Influenza Surveillance in Washington Anthony A Tellez-Marfin Washington State Department of Health

Making Sausage How does tradition disease surveillance work in most states?

Traditional Disease Surveillance Health Events of Interest HCFsHCPsLabs Reporters

Traditional Disease Surveillance Health Events of Interest HCFsHCPsLabs Reporters

Traditional Disease Surveillance Health Events of Interest HCFsHCPsLabs Reporters ???

Traditional Disease Surveillance Health Events of Interest HCFsHCPsLabs Reporters County

Traditional Disease Surveillance Health Events of Interest HCFsHCPsLabs Reporters County

Traditional Disease Surveillance Health Events of Interest HCFsHCPsLabs Reporters County

Traditional Disease Surveillance PHIMS

Why Isn’t Influenza Notifiable? Significant PH problemSignificant PH problem Leading cause of mortalityLeading cause of mortality Transmission interruption possibleTransmission interruption possible Preventable (vaccine)Preventable (vaccine) Lots of cases ….every yearLots of cases ….every year Traditional surveillance for flu resource-demanding for yieldTraditional surveillance for flu resource-demanding for yield Annual reports (hospitalization & death certificate data) to evaluate vaccine delivery & identify at-risk groupsAnnual reports (hospitalization & death certificate data) to evaluate vaccine delivery & identify at-risk groups Never been need for real-time surveillanceNever been need for real-time surveillance

Goals of Influenza Surveillance Changing Start & stop of annual epidemicStart & stop of annual epidemic Cost, morbidity, & mortality of influenzaCost, morbidity, & mortality of influenza Measure vaccine / vaccine delivery effectiveness & make correctionsMeasure vaccine / vaccine delivery effectiveness & make corrections Evaluate public health outreach to high-risk groupsEvaluate public health outreach to high-risk groups Monitor emergence of anti-viral resistanceMonitor emergence of anti-viral resistance Emergence of significant viral mutationsEmergence of significant viral mutations Anticipate impact on healthcare & HCFsAnticipate impact on healthcare & HCFs Bed availabilityBed availability Ventilator availabilityVentilator availability Anti-viral availabilityAnti-viral availability

How Much Data Do We Really Need for Flu Surveillance? For annual epidemic influenza, not so much data needed to answer these new, pressing questionsFor annual epidemic influenza, not so much data needed to answer these new, pressing questions Minimize reported data for each caseMinimize reported data for each case Basic demographicsBasic demographics AgeAge GenderGender County of residenceCounty of residence Date of illness onset or sample collectionDate of illness onset or sample collection Lab resultLab result

New / Enhanced Influenza Surveillance (Post-Pandemic) 7 new surveillance systems (largely automated) Sentinel lab network (typing, resistance)Sentinel lab network (typing, resistance) Mandatory influenza death reportingMandatory influenza death reporting Pneumonia & influenza mortality eDR (in , 6 counties; in , all counties)Pneumonia & influenza mortality eDR (in , 6 counties; in , all counties) Statewide sentinel ER ILI surveillanceStatewide sentinel ER ILI surveillance ELR: Messaging individual records (PHRED)ELR: Messaging individual records (PHRED) ELR: Web-based aggregate data entry (PHRAID)ELR: Web-based aggregate data entry (PHRAID) Limited flu hosp surveillance using HIE (Spokane)Limited flu hosp surveillance using HIE (Spokane)

PHRED & PHRAID Use ELR for surveillanceUse ELR for surveillance Developed during 2009 flu pandemicDeveloped during 2009 flu pandemic PHRED: Centralized reporting from labs to DOH with distribution to local health jurisdictionsPHRED: Centralized reporting from labs to DOH with distribution to local health jurisdictions PHRAID: Centralized reporting aggregate data from labs to DOH (influenza A, influenza B, RSV)PHRAID: Centralized reporting aggregate data from labs to DOH (influenza A, influenza B, RSV) Next step? More complete lab data to populate web- based notifiable condition reporting system (PHIMS)Next step? More complete lab data to populate web- based notifiable condition reporting system (PHIMS) Changes in WA administrative code to improve content of lab-submitted reportsChanges in WA administrative code to improve content of lab-submitted reports

LABS PHRED WA DOH PHRED Flu Lab Results WA DOH CDES

Weekly surveillance report LABS PHRAID WA DOH PHRAID Aggregate Flu Lab Results WA DOH CDES

PHRED-to-PHIMS Under developmentUnder development Use content of the PHRED data message to pre- populate PHIMS case reportUse content of the PHRED data message to pre- populate PHIMS case report Distribute pre-populated PHIMS records to local health jurisdictionsDistribute pre-populated PHIMS records to local health jurisdictions LHJs to handle as per available resourcesLHJs to handle as per available resources Entry into PHIMS or identification as a case does not mean mandatory investigationEntry into PHIMS or identification as a case does not mean mandatory investigation

LABS WA DOH PHRED Flu Lab Results WA DOH PHIMS Lab data pre-populates PHIMS record PHRED-to-PHIMS

Next Step: Health Information Exchange Move data from EHR → “cloud” (“hub”)Move data from EHR → “cloud” (“hub”) Data messaging (HL7)Data messaging (HL7) Inland Northwest Health ServicesInland Northwest Health Services 21 hospitals in 14 WA & ID counties21 hospitals in 14 WA & ID counties Inpatient, emergency department, & lab data sinceInpatient, emergency department, & lab data since Massive amounts of data transmitted every 20 minutes (“sipping from a fire hose”)Massive amounts of data transmitted every 20 minutes (“sipping from a fire hose”) UW staff package data; DOH staff link data for useUW staff package data; DOH staff link data for use 2010, greater data utilization2010, greater data utilization Start with influenzaStart with influenza

LABSHIE Data Hub HCV Lab Results WA DOH PHRED WA DOH PHIMS Lab data pre-populates PHIMS record

HIE Use in * Within 2-3 days of occurrence:Within 2-3 days of occurrence: Identified first lab-confirmed flu cases in E WashingtonIdentified first lab-confirmed flu cases in E Washington Cluster primarily comprised of unvaccinated Latinos from an agricultural communityCluster primarily comprised of unvaccinated Latinos from an agricultural community Identified that more than 70% women presenting for delivery in December 2010 not vaccinated against influenzaIdentified that more than 70% women presenting for delivery in December 2010 not vaccinated against influenza Information distributed to local public health and healthcare providersInformation distributed to local public health and healthcare providers * Kathy Lofy, Natasha Close, Tracy Sandifer, & Marisa D’Angeli

Summary : Flu surveillance emphasized centralized ELR system with local distribution of results : Flu surveillance emphasized centralized ELR system with local distribution of results Model emerged in Spring 2009 Influenza PandemicModel emerged in Spring 2009 Influenza Pandemic Applicable to other high volume diseases where traditional surveillance is too resource-intense (e,g., Campylobacter, RSV, pneumococcus, hepatitis C)Applicable to other high volume diseases where traditional surveillance is too resource-intense (e,g., Campylobacter, RSV, pneumococcus, hepatitis C) Next step, more integration of HIE data to identify potential points for intervention in real-timeNext step, more integration of HIE data to identify potential points for intervention in real-time

Thank you!!