Patients affected by highly infectious diseases: EUNID 27-28 May 2005 Rome Patients affected by highly infectious diseases: definitions are an arcana Emanuele Nicastri National Institute for Infectious Diseases Rome Italy

Do you really think that the mistery is in Yes, at all the mistery is in Rome, but in the Sistina Chapter where since 1512 most Popes have been designed

A careful monitoring of specific clinical syndromes can provide public Many potential highly infectious agents initially produce nonspecific clinical manifestations and even the most astute clinician may not suspect one of these agents in the absence of more specific data. A careful monitoring of specific clinical syndromes can provide public health with the earliest evidence of an outbreack? Separation of Light from Darkness

With a 1% rate of foodborne reporting, what is the meaning of the reports that we do have? Or Tip of an Iceberg? Isolated Snow Flake? Or it is 1/99 other cases part of the same outbreak? One of many sporadic cases Creation of sun, moon and plants

“Round up the usual suspects” “Casablanca” We can only find agents for which we look, and we only look for what we expect to find. A serious problem for lab or clinical based systems. Separation of the Earth from the Waters “Round up the usual suspects”

Assumptions t Symptom Onset Severe Illness Number of Cases Days 1 2 3 Exposure Number of Cases 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 Most of the biological agents of concern have a non-specific, flu-like prodrome. This graph demonstrates one of the critical assumptions about syndromic surveillance, that the interval between the prodrome and more serious manifestations is 1-3 days. This would mean that an early warning would allow the health department time to identify those exposed and institute control measures to limit morbidity and mortality. Days Creation of Adam

Data sources for early detection of acute illness Day 0 - exposure occurs Day 1 - feels fine Day 2 - headaches, fever- buys OTC meds Day 3 - develops cough- calls provider Day 4 - sees private doctor: “flu” Day 5 - worsens- calls ambulance seen in Emergency Dept. Day 6 - admitted- “pneumonia” Day 7 - critically ill- ICU, lab tests + Day 8 - expires- “respiratory failure” Pharmaceutical Sales Nurse’s Hotline Outpatient Visit Data Absenteeism Ambulance Dispatch (EMS) ED Logs Creation of Eve Diagnosed Reported

Data Transfer Ambulance E/A Department Absenteeism Pharmacy The fall and the expulsion fron the Eden

Scenario A favoring earlier detection by means of clinical evaluation Sacrifice of Noah Buehler EID 03

Scenario B favoring earlier detection by means of syndromic surveillance The Deluge Buehler EID 03

Drunkeness of Noha

Good work in the small groups What is the mistery behind the most famous Michelangelo paintings that, since half a millenium is influencing the election of each Pope? What is the best definition of our HID, clinical, syndromic, lab linked, or epidemiological linked?