| Home > Events > 2nd National Symposium > Michael Osterholm How to Vaccinate 30,000 People in 3 Days: Realities of Outbreak Management
Michael T. Osterholm, PhD, MPH DR. INGLESBY: Our next speaker is Dr. Michael Osterholm, who is known to many of you. He's the current Chairman and CEO of ICAN, Inc. Prior to this position, he served in various capacities for 24 years in the Minnesota Department of Health, 15 years as the State Epidemiologist and Chief, Acute Diseases Epidemiology Section. He's an Adjunct Professor at the Minnesota School of Public Health, University of Minnesota School of Public Health, written more than 185 papers, 18 book chapters, countless publications on bioterrorism. He served as a personal advisor on bioterrorism to King Hussein of Jordan, has spoken widely on the subject, and has recently published a book on bioterrorism entitled "Living Terror." His talk entitled "How to Vaccinate 30,000 People in Three Days: Realities of Outbreak Management." Dr. Osterholm? DR. OSTERHOLM: Good morning. Thank you, Tom. Thank you also for the invitation to be here today. Let me just say, parenthetically, in follow up to last night's discussion -- Tom mentioned my role with King Hussein -- if there's any doubt whether Iraq has small pox, His Majesty told me a month before he died that he knew Iraq had small pox. So there is an answer to that; some were doubting that last night. There's no doubt in my mind. But today what I'm here to talk about is the issue of, how do we begin to look at response? And what you're going to get from me today is really a collective experience. There is no textbook. There is no chapter written. There is no one way to define it. As much as I congratulate the New York City Health Department for their work with West Nile Virus, it only brings back memories to me where in 1984 I was in charge of spraying malathion on 287 Minnesota cities, over 45,000 square miles, because of an outbreak of western encephalitis. Our group has worked up the single largest food-borne outbreak in this country with 320,000 cases of salmonellosis associated with Schwann's ice cream. And today I'm here to talk to you about the issue of meningitis outbreak and a very large immunization program.
Not any one of these experiences give us the answers. All of these experiences give us a common vision of what the future might be -- a vision that, I might add, that to date I am concerned that we have not really learned from the local to the state to the federal level. What I'm here to talk about today is an outbreak that occurred, as they usually do, on weekends. A phone call came in on a Saturday morning, on Super Bowl Sunday weekend in 1995, to Dr. Richard Anella, who's in the audience here. I quickly received that call. Three students in the community of Mankato, Minnesota, all from one high school, had been hospitalized in the previous 12 hours at the local hospital with suspected Neisseria meningitidis infection. All three of them were in serious to critical condition. What then transpired over the next month was actually two separate clusters involving ultimately 10 cases and one death of Neisseria meningitidis, resulting in an immunization program where over 30,000 of the residents of Mankato, Minnesota, were ultimately vaccinated. There are 55,000 residents in the community. As some of you may not be aware of, Neisseria meningitidis, particularly group C, is the strain that we worry about most in cluster outbreaks that had occurred particularly during that time in the mid 1990s, and usually involving college campuses in particular. What I want to talk about today briefly is the overall view of the panic and fear that did occur, and why I think it so distinguishes itself from the acute event, like an explosive device or a natural disaster like an earthquake or a hurricane, whereas I think a biologic event does, Tom, give a very different sense of potential for panic and fear -- issues around surveillance and medical care of the communications systems that are necessary, vaccine and antibiotic distribution, public relations, political considerations, medical community relations, and cost. But before I can really comment on those, let me walk you through the experience as we had it unfold for us. As we talked about, we had a situation where by Saturday morning we recognized that we had a particular outbreak occurring. We continued to work through this on Saturday. With Sunday, a new admission had come in Sunday night, although at that time was not yet one of the three cases. We actually had a meeting with the local medical community, the hospital, the local public health, and we actually did bring the media in very early, along with elected officials. And we decided, because of this issue, that we would need to vaccinate students in one of the two high schools in that town, in particular where all three students came from. We ultimately expanded later in that night's discussion to all high school students, all junior high students, based on this particular potential for explosion you might say. An actual immunization clinic was planned for two days later. It took us that long to get the vaccine in, and, fortunately, we were able to get vaccine. However, things continued to unfold as the week went on. The immunization clinic which we held on Tuesday morning was quite remarkable. We vaccinated 1,000 students in 35 minutes. Public health does have the ability to do some remarkable things. We had six lines set up, and I'm going to tell you that because that all happened within the context of a school setting under a very controlled situation with a very well-defined system for obtaining consent. You can't do that in the general public. It's the difference between how you handle prisoners and how you handle the general public, you might say. (Laughter.) That's a big difference. (Laughter.) And that's an important point, because you might want to extrapolate those numbers from that particular point. As the week went on, we actually had five students that had become ill. We also had -- four students, excuse me, and a 64-year old woman who had a lot of contact with the students; and, therefore, we felt that this person was part of it. We thought things were winding down. We immunized 3,300 people against meningitis, using a combination of the public health system, the hospital-based system, volunteers within the nursing community, and so forth, and set this thing up. This was a challenge, just to do this in the amount of time. The panic and fear was not yet there. People were concerned but not yet there. But then, just as we thought this was winding down, on Friday morning I received a very dreadful call, and, in fact, a student, a junior in the high school at that time, walked into the hospital under his own power at 7:30 on that Friday morning with what was obviously rapidly-developing meningitoxemia. At 10:30, they pronounced him dead. It was one of those situations where the panic and fear -- and now, by the way, another student was just now being admitted, and this individual, by the way, had been vaccinated. He had gotten his vaccine on Tuesday. It obviously had not yet had time to take effect. I also wanted to here, as the panic and fear took over, this was one of those situations where you talk about taking care of the caretakers or the Health Department people. This particular boy that died -- actually, I spent a fair amount of time with his parents that afternoon -- happened to be exactly the same age as my daughter. I wanted so desperately to go home and kiss her goodnight that night. I couldn't. I went to bed at 2:30 that morning and got up at 5:00 like everybody else to get ready for the additional efforts. And we often don't appreciate what toll that takes. We had the classic news issue. Unfortunately, this happened during the month of February, which, many of you know, in this country is sweeps month. And so this became the sweeps month story for all of the midwest media. We had satellite trucks all over through town. That was not such a problem in the sense on a whole they were doing a pretty good job with the media, particularly the local media. But there were many examples where just a single media mistake made major issues. On the Sunday night of this particular weekend, one reporter doing a live standup report got confused and thought he had heard the Mayor say they were going to close all of the schools. So he reported that live on TV at the 10:00 news on the number one news channel in the State of Minnesota, and we then had to deal for the next three days with what the confusion was around this one reporter's error. And I think there is also a big distinguishing feature between live media and print media. And I would urge, as we talk about media, we don't lump them into one category. I think there's a big difference there that's very important. We had a weekend of watching and worrying. This was -- we were going to now vaccinate additional individuals. Every student in the Mankato area was now going to be vaccinated. This was an auditorium full of individuals, much larger than this auditorium, and the panic and fear began to develop as we talked on that Saturday afternoon. I think the issue of what people are looking for in times like this -- they're looking for someone that they can feel confident and reassured in. I'm not sure that I offered that voice at that time, but it was ironic that I had just helped complete writing the American Academy of Pediatrics Red Book Committee, or Committee on Infectious Diseases, guidelines on how to deal with meningitis. And I had never been at one like this before, and I just got done writing the guidelines before that. But it gave some people the sense, we must know what he's talking about; he wrote the guidelines -- even though they didn't know I was making it up as we went. (Laughter.) But I think that's a very important message, that you've got to have somebody that people believe is in charge, and somebody that can help. This particular father you see here was an individual who was extremely angry, wanted the schools closed. We figured that, as the epidemiology had shown in many other instances, that the transmission of Neisseria meningitis likely was through intimate contact, saliva sharing, and so forth, and that the places where that often occurred was in the shopping malls where they shared pop and sodas, and beer at beer parties, and etcetera, etcetera. And, in fact, ultimately, we could trace most of these students back to a single party that had occurred -- the students that were cases. What was amazing is this particular individual right here kept his daughter home that next Monday, along with 14 other daughters, who all went to his house and had a party there all afternoon sharing pop cans. Again, what people may perceive as risk reduction may be risk enhancement, and what you're saying is risk reduction may not be believed. And so you often have to deal with that issue. We tried to get or regain a sense of normalcy after this immunization program. This is now February 17th, two weeks later. And I only set the tone here because now our staff has been going non-stop for basically 23 days, 18-hour days. We no sooner get done, we're ready to go here, and an outbreak of invasive streptococcal group A disease occurs in Rochester, Minnesota, in an area around there. Seven cases occurred very quickly. Four patients died. We did not even have a moment to ourselves. We literally went to Rochester, and now we're in the middle of this big outbreak, which was a second huge news media story for sweeps month. And we still had people working 18-hour days. We were just getting ready -- we got that one wound down, and we got people pretty comfortable with that, and then kind of all hell broke loose. The last Friday of February, as we were just winding down the invasive group A strep situation in southeastern Minnesota, a second case -- a student outside of the school district -- and then a third case in a college student. There was a college in this town -- then occurred on that particular Friday and Saturday. And so we never skipped a beat. We went right into it, and at that point it was clear that the outbreak was no longer contained in these students. It was in the community. It was much larger. Not knowing what was going to happen here and in other communities where group C meningococcal outbreaks emerged like that, they continued to often be big. And so we knew we had to vaccinate largely the community, particularly those under age 35. We then moved to do that, and in a period of four days we ended up vaccinating 26,000 people. We thought originally it was going to be 20,000. It ultimately ended up as 26,000 people. The logistics were a nightmare, in terms of attempting to basically get us put together here, and what was the necessary materials we needed. What you saw happening here was long lines occurring. We actually put together a single site to do this at, which was an Army Reserve location. We did that because of traffic and because of the fact that we could get at it. One of the issues that -- it was addressed earlier -- was in this case we also gave rifampin, along with immunizations. Rifampin is an antibiotic. All of this came in large containers, and in Minnesota you have to be a registered pharmacist to dispense medications. We had to get special dispensation to have people literally sit hand-counting rifampin, and actually also making it up into simple syrup for pediatric doses, which was a nightmare. We literally called in every pharmacist we could find in the State of Minnesota to get involved with this situation. The long lines in Minnesota are not that bad, unless it is the middle of the winter where the elements are substantial, and we had lines that were blocks long. We had traffic jams that occurred. We actually worked out a transportation system to get people to move in from other locations and park and then come in and get back out again. Within the first day, also realize that people have other human needs -- (Laughter.) -- and that you don't often think about those kinds of things that were very important. We ended up getting 6,000 people who got their shots on the first day. Ultimately, over a four-day period, we vaccinated 23,452 individuals. With the original 5,800 and some we vaccinated, we came out at 30,000 people. The outbreak stopped. But what did it mean? Well, first of all, we did have a lot of panic even in this situation. We actually had truckers that would not come through this community, and because this community was on a main highway in Minnesota -- for weight-bearing purposes, those trucks can only go on certain highways. We had truckers that literally went 210 miles out of their way to get from town A to town B, just so they wouldn't have to drive through the community. Panic was clear and evident, and it's because partly it's an infectious agent, which hits all of our psychological buttons, and part of it was the fact that it also was something that dragged on, and no one knew who was next, when was it going to hit, where was it going to hit. So I would -- unlike Dr. Glass' examples, which I think are very good ones, biologic agents take on a whole new dimension to them than something that happens right now and we're into consequence management thereafter. What were some of the issues that we learned? Panic and fear was clear. And in this case, where we didn't have a respiratory transmitted agent as such, we were able to convince people that there was some nature to the saliva contact, etcetera, that helped. I can only imagine where there wasn't enough antibiotics or wasn't enough vaccine, and we had a respiratory-transmitted agent, the panic and fear that we saw here would be mild. Surveillance and medical care must be kept up and ongoing. I can tell you that any time something like this happens, anyone who had a flu-like illness came in. Every person thought that their son was that kid dying, because that son woke up one morning with a fever, the same way that that boy that did die woke up with a fever. The emergency room was overwhelmed in this community. We actually had to set up a separate emergency room for the hospital. That was a major triage issue. And we were sitting there constantly trying to figure out who was really a potential case and who wasn't. Remember, this occurred right over flu season, and so we had the two sitting on top of each other. In terms of communication systems, I can only tell you that we typically really don't understand what communication means from an electronic standpoint or from a person-to-person secure standpoint. And in terms of just trying to communicate with professionals who are already overwhelmed -- it wasn't just the electronics of it. If they are working 18 hours a day, how do you get them to take half an hour out or whatever to give them an update, to make sure they know and to have them be a stakeholder in what's going on. So you have to force communication. Some people may think that sounds crazy. You have to force it, so people know what's going on. And as far as the general public, we had to set up a phone bank. We brought down two different phone systems in a period of one day, and very few of us have really thought far in advance of, how would you set up a multi-line phone system that would not bring down a particular exchange? You've got to have that in place, and then you've got to know how you're going to staff it. We actually had -- every nurse at that hospital literally was working 18-hour days, both as a nurse on staff and then volunteering in their off time to man the phone bank, along with public health, to answer all of the calls. We have a situation in vaccine and antibiotic distribution. That was the right slide. You have the issue of the source. We were fortunate to be able to get meningococcal vaccine flown in from Pennsylvania, although we did have all of the same problems of weather. It was in the middle of the winter. We actually almost had a flight missed because O'Hare was snowed in. All those kinds of things. You have the issue of cost. This ultimately, just the vaccine part of it alone, cost the State of Minnesota $1.2 million. My entire budget for the section at that time was about $2.2 million for the entire year. At first we thought we were going to have to eat that cost. Fortunately, the state legislature did an emergency appropriation. The hospital was never reimbursed. The hospital took a heavy hit. It was a major hit on them. And to this day, they had to eat it as a community. In terms of the issues of packaging, and so forth, I mentioned earlier that we paid very little attention to that. That is a key issue. And the federal stockpile has to listen to the local people tell us -- tell them how they need it, how it's going to work best, in terms of just getting it out there. If you have to spend twice as much time to get it ready to give as you have to give it, that's a problem. Also, the issues of storage and security, we weren't really in a problem situation here, but I can only anticipate that in future outbreaks where vaccines are in short supply, or antibiotics, that will be an issue. And then, finally, in terms of administration, let me just show you a whole series of things. Having enough professional staff -- we ultimately involved over 600 people in this outbreak response. To be able to actually have the physical location, you've got to find a place that, from a traffic pattern standpoint, from a security standpoint, from all of the elements of having thousands of people converge it, you can deal with. You actually have to have crowd control. You saw the long lines there. This wasn't a panic and fear situation, as it might be in some. But very few people really understand what it means to have crowd control in that kind of setting where lines can last for hours. We had people that literally waited out in the cold for 10 hours to get their shots, with young children. And so the point is, how do you deal with crowd control in a setting like that, where you can expect nervous, panicked people are only going to get more frustrated? You have the issue of eligibility. We actually had people who were scared away from this community. We had people who came in 30, 40, 50 miles to get vaccinated, because they knew it was going to hit their community next. How do you determine what eligibility is? You don't have time to sit there and argue. But if you're trying to measure out a very limited supply for a very high-risk group, much as we're trying to do with the influenza immunization right now -- and we're not doing a very good job of it because we've got a lot of healthy 20-year olds getting vaccinated right now in workplace settings -- how do you do that? And that's an issue. The area also, then, of consent, particularly for minors, is a very, very big issue. And then you run into the issue of contraindications, and what are you going to do with that. Let me just close off here, then. Public relations is a key piece. I think all of the comments that have been made about the media, and so forth, are very important. We need to be able to deal with that. The political considerations -- we were lucky in Minnesota that several of us were well known to the political leaders. We involved them early on. The governor of Minnesota, who was a former participant in the first symposium, was someone that I had worked with closely, and so he, of course, kept telling the media that he was very convinced we were doing the right thing, and that was good. But I know in other situations where you can get a political crosswire going between a local and a state that can bring the whole thing down like this in terms of questioning. And finally, last but not least, is just the medical community relations. Remember, we've all been talking about how the medical community is not involved in this planning. Well, they typically are too busy. But now when it's in their backyard, and they need to be the local authority, they need to be seen as the trusted voice, how do you communicate with them quickly that you're going to go do this program, and yet they've got to be part of it, but they don't know what's going on, and yet they've got to support it. And working with your medical community at that time is kind of like trying to drain the swamp when you're up to your ass in alligators. That is something that's got to be done now, not later. You've got to get the medical community on board. I would just close by saying, in response to an outbreak of meningitis in Minnesota, pushed one of the premier state health systems in the country to the edge. I've done a survey of state epidemiologists, an informal one. I think that there isn't a state in this country right now that, on average -- larger states could do different -- that could vaccinate more than 10,000 people per day. This past weekend, the Thanksgiving weekend, there were 300,000 people that came to the Mall of America in the Twin Cities. If you look at any large city in this country, Minneapolis-St. Paul, of 2.5 million people, you do the math -- if we could vaccinate 10,000 people a day, how long it would take to get done. Totally unacceptable. There is no local system in this country that's prepared to deal with this. It's going to have to be a federal, state, local partnership that has to get planned right now, because we're going to have to vaccinate. We're going to have to give out antibiotics in a very short period of time. I think this really benchmarks our ability to respond to a -- this outbreak to this particular bioterrorism event. But I think the thing I'd really leave you with is it isn't really pretty from where we stand right now. We could not do much more than what we did here in Minnesota. We have a very, very premier system. If this had been a need to vaccinate 100,000 or 200,000 people, for me, it would have been the difference between having to walk from here to across the street versus having to walk home to Minnesota today. I'd have probably just given up and said, "It can't be done." We've got to address that issue now, or I'm afraid when it does happen we're going to have a lot of people thinking, well, it just can't be done. Thank you very much.
(Applause.)
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