Experiences in the Use of NonTraditional Data Sources in a Rural State South Carolina

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Experiences in the Use of Non-Traditional Data
Sources in a Rural State South Carolina

• Dan Drociuk, MT(ASCP), MSPH Director
• Epidemiological Response / Enhanced Surveillance
  Section
• Division of Acute Disease Epidemiology
• South Carolina Department of Health and
  Environmental Control

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Outline

• Part I
• The People
• How we are organized to develop, implement,
  monitor and respond to EED system needs.
• Part II
• The Push
• How we disseminate information about EED systems
  and general epidemiological activities.
• Part III
• The Products
• Case studies showing the interaction and
  intersection of EED systems currently in use in
  South Carolina.

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Part IThe People
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A bit about South Carolina

• Approximate population 4,350,500 (sans golf
  courses and beaches)
• Three MSAs in the Top 100
• Columbia, Charleston, Rock Hill/Charlotte
• Tourism a main industry along the costal areas
• Centralized health department structure
• All public health employees are state employees
  regardless of location
• No local boards of health

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Current Systems in Use

• Palmetto Poison Center (electronic daily feeds to
  public health),
• National Retail Data Monitoring (NRDM) for OTC
  sales (using home-grown C1, C2, C3 indicators),
• BioSense for DoD and VA ambulatory care
  procedures and ambulatory care diagnosis,
• Essence data monitored and crossed with
  Biosense alerts and indicators.
• Sentinel providers with Influenza-like Illness
  reporting (number/wk).
• Two (2) pilot hospitals providing chief-complaint
  data in home-grown categories.

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Regional Epi Teams

• Services are delivered and surveillance happens
  at the local/community level
• Surveillance, case and outbreak investigation
  response starts with the Regional Epi Team
• 6-20 members
• Mix of skills nurses, Env. Health, PIO
• Established 1995 to provide trained integrated
  team-based response to routine surveillance, case
  investigations, and outbreak investigations
• Available for Urgent Reports 24/7 via on-call
  rotation.

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Epidemiological Responses to Events of Public
Health Significance

• White powder events
• Ricin in a U.S. Postal Facility in Greenville
• Chlorine tanker train derailment, Graniteville,
  SC
• Numerous point-source outbreak investigations
• Food-borne (Salmonellas),
• Water-borne (Legionella cluster, rash-illness),
• Respiratory (Pertussis)
• Hurricane Katrina Evacuation Center surveillance
  activities, Greenville, SC

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Part IIThe Push
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Dissemination of Epi-related information

• Daily
• Provided to the South Carolina Intelligence
  Fusion Center
• Reports from our Division of Acute Disease
  Epidemiology on-call staff for overnight calls
  received,
• Summary information from our Early Event
  Detection Systems (BioSense, OTC sales, Palmetto
  Poison Center)
• Previous day on-call events of public health
  significance
• Weekly
• Provided via the Epidemiological Weekly Report
  (EWR)
• Summary information from our Regional and Central
  Office
• Monthly
• Meetings with Regional Epidemiology Response
  Staff
• As Needed
• Distribution via the SC Health Alert Network
• CDC and DHEC Health Alerts/Advisories/Updates

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Example of a Daily SCIEx report
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Example of a weekly EWR
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EWR Epidemiological Weekly Report

• The EWR is compiled weekly from Regional and DADE
  reports.
• It includes basic summary information related to
  an ongoing or concluding epi-investigations.
• Submissions usually include what is known or
  hypothesized about etiology, geographic location,
  and numbers of persons affected.

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EWR Epidemiological Weekly Report

• Circulation
• The EWR is submitted to the Deputy Commissioner
  for Health Services, members of the Senior
  Leadership Team, Central and Regional Office
  Leadership, the Office of Public Health
  Preparedness, etc.
• Goal
• Provide situational awareness regarding Epi
  activities across the state.

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EWR Epidemiological Weekly Report

• Statistics
• In 2005, EWRs documented 288 new
  investigations of potential outbreaks or single
  cases of disease or events of public health
  significance.
• In 2005 documented outbreaks totaled 62
  stratified as follows (by modes of transmission)
• Respiratory 20 (32)
• Foodborne 16 (26)
• Unknown 11 (18)
• Person-to-person 7 (11)
• Fecal-oral 5 ( 8)
• Contact 2 ( 3)
• Nosocomial 1 ( 2)

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2004-2005 SC Foodborne Outbreak Statistics
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Part IIIThe Products
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Case Study 1Chlorine Release in Graniteville,
South Carolina
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What Happened?

• At 239 AM, a 42-car Norfolk and Southern train
  derailed
• A tanker car containing chlorine was punctured,
  releasing approximately 60 tons of chlorine
• The chlorine was released in the immediate
  vicinity of Avondale Mills, the commercial
  district, and residential areas of Graniteville SC

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Objectives of a Rapid Epidemiological Assessement

• Assess
• Extent of exposure
• Morbidity
• Health services used
• Identify persons at risk for long-term sequelae
• Risk factors for severe outcomes
• Location of exposure

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Case Definition

• Person treated for symptoms or complications from
  chlorine exposure
• Identified by
• Hospital emergency department logs
• Physician reporting

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Emergency Department Visits within 24 Hours
ED Visits, N272 ()
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Signs or Symptoms Reported
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280
280
260
260
100
100
Number of Events
Number of Events
80
80
60
60
40
40
20
20
0
0
1
3
5
7
9
11
13
15
17
19
21
23
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Day(s) Since Accident
Day(s) Since Accident
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Hospitals that Treated Patients for Chlorine
Exposure
January 6-7, 2005
40
Barnwell
Edgefield
35
Lexington
St. Josephs
30
Doctors
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MCG
Number of Patients
University
20
Aiken
15
10
5
0
2-3 am
4-5 am
6-7 am
8-9 am
2-3 pm
4-5 pm
6-7 pm
8-9 pm
12-1 pm
12-1 am
10-11 am
10-11 pm
Time
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Situational Awareness Issues

• Healthcare providers are going to treat people
  first, and worry about the coding later
• Review of charts showed a broad span of chief
  complaints (n81), primary diagnosis (n48) and
  ICD-9 codes (n51) used.
• Data used for situational awareness, many are
  going to be relying upon the data to make
  decisions. This is a paradigm shift beyond
  being simple early event detection system.

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Opportunities

• Use of Early Event Detection systems for
  monitoring an emerging event must be flexible and
  sensitive to be able to answer the questions
  being asked, an EED must have the flexibility to
  allow local users to create ad hoc syndrome
  categories.
• The wealth of information present via an
  electronic medical record only tells part of the
  story. The ability to identify the needs of the
  people impacted greatly contributes to the
  overall situational awareness of an emerging
  event.

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Next Steps

• Within the 3-digit ZIP code area (ZIP3) 298 that
  surrounds Graniteville, BioSense identified a
  data anomaly based on the graphical visualization
  in the Respiratory syndrome category that
  corresponded to day 2 of the exposure.
• However this anomaly was only apparent for 1 day
  (1/7/05) and the source of this anomaly has not
  been validated to determine both the source of
  this anomaly and its relationship to chlorine
  toxicity.

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Case Study 2Use of Poison Control Center data
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Palmetto Poison Center

• 1-800-222-1222
• Located in Columbia, SC
• Serves the entire state of South Carolina
• Staff consists of pharmacists
• and nurses
• Medical Director is trained in toxicology and
  emergency medicine

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Palmetto Poison Center

• Services Provided
• 24 hours/7 days a week
• Phone service to provide poison treatment
  information
• For the public and health care professionals
• Information requests
• Medications
• Pesticides
• Plants
• Food poisoning
• Chemicals

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Statistics

• South Carolina
• 2005 Over 37,000 calls to the Center
• 74 of total calls involved human poison
  exposures
• 30 involved adults over 21yo
• 80 managed by Poison Center without further
  medical evaluation needed

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Documentation

• Every incoming call documented
• Follow up calls included
• Record includes name, phone number and zip code
  of caller
• Patient data
• Age, gender weight
• Exposure substance, route and amount
• Reason for exposure
• Time of exposure
• Symptoms
• Treatment provided
• Outcome

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State Surveillance - DHEC Notification

• Require notification of Public Health for
• Potential food poisoning/food tampering cases
• Occupational pesticide exposures
• Questionable exposure to current public health
  concerns, i.e. anthrax (suspicious powder
  calls), West Nile Virus, chlorine toxicity
• Animal bites

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State Surveillance - DHEC Notification

• Currently faxing cases and providing downloads of
  toxidromes every 24hrs into Toxitrak
• Case information from Poison Center is included
  in the upload
• Reports can be generated
• Ex. How many cases had vomiting, diarrhea, fever
  in Clarendon county in the last 4 weeks number
  of suspected food poisoning cases from
  restaurants per county, city or zip code

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The Epi of Poisonings in SC

• Who?
• 62 of calls involve children lt5
• Where and When?
• 92 of all accidental exposures occur in the home
• 0.8 at school
• Early evening at meal time most likely, followed
  by late morning.

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The Epi of Poisonings in SC

• What?
• 38.8 Prescription and OTC medications, e.g.
  analgesics, cough/cold
• 9.0 Household cleaning substances
• 9.1 Cosmetics and personal care products
• 9.1 Plants
• 8.5 Insecticides, herbicides, rodenticides
• 4.5 Bites/envenomations

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Case Study 3Parris Island, South Carolina
Respiratory Sentinel Alerts
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Disease Surveillance at Marine Corps Recruit
Depot (MCRD), Parris Island

• Marine Corps Recruit Depot, Parris Island
• Marine Corps Air Station, Beaufort SC
• Naval Hospital, Beaufort SC

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Recruit Training Regiment
Within 1st, 2nd, and 3rd Battalions, there are
four companies. Each company contains an average
of six platoons with 60 to 80 recruits in each.
360 480 per company. 1440 1920 per
Battalion. Within 4th Battalion (350-400), there
are three companies, N, O, and P. Each company
contains an average of two platoons with 50 to 60
recruits in each. Fourth Battalion trains only
female recruits.
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Beaufort Naval Hospital

• Provides general medical services to all
  Active Duty Navy and Marine Corps Personnel, as
  well as Retired military personnel and all
  military dependents residing in the Beaufort
  area, a total population of approximately 30,000
  beneficiaries.

Officers 28 Enlisted 158 Civilians 22 Total
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Hospital
 
Branch Health Clinic, MCAS
Branch Health Clinic, MCRD Parris Island
Director Clinical Support Services
1st BAS
Director Clinical Support Services
2nd BAS
3rd BAS
Preventive Medicine
4th BAS
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Methods of Disease Detection

• Traditional reportable disease surveillance
• State processes.
• Navy Disease Reporting System (NDRS)
• Sentinel Surveillance
• Naval Health Research Centers FRI surveillance
  at recruit training centers
• Astute clinicians
• Syndromic surveillance
• ESSENCE IV

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14 admissions to BMH in September and October
2005

• 2 from 1st Battalion
• Charlie company 2
• 7 from 2nd Battalion
• Foxtrot company - 3
• Gulf company 4
• 5 from 3rd Battalion
• Lima company - 2
• Kilo company 3

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Patients are admitted to BMH when a chest tube is
needed
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Why the rise?
Crowded living conditions
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Why the rise? We considered

• Crowed Living Conditions.
• Poor hygiene?
• Always a struggle, but the Marine leadership is
  more cooperative than ever in this area.
• Random interviews of recruits in the clinic
  indicate that they have been properly instructed
  re hand hygiene.
• Recruits presenting too late?
• Interviews of the admitted recruits indicate that
  they were encouraged vs. discouraged to seek
  medical care early.

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Why the rise? We considered

• Something in the buildings?
• Mold and moisture is a problem in some buildings
  aboard MCRD PI. Toxic mold was discovered in one
  building where all recruits are massed together
  for training.
• Slow recognition of cases by providers?
• Some recruits admitted to BMH have been ill with
  respiratory symptoms for 3-4 weeks prior to
  admission, and they had been seen in medical
  two or more times prior to admission.
• Too high a turnover in medical staff to ensure
  effective leadership and staff competency?
• 3 SMOs in last 4 months
• Nearly 100 turnover of BAS staff in Sept-Oct.

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Lab Results

• Nine of the 17 admission to BMH have grown GABS
  from pleural fluid, including 5 out of last 6
  admitted in October.
• Nothing atypical about resistance patterns

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Actions Taken

• Chemo prophylaxis with Bicillin provided to all
  recruits in high incident Companies, to their
  DIs and to their medical staff (BAS).
• Presented data to MCRD Providers

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Early Event DetectionOver-the-Counter Drug Sales

• In South Carolina as of February 2006
• 536 distinct sources are represented in the data
• Which is approx 2.6 of the National data sources
• Possible Uses for OTC Sales Data
• If OTC sales data indicate an increase in use of
  anti-diarrheals, this could point to a foodborne
  outbreak.
• An increase in the use of cold/flu remedies might
  give information on severity of the influenza
  season or an acute respiratory event (i.e.
  release of chlorine).

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Next Steps

• Currently engaged in retrospective studies for
  all documented outbreaks from 2005, by mode of
  transmission, to determine if an temporal
  association can be made and at what level.

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Bottom-line

• Syndromic surveillance is another arrow in our
  quiver of ways to detect and respond to both our
  routine outbreaks of public health significance
  and also those large-scale events that will
  require exceedingly complex reporting and
  situational awareness requirements.

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Acknowledgements

• SC DHEC
• Amy Belflower
• Claire Youngblood
• Marya Barker
• Amy Roach
• Michelle Myer
• Mary Anne Wenck, EIS Officer
• Palmetto Poison Center
• Jill Michaels, PharmD
• William Richardson, MD

• Marine Corps Recruit Depot (MCRD), Parris Island
• LT Allen D. Wright, Preventive Medicine
  Department, Naval Hospital Beaufort
• CDC
• Leslie Z Sokolow
• Roseanne English
• Haobo Ma

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Questions?