Barriers to Public Health Management of a Pertussis Outbreak in Arkansas

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Abstract
Background During the 2001-2002 respiratory season, Arkansas experienced one of its worst pertussis outbreaks. This crisis occurred shortly after the September 11, 2001, terrorist attacks. Objective To determine whether vulnerabilities in the public health infrastructure existed in the context of emerging infectious diseases or possible bioterrorist attacks. Design Key personnel involved in the Arkansas pertussis outbreak were interviewed, and health department epidemiologic data were reviewed. Setting Observations were made for the statewide private-public management of the epidemic. Participants Physicians, infectious disease specialists, epidemiologists, field nurses, health department staff, laboratory staff, and administrators. Main Outcome Measures Diagnosis capability; vaccine, prophylaxis, and treatment programs; and effectiveness of global outbreak management. Results Diagnosis of pertussis was a major barrier to management of the outbreak. The nonspecific clinical diagnosis, unreliability of testing methods, excessive number of samples, unavailability of reagents, and inadequate transport system, laboratory personnel, and equipment all impeded effective diagnosis. Vaccine shortage was not believed to contribute to the extent of the outbreak. Prophylaxis was problematic because of feared adverse effects of drugs and uncertainty about the efficacy of new drugs, but compliance was found to be good. From a public health perspective, isolation procedures, school absence policies, and health department referrals to private physicians all contributed to confusion. Problems with communications, staffing, and public cooperation were identified. Despite these barriers, the epidemic was well tolerated, with no known mortality and limited morbidity. Conclusions Despite many identified barriers to effective public health management, Arkansas tolerated its worst epidemic of pertussis in many years. However, were the state to experience an outbreak of a more pathogenic agent, introduced either naturally or of bioterrorist origin, these vulnerabilities could become critical. Natural outbreaks serve as excellent experiences on which to recognize and correct barriers to public health management.