Environmental and Global Health Issues
Laralee Shaffmaster
Western Governor’s University

Environmental and Global Health Issues
This paper on environmental and global health issues in community health nursing will discuss and analyze the communicable disease measles. It will present epidemiological data, causes, manifestations and the route of transmission for measles. A graphic representation of the measles outbreak will be presented to discuss the international pattern and movement of the disease. A discussion of how the measles outbreak could affect the community will also be presented. Next, this paper will present the appropriate protocol that a community health nurse will follow to report a SARS outbreak in the community. The last subject this paper will discuss is how a community health nurse modifies their care of clients with respiratory diseases during a time when the air quality index is poor. A. Measles
Rubeola or measles is a respiratory disease. Measles is a virus that normally grows in the throat cells that line the back of the throat and lungs. Once infected, measles causes runny nose, fever, cough and a head to toe rash that occurs 14 days after exposure (CDC, 2013).
A1. Outbreak
In the year 2000 measles became eliminated in the United States. Elimination means the disease is no longer native to the U.S. and cases are not reported for a twelve month period in endemic proportions. Outbreaks occur when people travel to countries where the disease is still present (Gastanaduy et al., 2014). Europe, Asia, Africa, and the Pacific have countries where the disease has not been eliminated. International travel to these other countries can expose travelers bringing imported cases of measles to the United States (Gastanaduy et al., 2014).
The Los Angeles County Department of Public Health (LACPDH) was notified on August 26, 2011 that a refugee from Burma had arrived in Los Angeles, California from Kuala Lumpur, Malaysia. The refugee was suspected of having measles. The plane held another 31 passengers traveling from Malaysia; these passengers traveled to seven other states (CDC, 2012).
The LACDPH and the California Department of Public Health (CDPH) worked together investigating over 298 contacts; three of the contacts were diagnosed with measles. One was a customs worker and the other two were passengers on the flight with the refugee first diagnosed with measles. There were no other cases linked to these three additional cases (CDC, 2012).
The refugee from Burma got a fever on August 21 and a rash followed the next day. This person was traveling with his siblings and his mother and did not report any symptoms to the health care provider in Malaysia. One of the siblings claimed to have a fever with a rash on August 18, but all the family members had no symptoms when they arrived in Los Angeles County (CDC, 2012). This patient was diagnosed with measles on August 30, 2011 (CDC, 2012).
Another patient who arrived on the same airplane in Taiwan developed a fever six days after their arrival in the U.S. A rash followed the next day and on September 9, 2011 it was confirmed that this patient had measles. Pediatrician office contacts and family members were some of the 12 contacts of the patient interviewed during the investigation of the measles outbreak (CDC, 2012).
One girl developed a fever on September 1, 2011, but her family failed to mention this during their interview with LACDPH employees at the time. Although LACDPH instructed the girls’ family to remain in quarantine because of her possible association to the measles disease the family traveled on a chartered bus to Las Vegas, Nevada. The family stayed in two hotels in Las Vegas and returned to Los Angeles in a rented car (CDC, 2012).
The next day the family attended church and visited a doctor’s office on September 7, 2011. LACDPH investigated family and church members, bus passengers and contacts at the pediatrician’s office. There were a total of 79 people investigated who were connected to this case (CDC, 2012). Nevada health officials conducted a separate investigation of the contacts in Las Vegas (CDC, 2012).
The final contact investigated was diagnosed with measles after he visited a local emergency department for a fever that appeared on September 3 followed by a rash on September 6, 2011. This patient processed the refugee when he arrived at the airport on August 24, 2011. Although this patient was ill he showed up for work at the airport in Los Angeles County September 2 through September 4, 2011 (CDC, 2012). There were a 110 contacts interviewed; five more customs officers reported measles-like illness, but none were confirmed as measles (CDC, 2012).
Since the diagnosis in the first patient was delayed the use of measles-mumps-rubella (MMR) vaccination as an intervention for the outbreak was not provided. This particular outbreak shows the importance of maintaining high vaccination rates for measles in the United States to combat international travelers infected with measles. It also shows that the public could use more education on when to report symptoms of possible measles outbreaks (CDC, 2012).
A2 and A3. Epidemiological Indicators and Data
It is estimated that in the 10 years before the two-dose MMR vaccine was introduced for children in the United States that three to four million people were infected annually with measles. Measles caused 300 to 400 deaths, 48,000 were hospitalized and 1,000 suffered chronic disability from encephalitis. The use of the measles vaccine has decreased the number of cases in the U.S. by 99 percent (CDC, 2014b).
Populations with the highest risk for measles are children under five and adults over twenty years of age. The disease is highly contagious and can cause complications in pregnancy like miscarriage and premature birth. These populations and those immunocompromised from HIV or leukemia are also at a higher risk for complications like pneumonia, hospitalization and death from measles (CDC, 2014a). Measles is accompanied by ear infections in one of 10 cases, pneumonia in one of 20 cases; death occurs in one or two out of 1, 000 cases (CDC, 2014a).
The measles outbreak associated with Los Angeles County, California in 2011 involved four cases between the ages of 12 months and 25 years. The first case reported was a male who was 15 years old emigrating to the U.S. from Malaysia without proof of measles vaccination (CDC, 2012).
A U.S. born 12-month old female was vaccinated for MMR five days after the flight at a regular well-baby check. This patient was traveling from Taiwan where measles has a low incidence and she sat nine rows from the 15 year old emigrant. A day after her vaccination she developed a fever and shortly later developed a rash (CDC, 2012).
The third measles case identified was a 19-month old unvaccinated Indonesia born female who came to visit family in Los Angeles County. The last case identified in the outbreak was a 25 year old unvaccinated U.S. Customs and Border Protection Officer (CDC, 2012).
The four cases identified in the outbreak were all unvaccinated or had no proof of vaccination for MMR. In the United States the MMR vaccine is recommended for children at age 12 to 15 months and a booster is routinely administered at four to six years old (CDC, 2012).
A4. Route of Transmission
People exposed to measles who are not immune will most likely get the disease. It is spread from human to human through breathing in contaminated air, coughing and sneezing. The disease can be spread four days before and up to four days after the rash appears (CDC, 2009). The measles virus can survive on infected surfaces for two hours and someone not immune will acquire it by touching the contaminated surface and then touching their mouth or nose. Measles is transmitted by humans and not transmitted from other animals (CDC, 2009). It is mostly likely that the passenger who developed measles came in contact with something contaminated by the refugee or the droplets of the disease were spread through a cough or sneeze to at risk passengers. Close quarters and contact with the initial case caused this easily spread disease to infect others (CDC, 2012).

A5. Graphic Representation 15 year-old refugee-infected from brother gets on plane in Malaysia.
8/21/11-fever; 8/22/11-rash
8/24/11 Arrives in L.A. County Ambulance transfer to ED (not isolated for 8 hrs.)
Transfer to another hospital where he is isolated for measles suspicion. 8/26/11- LACDPH notified.
8/30/11-Laboratory confims measles for 15 year old and 16 year old brother.
97 contacts interviewed-(family, plane members, ambulance and ED staff, bus and motel guests)
21-day incubation promts repeated interview of contacts. Lab identifies 4 confimed cases.
9/1/11-Refugee-15 year- old symptoms resolve and cleared to travel to Wisconsin 9/2/11.
(6 Cases)
15 year-old refugee-infected from brother gets on plane in Malaysia.
8/21/11-fever; 8/22/11-rash
8/24/11 Arrives in L.A. County Ambulance transfer to ED (not isolated for 8 hrs.)
Transfer to another hospital where he is isolated for measles suspicion. 8/26/11- LACDPH notified.
8/30/11-Laboratory confims measles for 15 year old and 16 year old brother.
97 contacts interviewed-(family, plane members, ambulance and ED staff, bus and motel guests)
21-day incubation promts repeated interview of contacts. Lab identifies 4 confimed cases.
9/1/11-Refugee-15 year- old symptoms resolve and cleared to travel to Wisconsin 9/2/11.
(6 Cases)
Malaysia
16 year-old refugee infected with measles about 08/18/11.
(Unknown cases)
Malaysia
16 year-old refugee infected with measles about 08/18/11.
(Unknown cases)
Burma where refugee originates
Burma where refugee originates

31 other refugees travel to 7 other U.S. states creating more investigations and possible outbreaks.
31 other refugees travel to 7 other U.S. states creating more investigations and possible outbreaks.

8/24/11 50 LACDPH and CDPH workers begin to investigate 298 contacts

8/24/11 50 LACDPH and CDPH workers begin to investigate 298 contacts

Indonesia Born 19- month old girl
8/24/11-unvaccinated, also seated 9 rows from initial case on flight.
8/30/11-instructed family quarantine at home for known exposure.
9/1/11-fever unreported to LACDPH and child with parents travel to Las Vegas via bus, stay in 2 hotels.
9/3/11-rental car back to Los Angeles and gets rash.
9/4/11-attends church
9/6/11-family reports all to LACDPH officials.
9/7/11-visits pediatrician against instruction.
9/9/11-Confirmed measles. 79 contacts are investigated. Nevada officials investigate Las Vegas contacts (unknown)
(9 known Cases)
Indonesia Born 19- month old girl
8/24/11-unvaccinated, also seated 9 rows from initial case on flight.
8/30/11-instructed family quarantine at home for known exposure.
9/1/11-fever unreported to LACDPH and child with parents travel to Las Vegas via bus, stay in 2 hotels.
9/3/11-rental car back to Los Angeles and gets rash.
9/4/11-attends church
9/6/11-family reports all to LACDPH officials.
9/7/11-visits pediatrician against instruction.
9/9/11-Confirmed measles. 79 contacts are investigated. Nevada officials investigate Las Vegas contacts (unknown)
(9 known Cases)

U.S. Born 12- month old 8/24/11- boarded plane in Taiwan, seated 9 rows from initial case.
8/29/11- receives first dose of MMR vaccine in L.A. County.
8/30/11 develops fever, 8/31/11-Rash.
9/9/11-Lab confirmed. 12 contacts from pediatrician office and family members interviewed.
(7 Cases)
U.S. Born 12- month old 8/24/11- boarded plane in Taiwan, seated 9 rows from initial case.
8/29/11- receives first dose of MMR vaccine in L.A. County.
8/30/11 develops fever, 8/31/11-Rash.
9/9/11-Lab confirmed. 12 contacts from pediatrician office and family members interviewed.
(7 Cases)

U.S. Customs 25 year old
8/24/11-no MMR vaccination proof-processed 15 year old refugee
9/3/11-fever-contines working until 9/4/11 contacts 110 9/6/11-rash-pt visits local ED
9/9/11-Measles confirmed
9/13/11-5 other customs workers develop symptoms-no confirmed measles.
(8 cases)
U.S. Customs 25 year old
8/24/11-no MMR vaccination proof-processed 15 year old refugee
9/3/11-fever-contines working until 9/4/11 contacts 110 9/6/11-rash-pt visits local ED
9/9/11-Measles confirmed
9/13/11-5 other customs workers develop symptoms-no confirmed measles.
(8 cases)

A6. Outbreak Effect on Community The community nurse may need to help develop ideas to control the outbreak. Individuals could potentially be quarantined if suspected to be infected. The community would need education on the outbreak, how it’s spread and where to obtain medical care. An outbreak would require additional health care workers and could potentially interrupt cares of their everyday patients (Clark, 2008). People would have to stay away from work and business may close leading to reduced incomes. Schools and daycares may be shut down causing struggle for parents to remain home and care for children. Traffic to and from the community would be stopped leading to difficulty getting medical supplies, groceries and other necessities to the community (Clark, 2008).
The interventions to control the spread of disease can cause social and economic drain on the community affected. The outbreak may cause travelers to avoid the community causes businesses and communities to lose out on money (Clark, 2008). B. Protocol for Reporting SARS Outbreak
This section will identify the proper protocol for reporting a SARS (Severe Acute Respiratory Syndrome) outbreak confirmed by laboratory testing at a health care facility. If the SARS case is not linked to a worldwide transmission any positive SARS cases should be reported immediately to the local health department by telephone. This will insure immediate control and isolation precautions, the ability to trace future outbreaks and necessary follow-up (CDC, 2005).
The health clinic should report to the state and local health department any hospitalizations for radiographically confirmed pneumonia for people who report recent travel or contact with travelers from China, Hong Kong or Taiwan. They should also report cases of confirmed pneumonia of any health care workers especially those providing patient cares with those patients at risk of SARS or workers in the laboratory. Any cases associated with a cluster of atypical pneumonia cases that do not have alternative diagnosis for pneumonia should also be reported to state and local health departments (CDC, 2005).
Continued use of SARS testing should be used carefully to avoid panic in the community by coordinating with the state and public health officials. Testing should be done only when the criteria explained above are met for suspected cases. Healthcare workers should be alert and report to local state and public health officials any cases of atypical pneumonia confirmed in more than two health care workers who work at the same facility (CDC, 2005). Any cases confirmed by laboratory with SARS must be reported to state and local health officials immediately (CDC, 2005).
In addition to reporting, the healthcare clinic should follow-up on any suspected cases and isolate people who may have been in contact with the disease. The states and local health departments will coordinate with the local healthcare clinic and the community involved in the suspected outbreak as well as report directly to the Centers for Disease Control and Prevention (CDC, 2005).
Local healthcare workers will need to continue monitoring the community for suspected outbreaks. This can be done by considering any epidemiological links to SARS cases, risk factors such as the development of illness within 10 days of contact to suspected transmissions of the disease. Any people with respiratory illness or fever who may have been in contact with foreign or domestic travel with suspected cases should also be reported to local public health officials (CDC, 2005). It is also necessary to monitor and screen any and all healthcare workers, patients and visitors who may have come in contact with or developed symptoms of SARS (CDC, 2005). C. Reducing Risk Due to Poor Air Quality
In this final section a discussion of how to modify care for populations with asthma and other respiratory diseases in the event of poor air quality index in the community will be provided. The Air Quality Index (AQI) is a national index used to report daily air quality. There are five reported common air pollutants reported, ozone at ground level, particulate matter, sulfur dioxide, carbon monoxide and nitrogen dioxide levels are reported and forecasted (EPA, 2014).
Air qualities reported below 100 are considered satisfactory and reports of an AQI of 101 to 150 are considered unhealthy for sensitive groups. The higher the AQI the more risks are associated with those who suffer from respiratory diseases. Sensitive groups include active children and adults as well as individuals with lung disease such as asthma and other respiratory illnesses (EPA, 2014).
Providing care to these vulnerable populations is important for the community nurse to address. The clients with asthma and other respiratory diseases should be advised to limit activity that requires moderate to strenuous exercise especially outdoors. These activities can be accomplished in the morning or evening when the air quality is better or by limiting the amount of time spent on the activities (EPA, 2014).
Moderate exertion includes activities such as climbing stairs, playing baseball and tennis, gardening, brisk walks or jogs, hiking and cycling. Heavy exertion are activities such as playing sports like basketball or soccer, vigorous digging, running, hiking or jogging are also included. Individuals should be instructed not to perform these strenuous activities when the air quality index rating is unhealthy, very unhealthy or hazardous (EPA, 2014).
When the AQI is rated above 150 to 200 susceptible people with asthma or respiratory diseases should be educated to reduce any time spent outside for heavy exertion. Levels above 300 warrant instruction for clients to limit any time or activities spent outside (EPA, 2014).
Conclusion
This paper has analyzed and discussed at length a communicable measles outbreak that occurred in Los Angeles County in 2011. The analysis included specifics about the outbreak including epidemiological indications and data associated with measles, the route of transmission, a graphic representation of the outbreak and finally how the outbreak could affect the community. The protocol a health clinic would follow for reporting a possible SARS outbreak was presented. The last section showed how the community nurse would modify care of susceptible clients with asthma and other respiratory diseases when the air quality index is poor.

References
Centers for Disease Control and Prevention. (2005). Severe acute respiratory syndrome (SARS). V. Reporting of cases of SARS-CoV disease. Supplement B. SARS surveillance. Retrieved from http://www.cdc.gov/sars/guidance/B-surveillance/cases.html#healthcare
Centers for Disease Control and Prevention. (2009). Transmission of measles. Retrieved from http://www.cdc.gov/measles/about/transmission.html
Centers for Disease Control and Prevention. (2012). Measles outbreak associated with an arriving refugee-Los Angeles County, California, August-September 2011. Morbidity and mortality weekly report, 61(21); 385-389. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6121a1.htm
Centers for Disease Control and Prevention. (2013). Overview of measles disease. Retrieved from http://www.cdc.gov/measles/about/overview.html
Centers for Disease Control and Prevention. (2014a). Measles (Rubeola). Retrieved from http://www.cdc.gov/measles/index.html
Centers for Disease Control and Prevention. (2014b). Measles vaccination. Retrieved from http://www.cdc.gov/measles/vaccination.html
Clark, M.J. (2008). Communicable diseases. Community health nursing: Advocacy for population health. Retrieved from http://media.pearsoncmg.com/pcp/2008935461/ebook/
Gastanaduy, P.A., Redd, S.B., Fiebelkorn, A.P., Rota, J.S., Rota, P.A., Bellini, W.J., . . . Seward, J.F. (2014). Measles. Morbidity and mortality weekly report, 63/22; 496-499.
U.S. Environmental Protection Agency. (2014). Patient exposure and the air quality index. Retrieved from http://www.epa.gov/o3healthtraining/aqi.html#advise