Syndromic Surveillance - Northwest Center for Public Health Practice
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Transcript Syndromic Surveillance - Northwest Center for Public Health Practice
Preparing for and Responding to
Bioterrorism:
Information for the Public Health
Workforce
Northwest Center for Public Health Practice
University of Washington School of Public Health and Community Medicine
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Acknowledgements
This presentation, and the accompanying instructor’s manual,
were prepared by Jennifer Brennan Braden, MD, MPH, at the
Northwest Center for Public Health Practice in Seattle, WA, for the
purpose of educating public health employees in the general aspects of
bioterrorism preparedness and response. Instructors are encouraged
to freely use all or portions of the material for its intended purpose.
The following people and organizations provided information and
support in the development of this curriculum. A complete list of
resources can be found in the accompanying instructor’s guide.
Patrick O’Carroll, MD, MPH
Project Coordinator
Centers for Disease Control and Prevention
Judith Yarrow
Design and Editing
Health Policy and Analysis; University of WA
Washington State Department of Health
Jeff Duchin, MD
Jane Koehler, DVM, MPH
Communicable Disease Control,
Epidemiology and Immunization Section
Public Health - Seattle and King County
Ed Walker, MD; University of WA
Department of Psychiatry
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UW Northwest Center for Public Health Practice
Health Surveillance and
Epidemiologic Investigation
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UW Northwest Center for Public Health Practice
Health Surveillance and
Epidemiologic Investigation
Learning Objectives
Describe the basic steps in communicable
disease case and outbreak investigations
Define “syndromic surveillance” and describe
how it can be used to identify disease
outbreaks
Identify potential sources of information for
syndromic surveillance systems
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Health Surveillance and
Epidemiologic Investigation
Learning Objectives
Describe the Laboratory Response Network
(LRN)
Define and describe its purpose and function
in BT response
Identify resources available through the LRN
for public health
Describe public health’s participation in the
LRN
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Disease Surveillance and Investigation
Legal Basis in Washington
RCW 70.05.070 gives the local health officer
power to “take such measures as he or she
deems necessary in order to promote the public
health.”
RCW 70.05.090 requires physicians to report
contagious diseases.
RCW 68.50.010 requires medical examiners to
report deaths from contagious diseases.
Notifiable conditions in WA
UW Northwest Center for Public Health Practice
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Disease Surveillance and Investigation
Legal Basis in Washington
WAC 246-101 specifies contagious disease
reporting for health care providers, hospitals,
laboratories, and local health jurisdictions:
Lists of notifiable conditions
Time frame for reporting
Responsibilities for disease control
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Disease Surveillance and Investigation
Legal Basis in WA
Effective September 2000, the following are
immediately reportable to the local health
jurisdiction
All suspected illnesses caused by potential
bioterrorism agents
Unexplained critical illness or death
Rare diseases of public health importance
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Recognition of a BT Event
Surveillance/Detection
Detect unusual medical events sooner rather
than later
Depends on ability to identify a greater than
expected number of “cases” or syndromes
More on public health surveillance...
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Syndromic Surveillance
Sensitivity to unusual clusters of disease
syndromes compatible with naturally occurring
or BT-related outbreaks
Influenza-like illness
Invasive bacterial disease
Encephalitis/meningitis
Unexplained critical illness or death
Rash illnesses
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Syndromic Surveillance
Potential information sources
Primary care clinic visits
Emergency room visits
Calls to poison control centers
Pharmacy visits/requests
Nurse hotline calls
911 calls
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Syndromic Surveillance Project
A CDC-funded Project
Syndromic surveillance began in 1999 in King
County
Traditional Public Health surveillance depends
on labs and doctors reporting confirmed
diseases (usually laboratory confirmed)
Syndromic surveillance identifies disease
syndromes prior to confirmation
Goal is to identify an increase in disease
syndromes, not confirmed case reports
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Syndromic Surveillance Project
Aberration Detection
Hospital Emergency Department Discharge Data
Primary Care Clinic Discharge Data
Seattle Emergency Medical Services Calls (911)
Medical Examiner (ME) - Unexplained Deaths
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Syndromic Surveillance Project
Hospital Emergency Department and
Primary Care Clinic Discharge Data
Data extracted from clinical discharge diagnosis
databases at three hospitals and nine primary
care clinics
Transmitted electronically to PHSKC
Analyzed using CDC aberration detection
program
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Syndromic Surveillance Project
Seattle Emergency Medical Services Calls (911)
The number and type of triage protocols are
monitored during each 24-hour period
Analyze using CDC Aberration Detection
Software
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Syndromic Surveillance Project
911 Triage Protocols
Abdominal Pain
Headache
Sick Unknown
CVA/Stroke
Breathing Problems
DOA
Person Down
Chest Discomfort
Convulsions/Seizures
Dizzy/Fainting
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Syndromic Surveillance Project
Medical Examiner (ME) Unexplained
Death Surveillance
Data source: Daily Log from the King County ME
Definition: Unexplained death in a previously healthy
person aged 1-49 years with hallmarks of infectious
disease
Daily Log is reviewed daily for deaths meeting the
definition of unexplained death
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Syndromic Surveillance Project
Enhanced Surveillance Activities
Number and type of calls from HospitalBased Consulting Nurse Hotlines
Year-Round Influenza Surveillance
Infectious Disease
Surveillance Systems
UW Northwest Center for Public Health Practice
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Syndromic Surveillance Project
Active Surveillance for School Absenteeism During
Influenza Season
Ten schools participated in 2000
Schools receive weekly reminders to report
when absenteeism exceeds 10%
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Syndromic Surveillance Project
Consulting Nurse Hotlines
Two hospital-based Consulting Nurse
Hotlines participate
Total Calls and the proportion of calls for
symptoms of influenza-like illness (ILI) are
monitored:
Flu
Fever
Sore Throat
Cough
Colds
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Syndromic Surveillance Project
Year Round Influenza Surveillance
King County Lab participates in CDC’s
National Respiratory and Enteric Virus
Surveillance System
12 primary care providers submit specimens
year-round from persons with ILI
Providers receive periodic e-mail reminders
to submit specimens from persons with ILI
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Outbreak Investigation
Basic Steps
Establish the existence of an outbreak
Verify the diagnosis
Develop a case definition (confirmed, probable,
possible)
Identify cases
Characterize the outbreak (person, place, time)
Develop and test hypotheses
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Outbreak Investigation
Additional Steps
Determining appropriate containment strategies
Evaluation of expected and unexpected epi
features of the outbreak
Identifying the population at risk
Prophylaxis (immunization/antibiotics) for
exposed, isolation and/or quarantine for
suspected/confirmed cases
Depends on disease and outbreak characteristics
Health officer and/or medical epi decision
If person-to-person transmission
Contact tracing and identification
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Post-BT Event Surveillance
Active surveillance for suspected, confirmed,
probable cases
Follow-up on case outcomes
Surveillance for vaccine and antibiotic-related
adverse events
VAERS - The Vaccine Adverse Event Reporting System
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Laboratory Response
Network
Multilevel network of local, state, and federal
laboratories
Laboratories identified by increasing level of
sophistication (A – D)
Facilitates sample collection, transport, testing,
and training for laboratory readiness for
bioterrorism
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Laboratory Response Network
For Bioterrorism
D - Highest level characterization (Federal)
Level D Lab
BSL-4
C - Molecular assays, reference capacity
Level C Lab
BSL-3
Level B Lab
BSL-2 facility + BSL-3 Safety
Practices
B - Limited confirmation and transport
A - Rule-out and forward organisms
Level-A Lab
Use Class II Biosafety Cabinet
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Laboratory Diagnosis of Category A Agents
Required Bio-safety* Levels
B. anthracis (anthrax)
BSL 2
Y. pestis (plague)
BSL 2
C. botulinum (botulism)
BSL 2
F. tularensis (tularemia)
BSL 2/3
Variola major (smallpox)
BSL 4
Filoviridae & arenaviridae
(viral hemorrhagic fevers)
BSL 4
*BSL 2/3 - State and some local public health labs
BSL 4 - CDC and USAMRIID
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Laboratory Diagnosis of Category A Agents
Protocols for Testing and Referral
Level A protocols available at:
http://www.bt.cdc.gov/LabIssues/index.asp
Level B/C protocols available through
password-protected Web site for LRNregistered members
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Laboratory Diagnosis of Category A Agents
Resources for Testing and Referral
LRN members can
Search for nearest equal or higher-level lab
via password-protected Website
Order reagents for B/C testing through
password-protected Website
Specimen packaging and transport
General information available at:
http://www.bt.cdc.gov/LabIssues/PackagingInfo.pdf
Specific information available from public
health laboratory
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Summary of Key Points
Early detection of a bioterrorism event requires
sensitivity to unusual clusters of disease
syndromes, in addition to traditional disease
reporting.
Syndromic surveillance systems integrate data
from a variety of sources and alert public health
officials to potential outbreaks, prior to the
establishment of a diagnosis.
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Summary of Key Points
The investigation of any disease outbreak
follows several basic steps.
Post-event surveillance includes systems to
monitor for the development of new cases, case
outcomes, and adverse events related to
treatment and prophylaxis.
The Laboratory Response Network is a system
of local, state, and federal laboratories identified
by increasing levels of proficiency to respond to
bioterrorism.
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Resources
Centers for Disease Control and Prevention
Bioterrorism Web site
http://www.bt.cdc.gov/
Epidemiology Program Office
http://www.cdc.gov/epo/index.htm
Council for State and Territorial Epidemiologists
http://www.cste.org/
Roundtable on bioterrorism detection –
summary of several syndromic surveillance
systems in development JAIMIA 2002;9:105-115
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