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.



Communications Chair Anna’s CDC Practicum

Anna Tate

Communications Chair 


CDC, Office of Public Health Preparedness and Response (OPHPR):​

For the last month, I’ve been working as a Fellow in CDC’s OPHPR under the Office of the Director.

The ongoing and unprecedented Ebola outbreak in West Africa has triggered CDC to fully activate their Joint Information Center (JIC), a 24/7 emergency preparedness unit within OPHPR, and, more recently, to move its emergency operations center (EOC) to its highest activation level – level 1.  And THAT means that there is a wealth of people working diligently to help ameliorate the outbreak—both here in Atlanta and in the field in West Africa.

My job has been to update CDC’s official statistics on the number of cases and deaths in each of the affected countries. Whenever WHO publishes an update (which is typically every few days), we update our figures to be consistent with those of WHO. In addition to the number of cases and deaths, CDC also reports the affected districts and number of CDC staff members in each of the countries.

As part of my involvement in the response, I was able to attend one of the meetings in the EOC’s command center with leaders integral to the response (see picture below). Epidemiologists, logisticians, and communications experts, to name a few, were in attendance, and representatives from the Department of Defense (DoD) and WHO participated via teleconference. It was fascinating to get a glimpse into the workings of an outbreak response with some of the world’s leading experts in the field.












I am excited to continue working on the outbreak response this year and am particularly looking forward to working closely with OPHPR’s communications experts, who are keeping very busy. In fact, my boss is currently in Nigeria working with partnering organizations to provide accurate information about Ebola to both the public and health care workers (you can read more about his experience here: http://www.cnn.com/2014/08/13/health/ebola-outbreak-frontlines/index.html?hpt=he_c1).


CDC, Division of Viral Hepatitis:

Earlier in the summer, I also worked for a bit in CDC’s Division of Viral Hepatitis, which is in the Office of Global Health within the National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention (a mouth-full, I know). There, I helped draft country-specific guidelines and comprehensive plans of action related to viral hepatitis prevention methods and treatment options.


This summer has been exciting and rewarding, and I look forward to getting back into school mode and for another exciting year in SORT! Even though the Fall semester is still a week away, some of our members are already working on the first outbreak response of the year, assisting CDC by using OpenStreetMap to gather infrastructural spacial data in affected regions.


On a side note, I also got to see Sanjay Gupta report on the two Ebola patients residing at Emory’s hospital!


CNN’s Senior Medical Correspondent Sanjay Gupta reporting on the two Ebola patients at Emory University Hospital


Co-President Dasha’s Practicum in Belize

By: Dasha Klebaner, SORT co-President
Summer 2014

I’ve been lucky enough to spend this summer working with CDC’s International Emergency Preparedness Team in Belize for my practicum. During the spring semester, I participated in weekly training workshops on emergency preparedness, plan development, and Emergency Operations Center development with IEPT in order to prepare for the summer. CDC IEPT does amazing work focused on increasing preparedness and emergency response capacity throughout the world and this is the first time they’ve had someone on the ground for an extended period of time in Belize. It’s been an amazing experience building connections with the Ministry of Health here, and learning about public health preparedness.
 I was given the task of researching and writing the first draft of the Belizean Ministry of Health’s All-Hazards Emergency Action Plan under the guidance of my supervisor, Belize’s Disaster Focal Point. The point of writing a plan from an “all-hazards” approach is to standardize the way a governing health body responds to public health emergencies. The same basic steps are often taken in nearly all public health emergencies, whether it be an influenza epidemic or a hurricane, and ensuring that these steps are not only followed consistently, but executed in an efficient manner, is essential to a cohesive response.

Through a series of interviews with Ministry of Health officials, consultations with CDC, and extensive conversations with my supervisor (who probably got tired of answering my questions), I gathered basic information about what is usually done to respond to emergencies, and what could be done better in the future. I gradually honed this information into a series of steps, broken down into strategic areas and followed by standard operating procedures. I also worked with MOH staff to develop Belize’s Incident Command System structure to ensure that the plan could be executed in the most standardized, efficient manner possible. Throughout all this, CDC supported my work with supplementary materials and templates to ensure consistency in Belize’s approach to emergency response.

Earlier in the summer, I was fortunate enough to be able to attend a conference in Belize City with emergency coordinators from all the other Central American countries; it was a valuable experience to be able to see how culture and government structure influence emergency response, and to improve my non-existent Spanish! When you literally only know 10 words of a language, there’s nowhere to go but up.

In addition to working, I have also had the opportunity to do fun things (see pictures below)! Belize is an amazing country with so much to offer, and I’ve been lucky enough to see some of the highlights, ranging from massive Mayan ruins to incredible scuba diving sights! I also went ziplining in Guatemala, which was equally awesome. I’ve tried my best to learn some Creole, the language most Belizeans speak, but have only been successful in learning “Mek a tek wah picha,” which either means “Can I take your picture?” or “Can you take my picture?” That, and “Dis da fiwi chikn,” which is on a bunch of billboards advertising a poultry distributor and means “This is our chicken.” Clearly the Creole learning is going well. FYI, I probably butchered the spelling of both of those.

While I will miss this incredible country and its amazingly friendly people, I’m very excited to be back in Atlanta (with 20 bottles of Marie Sharp’s Habanero hot sauce in tow, obviously). I can’t wait to get back to classes (weird, I know), SORT activities, and of course, to a new class of SORT members in the fall!



The National Emergency Management Organization, or NEMO. I found it. Get it?


The path I took to work everyday. Although Belmopan is the capital, it’s rather small and has under 10,000 inhabitants. Belize itself has a little over 300,000 people! That’s half the size of most US cities.


One of the many temples in Tikal Park, which is the largest Mayan site. It held close to 90,000 inhabitants at its peak, and spans an area of 23 square miles. It is GORGEOUS!


Me looking much more intense than I actually am.


My best friend in Belize


Belize is clearly a very ugly country


SORT Members Assist CDC with Response to Potential Rabies Virus Exposure in SC Hospital

By: Anna Tate
MPH Candidate 2015 | Global Health
SORT Secretary & Communications Chair

We are excited to announce SORT’s participation in the first official outbreak response of the year!

Two weeks ago our members took advantage of an incredible opportunity to assist CDC with a response to a potential rabies virus exposure in a South Carolina hospital, where over fifty bats were reported to have been seen. Because bats are now the most common human source of rabies in the United States, a potential exposure of this magnitude – particularly one that included hundreds of vulnerable hospital patients – is a critical situation and requires a coordinated response. CDC was asked to lead the investigation (in collaboration with the Department of Health and Environmental Control and the hospital), and the team needed to be diligent and to act quickly.

The rabies virus infects the central nervous system (causing acute encephalitis) of those infected and, if not treated with post-exposure prophylaxis before the onset of symptoms, is nearly always fatal. While rabies is rare, a potential exposure (from bats, for instance) necessitates diligent precautionary measures to ensure timely treatment for those who may have been exposed (typically via a bite).

Dr. Neil Vora, MD, an EIS officer in CDC’s Poxvirus and Rabies Branch, led the investigation and coordinated SORT’s involvement in the response. Working shifts over a span of several days, members worked in CDC’s Emergency Operations Center (EOC) entering data into Epi Info, conducting systematic data quality checks, and facilitating a centralized call center to interview both patients and staff at the hospital who were potentially exposed to rabies virus.

This hands-on and multifaceted experience at the EOC proved to be a very valuable and rewarding experience for SORT, as our members were able to gain practical experience in a real-time and critical investigation, learning about the various challenges and intricacies of such a response.

Here is what several of the participating SORT members had to say about their experiences:

“It was amazing how quickly those of us working on the response were able to coalesce as a team, even with our varied backgrounds, to work towards the common goal of notifying the public about their potential exposure to a deadly disease. Over the two shifts I was able to contribute to the response, I was personally in a group of two EIS officers and a medical student and a mix of fellow SORT members with very different interests. With one SORT orientation and the open leadership style of Dr. Neil Vora, we had the opportunity to make a real difference in an affected community and to do some good public health work at the same time–in our spare time! In short, a wonderful and unique opportunity to participate in a real, fast-paced and meaningful public health emergency response.”

-Grayson Mitchell Privette
MPH Candidate 2014 | Global Environmental Health


“During the rabies response recently, my role was mostly to conduct data quality checks by double-checking survey entries against what was recorded in an Epi Info database. It was emphasized to us, at multiple times during our shifts, that there was no room for error, so it was useful to be a stickler for correct data!

What I got out of the experience, mostly, was an increased appreciation for Epi Info (I had previously taken a class in it, but never really thought of how to use it in a “real-life” application). At any rate, the whole experience gave me a better sense for what it was like to work in disease response. It’s not just the flashy “go in and save the day” response that a lot of people expect from an outbreak response, but rather more of a methodical “let’s make sure we’ve traced everything” approach — which I really appreciated getting a practical introduction into!”

-Michelle Schmitz
MSPH Candidate 2015 | Global Epidemiology


To see more photos of the response, check out our Facebook page (a special thanks to Sunshine Lickness (SORT) and Mark Fletcher (CDC) for the photos!): https://www.facebook.com/SORTEmory

Additional information on the bat exposure:



Additional information on CDC’s EOC:


Law Enforcement Public Health and Stockpiles

You know how much of a hassle it can be to get medication when you are ill. First, you have to go to the doctor and get an exam. Once you get the prescription, you go to the pharmacy to fill it. And if you’re a graduate student like me, you hope you have enough money to pay for the pills. However, in a public health emergency (say an anthrax release), it would be even worse. There would be long lines and limited doses. The Centers for Disease Control and Prevention (CDC) has come up with a program to avoid this situation called the Strategic National Stockpile (SNS). SNS is stashes of critical medicines and medical supplies established to protect the American public if there is a public health emergency large enough to cause local supplies to run out. This means that if there were a disaster, SNS would ship its supplies wherever it’s needed in the U.S. It’s fast and free.

Where would you go to get your medication in an emergency? You would go to a Point of Dispensing (POD). You won’t need a prescription or your credit card. Pick up your pills, take them as directed, and you won’t get sick. It’s prophylactic medicine. If you’re already ill, you’ll need medical attention at a hospital or clinic.

Simple? Well, emergency planners try to make it look easy, but there is a LOT of planning that must happen long before an emergency occurs to ensure it goes as smoothly as possible. I learned this when I was part of a POD planning team. We researched, wrote, and revised (and reviewed, revised, researched, and revised some more) a plan to distribute medication to our employees in the case of an emergency. Many other employers have similar plans to distribute medications to their employees. PODs run by local health departments will be stocked and available to everyone.

When I learned that SORT students had the chance to attend a Law Enforcement Summit on this topic, I jumped at the chance to learn more about the security aspects of PODs. The Law Enforcement Summit added a lot to my understanding of how POD security operates. One of the first things I noticed was the large number of law enforcement agencies present at the summit. The U.S. Marshals Service, Georgia State Patrol, and numerous local law enforcement agencies came together to plan security for distributing and dispensing SNS supplies. A lot of people need to be involved to develop a reliable plan.

Some of the issues considered included crowd control, directing parking, security sweeps of the PODs, active shooter planning, security during transportation of the medicine from the warehouse to the PODs, and what to do if a security breach happens.

As a participant in this summit, I furthered my emergency preparedness planning experience and met local law enforcement and planning leaders. To learn more about the Strategic National Stockpile, visit http://www.cdc.gov/phpr/stockpile/stockpile.htm.

Dara Burris is a second year epidemiology student and SORT member since Fall of 2013.

Learning about the CDC’s Emergency Operations Center (and many acronyms too!)

On Thursday, January 24, 2013 several SORT members attended a full-day training at the Centers for Disease Control and Prevention (CDC) to become qualified to work in the Emergency Operations Center (EOC).

When the EOC is activated, SORT members may be called upon for a variety of tasks that require an understanding of the organizational structure and systems in place at the EOC.  Students heard presentations from each of the main units in the EOC, including the Logistics section and the Operations section. It was fascinating to learn about the equipment and supplies that are available from the Strategic National Stockpile (SNS) at a few hours’ notice in the case of an emergency.

During the training, students interacted closely with CDC employees by engaging in-group exercises. Software demonstrations were also conducted to familiarize trainees with the EOC’s intranet platform.

Finally, the day wrapped up with a tour of the EOC. For those of us who have not yet worked on a response, it was pretty amazing to see such a state-of-the-art facility and know that we are very well equipped to handle a wide range of emergency responses. As a student in the Behavioral Sciences and Health Education department at Rollins, my favorite part was learning about the function of the Joint Information Center (JIC) and the channels through which they handle risk communication. Although no one ever “wants” the EOC to be activated, I look forward to volunteering at the EOC should we be called upon for assistance!

To learn more about the EOC visit: http://www.cdc.gov/phpr/eoc.htm

To contact SORT, please email mailto:sort@emory.edu

Samantha Jacobs is a first-year MPH candidate in the Behavioral Sciences and Health Education department at the Rollins School of Public Health. She has been a member of SORT since fall of 2012.