Our 2022 Mpox response required the involvement and participation of a number of community partners and external stakeholders, including municipal governments, contracted HIV/STD care providers, community organizations, and private businesses. In addition, by fostering a culture of continuous communication within the department itself, DOH-Broward was able to effectively monitor and manage the Mpox outbreak in Broward County. An essential part of our communication strategy was the bi-weekly IMT meetings, which helped to promote situational awareness and logistical cohesion.
DOH-Broward convened its first IMT meeting on May 22, 2022, utilizing the Federal Emergency Management Agency's (FEMA) Incident Command Structure. DOH-Broward provided numerous briefings, offered subject matter expertise, and attended meetings on a regular basis with groups and organizations across the County. These organizations and groups included but are not limited to: Hospitals, Broward County Healthcare Coalition, County and Municipal Mayors, Broward County Legislative Delegation, Emergency Coordinating Council, EMS subcommittee of the Fire Chief's Association, and School Board.
We also collaborated with the HIV Prevention's Business Responds to AIDS (BRTA), a coalition of 359 Broward County businesses managed by HIV Prevention, to distribute educational materials to residents. We have since enlisted other businesses in our outreach efforts, due to their location in high-impact areas or their popularity with high-risk individuals - connecting with a total of 1,274 businesses in 101 days. Some businesses were visited repetitively, resulting in the distribution of educational materials to 1,967 businesses.
All communication and messaging distributed by DOH-Broward came directly from DOH Communications Office and the CDC. The DOH-Broward website is managed by DOH in Tallahassee and directed the public to DOH website for Mpox-related information. DOH-Broward began community outreach early regarding mpox prevention via the distribution of flyers, palm cards and posters to businesses in neighborhoods with high concentrations of populations at high risk.
The primary goal of the DOH-Broward public information officer (PIO) was to disseminate messages to the community through multiple mediums. This included utilizing the DOH-Broward Twitter account and multi-media campaigns. The DOH-Broward PIO made sure to post to Twitter at least every couple of days. While it was important that key information was transmitted quickly and efficiently, it was also crucial that the information was presented in relatable and easy-to-read/understand messaging. Additionally, the DOH-Broward PIO made sure to answer questions that were posted on the Twitter page or that were sent via direct message in a timely and private manner. The DOH-Broward PIO used the Twitter page to post information about Mpox resources including vaccination PODs locations/hours in real-time. Between May and October of 2022, the follower count of the DOH-Broward Twitter account increased by approximately 1000 followers. Between May and September of 2022, DOH-Broward worked with a variety of vendors to implement and create a multi-media campaign around vaccination. These vendors were chosen to reach as many different populations as possible in several different platforms. These vendors included South Florida Gay News, OutClique and HotSpots magazines. The information included in these campaigns included the location of vaccination PODs, where residents could sign up for vaccinations, that the vaccinations were free, and that the vaccinations did not require insurance. DOH-Broward ensured that the ads with vendors were thorough, accurate, and conspicuous. The ads also included a link to more information should the public still have questions.
In December 2020 DOH-Broward invested in an in-house print shop for its Special Project's Team, which allowed internal staff to create most of the flyers, signage, consent forms, vaccination information sheets and other materials used at the POD's.
DOH-Broward recognized that providing timely and accurate information to health care providers was extremely important. DOH-Broward has a robust contact list capability which includes electronic databases of physicians, hospital infection control practitioners, long term care and congregate facilities, etc. DOH-Broward utilized our email notification process to provide healthcare providers CDC or DOH guidance documents throughout the pandemic.
DOH-Broward educated the call center staff to provide information and referral regarding Mpox. The call center was utilized to provide general information about Mpox, Mpox vaccination sites, and referrals to epidemiology as necessary.
DOH-Broward provided vaccination to contacts as prophylaxis indicated. Contacts were provided appointments by epidemiology staff and vaccinated at a designated closed” vaccination site. Second dose appointments were scheduled during the initial dose appointment. DOH-Broward worked with businesses with employees at higher risk to schedule pop-up” closed PODs to provide employee vaccinations. DOH-Broward utilized relationships developed during the COVID response to secure memoranda of agreements with municipalities to provide POD locations for vaccination sites. The peak number of fixed vaccination PODs that were established by DOH-Broward was 10. DOH-Broward also coordinated with municipalities to provide vaccine more than 40 pop-up” opportunities at local events. In addition to the PODs, DOH-Broward utilized the Region 7 mobile vaccination van to provide vaccination at local businesses. DOH-Broward utilized environmental scans throughout the response to proactively plan the number, location, and size of PODs.
Initially, the number of vaccines and ancillary supplies were based on the estimated number of first- and second-dose appointments scheduled at each POD. The vaccination kits included syringes, mixing diluent, biohazard/sharps containers, vaccination cards, Epi Pens, etc. Once vaccine became more widely available, and appointments were no longer necessary, estimated total number of doses were prepared for the week per site, vaccine and ancillary supply kits were prepared and sent based on the daily estimates. Additional vaccine and ancillary supplies were sent via courier in case demand was higher than estimated. COVID-19, Menactra and Hepatitis A vaccinations were also offered in conjunctions with Mpox vaccine activities.
DOH-Broward worked with infectious disease practitioners, contracted STD and HIV providers, and hospitals to supply, and as cases and antiviral medication supplies increased, pre-position antiviral medication to rapidly provide medication to clients in need. DOH-Broward also served as a hub for vaccines for the region.
In May 2022, person under investigation (PUI) cases were presented to the Regional or State Epidemiologist to request approval for testing as Mpox testing was not yet publicly available and was conducted by BPHL with confirmation conducted by CDC. If approved, epidemiology staff collected the specimen from the client if needed and/or coordinated with hospitals and healthcare providers as to the type of specimen to collect. Epidemiology staff picked up the specimens and packaged for shipment. The Regional Emergency Response Advisor was contacted to transport specimens to the designated BPHL. Tracking numbers and summary of PUIs were provided to BPHL and regional and/or State epidemiologist. Results were provided from the state of Florida Dept of Health so that epidemiology staff could notify the hospital or healthcare provider and conduct epidemiological investigations. The State Bureau of Epidemiology had established criteria to utilize in determining the need to collect a specimen for testing.
As the outbreak progressed, DOH-Broward epidemiology staff was approved to evaluate all testing through BPHL. Each PUI was entered into Merlin and the Merlin case number was provided to BPHL that the specimen collected had been approved by the Epidemiology Department. In some cases, epidemiology staff arranged for test kits for specimen collection to be delivered and subsequently picked up from hospitals and other acute care facilities (including Urgent Care Centers) with PUIs that met state testing criteria. Epidemiology staff initially provided all local transport, however, as the outbreak progressed, a courier was assigned by general services to assist in this in this operation.
In mid-July, commercial laboratories were approved to conduct testing and public health testing at the BPHL was utilized only for priority testing. Epidemiology staff realigned activities at this point to investigate positive results or provide early treatment based on suspected cases.
DOH-Broward actively monitored the Mpox outbreak across the county, not just in healthcare settings. This surveillance consisted of monitoring and collecting data of all cases, close contacts, and outbreaks throughout county, as well as constant communication with the local hospital medical directors, infection control practitioners and healthcare providers. This communication included giving recommendations, getting information, discussing guidance and changes in guidance, keeping hospitals and healthcare providers updated on what trends they were seeing, and sending regular updates to the hospitals. Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) queries were expanded to assist in early identification of cases and monitor trends. Additionally, DOH-Broward has access to the electronic records of the two largest health systems in the State to assist in obtaining additional information about suspected and/or confirmed cases. Epidemiology provided data to develop GIS mapping of cases, contacts and exposure location/social gatherings.
Epidemiology staff conducted all contact tracing of Mpox cases. A questionnaire was developed in order to determine the risk level based on CDC's Mpox risk assessment. The assessment was utilized to determine the level of monitoring required for each contact. Every identified contact was entered into the Merlin system (Florida's communicable disease reporting system) and into an internal log which included data for each case and their contacts. For the contacts, various data points were included such as demographics, risk levels, whether PEP (Jynneos) had been administered, monitoring timeframe, and disposition.
Epidemiology staff would attempt to get in contact with the individual identified in the Merlin system; this included at least three phone call attempts. If contact could not be made with the individual, staff would conduct a home visit. If the individual was still unable to be reached/located, the contact would be marked with a lost to follow-up” disposition.
Between May 21, 2022, and October 11, 2022, DOH-Broward was able to contain the outbreak and rapidly reduce transmission from its peak number of cases in week 7 (134 new cases week of August 10th, 2022) with rapidly declining new cases week over week from that point through our rapid and targeted response efforts.