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Outbreak Management

  • Ravi Jhaveri
    Correspondence
    Address correspondence to: Ravi Jhaveri MD, Division of Infectious Diseases, Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, CB 7509, 101 Manning Dr, Chapel Hill, NC 27599-7509.
    Affiliations
    Division of Infectious Diseases, Department of Pediatrics University of North Carolina at Chapel Hill School of Medicine Chapel Hill, NC
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      The Year of the Outbreak is among many apt descriptions of 2015 because several major outbreaks of infectious diseases dominated the news for much of the year. A standout was Ebola virus disease (EVD) in West Africa.
      • Bah E.I.
      • Lamah M.C.
      • Fletcher T.
      • et al.
      Clinical presentation of patients with Ebola virus disease in Conakry, Guinea.
      • Schieffelin J.S.
      • Shaffer J.G.
      • Goba A.
      • et al.
      Clinical illness and outcomes in patients with Ebola in Sierra Leone.
      In addition to the tremendous burden of local morbidity and mortality, fear and panic concerning disease importation spread throughout the world. Later in the year, focus in the United States shifted to the outbreak of a respiratory illness causing an increase in intensive care admissions among children with a history of asthma.
      • Midgley C.M.
      • Jackson M.A.
      • Selvarangan R.
      • et al.
      Severe respiratory illness associated with enterovirus D68 - Missouri and Illinois, 2014.
      Eventually the cause of the respiratory infection was identified as enterovirus D68 (EV-D68). Finally, the end of the year brought news that an antigenically drifted isolate of H3N2 influenza virus was the dominant strain circulating that season.
      • D’Mello T.
      • Brammer L.
      • Blanton L.
      • et al.
      Update: Influenza activity--United States, September 28, 2014-February 21, 2015.
      As a result, the available influenza vaccine was not likely to offer much protection.
      • Flannery B.
      • Clippard J.
      • Zimmerman R.K.
      • et al.
      Early estimates of seasonal influenza vaccine effectiveness - United States, January 2015.
      Although these outbreaks appear to have very little in common at first glance, all required recognition of events that fell outside the expected norms for a season or region. Furthermore, they all required dedicated health care personnel to provide care—often in circumstances in which very little detail of the etiologic agent was known. Finally, they required rigorous collection of data to deal with the outbreak and to prepare for subsequent ones. With these themes in mind, we have organized this supplement to Clinical Therapeutics to offer insight into managing an infectious disease outbreak.
      In the first article, Schuster and Newland discuss their primary experience in managing the EV-D68 outbreak at 1 of the sentinel sites.
      • Schuster J.E.
      • Newland J.G.
      Management of the 2014 Enterovirus 68 Outbreak at a Pediatric Tertiary Care Center.
      The authors summarize their experience thusly:
      • Outbreak identification and management requires a coordinated effort among multiple teams to provide optimal patient care and ensure public safety. The 2014 EV-D68 outbreak was an example of swift recognition of a severe disease, rapid identification of the pathogen, coordination of local and national organizations, and dissemination of information internationally.
      They use specific examples from this past year to illustrate many of the common steps in dealing with any new outbreak: recognition, building a case definition, instituting infection control procedures, managing diagnostic and treatment algorithms, and educating the public. They offer tangible steps for anyone to begin to deal with an outbreak.
      In the article by Fischer, Weber, and Wohl a major aspect of dealing with the EVD outbreak is discussed. The use of personal-protective equipment (PPE) by health care providers was a major factor in aiding to reduce the spread of EVD in health care settings.
      • Fischer II W.A.
      • Weber D.
      • Wohl D.A.
      Personal Protective Equipment - Protecting Healthcare Providers in an Ebola Outbreak.
      In the United States, the improper use of PPE was the likely cause of transmission to health care providers in Dallas, Texas. Dr. Fischer offers this perspective:
      • The current EVD epidemic has been unprecedented not only because the numbers of infections and deaths have eclipsed that of all prior outbreaks combined, but also because of the health care workers infected. Although PPE plays a critical role in mitigating the risk of exposure to virus-laden body fluids during care of an infected patient, it is 1 step in a comprehensive approach that must be taken to protect health care providers. It is critical that we continue to improve both PPE and the process of donning and doffing so that health care providers can provide the critical supportive care that has been shown to decrease mortality in this epidemic.
      Although the article focuses on EVD and PPE, the larger lessons are relevant to any outbreak.
      For many people, the EVD outbreak seemed a world away, and even the EV-D68 activity described largely in the Midwest seemed removed from local experience. However outbreaks occur everywhere in varying sizes and degrees of severity. The lessons discussed in this supplement offer readers the tools to help manage an outbreak when it happens.

      References

        • Bah E.I.
        • Lamah M.C.
        • Fletcher T.
        • et al.
        Clinical presentation of patients with Ebola virus disease in Conakry, Guinea.
        N Engl J Med. 2015; 372: 40-47
        • Schieffelin J.S.
        • Shaffer J.G.
        • Goba A.
        • et al.
        Clinical illness and outcomes in patients with Ebola in Sierra Leone.
        N Engl J Med. 2014; 371: 2092-2100
        • Midgley C.M.
        • Jackson M.A.
        • Selvarangan R.
        • et al.
        Severe respiratory illness associated with enterovirus D68 - Missouri and Illinois, 2014.
        MMWR Morb Mortal Wkly Rep. 2014; 63: 798-799
        • D’Mello T.
        • Brammer L.
        • Blanton L.
        • et al.
        Update: Influenza activity--United States, September 28, 2014-February 21, 2015.
        MMWR Morb Mortal Wkly Rep. 2015; 64: 206-212
        • Flannery B.
        • Clippard J.
        • Zimmerman R.K.
        • et al.
        Early estimates of seasonal influenza vaccine effectiveness - United States, January 2015.
        MMWR Morb Mortal Wkly Rep. 2015; 64: 10-15
        • Schuster J.E.
        • Newland J.G.
        Management of the 2014 Enterovirus 68 Outbreak at a Pediatric Tertiary Care Center.
        Clin Ther. 2015; 37: 2410-2417
        • Fischer II W.A.
        • Weber D.
        • Wohl D.A.
        Personal Protective Equipment - Protecting Healthcare Providers in an Ebola Outbreak.
        Clin Ther. 2015; 37: 2401-2409

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