Event Detection in a Vulnerable Population

1
Event Detection in a Vulnerable Population

• Erin L. Murray, MSPH
• Georgia Division of Public Health
• Robert J. Finton, MSPH
• Fulton County Department of Health Wellness

2
Background Atlanta Homeless Services

• Several homeless shelters operated throughout
  city with variety of services
• Day services
• Meals
• Mail collection
• Medical clinics
• Overnight shelter accommodations
• Atlanta homeless also utilize emergency
  departments in Fulton County

3
Background Active Surveillance in GA Hospitals

• Emerging Infections Program (EIP)
• gt100 clinical laboratories
• Syndromic Surveillance
• 29 Georgia Emergency Departments (ED)

4
Background Emerging Infections Program (EIP)

• Network of CDC and 11 state health departments
• Conduct active population-based surveillance
• Active Bacterial Core Surveillance (ABCs)
• Invasive diseases caused by emerging,
  vaccine-preventable, and drug-resistant bacterial
  diseases
• FoodNet
• Foodborne and waterborne diseases

5
Background Syndromic Surveillance in GA

• 22 emergency departments enrolled in March 2007
• 2 in Fulton County
• Data received daily for previous 24 hour period
  (midnight to midnight)
• Chief complaints categorized into 26 non-mutually
  exclusive syndromes
• 4 Priority Syndromes
• Fever Flu
• Rash Fever
• Diarrhea
• Vomit

• 22 Secondary Syndromes
• Notifiable Diseases
• Bioterrorist Agents
• Non-infectious conditions

6
Background Syndromic Surveillance in GA

• Data analyzed using CuSum (EARS) 3 levels
• State
• Health District
• Hospital
• Districts responsible for
  monitoring their hospitals
• State takes secondary role
• Multi-District anomalies
• Within District anomalies

7
Background Syndromic Surveillance in GA

• Results available daily via Syndromic
  Surveillance secure web interface
• Counts
• Line list
• Time series
• Demographic distributions
• Interactive map

8
The Event Bloody Respiratory Syndrome

• March 12, 2007
• C1C2C3 flags identified
• 8 total events statewide on March 11
• 6 at Hospital A
• Most visits on single day at single ED ever

9
Bloody Respiratory SyndromeMarch 12

• All had similar chief complaint
• 2 from same zip code
• Fulton County Department of Health Wellness
  (FCDHW) immediately notified

10
Bloody Respiratory SyndromeMarch 12

• FCDHW contacted Infection Control Practitioner
  (ICP) at Hospital A
• Two from same zip code reported same address
• Day shelter for homeless
• Both discharged as rule out tuberculosis
• One returned and was admitted

11
Bloody Respiratory SyndromeMarch 13

• Culture results available
• Both positive for Streptococcus pneumoniae
  (non-sterile sites)
• ICP contacted GA EIP to inquire about possibility
  of other cases
• 4 cases of invasive S. pneumoniae with same day
  shelter address reported
• Onset from late-February and mid-March, 2007

12
Invasive S. pneumoniae

• Notified CDC of cluster of invasive S. pneumoniae
  among homeless
• Review of all Atlanta invasive S. pneumoniae
  cases in 2007 (Jan-Mar)
• 10 cases with addresses reported as known
  homeless shelters

13
Invasive S. pneumoniae

• All hospitalized
• 8 at Hospital A
• 2 at Hospital B
• 7 had HIV
• 2 deaths
• 6 isolates with known serotypes
• 5 different S. pneumoniae serotypes
• No person-to-person transmission of S. pneumoniae

14
Invasive S. pneumoniae in Homeless
15
Invasive S. pneumoniae in Homeless
16
The Investigation

• Hypothesis
• Invasive S. pneumoniae infections represent
  secondary infection from viral primary infection
• Possibly influenza
• March 16 formal investigation initiated
• Fulton County Department of Health Wellness
• Georgia Division of Public Health
• Centers for Disease Control and Prevention
• Georgia Emerging Infections Program
• Service Provider A

17
Investigation Objectives

• Determine if significant increase in invasive S.
  pneumoniae occurred among homeless during 2006-07
  influenza season
• Determine if influenza or another viral
  antecedent was circulating among homeless
• Recommend interventions to interrupt transmission
  of agents involved

18
Methods S. pneumoniae Surveillance

• Focus on inpatients
• Most homeless persons with community acquired
  pneumonia are hospitalized
• Prospective
• Included respiratory virus testing
• March 17-30 - surveillance at hospital A
• March 22-30 - surveillance at hospital B
• Retrospective
• October 1, 2006 - March 16, 2007

19
Methods Influenza-like Illness (ILI)
Surveillance

• Outpatient clinics of Service Organization A
• Prospective
• March 21-30, 2007
• Respiratory virus testing
• Any respiratory symptoms, e.g., cough, sore
  throat, etc.
• Retrospective
• November 1, 2006 - March 20, 2007
• ILI visits
• Acute respiratory infections (ICD-9 codes
  460.0466.19)
• Pneumonia and influenza (ICD-9 codes 480.0487.1)

20
Results Prospective and Retrospective S.
pneumoniae Surveillance

• 23 cases of invasive S. pneumoniae identified in
  homeless persons
• 1 new case from prospective surveillance
• No laboratory evidence of coincident viral
  respiratory infection
• 16 had HIV/AIDS

21
Results Prospective and Retrospective
Outpatient Surveillance

• 10-20 of visits due to ILI
• Sentinel Providers (2-5)
• Laboratory Results
• 1 influenza B virus
• 3 coronavirus
• 1 also positive for rhinovirus

22
Investigation Limitations

• Prospective surveillance lt2 weeks
• Investigation began when influenza season ending
• Only 1 new invasive S. pneumoniae case detected
• Only 1 influenza isolate identified

23
Investigation Findings

• Previously unrecognized burden of invasive S.
  pneumoniae in homeless
• Contribution of specific viral antecedent cases
  S. pneumoniae not established
• High burden of respiratory illness in homeless
  population

24
Investigation Recommendations

• Continue prospective surveillance for invasive S.
  pneumoniae among homeless
• Promote hand-hygiene among homeless
• Consider providing pneumococcal vaccine to
  HIV-positive homeless persons
• Provide influenza vaccine to entire homeless
  community

25
Investigation Benefits

• Fostered multi-jurisdictional and multi-agency
  collaboration
• Provided immediate evaluation of the health
  status of many registered homeless
• Refined how providers work together to expand
  public health services to homeless

26
Investigation Benefits

• Expanded relationship between public health and
  homeless service providers
• Increased notifiable disease reporting from
  homeless health care providers
• Allows for planning of future health promotion
  efforts in this population

27
Summary Syndromic Surveillance

• Alerted public health of event in community
• May have otherwise gone unnoticed
• Allowed for immediate response
• Allowed for development of public health
  prevention strategies for homeless
• Example of how GA using syndromic surveillance to
  assist local public health

28
Acknowledgements

• Fulton County Department of Health Wellness
• Robert J. Finton, MSPH
• Priti Kolhe, MSHA
• Steven R. Katkowsky, MD
• Wayne Ford, MPH
• Jamie Howgate, MPH
• Shamimul Khan, MPH
• Centers for Disease Control and Prevention
• Roopal Patel, MD (EIS)
• Scott Epperson, MPH
• Hospital A
• Nancy White, RN, CIC
• Jessica Garcia, MPH
• Service Organization A
• Mae Morgan, MD, MPH

• Georgia Division of Public Health
• Wendy Cameron, MPH
• Petra Wiersma, MD (EIS)
• Katie Arnold, MD, MPH
• Cherie Drenzek, DVM, MPH
• Susan Lance, DVM, MPH
• Karl Soetebier, MPW
• Georgia Emerging Infections Program
• Monica Farley, MD
• Wendy Baughman, MPH
• Hospital B
• Betsy Hackman, RN, CIC
• Connie Bryant, RN, CIC
• Paul Malpie, MD
• Georgia Public Health Laboratory

29
(No Transcript)
30
Questions?
31
Case Definitions

• CAP
• Chest x-ray confirmed Community Acquired
  Pneumonia in homeless person admitted to Hospital
  A or Hospital B
• IPD
• Isolation of S. pneumoniae from a normally
  sterile site from a homeless person admitted to
  Hospital A and Hospital B

32
Methods Respiratory Virus Surveillance

• Inpatient and Outpatient
• Influenza A and B viruses
• Respiratory syncytial virus (RSV)
• Human metapneumovirus (hMPV)
• Parainfluenza viruses 1,2, and 3 (PIV1-3)
• Adenovirus
• Coronaviruses
• Rhinoviruses

33
Results - Prospective and Retrospective S.
pneumoniae Surveillance
34
Results Respiratory Disease Surveillance

• 10 and 20 of clinic visits for ILI