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Vectorborne Disease Response Planning 

State: OK Type: Promising Practice Year: 2018

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Oklahoma City-County Health Department 
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Vectorborne Disease Response Planning 
The Oklahoma City-County Health Department (OCCHD) is a local health department that serves a population of more than 750,000 residents and 1.3 Million people commuting within the OKC Metro. Historically, efforts had been operating in silos even within the LHD with resources scattered throughout the county, without recognition of the need to allocate resources geographically or within specific population. Vectorborne disease, such as West Nile Virus, is a potentially serious illness. Two mosquito borne disease that impact Oklahoma City-County are West Nile Virus and travel-related Zika Virus cases. Zika Virus has impacted Oklahoma City-County due to community members traveling to countries with active transmission of the virus and returning to Oklahoma City-County. The heightened vector activity in the Oklahoma City-County area occurs April through September, and West Nile Virus human cases typically occurs in the warm summer months. While the State maintains a list of reportable diseases, the OCCHD Epidemiology team conducted case investigations for limited vectorborne diseases, including West Nile virus and other arboviral infections, Lyme disease, Rocky Mountain Spotted Fever, and Malaria. In 2010, human disease surveillance, to include reporting and case investigations, began in Oklahoma City along with mosquito larvicide on a complaint basis through the municipalities within the OCCHD jurisdiction. A severe West Nile Virus outbreak occurred in 2012 that caused over 50 hospitalizations in the Oklahoma City area and several individual died as a result of West Nile Virus. In the midst of the outbreak, efforts to improve the disease prevention and response were top priority. The Oklahoma City-County Health Department collaborated with City managers and municipal partners and have bolstered the response planning over the past 7 years. Oklahoma City-County deploys a phased vectorborne response plan to address multiple diseases, including Zika Virus and West Nile Virus. This plan is scalable and flexible, but must necessarily prepare for the worst case” scenario. Although not currently a local threat in Oklahoma City-County, Zika virus response planning requires early coordination between state, local and federal agencies in order to mitigate risk to the population. The backbone of the Vectorborne response planning has been proven successful through West Nile Virus response in which Oklahoma has experienced three outbreak seasons: 2003, 2007 and 2012. (OSDH) In 2015, the Oklahoma City area experienced a greater than 112% increase in the number of vectors and 18 WNV positive test pools were observed. The heightened number of vectors and positive test pools did not translate to the same escalation in human cases, which demonstrates the strength that Public Health collaboration between surrounding municipalities and community members has on reducing the potential impact of this seasonal epidemic. Leveraging partnerships and resources acted upon during West Nile season in Oklahoma City-County, the Oklahoma City-County Health Department created a powerful Vectorborne response plan that allows for immediate deployment based on Zika Virus activity in and near Oklahoma City-County.
OCCHD coordinates the multi-sector vectorborne disease program with local, state, federal partners. Trapping is conducted using CDC Gravid Traps and BG-Sentinel. Culex mosquitos are one of the more prevalent WNV vector mosquitos in Oklahoma. Therefore, the Gravid Trap we use is designed to selectively capture female Culex mosquitos by utilizing hay and tap water as the attractant. Once a week the nets with trapped mosquitos are brought OCCHD Consumer Protection and frozen overnight. Mosquitos are sorted and tested the following day. During the 2017 mosquito season, ECE, OKSWQ, and Consumer Protection deployed a total of 18 CDC Gravis and BG Sentinel traps. The overarching goal is to mitigate risk of vectorborne disease through prevention, quick response and remediation. The multilevel approach deployed in this city-county jurisdiction provides best practices for collaboration with partners and surrounding municipalities in order to reduce disease impact. This methodology includes media outreach, vector surveillance, environmental treatments, partnerships and human disease surveillance. As a single agency, this timely response would be impossible to achieve without partnerships with surrounding municipalities. Functioning as a cohesive unit, the local public health system is able to set, maintain, repair and collect traps at each site, disseminate surveillance reporting information, coordinate treatment applications and investigate harborage areas. Additionally, municipalities coordinate with habitat remediation efforts. Consumer Protection. Consumer Protection identifies and treats areas with stagnant water following a complaint. These include but are not limited to vacant pools and properties where the inspector cannot contact or identify the owner. This year, similar to 2015 and 2016, we used two different types of larvicide. The first is Altosid XR, which has a low cost of application and is effective for 150 days. The second larvicide used was Fourstar, which is effective for 180 days and has fewer ecological concerns compared to Altosid XR. With Fourstar, we can treat more than just stagnant pools without the fear of harming aquatic life. Other forms of stagnant water include storm drains, catch basins, underground drainage systems, storm water retention areas, and ponds. With every use of larvicide, the inspectors notify the program coordinator of the number used and the address. In the case where there is a positive human case, we traced the location of the infected persons to a territory of one of the inspectors with Consumer Protection. We do not disclose the exact address to the inspector but instead provide an area to survey for stagnant water as well as pass out flyers in the community. Throughout the season, epidemiologists collect the geographical data and produce GIS mapping to identify clusters of human cases and possible major sources of vectors. Epidemiologists provide data such as the address of persons who contracted the disease. In addition to mapping data, they gather information relating to where and when the infected person was outdoors, travel history and hobbies that may increase risk of contracting a vectorborne disease. Specific to Zika Virus, the Epidemiologist also collects travel history of spouse/partner and, if travel was to an area with local Zika activity, any Zika associated signs or symptoms. During the mosquito season, the OCCHD Epidemiology department sends out vectorborne reports providing information of state and national cases of WNV and Zika. This report also includes the quantity of local complaints of stagnant water and the quantity of stagnant water treated with larvicide. This comprehensive report provides detailed data for targeted messaging, abatement efforts and aids in trend identification. Habitat Assessment is aided by satellite image with 500-foot radius. Aerial view allows response team members to better inspect areas of potential vector habitat. Communications are a critical piece the vectorborne disease prevention toolbox. The OCCHD holds a joint press conference with all interested channels when the first positive vector pools are identified (for West Nile Virus) or when an outbreak scenario/heightened awareness requires media communication. In addition, marketing and communications staff at the OCCHD developed prevention messaging and earned more than $600,000 in prevention messaging across the metro, to include outdoor billboard exposure, television, radio and print ads. In 2016, a celebrity PSA was created to communicate the importance of prevention strategies. During a typical season, the public health protection division staff engage with numerous news outlets, council meetings and university workgroups to communicate status updates and prevention messaging. The municipality agencies collaborating with OCCHD set, maintain, repair, and pick up the traps at each site. OKCSWQ sends us weekly reports for each of the trap sites. These reports include the trap condition, needed repairs, and if the trap caught mosquitos at the end of the week. We provide the municipalities with larvicide to treat areas of stagnant water that are mosquito-breeding habitats. With each application of larvicide, they document the address and date. At the end of the season, we use that data to note how much larvicide has been used in relation to OCCHD's mosquito data. In the case of a positive WNV result, the municipalities receive an email from OCCHD informing them of the site number. This allows them to remediate the problem through area surveys and elimination of mosquito habitats within one mile of the trap location. Collaboration has been further developed with the Oklahoma Department of Environmental Quality (ODEQ) involving the issue with the storage of large amounts of tires. Part of the collaboration includes the discussion of providing OCCHD with a Tire Exemption Authorization S no. for tire sites that pose an imminent health hazard. Sites that do not pose an imminent health hazard will be referred to ODEQ. RESPONSIVENESS AND INNOVATION The Oklahoma City-County Health Department (OCCHD) serves a population of more than 750,000 residents, but on weekdays, the population grows to an estimated 1.2 to 1.3 million as people from outlying counties come into Oklahoma County to work. The residential population is approximately one-fifth of the total state population, but the commuter population brings that number closer to one-third of the state population. Target Population and Reach The innovative practice focuses on a multi-stage approach to combat vector borne disease in Oklahoma City-County; this includes communities with high concentration of elderly. Community based interventions provide education to the community at large and GIS mapping capabilities provide targeted outreach in response to human case identification. The technical package the OCCHD has implemented utilizes a comprehensive, multi-sector approach to preparing for, mitigating risk and responding to vector borne disease outbreaks. The tested approach illustrates a seamless effort between the local health department and neighboring health officials, municipalities, media channels, laboratory, federal partners, preparedness officials and community members. The comprehensive package conducts vector surveillance, environmental treatments, habitat remediation, municipality partnership, human disease surveillance and prevention and media outreach. The multi-sector approach engages Oklahoma City Storm Water Quality (OKCSWQ) and Edmond Code Enforcement (ECE) who set, maintain, repair and collect traps at each site during vector surveillance. Background of Innovation Historically, the OCCHD has subscribed to the identification and implementation of existing evidence-based best practices to improve health outcomes for its jurisdiction. These practices were consistently implemented according to guidelines, but largely without coordination across target populations. Efforts have been operating in silos even within the LHD with resources scattered throughout the county, without recognition of the need to allocate resources geographically or within specific population. While the State maintains a list of reportable diseases, the OCCHD Epidemiology team conducted case investigations for limited vectorborne diseases, including West Nile virus and other arboviral infections, Lyme disease, Rocky Mountain Spotted Fever, and Malaria. In 2010, human disease surveillance, to include reporting and case investigations, began in Oklahoma City along with mosquito larvicide on a complaint basis through the municipalities within the OCCHD jurisdiction. A severe West Nile Virus outbreak occurred in 2012 that caused over 50 hospitalizations in the Oklahoma City area and several individual died as a result of West Nile Virus. In the midst of the outbreak, efforts to improve the disease prevention and response were top priority. In Fall 2012, surveillance enhancement and vector mitigation strategies grew as a result of research and collaboration with our local partners. In 2013, CDC Gravid traps were added to the toolkit to begin collection for mosquito population data and testing kits were deployed to identify West Nile Virus within the vector population. A key feature to this toolkit strengthened in 2013 with the cohesive approach of the local, city and municipality mitigation strategies and training. The OCCHD has committed significant resources to leverage partnerships and develop a plan of action to direct community planning and implementation efforts aimed at developing systems and environmental improvements through the use of a technical package approach to health systems improvement. Use of a technical package that focuses resources on a single goal is critical to the success of the proposed strategies. Each component of the innovative practice focuses on a different intervention area that collectively addresses planning, prevention and environment. The approach aggregates successful programmatic best practices including Vector surveillance (trapping, testing and GIS mapping), human surveillance (epidemiological investigations) and environmental strategies (treatments and habitat remediation), in the target communities in order to engage multiple sectors at multiple intervention points common to the communities. Programmatic activities are complemented by policy action undertaken by the Public Health Protection division which includes city vector ordinances, public health nuisance response and/or public health emergency declarations. In 2015, through development of the vectorborne disease group, local, state, and federal officials had a joint communication system developed for timely communication of results across organizations. At the same time, the OCCHD, through use of grant funding, developed an emergency preparedness and response mobile application to provide on demand access to articles, media interviews and fact sheets. Qualitative data collected during the season, support from multi-sector partners and community engagement qualitative data collected through social media outlets illustrates a successful model that leverages community resources, enhances community protection and promotes vectorborne disease education through a unique technical package. As a major population and activity center for the state of Oklahoma, this inevitably translates into improved prevention for the state as a whole. The innovation represents a creative use of existing tools and practices found through the Centers for Disease Control and Prevention, MMWR Recommendations and Reports, Preparedness workgroups, academic groups and professional public health committees and includes the following elements, placed in targeted, disparate health outcome ZIP codes within the LHD jurisdiction: 1. Access to timely surveillance, disease burden and remediation data, available in weekly situation reports and various media conferences. 2. Communication strategies: Communication strategies are vital to the success of the Vectorborne Disease Response Plan (VDRP). Affecting behavior change of actions to protect against mosquito bites, education has an integral role. Consider multiple faucets in relaying a clear, timely, and consistent message within state and local jurisdictions. Prepare press briefs for each response phase to include the reason for the announcement, the risk to the jurisdiction, and how to reduce the risk. When reusing messaging, it is encouraged to personalize it to your jurisdiction. 3. Community Awareness: The Skeeter Meter was developed by OCCHD epidemiologist and is an awareness tool for use in alerting the residents of OKC-Co of risk from disease carrying mosquito activity. To calculate this risk the OCCHD Vectorborne Disease Surveillance team uses data from the following multiple sources: Temperature, Weekly Mosquito counts (compared to historical numbers), Disease Rate (within Captured Mosquitoes), Complaints from residents (compared to historical data), Human Surveillance (WNV cases in the state of Oklahoma and/or within OCCHD.) 4. Emergency Response Planning: In coordination with City and Emergency managers, the OCCHD integrated a phased response plan with the City Emergency Response Plan and Procedures. This annex was developed using available epidemiology, entomologic, geographical and environmental data. This annex also set the foundation for phased response planning and sharing across the professional network. Due to requests from the international community, the OCCHD shared it's program development story and results at multiple forums, to include the international Zika Virus Conference, NACCHO Preparedness Summit, The United States Public Health Service Scientific Symposium, City Council and The University of Oklahoma Medical Ground Rounds.
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The overarching goal of the innovation is to reduce risk of vectorborne diseases and respond timely. The OCCHD seeks to leverage resources with partners to ensure risk reduction, with regards to vectorborne disease. Integral components of this program include: 1. Comprehensive data collection, analysis and dissemination utilizing the Mobilizing for Action through Planning and Partnership Tool, conducted every third year by the LHD. 2. Integration of cross-functional organizations, including City officials, code enforcement, media outlets, clinical, and public health preventive services for targeted abatement and risk reduction for high-risk populations and locations (including the elderly, golf courses, outdoor workers). 3. Targeted education, awareness and code enforcement implementation county-wide. Implementation Activities The technical package the OCCHD has implemented utilizes a comprehensive, multi-sector approach to preparing for, mitigating risk and responding to vector borne disease outbreaks. The tested approach illustrates a seamless effort between the local health department and neighboring health officials, municipalities, media channels, laboratory, federal partners, preparedness officials and community members. The comprehensive package conducts vector surveillance, environmental treatments, habitat remediation, municipality partnership, human disease surveillance and prevention and media outreach. The multi-sector approach engages Oklahoma City Storm Water Quality (OKCSWQ) and Edmond Code Enforcement (ECE) who set, maintain, repair and collect traps at each site during vector surveillance. The background referenced prior provides implementation timeline and strategies. The six part process includes vector surveillance, environmental treatments, habitat remediation, municipality partnerships, human disease surveillance and media outreach. For a complete kit visit occhd.org/vectorborndiseasetoolkit. Criteria for Inclusion The program requires that funds be allocated in ZIP codes within the OCCHD jurisdiction. Targeted communications may be focused on areas with highest risk, as identified through the Wellness Score and client interviews. Prevention messaging are also focused on the high traffic highways and prime time news segments. Timeframe Programs included within the innovative practice have operated as independent programs in the OCCHD jurisdiction for 7 years. Both the acute disease investigation and vectorborne disease programs were evaluated over the past 18 months to determine opportunities for improvement in process or delivery of program elements. The mobile app was recently launched in 2017 using public health emergency funding. Stakeholders The entire strategy relies heavily on the direction and support of the broad-based, multi-sector collaborative partnerships within Oklahoma. A broad array of partners has supported efforts to ensure timely response and implementation of a scalable vectorborne disease response plan and include: OCCHD Consumer Protection Division and Epidemiology, Oklahoma State Epidemiology, Tulsa Health Department, Tinker Air Force Base, Municipal partners, Big Cities Preparedness Workgroup, Public Health Laboratory, Oklahoma City Emergency Management, Edmond Code Enforcement, Oklahoma City Storm Water Quality, Local media (television, radio and print) and The University of Oklahoma College of Public Health. Funding Funds to support the described innovative practice have been allocated as a combination of the OCCHD local tax levy base and periodic grant funds. City and municipal partners allocate funding to repair and staff the traps in their area of responsibility. During the Zika virus outbreak, federally awarded grant funds were utilized to purchase additional BG Sentinel traps and larvicide.
The total number of mosquitos captured, tested, positive traps, positive pools and positive mosquitoes are presented weekly in the OCCHD Situation Report. A comprehensive annual report is produced at the conclusion of each mosquito season. This report analyze trapping and testing results, larvicde used, habitat remediation, community education, emergency response activities implemented and media outreach conducted. During the most recent 2017 mosquito season, local code enforcement, city officials and consumer protection deployed a total of 18 CDC Gravid and BG Sentinel traps. The final day of sorting took place during the last week of October, as consistent with the decrease in mosquito numbers. There were 23 trapping and testing weeks with a total of 43,079 mosquitos trapped and 33, 846 mosquitos tested. An average of 66% of all trapped mosquitos were tested each week. BG traps accounted for the majority of the mosquitos trapped (40,149). Positive test pools began to occur in week 12 of the 2017 season. The Maximum Likelihood Estimation (MLE) Infection Rate is calculated each week. The OCCHD believes strongly that public health interventions should be implemented utilizing place-based strategies that employ a technical package. By targeting neighborhood and property assessments using GIS mapping, case interviews and community based interventions, the OCCHD is allocating resources to areas where the greatest risk reduction can be achieved in the shortest time frame. Complaints: The Complaints Program in Consumer Protection receives stagnant water complaints. These complaints are given to the area inspector to investigate. If stagnant water is observed at a vacant property, they remedy the problem by either applying larvicide or having the property owner treat the water. If the property is not vacant, an abatement notice is issued to the property owner. There were 255 stagnant water complaints in 2017, 2 were entered during the month of November. Throughout the season, 28 locations had multiple complaints and 68 (26.7%) complaints were associated with duplicate locations. Without including the duplicate locations, there were 215 complaints entered. There were two slight peaks in complaint numbers during the months of June and September. The peak in mosquito numbers did not occur until September. Responding to Human Cases: In 2017, 7 human cases of Vectorborne disease were investigated in Oklahoma County; 1 West Nile Fever (WNF), 5 West Nile Neuroinvasive (WNV Neuro) and 1 Zika Virus travel related cases. Statewide, there were 60 total cases (12 WNF, 27 WNV Neuro, and 1 Zika). After confirmation of a positive human case, the Epidemiologist conducts a detailed case investigation and after obtaining consent, provides the exact location where the case resides to the Consumer Protection area inspector in order to conduct a survey of the surrounding area and pass out flyers to the community on education and prevention mechanisms. This season Consumer Protection also did area surveys with travel associated positive Zika cases to help prevent the virus from potentially being introduced into the Oklahoma City-County vector population. In total, Consumer Protection completed four WNV and three Zika surveys. To measure impact the number of mosquitos tested is compared against the number of human cases. During the course of the 2017 program, there was an increase in mosquitoes captured by 151% compared to 2016. This could be attributed to the increase in traps or the increase in trapping weeks. When only comparing the CDC Gravid traps, there were 16,591 mosquitoes captured in 2016 and 40,149 in 2017. Also, when comparing total mosquitoes per week there were 754 per week in 2016 and 1,745 per week in 2017 making the percent increase in mosquitoes per week at 131%. Another difference in program years is the addition of trap shelters for the CDC gravid traps. These shelters protected the traps from excess sun and rain exposure. Each program year had differing progressions of mosquito numbers. Figure 13 illustrates the number of mosquitos for each program year. In 2013, the number of mosquitos peaked in August before decreasing each week until October. In 2014, the numbers of mosquitos were consistent each month from July to September instead of steadily increasing. In 2015, the number of mosquitos began low and gradually increased each week. In 2016, there were a large number of mosquitos captured at the start of the season prior to a sudden decrease in numbers. This year, the numbers increased gradually each week with the number spiking towards the end of September before a steep decrease. Detailed tables, graphs and charts are included in each report to present historical and current data points. Given these parameters, the planning, reporting and annual evaluation efforts for this innovative practice were developed with Public Health preparedness in mind, and focus on considering cross-sector, program efficacy and community based prevention outcomes collectively. Evaluations for each component of the innovative practice have been developed to incorporate qualitative and quantitative analysis, and incorporate multiple systems through the course of implementation to allow for collaborative improvement. The inclusion of partner engagement and periodic reporting is a component of the program planning and development was purposeful and is considered an aspect of the innovative practice. The weekly situation reporting ensures the following: 1. Community partners are properly updated on local, state and national events. 2. Emergency preparedness groups are prepared for phased response 3. Data collection is accurate and provided in a timely and consistent manner. The annual report provides information to: 1. Assess the effectiveness of the activities in place during the most recent year, in comparison to historical activities. 2. Estimate resources required for the following season 3. Understand the effect of integrated and collaborative prevention strategies on prevention of vectorborne disease 4. Evaluate media outreach and community education strategies on prevention techniques and strategy
This toolbox ensures each partner has a method to reduce risk of disease in their setting while the health department has provided the technical package for other communities to adopt as they see best suited for their population. The OCCHD is committed to developing and implementing strategies that have long term impact and sustainability for the community. The integrated and strategic delivery of program interventions was critical to community-wide vectorborne disease protection realized by Oklahoma City and Oklahoma County following the launch of the integrated approach. To maintain these strategies and the long term impact for continued preparedness, Interventions must focus on multi-generational, and place-driven. Engaging partners and program implementation staff in implementation design was critical not only to successful implementation but to program sustainability.
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