Facility-level clustering of unvaccinated students in the Portland, Oregon metro area prompted Multnomah County Health Department to develop a cooperative measles response protocol for public health agency use in the event of a school or daycare outbreak. Responding to vaccine-preventable diseases in schools or daycares is a key responsibility of a local health authority (LHA) and requires swift action from public health officials in close coordination with schools and other public health partners. Given our vulnerability to an outbreak, Multnomah County Health Department determined a need to assure appropriate response protocols were in place for the four-county Portland Metropolitan region. To assess and address metropolitan area preparedness, we drew on Homeland Security Exercise and Evaluation Program (HSEEP) guidelines, with a strong emphasis on the improvement planning section of the cycle. Goals of the project were to 1) conduct a stakeholder-engaged process to develop a measles case report response plan and 2) develop an accessible, easy-to-use toolkit for LHA use in responding to a measles case report or cluster. Stakeholders used a tabletop after-action report to identify six workgroups for addressing specific gaps. Non-public health participants (e.g. schools and daycares) shared their response capacity, and specific guidance on how to best work collaboratively during an outbreak. Using a HSEEP framework for planning more routine public health response proved an effective way to organize and track a multi-stakeholder process.
Multnomah County Health Department
Quad-County Measles Protocol and Toolkit Development
Brief description of LHD
Multnomah County is an urban and suburban community located in the northwest corner of Oregon and is home to the state’s largest and fourth largest cities. Despite being the smallest in square miles, Multnomah County is the state’s most populous (766,135 residents, 19.5% of Oregon’s population) and diverse county, with a population that is 11.1% Latino, 6.9% Asian, 5.3% Black/African American, 3.7% multiracial, 0.8% Native American, 0.6% Pacific Islander (together totaling 24.5% of Oregon’s persons of color), and 71.7% non-Latino White.
Public health issue
During 2012-2014, Oregon had the highest rate of non-medical vaccine exemptions among kindergartners in the United States. Even higher rates of exemptions have been seen in children enrolled in childcare facilities (e.g., day cares, head start programs, etc.) . In 2014, 6.8% of Oregon parents exempted their children specifically for the measles vaccine. In Oregon, Multnomah County had among the highest percentages of children in the state with any vaccine exemption at 9.6%. Clustering of unvaccinated children in a school or daycare setting made us particularly vulnerable. For example, 29% (48/167) of kindergarten facilities (kindergartens in Multnomah County with an adjusted enrollment of ≥ 10) had fewer than 90% of children up-to-date on the measles vaccine (herd immunity threshold is 90-95%). Responding to vaccine-preventable diseases in schools or daycares is a key responsibility of a local health authority (LHA) and requires swift action from public health officials in close coordination with school administrators and other public health partners. Thus, we determined a need to assure appropriate response protocols were in place.
Goals and objectives
Goal 1: Conduct a stakeholder-engaged process to develop a measles case report response plan Objective 1.1: Identify gaps across multiple agencies and school and daycare facility partners Objective 1.2: Achieve up-front buy-in on response plan from community partners Objective 1.3: Provide a forum for agencies and partners to networkGoal 2: Develop an accessible, easy-to-use toolkit for LHA use in responding to a measles case report or cluster Objective 2.1: Use stakeholder knowledge and experience to develop a realistic and broadly acceptable toolkit for public health agency use within six months Objective 2.2: Use Homeland Security Exercise and Evaluation Program (HSEEP) guidelines to structure a process for developing a plan for routine public health response Objective 2.3: Establish clear guidance for communicating expectations for exclusions and re-admissions.
We drew on HSEEP guidelines with a strong emphasis on the Improvement Planning section to develop a plan that would account for the unique characteristics of a school-based measles exposure, and ensure rapid, coordinated response. HSEEP supported the integration of key health and educational partners, essential to the development of our public health plan. We adapted and incorporated components of HSEEP, streamlining the approach to better accommodate routine planning. For example, exercise design was contained to the Health Department. Exercise materials were created, and then shared at the time of the tabletop, to not only introduce the exercise, but also identify overarching planning intents. Similarly, evaluator packets were kept to a minimum, focusing on exercise goals. Evaluative methods were expanded, and Participant Feedback Worksheets were completed by all players to collect information for the AAR/IP.
Milestone and Dates CompletedExercise logistics in place - September 2014Tabletop conducted - October 27, 2014Distribute After Action Report/Improvement Plan - January 9, 2015Invite partners to After Action Conference (plan corrective action/protocol development) - January 2015Set work groups for corrective action/protocol development - February 13, 2015Midpoint meeting: track corrective actions - April 9, 2015Final tabletop & protocol/toolkit review - June 9, 2015Release of toolkit materials to LHAs - August 13, 2015
Public Health impact
Using a HSEEP framework for planning more routine public health response protocols was an effective way to organize and track a multi-stakeholder process. Given existing relationships in these more routine situations, we were able to de-emphasize some of the early planning steps (e.g., MSELs), and focus on the improvement process. We also built our the AAR/IP findings to identify clear working group sections, tasking each with a fairly narrow set of deliverables that allowed each group to stay on task and sustain stakeholder involvement. In addition to yielding a protocol and related materials for a response, benefits of the process included the following: promoting regional consistency across multiple jurisdictions for a local measles outbreak response; preparing partners for what to expect in an event; assuring a realistic protocol through education and childcare partner involvement; and establishing new working relationships for all participants through cross-organizational work groups.
Statement of the problem/public health issue
In 2014, only 91% of kindergartners in Multnomah County were up-to-date on the required 2 doses of measles vaccine. While overall in range for measles herd immunity (90-95%), facility-level clustering of the un-immunized nine-percent of children into roughly a third of our jurisdiction’s schools and childcare facilities greatly increased our vulnerability to the spread of measles in these settings. A large number of affected children within such a setting can also increase the risk to the community at large. Multnomah County is far from the only jurisdiction vulnerable in this situation; even jurisdictions with relatively high rates of coverage can still see clustering through like-minded parents enrolling their children certain facilities or schools.
Due to a still-low risk of exposure in the United States (and good luck), measles has not recently found its way into our high-exempting school or daycare settings. A lack of measles cases in Multnomah County school settings since 1999 has left responders with little direct experience of facility-level measles events. Vulnerabilities combined with lack of recent experience with measles outbreaks warranted public health leadership for preparedness planning that would assure a rapid and coordinated response to containing this risk.
Target population is affected by problem
Target population size
The population of Multnomah County is approaching 800,000. Within this population, the total 2014 adjusted school enrollment (adjusted to avoid double-counting children who are enrolled in multiple facilities for child care and school) was 121,224. Children younger than 19 months are not included in this figure. Specific to this planning process, the Kindergarten and childcare facility 2014 adjusted enrollment was 24,460.
The tool kit developed is being shared in the Portland-Metro area (~1.6 million residents). Since developing the tool kit, we have not had a measles case, so the actual population reached is undefined.
What has been done in the past to address the problem
Current response activities
Multnomah County Health Department (MCHD) Communicable Disease Services routinely responds to school-based outbreaks, coordinating with other metro-area local health departments (LHDs) and school health providers. Response to a vaccine-preventable disease exposure in a school setting requires consideration of age group, enrollment number and immunization coverage, as well as unique challenges. Public health access to student health information must account for Family Educational Rights and Privacy Act (FERPA) protections and varied record-keeping systems. Excluding students creates academic challenges and potential financial strain for parents needing to assure childcare. Therefore, during a response, multiple agencies must provide consistent messaging about susceptibility, exclusion requirements, and readmission criteria. School administrators and health providers provide timely access to immunization and health records, serve as trusted sources of information for parents and staff, and provide a healthy environment by enforcing exclusion orders and taking other preventive actions. To this end, LHD’s must work closely with non-public health partners to navigate the unique challenges of school-based disease exposures.
Why the current/proposed practice is better
Building upon current response activities, we sought to develop a plan that would account for the unique characteristics of a school-based measles exposure and ensure rapid, coordinated response. With public health as the ultimate authority on exclusion and re-admittance, there must be a clear line of communication with educational partners to achieve a response fast enough to contain exposure. Engaging partners across the public health/childcare/education spectrum fostered awareness and cooperation throughout the exercise, evaluation, and implementation of corrective action for internal protocol development.
Additional practice changes to address increasing exemption rates and facility-level clustering included establishing a Vaccine Hesitancy Strategic Planning Group to identify barriers to and promote vaccine acceptance. Regional local Health Officers led school-based vaccine education sessions at select, high-exempting schools. Multnomah County Public Information Officers also have worked with Program staff on media releases on increasing exemption rates and the benefits of timely vaccination.
Creative use of existing tool or practice and tools or practices used
Homeland Security Exercise and Evaluation Program (HSEEP) guided a multi-agency exercise and evaluation of coordinated outbreak response activities. The HSEEP doctrine provided a well defined approach to keep community partners engaged, and to develop protocols that would have buy-in from all participants. While HSEEP has traditionally been used by MCHD to guide large-scale public health emergency preparedness, our tailored application proved useful for engaging partners in planning routine public health response. This process ensured unprecedented incorporation of community partners in the development of an internal protocol with continuous evaluation.
Evidence-based of current practice
HSEEP is a national best practice for exercise planning and implementation. Measles vaccination for school-aged children is a well-established recommendation across multiple national and international agencies and organizations. Exclusion of children with measles is outlined in Oregon state statutes and rules.
Goals and objectives of practice
Goal 1: Conduct a stakeholder-engaged process to develop a measles case report response plan Objective 1.1: Identify gaps across multiple agencies and school and daycare facility partners Objective 1.2: Achieve up-front buy-in on response plan from community partners Objective 1.3: Provide a forum for agencies and partners to networkGoal 2: Develop an accessible, easy-to-use toolkit for LHA use in responding to a measles case report or cluster Objective 2.1: Use stakeholder knowledge and experience to develop a realistic and broadly acceptable toolkit for public health agency use within six months Objective 2.2: Use Homeland Security Exercise and Evaluation Program (HSEEP) guidelines to structure a process for developing a plan for routine public health response
What we did to achieve the goals and objectives
Steps taken to implement the program Multnomah County led a tabletop exercise with regional, multi-agency participation. The areas for improvement, defined in the AAR/IP instructed constructive action, including the development of a Quad-County Health Department Measles protocol response toolkit, informed by stakeholder participation.
We implemented our process according to incident command system principals, developing protocol materials and corresponding incident action plans for application in measles outbreaks of any scale and demographic. The related tools may be selectively applied for response to an outbreak at any local school, daycare or child care facility.
The two main objectives presented to tabletop participants included: 1) By the end of the exercise, participants understand the community health implications of a measles case introduced into a school or daycare setting.2) By the end of the exercise, participants understand the roles, responsibilities, and authorities of all parties responding if a measles case is introduced into a school or daycare setting.
We provided education through participant briefings, multimedia presentations and a situation manual. Facilitators reviewed community health implications of measles cases in schools or daycares, and asked participants to identify concerns that might arise during an outbreak. In small, facilitated discussion groups, representatives from participating agencies described their roles and responsibilities at different points throughout a realistic outbreak scenario, sharing conversation highlights with the larger group. The exercise was designed to identify major questions and concerns that might arise among different parties during a real outbreak. Exercise evaluators noted themes for later review in the After Action Conference. Participants completed an evaluative tool, providing exercise feedback and assessment of their own agency’s level of preparedness.
HSEEP designated wrap-up activities, including debriefings and a Player Hot Wash occurred, information from which was captured in an After Action Report/Improvement Plan (AAR/IP). To identify priority corrective actions, a subset of stakeholders grouped AAR/IP findings into categories. Workgroups were assigned to develop protocol content for each category, beginning our corrective action tracking and implementation undertakings. Two coordinators oversaw work group meetings and facilitated the overall process, tracking improvements and corrective action according to the designated timeline. Corrective actions were tracked and assessed by conducting follow-up HSEEP evaluation methods, including a repeat tabletop exercise.
Criteria for who was selected to receive the practice
All government entities with potential leadership roles in a local or regional response were invited. This included representatives of the Oregon Health Authority Immunizations and Acute & Communicable Disease Programs; Health Officers, Communicable Disease Nurses, Epidemiologists, and Administrators from four Portland-Metro area Local Health Authorities (Multnomah, Washington, Clackamas, and Clark Counties); and the Multnomah Education Service District (overseas school nursing program and school immunization law enforcement across multiple school districts). The schools and day cares invited to participate in the exercise and protocol development were identified based on existing relationships and representation for a range of herd immunity levels. The latter was emphasized to encourage varying institutional perspectives.
Timeframe for the practice
The development of the AAR took place over two months (November 2014 to January 2015), during which MCHD leaders compiled exercise notes and solicited additional participant feedback. A planning meeting occurred in February 2015 to designate work groups and brainstorm protocol components according to gaps identified in the AAR. Workgroups were guided by a section leader, and met from January 2015-June 2015. Workgroups reviewed and adapted existing resources to develop protocols and new tools. Approximately halfway through the process, section leaders reported progress to the project sponsor and each other. In addition to these workgroups, MCHD Emergency Preparedness staff developed contingency incident action plans for use in a large event, should the local public health agency go into incident command. The primary workgroup and preparedness outputs were integrated into a public health response toolkit for use by an LHD during an outbreak.
In June 2015, the work groups met for a final review the protocol. This review was structured to use the protocol and toolkit in the context of the initial tabletop scenario, to assess how well the process outputs addressed the gaps initially identified in October 2014. Participants were invited to provide feedback on how well the protocol met the needs of the theoretical scenario, and asked to consider if the protocol was flexible enough for use in both simple and complex outbreaks.
Involvement of other stakeholders and roles
This multi-workgroup structure successfully incorporated conversations with the necessary expertise, allowing for prior agreement on communication, authority, and information sharing that might otherwise delay response during an outbreak.
Subsequent protocol development processes assured that appropriate stakeholders were brought in to develop each component. For example, orders for exclusion and readmission of children falls to local health officers under Oregon statute, so county health officers were involved in this work group. Likewise, health record collection tools were reviewed by school and daycare representatives, who have the clearest access to these records; and communication tools were developed by professional public information officers. Specific concerns including scale and response duration, potential surge capacity need, decisions around activating a formal response organization (e.g. LHD’s Incident Management Team) were discussed by MCHD Communicable Disease Services to enhance existing Standard Operating Procedures.
Corresponding tools were identified or developed for inclusion in the toolkit. Smaller specialized work groups with periodic large-group check-ins allowed for an efficient six month timeline yielding a flexible resource to support regional preparedness and response capacity. To ensure the continuous improvement of the protocol, all tools were modifiable and adjustable to fit the needs of most LHDs. Tools like check lists, conference call agendas, parent letters, and media communication templates included basic components that could be adapted to meet the changing needs of specific scenarios.
Throughout the protocol development process, participants voiced interest in future meetings to encourage ongoing regional collaboration on measles preparedness, in addition to possibly replicating the process for other diseases of particular concern to the school and daycare population. Anecdotally, those involved also reported that the process created a platform for networking and collaboration outside of the traditional public health sector, yielding useful and relevant resources to promote preparedness and future cooperation.
Repeating the tabletop exercise for the final protocol review allowed public health and educational partners to test the newly developed tools against the same outbreak scenario originally used to uncover gaps in our preparedness. In the discussion-based exercise, stakeholders referenced protocol tools to satisfy questions about exclusion duration, surge capacity, organizations’ roles and lines of authority, all identified as areas of improvement in the AAR/IP. This review validated the usefulness of the outbreak response tools in streamlining decision making and satisfied the corrective action requirements identified by our original exercise and evaluation. Still, at this final review, participants were able to contribute suggestions and additions to the draft, proving the usefulness of HSEEP exercises to supporting continuous improvement.
Start-up costs and funding
Estimated costs include the following: Staffing (Fellow): 0.5 FTE x $41,000 x 10 months = $17,082Meeting supplies, including food = $200Printing = $200Total = $17,482
The extent objectives were achieved
The Goals and Objectives were: Goal 1: Conduct a stakeholder-engaged process to develop a measles case report response plan Objective 1.1: Identify gaps across multiple agencies and school and daycare facility partners Objective 1.2: Achieve up-front buy-in on response plan from community partners Objective 1.3: Provide a forum for agencies and partners to networkGoal 2: Develop an accessible, easy-to-use toolkit for LHA use in responding to a measles case report or cluster Objective 2.1: Use stakeholder knowledge and experience to develop a realistic and broadly acceptable toolkit for public health agency use within six months Objective 2.2: Use Homeland Security Exercise and Evaluation Program(HSEEP) guidelines to structure a process for developing a plan for routine public health response
The tabletop exercise successfully set the foundation for our achievement of both Goals 1 and 2, engaging stakeholders in evaluation of outbreak response preparedness and subsequent improvement planning. Exercise evaluation tools specifically solicited player’s opinions on areas of improvement within their agency. HSEEP improvement planning tools, specifically, the AAR/IP informed the Protocol and Toolkit development process, according to the tabletop findings and multi-agency feedback.
The data for this evaluation was primarily qualitative, with an emphasis on evaluation techniques specified in HSEEP. Data was collected by independent observers based on the evaluator handbook developed by tabletop organizers. Secondary data sources used to track vulnerability (i.e., exemption clustering) and identify process participants are based on administrative data collected by schools, childcare providers, and local health authorities through the school immunization law process. This data includes condition-specific exemption information (e.g., measles exemptions as distinct from exemptions for other vaccines).
a. Primary data, performance measures, and analysis
In October 2014, MCHD Communicable Disease Services program invited surrounding LHD’s, the State health department, and educational and childcare partners to participate in a tabletop exercise developed using HSEEP guidelines to assess regional preparedness for measles in schools and childcare facilities. Consistent with HSEEP guidelines, our tabletop included assigned Evaluators. These individuals observed the exercise, and noted their findings, specifically whether players met expected agency-specific outcomes. Evaluators reported on the following categories in the context of the posed outbreak scenario:
1) Participants’ understanding of their roles2) Agency-specific priorities3) Pre-existing plans and guidelines4) Participants ability to identify multiple ways to control spread of measles5) Communications with partners6) Identifiable resources7) Means of assistance8) Vaccine and immunoglobulin supplies9) Improvement capacity
Their findings were incorporated in the Tabletop After Action Report/ Improvement Plan (AAR/IP).
At the end of the exercise, participants understood the implications of a measles case introduced into a school or daycare setting, and agreed on the mitigation steps needed to limit the spread of measles. Gaps identified related primarily to the roles and responsibilities of public health authorities and childcare facility staff through the course of the response, specifically,
“…identifying players/organizations who would be involved; … communicating/ coordinating with other schools, daycares, and public health; updating parent/sibling records; translation; communicating with… and educating parents; and the creation of protocols and plans that provide step-by-step instructions and clear lines of authority… [Also,] the limited capacity for both health departments and schools to manage the data needs was noted as an issue. “ (AAR/IP, p.6)
Using the AAR/IP, stakeholders summarized these areas for improvement into six categories for workgroups to develop protocol content: medical assessment of suspect cases (Medical Assessment), waiting for laboratory confirmation (Waiting Window), exclusion and readmission of un- or under-vaccinated students/staff (Exclusions), ongoing contact management (Contact Management), provision of immunizations or prophylaxis (Prophylaxis), and communications (Communication Plan).
In addition to using the AAR/IP as a key part of the evaluation, Multnomah County, in coordination with Oregon Health Authority’s Immunizations Program, tracks vaccine coverage and exemption data for public health surveillance and documenting adherence to state immunizations law. In addition to vaccine-specific exemption rates, MCHD Communicable Disease Services has conducted data projects to track the increasing clustering of vaccine exemptions among child care facilities and kindergartens.
Modifications made as a result of the data findings
Modifications made as a result of our findings are integrated into the toolkit components developed through the process. LHA response procedure in close coordination with the affected educational partners was the focus of the toolkit, organized according to the timeline of case confirmation. A representative selection of these tools includes the following:
Algorithms for Post-exposure Prophylaxis, Exclusion and Surveillance
Conference Call Agenda Templates (between LHAs, Schools and Health Care Providers)
Information gathering tools for contact tracing
Immunization clinic site maps and staffing suggestions
Press release templates
Letter templates for parents and school staff
Measles talking points for Health Officers
Informational packet for parents of excluded children
Accompanying Incident Action Plan and Delegation of Authority
In addition, MCHD developed a supplementary document outlining of department-specific surge capacity and informal command structure, including thresholds for activation of formal incident command. Because the protocol was written for adaptation by any regional LHA, the document was excluded from the Protocol. However, it is an example of how the toolkit can guide the preparedness efforts of any LHA. No changes were made to the state Investigative Guidelines.
Lessons learned in relation to practice
Within existing Public Health partnerships, we engaged regional counterparts not always at the table. For example, we included Clark County, Washington. While Washington state and Oregon differ in exact Investigatory Guidelines, Clark Counties experience and connections brought additional insights and specific tools into the process.
The tabletop exercise emphasized the interconnectedness of public health and educational agency responses to a measles outbreak, and the opportunity to prepare a toolkit of resources to aid streamline a coordinated response. As these tools would be implemented by the LHA in coordination with the facility, potentially-affected partners were assured a voice.
Lessons learned in relation to partner collaboration
In public health practice, preparedness planning processes can be thoughtfully utilized for future community health needs. LHDs usually lead outbreak responses in individual schools, and this internal protocol was designed to better equip LHD’s to lead an effective response. That said, including multiple stakeholders in collaborative planning projects, from communicable disease to injury prevention and beyond, lays groundwork for broader community acceptance of public health principles and engagement in local public health practice.
This protocol development process helped promote regional consistency in responding to local outbreaks of measles, and possibly other diseases, in schools and daycares. Inclusion of school and daycare representatives ensured the protocol realistically outlined their involvement in a potential outbreak. These conversations also helped prepare our educational partners for what to expect should an outbreak occur in one of their facilities. Finally, the ongoing dialogue across agencies helped improve existing and establish new working relationships.
We found that HSEEP provided a strong foundation for including community partners in planning for standard public health response. This approach should be considered by other jurisdictions facing concerns around rising vaccine exemption rates and school and daycare outbreaks.
Inclusion of a cost/benefit analysis?
Description of sustainability plan
The toolkit will remain available for use. As much as possible, we made role-specific references specific to positions rather than people, to reduce the need for updating contact information. While the toolkit itself will be used by public health agencies, we are partnering with our County school districts to inform school administrators of the existence of the plan. MCHD composed a high-level description of the Protocol for distribution to educational partners. This letter informs administrators of the availability of:
Measles clinical assessment tools for health care providers
Public health tracking tools to assure consistent, high-quality monitoring of exposed persons
Guidelines for exclusion and readmission of unvaccinated persons at a school or childcare facility
Details for administering preventive measures, like vaccines, when appropriate
Communication tools including letters to parents; key messages for stakeholders; and a measles informational brochure
We are planning to use the process itself for an up-coming round of Pertussis outbreak planning for the same settings.