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.