How a Shelter’s Triple Outbreak Was Quelled During Los Angeles Fires

Infection control became a challenge among the children sheltering during the Los Angeles County fires this past January, said a public health expert on site at the shelter inside Pasadena’s convention center.

“Oh, man, it really affected me,” Matthew Feaster, PhD, division manager of Disease Control and Epidemiology at Pasadena Department of Public Health, told Medscape Medical News regarding recent infectious disease prevention measures among evacuees of wildfires. “The kids in the shelter need something to play with, but in theory, they can’t share their plushy toys because that plushy could have norovirus on it,” he said.

Instead, toys were assigned, and routinely disinfected, Feaster said. “We want our shelter neighbors to have an enjoyable experience but also a safe one.”

Not allowing the children to share toys was one of the arsenal of infection control techniques employed at the shelter by Feaster and his disaster response colleagues to help stem a triple outbreak of norovirus, flu, and COVID-19 in roughly 700 evacuees, many of whom were already in poor health, in just less than a week.

The key to doing so was collaboration with decisive leadership and a focus on creating and maintaining a comfortable, pro-health culture, along with a rigorous cleaning routine, according to Feaster and his colleagues.

Comprehensive Clinical Operations 

The City of Pasadena set up and ran the shelter during the first week of the fires. The following Monday, they handed over operations to the American Red Cross.

Within days of the shelter’s opening, there were about 1100 evacuees in the convention center, many of whom were from assisted living facilities, according to Timothy Dahlum, the Red Cross complex site manager assigned to the convention center shelter.

“This was more challenging than the average shelter because of the volume of people, many of them medically fragile,” Dahlum told Medscape Medical News. “We don’t normally have multiple medical clinics available at a shelter. We have basic first aid and some basic client care but full-on medical care is done offsite.”

In this case, on-site clinical operations needed to be more robust to meet the needs of the Pasadena evacuees, said Dahlum.

“Pasadena had three full-time, 24-hour pharmacies, anywhere from three to ten medical doctors on site at any given time, and 20 or more nurses on staff at all times,” Dahlum said. Medical staff were primarily associated with Kaiser Permanente and Altamed, two Pasadena health systems, as well as some Red Cross clinical staff, he added.

Need for Collaborative Leadership

The first case of norovirus was reported the day after the Red Cross assumed operations of the shelter, according to Dahlum. “By Wednesday, we had 36 cases reported,” Dahlum said.

“We stepped in immediately because we know norovirus is among the most infectious and unpleasant viruses,” Feaster said, speaking about his department of public health, which he said already had been preparing for a higher than average norovirus season, as well as for influenza which was already spiking in the region.

With the Red Cross now in charge of the shelter’s operations, Feaster said having clear and collaborative leadership was essential to leverage the “ad hoc” nature of the system for the best. “It was a big lesson to learn for me, which is that it’s a system with a lot of players and you really need to prepare to work with all of them,” Feaster said.

Personnel from both health systems on-site all walked the halls of the shelter to check the status of evacuees and to explain the essential nature of the protocols in place such as masking and hand washing.

Twice-daily huddles, where what was learned while rounding was shared with the other disaster response team members, allowed for real-time adjustments to their clinical operations, such as when norovirus cases started cropping up.

“The most effective way to stop the spread of norovirus is handwashing,” Michele Lampshire, BSN, RN, told Medscape Medical News. “We had about 12 handwashing stations left over from something else we’d been working on, so we just said the shelter could have them.” Lampshire is Kaiser Permanente Southern California’s senior director of infection prevention, and one of the leadership team at the shelter.

A dozen portable sinks, the transport of which was organized by Dahlum, arrived only hours later, Lampshire said.

Dahlum also attended the twice-daily huddles. “I was there to understand exactly what they were trying to do,” he said. “They would all decide what was the best process and then I had to figure out how to implement it.”

Enforcing Compliance

Striking a balance between safety and comfort was essential but delicate. Compliance with infection control protocols was important but not enforced.

“We have to make sure everybody’s part of the process,” Dahlum, of Red Cross standard operating procedures, said. “You don’t just tell people what to do, you explain why we’re doing something. You never just walk into a room and start giving orders to people. It’s walking into the room, talking to people, going cot to cot, to make sure that everybody understands.”

Feaster said that when the shelter residents understood the rationale for masking and handwashing, they tended to comply. When they did not, he said it was more to do with forgetfulness than noncompliance. “Maybe they’d pulled it down to whisper, and then not pulled it back up,” he said.

Still, masks for residents were suggested but not mandatory. Volunteer workers at the shelter, however, were given no leeway with masking orders.

“We told them we would find other people to work there,” Feaster said. “We want people to be all in on protecting the shelter residents who don’t have a choice to be there.”

Signage throughout the convention center, near the restrooms, the showers, and the hand washing stations reminded evacuees to wash their hands, wear their masks, and practice respiratory etiquette to help curtail the spread of influenza and COVID.

Additional signage near the norovirus quarantine hall directed noninfected people to go elsewhere. Feaster said it was important not to use stigmatizing language like “biohazard” or “danger”, but to just state it was an area reserved for “designated” persons.

Shelter residents infected with COVID-19 were immediately isolated in hotels. Loved ones were allowed to stay with them, if they chose, said Feaster. “Flu cases were also isolated in either a hotel or separate hall that was designated later. Flu is not as infectious as COVID so the need to isolate in a hotel was less,” he said.

Disinfect the Right Way

Constant disinfection of hard surfaces, including any plastic toys used by the children living in the shelter, was another essential part of the infection control plan at the shelter. Tarps were used to line floors and other surfaces.

“Everybody thinks the Red Cross has a fetish for tarps,” Dahlum said. “We do, but it’s because you can easily clean and disinfect a tarp, whereas with a carpet you can’t.” 

The Red Cross was instrumental to the disinfection and other infection control processes. “I just had to figure out how to make sure it could happen, whether it was the deep cleaning of something 8-foot high, or getting a [vendor] contract in place rapidly, or getting the handwashing stations there within the next couple hours,” Dahlum said. “It was straightforward, it had to be done to stop the spread of infection and prevent people from getting sick.”

Lampshire and Feaster both spoke about the importance of using the right products to kill the norovirus. Feaster said products from the Environmental Protection Agency’s “List G” of registered antimicrobial agents were essential, as not all disinfectants kill the norovirus.

“The most common disinfectant that would work is household bleach,” Feaster said, “But these were enhanced.”

Outcomes and Lessons Learned

“I think it would be very difficult to control any GI outbreak in an evacuation shelter,” Terri “T” Rebmann, PhD, RN, told Medscape Medical News. Rebmann is the lead author of the guide, “Infection Prevention and Control for Shelters During Disasters”, published in late 2023 by the Association for Professionals in Infection Control and Epidemiology.

Yet, 1 week after the first norovirus case was detected at the Pasadena shelter, the human case load had dropped from 99 to zero. “It went through about two epi-transmissions, about 24-28 hours each,” Feaster said.

Although Rebmann said there is no formula for how quickly certain kinds of outbreaks should be contained, judged against the number of people in a shelter, “To me it sounds very impressive that they were able to do it, to get it under control that quickly, and in a setting such as an evacuation shelter, to me is just very impressive.” 

Rebmann is the director of the Institute for Biosecurity at the College for Public Health and Social Justice at Saint Louis University in St. Louis, where she is also an adjunct professor of epidemiology and biostatistics.

“It sounds like they must have put the correct interventions in place,” Rebmann said. “The single best thing you can do is ensure that people are washing their hands routinely. And that is not the easiest thing to do,” Feaster said.

“So we set up the mobile hand washing stations and made sure we had enough paper towels which can help with mechanical wiping of people’s hands. And we had plenty of soap and water.”

The flu and COVID-19 infection control measures put in place simultaneously with the ones for norovirus helped attenuate the spread of all three viruses, but because of the longer incubation periods for the respiratory ones, human case load reductions did not resolve as quickly as with norovirus, according to Feaster.

“Though, flu and COVID cases at the shelter were reduced significantly within 1 week,” he said.

“I’ve seen the norovirus at a few shelters before, but never with this many people and at the scale that it was here,” Dahlum said. “But the basic idea of how to shut the infection down is the same, there should be nothing gradual about stopping the spread of the infection, and that’s how it was approached here.”

The heavy clinical presence at the shelter, though unusual, helped with the immediacy of the response to the infections, according to Lampshire. “We are used to dealing with infections in hospital settings. It’s not the same thing, but we knew we had to be on it, and consistent in our efforts,” she said.

“The biggest take-away from what we were able to accomplish at the shelter is that when you work together and have leadership that is focused on the best possible outcomes, you can really make a difference,” said Lampshire.