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Outbreak response to an unexpected exposure


By: Hannah Wang, 2nd year EMPH Applied Epidemiology student

Disclaimer: The content of this blog is a reflection of my personal experiences and opinions and does not represent the official position of Denver Public Health, the Centers for Disease Control and Prevention, the Department of Health and Human Services, or Emory University. 

In August of 2013, Denver hospital emergency departments (EDs) and the Rocky Mountain Poison and Drug Center reported an increase of patients with excited delirium. At the time, I was a Centers for Disease Control and Prevention (CDC) Public Health Associate working at Denver Public Health (DPH), Denver’s local health department, on their Emergency Preparedness team. It was Friday around 4:30pm, when my supervisor at the time, asked me to join a call with the Colorado Department of Public Health and Environment to discuss a potential public health outbreak.

During this call, the cause of the outbreak was determined to be related to synthetic marijuana, a novel exposure that many of us were unfamiliar with. Synthetic marijuana is a mixture of dried herbs and spices sprayed with chemicals that, when smoked, create a high similar to THC, the main active ingredient in marijuana. They are usually sold as dried leaves in a small bag and labeled as incense, potpourri, or herbal smoking blend that warns consumers that it’s not for human consumption. These products are often sold in gas stations and convenience stores, under a variety of brand names including K2, Spice, Funky Monkey, etc. Reports from hospital EDs had showed that people were coming in with elevated heart rates, agitated delirium, hallucinations, drowsiness, and even comas after reporting using synthetic marijuana.

In order to better understand the scope of the illnesses caused by synthetic marijuana, we needed to establish methods to capture information about those affected to conduct an outbreak investigation. Our first step was to notify hospital EDs and essential partners like other local public health departments, Denver Environmental Health, Denver Health paramedics, etc. to ask for their help in the investigation. We created a surveillance form to ask hospital ED staff to record the medical record number (MRN) for patients with suspected synthetic marijuana exposure and fax the completed forms to DPH. This was needed for us to flag patients who may have been exposed to synthetic marijuana while we figured out how to investigate this unusual outbreak. In the meanwhile, Denver Health Paramedics collected patient transport data to show the geographical dispersal of the outbreak to identify potential ‘hot spots,’ which was helpful in showing some clusters.

Because the outbreak spanned multiple metric area jurisdictions, the state health department took the lead in the outbreak investigation while we provided our surveillance information to them. Eventually, CDC epi-aids were called in to assist with chart abstraction and patient interviews and analyze data. You can read the MMWR here.

Although I did not have a large role in this outbreak, it was a phenomenal learning experience, from identification of the outbreak to the development of the outbreak investigation. This event was unusual because it didn’t involve a communicable disease, which public health is more accustomed to dealing with, and was related to an illicit drug that is hard to track. Moreover, the investigation heavily relied on effective partnership from various areas (such as local health departments, paramedics, poison control center, and even law enforcement) because traditional surveillance methods didn’t capture this exposure. It even sparked a debate among healthcare professional with little public health background on whether this was a public health emergency that required a response and what their role was in the outbreak investigation, which was an interesting conversation to be a part of. It really demonstrated the various public health issues we may face, the need to be adaptable during outbreak investigations, and the importance of strong partnerships.

2017-2018 Applications

Interested in joining SORT?

We’ll be tabling at the Rollins Student Resource Fair on August 21st from 12pm to 3pm. Come by and talk to us!

Also, be sure to come to a SORT Information Session on August 29th or August 30th from 12pm to 1pm in CNR 3001. We’ll go over the application process and tell you more about the opportunities as a SORT member.

Applications will be available on August 31st and due on September 8th! Check our website and Facebook page for updates. If you have any questions, please email



Happy National Public Health Week!

SORT members and other Rollins students had a great time celebrating National Public Health Week at today’s Lunch ‘n Learn. A big thanks to Thomas Paige of the DeKalb Emergency Management Agency for speaking with us. The topic of community emergency response couldn’t have been more appropriate given today’s weather!


SORT Member Practicum Spotlight: Laura de Mondesert

As part of their Rollins School of Public Health requirements, many SORT members engage in full-time practicum experiences both domestically and abroad.

In our ongoing series, we hope to highlight some of the amazing things our members are doing in the field of outbreak and response. First up, a recap of second-year SORT member Laura’s field experience in Brazil!

From May to July 2016, Laura worked as a research assistant in Minas Gerais, Brazil, piloting a mixed case-control study. Her study aimed to delineate the role of parasitic co-infections and micronutrient deficiencies on the onset and progression of Hansen’s disease, also known as leprosy. In piloting the study, she translated study documents, worked to gain study approval by the Brazilian IRB, trained collaborators on the study protocol, assisted community health professionals with contact tracing, and managed active patient recruitment in rural communities surrounding the city of Governador Valadares. During her time in Brazil, her team screened close to 120 patients for leprosy in the community of Limeira de Mantena. In a second component of this project, Laura collaborated with local health departments to obtain geospatial data on cases of leprosy, schistosomiasis, and leishmaniosis in the past five years. Using the Brazilian national notifiable disease surveillance system, SINAN, she conducted a preliminary spatial analysis of Schistosoma mansoni and Mycobacterium leprae infections in the micro-region of Governador Valadares, Minas Gerais, Brazil, and surrounding areas, reported over the last five years. The goal of this study is to determine whether spatial and temporal associations of these two infections exist in this area of Brazil. As one of Laura’s deliverables to the project, she created maps of the study area using geocoding techniques learned in Brazil, and presented these maps to the Board of Directors at the collaborating medical school in Vespasiano, Minas Gerais, Brazil. The success of this presentation led to the study being awarded continued financial support!

Stay tuned for more updates from the field! 

An Unexpected E-MERS-ency

My name is Kevin Weiss, and I spent my summer as a graduate intern at the U.S. Centers for Disease Control and Prevention (CDC) – Thailand Ministry of Public Health (MOPH) Collaboration (TUC) office in Bangkok, Thailand. I was working as an intern for the HIV/STI Research Program (HSRP) in the CDC’s Division of HIV/AIDS Prevention (DHAP). Acronyms upon acronyms!

My initial project focused on completing a spatial analysis of an HIV voluntary counseling and testing (VCT) dataset from a CDC-backed clinic intended to serve men who have sex with other men (MSM) and transgender women (TGW). This was a fruitful analysis as well, with fresh abstracts to be submitted for an HIV conference.

My summer took an unexpected SORT-like turn when my supervisor asked if I could set aside my practicum for a week to assist in a MERS response. I agreed!

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A peek into the EOC room at the Thai Ministry of Public Health

The TUC office was located on the campus of the MOPH, which facilitates collaboration and cooperative work. As such, when an Omani tourist who had traveled to Bangkok for medical reasons tested positive for Middle East Respiratory Syndrome (MERS), we noticed an uptick in activity around campus. I and a few other CDC-ers actually made it into one news channel’s broadcast of a joint World Health Organization-Ministry press conference.

I was asked to serve by the MOPH, with an initial focus on contact tracing for the individuals who had contact with the individual who was isolated at a government infectious disease hospital. Including medical personnel and airplane passengers, this number was estimated at over 175 people. Although I didn’t get involved too much on that end, some of the concepts and ideas used to trace contacts included use of social media platforms. The job of an outbreak-responder or epidemiologist includes thinking outside the box in manners such as these.


Thai and English versions of the Health Advisory

As part of a MERS working group, I spearheaded the creation of a rapid respiratory infection control questionnaire for a rapid capacity assessment for 70+ regional and provincial hospitals in Thailand. I drafted an initial list of questions in English using resources from the World Health Organization, CDC, and other previous investigations. After a number of revisions, the assessment was translated into Thai and piloted among infection control nurses at a few Bangkok hospitals as a trial.

Unfortunately this was when my practicum ended. The results of the survey are intended to be used to evaluate response capacity for severe respiratory conditions country-wide and identify areas for improvement or targeting of resources.

On the whole my practicum was an excellent experience, and the MERS experience exposed me to outbreak and response in a professional capacity. Two weeks had passed and no more cases were reported, so while my survey was not used during this summer response, it can serve as a base for future response efforts.

This experience was unparalleled, providing a gratifying and meaningful time for an aspiring student. I am deeply grateful to all who allowed this to happen and for me to participate, and I hope to take these lessons and experiences and apply them in the future.