Epidemiology is the cornerstone of public health practice and the foundation for public health preparedness. In 2007 Marion County Health Department successfully applied for Project Public Health Ready. Completion of this recognition program enabled Marion County Health Department to develop a comprehensive Epidemiology Annex to its Emergency Operations Plan. While the health department had established standard operating procedures for epidemiological outbreak investigation previous to the annex’s completion, the completed annex provided well-defined linkages to the agency Emergency Operations Plan, health and medical response partners and the community’s Comprehensive Emergency Management Plan. Trigger points beyond a “normal” outbreak investigation were established.
Marion County Health Department
Public Health Preparedness Epidemiology Annex Activation
Epidemiology is the cornerstone of public health practice and the foundation for public health preparedness. In 2007 Marion County Health Department successfully applied for Project Public Health Ready. Completion of this recognition program enabled Marion County Health Department to develop a comprehensive Epidemiology Annex to its Emergency Operations Plan. While the health department had established standard operating procedures for epidemiological outbreak investigation previous to the annex’s completion, the completed annex provided well-defined linkages to the agency Emergency Operations Plan, health and medical response partners and the community’s Comprehensive Emergency Management Plan. Trigger points beyond a “normal” outbreak investigation were established. While the annex had been utilized upon completion with small-scale epidemiological outbreak investigations, the plan received its first large-scale activation in April 2009 when the novel H1N1 North American Influenza Virus emerged and began causing widespread outbreaks.
Marion County received its first positive case of H1N1 on May 14, 2009. In total, from May 14, 2009 through August 10, 2010, Marion County reported 256 cases of H1N1 influenza and 2 deaths. Of these 256 cases, 71% were aged 24 years or younger; 24% of the cases were between the ages of 25 and 64, one case was 65 or older and age was not noted in 5% of the cases reported. Twelve (12) of the 256 cases, or 5%, were hospitalized in Marion County. While 256 cases were confirmed and reported from May 14, 2009 through August 10, 2010, many more investigations were conducted. Test results poured into the health department and all had to be investigated, interviewed and a determination made whether each met or did not meet the novel H1N1 case definition. From April 1, 2009 through August 10, 2010, Marion County Health Department Epidemiology staff conducted 502 novel H1N1 investigations. The goal of the Epidemiology Annex is to reduce morbidity and mortality in human populations, thereby controlling disease and improving health outcomes. Utilization of the Epidemiology Annex ensured that processes were in place to respond to a public health emergency and scale the response to fit the situation. The application of the Incident Command System within the annex ensured that response operations would be scalable and flexible to fit the situation as it changed and provided structure in managing the response.
Development of the Epidemiology Annex was made possible as job-related duties through the CDC Cooperative Agreement to maintain a public health planner and epidemiology staff who worked to develop the annex. Direct costs were not incurred throughout plan development or response. Implementation of the Epidemiology Annex was successfully utilized during the H1N1 Influenza Pandemic. Feedback received by management and epidemiology staff indicated satisfaction with response actions and results. The Epidemiology lead met weekly with command and general staff to provide a snapshot report regarding case count, influenza like illness reports from health care providers and deaths.
The Epidemiology Annex provides for the response actions to be taken, authorities by which actions are taken and outlines department and position responsibilities related to responding to a public health emergency in which an epidemiological response is indicated. The annex was utilized to respond the novel H1N1 pandemic in Marion County, FL.
This practice addresses the issue of epidemiological response within Marion County during a public health emergency. In order to reduce adverse outcomes, Marion County Health Department Epidemiology staff members were able to track cases of the novel H1N1 pandemic. The processes of data gathering, conducting interviews, tracking the disease in the target populations indicated for vaccination all provided the information necessary for public health officials to make decisions and recommendations based on data findings. As disease appeared in Marion County, it became rapidly evident that those groups targeted for vaccination, experienced the highest incidence of disease, as compared to other groups outside of the target population. This information validated the strategy of reaching those in the target population first, followed later by those not meeting the target population indicated for vaccination. Public health officials were able to communicate this information to the public and in doing so provided a greater level of understanding and cooperation on their part throughout the duration of the target group vaccination campaign.
By utilizing the Epidemiology Annex to respond to the H1N1 pandemic, staff members were able to save time and efficiently assume their roles as indicated by the annex. The epidemiology department, as outlined by the annex, already had processes in place to conduct a large scale response, which included partner notification, surveillance, investigation tasks and responsibilities, internal reporting, data sharing and data management activities. The annex provided the organizational structure through the use of the Incident Command System for staff to assume their roles. Processes were in place to reassign and cross-train public health staff to assist with the epidemiological response if the pandemic became more severe and as indicated by incident objectives. When the novel strain of H1N1 was first identified in California and later in Florida, epidemiology staff were on high alert. Initial control objectives were to increase virologic surveillance within Marion County via passive and active surveillance systems; obtain specimens in the first 5 individuals per week that present with ILI at sentinel providers’ offices within Marion County, regardless of travel history; continue case-based containment measures until not feasible; provide information to hospitals, physicians, institutional care facilities regarding infection control, surveillance and testing procedures; provide community education as requested and as situation changes; and, validate rumors and incoming data. As influenza like illness and H1N1 cases began to increase and appear in Marion County respectively, staff members prioritized surveillance and case follow-up over normally occurring or routine communicable disease reporting and follow-up. Marion County Health Department has been an ILI sentinel provider since the 2002-2003 season. During a typical seasonal flu season, the percentage of visits for influenza like illness has been consistently at or below the national baseline percentage of 2.4%. However, during the H1N1 pandemic, the percentage of visits for ILI spiked at 11.99% in week 36. This resulted in a 400% increase over seasonal levels. The percentage of ILI visits was higher than the baseline in 13 of the 61 weeks of the pandemic, beginning with week 35 through week 49.
Project Public Health Ready criteria for Epidemiology were utilized to develop an Epidemiology Annex to the Marion County Health Department Emergency Operations Plan. The Epidemiology Annex was requested to be added to the NACCHO PPHR toolbox upon successful completion of Project Public Health Ready in 2007. A plan template was developed based upon the criteria set forth for Epidemiology in Project Public Health Ready, as well as blended with plan structure and formats to develop emergency operations plans and annexes. The health department submitted an updated Epidemiology Annex as part of the Project Public Health Ready re-recognition application in 2011 and notification of re-recognition is currently pending.
Determination that the development of the Epidemiology Annex and its application was an inventive use of existing practice was made by reviewing the NACCHO toolbox and Project Public Health Ready toolbox. Peer review indicated 5 of 5 stars for the annex. Since the annex has been posted to the PPHR toolbox, inquiries from other states, such as Virginia, Kentucky and South Carolina have been received directly. During the pandemic influenza response in Marion County, data provided based upon the epidemiologic investigation was one of the factors that led to the decision for a local disaster declaration in Marion County. Marion County was the only county in the State of Florida to declare a local state of emergency. The annex provided an outline for response triggers and actions, which was utilized by decision makers to manage the epidemiological investigation within the county.
The Epidemiology Annex and its recent application in the H1N1 response differ from other approaches because of its process inclusiveness. The concept of operations not only ties together in an organized, formatted way, staff roles and responsibilities, trigger points, disease tracking, data management, reporting, surveillance, assimilation of volunteers and other public health staff who have been reassigned to assist with epidemiological investigation tasks, it also links to the county response picture with Public Health and Medical and Emergency Management.
The local state of emergency declaration made additional resources available to the public health response and made coordination and collaboration with response partners integrated as several other response agencies filled general staff positions alongside the health department. Marion County Fire Rescue provided a Planning Section Chief, Marion County Sheriff's Office Division of Emergency Management provided the Logistics Section Chief and the Marion County Clerk of Courts provided the Finance Section Chief. The health department assumed the role of Incident Commander and Operations Section Chief. A citizens information line was established at the Marion County Emergency Operations Center. Citizens could call in with H1N1 related questions. The call center was staffed by the Citizen's Emergency Response Team under the direction of the Division of Emergency Management. The health department provided a FAQ document to the call center volunteers. When questions were received outside of the scope of the FAQ document, the questions and caller information were referred to the health department's Epidemiology Department to address.
Marion County Health Department
Role of Stakeholders/Partners
The Marion County Sheriff's Office Division of Emergency Management requested a local declaration of emergency, opened the citizens information line and staffed it with CERT volunteers, received vaccine shipments and delivered them to the POD sites in a converted van that enabled vaccine refrigerators to remain plugged in to assure the cold chain was maintained. Emergency Management also utilized the Code Red Alert system to call all Marion County Health Department clients who fit the vaccine target groups, notifying them of the availability of vaccine and clinic locations. Marion County Fire Rescue worked with the health department's epi staff to develop weekly incident action plans. The Marion County Clerk of Courts provided the Finance Section Chief to assist the health department's business department. The Marion County Public Schools system collaborated with the incident management team to utilize their facilities for public Points of Dispensing. In total the public PODs were held at five locations strategically placed in Marion County (by geography and population) using feeder high schools. Thirty mass clinics were conducted over a 4 month timeframe, while 12,943 people were vaccinated. Another way that the school system assisted the response was they provided the use of their reverse dialogic alert system enabling targeted information and clinic announcements to be sent out to those families living in each geographic area where clinics were being conducted.
The Marion County Health Department developed standard operating procedures for treatment of influenza like illness, treatment of H1N1, obtaining tamiflu to dispense to clients, influenza fast track (client intake) and cough protocol. Data sharing between the health department and community partners occurred. The health department developed the FAQ document to be used at the call center. Health department epi staff provided in-service training to practitioners to keep them updated on the situation and guidelines.
The Marion County Health Department works with community response stakeholders throughout the county to facilitate preparedness planning. The health department is designated as the lead agency for Public Health and Medical response to public health emergencies within Marion County. As such, the health department chairs the Health and Medical Preparedness Coalition in Marion County. There are 74 members in the coalition representing many primary and support stakeholders. The coalition meets every other month, while on the opposite months, the 4 established Task Forces (Planning, Resources, Training and Exercise)meet to work on their work plan objectives. The work plan objectives were established from assessments conducted by the coalition and a recent Hazard Vulnerability Assessment workshop for the county's health and medical system. The health department led the planning group's efforts for planning the workshop. Coalition members include Munroe Regional Medical Center, Kindred Hospital, Ocala Health System, Marion County Emergency Management, College of Central Florida, American Red Cross, Central Florida Eye Institute, Children's Medical Services, Conficare Home Health, District 5 Medical Examiner, ESF 8 Mortuary Liaison, First Baptist Church of Ocala, Heart of Florida (FQHC), Heart of Florida United Way, Hospice of Marion County, Department of Veteran's Affairs, 911 Communications, Lifecare Center of Ocala, LifeSouth Blood Center, Lockheed Martin, Marion County Fire Rescue, Marion County Medical Society, Marion County Public Schools, Marion County Senior Services, Marion County Sheriff's Office, Marion County Utilities, Marion Emergency Radio Team, Marion House, Marion County Medical Reserve Corps, Ocala Fire Rescue, Odyssey Hospice, Oxylife Respiratory, Palm Garden, Specialty Surgery of Ocala, TE Langley Medical Center (FQHC), The Villages Public Safety, Vitaline, Walgreens and Withlacoochee Planning Council. These established relationships enabled the health department to facilitate pandemic influenza planning. Another outcome of this ongoing preparedness planning was a Surveillance and Containment Annex for the Marion County Pandemic Influenza Plan. This annex integrated directly with the Marion County Health Department's Epidemiology Annex and provided response guidance during the H1N1 pandemic response.
In order to develop successful collaborations, many lessons have been learned along the way. A lead agency must step forward and make it vital to its mission to develop partnerships during the preparedness phase. In our case it has been the health department. It is also important for the leadership of the agencies involved in the process to have a stake in preparedness activities and understand what their role is. The Health and Medical Preparedness Coalition is all inclusive in terms of its membership. It is important to hear and understand the feedback from all partners involved, no matter the size of the agency or organization or their role in response. Our response partners learned through the Hazard Vulnerability Assessment of the Marion County Health and Medical System how interdependent we are on each other. This was crucial in forwarding our planning efforts. The more that is understood, the better all of our abilities are to help plan for all-hazards. Some of the barriers to developing and maintaining collaborations and partnerships are the amount of time that partner agencies/organizations can dedicate to planning activities. Funding cuts have also contributed to the availability of staff to continue these activities. Complacency also plays a role in keeping agencies and organizations interested in moving forward with planning. As human nature indicates, the further we are from our last disaster response; sometimes keeping partners engaged becomes a challenge.
Specific tasks taken that achieve each goal and objective of the practice include ensuring the local health department in cooperation with community partners establish a preparedness cycle prior to any disaster response. Plans must be in place prior to an incident so that all assisting and cooperating agencies know and understand their roles and have equipped their responders, trained them and conducted exercises. It is vital to know your partners and what their capabilities are. Health departments must also ensure that their staff have the required training and experience so that plans can be implemented effectively. Public health education and on the job training are crucial to maintaining a competent staff.
Due to the complexity of the preparedness cycle and the number of partners that a jurisdiction has, the timeframe is ongoing. The Marion County Health Department began planning for an influenza pandemic in January 2006. Since then plans such as the health department's Emergency Operations Plan, Epidemiology Annex, Crisis Emergency Risk Communications Plan, Alternative Medical Treatment Site Plan, Mass Fatality Appendix, Surveillance and Containment Annex, Pandemic Influenza Plan and Strategic National Stockpile plan were developed or enhanced. Staff and partners were educated and several tabletop, workshop and full scale exercises were conducted. The Alternative Medical Treatment Site was exercised two times as a full scale exercise. A county-wide pandemic influenza workshop and tabletop were conducted. A Family Assistance Center functional exercise was conducted. After five years, the health department continues to lead public health preparedness efforts in Marion County through the Marion County Health and Medical Preparedness Coalition. We are fortunate to have engaged and committed partners to continue the preparedness cycle to ensure that Marion County is ready to respond successfully to any public health emergency.
Process & Outcome
Reduce and monitor morbidity and mortality in human populations that are affected by a public health emergency. Provide a planning template/model for a local health department Epidemiology Annex, which can be modified to fit the needs of the local jurisdiction.
Objective 1: Reduce and monitor morbidity and mortality in human populations that are affected by a public health emergency. Performance Measure 1: From April 1, 2009 through August 10, 2010, Epidemiology staff conducted 502 investigations, with 256 of those being reported as confirmed cases. Data: Cases and case investigations were researched for reporting dates April 1, 2009 through the official conclusion of the pandemic, August 10, 2010. The Epidemiology Supervisor assisted the Preparedness Planner with providing the data from the Florida Department of Health's real time web-based surveillance system for communicable disease reporting, called Merlin. The data was extracted from Merlin and exported into an Excel spreadsheet for analysis. Evaluation Results: The Epidemiology Annex was activated on a large scale to respond to the H1N1 Influenza Pandemic. Processes and procedures outlined in the plan were operationalized during the H1N1 response. Standard Operating Procedures were developed that were specific to the H1N1 response. Epidemiology staff provided weekly situation updates throughout the pandemic response to health department leadership. Reports included influenza like illness from providers, updated weekly case counts and deaths. Summary reports were provided at coalition meetings, where information was then taken back and shared with leadership of the various agencies/organizations represented. Feedback: The information regarding cases and investigations was shared with the Florida Department of Health Bureau of Epidemiology and the Centers for Disease Control and Prevention.
Objective 2: Provide a planning template/model for a local health department Epidemiology Annex, which can be modified to fit the needs of the local jurisdiction. Performance Measure 2: PPHR Toolkit 5 of 5 stars for Epidemiology Annex and 3 state requests to share annex. Data Collection: Anecdotal evidence was collected from the PPHR Toolkit and direct comments from representatives from other states when requesting a copy of the Epidemiology Annex. The Preparedness Planner collected the data directly from the NACCHO PPHR Toolkit and via telephone from requesting states. Evaluation Results: The Epidemiology Annex continually receives positive feedback from colleagues and a 5 of 5 star rating on the NACCHO PPHR Toolkit. Feedback: The Marion County Health Department director and Public Health Preparedness leadership were notified. The Marion County Health Department has reapplied for PPHR recognition in 2011. In doing so, the Epidemiology Annex has been updated to reflect new criteria requirements and formatted as recommended by the FEMA Community Preparedness Guide 101 planning templates.
The Marion County Health Department is able to ensure this practice both because of Chapter 381 Florida Statutes regarding communicable diseases and public health emergencies and also because epidemiology is the cornerstone of public health practice. The health department maintains a Communicable Disease / Epidemiology Department with 3.6 FTEs and a Public Health Preparedness Department with 1.5 FTEs. The Marion County Health and Medical Preparedness Coalition has developed by-laws establishing its existence, goals and objectives. The coalition is growing and is doing so because of the value that agency and organization representatives are recognizing through its work. Leaders have committed themselves or a representative from their staff to serve on the coalition and its task forces.
Plans to sustain the practice over time include annual review and updates of all plans and procedures. Staff training is available through webinar and video conferencing formats in order to reduce travel expenditures. Coalition members are concerned about dwindling resources and budget cuts, which has strengthened the commitment and impetus to share resources with each other.
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