1. School Rash Investigation Presented by: Kristy M. Bolen, MPA Fivco Regional Epidemiologist

2. Investigation Team Little Sandy District Health Department  Lloyd Miller, Director  Heidi Fosson, Preparedness Planner  Henry Sturgill, Environmentalist  Jeff Barker, Environmentalist  Ellen Blevins, Nursing Supervisor  Rita Sexton, School Nurse

3. Investigation Team Regional Epidemiologist  Kristy Bolen Department of Public Health  David Jones  Dr. Nato Tarkhashvili  Dr. Doug Thoroughman  Colleen Kaelin

4. BALLARD CARLISLE GRAVES McCRACKEN FULTON HICKMAN CRITTENDEN CALDWELL TRIGG LYON LIVINGSTON MARSHALL MCLEAN HENDERSON UNION WEBSTER HOPKINS CHRISTIAN WOODFORD BOONE GALLATIN CARROLL TRIMBLE PENDLETON OWEN KENTON GRANT CAMPBELL BOYLE FAYETTE JESSA’ ’ MINE MERCER WASHINGTON ANDERSON GARRARD SPENCER SHELBY HENRY OLDHAM HARRISON SCOTT FRANKLIN NELSON BULLITT JEFFERSON GRAYSON HARDIN BRECKINRIDGE MEADE MARION HART EDMONSON BARREN LARUE CALLOWAY SIMPSON TODD BUTLER MUHLENBERG LOGAN ALLEN WARREN HANCOCK DAVIESS OHIO METCALF RUSSELL ADAIR CLINTON CUMBERLAND MONROE CASEY PULASKI WAYNE McCREARY TAYLOR GREEN NICHOLAS BOURBON BELL JACKSON LAUREL ROCKCASTLE KNOX LINCOLN CLAY WHITLEY OWSLEY ESTILL MADISON KNOTT PERRY LETCHER LESLIE HARLAN LEE FLOYD BREATHITT PIKE POWELL BOYD MORGAN JOHNSON MARTIN WOLFE MAGOFFIN MONTGOMERY CLARK MENIFEE GREENUP CARTER ELLIOTT LAWRENCE BATH Map of Kentucky Counties and Area Development Districts = Area Development District Boundaries BRACKEN MASON LEWIS FLEMING ROBERTSON ROWAN

5. Tri-State Preparedness Planners & Epidemiologists Group Ohio West Virginia

6. Carter County Demographics Population  26,889 (2000 Census) County School system  Two Middle & High Schools  Six Elementary Schools  Total District Enrollment 4,771 (2003-2004)

7. Timeline of Investigation January 5, 2005  Regional Epidemiologist is contacted by Little Sandy District Health Department (LSDHD) Four female students had left East Carter High School (ECHS) with a rash One student had went to the Emergency Department with a severe reaction Regional Epidemiologist planned to visit LSDHD and ECHS next morning to investigate

8. Timeline of Investigation January 6, 2005  Team from LSDHD & Epidemiologist visit ECHS Inspect classrooms & common areas Talk to school nurse & office staff about students who left on the 5 th Interview female student who comes in with rash while we are still in building

9. Timeline of Investigation January 6, 2005  Epidemiologist prepares questionnaire for distribution to students at ECHS with rash  LSDHD calls later that afternoon to report 40 students have left ECHS with rash  School officials cancel classes for Friday to “disinfect” the school  Contact DPH, set up meeting for next morning

10. Timeline of Investigation January 7, 2005  Epidemiologist meets with LSDHD & DPH team (David and Nato)  Entire team visits ECHS to inspect building & talk to maintenance staff Asks about cleaning products used everyday & over Christmas break Acquires MSDS sheets on products used regularly Acquires Orkin’s number (sprayed over break) Looked at heating/cooling system

11. Timeline of Investigation January 7, 2005  School nurse begins to report East Carter Middle School (ECMS) students are coming in with same rash  Investigation team visits ECMS Takes pictures & blood samples (from staff)  Team finalizes questionnaire to distribute to students who’ve left with rash or students that leave Monday with rash

13. Timeline of Investigation January 10, 2005  No cases reported over weekend  By days end 100 students have checked out of both schools 29 students from ECHS 71 students from ECMS  Regional Epidemiologist plans to return next day to enter completed questionnaires

14. Timeline of Investigation January 11, 2005  By days end 49 students have checked out of five schools in the district 20 students from ECHS 14 students from ECMS 2 students from Upper Tygart Elementary 11 students from West Carter High School 2 students from West Carter Middle School  School officials decide to close schools until January 18 th

15. Timeline of Investigation January 11, 2005  Media “blitz” begins Calls received from local station & Lexington station Regional Epidemiologist becomes PIO for case  Phone conference with DPH officials Dr. Kraig Humbaugh, Dr. Barry Wainscott, Dr. Doug Thoroughman, David & Nato Set time for update next morning  ECHS plays basketball game against another area high school Creates an issue for media to focus on

16. Timeline of Investigation January 12, 2005  Team creates Information sheet Sheets sent to surrounding Regional Epidemiologists to distribute to their counties Sheets also sent to area hospitals  Completed questionnaires are entered & first “Epi- Curve” is produced  During phone conference with DPH decide that Dr. Thoroughman, Colleen Kaelin, David and Nato will visit next day to meet with school officials & staff

18. Timeline of Investigation January 13, 2005  Investigation team meets with school officials & staff Assure school that it is safe to open on Tuesday  Continue to enter questionnaires into database

19. Timeline of Investigation January 14, 2005  Final media interviews Assure public that its safe for children to return  Decide not to call students that didn’t return questionnaire Did not want to “stir-up” issue again

20. Timeline of Investigation January 18, 2005  Students return to school 1 case at ECHS 1 case at ECMS 3 cases at three different elementary schools January 21, 2005  Investigation is closed No definitive cause found  Lack of questionnaires returned  MMWR Article

21. Lessons Learned “In the midst of difficulty, lies opportunity.” - Albert Einstein

22. Showed how beneficial regional epidemiologists are in an incident  Team worked well together  No territorial issues Showed how beneficial partnerships are to an investigation  West Virginia & Ohio partners  DPH Partners

23. Lessons Learned Misconception of our jobs  Expectation versus reality  Allowed community to see what our true function in an incident is Communication is key  With community (through media)  With School officials (local and area wide)  With DPH

24. Lessons Learned Need to delegate one or two people to answer phone questions from public Contact notebook is a necessity  Didn’t have fax numbers for other Regional Epidemiologists or area physicians  Didn’t have area school contact information  Didn’t have media contact information

25. Lessons Learned Need to contact media first  Provide them with information sheet  Don’t let them dictate the story Data needs to be collected as soon as possible  Lost chance to collect data when schools closed

26. Conclusion Even though a thorough investigation was conducted, no cause for the rash was discovered Lessons learned helped with next investigation (February) A good test of emergency plans & procedures