Donna Mazyck: Books will be written about this COVID era, but school nurses have met this moment by advocating for health and safety protocols against all odds, and truly against tremendous pushback from the community. Speaker 2: Imagine a typical school morning, students coming off the bus, many sick and headed straight for your clinic. You are their first line of defense. That's why thousands of school nurses rely on FLUency, a school health program by this episode's sponsor, Kinsa, that has been reducing the spread of illness in classrooms for seven years. Join over 5,000 schools and receive free smart thermometers for your families and staff. Track illness early, and take action before it spreads. Sign up now to get FLUency for free. Text "apply" to 24020. That's A-P-P-L-Y, to the number, 24020, to get started. Donna Mazyck: Hello. I'm Donna Mazyck, executive director of the National Association of School Nurses. Welcome to the School Nurse Chat Podcast. Today we will be talking about identifying contagious disease outbreaks in schools. Our guests today are Danielle Bloch, an infectious epidemiologist at Kinsa, who previously worked at the New York City Department of Health and Mental Hygiene, and who's a volunteer with the COVID tracking project. We also have with us, Robin Cogan, a nationally certified school nurse working in Camden, New Jersey. Robin has received the NASN President's Award, and she's also a Johnson & Johnson School Health Leadership fellow. Donna Mazyck: You can find Robin on her blog, The Relentless School Nurse, and she also writes a column at My American Nurse. Welcome, Danielle and Robin. So, let's get started with today's podcast topic. Danielle, what's your experience identifying contagious disease outbreaks in educational settings, and how do you collaborate with school officials? Danielle Bloch: Thanks for the question, Donna, and thanks so much for having me on the podcast. My experience identifying outbreaks in educational settings with the Health Department really comes in two different ways. The first is that, at the Health Department we would sometimes get calls from who we called "astute clinicians", basically the eyes and the ears on the ground, and in educational settings, the school nurses. And we would get calls when sometimes they needed some outside advice on how to handle an outbreak or to let us know that there was something bizarre going on and get our input. Danielle Bloch: The other way that we would sometimes identify outbreaks in the educational setting is through routine case investigations and public health surveillance. So, there's a bunch of diseases that are reportable to health departments, and a number of those require more investigation from epidemiologists. And doing contact tracing and getting different exposure notifications, we would learn about shared exposures, and sometimes that would be a school. I'm going to tell two quick stories that I think highlight the ways that public health departments can work really well with school nurses, and in different educational settings, that I was a part of. Danielle Bloch: The first is that there was an instance where we were doing routine case investigations at the Health Department and got a report of meningococcal disease in a woman. And after doing more case investigation, learned that there had been a volunteer at a school recently during the exposure period where we were concerned about giving out prophylaxis. And in that instance we reached out to the school to let them know about this, worked with the school nurse to learn more about what the type of exposure was between the parents and different students, and actually went into the school to give some education about meningococcal disease and its transmission. Danielle Bloch: The other instance that I think really showcases how the health department can work well with health officials in the school was an instance, actually, in a college where we heard about an outbreak from an astute clinician of Methicillin-Sensitive Staph Aureus. And we worked with the nurse to create a case definition, constant communication every day throughout the outbreak, to learn about different increases in cases, and to try to find a common exposure to stem the outbreak. So, those were two different instances where I think public health and schools could really work hand in hand. Donna Mazyck: Thank you, Danielle, for that picture of how it works, how school officials and health departments work together. I really appreciate your term, "astute clinician". So, we're going to Robin now. As an astute clinician, what are other school nurses like you doing to track potential infectious disease outbreaks? Robin Cogan: First, thank you for having me. I'm so honored to be on this podcast, and certainly, through COVID school nurses have become really good friends with our local epidemiologists, so I'm really excited to be on with Danielle as well. I think it was actually Lori Combe who said that school nurses were population health gold, because we're able to see the full picture of our student population and the individual student at the same time. So, this really relates to our discussion today, because what we do and what we're so astute at, and thank you for acknowledging that, Danielle, is identifying trends. Robin Cogan: For example, let's say several children who exhibit similar symptoms from the same classroom, the same wing of the school, or they intended a common event. I had an interesting case where one second grade class had a multiple outbreak of MRSA, and it was, believe it or not, when they finally did the case investigation, it was linked to the pencil sharpener. It really was a very interesting case. I think we learned a lot about, we certainly learned a lot about MRSA that year and how it was spread, and how a common object can be the intense focus of a case investigation. Robin Cogan: Also, when there's an increase in school absences and parents reporting similar symptoms as the reason why their children are not attending school. The famous case since I've been a school nurse was the H1N1 outbreak. Mary Pappas, I think she was a New York State school nurse who saw a trend of students, very concerning trend of high fevers in her students. And when it was reported to the Health Department, I think one day she sent home more than a 100 students and the next day it was 90. It was a very large number. And that was determined to be the first evidence of the swine flu in New York State. So, it's looking at trends, it's identifying commonalities, and then knowing what to do with that information and who to reach out to. Donna Mazyck: Well, that expression of how school nurses are population health gold is really one that I appreciate you identifying and amplifying, Robin. With being able to identify those trends, does lead us to a question of how that information is used in actually helping around this identification of outbreaks. So, how should school nurses and school districts collaborate with public health departments, Robin, as they're identifying, much like Mary Pappas did, outbreaks of contagious diseases? Robin Cogan: Right. So, that's the key is, first of all, building those relationships ahead of time. With COVID, I think, we've all learned how we were taken by surprise, honestly, in terms of the long term impact of what we were facing. When COVID first happened in March 2020, my district, and I think many others also, we were told to pack up, we'd be back in two weeks. The date was March 18th 2020, we were told we would be back in school on March 30th, 2020. We actually returned to school March 29th 2021. Robin Cogan: But in between all of that time, tremendous strides were made in connecting with our local health departments, really solidifying those relationships that had always been there but had never been tested to this degree, had never been stretched to this capacity, and I think really understanding what each of our roles it are and how we are symbiotic, codependent, really needing to give each other information, being transparent, following trends that we see happening, being in close communication with our state and local health officials, updating our own emergency plan so that they are in place before an outbreak occurs, I think all of those lessons were learned and reinforced with COVID. Robin Cogan: And it begins right with establishing relationships with our state and local public health officials for this ongoing communication that's needed, because as the evidence comes to light, as the research is published, then our guidelines change. So, that ongoing communication, knowing where to look, understanding where your resources are, certainly, it makes managing the spread and preventing the further spread of communicable diseases so important. Donna Mazyck: So well said, Robin. So, that collaboration enables the coordination, which needs to be communicated, and it really makes for a better picture of keeping students healthy and safe in school. Robin Cogan: Yes. Donna Mazyck: Danielle, tell us about technology and the role of technology in identifying outbreaks, and what are some new ways that can be used? Danielle Bloch: Yeah, it's really interesting how the COVID-19 pandemic has really both expedited and brought to light different ways that technology can help identify outbreaks. And I think they fall into a few different categories. I think the first is new ways of identifying cases and identifying increase in cases above the norm. Another is, identifying new cases related to an outbreak, contact tracing, as well as different laboratory technologies. So, I think one that a lot of people will be familiar with in terms of contact tracing, are exposure notifications that you can enable on your cell phone. Danielle Bloch: And a bunch of states across the US, I think in over half of states, there have been collaborations to allow for an option on your phone that you can turn on, and if you're within six feet of Bluetooth range of someone who opts in and alerts the app that they have tested positive for COVID, that you would subsequently get a notification about that, and could take the steps to get a COVID test, to self-isolate until you have the results from that test, et cetera. Danielle Bloch: And there's been some really interesting modeling studies around that, showing that if just 15% of the population can opt into that system, which is a pretty low percent, that can actually help reduce the impact of COVID in the community. Obviously it's better if more people opt in, but it's pretty cool that an effect can be seen even that low. So, I'm really excited about that in terms of contact tracing efforts. Donna Mazyck: Mm-hmm (affirmative). Danielle Bloch: Something else that I find really cool, I had an application at the beginning of the COVID-19 pandemic is, the ability for machine learning technology to scan news articles across the internet and find these common threads. And there was some work done at the very beginning of the pandemic that identified this novel Coronavirus in Wuhan right at the start of the pandemic before it was really making international news just from those more local news sources. Danielle Bloch: And in that same realm of processing different texts on the internet, there's been some really cool work that has been done at the New York City Department of Health in terms of foodborne outbreaks, scanning Twitter and Yelp for negative food reviews related to foodborne illness, and using that as a flag for epidemiologists to go in and do some case investigation, learn more about common exposures, and try to stem those exposures. Danielle Bloch: And the last one that I'll highlight that I think is really important, especially for foodborne outbreaks, and also in COVID in general, is some laboratory testing techniques, including whole genome sequencing. And whole genome sequencing, even 10 years ago, 15 years ago, is a really arduous process, now can be done in less than a day. And it's really important for foodborne outbreaks in terms of identifying cases that are in common with each other, cases in common with a source. Danielle Bloch: We recently had a multi-state outbreak across the US, Salmonella that was associated with onions, and that was identified via whole genome sequencing, in addition to case investigation. So, that's really important for pushing forward and expediting the path of finding common sources and being able to alert the public about those types of common outbreaks. Donna Mazyck: Thank you for sharing those examples, Danielle, of how technology is facilitating health and safety. Robin, what do you need to be aware of, to spot and track symptoms in the clinic? Robin Cogan: Well, you need to really be up on how things are changing and how there are new symptoms that are being associated with different variants. For example, with COVID, it hasn't been fully flushed out yet, but what we are seeing on the ground, especially related to the Delta variant, and I'm very interested to hear what Danielle has to say about this, is that we're seeing kids complaining of ear pain as one of the early symptoms for COVID in younger children. I don't know if you've seen that Danielle, but we have seen it multiple times, and I've read a bit about it. I don't think that the research is quite up with what we're necessarily seeing anecdotally on the ground. Robin Cogan: So, understanding some trends, maybe even reaching out to your local health department, which we did, to report this is what we're seeing, but also understanding what the school-related illnesses that are reportable to the Department of Health include. Working in elementary school understanding what does fifth disease look like, hand-foot-mouth-and-disease is something we have to know the signs and symptoms of. Certainly influenza. And we're about to enter, or we're already in the midst of ... Robin Cogan: For us in New Jersey, we're one of the only states that requires the flu vaccine for children six months to 59 months, because the data showed that our youngest children were bringing home the flu to our oldest family members. So, quite a few years ago, flu vaccine became mandatory in New Jersey for preschoolers, anyone in daycare, six months to 59 months. Certainly MRSA, scabies, the things that we know are school-related illnesses that are reportable. Also, school nurses can help expand the efforts that public health nurses do by conducting our own disease surveillance in our school communities. Robin Cogan: We really are that trusted physician within the school community, and one of our greatest strengths, we have quite a few, but it's efficiently communicating this health information, and partnering with our local health department to talk about some concerning trends that we see. I wanted to just touch, if I could, on the whole idea of using the technology piece, and certainly social media. And I am a big proponent of the technology piece. I do believe though that we have to also understand the needs of the community and the capability of the community. And the community where I serve, technology has been somewhat of a barrier. Robin Cogan: Having access to the internet has been a barrier. And I've found, actually, with the testing company that we're using, there's been a really unfortunate disconnect between their very fancy-dancy testing reporting system that is not reaching the parent, and so the test results are coming back to the school nurse to report the positive cases. Donna Mazyck: Robin, you bring up a really good point around being aware of where technology is and who's benefiting from it, and is it the ones that we want to make sure benefiting. Robin Cogan: Right. Donna Mazyck: And speaking of that technology, we know, Danielle, that health systems track outbreaks. They track outbreaks of the flu, MRSA, RSV, measles, and even more. You talked about those reportable communicable diseases, and there are others. How can schools better work with health systems to make use of this information? Danielle Bloch: I really want to echo what Robin was saying before about school nurses knowing the community so intimately and knowing what's going around, knowing how to best communicate concerns and information back to students and parents, because in health departments, we get a lot of data about test results that come in, but we don't get data about people who don't get tested. And sometimes that can be a huge barrier, and we just have huge blind spots in terms of what's going on in the community. Danielle Bloch: So, I want to echo how much that relationship between health departments and school nurses, in the ideal world, is that to-way street, that if there is something weird going on, if there are outbreaks of a flu or MRSA, that might be more clinically diagnosed in the nurse's office and not necessarily getting reported, the Health Department wants to know about that. That too is a really important information stream to know what's going on in the community. In addition to that, from the test results that the Health Department does track and the case investigations that it does, it is a really nice aggregate of the bigger picture, maybe not necessarily an individual classroom, but to know what's circulating in the greater community. Danielle Bloch: Most health departments put out health alert networks to flag different outbreaks and information that's critical to clinicians in the area, so subscribing to those is always useful. And during flu season, most states and some local health departments publish weekly flu reports that oftentimes include information on other influenza-like illnesses, rates of RSV, adenovirus, enteroviruses, et cetera. And I think that can also be helpful to contextualize what's going on both in the greater community, and then if you see a kid with a runny nose, for example, in a classroom, to have a sense of what is going on that may be affecting that child. Donna Mazyck: Robin, when you get information about an outbreak such as flu or RSV, what's your role as the school nurse? Robin Cogan: We have to certainly understand our responsibilities to report this information, to track the information. We have done tremendous amount of education at the school level, at the community level, one-on-one with parents. I think our greatest challenge right now, and our greatest opportunity, is to be that credible messenger for promoting vaccine confidence about our youngest children getting the COVID vaccine ages five to 11, and then also encouraging our 12 to 17-year-olds to get the COVID vaccine, really understanding how important our role is in being that intermediary between home and school, and school and the Health Department. I don't think the role has ever been more consequential as it has been over these last 20 months. Robin Cogan: And those relationships have been strengthened, although identifying gaps in all of our work bandwidth, I think is also something that we have to acknowledge. We are all working very hard against some very difficult odds to keep our kids and our school community safe. One of the things that we did in my district, and I was so thankful to our local health department, is that, we wanted to make sure that we were doing the right thing in terms of contact tracing and quarantining at the beginning of school. I know it's only the middle of October, the third week of October. It feels like June, to tell you the truth, but it's only been not even eight weeks in school, and we were feeling like we were quarantining a lot of kids. Missing a lot of school days. Robin Cogan: So, we asked our local health department if they would give us a private tutorial to go through our roles and responsibilities and how we can work best together. And it was a fantastic hour-long discussion of really taking a deep dive into what had changed, answering our questions about the Delta variant and its impact, and really beginning to understand how we could make some tweaks and changes, and just reinforce that we were doing the right thing. Even though we are getting pushback, we are still doing the right thing. Robin Cogan: And just that support from the Health Department, even knowing that they are incredibly stretched, under-resourced, just like school nurses, but yet gave of their time and expertise was so appreciated, and I think strengthened our resolve to continue this work, and also strengthen our relationship, because ultimately, that's really what it is about. It's feeling like you have a connection, someone who can answer your questions. And I think it's a two-way street, I really do. Donna Mazyck: Well, it definitely it's a two-way street because that was a win-win to spend that time, from the Health Department's perspective, to instill more confidence to act, in school nurses, and for our school nurses to be able to take that back and increase the confidence that families would have and the care that you're giving during this time. So, this is a shout-out to school nurses as well for the incredible work that's being done right now. Thank you, Robin. Danielle, how do you think the COVID-19 pandemic is changing how the public is reacting to influenza-like illness? Danielle Bloch: I think after the past, almost two years, I think the general public is a lot more aware of infectious diseases and infectious illness than they had been in the past. But at the same time I'm a little concerned that we're all just really fatigued about having to spend our brain space thinking about disease prevention, thinking about potential contacts and exposures and everything like that. I do think that people are more likely to take preventative measures when they are sick now, versus prior to the pandemic. Danielle Bloch: What I mean by that is, I think before the pandemic, many of us wouldn't bat an eye if a colleague came into work with a cough and you just, that was a fact of life, that's what you do. I think that now, oftentimes people will think twice before doing that, will think about getting a test if it's accessible to them, and or if it's required by their employer or school in order to attend that day. I think at the same time, because we had such a light flu season last year, I'm a little concerned that there is an overall lower perceived risk of influenza-like illness. Danielle Bloch: Because last year we had so many COVID precautions in place, mask wearing, social distancing, advisories not to travel, that really totally knocked out the flu season. I think people may be in for a surprise in the coming season as things start to pick up. Flu is remaining pretty low right now, but we're seeing an early RSV season, elevated rates of RNA viruses and adenoviruses as well. So, I would just urge people to make sure they're still thinking about diseases that are not COVID as we enter flu season, and the best ways of protecting themselves and others. Donna Mazyck: Thank you, Danielle, for that public health announcement to remember that using those mitigation strategies and prevention strategies around influenza-like illness is as important now as it ever has been for us individually and for families and for communities. Robin, with the 2021 school year well underway, as you noted, and we're still in this COVID-19 pandemic, what is the best strategy for schools to use to identify COVID outbreaks as fast as possible? Robin Cogan: Well, of course, Donna, you know that I'm going to say make sure there's a school nurse in every building- Donna Mazyck: Absolutely. Robin Cogan: ... To do the assessments, because I can't even fathom not being available to my school community. I worry about those schools across the country where there is no school nurse to do these assessments. Just today I sent six kids home, in a very rapid pace. Very curious as to what the outcome is going to be. And as Danielle said, there're other things that are popping right now. Well, I have certainly seen RSV. I just had a student hospitalized with it last week. And of course the first we think of is COVID. Many of the other infectious diseases do mimic COVID, because that's what's been at the top of our mind. Robin Cogan: So, really, being on the top of our game, but also having the resources necessary and the bandwidth necessary to do this job, because, not to take away from the incredible work of the Health Department, but they are stretched, our health department called "surge capacity", which meant that they are really turning to the school nurses on the ground to do the extensive contact tracing that we can within our school community. So, we have faced the most challenging and demanding times in our modern history as school nurses. Going back to the beginning of school nursing, which, ironically, the 1918 flu was at the very end infancy of our school nurse history, right- Donna Mazyck: That's right. Robin Cogan: ... And the things that worked then are exactly what we're using today, minus the vaccine. So, we're fortunate to have that, but everything old is new again. So, here we are, and this is our most important role is that education piece. We have to give people our calm and not our anxiety, even though underneath we have felt tremendous anxiety. And somebody told me once, and it's a good visual, that school nurses need to be the solid object in the room, because swirling around us is a lot of anxiety, a lot of pushback, a lot of stress. Robin Cogan: As the messenger of the public health information, to tell a parent your child has tested COVID positive, there was a glitch in the system, so we're the ones that are telling you, that doesn't go over well. Or your child has been exposed to someone who was COVID positive. Books will be written about this COVID era, but school nurses have met this moment by advocating for health and safety protocols against all odds, and truly against tremendous pushback from the community, because we straddle the worlds of education and healthcare. Our decisions are grounded in science. We practice evidence-based school nursing, we use public health principles, but our resolve has been tested to extreme levels. And yet we are still standing. A bit battered and bruised, but here we are. Donna Mazyck: Absolutely. Absolutely, Robin. And we are so grateful to you and to school nurses who have really been that rock of solid calm in the midst of storms, even to the point of having to pivot in more ways than one to keep schools safe and healthy. We do believe that what we've heard today from Danielle and from Robin is, that collaboration, the coordination, in terms of what to do in detecting and making sure that we recommend what to do for infectious diseases and schools is an important role. School nurses and local health departments and other partners together make a difference for the health of the community, the school community, and beyond. Donna Mazyck: Thank you, Robin Cogan, The Relentless School Nurse, for being with us today. Thank you, Danielle Bloch, giving us the perspective of your epidemiologist background, and we appreciate what you've done today for us in informing and helping us to make sure schools are healthy places for students to learn. Danielle Bloch: Thanks for having us Donna. What a pleasure. Thank you so much. And shout-out to Robin and to all of the school nurses who are doing the most, always, and especially this season. So, much respect for you all. Robin Cogan: And thanks for partnering Health Department. We could not do what we do without your incredible effort. So, thank you. And thanks, Donna, for having us. Donna Mazyck: We appreciate you both. Thank you. Speaker 2: This episode's sponsor, Kinsa's FLUency School Health Program, stops the spread of illness through early detection and early response. For seven years FLUency has helped school nurses predict, prepare for, and prevent outbreaks in their community by arming families and staff in your school with free Kinsa smart thermometers. You'll catch and contain outbreaks earlier by knowing when and where symptoms are starting. Best of all, it's completely free. Sign up now by texting "apply" to 24020. That's A-P-P-L-Y, to the number, 24020, to get started. Speaker 2: (Silence)