Yale School of Public Health Partnerships With State And Local Health Departments For Covid-19 Response

April 18, 2020

Information

Linda Niccolai, PhD, Professor of Epidemiology (Microbial Diseases)

ID5080

To CiteDCA Citation Guide

00:00Thank you very much, uh, I would now like to introduce our next Speaker,
00:07Professor Linda Nicholi. Doctor Nicholi is a professor of Epidemiology of microbial diseases at Yale.
00:13She's also the director of the Connecticut emerging infections program and the HP vaccine Working Group at Yale.
00:21Doctor Nicholi received her Master of Science at Harvard School of public health and her PhD at Tulane University.
00:28She has served as an advisor,
00:30an reviewer for the NIH and CDC conferences,
00:33and grant programs. Professor Nikolai thank you for being here.
00:37Thank you for having me,
00:39uhm, you can hear me,
00:40OK? Yes great OK thanks.
00:44So um, as noted in the title of this presentation.
00:47But I'd like to talk to you all about today is about the academic public health partnerships that have either been newly developed or existing partnerships that have been called
00:59action in response to COVID-19 next slide.
01:01Please thank you. So I'd like to begin with a really high level overview of what is the role of public health departments in outbreak or pandemic situations.
01:12I think most of us at the University recognize the really important need for research,
01:18and in many of us actively engage an important research that research questions that arise during outbreaks and now what has become a pandemic,
01:28questions about transmission, immune response,
01:30clinical presentation, treatment, all of these things are really,
01:34really important. What public health departments do?
01:37That's quite different is they play a real critical role in response activities,
01:42response activities, things we do to detect trends and patterns during the course of an outbreak,
01:48and pandemic. An implement control measures so public health department's really do this as outlined in this report from the Institute of Madison Public Health departments do this through epidemiological
02:00investigation. Surveillance are very important.
02:01Function is communicating with the public and strategic planning.
02:05So this is all again outlined in this IOM report.
02:08I really like the preface of this IOM report actually has a quote that I think very succinctly summarizes what public health systems do in times of emerging infections.
02:18In the quote you can read it there knowing is not enough,
02:22we must apply willing is not enough.
02:24We must do, and that's the critical role public health department's next slide please.
02:30So then what is the added value of public health academic partnerships?
02:34and I think there are several benefits to these partnerships during this time of pandemic,
02:40academic institutions can provide resources to public health efforts.
02:43I pretty sure I don't need to tell anybody at this workshop how.
02:49Woefully underfunded, our public health system,
02:51it is. It's a real,
02:53real modern tragedy even can't think of another word.
02:56So I'm not saying that academic institutions can provide actual dollars,
03:00but we do have access to resources that are public.
03:03Health system doesn't. And one of those resources would be a range of expertise.
03:09So academic centers, places like Yale have world renowned experts in basic and Clinical Sciences,
03:15population science, pop policy experts and these can bring added value to the public health response.
03:22And finally, I think it's really worth noting the academic institutions have an agility or nimbleness to mobilize in ways that public health Department may not be able to in
03:34terms of bureaucratic structures that exist.
03:37You know, sometimes we feel like.
03:39Our academic centers are highly bureaucratic,
03:41but I can tell you that public health systems can be even more so,
03:47so there are many, many Venice benefits to given the role of Public Health Department.
03:52There are many benefits to these academic partnerships next slide,
03:56please. So this is a really busy slide,
04:00and that's because we have been really busy over the past couple of months.
04:05On this slide, I'm just highlighting some of the different activities that we've been involved in.
04:11Partnerships between Yale and sitting in state health departments.
04:14So most of this work has been really facilitated by the presence of the Connecticut emerging infections program here at Yale.
04:22So this the EP is a CDC funded partnership between the Connecticut Department of Public Health.
04:28In the Yale School of Public Health,
04:30this is a program that has been at Yale continuously funded since 1995.
04:35So for over or just about 25 years now,
04:38the general function of the EP is to do public health surveillance and applied epidemiologic research for a variety of Infectious Diseases.
04:47And over the past six weeks,
04:49it's incredible to think that it's only been six weeks.
04:52It feels like a lifetime,
04:53but over the past six weeks or so for Cobain 19,
04:57we've done the following. So first of all,
04:59we have implemented surveillance for laboratory confirmed hospitalizations for COVID-19 and the results of the first month of surveillance have already been published in an MMWR that was released about
05:08a week and a half ago.
05:10We are currently in the planning phases of an epidemiologic investigation of healthcare personnel in terms of what are their risks and what are their exposures.
05:19We have already completed a rapid supplemental case series investigation of COVID-19 patients.
05:26We currently staff at the IP.
05:28It's incredible what they're doing.
05:30They are currently providing surge capacity for COVID-19 case reporting to DPH that includes follow up a positive lab reports gathering missing information and data entry,
05:40and that information is really critical is we need to monitor the spread of the epidemic.
05:46We also worked initially with DPH to develop and implement a volunteer contact tracing program in which we do rapid follow-up of case reports.
05:54Patients who are newly diagnosed with COVID-19,
05:57we identify who their Contacts are,
05:59people who potentially been exposed,
06:00and then we notify them about this exposure and provide them appropriate guidance so that effort is currently a partnership with the city of New Haven Health Department.
06:10We work closely with Marissa Bantus name.
06:12You've already heard handy all hell.
06:15So each of these activities is really worthy of their own presentation.
06:19But since I don't have time to do that today,
06:22what I'd like to do in the next 10 or 15 minutes or so is talk about our newest project,
06:27which is a partnership between Yale and the Connecticut Department of Public health,
06:31where we have set up an active daily monitoring system for COVID-19 in long term care facilities.
06:36So I'll just focus on that,
06:38but anybody wants to hear about any of these other activities.
06:41I'm happy to speak more about those later.
06:43Next slide, please. So I think everybody appreciates the significance of long term care facilities in this current pandemics.
06:52So one of the earliest signals of their significance was the devastating outbreak that occured in a long term care facility in Washington state in early March.
07:04So again, this is really one of the earliest occurrences as the COVID-19 came to the US,
07:11really devastating. Over 130 people were diagnosed with COVID-19,
07:14including more than 80 residents.
07:16Over 30 staff members and 20 three people died in this outbreak.
07:21So as noted in this MMWR,
07:24and I think what's clear to probably most people at this workshop is long term care facilities are really important setting because the residents tend to be older and have
07:35underlying or comorbid health conditions which make them vulnerable to infection and worse outcomes.
07:41And it's also a vulnerable.
07:43It's also vulnerable. Settings like this congregate nature of living.
07:47Furthermore, it's really important setting because it's this interface with the health care system and it really highlights the risks to the health care workforce and how important of a
07:58population that is and how hard we need to work to preserve our health care workforce at this time.
08:05So since this early report,
08:07long term care facilities are in the news locally and nationally,
08:10just about every day, so hopefully people can appreciate the significance of this population.
08:15Next slide, please. So what's going on in Connecticut?
08:20These are data from the Connecticut Department of Public Health.
08:24They are updated regularly on their website.
08:27This is a screenshot I pulled from April 13th where you can see that by April 13th,
08:3450% of long term care facilities in Connecticut reported having had at least one case of COVID-19.
08:41They also note a total of over 1500 residents had been diagnosed with COVID-19.
08:47Nearly 400 of them. I been hospitalised and 14%
08:50or over 200 of them had died.
08:53So these data, and of course these numbers are constantly changing,
08:57so these data are really important and they reflect the information that was coming from the existing surveillance that had been ongoing for Kobe 19 in long term care facilities.
09:07But some important limitations had been noted.
09:10In this surveillance system is as important as good as these data are that the Department of Public health realized there was some room for improvement.
09:17Next slide, please. So in the existing system diagnosis of COVID-19 in long term care facilities would be reported both to the local well into three places to the local
09:30health Department into two different groups.
09:33At DPH they would be reported to the infectious disease Epidemiology group into the facility licensing investigation section or less.
09:40So there was sort of triple reporting of cases from long term care facilities and is create some inefficiencies for an already overburdened staff both.
09:50At the long term, care facilities who do the reporting and at the public health,
09:55local and state level that was receiving these reports.
09:58There was also some concern that delays in reporting could allow a single case of COVID-19 to turn into larger outbreaks,
10:05so the need for real time data is just essential,
10:09so recognizing the need to revamp this system,
10:12the Department of Public health put out a call essentially to us at Yale for assistance so that emodi pH you can see them all listed there are folks who
10:22work in the healthcare associated infection group,
10:24folks who work in syndromic surveillance folks who work in information technology.
10:29You'll see, that's been a really important component to this.
10:32We're also very fortunate to have doctor Kevin O'laughlin in this group.
10:37He is ACDC signee to the state of Connecticut to help with COVID-19 so we're very grateful for his presence.
10:44Next slide, please. So essentially the ask from DPH to Yale was to assist with developing and implementing an active surveillance system for COVID-19 in long term care facilities that
10:55could do the following. Ultimately,
10:59the goal is to reduce the size and scope of Coben 19 outbreaks in long term care facilities by early detection.
11:05Early detection is really what's so important to improve data collection to meet the existing reporting needs,
11:11things need to be reported,
11:13but we wanted to improve the ways in which this could be done efficiently and accurately to provide timely information to leadership via daily reports to enable rapid intervention when
11:23suspected or confirmed outbreaks are identified an to triage prevention and control questions for response.
11:29So long term care facilities.
11:30Have a lot of questions and we wanted to be able to use this system to address those.
11:36Next slide, please. So we assembled a team at Yale and this is what it looks like.
11:41So there it is. Includes folks from school public health.
11:45Folks from the Institute for Global Health and from the school of Madison,
11:51the members of the team include faculty,
11:55staff, and students. Collectively, this group represents expertise in Epidemiology,
12:00public health, clinical Medison, Infectious Diseases,
12:03infection prevention, and really importantly,
12:05an outstanding student workforce. Next slide,
12:09please. So operationally, this is what it looks like,
12:13so we set up this electronic database of portal through flips.
12:16Again, the facility licensing investigation group at DPH on line reporting system.
12:20So the long term care facilities are supposed to enter their daily reports and I'll show you in the next slide what a daily report looks like every morning by
12:2910:00 AM. So every day there's supposed to complete a questionnaire on this portal.
12:35Up by 10:30 in the morning we have run a report identifying which long term care facilities have not entered their data.
12:44They are contacted by phone good old-fashioned telephone call that is either the student team at Yale makes these phone calls or staff at the pH make these phone calls,
12:54the facilities are also sent an email reminder at reminding them to report to the system.
13:00And if they don't then they get a phone call from us.
13:04And while we're on the phone with them.
13:07We complete the reporting worksheet and enter that directly into this portal so this all happens every day between about 10:30 and 2:30,
13:15so during the middle of the day we're actively calling log.
13:19Home care facilities and asking them some questions.
13:21Again, I'll show that on the next slide,
13:24then by three o'clock report of these data is run,
13:27any signals of an outbreak are identified.
13:30This is could include one case of COVID-19,
13:32and that's a signal that's an outbreak.
13:35This is communicated to the leadership at DPH,
13:37who can then implement appropriate response and control activities,
13:40and I'll show more of that on the next slide.
13:44So essentially yeah, so essentially the students that are calling from Yale collect these data and submit this to DPH.
13:52And what this really does is it frees up the frontline public health staff or other critical tasks.
14:00So realize this image is a little difficult to see.
14:04It's a screenshot from the online portal and it just gives you an idea of the data that we gather,
14:11so it's important to note this is a facility level surveillance system.
14:15We are not getting individual information about any residents or any patients were getting facility level information.
14:21So for example, survey asks if any residents currently have any symptoms of coded 19 weather.
14:27Any residents have been hospitalised with COVID-19.
14:30Like symptoms, whether any residents have died of these symptoms,
14:34whether anybody has tested positive for cocaine,
14:3619 weather, people have test pending for COVID-19,
14:39so all of the things that we can run a daily report on to identify signals for a potential outbreak.
14:47Next slide, please. So then if a signal is detected,
14:51if something is going on,
14:53this is when the infection prevention response team is activated.
14:56These are the clinical experts I showed you from most from school medicine at Yale.
15:02And they provide several important functions in this active surveillance system.
15:05So the first thing they can do is field some of the questions from the long term care facilities regarding prevention and control,
15:13and this is all done using CDC guidance,
15:16CDC, MD pH guidance. They will participate in calls with DPH and long term care facilities to assist in control and Prevention when indicated.
15:23Should there be a signal or an outbreak,
15:26they provide clinical expert guidance to DPH in long term care facilities,
15:30unrelated matters and importantly, going forward,
15:32they're going to be involved in a CDC LED initiative.
15:35To do more proactive work in this area rather than reactive work,
15:39so this is going to be a new area of work at CDC that's really looking to keep Cove it out of long term care facilities that have had no
15:48cases or a low number of cases.
15:52Next slide, please. So I just want to show you how quickly we launched this system.
15:58You know it's like the time frame we're all working on now is just really remarkable.
16:03So the initial request came to DPH came from DP.
16:06HTML came from the state epidemiologist Matt Carter Dr Mac harder on March 28.
16:11The A-Team at Yale of what's faculty,
16:13staff and students. The team at Yale was assembled the very next day on March 29th and we had our first call on April 1st.
16:22We then spent about a week figuring out the logistics of the program,
16:27including a lot of it logistics.
16:29You think about setting up the surveillance system,
16:32communicating with a long term care facilities that they need to enter into it,
16:37getting the students access to it so that they could enter the data.
16:41Again, being as efficient as possible,
16:43so a lot of it work.
16:46So then the student training began on April 9th,
16:50students have received training not only in this surveillance system,
16:54but also more broadly in infection prevention,
16:57so they can field questions possibly.
17:01And on April 13th. Yeah,
17:05that was just earlier this week.
17:06Just a few days ago this system was launched.
17:09It's just the timing is incredible.
17:12OK, next slide plays. So this just shows you the status of this program for the first 2 days we launched the system on the 13th and what we know
17:23from the first 2 days of active surveillance is at about 350.
17:27Phone calls have been made to long term care facilities together.
17:30This important information half of these calls have come from were made by DPH staff and about half were made by the student team.
17:38So this just really provides an idea of how great the need was for this program.
17:43The number of calls that are being made.
17:46Just shows you how much more quickly and how much more completely we can gather data in near real time from a long term care facilities.
17:56So it really just incredible.
17:57And it also I think signals that points to just how potentially impactful this program can be in terms of its ability to collect this information so quickly and so
18:09completely. We do expect that overtime the number of calls may go down as long term care facilities become.
18:16More able to enter the data on their own again,
18:19it's a new system for them as well,
18:21so we're all getting up to speed.
18:24So where do we go from here?
18:27Well, all of this work will continue and I'm sure it will evolve overtime.
18:31Will make improvements to the system and then at some point,
18:35I think some really important research questions can be can be answered from this program and from the data that we're collecting,
18:42whether it's from an implementation science perspective or about the effectiveness of infection control and Prevention programs,
18:47or about the effectiveness of being more proactive in keeping COVID-19 out in the first place will be a lot of really interesting questions.
18:55That we can answer and will have a tremendous amount of data to do that,
19:00and I think that's true for all of the public health academic partnership programs I talked about on a much earlier slide.
19:08Tremendous amounts of data that are being collected in such unique circumstances.
19:12I think there will be lots of opportunity for analyzing data in learning.
19:17Learning from this experience, but right now.
19:20The real priority is again,
19:22the public health response activity of identifying and controlling outbreaks.
19:28Next slide, please. So, to conclude,
19:32Jean Brown, use the word extraordinary in her introduction today and I'm using it here as well.
19:38I really want to acknowledge that during this incredibly extraordinarily difficult at frankly horrible time that I have been honored at truly honored and so lucky to be able to
19:50work with some of the most extraordinary people in the world.
19:54At each of these institutions,
19:56on all of these projects that I mentioned in the beginning.
20:01I, the commitment and the resilience and the effort and the way in which people do it in.
20:07Just stay calm and cool and collected in these just unreal times.
20:12It's truly inspiring really. Get choked up thinking about all of the people that I worked with on all these projects.
20:21And I will say it really,
20:23it does give me hope that the people at all of these institutions and organizations,
20:29tremendous hope that we will emerge sooner rather than later from this pandemic.
20:34and I think the ties between all these institutions will be strengthened throughout this process.
20:42Thank you.