St. Louis County Department of Public Health (DPH) is a local health department that services the most populous county in Missouri. St. Louis County borders, but does not include, the city of St. Louis, and is home to approximately 1 million residents. The Basic Infectious Disease Training and Education for Law Enforcement program began in 2013, and was initiated by the inquiry of a Ferguson Police Captain who brought it to a St. Louis County Department of Public Health Emergency Preparedness employee regarding infectious disease training for law enforcement. The overall goal of this training to is to educate the local law enforcement community on the most common airborne and blood borne infectious diseases and the measures that they can take to protect themselves while on duty.
The target audience of this education program is St. Louis County law enforcement, and potentially all law enforcement within the state of Missouri. It is an entirely voluntary program, focused on assessing and improving basic knowledge of infectious diseases, pathogens, and how officers can protect themselves on duty. This program especially focuses on police officers who spend most of their time in the field, in close contact with local residents who may be infected with or who may have been exposed to a potentially harmful infectious disease. This risk is extremely relevant and prominent in this line of work, especially during close encounters and physical contact between a police officer and a person in their custody. It is important that police officers and other law enforcement be aware of the potential hazards of physical contact with others, and of how to prevent the spread of such hazards if they were to contract such a disease. The US Department of Justice attempts to tackle the question of mandatory immunization (vaccination) of law enforcement officers, for the protection of themselves, the community, and their families in an article about the role of law enforcement in public health. It is thus important that any educational program highlight such diseases and provide alternate measures to prevent and avoid transmission. It is hard for police officers to take time off of work, as their service to our community is essential on a daily basis. Our hope is that, with this knowledge, police officers who are in danger of contracting an infectious disease in the field and spreading such a disease to their colleagues or families, will be equipped mentally and physically to either avoid such contact or follow appropriate procedures to ensure minimal infection post-contact.
The curriculum that has been drawn up for this program has five main objectives: that law enforcement will be able to identify the blood-borne and air-borne infectious diseases they could contract and likely situations in which these diseases could be encountered; to discuss barrier protection and prevention needed in the field; to understand the appropriate disposal of contaminated uniforms and other materials; to discuss the steps involved when a law enforcement officer is concerned about contamination, especially after contact with an individual who may have an infectious disease. Our overall goal is to give law enforcement the knowledge and procedures necessary to stay safe and healthy in their line of work, preventing an outbreak that would leave the county without sufficient law enforcement. This program involves a clear, concise curriculum that would be taught twice a year, so as to keep knowledge fresh, continue assessment, and educate new law enforcement members. There are also two brief assessments associated with this curriculum – they are both 15 question multiple choice assessments, one to be administered before the program is taught, and one to be administered after. These pre- and post-tests will help the Department of Public Health gather data on the effectiveness of our program to help determine if we may need to modify our curriculum if evidence shows it is necessary.
(RESULTS/OUTCOME) The outcomes of the initial pre- and post-tests administered in March and October of 2015 were overall positive. The class was taught to a total of 49 students (28 in March, 21 in October), which was around the expected number of participants for this program. Out of these 49 participants, only five had scores on the post-test that had decreased from the pre-test. And even then, only one of these participants’ scores decreased by more than two points. 36 of the 49 students had scores that improved up to five points. Thus, the program this year showed a 73.5% overall success rate in participants; confirming that the program has had a positive impact to date.
The new Basic Infectious Disease Training and Education for Law Enforcement program began after an inquiry to a St. Louis County Department of Public Health employee by a Captain of the Ferguson Police Department in 2013. This officer’s inquiry directly concerned infectious disease training for law enforcement officers within his jurisdiction, and spurred the conception of today’s program. The integration of law enforcement in Public Health is not always clear or highly prioritized, but local situations within the past year have shed light on the severity of this issue and a need to address it. In November of 2014, St. Louis County faced this issue head-on during the protests and events that occurred in Ferguson, MO. This was the most recent and widely publicized account of police officers interacting directly and physically with county residents in extremely close quarters and under potentially hazardous conditions.
The target population affected by this problem – the St. Louis County Police Department and other municipal law enforcement officers. The St. Louis County Police Department commissions 835 officers and authorizes over 250 civilian members in their work force (these numbers do not include the total law enforcement staff of the 91 St. Louis County municipalities). The Department runs seven precincts over the county area, each of which has jurisdiction over multiple stations and facilities. This region is an especially important region to reach with this program; the 2013 Missouri Data and Statistical Report on HIV/AIDS reported that there are 5,638 people living with HIV in the St. Louis county region, a number which is increasing annually, and there is a higher-than-average rate of people diagnosed with sexually transmitted diseases. The US also experiences high rates of the flu each year, an easily contracted communicable disease that could potentially wipe out the county police force for multiple days in the span of a few hours.
While certain publications have focused on the role and protection of law enforcement during a public health emergency, it is important to take into consideration the risk of infection during daily patrol, separate from that during a public health emergency. There is great discussion and detail of how law enforcement should protect themselves and their families from infection during times of a public health emergency (such as an epidemic or a bioterrorism attack) in an article published by the US Department of Justice, however these measures can and should be applied to their everyday work. While an officer is at higher risk of infection during a public health emergency, they are also at increased risk each day in the field, especially during a time such as flu season or in a situation with a large crowd of people who could potentially be infected. Police officers are continuously at risk for such infection, and if they are ill-prepared or ill-informed about these risks, they are more likely to contract an infectious disease.
In the past, most health-related studies of law enforcement officers focused on the impact of stress associated with their occupation. This stress is brought on by long or late shift hours, violence in the field, and other adversities associated with this rigorous and demanding occupation. There are many ways that this stress manifests that can be both physically and mentally detrimental to an officer’s health. There have been many cases of depression or Post Traumatic Stress Disorder (PTSD), as well as obesity and other physical ailments that can have long-lasting effects on these law enforcement officers. These studies, however, have yet to include the impact of infectious diseases on officers that can also become long-lasting or even fatal. This program is innovative in that it takes these issues into account and looks at one solution to the problem: education of law enforcement for prevention and protection against these diseases.
The curriculum, for this course, was available before this practice was implemented and was published by the Law Enforcement Training Network (LETN) (the SLCO DPH course developer however is in the process of writing their own curriculum using the LETN document as a resource). This new practice implemented by the St. Louis County Department of Public Health, however, seems to be the first within the St. Louis region to put this curriculum into use as continuing education for law enforcement officers in a classroom setting. Additionally, measuring the results of the pre- and post-test allows the Department of Public Health to retrospectively modify the curriculum as necessary in order to increase post-test scores in following years. The pre-test and post-test provide evidence-based results and feedback to assess how successful the program is. Both the number of officers who attend the training program as well as their scores on the pre-test and post-test may be used to evaluate the effectiveness of this training program and whether or not this program is reaching a wide enough audience.
The outcomes of the initial pre- and post-tests administered in March and October of 2015 were overall positive. The class was taught to a total of 49 students (28 in March, 21 in October), which was around the expected number of participants for this program. Out of these 49 participants, only five had scores on the post-test that had decreased from the pre-test. And even then, only one of these participants’ scores decreased by more than two points. 36 of the 49 students had scores that improved up to five points. Thus, the program this year showed a 73.5% overall success rate in participants.
HIV in the U.S.
The goal of this practice, as stated earlier, is to educate law enforcement officers on how to identify blood borne and airborne diseases and how to properly handle possible contamination. Before this particular practice was put into effect, research was conducted to determine if a similar course was offered in the St. Louis regional area or in the state. Once it was discovered that no such program existed in the area, a St. Louis County Department of Public Health Emergency Response Planner (course developer) contacted the Education Coordinator at the St. Louis County and Municipal Police Academy to assess the need and desire for this type of program. Then, the course developer and the instructors’ credentials (who are communicable disease registered nurses with extensive backgrounds in infectious/communicable diseases, tuberculosis specialization, and current university instructors) were presented to the Police Academy staff. The curriculum used and presented was a curriculum that already existed in another state and was discovered by the course developer at the DPH through her research. After the St. Louis County and Municipal Police Academy approved the need and expressed a desire for such a program, the necessary application and other paperwork for police continuing education credit purposes was completed, and the Department of Public Health waited on approval from the Board of the Police Academy.
The program was presented to the police academy board in late 2012 with the required paperwork completed by March 2013. The first class was held August 9, 2013 and is now offered twice a year; normally once in the Spring and once in the Fall. The program is designed for and open to those who work in all areas of law enforcement or who may have close contact with anyone in the penal system, including: police, corrections/jailers, property/evidence technicians, case managers, probation/parole officers, security staff, airport screeners, shelter staff, and dispatchers.
While there were no start-up costs for the class itself or for the submission of paperwork, there was a small cost associated with the materials in the hand-out bags that are given to each student at the conclusion of the class as a recommendation of items that should be kept in their patrol cars or work area. The bio-bags contain personal-sized hand sanitizer, exam gloves, band-aids, alcohol wipes, facial tissue, blood stain remover, one N95 and one surgical mask, and hand-wipes. The cost for these items (and folders) for two classes per year (unless requested) is approximately $740 for the entire year; as these items are purchased in bulk.
The goal of this program is to educate law enforcement on the appropriate steps they can take to lessen their exposure and help prevent contraction of infectious diseases in their line of work. The main objectives include: being able to identify blood borne and airborne infectious diseases and situations in which this infection might likely occur; to be knowledgeable about protection and prevention necessary in the field and about appropriate disposal of potentially contaminated materials; and to be aware of steps to take if an officer is concerned about contamination. This practice intends to achieve a short-term result (increased awareness and knowledge of infectious disease contamination) that is measured quantitatively by test scores. Additionally, a course evaluation of the objectives, and other areas of the course, is given to each student at the end of the class; participants have an opportunity to express their views. The evaluations also capture, on a scale of 1-5 (five being the most positive score), as to whether or not the class participants found the information helpful and practical. The response results, to date, show the average between a score of 4-5.
This program was conducted in March and October 2015 and reached a total of 49 law enforcement officers, corrections officers, security personnel and dispatchers combined. The primary sources of data were the pre-test and the post-test, the former administered before the course was given, and the latter administered after the class. Both tests are made up of the same exact questions so that the knowledge gained in the time of this course may be directly assessed. Each participant was to identify themselves anonymously on each test so that the two scores could be compared during data analysis. The data was collected by the St. Louis County Department of Public Health; whoever taught the course also administered the tests and scored them. The tests are corrected and the number of correct answers is tallied on each test to compare the number of correct answers on the pre-test versus the post-test. These scores were then assessed to determine whether participants’ individual scores increased or decreased after the course was given.
In the March course, out of 28 participants, 82% showed an increase in their basic infectious disease knowledge by scoring higher on the post-test than on the pre-test. Of the officers whose scores increased from the pre-test to the post-test, around 30% increased their score by a factor of 4 or 5. In the October course, out of 21 participants, 62% showed an increase with 14% showing an increased score by a factor of 4 or 5. These tests also demonstrate specific questions that officers continually missed on each test. This allows the St. Louis County Department of Public Health to assess their program annually and tailor their curriculum towards the needs of the law enforcement officers in the area. For example: one question that has been frequently missed is in reference to the contraction of Tuberculosis (TB). It was found that, because of the severity of disease coupled with the fact that it is air borne, class participants routinely chose the answer dealing with simply being in the presence of someone who has TB rather than understanding that the exposure must be prolonged. The course instructors have since been sure to emphasize and re-emphasize that the exposure to TB must be prolonged . Though these results will not alter the way the program is conducted, it may enhance the officers’ breadth of knowledge if the curriculum is updated annually in accordance to the pre- and post-test results.
This practice is directly related to the safety and protection of law enforcement officers in their daily work routine. These law enforcement officers act as sufficient stakeholders that will commit to sustain this practice, particularly because they are the ones who requested that this training program be implemented in the St. Louis region. Office management as well as the officers who participate in the program have a designated time in their schedule (three hours) for these semiannual classes and assessments. It is in their best interest to maintain this practice, as it can only increase their knowledge of infectious disease transmission and help keep them safe in the field. That being said, there is a resource component, as safety equipment is not free, should law enforcement agencies purchase the recommended bio-safety items for each of their patrol cars or work area. This program, however, may be conducted using this curriculum for new employees and any employee who feels they need to be refreshed on this information free of charge. This practice does not require an extensive amount of maintenance, as the same curriculum may be used year after year, or it may be sent to the Department of Public Health to be modified to better fit the needs of the law enforcement community, however if hand-out bags are given out by the hosting agency, there is a small cost for items which are to be placed in them; this can be purchased in bulk once-a-year. The need for any modifications would be evident in the scores of the participants.
Law enforcement comes into contact with a variety of potentially harmful or deadly bacteria and viruses on a daily basis, and a great need for this training was evident after presenting this course over the last two years. Some law enforcement agencies were not aware of protective measures they could take if exposed to an infectious disease while on-duty. A number of local agencies either do not have or their staff is not fully aware of their department’s policies should they come into contact with bodily fluids. We’ve learned that most agencies simply call 9-1-1. Thus, St. Louis County DPH recognized an issue with law enforcement agencies’ awareness concerning basic infectious disease protocol and was able to tailor the curriculum and program to fit the needs of local agencies. It is simple to assess which areas need to be addressed more closely, as the data analysis will point to questions on the assessments that most participants got wrong. These lessons learned can be easily implemented into the on-going program; whether it is between the semiannual assessments or at the beginning of a new year.
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