Disease Surveillance

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Disease Surveillance

• June 11, 2008
• Paul McGaha, D.O., M.P.H.Regional DirectorTexas
  Department of State Health Services Tyler, Texas

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Objectives

• Promote the importance of active reporting
• Identify mandated notifiable conditions
• Review Class A agents
• Identify reporting partners and their roles
• Understand reporting mechanism
• Identify case definitions
• Understand HIPAA and Public Health

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Overall Goal

• Early Detection
• Rapid Response

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Scenario 1

• Your are a paramedic in Trinity County. You
  make transports to three different hospitals that
  day. Three different previously health adults
  with severe pustular rashes and fever were
  transported. All patients were admitted. Should
  you inform anyone of the possible disease cluster?

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Perspective on Importance of Reporting

• The ability to control infectious diseases
  requires an effective and comprehensive public
  health surveillance and response capacity. Public
  health surveillance is an essential prerequisite
  for establishing local, national, regional and
  global priorities planning, mobilizing and
  allocating resources early detection of
  epidemics as well as monitoring and evaluating
  disease prevention and control programs.
• Source www.usaid.gov

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Public Health Actions

• The mission of Disease Surveillance is to monitor
  communicable diseases. 
  
• The Surveillance unit maintains the mandatory
  reportable disease system and is responsible for
  collecting, analyzing, interpreting and reporting
  infectious disease data. 
• The Disease Control unit is responsible for
  infectious disease control activities, case
  follow-up, patient and provider education and
  disease outbreak investigation.

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Goal of Surveillance

• To reduce morbidity and mortality through the
  control and/or prevention of disease.

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Process of Public Health Surveillance

• Systematic, ongoing
• Collection
• Analysis
• Interpretation
• Dissemination
• PUBLIC HEALTH ACTION

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Uses of Public Health Surveillance

• Estimate magnitude of the problem
• Determine geographic distribution of illness
• Portray the natural history of a disease
• Detect epidemics/ define a problem
• Evaluate control measures
• Monitor changes in infectious agents
• Facilitate planning

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Estimate Magnitude of Problem
Source Texas DSHS
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Determine Distribution of Problem
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Portray Natural History of Disease
Source Texas DSHS
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Detect Epidemics/Define a Problem
Source Texas DSHS
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Evaluate Control Measures
Source CDC
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Monitor Changes in Infectious Agents
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Scenario 2

• Your 18 month old child attends a day care
  center. Several children at the center have had
  a severe cough. You hear of one child that has
  been hospitalized. To your knowledge, the day
  care center director has not notified the local
  health department. What should you do?

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Facilitate Preventive Measures and Planning

• Coordinating prophylaxis treatment as needed
• Work with schools to promote consistent Public
  Health message - MRSA and seasonal influenza
  
• Promote education to public and providers
• Participating in exercises and tabletops

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Components of the Surveillance System

• Reporting Mandate
• Sources of Data
• Surveillance Staff
• Reporting Mechanism
• Case Definitions
• National Reporting
• Data Dissemination

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Reporting Mandate

• Several Texas laws (Health Safety Code,
  Chapters 81, 84, and 87) require specific
  information regarding notifiable conditions be
  provided to the Texas Department of State Health
  Services (DSHS). Health care providers,
  hospitals, laboratories, schools, and others are
  required to report patients who are suspected of
  having a notifiable condition (Chapter 97, Title
  25, Texas Administrative Code ).
• Source www.dshs.state.tx.us

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Are the Hoof Beats Horses or Zebras?

• In addition to reporting the communicable
  diseases required by law, health care providers
  and the public are encouraged to report to the
  health department any strange or unusual
  occurrence of disease. A heightened level of
  vigilance and reporting helps to minimize the
  likelihood that important risks to health will be
  overlooked.
•  

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DSHS Region 4/5N 24/7 Disease Reporting Hotline

• 866-310-9698

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Scenario 3

• You are a school nurse and you have noted that
  15 students in a second grade class are absent
  with a diarrheal illness. What should you do?

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Anthrax

• Anthrax is a serious disease caused by Bacillus
  anthracis, a bacterium that forms spores. There
  are three types of anthrax
  
• skin (cutaneous)
• lungs (inhalation)
• digestive (gastrointestinal)

Source CDC
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Anthrax Symptoms

• The symptoms (warning signs) of anthrax are
  different depending on the type of the disease
  
• Cutaneous The first symptom is a small sore that
  develops into a blister. The blister then
  develops into a skin ulcer with a black area in
  the center. The sore, blister and ulcer do not
  hurt.
• Gastrointestinal The first symptoms are nausea,
  loss of appetite, bloody diarrhea, and fever,
  followed by bad stomach pain.
  
• Inhalation The first symptoms of inhalation
  anthrax are like cold or flu symptoms and can
  include a sore throat, mild fever and muscle
  aches. Later symptoms include cough, chest
  discomfort, shortness of breath, tiredness and
  muscle aches.
• Inhalation Anthrax is not known to spread from
  one person to another.

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Anthrax Treatment

• Antibiotics are used to treat all three types of
  anthrax. Early identification and treatment are
  important.
  
• Prevention after exposure. Treatment is different
  for a person who is exposed to anthrax, but is
  not yet sick. Health-care providers will use
  antibiotics (such as ciprofloxacin, levofloxacin,
  doxycycline, or penicillin) combined with the
  anthrax vaccine to prevent anthrax infection.
• Treatment after infection. Treatment is usually a
  60-day course of antibiotics. Success depends on
  the type of anthrax and how soon treatment begins.

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Plague

• What is plague?Plague is a disease caused by
  Yersinia pestis (Y. pestis), a bacterium found in
  rodents and their fleas in many areas around the
  world.

Image Bubonic plague courtesy of CDC
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Pneumonic vs. Bubonic Plague

• Is pneumonic plague different from bubonic
  plague?Yes. Both are caused by Yersinia pestis.
  Pneumonic plague can be transmitted from person
  to person bubonic plague cannot. Pneumonic
  plague affects the lungs and is transmitted when
  a person breathes in Y. pestis particles in the
  air. Bubonic plague is transmitted through the
  bite of an infected flea or exposure to infected
  material through a break in the skin. Symptoms
  include swollen, tender lymph glands called
  buboes. Buboes are not present in pneumonic
  plague.
• What are the signs and symptoms of pneumonic
  plague?Patients usually have fever, weakness,
  and rapidly developing pneumonia with shortness
  of breath, chest pain, cough, and sometimes
  bloody or watery sputum. Nausea, vomiting, and
  abdominal pain may also occur. Without early
  treatment, pneumonic plague usually leads to
  respiratory failure, shock, and rapid death.

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Plague

• How quickly would someone get sick if exposed to
  plague bacteria through the air? Someone exposed
  to Yersinia pestis through the air either from
  an intentional aerosol release or from close and
  direct exposure to someone with plague
  pneumoniawould become ill within 1 to 6 days.
• Can pneumonic plague be treated? Yes. To prevent
  a high risk of death, antibiotics should be
  given within 24 hours of the first symptoms.
  Several types of antibiotics are effective for
  curing the disease and for preventing it.
  Available oral medications are a tetracycline
  (such as doxycycline) or a fluoroquinolone (such
  as ciprofloxacin). For injection or intravenous
  use, streptomycin or gentamicin antibiotics are
  used. Early in the response to a bioterrorism
  attack, these drugs would be tested to determine
  which is most effective against the particular
  weapon that was used.

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Smallpox

• What are the symptoms of smallpox?The symptoms
  of smallpox begin with high fever, head and body
  aches, and sometimes vomiting. A rash follows
  that spreads and progresses to raised bumps and
  pus-filled blisters that crust, scab, and fall
  off after about three weeks, leaving a pitted
  scar.
• If someone comes in contact with smallpox, how
  long does it take to show symptoms?After
  exposure, it takes between 7 and 17 days for
  symptoms of smallpox to appear (average
  incubation time is 12 to 14 days). During this
  time, the infected person feels fine and is not
  contagious.
• Is smallpox fatal?The majority of patients with
  smallpox recover, but death may occur in up to
  30 of cases. Many smallpox survivors have
  permanent scars over large areas of their body,
  especially their face. Some are left blind.

Source CDC
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Smallpox treatment

• Is there any treatment for smallpox?Smallpox
  can be prevented through use of the smallpox
  vaccine. There is no proven treatment for
  smallpox.

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Viral Hemorrhagic Fever

• Viral hemorrhagic fevers (VHFs) refer to a group
  of illnesses that are caused by several distinct
  families of viruses. In general, the term "viral
  hemorrhagic fever" is used to describe a severe
  multisystem syndrome.   Characteristically, the
  overall vascular system is damaged, and the
  body's ability to regulate itself is impaired.
• VHFs are caused by viruses of four distinct
  families arenaviruses, filoviruses,
  bunyaviruses, and flaviviruses  

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What are the symptoms of viral hemorrhagic fever
illnesses?

• Specific signs and symptoms vary by the type of
  VHF, but initial signs and symptoms often include
  marked fever, fatigue, dizziness, muscle aches,
  loss of strength, and exhaustion. Patients with
  severe cases of VHF often show signs of bleeding
  under the skin, in internal organs, or from body
  orifices like the mouth, eyes, or ears. However,
  although they may bleed from many sites around
  the body, patients rarely die because of blood
  loss. Severely ill patient cases may also show
  shock, nervous system malfunction, coma,
  delirium, and seizures. Some types of VHF are
  associated with renal (kidney) failure.

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How are patients with viral hemorrhagic fever
treated?

• Patients receive supportive therapy, but
  generally speaking, there is no other treatment
  or established cure for VHFs. Ribavirin, an
  anti-viral drug, has been effective in treating
  some individuals with Lassa fever or HFRS.

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Tularemia

• Q. What are the signs and symptoms of
  tularemia?A. The signs and symptoms people
  develop depend on how they are exposed to
  tularemia. Possible symptoms include skin ulcers,
  swollen and painful lymph glands, inflamed eyes,
  sore throat, mouth sores, diarrhea or pneumonia.
  If the bacteria are inhaled, symptoms can include
  abrupt onset of fever, chills, headache, muscle
  aches, joint pain, dry cough, and progressive
  weakness. People with pneumonia can develop chest
  pain, difficulty breathing, bloody sputum, and
  respiratory failure. Tularemia can be fatal if
  the person is not treated with appropriate
  antibiotics.

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Tularemia treatment

• Q. Can tularemia be effectively treated with
  antibiotics?A. Yes. Early antibiotic treatment
  is recommended whenever it is likely a person was
  exposed to tularemia or has been diagnosed as
  being infected with tularemia. Several types of
  antibiotics have been effective in treating
  tularemia infections. The tetracycline class
  (such as doxycycline) or fluoroquinolone class
  (such as ciprofloxacin) of antibiotics are taken
  orally. Streptomycin or gentamicin are also
  effective against tularemia, and are given by
  injection into a muscle or vein.
• Q. Can someone become infected with the tularemia
  bacteria from another person?A. People have not
  been known to transmit the infection to others.

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Scenario 4

• You are driving down Highway 69 in Wood County.
  In a pasture next to the highway, you notice 20
  cattle along with several birds have died.
  Should you do anything?

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What about influenza?

• Seasonal Flu
• Influenza (the flu) is a serious disease.
• Each year in the United States, on average
• 5 to 20 of the population gets the flu
• More than 200,000 people are hospitalized from
  flu complications, and
  
• About 36,000 people die from flu.

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What about influenza? (Cont.)

• Avian (or bird) flu (AI) is caused by influenza
  viruses that occur naturally among wild birds.
  Low pathogenic AI is common in birds and causes
  few problems. Highly pathogenic H5N1 is deadly to
  domestic fowl, can be transmitted from birds to
  humans, and is deadly to humans. There is
  virtually no human immunity and human vaccine
  availability is very limited.

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What about influenza? (Cont.)

• Pandemic flu is virulent human flu that causes a
  global outbreak, or pandemic, of serious illness.
  Because there is little natural immunity, the
  disease can spread easily from person to person.
  Currently, there is no pandemic flu.

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Influenza Treatment
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Sources of DataWho Should Report?

• Physicians/Practioners (hospital and clinic
  based)
  
• Laboratories
• Vital Records
• Other individuals and institutions

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Types of Reporting

• Passive Surveillance- receive reports
  passively, e.g., hospital mails weekly reports
  
  
• Active Surveillance- Public health actively
  pursues reports by calling health care providers,
  etc.
  

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Surveillance Staff

• Region 4/5 North
• Angelina Cities and County Health Department
• Cherokee County Health Department
• Gregg County Health Department
• Jasper-Newton Public Health District
• Northeast Texas Public Health District
• Texarkana-Bowie County Family Health Center
• Call reports to the staff that covers your
  county!!

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Report Locally

• Know who you should report to- local health
  department or regional health department.
  
• Know your Health Authority and their role in
  Public Health Intervention.
  

Think globally- report locally!
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Reporting Mechanism
Report the right disease to the right person at
the right time!
Know how quickly the disease should be
reported. Call, fax or electronically report
condition.
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Case Definitions

• A case definition is different from a clinical
  diagnosis. You can access case definitions at
  www.cdc.gov.
  

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National Reporting

• The disease reports have investigations completed
  and then are entered into National Electronic
  Surveillance System (NEDSS).
  
• This information helps is put into MMWR- you can
  get a weekly feedback from a state perspective.
  

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Data Dissemination

• MMWR- you can get an email copy free
• DSHS website
• Local dissemination
• Peer review and medical journals

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What About HIPAA?

• The Health Insurance Portability and
  Accountability Act of 1996 (HIPAA) privacy
  regulations implemented standards for how
  information that identifies a patient can be used
  and disclosed. (Title 45, Code of Federal
  Regulations (CFR), Parts 160 and 164)  The
  regulations apply to "covered entities" including
  health-care plans, health-care clearinghouses,
  and health-care providers. These privacy
  standards go into effect on April 14, 2003.

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What does this mean?
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What does this mean? (cont.)
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Case StudyGastroenteritis at a University in
Texas

• This case study is based on a real-life outbreak
  investigation undertaken in Texas in 1998
  
• On the morning of March 11, the Texas Department
  of Health (TDH) in Austin received a telephone
  call from a student at a university in
  south-central Texas. The student reported that
  he and his roommate, a fraternity brother, were
  suffering from nausea, vomiting, and diarrhea.
  Both had become ill during the night. The
  roommate had taken an over-the-counter medication
  with some relief of his symptoms. Neither the
  student nor his roommate had seen a physician or
  gone to the emergency room.
• The students believed their illness was due to
  food they had eaten at a local pizzeria the
  previous night. They asked if they should attend
  classes and take a biology midterm exam that was
  scheduled that afternoon.

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Question 1

• What questions (or types of questions) would you
  ask the student?
  
• WHAT is the persons problem?
• WHO else became ill, their characteristics (e.g.,
  age, sex, occupation), and the nature of their
  illnesses (e.g., symptoms, whether any persons
  were hospitalized or died)?
• WHEN did the affected person(s) become ill?
• WHERE are the affected persons located?
  (including names and telephone numbers)
  
• WHY (and HOW) do they think they became ill?
  (e.g., risk factors, suspected exposures,
  suspected modes of transmission, hints from who
  else did and did not become ill)

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Question 2

• What would you advise the student about attending
  classes that day?
  
• You probably should refer the student to his
  personal physician or the Student Health Center
  for a complete assessment.
  
• While symptomatic, the students would probably be
  most comfortable staying in their dorm room

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Question 3

• Do you think this complaint should be
  investigated further?
  
• Ideally, all reports of possible outbreaks of
  foodborne illnesses should be investigated to
  
• prevent other persons from becoming ill (either
  from the same food or method of food
  preparation),
  
• identify potentially problematic foodhandling
  practices, and
  
• add to our knowledge of foodborne diseases.

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Question 4

• How big is the threat?
• The most important diseases/complaints to
  investigate are those that are a severe threat to
  the publics health or where a timely control
  response is critical. Top priorities include
• an outbreak associated with a commercially
  distributed food product
  
• severe (life-threatening) illnesses such botulism
  or E. coli O157H7 infection
  
• confirmed clusters of a similar illness that
  appear to be associated with a specific food
  preparer or food service establishment
  
• instances where a large number of people appear
  to be affected
  
• indications of adulterated food presenting an
  imminent danger
  
• foodborne illness in a foodhandler

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Further information

• TDH staff were skeptical of the students report
  but felt that a minimal amount of exploration was
  necessary. They began by making a few telephone
  calls to establish the facts and determine if
  other persons were similarly affected. The
  pizzeria, where the student and his roommate had
  eaten, was closed until 1100 A.M. There was no
  answer at the University Student Health Center,
  so a message was left on its answering machine.
• A call to the emergency room at a local hospital
  (Hospital A) revealed that 23 university
  students had been seen for acute gastroenteritis
  in the last 24 hours. In contrast, only three
  patients had been seen at the emergency room for
  similar symptoms from March 5-9, none of whom
  were associated with the university.
• At 1030 A.M., the physician from the University
  Student Health Center returned the call from TDH
  and reported that 20 students with vomiting and
  diarrhea had been seen the previous day. He
  believed only 1-2 students typically would have
  been seen for these symptoms in a week. The
  Health Center had not collected stool specimens
  from any of the ill students.

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Question 5

• Do you think these cases of gastroenteritis
  represent an outbreak at the university? Why or
  why not?
  
• An outbreak is the occurrence of more cases of a
  disease than expected for a particular place and
  time. In a 2-day period, over 40 cases of
  gastroenteritis occurred among students at the
  university (assuming that individual students did
  not visit both the Student Health Center and the
  emergency room). This compares with the handful
  of students that would normally have been seen
  for these symptoms at the two facilities in a
  week. Therefore, it is highly likely that these
  cases represent an outbreak.

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Initial Investigation

• On the afternoon of March 11, TDH staff visited
  the emergency room at Hospital A and reviewed
  medical records of patients seen at the facility
  for vomiting and/or diarrhea since March 5.
  Based on these records, symptoms among the 23
  students included vomiting (91), diarrhea (85),
  abdominal cramping (68), headache (66), muscle
  aches (49), and bloody diarrhea (5). Oral
  temperatures ranged from 98.8F (37.1C) to
  102.4F (39.1C) (median 100F 37.8C).

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Question 6

• List the broad categories of diseases that must
  be considered in the differential diagnosis of an
  outbreak of acute gastrointestinal illness.
  
• There are two broad classifications for enteric
  diseases
  
• Infections are a consequence of the growth of a
  microorganism in the body
  
• Intoxications are caused by ingestion of food
  already contaminated by toxins

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Graphic Depiction of Outbreak
By March 12, seventy-five persons with vomiting
or diarrhea had been reported to TDH. All were
students who lived on the university campus.

• Onset of gastroenteritis among students,
  University X, Texas, March 1998. (N72) (Date of
  onset was not known for three ill students.)

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Further Findings

• Among persons who ate at the deli bar during the
  implicated meals, cases were three times more
  likely than controls to eat American cheese and
  mayonnaise. They were also 1.5 times more likely
  to have eaten ham.

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Final Comments

• Although food handlers are often victims of food
  borne disease outbreaks because they consume the
  contaminated food themselves, the facts in this
  outbreak suggest this food handler might have
  been the source of infection for the students
• The diarrheal illness in her child preceded the
  outbreak and occurred at the probable time the
  students were exposed (i.e., began three days
  before the outbreak and continued through March
  23).
• The food handler prepared ingredients and
  sandwiches served at the deli bar during the time
  that her child was ill.
  
• Finally, norovirus was isolated from the childs
  stool and was identical to that obtained from ill
  students and the deli ham.

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Review

• Early Detection---- Rapid Response
• When in doubt call!!! Dont assume that disease
  reporting has occurred.
  
• Local Health Department or
• 866-310-9698

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Tool Kit

• Your tool kit has some of the most common
  notifiable diseases in East Texas.

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Questions?
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Helpful Sources

• CDC - Center for Disease Controlwww.cdc.gov
• Texas Department of State Health Services
  www.dshs.state.tx.us
  
• World Health Organization www.who.int