Long Beach Department of Health and Human Services
Epi Academy: Building an Outbreak Response Surge Team with Limited Resources
Demographics: The Long Beach Department of Health and Human Services (LBDHHS) is one of only three city-run health departments in California, which allows for better engagement with its almost half a million residents. Having a city-run health department also allows LBDHHS to coordinate resources from all sources to best meet the needs of one of the most diverse cities in the United States. With 300 employees located in nine sites throughout the city, LBDHHS operates with a $117 million annual budget, 99% of which comes from Federal, State, County and private funds.
Public health issue: Within LBDHHS, there is limited capacity for epidemiology and outbreak response. Three full time epidemiologists make up the Epidemiology Program, and an additional epidemiologist is housed in the Public Health Emergency Management Program. While this is sufficient to respond to regularly reported communicable diseases on a weekly basis, staffing quickly becomes insufficient when an outbreak occurs. A Public Health Epidemiological Response Team (PHERT) had previously been established within LBDHHS, comprised of various staff throughout the Department, but by December 2016 most members were no longer working at LBDHHS, and there had not been a new training or meeting in years. An Epi Academyâ€ was proposed in January 2017, after the Emerging Infectious Disease Response Coordinator, who oversees Zika prevention and response for the City, determined that in order to adequately prepare for and respond to local transmission of Zika in Long Beach, there needed to be trained surge staff, and possibly additional community volunteers, to be trained and ready to respond at any given moment.
Goals and objectives: (1) Recruit at least twenty individuals who are able and willing to join the Public Health Epidemiology Response Team (PHERT); (2) Train PHERT members on the basics of epidemiology, communicable diseases, and outbreak investigations; (3) Evaluate PHERT members' knowledge of epidemiology before and after attending Epi Academy; (4) Deploy PHERT throughout the year as needed for various public health emergency response activities.
Implementation: Health Department staff from all programs were recruited by sending out Department-wide emails. Long Beach Medical Reserve Corps (MRC) volunteers were also notified and allowed the option to enroll. A total of 37 individuals (31 staff and 6 from MRC) enrolled in the Academy. Courses were held quarterly, for three hours each. Participants were allowed one absence, and in those cases they were required to obtain the PowerPoint slides and notes from the class they had missed. The final Epi Academy class consisted of a simulated outbreak investigation, in which the class was tasked with solving a foodborne outbreak using the tools they had learned throughout the year. The outbreak investigation was followed by a graduation ceremony on the final day.
Results (including which objectives and which factors): The objectives of Epi Academy were all met due to several factors. Enrollment in Epi Academy was open to both LBDHHS staff and MRC volunteers, which increased the pool of people interested, and also allowed for people of diverse backgrounds to join. In terms of staff who enrolled, it was required that their supervisor signed off on their participation. Have the managers and supervisors support their employees' participation for three hours each quarter was vital. Because of the looming threat of local transmission of Zika in Southern California last year, supervisors understood the necessity for such a surge team, and it was made clear to them that the outcomes of having these trained individuals would not only benefit the Health Department, but the City of Long Beach as a whole.
Public Health impact: The public health impact of Epi Academy and having a trained Public Health Epidemiology Response Team ready to respond to communicable disease outbreaks is wide-reaching, and benefits the entire City of Long Beach, as the Health Department will be able to respond to communicable disease-related threats to the public in a more timely and efficient manner. Since Epi Academy began in February of 2017, PHERT members have already been called upon on several occasions to deploy to certain outbreak prevention and response efforts.
Health Department Website: www.longbeach.gov/health
Public health issue: Epi Academy was developed to build upon the currently insufficient number of trained staff at the Long Beach Department of Health and Human Services (LBDHHS) who are able to respond to large-scale communicable disease outbreaks or potential local transmission of Zika in the City of Long Beach.
Target population (size/percentage): With a population of 470,130, Long Beach is one of the most diverse cities in the nation. LBDHHS responds to almost two thousand cases of communicable diseases each year, and dozens of outbreaks. With a staff of only three employees assigned to the Epidemiology Program, the level of work needed to control a communicable disease outbreak (including phone calls to patients, notifying providers, data entry and analysis) can quickly exceed their capacity. Without a strong surge team who is ready and able to assist when the Epidemiology Program becomes overwhelmed, the outbreaks become more difficult and take longer to control, meaning they are more likely to continue to spread throughout the City and affect more people. Epi Academy has the capacity to affect not only the almost half a million residents, but also those who work, visit, and spend time in Long Beach.
Past methods of addressing problem: A Public Health Epidemiology Response Team (PHERT) comprised of LBDHHS staff had been assembled years prior, but trainings were infrequent and repetitive (one hour introduction to epidemiology every couple of years). Many of the past PHERT members no longer worked at LBDHHS or were no longer interested in participating, and most importantly, most were not trained adequately to respond to a communicable disease outbreak. Finally, PHERT members in the past have always exclusively been recruited from within LBDHHS. Recruitment from Medical Reserve Corps (MRC) had never been done up until this point.
Why is the current/proposed practice better? Creating an Epi Academy and recruiting PHERT members from both the LBDHHS and MRC is a vast improvement compared to past practices for several reasons. First, there has been a great deal of turnover at LBDHHS due to budget changes and new positions being created, thus there are new employees that may be interested in being part of PHERT that would not have otherwise been identified. Second, enrolling in PHERT and having students commit to attend an entire year of classes ensures that those who do sign up to be part of PHERT are committed to the time it takes to undergo training. Third, having interactive and dynamic classroom time every quarter allows PHERT members and the instructor to develop rapport and determine which subjects or capabilities students may excel at or have more interest, so that in an emergency or outbreak situation, they can be assigned roles in which they will excel. Finally, recruiting PHERT members by enrolling them in Epi Academy is more useful than past practices because throughout the year, as new communicable disease outbreaks occur throughout the nation, or more specifically Southern California, the instructor can give PHERT members background knowledge on the disease in question and the interventions needed to prevent the disease, since the Epi Academy classes are held quarterly. In that case if something of interest, such as Zika, does come to Long Beach, LBDHHS can respond more quickly without having to first educate the surge team on the specifics of the disease.
The development of Epi Academy was a creative use of existing tool or practice. The tool used to create practice: The course was taught by the Emerging Infectious Disease Response Coordinator, an epidemiologist with over ten years of experience in both public health and clinical settings, in both national and international settings. The structure of Epi Academy was loosely based on key concepts referenced from the Center for Disease Control and Prevention's (CDC) Principles of Epidemiology in Public Health Practice: An Introduction to Applied Epidemiology and Biostatistics. This CDC course covers basic epidemiology concepts and is designed specifically for local, state and federal government health professionals responsible for disease surveillance and investigation. The book was used to structure the course, and the course instructor added local outbreak investigation case studies, videos, history, and currently occurring communicable diseases for context.
Is the current practice evidence-based? The development of Epi Academy was unique and therefore not previously published, however the material used to teach the course was published by some of the leading public health epidemiologists in the field.
Reference: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Office of Workforce and Career Development, Career Development Division. (May 2012). Principles of Epidemiology in Public Health Practice: An Introduction to Applied Epidemiology and Biostatistics. Atlanta, GA: U.S. Department of Health and Human Services.
Goals and objectives of practice: The objectives of Epi Academy were four-fold: (1) Recruit at least twenty individuals who are able and willing to join the Public Health Epidemiology Response Team (PHERT); (2) Train PHERT members on the basics of epidemiology, communicable diseases, and outbreak investigations; (3) Evaluate PHERT members' knowledge of epidemiology before and after attending Epi Academy; (4) Deploy PHERT throughout the year as needed for various public health emergency response activities.
How we achieved these objectives and steps taken to implement program:
Objective 1: The objective when creating Epi Academy was to have at least twenty attendees. To recruit LBDHHS staff members, an FAQ for supervisors was created which explained Epi Academy, enrollment in PHERT, and an estimated number of hours it would require for those who enroll. This FAQ was sent to the 12 program managers at LBDHHS, who were then asked to pass the information on their supervisors and staff of their respective programs. Once staff members expressed interest, they completed an enrollment form to capture demographic data and a basic skills assessment, including foreign language ability, Microsoft Office expertise, etc. This enrollment form required their supervisor's signature. To recruit Medical Reserve Corps (MRC) staff, an email with the Epi Academy FAQ was sent to all members signed up in the Long Beach area. The goal of twenty attendees was far exceeded, as 31 staff members and six MRC signed up to attend, for a total of 37 attendees. The group was very diverse and came from a wide variety of backgrounds, education levels, and interests. Participants included retired surgeons, social workers, immunization nurses, and even included the City Health Officer.
Objective 2: The second objective was to train Epi Academy attendees on epidemiology, communicable diseases, and outbreak investigations so they can be active and trained members of PHERT. This was achieved by holding four class sessions; one each quarter. Classes consisted of PowerPoint lecture, videos, hands-on exercises, and group work. The first class included epidemiological concepts, history of communicable disease investigations, and an in-depth review of an actual foodborne outbreak investigation that occurred in Long Beach fairly recently. The second class introduced communicable diseases, including transmission, types of communicable diseases, immunity and vaccines, and different types of outbreaks. The third class focused on data, surveillance and walking through the steps of conducting an outbreak investigation. Finally, the fourth class involved a simulated foodborne outbreak. Prior to the class, all of the attendees received an email to report to the LBDHHS Department Operations Center (DOC). When they arrived, they were briefed on a scenario and worked with groups to systematically investigate the outbreak. At the end of the final class, there was a graduation ceremony in which they received their certificates and were officially inductedâ€ into PHERT.
Objective 3: The third objective was to measure whether Epi Academy was successful at increasing attendees' knowledge of communicable diseases and outbreak response. This was accomplished by administering a self-evaluation two times; before Epi Academy began and after completion. Epi Academy attendees were asked to evaluate themselves on twelve basic epidemiological and communicable disease concepts: the communicable disease transmission cycle, incubation period, epi curve, rate ratio and attack rates, types of outbreaks, chain of transmission, zoonotic diseases, modes of transmission, bioterrorism agents, vaccine preventable diseases, and patient interviews. These twelve concepts were based on the main concepts outlined in the CDC's Principles of Epidemiology in Public Health Practice: An Introduction to Applied Epidemiology and Biostatistics as well as concepts important to the control of Zika and other foodborne outbreaks in which PHERT members were most likely to be utilized in our particular health jurisdiction. The results of the self-assessments showed that Epi Academy attendees gained knowledge in all twelve of the concepts presented. A more detailed explanation of the analysis can be found in the Evaluation section.
Objective 4: The fourth and final objective was to utilize the new PHERT members throughout the year as needed, to deploy to various response activities. This objective was vital, as not only did it allow PHERT members to learn by working out in the field in real-world situations, but it also helped the Epidemiology and Public Health Emergency Programs respond more quickly to public health emergencies by utilizing the new PHERT members, rather than wait an entire year for them to complete Epi Academy. PHERT members were activated and deployed more times than originally predicted. While there turned out to be no local transmission of Zika in Southern California in the summer of 2017, Long Beach discovered Aedes aegypti, the mosquito that can transmit Zika, for the first time in the City in July 2017. Because of this, a great deal of public outreach was needed, including answering hotline calls and going door-to-door in neighborhoods where the mosquitoes had been found. By the end of 2017, PHERT had been activated over six times for events including: local discovery of Aedes aegypti, a three-day Zika CASPER (Community Assessment for Public Health Emergency Response), education around Chrome 6 â€“ an airborne contaminant found in high levels in parts of Long Beach, and finally hepatitis A vaccination clinics for high-risk individuals over a period of several months. Because these activations varied substantially in terms of public health need and response, PHERT members were exposed to various activities involved in communicable disease response. These experiences allowed the new PHERT members to become better equipped and trained to deal with future public health response efforts.
Criteria for those selected: Enrollment in Epi Academy was open to all LBDHHS employees who had their supervisor's permission, and all registered members of the Long Beach Medical Reserve Corps (MRC). All interested applicants were required to complete an enrollment form which collected demographic information and included a basic skills assessment. In order to graduate from Epi Academy and become officially inducted as a PHERT member, attendees were required to be present for a minimum of three of the four classes, and if they were absent, they were required to obtain the notes and PowerPoints from the class they missed.
Timeframe of the practice: Epi Academy was designed to be a year-long course in which enrollees attend class once a quarter. Enrollment in Epi Academy and thus their membership in PHERT is meant to be indefinite, as each year there will be additional trainings and situational updatesâ€ to keep PHERT members abreast of emerging infections and public health risks that may affect Long Beach directly.
Stakeholder involvement and their role in planning and implementation and LHD fostering collaboration with community stakeholders: LBDHHS collaborates with local stakeholders constantly. There was not one activation mentioned above that did not include either a local council office, Long Beach Police and Fire, Long Beach Disaster Preparedness, or various community organizations. One example is the three-day activation of PHERT for the Zika CASPER, which involved setting up an Incident Management Team (IMT) consisting of various City staff from multiple departments in addition to Health. PHERT members worked alongside community volunteers, City staff, State and CDC partners, and elected officials to complete the goal of visiting almost 200 households to ask about knowledge of Zika and whether residents know how to protect themselves from mosquito-borne illness. The results from the CASPER were distributed City-wide, and the California Department of Public Health is now considering Long Beach the gold standardâ€ of how a CASPER should be run using various City departments rather than just Health. All of this contributes to the strength of knowledge of PHERT members and their familiarity with community collaboration to achieve a safe City for all residents.
Start up costs: The costs to recruit new PHERT members and conduct and Epi Academy were minimal. Epi Academy attendees were given a large binder at the start of the course, and each class session they added the PowerPoint slides and any exercises and additional handouts they received. An estimated cost for both the binders and printing is an estimated $250, which came out of the Public Health Emergency Management budget. In addition, graduation hats were purchased for the graduation ceremony at an estimated $50. PHERT members who were LBDHHS staff continued to charge their hours to their respective programs when they were activated and deployed, primarily due to the LBDHHS Director's support and encouragement of PHERT members participating in response activities, as it benefits not only the Health Department but the City of Long Beach as a whole. In the future, we would hope to acquire some sort of grant funding to allow PHERT members who are Health staff to be able to charge their hours to a special emergency activation fundâ€ when they are activated as PHERT and working after-hours or overtime.
What did you find out? To what extent were your objectives achieved? All of the objectives associated with Epi Academy were met. The first objective was to recruit at least twenty individuals to participate in Epi Academy and join PHERT, but there was a great deal of interest in joining the team, and we were able to recruit 37 staff and volunteers. Throughout the year, six people were lost due to job transfers or moving away, so the final number of graduates was 31 PHERT members. 2. The second objective was to train PHERT members on the basics of epidemiology, communicable diseases, and outbreak investigations. This was accomplished throughout the year using a combination of the CDC's Principles of Epidemiology, real-world case studies, videos, and hands-on exercises and activities. 3. The third objective, to evaluate PHERT members' knowledge of epidemiological concepts after attending Epi Academy, was done by administering self-evaluations before and after the course. Participants assessed their knowledge of 12 different communicable disease and outbreak investigations fields by ranking their knowledge on a scale of 1 to 4. On average, participants increased their knowledge by at least one point for each of the 12 fields. 4. The final objective was to deploy PHERT throughout the year as needed for various public health emergency response activities. This occurred much more than initially anticipated, as PHERT was called upon to assist with various activities involving communicable disease response in the community, including several outreach efforts involving Zika preparedness after the mosquito that can transmit Zika was found for the first time in Long Beach in June 2017.
Practice evaluation and data collection methods: As mentioned above, Epi Academy attendees were required to fill out a self- evaluation both before initiating and after completing the course. The self-assessment was used to determine their level of knowledge around 12 different epidemiology and communicable disease subjects. Participants assessed what they had learned by ranking their knowledge of each subject on a scale of 1 to 4. In addition, after the completion of each class session, attendees were asked to fill out an evaluation for that particular class, including what worked, what they would like to see more of, etc. The evaluations were primarily open-ended questions, although there were five initial questions at the beginning of each evaluation to have them score 1-4 on whether the training was well organized, the material easy to follow, the length of the training sufficient, the course met expectations, and whether the instructor presented the material well.
Performance measures used: The process evaluation was accomplished using the self-assessments and analyzing the data as described, while the outcome evaluation was accomplished by the evaluations at the completion of each class session of Epi Academy.
Analysis of results: Results of the self-assessments were analyzed in Excel by tabulating each individual's pre- and post level of knowledge on each of the 12 subjects. Averages were tabulated by both individual and subject, to determine which students had the highest level of increase in knowledge, and which of the subjects gained the highest level of knowledge, or in other words, in which subjects did the students gain the most knowledge. Results of the class evaluations were scanned and entered into a shared folder. Comments and suggestions given in the assessments after each class were immediately taken into account and considered when planning the next class session. When the next Epi Academy cohort is recruited and scheduled, those comments and suggestions will aid in improving the existing curriculum.
Modifications made to practice based on results: The results and analysis of the self-assessments showed that those subjects that had the greatest growth of knowledge were the more quantitative subjects such as the epidemiology curve and computing risk ratios and attack rates. The lowest levels of knowledge growth were around incubation period and vaccine-preventable diseases. Knowing this would help make small changes to the curriculum to help determine how much time to spend on each subject, knowing what the average growth of knowledge will be on certain subjects. In terms of the class evaluations, the responses were very positive. Some suggested that it may be more effective to have the class sessions closer together rather than once a quarter, as it was difficult to retain all of the information they had learned over a period of three months. Also, many appreciated and would like to see more of the real-world outbreak examples, as including case-studies in the curriculum helped put all of the theoretical epidemiological concepts together. These results and suggestions will be used when preparing for the next cohort of Epi Academy.
Lessons learned: Evaluations were a key part of Epi Academy. After every course, PHERT members were asked to complete an anonymous evaluation on the content, pace, and activities of the class. At the end of the year, they were also asked to fill out an evaluation for Epi Academy as a whole. In the future, Epi Academy will make some small changes based on evaluations from PHERT members. One finding was that students would have preferred to meet more often, since having quarterly classes, three months apart, led students to forget some of what they had learned in previous classes. Moving forward, Epi Academy will more likely be held for two hours every other month in order to space classes closer together. Another lesson learned based on the evaluations was the size of the printed slides was hard to read. Each student received an Epi Academy binder at the first class meeting, and each subsequent class they were given slides from that day's presentation to add to their binder. In the future, it may be easier for students to print out full-page slides to allow them to reference the content later.
Cost/benefit analysis: No cost/benefit analysis was done, as the instructor was already a LBDHHS employee, and the participating PHERT members were either staff or volunteers. The only costs incurred were the binders for each student and printing of the notes each class, which was absorbed by the Public Health Emergency Management division at LBDHHS. In this case, the benefit of having a group of 31 trained individuals who are ready to respond to any communicable disease outbreak in Long Beach, far outweighs the small cost of administering the Epi Academy course.
Stakeholder commitment: Given the success of Epi Academy and the proven benefit to having a trained surge team able to respond to communicable disease outbreaks in the City of Long Beach, the support throughout the City has been substantial. There have even been inquiries from other City departments asking if they could participate in an Epi Academy as well to gain a better understanding of communicable disease control throughout Long Beach. Internally, there is continued support from the Director and Health Officer for the staff time spent in trainings and activations of PHERT.
Sustainability plans: Fortunately, Epi Academy and the growth of PHERT is highly sustainable, because it costs almost nothing to run and is administered by LBDHHS staff. Because more people than anticipated joined PHERT and completed Epi Academy, there is no need to recruit and train even more staff immediately. In order to keep the 31 new PHERT members informed of current outbreaks, emerging infections, and communicable disease topics relevant to Long Beach, over the next year they will have the opportunity to attend quarterly seminars, which will include guest speakers and information they may need to know if a PHERT activation is foreseen. These seminars are meant to allow continued participation of PHERT members and will allow them to review the skills they have learned over the past year. The next Epi Academy cohort will likely be recruited in early 2019.