The Oklahoma City-County Health Department (OCCHD) serves a population of more than 750,000 residents, but on weekdays, the population grows to an estimated 1.2 to 1.3 million as people from outlying counties come into Oklahoma County to work. The residential population is approximately one-fifth of the total state population, but the commuter population brings that number closer to one-third of the state population.
Historically, efforts had been operating in silos even within the local health department (LHD) with resources scattered throughout the county, without recognition of the need to allocate resources geographically or within specific population. Two mosquito borne disease that impact Oklahoma City-County are West Nile Virus and travel-related Zika Virus cases. Zika Virus has impacted Oklahoma City-County due to community members traveling to countries with active transmission of the virus and returning to Oklahoma City-County. The heightened vector activity in the Oklahoma City-County area occurs April through September, and West Nile Virus human cases typically occurs in the warm summer months. While the State maintains a list of reportable diseases, the OCCHD Epidemiology team conducted case investigations for limited vectorborne diseases, including West Nile virus and other arboviral infections, Lyme disease, Rocky Mountain Spotted Fever, and Malaria. In 2010, human disease surveillance, to include reporting and case investigations, began in Oklahoma City along with mosquito larvicide on a complaint basis through the municipalities within the OCCHD jurisdiction. A severe West Nile Virus outbreak occurred in 2012 that caused over 50 hospitalizations in the Oklahoma City area and several individual died as a result of West Nile Virus. In the midst of the outbreak, efforts to improve the disease prevention and response were top priority.
The Oklahoma City-County Health Department collaborated with City managers and municipal partners and have bolstered the response planning over the past 8 years. Oklahoma City-County deploys a phased vectorborne response plan to address multiple diseases, including Zika Virus and West Nile Virus. This plan is scalable and flexible, but must necessarily prepare for the worst case” scenario. Although not currently a local threat in Oklahoma City-County, Zika virus response planning requires early coordination between state, local and federal agencies in order to mitigate risk to the population. The backbone of the Vectorborne response planning has been proven successful through West Nile Virus response in which Oklahoma has experienced three outbreak seasons: 2003, 2007 and 2012. (OSDH) In 2015, the Oklahoma City area experienced a greater than 112% increase in the number of vectors and 18 WNV positive test pools were observed. The heightened number of vectors and positive test pools did not translate to the same escalation in human cases, which demonstrates the strength that Public Health collaboration between surrounding municipalities and community members has on reducing the potential impact of this seasonal epidemic. Leveraging partnerships and resources acted upon during West Nile season in Oklahoma City-County, the Oklahoma City-County Health Department created a powerful Vectorborne response plan that allows for immediate deployment based on Zika Virus activity in and near Oklahoma City-County. Overall, the program must be built in incremental steps to provide for continuous improvement and operations. The staff at OCCHD, and across the City partners, provide their expertise during the vectorborne season in-kind, collecting no additional pay for the season. Resources are allocated to account for competing priorities and the teams collaborate to ensure each segment of the program is accomplish appropriately. The budget, as explained in this document, remains minimal, with supporting grants boosting capacity during various years of the program. Building the program from where an existing organizations is operating is the preferred method of enhancing a city's vectorborne disease response program. Organizations across the Country have reached out to OKC-County to boost local strategies. OKC-Co created a vectorborne disease toolkit for other city-county health departments start their own vectorborne response program or to provide municipalities with information. This can be accessed at: https://www.occhd.org/vectorbornediseasetoolkit
Target Population and Reach
The innovative practice focuses on a multi-stage approach to combat vector borne disease in Oklahoma City-County; this includes communities with high concentration of elderly. Community based interventions provide education to the community at large and GIS mapping capabilities provide targeted outreach in response to human case identification.
The technical package the OCCHD has implemented utilizes a comprehensive, multi-sector approach to preparing for, mitigating risk and responding to vector borne disease outbreaks. The tested approach illustrates a seamless effort between the local health department and neighboring health officials, municipalities, media channels, laboratory, federal partners, preparedness officials and community members. The comprehensive package includes:
Vector surveillance: Trapping, testing and GIS mapping
Environmental treatments
Habitat remediation
Municipality partnerships
Human disease surveillance and prevention: Epidemiological investigations
Media outreach: Engage community at various points of prevention and education
Multi-sector approach through engagement with Oklahoma City Storm Water Quality (OKCSWQ) and Edmond Code Enforcement (ECE)
Programmatic activities are complemented by policy action undertaken by the Public Health Protection division which includes city vector ordinances, public health nuisance response and/or public health emergency declarations.
Background of Innovation
Historically, the OCCHD has subscribed to the identification and implementation of existing evidence-based best practices to improve health outcomes for its jurisdiction. These practices were consistently implemented according to guidelines, but largely without coordination across target populations. Efforts have been operating in silos even within the LHD with resources scattered throughout the county, without recognition of the need to allocate resources geographically or within specific population. The timeline of activities below summarize the evolution of the vectorborne disease program, from initial case investigations to an outbreak year that propelled the program beyond limited epidemiological investigations.
Timeline:
2010: Human disease surveillance, to include reporting and case investigations, began in Oklahoma City along with mosquito larvicide on a complaint basis through the municipalities within the OCCHD jurisdiction.
2012: A severe West Nile Virus outbreak occurred in 2012 that caused over 50 hospitalizations in the Oklahoma City area and several individual died as a result of West Nile Virus. In the midst of the outbreak, efforts to improve the disease prevention and response were top priority. In Fall 2012, surveillance enhancement and vector mitigation strategies grew as a result of research and collaboration with our local partners.
2013: CDC Gravid traps were added to the toolkit to begin collection for mosquito population data and testing kits were deployed to identify West Nile Virus within the vector population. A key feature to this toolkit strengthened in 2013 with the cohesive approach of the local, city and municipality mitigation strategies and training.
2014: OCCHD committed significant in-kind staff resources to leverage partnerships and develop a plan of action to direct community planning and implementation efforts aimed at developing systems and environmental improvements.
2015: Through development of the vectorborne disease group, local, state, and federal officials had a joint communication system developed for timely communication of results across organizations. At the same time, the OCCHD, through use of grant funding, developed an emergency preparedness and response mobile application to provide on demand access to articles, media interviews and fact sheets. Qualitative data collected during the season, support from multi-sector partners and community engagement qualitative data collected through social media outlets illustrates a successful model that leverages community resources, enhances community protection and promotes vectorborne disease education through a unique technical package.
2015-Current: As a major population and activity center for the state of Oklahoma, this inevitably translates into improved prevention for the state as a whole.
The innovation represents a creative use of existing tools and practices found through the Centers for Disease Control and Prevention, MMWR Recommendations and Reports, Preparedness workgroups, academic groups and professional public health committees and includes the following elements, placed in targeted, disparate health outcome ZIP codes within the LHD jurisdiction:
1. Access to timely surveillance, disease burden and remediation data, available in weekly situation reports and various media conferences.
2. Communication strategies: Communication strategies are vital to the success of the Vectorborne Disease Response Plan (VDRP). Affecting behavior change of actions to protect against mosquito bites, education has an integral role. Consider multiple faucets in relaying a clear, timely, and consistent message within state and local jurisdictions. Prepare press briefs for each response phase to include the reason for the announcement, the risk to the jurisdiction, and how to reduce the risk. When reusing messaging, it is encouraged to personalize it to your jurisdiction.
3. Community Awareness: The Skeeter Meter was developed by OCCHD epidemiologist and is an awareness tool for use in alerting the residents of OKC-Co of risk from disease carrying mosquito activity. To calculate this risk the OCCHD Vectorborne Disease Surveillance team uses data from the following multiple sources: Temperature, Weekly Mosquito counts (compared to historical numbers), Disease Rate (within Captured Mosquitoes), Complaints from residents (compared to historical data), Human Surveillance (WNV cases in the state of Oklahoma and/or within OCCHD.)
4. Emergency Response Planning: In coordination with City and Emergency managers, the OCCHD integrated a phased response plan with the City Emergency Response Plan and Procedures. This annex was developed using available epidemiology, entomologic, geographical and environmental data. This annex also set the foundation for phased response planning and sharing across the professional network. Due to requests from the international community, the OCCHD shared its program development story and results at multiple forums, to include the international Zika Virus Conference, NACCHO Preparedness Summit, The United States Public Health Service Scientific Symposium, City Council and The University of Oklahoma Medical Ground Rounds.
5. Resistance Testing: The OCCHD Consumer Protection Division has procedures in place to perform insecticide resistance testing. The addition of this procedure was required after OCCHD gained the ability to apply adulticide via backpack and truck-base sprayers. In order to determine a baseline resistance in the mosquito population, it was decided to begin the implementation of a resistance testing program prior to the activation of a Phase 3 response.
The overarching goal of the innovation is to reduce risk of vectorborne diseases and respond timely. The OCCHD seeks to leverage resources with partners to ensure risk reduction, with regards to vectorborne disease.
Integral components of this program include:
1. Comprehensive data collection,T analysis and dissemination utilizing the Mobilizing for Action through Planning and Partnership Tool, conducted every third year by the LHD.
2. Integration of cross-functional organizations, including City officials, code enforcement, media outlets, clinical, and public health preventive services for targeted abatement and risk reduction for high-risk populations and locations (including the elderly, golf courses, outdoor workers).
3. Targeted education, awareness and code enforcement implementation county-wide.
Implementation Activities
Roles and Responsibilities:
OCCHD coordinates the multi-sector vectorborne disease program with local, state, federal partners. Trapping is conducted using 17 CDC Gravid Traps and BG-Sentinel 2 Traps. The Gravid Trap we use is designed to selectively capture female Culex mosquitos, the more prevalent WNV vector in OKC, by utilizing hay and tap water as the attractant. Once a week the nets with trapped mosquitos are brought OCCHD Consumer Protection and frozen overnight. Mosquitos are sorted and tested the following day.
The overarching goal is to mitigate risk of vectorborne disease through prevention, quick response and remediation. The multilevel approach deployed in this city-county jurisdiction provides best practices for collaboration with partners and surrounding municipalities in order to reduce disease impact. Functioning as a cohesive unit, the local public health system, including city and municipality partners, is able to set, maintain, repair and collect traps at each site, disseminate surveillance reporting information, coordinate treatment applications, coordinate habitat remediation efforts and investigate harborage areas. Roles are outlined below.
OCCHD Consumer Protection:
Collects complaints from residents and community members
Identifies and treats areas with stagnant water, including but not limited to, vacant pools and properties.
Orders and distributes larvicide (Altosid XR and Fourstar) to partners
Altosid XR: low cost of application; effective for 150 days
Fourstar: lower ecological concerns; effective for 180 days; can treat storm draims, catch basins, underground drainage systems, storm water retention areas and ponds.
For positive human case: inspectors trace the location of the infected persons to a territory and survey for stagnant water and educate community of prevention measures.
Apply for grants and funding to expand vectorborne disease program
Train staff to provide in-kind vectorborne disease program support
Conduct resistance testing
OCCHD Epidemiology:
Conduct case investigations of reportable diseases and conditions, including West Nile Virus, Zika virus, Rocky Mountain Spotted Fever, Lyme Disease and Malaria.
Collect data on suspect/confirmed vectorborne disease cases, such as location, exposure date/source, outdoor activities and hobbies that may have increased risk of exposure and travel history. Spouse/partner exposure history is also collected specific to Zika Virus.
Produce GIS mapping to identify clusters of human cases and possible major sources of vectors
Aids in habitat assessment by providing aerial view maps and satellite image with 500-foot radius area of focus.
Sends out vectorborne reports with local, state and national disease status and prevention measures, including stagnant water treatment and abatement efforts.
OCCHD Media and Communications:
Communications is a critical piece to the vectorborne disease prevention toolbox.
Joint press conference is held when the first positive WNV vector pool(s) is/are identified and in the event of an outbreak scenario or heightened event requiring media communications.
Develop prevention messaging, earning more than $600,000 in outdoor billboard exposure, television, radio and print ads.
Connect the public health protection division with numerous news outlets, council meetings and university workgroups to communicate status updates and prevention messaging.
Municipality Agencies:
Set, maintain, repair and pick up traps at each site.
Storm water quality (OKCSWQ) sends OCCHD weekly reports for each of the trap sites with information on trap condition, needed repairs, and counts of vectors trapped
Treats areas of stagnant water that are mosquito breeding habitats. Larvicide is provided by OCCHD.
Send address and date of larvicide application to OCCHD.
Conduct area surveys and elimination of mosquito habitats within on mile of positive trap location.
Oklahoma Department of Environmental Quality (ODEQ) collaborates with OCCHD on the storage of large amounts of tires, to include providing OCCHD with a Tier Exemption Authorization S no. for the tire sites that pose an immediate health hazard. Sites that do not pose an immediate health hazard are referred to ODEQ.
The technical package the OCCHD has implemented utilizes a comprehensive, multi-sector approach to preparing for, mitigating risk and responding to vector borne disease outbreaks. The tested approach illustrates a seamless effort between the local health department and neighboring health officials, municipalities, media channels, laboratory, federal partners, preparedness officials and community members. The comprehensive package conducts vector surveillance, environmental treatments, habitat remediation, municipality partnership, human disease surveillance and prevention and media outreach. The multi-sector approach engages Oklahoma City Storm Water Quality (OKCSWQ) and Edmond Code Enforcement (ECE) who set, maintain, repair and collect traps at each site during vector surveillance.
The background referenced prior provides implementation timeline and strategies. The six part process includes vector surveillance, environmental treatments, habitat remediation, municipality partnerships, human disease surveillance and media outreach. For a complete kit visit occhd.org/vectorborndiseasetoolkit.
Budget: The budget for this program is minimal but can vary depending on emergency plans and grant opportunities. In 2013, following outbreak scenarios, the vectorborne response budget grew by approximately $2,500 to boost practices already in place in OKC, such as expanded trapping, training and testing supplies. In 2015, along with development of Annex D in the City Emergency response plan, $40,000 was incorporated into OCCHD operating budget to purchase sprayers. Currently, in fiscal year 18, $20,000 was allocated to purchase monitoring device for one of the sprayers. Multiple years of funding from the CDC Epi and Lab Capacity Grant provided us the opportunity to purchase $5,000 of larvicide.
Criteria for Inclusion
The program requires that funds be allocated in ZIP codes within the OCCHD jurisdiction. Targeted communications may be focused on areas with highest risk, as identified through the Wellness Score and client interviews. Prevention messaging are also focused on the high traffic highways and prime time news segments.
Timeframe
Programs included within the innovative practice have operated as independent programs in the OCCHD jurisdiction for 8 years. Both the acute disease investigation and vectorborne disease programs were evaluated over the past 18 months to determine opportunities for improvement in process or delivery of program elements. The mobile app was recently launched in 2017 using public health emergency funding.
Stakeholders
The entire strategy relies heavily on the direction and support of the broad-based, multi-sector collaborative partnerships within Oklahoma. A broad array of partners has supported efforts to ensure timely response and implementation of a scalable vectorborne disease response plan and include:
OCCHD Consumer Protection Division and Epidemiology, Oklahoma State Epidemiology, Tulsa Health Department, Tinker Air Force Base, Municipal partners, Big Cities Preparedness Workgroup, Public Health Laboratory, Oklahoma City Emergency Management, Edmond Code Enforcement, Oklahoma City Storm Water Quality, Local media (television, radio and print) and The University of Oklahoma College of Public Health.
Funding
Funds to support the described innovative practice have been allocated as a combination of the OCCHD local tax levy base and periodic grant funds. City and municipal partners allocate funding to repair and staff the traps in their area of responsibility. During the Zika virus outbreak, federally awarded grant funds were utilized to purchase additional BG Sentinel traps and larvicide.
The total number of mosquitos captured, tested, positive traps, positive pools and positive mosquitoes are presented weekly in the OCCHD Situation Report.
A comprehensive annual report is produced at the conclusion of each mosquito season. This report analyze trapping and testing results, larvicde used, habitat remediation, community education, emergency response activities implemented and media outreach conducted. During the most recent mosquito seasons (2017-2018), local code enforcement, city officials and consumer protection deployed a total of 17 CDC Gravid and BG Sentinel traps. The final day of sorting took place during the last week of October, as consistent with the decrease in mosquito numbers. There were 23 trapping and testing weeks with a total of 18,068 (2018) and 43,079 (2017) mosquitos trapped and 15,775 (2018) and 33, 846 (2017) mosquitos tested. IN 2018, an average of at least 87% of the captured mosquitos were tested each week, with a total of 7,632 positive pools of mosquitos. The two main genera identified in 2018 include Aedes and Culex. Most of the mosquitos in the BG traps were of the Aedes genus (84.0%) and the second highest was Culex (15.1%). The Maximum Likelihood Estimation (MLE) Infection Rate is calculated each week.
The OCCHD believes strongly that public health interventions should be implemented utilizing place-based strategies that employ a technical package. By targeting neighborhood and property assessments using GIS mapping, case interviews and community based interventions, the OCCHD is allocating resources to areas where the greatest risk reduction can be achieved in the shortest time frame.
Complaints:
The Complaints Program in Consumer Protection receives stagnant water complaints. These complaints are given to the area inspector to investigate. If stagnant water is observed at a vacant property, they remedy the problem by either applying larvicide or having the property owner treat the water. If the property is not vacant, an abatement notice is issued to the property owner. There were 256 stagnant water complaints in 2018 and 255 in 2017. Throughout the season, 43 complaints (17%) were associated with duplicate locations. Eighteen of the 2018 complaint locations were also reported in 2017. This data is graphed and provided to inspectors and stakeholders for review. The months of May, June and July had the highest complaints reported while the months of August and September had the highest mosquito counts.
Responding to Human Cases:
In 2018, 3 human cases of mosquito borne disease were investigated in Oklahoma County; 1 West Nile Fever (WNF) and 2 West Nile Neuroinvasive (WNV Neuro). In 2017, 7 human cases of Vectorborne disease were investigated in Oklahoma County; 1 West Nile Fever (WNF), 5 West Nile Neuroinvasive (WNV Neuro) and 1 Zika Virus travel related cases. Statewide, there were 14 total cases (5 WNF and 9 WNV Neuro) in 2018 and 60 total cases (12 WNF, 27 WNV Neuro, and 1 Zika) in 2017. After confirmation of a positive human case, the Epidemiologist conducts a detailed case investigation and after obtaining consent, provides the exact location where the case resides to the Consumer Protection area inspector in order to conduct a survey of the surrounding area and pass out flyers to the community on education and prevention mechanisms. Consumer Protection also conducts area surveys with travel associated positive Zika cases to help prevent the virus from potentially being introduced into the Oklahoma City-County vector population.
Each program year had differing progressions of mosquito numbers. In 2013, the number of mosquitos peaked in August before decreasing each week until October. In 2014, the numbers of mosquitos were consistent each month from July to September instead of steadily increasing. In 2015, the number of mosquitos began low and gradually increased each week. In 2016, there were a large number of mosquitos captured at the start of the season prior to a sudden decrease in numbers. In 2017, the numbers increased gradually each week with the number spiking towards the end of September before a steep decrease. In 2018, there was a decrease in mosquitos captured by 166% compared to 2017. Detailed tables, graphs and charts are included in each annual report to present historical and current data points.
Resistance Testing:
Resistance testing for Deltamethrin was completed in the first week of August. Deltamethrin, a type II pyrethroid, is the active ingredient in our current supply of insecticide. For this reason, it was chosen for the first resistance testing trial. The location of mosquito trapping for resistance testing was determined by mapping the locations of previous year's human cases by zip code. Another round of testing with Deltamethrin was attempted with a second trapping location. In both cases, the minimum threshold of 10-25 female mosquitos, of the same species, was not met. Thus, a conclusion could not be made in 2018. Resistance testing will continue in 2019 and therefore to establish a baseline and continued measure of potential resistance in the population, in accordance with emergency response preparation.
Reporting:
The inclusion of partner engagement and periodic reporting is a component of the program planning and development was purposeful and is considered an aspect of the innovative practice. Given these parameters, the planning, reporting and annual evaluation efforts for this innovative practice were developed with Public Health preparedness in mind, and focus on considering cross-sector, program efficacy and community based prevention outcomes collectively. Evaluations for each component of the innovative practice have been developed to incorporate qualitative and quantitative analysis, and incorporate multiple systems through the course of implementation to allow for collaborative improvement.
The weekly situation reporting ensures the following:
Community partners are properly updated on local, state and national events.
Emergency preparedness groups are prepared for phased response
Data collection is accurate and provided in a timely and consistent manner.
The annual report provides information to:
Assess the effectiveness of the activities in place during the most recent year, in comparison to historical activities.
Estimate resources required for the following season
Understand the effect of integrated and collaborative prevention strategies on prevention of vectorborne disease
Evaluate media outreach and community education strategies on prevention techniques and strategy
This toolbox ensures each partner has a method to reduce risk of disease in their setting while the health department has provided the technical package for other communities to adopt as they see best suited for their population. The OCCHD is committed to developing and implementing strategies that have long term impact and sustainability for the community. The integrated and strategic delivery of program interventions was critical to community-wide vectorborne disease protection realized by Oklahoma City and Oklahoma County following the launch of the integrated approach. To maintain these strategies and the long term impact for continued preparedness, Interventions must focus on multi-generational, and place-driven. Engaging partners and program implementation staff in implementation design was critical not only to successful implementation but to program sustainability.
This data can be broken into three main categories for risk:
Temperature: The hotter the temperature the higher the risk of WNV being active in mosquitoes.
Mosquitoes: The higher the number mosquitoes captured, the greater the risk of exposure to mosquito bites. The higher the number of consumer complaints of mosquitoes, the greater the risk of mosquito bites.
Disease: The higher the Infection Rate of mosquitoes, the more likely they are to spread the disease. The more WNV cases in the state of Oklahoma or Oklahoma County, is proof of risk and the end result of mosquitoes infected with West Nile Virus biting humans.
Overall, the program must be built in incremental steps to provide for continuous improvement and operations. The staff at OCCHD, and across the City partners, provide their expertise during the vectorborne season in-kind, collecting no additional pay for the season. Resources are allocated to account for competing priorities and the teams collaborate to ensure each segment of the program is accomplish appropriately. The budget, as explained in this document, remains minimal, with supporting grants boosting capacity during various years of the program. Building the program from where an existing organizations is operating is the preferred method of enhancing a city's vectorborne disease response program.
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