Deaf Culture: Disabled or Different

Deaf Culture: Disabled or Different

Work type:   Research paper

Format:         MLA

Pages: 2 pages (550 words, Double spaced_) Academic level: Undergrad. (yrs. 1-2)

Subject or discipline:         Other

Title:   Deaf Culture: Disabled or Different

Number of sources:           2

Paper instructions:

Write a four-page (approximately 1,000 words when appropriately formatted) MLA style paper.

In your paper you should talk about each of the following issues as you try to explain how being labeled “disabled” is both a good thing and a bad thing for the Deaf community:

  • What the ADA is?
  • How the American Deaf community benefits from the ADA?
  • Explain empowerment as it applies to the American Deaf Community.
  • Explain “audism” and how it affects Deaf.
  • Explain the conflicts that arise within the American Deaf Community of being seen as both a distinct culture/a linguistic minority and a disabled group.

 

Determine the WACC for a given firm

Determine the WACC for a given firm

Work type:   Essay (any type)

Format:         APA    Pages:            2 pages (550 words, Double spaced

Academic level:       Undergrad. (yrs. 1-2) Subject or discipline:   Accounting

Title:   determine the WACC

Number of sources:           2

Paper instructions:

Your task is to determine the WACC for a given firm using what you know about WACC, as well as data you can find through research. Your deliverable is a brief report in which you state your determination of WACC, describe and justify how you determined the number, and provide relevant information as to the sources of your data.

Select a publicly traded company that has debt or bonds and common stock to calculate the current WACC. One good source for financial data for companies, as well as data about their equity, is Yahoo! Finance. By looking around this site, you should be able to find the market capitalization (E) as well as the β for any publicly traded company.

There are not many places left where data about corporate bonds is still available. One of them is the Finra Bonds website. To find data for a particular company’s publicly traded bonds use the Quick Search feature, then be sure to specify corporate bonds and type in the name of the issuing company. This should give you a list of all of the company’s outstanding bond issues. Clicking on the symbol for a given bond issue will lead you to the current amount outstanding and the yield to maturity. You are interested in both. The total of all bonds outstanding is D in the above formula.

If you like, you can use the YTM on a bond issue that is not callable as the pre-tax cost of debt for the company.

Assumptions:

As you recall, the formula for WACC is:

rWACC = (E/E+D) rE + D/(E+D) rD (1-TC)

The formula for the required return on a given equity investment is:

ri= rf + βi * (RMkt-rf)

RMkt-rf is the Market Risk Premium. For this project, you may assume the Market Risk Premium is 5% unless you can develop a better number.

rf is the risk-free rate. The risk-free rate is normally the yield on US Treasury securities such as a 10-year treasury. For this assignment, please use 3.5%.

You may assume a corporate tax rate of 40%.

Submit the following:

Write a 350- to 700-word report that contains the following elements:

  • Your calculated WACC
  • How data was used to calculate WACC (provide the formula and the formula with your values substituted)
  • Sources for your data
  • A discussion of how much confidence you have in your answer, including what the limiting assumptions you made were, if any

Include a Microsoft® Excel® file showing your WACC calculations discussed above

 

 

PERTUSSIS CASE OVERVIEW: Statistical Analysis of Pertussis Cases

PERTUSSIS CASE OVERVIEW: Statistical Analysis of Pertussis Cases

Work type:   Case study

Format:         APA

Pages:            2 pages ( 550 words, Double spaced

Academic level:       Master’s

Subject or discipline:         Health Care

Title:   Case Study 1 –  Statistical Analysis of Pertussis Cases

Number of sources:           2

Paper instructions:

Assignment Requirements

1.Identify immediate and basic issues within the case study, including the problem at hand, its significance and related assumptions.

2.Describe any missing information, risk factors, alternative strategies and negative outcomes.

3.Define a problem statement (see example provided in the Case Study Analysis Preparation worksheet).

4.Develop an action and implementation plan.

5.Summarize take-aways and reflections on the process, as well as the viability of the plan.

Assignment Scope

Citation requirements: 2

Word count: 600

APA formatting

Title page

Reference page

 

During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf OVERVIEW During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf OVERVIEW During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf OVERVIEW During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf OVERVIEW During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf OVERVIEW During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf OVERVIEW During 2004, a thirty-three-fold increase in pertussis (whooping cough) incidence in Southeastern Wisconsin triggered the activation of the unified command (see Appendix #1 for more details) of the public health consortium involving the fourteen local public health agencies in Milwaukee and Waukesha counties. BACKGROUND Pertussis (whooping cough) was endemic in Wisconsin for years, especially in the more populated southeastern region. Historically, pertussis accounted for approximately 170 cases annually in the state and caused small, isolated clusters in different regions. Prior to 2004, M and W counties (contiguously located within the southeastern region) averaged 34 and 15 pertussis cases per year, respectively. Though M and W counties were not affected, the state experienced a regional outbreak of pertussis cases in the northeastern portion in 2003; over 700 cases of pertussis were reported during this year, with the majority of cases related to the increased incidence in the northeastern region. Pertussis is an acute respiratory disease caused by the bacterium, Bordetella pertussis. Pertussis often begins insidiously with cold-like symptoms, including runny nose, possible low-grade fever and a mild, irritating cough that gradually becomes paroxysmal, usually within 1-2 weeks. The paroxysms are distinguished by a violent, explosive coughing that may interrupt breathing, eating and sleeping; vomiting may follow paroxysms. As they struggle to inhale air, patients may make a loud “whooping” sound characteristic of pertussis; infants and vaccinated individuals, however, may not have the typical whoop or cough paroxysm, making diagnosis difficult. 1,2 Spread through direct contact with respiratory droplets, pertussis is most contagious in the early stages of illness prior to developing paroxysms (generally the first two weeks). Communicability gradually wanes and becomes negligible in about three weeks, although the contagious period can be reduced to five days following effective antibiotic treatment. Persons with pertussis should be isolated from school, work or similar activities until they have completed at least five days of an appropriate antibiotic therapy. Appropriate antibiotics include a 5-day course of azithromycin, a 7-day course of clarithromycin, or a 14-day course of erythromycin or trimethoprim/sulfamethoxazole. Prophylaxis with an appropriate antibiotic is also recommended for close contacts (especially household contacts) of a case, to prevent or reduce illness severity. Pertussis is confirmed using polymerase chain reaction (PCR) or by laboratory culture of a nasal-pharyngeal swab specimen obtained during the early stages of illness. PCR has recently replaced culture as the test of choice for pertussis laboratory diagnosis because of its increased sensitivity, and the State Laboratory of Hygiene began using PCR for pertussis diagnosis in fall 2002. Vaccination with the diphtheria, tetanus and acellular pertussis vaccine (DTaP) is recommended for all persons under age seven who haven’t completed the five-dose vaccination series; the vaccine is not recommended for those over seven years because vaccine reactions are more frequent. Despite vaccination, the effectiveness of the vaccine is estimated to be only 80 percent in children receiving at least three doses. Additionally, recent research has shown that immunity begins to wane five to ten years following the last dose. CHRONOLOGY The start of 2004 brought increased pertussis rates in many areas of the state, including both M and W counties. Pertussis cases were reported to local health agencies at a steady rate throughout the first quarter of the year, with many local public health agencies reaching their average annual number of cases within the first few months of the year. Initially, public health practitioners believed the increased incidence was due in part to the 2003 outbreak in the northeastern portion of the state. January/February 2004 M County cases: 9 in January; 8 in February (17 cumulative total for year) W County cases: 4 in January; 6 in February (10 cumulative total for year) • State Health Officials within the Division of Public Health (DPH) sent 2003 provisional data on pertussis cases to local public health agencies stating, “… it appears that pertussis morbidity is beginning to subside…” March/April 2004 M County cases: 8 in March; 12 in April (37 cumulative total for year) W County cases: 4 in March; 10 in April (24 cumulative total for year) • Pertussis cases continued to increase and local public health agencies realized they were in the midst of a situation. • Clinical presentation was atypical from the “classic” pertussis symptoms, hampering accurate diagnosis. Most cases presented with prolonged minimal cough, with or without paroxysm or “whoop.” • The majority of cases occurred in adolescents and young adults who were fully immunized. • New cases required challenging cross-jurisdictional case management. May 2004 M County cases: 48 (85 cumulative total for year) W County cases: 21 (45 cumulative total for year) • Local Health Officers requested weekly or more frequent updates from DPH on pertussis activity in all regions and guidance on pertussis case management. • Questions arose as to whether DPH was monitoring incidence rates. • One local health agency instituted incident command (IC), to more effectively manage the pertussis epidemiological follow-up. • Other agencies informally changed their usual way of doing business, including reprioritization of daily functions and increased staff education, briefing, and updates. • Regional DPH personnel visited local health agencies to educate staff on pertussis. • DPH sent a letter to local health agencies on “significant increase in incidence of pertussis,” reiterating standard protocols as identified in DPH epidemiology manual. June 2004 M County cases: 57 (142 cumulative total for year) W County cases: 58 (103 cumulative total for year) • In absence of DPH guidelines, local public health agencies devised protocols to define and prioritize epidemiological follow-up. • DPH distributed 1999 CDC pertussis manual with updated state treatment guidelines. • DPH began posting positive laboratory results on the Health Alert Network (HAN) secure internet site after confidentiality concerns had been resolved. • Local public health agencies questioned reliability and validity of polymerase chain reaction (PCR) laboratory test. • Summer camp cases arose and frequently crossed jurisdictions. DPH sent 250 letters to camps with pertussis notification. • DPH sent letters to physicians on case definition, testing, and treatment. • An Antibiotic Resistant Network ongoing media campaign educated providers regarding appropriate antibiotic use. “Clinicians have worked hard to change their prescribing habits and to educate patients about the futility of antibiotics in the treatment of acute cough illnesses. The increased use of antibiotics caused by the pertussis outbreak is frustrating for clinicians who desire to both avoid antibiotic use for viral illness, and yet appropriately respond to a genuine public health need.” This contradicted public health protocols for pertussis prophylaxis, confusing providers about proper treatment guidelines and thereby increasing the difficulty of local public health agencies to assure appropriate prevention and control. • Local public health agencies needed to convey unified case management policies (case definition, close contact definition, testing, treatment, and isolation) to health care providers serving clients in multiple jurisdictions. July 2004 M County cases: 69 (211 cumulative total for year) W County cases: 87 (190 cumulative total for year) • A second local public health agency instituted IC. • PCR results displayed with regularity on the HAN. • DPH offered training on nasopharyngeal (NP) swabs to test for pertussis. • DPH assisted in obtaining test results from private clinical labs. • DPH instituted weekly pertussis teleconferences. • DPH issued a press release focusing on camps and recreation facilities due to increased incidence in these settings. • One local public health agency developed a suspect flow sheet. • The CDC did not administer guidance on accelerated pertussis vaccination schedule in spite of the “increased sustained incidence.” • DPH press release: “Pertussis usually has a three- to four-year cycle when we have larger numbers of cases. We’re in one of those cycles.” • Local public health was perceived as too aggressive with providers and was advised by state health officials to relax pursuance of guideline requirements. Distributing current policies to providers clarified the responsibility of local public health to prevent and control the spread of disease in the community. August 2004 M County cases: 65 (276 cumulative total for year) W County cases: 75 (265 cumulative total for year) • The consortium member agencies voted unanimously to activate unified command due to a concern of increased transmission when the school year began. • Unified command was led by the consortium chair and initially consisted of weekly teleconferences to problem-solve issues with epidemiological follow-up • The consortium issued a press release announcing activation of unified command. • DPH sent letters to school districts regarding pertussis, vaccine, and exclusions. • Local public health agencies communicated with schools, hospitals, clinics, and day cares on communicable disease prevention, control measures, and surveillance surrounding pertussis. • DPH held a press conference and issued a press release on the “particularly high” number of pertussis cases. • Local public health agencies were concerned about costs related to managing pertussis. • Local public health agency staff resources were limited. Mutual aid was not requested due to a perception that all consortium resources were exhausted. September 2004 M County cases: 58 (334 cumulative total for year) W County cases: 57 (322 cumulative total for year) • DPH sent a letter to clinicians on aggressive control measures, including widening case definition to any cough of seven-day duration. • DPH approved use of consortium grant funds for antibiotics, staffing, and overtime costs. • Prioritization and resource allocation guidelines were disseminated by unified command. • The unified command encouraged local public health agencies to request mutual aid, if needed. • Consortium sent letter to clinicians updating them on current situation. • Local public health agencies enhanced surveillance efforts with school districts. • The unified command secured drug samples for uninsured and underinsured. • The consortium held a press conference regarding current situation. • DPH sent a letter to college/university health services with fact sheets, treatment information, case definition, and specimen collection. • DPH acknowledged a pertussis outbreak: “Upon review of the epidemic curves of the pertussis cases… it is clear that a sustained outbreak of pertussis is occurring.” • Due to time restraints, many local public health agencies were unable to participate in weekly teleconferences. October/November/December 2004 M County cases: 99 in October; 94 in November; 43 in December (570 cumulative total for year) W County cases: 64 in October; 63 in November; 39 in December (488 cumulative total for year) • Local public health agencies were forced to reprioritize due to influenza vaccine shortage. • Local public health agencies had concerns about the cost associated with probable and suspect cases without an epidemiological link. January 2005 M County cases: 15 W County cases: 13 • Estimates maintained by member agencies throughout 2004 identified a cost of approximately $450 per case to manage the outbreak. POPULATION CHARACTERISTICS (See appendix #2 for additional socio-economic data) Region is most evident in the 40- to 44-year, the 45- to 49-year, and the 50- to 54-year age groups, largely reflecting the aging of “babyboomers” (those born from 1946 through 1964). Conversely, the largest decreases in population between 1990 and 2000 occurred in the 25- to 29-year and 30- to 34-year age groups, a reflection of baby boomers moving out of, and comparatively smaller cohorts of the late 1960s and early 1970s moving into, those age groups. The proportion of the population 65 years of age or older was essentially unchanged over the past 10 years, accounting for about 12 percent of the total population in both 1990 and 2000. The population 65 to 69 years of age decreased during the 1990s, while the population in the 70- to 74-year age group and older age groups increased. These changes can be related back to the birth cohorts and migration patterns of the past. The median age of the regional population (the age above and below which there is an equal number of persons) was 35.4 years in 2000. The median age has increased steadily over the past three decades, from 27.6 years in 1970, to 29.7 years in 1980, and to 32.8 years in 1990. Among the seven counties in the Region, the median age in 2000 ranged from 33.7 years in Milwaukee to 38.9 years in Ozaukee. Changes in the age composition will also have an important bearing on the future size and makeup of the Region’s labor force, particularly as the large baby boom segment (age 36 to 54 in 2000) continues to age and begins to move into retirement years. Gender Composition Males comprised 48.7 percent of the total regional population in 2000, while females comprised 51.3 percent. Males slightly outnumbered females through early childhood and young adulthood. Racial Composition The vast majority of the population in the Region (98.3 percent) reported only one race. This includes 79.4 percent reporting White; 13.6 percent reporting Black or African American; 0.5 percent reporting American Indian or Alaska Native; 1.8 percent reporting Asian; less than 0.1 percent reporting Native Hawaiian or Other Pacific Islander; and 3.0 percent reporting some other race. Among the Region’s seven counties, Milwaukee County remains the most racially diverse county, followed by Racine and Kenosha. Marital Status About 53 percent of the Region’s population age 15 years and older was reported as married in 2000. Among the seven counties in the Region, the proportion of married persons ranged from 45 percent in Milwaukee County to over 64 percent in Ozaukee, Washington, and Waukesha Counties . Persons who have never married comprised about 30 percent of the Region’s population age 15 years and older in 2000. Separated and divorced persons combined comprised about 11 percent of the population age 15 years and older, while widowed persons comprised about 6 percent. The marital status of the Region’s population has changed considerably over the past 30 years—the most significant changes being a decrease in the proportion of married persons and an increase in the proportion of divorced persons. The proportion reported as married at the time of the census decreased from 61 percent in 1970 to about 53 percent in both 1990 and 2000. The proportion reported as divorced increased from about 3 percent in 1970 to about 9 percent in 2000 Education Almost 87% of this Region’s residents (1,168,539 people) age 25 and over graduated from high school or beyond, and 18% (245,340 people) have achieved a bachelor’s degree. Ozaukee and Waukesha counties have a higher percentage of high school graduates (94%) than all other counties. Milwaukee County is three percentage points lower than the regional average for the percentage of people who are high school educated; about 84% of adults age 25 and over have graduated from high school. Veteran Status Ten percent (148,161 people) of the Region’s population 18 years of age and above are veterans. Kenosha County has the highest population of veterans at 12%, while Milwaukee, Ozaukee, and Washington each counties have a veteran population of 9%, 58,680, 6,102, and 8,671 people respectively. People with Disabilities There are a total of 251,136 disabled people over age 4 in the Region. This represents 12% of the Region’s population age 5 and over. Across the region, there is a seven-percentage point difference in the percentage of people with disabilities; Ozaukee County at 9%, and Milwaukee County at 16%. Poverty and Unemployment The Southeastern Region unemployment rate ranges from 2.3% in Ozaukee County to 8.1% in Milwaukee County. The average household income is $68,500. Ozaukee County has the highest average household income in the Region at $87,793 and Milwaukee County has the lowest average household income at $53,628. Of the Southeastern Region population, about 9.8% of all people, and 6.9% of all families live below the federal poverty level. The population living below the poverty level ranges from 2.7% of all people in Ozaukee County to 18.5% of all people in Milwaukee County. References 1. Heymann DL, (ed.) Control of Communicable Diseases Manual, 18th Ed. (2004). American Public Health Association: Washington. 2. Evans AS, Brachman PS. Bacterial Infections of Humans, 3rd Ed. (1998). Plenum: New York. Appendix #1: Unified Command Information https://training.fema.gov/emiweb/is/is100he/student%20manual/l6_ics100highered_sm.pdf Appendix #2: Demographical Data From Southeastern Wisconsin http://www.sewrpc.org/SEWRPCFiles/Publications/TechRep/tr-011_population_southeastern_wisconsin.pdf Adapted From: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6348a2.htm

Change Management Process

Change Management Process

Paper Type: 1#essay Subject:    Business 4 Pages  Sources            3 Citation      APA

Academic Level       Doctoral

Paper details

In one of this course’s optional reading resources, Hunter and Westerman (2009) list four changes led by IT that can improve business performance. These are Optimizing, Reshaping, Internal Informing, and External Informing. Other experts in organizational change will list a variety of changes that can be led by IT, and you have likely seen changes in organizations that were driven or led by IT.

For this assignment, write a paper that describes, in practical terms, how such changes could be implemented in an existing and mature IT organization. Support the change processes you suggest with change management theory. Some possible seminal sources for organizational change theory would be Kurt Lewin, Peter Senge, and Edgar Schein. Feel free to cite their works or any other peer-reviewed sources that you feel make a strong case for your proposed processes. In your paper:

  • Propose a change management process for implementing changes in an organization that will improve business performance, including a supported rationale.
  • Describe an implementation process for IT changes in a change management process, supported by change management theories.
  • Evaluate IT leadership’s role in a proposed change management process.

Your paper should be 3–4 double-spaced pages and include 2–3 academic sources that support your perspectives. Remember to use proper APA format for your paper, including citations and references. Review the scoring guide to be sure that you have addressed the grading criteria for this assignment.

 

Navy Mentorship Program

Navy Mentorship Program

Work type:   Essay (any type)

Format:         APA

Pages:            6 pages ( 1650 words, Double spaced

Academic level:       Undergrad. (yrs 1-2)

Subject or discipline:         Psychology

Title:   Writer’s choice

Number of sources:           5

Paper instructions:

Please write an essay on the Navy Mentorship Program. Be sure that you are not simply explaining the existing program please remember it is a research paper so you need outside info incorporated. You could reference any outside contractors that assessed effectiveness for example

 

 

 

 

Human Resources Management (HRM), HR Strategic Plan (HR Metrics), Staffing Strategy and Porter’s Five Forces Model

Human Resources Management (HRM), HR Strategic Plan (HR Metrics), Staffing Strategy and Porter’s Five Forces Model

Work type:   Research paper

Format:         APA

Pages:            2 pages ( 550 words, Double spaced

Academic level:       Undergrad. (yrs 3-4)

Subject or discipline:         Human Resources Management (HRM)

Title:   Writer’s choice

Number of sources:           2

Paper instructions:

This is a three-part assignment. The instructions have been uploaded to the files section. If you do not read the instructions in their entirety before starting, you may very well do this wrong and have to redo it. Please read all the instructions first. You will be completing two pieces of a group assignment. The files section has a course project template, and my group has sectioned off work for each person. You will only be completing sections of these three parts, the Company Background (Strategy), HR Strategic Plan (HR Metrics), and the Staffing Strategy (Job Analysis). Each piece of that section which you are doing (Strategy), (HR Metrics), and (Job Analysis) are to be cited properly, and the sources must be scholarly. Please read the template carefully, as well as any other files labeled “Guidelines for writing.” Otherwise, you will miss something or perhaps do too much. Either way, it could cause a revision, and we don’t want that. If you have ANY questions about what to do or are confused in any way, please message me within the due date. Thank you in advance. If you have any issues or questions, please message me.

Our objective is to develop an HR plan for our STEP, our online retail store, looking to expand into brick and motor locations. I have included all the decisions my group has made for the company. Such as we have decided to use Porter’s Five Forces Model. If you read the template and the project overview, you will see what I mean. You are coming up with specific things for us to do as a company. Things we can implement as a strategy for our HR plan for the company we made up “STEP”. PLEASE READ the “Sample of a paper” it is the actual paper that my group has started. All of their parts are there. This is not intended to be extensive. It is a draft. It simply needs to be accurately researched and cited if necessary.

 

As for the HR Strategy, we are interested in being a brand that looks after our employees first. We want to implement things like profit sharing and bonus structures that incentivize our employees to do their jobs well and grow with our company.

 

As for HR Metrics, you can take baselines from any of the competitors listed in the paper and make projections for using the information provided from my group in their parts of the paper that is provided.

Then as for The Job Analysis, it needs to be done on the District Manager position. Reason: because we are stepping into the brick and mortar retail space, we have to have a qualified person spearheading that process. They must be knowledgeable of the company, but also the multi-faceted process that is a retail location.

 

Compare and contrast essay on the essays Disability by Nancy mairs and Fatso by Cheryl peck

Compare and contrast essay on the essays Disability by Nancy mairs and Fatso by Cheryl peck

Work type:   Other : See paper instructions

Format:         APA

Pages:            1 pages ( 275 words, Double spaced

Academic level:       Undergrad. (yrs 1-2)

Subject or discipline:         Nursing

Title:   Writer’s choice

Number of sources:           6

Paper instructions:

5 paragraph Compare and contrast essay on the essays Disability by Nancy mairs and Fatso by Cheryl peck

 

“Fences” Act 2

“Fences” Act 2

Work type:   Discussion Essay

Format:         APA

Pages:            1 pages ( 275 words, Double spaced

Deadline:      Nov 19, 2020 at 3:21 AM (2 d, 07 h, 56 m)

Academic level:       Undergrad. (yrs 1-2)

Subject or discipline:         Composition

Title:   Writer’s choice

Number of sources:           0

Paper instructions:

Please respond to the question below in one clearly-written & write 1/2 page only question. Another 1/2 a page I will post 2 classmates discussion then response in 2-3 sentences thanks.

“Fences” Act 2 Instructions

After you finish reading Act 2, choose ONE of these three questions and respond to it in a paragraph.

  1. Rose says to Troy, “Times have changed from when you was young. People change. The world’s changing around you and you can’t even see it.” (p. 909) Is she right? Discuss, keeping in mind the play is set in 1957.
  2. Discuss the play’s title. How is it a metaphor?
  3. Cory initially announces he is not attending Troy’s funeral at the end of the play. How/why does he change his mind?

 

theme in “Fences.”

theme in “Fences.”

Work type:   Reflection paper/Reflection essay

Format:         MLA

Pages:            1 pages ( 275 words, Double spaced

Academic level:       Undergrad. (yrs 1-2)

Subject or discipline:         Composition

Title:   Writer’s choice

Number of sources:           0

Paper instructions:

Last week you reflected on a significant theme in “Fences.” A few weeks ago you wrote an analytical essay on why Danusha Lameris should win a Pulitzer Prize for her book of poems, “The Moons of August.” The author of “Fences,” August Wilson DID win a Pulitzer Prize for his 1987 play.

In your opinion, why do you think his play won literature’s highest honor? Write a 1-2 page reflection. Feel free to do some research, but that’s not required. Mainly focus your reflection on the play itself. Include 2-3 brief quotes from it to support your analysis. Feel free to use “I” and write personally. Be sure to proofread carefully before submitting.

 

Are there human behaviors that should not be studied? Are some things so sacred or dangerous that we should not study them?

Are there human behaviors that should not be studied? Are some things so sacred or dangerous that we should not study them?

Work type:   Essay (any type)

Format:         MLA

Pages:            4 pages 1100 words, Double spaced

Academic level:       Undergrad. (yrs. 1-2)

Subject or discipline:         Psychology

Title:   Are there human behaviors that should not be studied?

Number of sources:           3

Paper instructions:

ESSAY TOPIC: Are there human behaviors that should not be studied? Are some things so sacred or dangerous that we should not study them?

 

3-4 double spaced pages, size 12 font.

  • should clearly address the original prompt, or some specific aspect/facet of it.
  • The focus of the essay should not go beyond addressing the issues raised in the original prompt.
  • The essay should be addressed to a general audience, and written in a way that does not presume prior knowledge of the topic/focus of the essay.
  • Where appropriate, the essay should give consideration to counterarguments or other perspectives on the issue at hand.
  • essay should make use of information from one or more outside sources that is relevant to the topic at hand.

 

Answer additional questions below in 1 short paragraph separate from the essay.

 

1.Some people claim that science has done more harm than good. What do you think?

  1. If you were a research psychologist, what phenomena or behaviors would most interest you?
  2. Consider the significance of gender roles in the United States today. Are gender roles too important and too recognized, or should they be given more importance/recognition? Write an argument in favor of either side.

4.Describe a situation in which people conform for arbitrary reasons.

The question answers can be short 3-4 sentences.