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Analysis of a Communicable Disease Outbreak
Analysis of a Communicable Disease Outbreak
The Middle East Respiratory Syndrome coronavirus (MERS-CoV) is a viral communicable illness of the respiratory system discovered in 2012 and caused by a new beta strain of coronavirus associated with animals (CDC, 2015). To date, 23 countries have reported cases of MERS-CoV, majority of which are in the Middle East and Europe. The first outbreak began in Jordan in 2012 and then more extensively in Saudi Arabia in the same year having since then been exported to other Middle East countries as well as Europe, Africa, Asia, and the U.S. (WHO, 2015). Imported cases in the UK were confirmed in February 2013 and similar cases in the U.S. in May 2014 (CDC, 2015). A specific outbreak with laboratory confirmation of human MERS-CoV infection occurred in a health care facility in Al-Ahsa, Eastern Saudi Arabia in May 2013. It affected 22 patients aged 24 to 94 years over the course of one week. The patients manifested with severe acute respiratory infection (SARI) resulting in 9 patients and further morbidity and increased hospital stays in the survivors (WHO, 2013).
The primary route of transmission of MERS-CoV among humans is believed to be close contact. Many of the case reports prior to the Al-Ahsa hospital outbreak were clusters involving members of the same family (WHO, 2013). Sustained transmission in the community such as that observed in airborne viruses has not occurred in Saudi Arabia and other affected countries further supporting close physical contact as the major route of transmission.
Caring for patients in the hospital setting requires the same degree of close contact as caring for a sick family member which explains the spread of the virus among unrelated patients. The virus has been isolated in saliva and sputum and primarily affects the lower airways making the respiratory tract the probable portal of entry and exit (WHO, 2015). As nursing and medical staff render close contact care to both infected and uninfected patients, there is a high likelihood that they, via contaminated hands and equipment, facilitated the nosocomial spread of the agent from infected patients as human reservoirs to susceptible hosts in the facility.
Infection control systems in the hospital constitute part of the environment which influences disease transmission. With poor infection control, nurses may have bridged the portals of exit and entry in the course of providing care. In addition, while none of the Al-Ahsa hospital staff manifested with symptomatic MERS-CoV and none were also tested for carrier status, health care workers accounted for 14% of all positive cases globally (WHO, 2015). Thus, it is also possible that some of the staff were human reservoirs transmitting the virus to patients directly.
The primary risk factor is close contact with an infected person either as a family member or health care provider (WHO, 2015). Based on a review of the case descriptions in the WHO website since the discovery of the strain in 2012, other possible risk factors include age, especially the very young and the very old, and having an underlying severe illness. Of the patients in the Al-Ahsa outbreak, majority were aged 44 or older. Of the ten patients who died in the outbreak, most were older adults with coexisting critical illnesses or were immunocompromised (WHO, 2013).
Contact with farm animals, especially camels, and recent travel to Saudi Arabia and other countries in the Arabian Peninsula are also risk factors (WHO, 2015). Camels are bred for meat and milk in the region, but these animals appear to be reservoirs of MERS-CoV. A sample of camels in Oman were tested and found positive for the virus which makes zoonotic transmission very likely (European Union, 2015). The consumption of camel meat and raw camel milk constitutes a cultural determinant that supports transmission. Specifically in the Al-Ahsa outbreak, one of the patients was admitted because of SARI and was a farm worker who had contact with camels (WHO, 2013).
Effect of an Outbreak in Greer, South Carolina
An outbreak in the City of Greer will affect the functioning of schools, hospitals, businesses, and local government at a systems level. The suspension of classes as a result of infection among students will cause extensions in the school calendar to enable schools to cover all the content in the curriculum for each level and fulfill the mandated number of school days. Until all content is covered in make-up classes, there will be no promotion of students. Depending on the duration, the disruption in the normal schedule of classes will also affect the schedules of teacher trainings, curriculum evaluations, school improvement projects, and other activities.
Similarly, the suspension of work because of infected employees negatively affects industries in the city. Suspensions are necessary to reduce the risk of close contact transmission especially in high-risk environments, but a skeletal workforce in the service sector such as recreation facilities and transportation, will only serve to keep operations at the bare minimum. The effect is a reduction of services in the city. In assembly-line industries where one task relies on the completion of other tasks, businesses will not be able to meet daily production quotas for their products with the absence of many employees. Reduced production will also be true of food services, tourism, retail, and other industries. The net effect is a standstill in the local economy.
Moreover, the normal functions of the different departments of the city government will be disrupted with employee sick leaves resulting from a MERS-CoV outbreak. There will be fewer police officers and fire fighting personnel available to respond to citizens’ requests for assistance. The issuing of permits, processing of documents, and other administrative duties at city hall will slow down as well. Public works repairs and other projects may be delayed. Garbage collection may not proceed as scheduled with not enough staff to cover the number of shifts as well. Public health programs may also be limited in its scope operations. Thus, the outbreak affects the delivery of government services that ensure the community’s health, safety, and sanitation.
Health care utilization will be expected to rise with a major MERS-CoV outbreak in the City of Greer. While the Greenville Health System can accommodate the community’s health care demands at current capacity, the workload of medical and nursing staff will increase with the influx of infected individuals and families, possibly including health care employees, and with the addition of procedures such as stricter infection control in the workflow. Staffing shortages will result in a rise in the ratio between health care worker and patient. Moreover, isolation rooms need to be designated in the medical-surgical units and ICUs. Equipment and supplies for laboratory analyses, diagnostic procedures, and infection control will need to be procured. Hence, a MERS-CoV outbreak will cause a strain on the community’s health system.
During a disease outbreak, the Greer City Public Health and Sanitation protocol is for the incident to be reported by telephone immediately to the local health officer by any health care provider (OEM, 2013). However, facility-level protocols often identify the infection control committee as the body tasked with monitoring suspected, probable, and confirmed cases and reporting such cases in a timely manner. A formal Confidential Morbidity Report must be submitted to the Public Health and Sanitation Department within 24 hours following laboratory confirmation of an infection to facilitate surveillance, control, and prevention.
The protocol emphasizes confidentiality in that the information communicated to the local health officer must be devoid of identifying information (OEM, 2013) such as the patient’s name and birthdate to protect the patient in accordance with the HIPAA. The report includes the onset and diagnosis of the infection, patient’s possible risk factors, clinical status, and treatment which are important in subsequent epidemiological investigations. The Public Health and Sanitation Department reports the outbreak to the Greenville County Health Department which will, in turn, report it to the South Carolina Department of Health and Environmental Control (OEM, 2013) and the CDC via the National Outbreak Reporting System (NOPS) (CDC, 2015).
Plan for Reporting the Outbreak to Key Stakeholders
The key stakeholders in the community include the residents, health care workers, businesses, and schools. The content of the report will include what MERS-CoV is, the signs and symptoms, the mode of transmission, the number and characteristics of affected individuals, interventions being done to limit transmission, and resources needed (OEM, 2013). At the same time, it should detail what stakeholders can do to assist in managing the outbreak. Mass media will be employed as a reporting strategy in order to reach the most number of stakeholders. A more technical report than that intended for the public will be relayed to health care professionals who require this level of information for clinical and managerial decision-making (Bahk et al., 2015).
Strategies for Prevention
Effective prevention relies on giving the right information to as many people as possible and engaging patients and the public in prevention (Catalan-Matamoros, 2011). As much, multiple forms of media will be used. Leaflets about MERS-CoV with emphasis on prevention will be made available in health care settings for dissemination to patients. Posters will also be produced and placed in conspicuous areas for patients, families, or visitors. The community education strategy will employ mass media – local television and radio – as well as the City of Greer, Department of Health, and the Greer Today websites in disseminating information. Posters will be distributed to schools, businesses, and local government offices to build wider awareness as well.
Bahk, C.Y., Scales, D.A., Mekaru, S.R., Brownstein, J.S., & Freifield, C.C. (2015). Comparing timeliness, content, and disease severity of formal and informal sources of outbreak reporting. BMC Infectious Diseases, 15, 1-6. doi:10.1186/s12879-015- 0885-0.
Catalan-Matamoros, D. (2011). The role of mass media communication in public health. In K. Smigorski (Ed.), Health Management: Different approaches and solutions, pp. 399-414. Rijeka, Croatia: In Tech Europe.
Centers for Disease Control and Prevention (2015). Middle East Respiratory Syndrome (MERS). Retrieved from http://www.cdc.gov/coronavirus/MERS/about/index.html
Centers for Disease Control and Prevention (2015). The National Outbreak Reporting System (NORS). Retrieved from http://www.cdc.gov/nors/
European Union (2015). Updated rapid risk assessment on MERS-CoV – ECDC. Retrieved from https://www.ecdc.europa.eu/en//MERS-CoV-novel-coronavirus-risk- assessment.pdf
Office of Emergency Management (2013). Greenville Country Emergency Operations Plan. Retrieved from http://www.gceoc.com/gc-emergency-operations.php
World Health Organization (2013). Global Alert and Response (GAR). Retrieved from http://www.who.int/csr/don/archive/year/2013/en/
World Health Organization (2013). Middle East respiratory syndrome coronavirus Joint Kingdom of Saudi Arabia/WHO mission. Retrieved from http://www.who.int/csr/disease/coronavirus_infections/MERSCov_WHO_KSA_Miss ion_Jun13u.pdf?ua=1
World Health Organization (2015). Global Alert and Response (GAR): Coronavirus infections disease outbreak news. Retrieved from http://www.who.int/csr/don/archive/disease/coronavirus_infections/en/
World Health Organization (2015). Middle East respiratory syndrome coronavirus (MERS- CoV): Summary of current situation, literature update and risk assessment – as of 5 February 2015. Retrieved from http://www.who.int/csr/disease/coronavirus_infections/mers-5-february- 2015.pdf?ua=1
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