Month: November 2020

Effective working capital management techniques
Work type: Presentation/PPT
Format: APA
Slides: 6
Academic level: Undergrad. (yrs. 1-2)
Subject or discipline: Accounting
Title: Writer’s choice
Number of sources: 3
Paper instructions:
Create a 5-6-slide presentation in which you:
Evaluate effective working capital management techniques.
Evaluate alternative capital projects.
Format your citations according to APA guidelines.

Leading Change in the IT Organization

INTRODUCTION

In Unit 5, we explore the CIO’s role in leading change both within the IT organization as well as leading change across the enterprise. Without a means of making changes to the organization, strategy, tactics, and so on, all one can do in a leadership role is serve as a caretaker. And organizations left with a caretaker will wither and die.

Change is good. Change is necessary—and leading change is challenging. More relevant to the CIO’s world are the unique challenges of making changes in an organization accustomed to rapid technological change. Dealing effectively with technological change has both similarities and differences with organizational change. Leveraging that knowledge is key to moving the IT organization and its parent enterprise forward.

OBJECTIVES

To successfully complete this learning unit, you will be expected to:

1. Analyze the ways in which IT and the IT leader can best support and drive change across an enterprise.
2. Propose a change management process for implementing changes in an organization that will improve business performance, including a supported rationale.
3. Describe an implementation process for IT changes in a change management process, supported by change management theories.
4. Evaluate IT leadership’s role in a proposed change management process.
5. Outline, explain, and organize the main points of an IT enterprise strategy project.

PERTUSSIS CASE OVERVIEW

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

Discussion Essay on Troy Maxson, the main character of “Fences,” relationships with other characters in the play

Format:         APA

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:

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 sentences thanks.

Troy Maxson, the main character of “Fences,” has important relationships with several other characters in the play: his wife Rose, his sons Lyons and Cory, his brother Gabriel, and his friend Bono. Choose one of these characters and write a post that discusses both a positive and a negative aspect of Troy’s relationship with that character. From what you’ve read so far in Act I, how does Troy help this person? How does Troy hurt this person? What is their main area of disagreement?

 

Reflection essay on August Wilson interconnected themes in “Fences”

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:

Reading Reflection Instructions

August Wilson explores several interconnected themes in “Fences” including:

• family commitments
• sports (baseball, football)
• racism
• money
• death

Choose one of these themes and write a 1-2 page reflection on it by analyzing (not summarizing) Act I of “Fences.” Feel free to build on comments from the Graded Discussion this week; be sure, though, not to simply repeat them. Feel free to use “I” in your reflection. Include 2-3 brief quotes from the play to support your analysis. Be sure to proofread carefully before submitting.

Human Resources Management (HRM)

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:           4

Paper instructions:

This is a two-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. In the files section is a course project template and my group has sectioned off the work for each person. My name is Tashina. You will only be completing sections of these two parts the Company Background (Strategy) and HR Strategic Plan (HR Metrics). Each piece of that section which you are doing (Strategy) and (HR Metrics) are to be one page each and the sources must scholarly. The company you will be researching is Target. Please read the template carefully, as well as any other files labeled “Guidelines for writing”. Otherwise, you will miss something or perhaps just 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 if you are confused in any way please message me at any time within the due date. Thank you in

Can a counseling group help African descents cope with Covid-19’s impacts?

 

Topic: Counseling Group

 

1. Introduction
   1. Definition Counseling Group
   2. List general impacts of Covid-19 on African descent, particularly psychological impacts.
   3. Thesis statement (Do you believe a counseling group can help?)

 

1. An Overview of a Counseling Group
   • .

1. Which group (Opened group vs Closed group?)
2. Stages of group formation
3. Criteria to join the group (can include individual’s background and culture, ethic, gender, socio-economic status etc…)
4. How would you recruit individuals for the group?

 

• Leadership
  • .

1. Roles of a group leader
2. Characteristics (Personal and Professional) of an effective group leader
3. Challenges face the group leader

 

1. Discuss cause (s) and consequence (s) of Covid-19 on African descents.
2. Focus the argument on the psychological impacts.

 

1. Proposition to the psychological impacts of Covid-19
   • . The proposition debate (Solution). Addressing two sides: How and why the recommendation (s) would work.

 

1. CONCLUSION
   • . Summary of Arguments

1. Summary of the psychological impacts and the recommendation to alleviate such impacts
2. Concluding statement based on gathered data.

 

 

 

 

Management of COVID-19’s Psychological Stresses

Work type:   Research paper

Format:         APA

Pages:            6 pages ( 1650 words, Double spaced

Academic level:       Undergrad. (yrs 3-4)

Subject or discipline:         Nursing

Title:   Management of COVID-19’s Psychological Stresses

Number of sources:           5

Paper instructions:

Can a counseling group help African descents cope with Covid-19’s Stresses?

Topic: Counseling Group

1. Introduction
2. Definition Counseling Group
3. List general impacts of Covid-19 on African descent, particularly psychological impacts.
4. Thesis statement (Do you believe a counseling group can help?)
5. An Overview of a Counseling Group
6. Which group (Opened group vs Closed group?)
7. Stages of group formation
8. Criteria to join the group (can include individual’s background and culture, ethic, gender, socio-economic status etc…)
9. How would you recruit individuals for the group?

III. Leadership

.A. Roles of a group leader

1. Characteristics (Personal and Professional) of an effective group leader
2. Challenges face the group leader
3. Discuss cause (s) and consequence (s) of Covid-19 on African descents.
4. Focus the argument on the psychological impacts.
5. Proposition to the psychological impacts of Covid-19

. The proposition debate (Solution). Addressing two sides: How and why the recommendation (s) would work.

1. CONCLUSION

. Summary of Arguments

1. Summary of the psychological impacts and the recommendation to alleviate such impacts
2. Concluding statement based on gathered data.

 

1. This guideline is not mandatory
2. No plagiarism
3. Use at least 5 reliable sources
4. The documents titled guide are for ideas only, do not quotes from the documents.
5. Thank you for your assistance
6. If you have questions, leave a message .

 

Racial wealth gap voiced in the essay “White Supremacy is a Pre-existing Condition”

Work type:   Analysis (any type)

Format:         MLA

Pages:            1 pages ( 275 words, Double spaced

Academic level:       Undergrad. (yrs 3-4)

Subject or discipline:         Other : Technical Writing

Title:   Racism and Healthcare

Number of sources:           0

Paper instructions:

Write a 250 or so words discussing the solutions offered to the racial wealth gap voiced in the essay “White Supremacy is a Pre-existing Condition.” Evaluate which of them would be the most effective or with which you are the most comfortable.

 

IOM report, “The Future of Nursing: Leading Change, Advancing Health,”

Work type:   Essay (any type)

Format:         APA

Pages:            4 pages ( 1100 words, Double spaced

Academic level:       Undergrad. (yrs 3-4)

Subject or discipline:         Nursing

Title:   Writer’s choice

Number of sources:           2

Paper instructions:

Review the IOM report, “The Future of Nursing: Leading Change, Advancing Health,” and explore the “Campaign for Action: State Action Coalition” website. In a 1,000-1,250 word paper, discuss the influence the IOM report and state-based action coalitions have had on nursing practice, nursing education, and nursing workforce development, and how they continue to advance the goals for the nursing profession.

 

Include the following:

 

Describe the work of the Robert Wood Johnson Foundation Committee Initiative that led to the IOM report, “Future of Nursing: Leading Change, Advancing Health.”

 

Outline the four “Key Messages” that structure the IOM Report recommendations. Explain how these have transformed or influenced nursing practice, nursing education and training, nursing leadership, and nursing workforce development. Provide examples.

 

Discuss the role of state-based action coalitions. Explain how these coalitions help advance the goals specified in the IOM report, “Future of Nursing: Leading Change, Advancing Health.”

 

Research the initiatives on which your state’s action coalition is working.

Summarize two initiatives spearheaded by your state’s action coalition. Discuss the ways these initiatives advance the nursing profession.

 

Describe barriers to advancement that currently exist in your state and explain how nursing advocates in your state overcome these barriers.

 

You are required to cite to a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.

 

Prepare this assignment according to the guidelines found in the APA Style Guide

 

 

Sources referred to:

Read “The Future of Nursing: Leading Change, Advancing Health,” located on the National Academies of Sciences Engineering Medicine website, as needed to complete your assignment.

URL:

https://www.nap.edu/catalog/12956/the-future-of-nursing-leading-change-advancing-health

Explore the Campaign for Action website.

URL:

https://campaignforaction.org/our-network/state-action-coalitions/

 

Rubric

A clear and accurate description of the work of the Robert Wood Foundation Committee Initiative that led to the IOM report is presented.

The four key messages that structure the IOM report are clearly outlined. A description of how these transformed nursing practice, nursing education and training, nursing leadership, and nursing workforce development are thoroughly discussed.

The role of state-based action coalitions is thoroughly discussed. A detailed and accurate discussion of how they help advance the goals in the IOM report is presented.

Two initiatives spearheaded by a state action coalition and how they advance the nursing profession are thoroughly discussed. The discussion demonstrates a clear understanding of the state action committee and the role in advancing the nursing profession

Barriers to advancement that currently exist in the state are thoroughly explored and how nursing advocates in the state overcome barriers are thoroughly described.

Thesis is comprehensive and contains the essence of the paper. Thesis statement makes the purpose of the paper clear.

Clear and convincing argument presents a persuasive claim in a distinctive and compelling manner. All sources are authoritative.