Case Study: Possible Measles Outbreak

PARTICIPANT VERSION

Objectives
 List three (3) strategies for active case finding
 Describe outbreak control measures
 Prepare a statement for media during an outbreak situation
 Identify critical components of an outbreak investigation report

Instructions
Read each update aloud and, as a team, discuss the questions that follow.

Time Allotted: 1.5 hours

Background Material
The following trainings, found at the North Carolina Center for Public Health
Preparedness Training Web Site (http://nccphp.sph.unc.edu/training/), are recommended
for Epi Team members without prior outbreak investigation experience. They can be
viewed prior to completing the case study.

1. Embarking on an Outbreak Investigation (FOCUS on Field Epidemiology

Volume 1, Issue 3)
2. Writing an Outbreak Report (I is for Investigation Session VI)
3. Risk and Crisis Communication (I is for Investigation Session VII)

Resources
CDC. Prevention of Specific Infectious Diseases: Measles. In CDC Health Information
for International Travel 2008. Available at http://wwwn.cdc.gov/travel/yellowBookCh4-
Measles.aspx. Accessed on September 10, 2007.

WHO. Measles Fact Sheet. 2007. Available at

http://www.who.int/mediacentre/factsheets/fs286/en/. Accessed on September 10, 2007.
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Index case returns

with rash

Index case
visits hospital Patient diagnosed with possible
measles. Case reported to health
department

Background
It is Tuesday, January 23rd and you are an employee at a local health department. You
are notified by the infection control nurse at the local community hospital that a
patient at the hospital has been diagnosed with “possible measles.” The nurse tells you
that the patient is a 23 year-old female from India. She first came to the hospital
emergency room on January 20th with gastrointestinal symptoms and fever and
returned to the hospital the next day with a rash which started on her face and
progressed to cover most of her body. She was admitted that evening, and is still
hospitalized.

Question 1: What questions do you have for the nurse?

Question 2: Would you recommend that any laboratory tests be conducted at this point?
If so, describe the test and the type of specimen that should be taken.
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Index case Symptom onset Index case returns

arrives in US for index case with rash

Welcome Index case

party visits hospital Patient diagnosed with possible
measles. Case reported to health
department

Update 1
You recommend the patient be tested for measles antibodies (IgM and IgG) and that a
blood sample be taken immediately to the NC State Laboratory of Public Health to
conduct the tests. You also recommend starting appropriate isolation precautions
(placing the patient in an airborne infection isolation room, equipping healthcare
personnel with appropriate personal protective equipment, etc.) if these are not already
in place. Because measles is highly contagious, you should proceed as if she does have
the disease, even though confirmatory laboratory results are not yet available.

The infection control practitioner tells you more about the patient, Pina, who recently
moved with her husband and infant daughter to the United States from India. She
arrived in North Carolina on January 15th, and attended a welcome party on January
16th. Since the party, she has stayed at home with her 5 month old infant while her
husband looks for work. Her fever began on January 17th.

Question 3: Given the timeline of events, do you believe Pina contracted the disease in
North Carolina or in India?

Question 4: Is it possible that Pina exposed others to measles? Consider the incubation
period of measles, and the date of onset of her symptoms.

3
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Index case Symptom onset Index case returns Lab confirms

arrives in US for index case with rash measles

Welcome Index case

party visits hospital Patient diagnosed with possible
measles. Case reported to health
department

Update 2: January 25th

You receive the results from the NC State Laboratory of Public Health. The patient
tested positive for both IgG and IgM antibodies, confirming that she does have
measles.

Question 5: Would you activate your Epi Team at this point? Why or why not? If so,
which members of your Epi Team would be involved in this investigation?

Question 6: What public health agencies would you contact now?

Question 7: You realize that Pina’s 5 month-old infant is at risk for contracting the
disease, since the Measles, Mumps, and Rubella (MMR) vaccine is not usually given
until 12 months of age. Should you provide the MMR vaccine to the infant?

4
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Index case Symptom onset Index case returns Lab confirms

arrives in US for index case with rash measles

Welcome Index case

party visits hospital Patient diagnosed with possible
measles. Case reported to health
department

Update 3: January 26th

You call a meeting of your Epi Team, and identify the tasks that must be accomplished
immediately. First, you decide to conduct active case finding to locate other
potentially sick people in the community. You learn from the patient’s husband that
there were about 45 people present at the welcome party on January 16th.

Question 8: What methods could you use to find additional cases?

Question 9: What information should you collect when speaking with asymptomatic
exposed individuals?

5
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Index case Symptom onset Index case returns Lab confirms

arrives in US for index case with rash measles Media contacts
health department
Welcome party Index case
visits hospital Patient diagnosed with possible
measles. Case reported to health
department

Update 4: January 26th

While you and your team are busy tracking down exposed individuals, a reporter from
the local newspaper calls you and asks for a statement about the measles case. News
about the case has spread, and people in the community are beginning to panic. At this
point, there is only one sick individual, but potentially dozens of people who have
been exposed to the disease.

Group Activity
Draft a message to share with the public based on what you know so far about the
measles case and the potential for a larger outbreak. Keep in mind that you want the
media to help you locate potential case-patients and provide information about the
outbreak to the public in a way that does not cause alarm or fear.

Question 10: What other media communication might be appropriate?

6
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Index case Symptom onset Index case returns Lab confirms

arrives in US for index case with rash measles Media contacts
health department
Welcome party Index case
visits hospital Patient diagnosed with possible Epi team conducts
measles. Case reported to health interviews and provides
department vaccinations

Update 5: January 27th

Your Epi Team has been busy conducting interviews with the people who were in the
hospital emergency room, and the 45 individuals present at the welcome party,
including the patient’s husband and child. None of the people you have contacted so
far are currently displaying symptoms.

Question 11: Should you offer Measles, Mumps, and Rubella (MMR) vaccine to exposed
people?

Question 12: If you choose to offer MMR vaccine, describe how vaccine should be
delivered. For example, will you hold a mass vaccination clinic? Do you have enough
vaccine available at your health department, or will you need to order additional doses?

Question 13: What kind of protection do you need to provide for your team members
who are interviewing potentially exposed individuals? What about the community
hospital staff who vaccinate potentially exposed individuals?
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Index case Symptom onset Index case returns Lab confirms

arrives in US for index case with rash measles Media contacts
health department
Welcome party Index case
visits hospital Patient diagnosed with possible Epi team conducts
measles. Case reported to health interviews and provides
department vaccinations

Update 6: February 2nd

On January 28th, Pina’s 5 month-old daughter began exhibiting symptoms of measles,
including a cough, fever and rash. The child was treated with Vitamin A supplements
and kept in airborne isolation until yesterday. You followed up with the child’s
contacts, but no other cases have been detected. Pina, the original patient, has
recovered without any major complications.

Together with the hospital and members of your regional surveillance team, your Epi
Team contacted 305 potentially exposed persons, and administered 165 MMR
vaccinations.

Question 14: Since the outbreak appears to be under control, your health director suggests
that the Epi Team write an outbreak report. What are some reasons for writing an
outbreak report?

Activity
In small groups, draft an outline of an outbreak report listing all of the topics that should
be included. Make sure to note the intended audience – your group should decide whether
the outbreak report will be shared with 1) colleagues and superiors within your local
health department, 2) other partners in the community, including the hospital, 3) the state
health department, state laboratory, and public health regional surveillance team, and
CDC, 4) the general public, and/or 5) other groups.
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Index case Symptom onset Index case returns Lab confirms

arrives in US for index case with rash measles Media contacts
health department
Welcome party Index case
visits hospital Patient diagnosed with possible Epi team conducts
measles. Case reported to health interviews and provides
department vaccinations

Conclusion: February 8th

In all, there were only 2 cases of measles associated with this outbreak: Pina, the
index case, and her 5-month old infant daughter. Both recovered without
complications. Now your Epi Team is meeting to discuss the outbreak investigation.

Group Brainstorm
Choose one member of the epi team to record responses on a flip chart. As a group,
discuss one or more of the following questions.

 What aspects of the investigation were successful?

 All outbreaks present unique challenges. What characteristics of this outbreak made it
challenging?

 What areas of the investigation could have been improved?

 If a similar outbreak occurred in your county, do you think that your epi team would
be prepared to handle it?

 Did your Epi Team communicate effectively with a) the general public/media, b)
hospital, c) state health department, and d) CDC?