Continuing Medical Education Course Handout FY18 Epi-Tech Surveillance Training

Continuing Medical Education Course Handout

Continuing Medical Education Course Handout

ANNOUNCEMENT To Register for the Monthly Disease Surveillance Trainings: Contact your Service Surveillance HUB to receive monthly updates and reminders Log-on or Request log-on ID/password: https://tiny.army.mil/r/zB8A/CME Register at: https://tiny.army.mil/r/MEHsS/EpiTechFY18 Confirm attendance: Please enter your full name/email into the DCS chat box to the right or email your Service hub You will receive a confirmation email within 48 hours with your attendance record; if you do not receive this email, please contact your Service hub

Managing Misreporting: Common Mistakes and Misreported RMEs Victoria Holbrook, MPH Epidemiologist Epidemiology Consult Service (USAFSAM/PHR)

Learning Objectives Prevent misreporting by understanding what misreporting is and why accuracy in reporting is critical Recognize common mistakes and misreported Reportable Medical Events (RMEs) to improve reporting Understand the interpretation of case classifications and their associated labs to increase accuracy of reporting

Case Definitions Misreporting Part 1: Reporting Requirements Case Definitions Misreporting

Reporting Requirements Air Force: AFI 48-105 “Surveillance, Prevention, and Control of Diseases and Conditions of Public Health or Military Significance” Navy: BUMED INST 6220.12C “Medical Surveillance and Medical Event Reporting” NMCPHC-TM-PM 6220.12 “Medical Surveillance and Reporting” Army: Army Regulations 40-5 "Medical Services Preventive Medicine“ Department of the Army Pamphlet 40-11 "Medical Services Preventive Medicine"

2017 Guidelines

Although slightly different, they are typically used interchangeably! Case Definitions Case Definition vs Case Classification? Case Definition: the specific clinical, laboratory, and other objective criteria that define who is included as a case in the surveillance of public health conditions (i.e. RMEs) E.g. the Mumps case definition Case Classification: subcategories of a case definition – typically suspected, probable, and confirmed; specifies what is needed to meet the case definition of an RME E.g. the Mumps confirmed case classification Although slightly different, they are typically used interchangeably!

Case Classifications

Case Classification Example Meningococcal Disease

Case Classification Example Campylobacteriosis Chlamydia

Misreporting The inaccurate reporting of an RME Can include: Reporting an RME under an incorrect case classification Reporting an event that does not meet any case classification Filling out a medical event report incorrectly Why does accuracy matter?

Part 2: In-Depth Case Definition Interpretation Hepatitis A Campylobacter Influenza-Associated Hospitalization Hepatitis B Lyme Disease

Reading a Case Definition Look at requirements: Symptoms Laboratory requirements Lab method Sample type Result interpretation Exposure history Epidemiologically linked (i.e. sick contacts) Travel history Endemicity of disease

Hepatitis A Page 42 ONE case classification When reporting check: Critical Reporting Elements Comments for clarification

Hepatitis A What is important to notice? Requires symptoms Has an “or” (i.e. two ways to meet the case definition) Specific laboratory result from a specific sample type This case definition requires two things: 1) symptoms and 2) meeting one of the bullets

Hepatitis A Case must meet the clinical description Description has an and, or requirement

Is this case reportable? The following lab shows up on your spool A look at their encounters shows that the patient presented with diarrhea and jaundice

Is this case reportable? The following lab shows up on your spool A look at their encounters shows that the patient presented with diarrhea and jaundice Yes, as a Confirmed case They exhibited the necessary symptoms (diarrhea plus jaundice) and a positive Hepatitis A IgM antibody (ab).

Is this case reportable? Same scenario, but what if these were your lab results instead? and the result is positive.. Is this reportable? (next slide.)

Is this case reportable? Same scenario, but what if these were your lab results instead? NO. Why? Because this lab is a hepatitis A virus TOTAL ab test. The case definition requires a positive IgM Ab. In this case you cannot determine if the IgM or the IgG ab is positive. Additional testing would need to be done.

Campylobacter Page 19 TWO case classifications When reporting check: Critical Reporting Elements

Campylobacter What is important to notice? Lab results do NOT require symptoms Has an or This case definition requires only one thing: 1) meeting one of the bullets

Is this case reportable? The lab alerts you to the following result:

Is this case reportable? The lab alerts you to the following result: Yes, as a Probable case The rapid Campylobacter test is positive. Rapid tests are typically EIAs. This rapid test was performed as part of the culture panel. The result is NOT culture positive for Campylobacter.

Influenza-Associated Hospitalization Page 46 ONE case classification When reporting check: Critical Reporting Elements Comments for clarification

Influenza-Associated Hospitalization What is important to notice? Requires symptoms Has two and’s and one or This case definition requires two things: 1) symptoms and 2) meeting three of the bullets

Is this case reportable? On your ad hoc report you find the following result: Additional research tells you that the patient is 35, has flu-like symptoms, and was admitted to the hospital on 27 Jan 2018

Is this case reportable? On your ad hoc report you find the following result: Additional research tells you that the patient is 35, has flu-like symptoms, and was admitted to the hospital on 29 Jan 2018 Yes, as a Confirmed case The patient displayed symptoms, is younger than 65, had a positive flu test, and was admitted to the hospital less than 14 days after the positive test.

Is this case reportable? On your ad hoc report you find the following result: Additional research tells you that the patient is 63, has flu-like symptoms, and was seen in the ER

Is this case reportable? On your ad hoc report you find the following result: Additional research tells you that the patient is 63, has flu-like symptoms, and was seen in the ER NO. Why? Although they meet most criteria, they were seen in the ER but not admitted to an inpatient ward of the hospital.

Hepatitis B Page 43 ONE case classification When reporting check: Two options: Acute & Chronic When reporting check: Critical Reporting Elements Comments for clarification

Hepatitis B

Hepatitis B What is important? For this example we’re going to look only at Chronic Hep B. What is important? The CHRONIC case case definition requires one thing: 1) meeting one of the bullets Does NOT require symptoms Has one and, multiple or’s

Is this case reportable? You come across this Hep B panel:

Is this case reportable? You come across this Hep B panel: Yes, as a Confirmed case The results have a negative core IgM (HBc-IgM) ab AND a positive surface antigen (HBsAG)

Is this case reportable? What about this Hepatitis A+B+C Virus panel?:

Is this case reportable? What about this Hepatitis A+B+C Virus panel?: NO. Why? The surface antigen (HBsAg) is negative, and there are no Hep B e antigen or PCR results.

Lyme disease Page 52 & 53 THREE case classifications When reporting check: Critical Reporting Elements Comments for clarification

Lyme disease What is important to notice? Does NOT require symptoms Requires “provider diagnosis” Includes superscripts that refer to the comments Has one and, many or’s This case classification requires two things: 1) provider diagnosis and 2) meeting one of the bullets Two things I want to talk about before we get to an example – “two tiered testing” and the superscripts

Two-Tiered Testing

Lyme disease Superscripts referring to the comments Explains laboratory details, interpretation; clarifies case definition requirements

Is this case reportable? You find these results in your ad hoc and see the provider diagnosed them with Lyme:

Is this case reportable? You find these results in your ad hoc: Yes, as a Probable case Both the first and second tier tests are positive and in the AHLTA encounter the provider diagnosed the patient with Lyme disease

Is this case reportable? These results come up in your ad hoc: Per their history, a Lyme screening test was NOT ordered, no symptoms were reported, and the doctor has not diagnosed them.

Is this case reportable? These results come up in your ad hoc: NO. Why? The IgM WB is positive, but this result is NOT reportable without a preceding positive screening test.

Lyme Disease Erythema Migrans (EM) 2017 Armed Forces Reportable Medical Events Guidelines and Case Definitions Lyme Disease Erythema Migrans (EM) OR Late Manifestation (LM) of Lyme Disease? (e.g. Bell’s palsy, swollen knees, Lyme carditis) No Yes (LM) Yes (EM) Provider diagnosed Lyme disease? No Yes Known exposure* in endemic or non-endemic area? Any clinical information available? (+) LD total Ab screen WITH (+) IgM within 30 days of illness onset? (Two-tier testing) No Yes SUSPECT (+) LD total Ab screen WITH (+) IgM within 30 days of illness onset? (Two-tier testing) No Yes No Yes (+) LD total Ab screen WITH (+) IgM within 30 days of illness onset? (Two-tier testing) Start over. Or, if NO LM/EM and NO diagnosis, does not meet case definition. (+) LD total Ab screen WITH (+) IgG? (Two-tier testing) PROBABLE No Yes Yes No (+) LD total Ab screen WITH (+) IgG? (Two-tier testing) CONFIRMED No Yes (+) IgG? (Single-tier testing) Yes PROBABLE No Yes No (+) LD total Ab screen WITH (+) IgG? (Two-tier testing) Yes SUSPECT (+) IgG? (Single-tier testing) CONFIRMED (+) culture? No Yes No Yes No (+) IgG? (Single-tier testing) Yes NOT A CASE PROBABLE (+) culture? CONFIRMED No No (EM) No (LM) Yes NOT A CASE (+) culture? SUSPECT CONFIRMED NOT A CASE CONFIRMED No Yes * Exposure is defined as having been (≤30 days before onset of EM) in wooded, brushy, or grassy areas in a county in which Lyme disease is endemic. History of tick bite is not required. Possession of physical tick is not required. Endemicity is defined as a county in which at least 2 confirmed cases have been acquired or established populations of the blacklegged tick are infected with B. burgdorferi.

Part 3: Misreporting Notes Event Report Completion Consistency in Reports Conclusion

Medical Event Report Completion Accuracy in reporting includes completing details like Event Related Questions in DRSi Event Related Questions: Reflect the Critical Reporting Elements and the case definition in the Guidelines Answer as thoroughly as possible Are pertinent to the event & your surveillance hub Event related questions in DRSi. CREs give basic situational awareness to reviewers, but also provide information about likelihood of disease transmission, exposures, and often should help local public health with their investigation. Answering these as thoroughly as possible prevents us from reaching out to ask for details (sometimes) and Trust me, we’re asking questions we think are important.

Consistency – PEP against Rabies Answers to Event Related Questions should be consistent with AHLTA records and the case definition

Reporting PEP against Rabies What is wrong with this report? The first question is answered. The second lists the species, dog. (Which, to save time, just the species of the animal is fine. Descriptions aren’t necessary!)

Reporting PEP against Rabies What is wrong with this report? One exposure criteria MUST be met in order to be reportable

Conclusion Case definitions Accuracy in reporting Classifications Symptoms Laboratory requirements (lab method, sample type, result interpretation) Exposure history Ands and Ors Accuracy in reporting Reporting completion and consistency

Contact Information Army: APHC – Disease Epidemiology Division Aberdeen Proving Ground – MD COMM: (410) 436-7605   DSN: 584-7605 usarmy.apg.medcom-aphc.mbx.disease-epidemiologyprogram13@mail.mil Navy: NMCPHC Preventive Medicine Programs and Policy Support Department COMM: (757) 953-0700; DSN: (312) 377-0700 Email: usn.hampton-roads.navmcpubhlthcenpors.list.nmcphc-threatassess@mail.mil Contact your cognizant NEPMU NEPMU2: COMM: (757) 950-6600; DSN: (312) 377-6600 Email: usn.hampton-roads.navhospporsva.list.nepmu2norfolk- threatassess@mail.mil NEPMU5: COMM: (619) 556-7070; DSN (312) 526-7070 Email: usn.san-diego.navenpvntmedufive.list.nepmu5-health-surveillance@mail.mil NEPMU6: COMM: (808) 471-0237; DSN: (315) 471-0237 Email: usn.jbphh.navenpvntmedusixhi.list.nepmu6@mail.mil NEPMU7: COMM (int): 011-34-956-82-2230 (local): 727-2230; DSN: 94-314-727-2230 Email: NEPMU7@eu.navy.mil Air Force: Contact your MAJCOM PH or USAFSAM/PHR USAFSAM / PHR / Epidemiology Consult Service Wright-Patterson AFB, Ohio COMM: (937) 938-3207   DSN: 798-3207 usafsam.phrepiservic@us.af.mil T Alright, that concludes our presentation. At this time we will take questions and comments in the chat box on DCS or over the phone! On the screen is contact information for service-specific surveillance hubs if you’d like to contact them specifically.