As a guy who went to the Mountain State Fair this year — and roamed around the Davis Event Center — I’m not feeling all that great about the public health response to the Legionnaire’s outbreak.
I know public health officials have a tough job to do, and nailing down exactly what this ailment was, when it emerged and who it was affecting took time, especially as people who have contracted the disease typically present symptoms within 14 days of exposure to the bacteria. The Mountain State Fair ran Sept. 6-15, so that incubation period should have closed by Sept. 29.
The public found out Sept. 24 — from a television reporter — that multiple people were sick with the disease, with a connection to the Mountain State Fair. Buncombe County issued a statement after the news report aired.
The source of the bacteria has been difficult to nail down, although health officials know Legionnella bacteria lives in water and often spreads through ventilation systems or via water sources such as misters or hot tubs.
On Oct. 3, the state issued information narrowing down the possible source of the bacteria to hot tubs on display in the Davis Event Center at the Mountain State Fair.
“We do have indication from our epidemiological study … that having walked by the hot tubs is linked to Legionnaires’ disease,” said Dr. Zack Moore, state epidemiologist, on a media call that day. Legionnaires’ patients are also more likely to have visited during the “latter half” of the fair.
On the Legionnaires’ outbreak:
► Davis Center connected to Legionnaires’ outbreak; authorities suspect hot tub
► Legionnaires’ diagnosis leaves Henderson family asking and answering questions
I walked by the tubs, but not that close, and it was early on in the fair. So I feel safe.
But a lot of folks don’t. Overall, the response of county and state health officials, and the dissemination of accurate, useful information, has seemed sluggish and unsure.
Buncombe County on its response
Also on Oct. 3, I sent to the Buncombe County Department of Health and Human Services a list of questions and concerns, some my own and some that I’ve heard from other folks. Jan Shepard, county public health director, provided answers via email.
Here’s the Q&A:
Question: It seems the first anyone heard of this outbreak was when WLOS reporter Kim King reported on it (Sept. 24). Once the health departments knew she was preparing a story, why didn’t they issue a press release or hold a press conference?
Shepard: “This situation unfolded very rapidly with significant changes occurring almost hourly AND it involved multiagency, multicounty, state and national entities, so although this started as a somewhat local event, it quickly grew in ways that made it difficult to manage. As you say, the complexity of this situation is really the point, and allowed for disruption in the ways we would normally coordinate public communication.”
Q: Why have no press conferences been held, other than the one Oct. 3? That was a teleconference, hosted in Raleigh, by the way. It seems like coordinated, accurate information releases would be critical to public safety, and the best way to do that would be press conferences.
Shepard: “Once coordinated, daily press releases have been coming out.”
(Shepard did not address press conferences).
Q: Is the state supposed to take the lead on this type of situation?
Shepard: “In any disease outbreak, the State Division of Public Health works in tandem with local health departments. Who takes the ‘lead’ is determined by the details and circumstances of the outbreak. Again, I will point to the multisector nature of this outbreak (multiple agencies, multiple counties, multiple states involved), the need for coordination of communication and the complexity and rapid changes of this event.”
Q: Why were certain news outlets given extensive interview time and more timely information than others, i.e. the Citizen Times? Not to gripe about getting old information, but Isn’t the idea of public health in general to get out accurate, timely information to the maximum number of news outlets?
Shepard: “The public health response to outbreaks of communicable disease involves surveillance to identify cases of disease, investigation of those cases to determine the cause of the outbreak, and implementation of control measures to prevent additional cases of the disease. Communication to the public is a part of that process. Accuracy and timeliness are our goals, and many factors weigh in to how, when, and what is shared. Again, the complexity and fluid nature of this situation contributed to how and when we were able to share information.”
Q: Are the health departments involved doing a “debriefing,” so to speak, on all this? Do they acknowledge errors in information dissemination? Will changes be made to avoid future failures?
► Legionnaires’ disease North Carolina: What it is, how it spreads, where it’s been reported
Shepard: “Every disease outbreak is unique and involves a lot of behind the scenes work to manage the circumstances in order to keep people from getting sick and/or spreading disease. Sharing information for that purpose is essential. Lessons are always learned from each unique situation and those lessons are applied going forward, but outbreaks rarely repeat themselves exactly. This situation is so unique and our hope is that it will never happen in this way again, but it is hard to predict how a situation will unfold in the future. It is our earnest intent to always communicate in an effective way that supports our role in the community to prevent outbreaks and control communicable disease.”
The public’s need for information from professionals
Seriously, the first I heard of the outbreak was King’s reporting on WLOS-News 13 on Sept. 24. In that segment she had an interview with Dr. Jennifer Mullendore of Buncombe County DHHS in which the doctor looked like she was being held hostage.
It was not a reassuring moment about a disease that has a 10% fatality rate. So far, we’ve had 128 cases as of Oct. 4 and just one fatality, so I’m fully expecting the number of deaths to increase.
Two of our reporters here at the paper, Elizabeth Anne Brown and Brian Gordon, have filed some excellent stories on the outbreak. WLOS has stayed right on top of the story, too.
No one wants panic in these kinds of situations, but the public definitely needs as much information as can responsibly be given out, by professionals in a professional setting.
In this case, as someone who walked by the hot tubs, I would’ve liked to have known some details about Legionnaires’ as soon as possible, including the fact that it lives in water and is usually transmitted through aerosolized water.
Imagine this scenario: You went to the fair. A few days later you start feeling pretty bad — tired, feverish, maybe experiencing diarrhea. You’re not the type that runs to the doctor all the time, or maybe you just have crummy insurance these days, like most of us.
So you decide to ride it out.
Would you have made that choice if you knew Legionnaires’ had been detected at the fair? And that it has a 10% fatality rate? Or if you knew you might end up in the ICU?
I suspect you would’ve gone to the doctor to get some antibiotics on board, as this is a bacterial infection. Then consider this: 170,000 people attended the fair, from all over the mountains, and across the state in some cases.
Further, I suspect some fans of quilting are really unhappy with health officials and the WNC Agricultural Center. First, the Davis Event Center at the Ag Center was ruled safe, allowing the quilt show to take place there last weekend.
Then last week the Davis Event Center tested positive for Legionella bacteria, and a gun show scheduled for this weekend was canceled. How does that happen?
More on Legionnaires’:
► Why Legionnaires’ cases keep increasing and what researchers say can halt the trend.
► Legionnaires’ disease: 95 confirmed cases, 1 dead. Can they sue?
One wonders who’s in charge here, and how the decisions are being made.
Last week, Brown interviewed Mullendore, DHHS medical director, and Stacey Wood, department spokeswoman, asking them about the timeline and the health officials’ response. They detailed the complexity of the reporting system, which involves reports going to the state and then the state notifying counties.
It’s a cumbersome system, and one that I would argue needs tweaking.
Wood also acknowledged that, “We’ve learned a lot from this situation.
“Things were happening so rapidly, and just a lot of moving parts and pieces,” she told Brown. “And I think in the future when this happens, if it happens, again … we’re going to pull together a press conference — start from the very beginning. So everybody has equal … the same kind of access to information.”
Shepard, in the email, said, “… this is a highly sensitive event with many moving parts and as we consider the possibilities of what could have occurred, we believe that we are fortunate in that this outbreak was identified early. We would be remiss if we did not acknowledge the professionalism, dedication and integrity of those who are involved in investigating the source of this outbreak, helping to protect the health and safety of our community.”
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Improvement should be on horizon
Look, these folks have a very difficult job, with enormous pressure. Lives are literally on the line, and they’ve got to get it right.
They got a lot right about this, but they got some things wrong, too. So I think the recognition that the response was less than optimal is a really good start.
With a multicounty event like this, one entity needs to take the lead and get good, reliable, accurate information out to as many news sources as possible. The state seems like the natural choice.
That means press conferences where state and county health officials, as well as medical doctors with epidemiology expertise, are present to present the latest information and take reporters’ questions.
With flu season on the horizon and reports that it’s been a really bad one in Australia, the Legionnaires’ response we’ve seen does not instill a lot of confidence that our public health officials can get the public the information it needs in a timely, accurate fashion.
I truly hope they hold a debriefing session on this and identify some areas for improvement, chief among them the dissemination of information.
God forbid we have an outbreak of a disease with a much worse fatality rate.
This is the opinion of John Boyle. Contact him at 828-232-5847 or firstname.lastname@example.org.