreak/facility/checkl ist.html. Accessed April 6, 2016. North Carolina Division of Public Health. Steps of an outbreak investigation. July 2012. http://epi.publichealth.nc.gov/cd/lhds/manuals/cd/conference/2012/2012_OB_invest igation_steps.pdf. Accessed April 6, 2016. Schwab NC, Gelfman MHB. Legal issues in school health services a resource for school administrators, school attorneys, school nurses. New York: Authors Choice Press, p. 193; 2005. U.S. Department of Education. Family Educational Rights and Privacy Act (FERPA) and the disclosure of student information related to emergencies and disasters. June 2010. https://www2.ed.gov/policy/gen/guid/fpco/pdf/ferpa-disaster-guidance.pdf. Accessed April 6, 2016.

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Case Study 5: Outbreak in a School Setting

Post-Test

1. True or False: A school nurse is not required to report an outbreak to the local health department.

2. What data can be used to determine whether an outbreak is occurring in a school

setting? a. Comparison of current rates of disease observed among the population

with baseline rates in the same group b. Comparisons of the current absenteeism rate with baseline rates c. Interviews with students and/or their parents on their condition and

possible exposures d. All of the above e. A and C only

3. True or False: Once case definitions for probable and confirmed cases are developed, they cannot be changed.

4. Which of the following information would NOT be included in a message to parents about a school outbreak?

a. A summary of the outbreak to date b. A list of control measures c. Signs and symptoms of the disease d. Instructions on proper hygiene practices e. Information about treatment f. Indicators of severe illness requiring hospitalization g. Contact information for the school nurse h. All of the above information should be provided