1. Madhura Sundararajan, MPH
Reporting diseases that rely on a clinical diagnosis: A look at Hemolytic Uremic Syndrome (HUS)
Madhura Sundararajan, MPH

2. The Effect of Misreporting
Three cases from three nearby counties. All tested positive for both Campylobacter antigen and Shiga toxin.
August 4-5
Two specimens sent to ISDH Lab both tested positive for Shiga toxin producing E. coli O157:H7 and negative for Campylobacter
August 8
Investigations revealed that 2 cases from two separate counties attended same day care
Back in 2015 we observed through routine surveillance 3 cases [ADVANCE SLIDE] from 3 nearby counties tested positive for both campylobacter antigen and shiga toxin type 2 [ADVANCE SLIDE]
We started to investigate these as though they were co-infections
Was there a common source?
Could it be a lab testing error?
[ADVANCE SLIDE]
The specimens were sent to our state lab for confirmation and 2 of the 3 specimens ended up tested positive for E. coli O157:H7 and were negative for campylobacter.
After we reviewed the case investigation we found that the Fulton and Wabash county cases attended the same day care.
SO Now that we had an epidemiological link between the two cases, we deemed it an outbreak and responded accordingly. We contacted the ill individuals to document an exposure history and we implemented control measures at the school
Control measures implemented at day care

3. A B Local hospital suspected HUS and transferred patient Hospital A
August 10: ISDH learned from social media post that two cases were hospitalized for HUS Situation escalated and community members picketed the health department
Because we were doing this, community members in county A became aware of our outbreak investigation, and suddenly we were getting some heat because a family of a child that had passed away recently from HUS was never contacted about the case.
We had never heard about this case.
On August 10th, 2015, ISDH learned from a social media post (and not through hospital reporting mechanisms) that two cases were hospitalized for hemolytic uremic syndrome (HUS) and one case later died.
Members of the community began picketing outside the doors of the local health department. Protests at the health department became so bad that the public health nurse did not feel comfortable coming in to work.
SO this is what happened:
[ADVANCE SLIDE]
Hospital A suspected HUS and [ADVANCE SLIDE] transferred patient to Hospital B
Patient was treated and passed away at Hospital B
Somewhere along the line the health department was never notified.
Hospital A expected Hospital B to report
Hospital B expected Hospital A to report
Whether suspect or confirmed it’s everyone’s job to report
Here are some things to note:
We absolutely understand the magnitude and importance of your job. The hospital’s number one focus is, and should be, taking care of sick people. You should also know that most of these reportables have lab results and technology is our friend here and these labs (like salmonella, etc.) are automatically sent to us and you don’t have to do anything. IT’s when we have these tricky cases that are dependent upon a CLINICAL diagnosis (such as HUS or meningitis) and/or are IMMEDIATELY NOTIFIABLE that we run into some trouble. I’ve had so many doctors come to me and say “you know, that’s really the last thing we’re thinking about. Reporting it to public health”. And that makes COMPLETE sense to me. But we want to give this presentation and provide you with this information so you can see that reporting does have an impact. And we can make sure you have fewer patients to treat!
Ultimately in this scenario:
We were never able to determine if the fatal case was related to the other two cases of STEC through lab testing because we didn’t get a specimen
If we don't have all the information we need it makes it so much harder to find out why people are getting sick and stop it from happening again.
Patient was treated at Hospital B, but died B

4. Background: Shiga-toxin producing E. coli (STEC)
Most E. coli are harmless, important for healthy human intestinal tract
Pathogenic E. coli  diverse group of bacteria, cause illness
Shiga toxin-producing E. coli (STEC)
most commonly mentioned in the news associated with foodborne outbreaks
most common cause of post- diarrheal HUS in children
HUS is a condition that results from the destruction of red blood cells which inhibits the kidneys’ ability to filter waste.
Pathogenic e. coli: can cause either diarrheal illness or illness outside of the intestinal tract
Diarrheagenic E. coli: 6 pathotypes associated with diarrhea
-HUS Occurs in both children and adults
-About 15% of young children and a much smaller proportion of adults with STEC:O157 diarrhea develop D+HUS.
Photo/Figure taken from CDC Image Library

5. Shiga-toxin producing E. coli (STEC)
O157 STEC
STEC O157:H7
Non-O157 STEC
Includes O26, O103, O111, O121, O45, O145 among others

6. Hemolytic Uremic Syndrome (HUS)
Thrombotic microangiopathy: formation of a blood clot in capillaries and arterioles
Hemolytic anemia:  destruction of red blood cells
Thrombocytopenia: deficiency of platelets causing bleeding, bruising, and slow blood clotting after injury
Acute renal dysfunction: kidneys suddenly become unable to filter waste products from blood
When the kidneys and glomeruli become clogged with the damaged red blood cells, they are unable to do their jobs.
If the kidneys stop functioning, a child can develop acute kidney injury—the sudden and temporary loss of kidney function. Hemolytic uremic syndrome is the most common cause of acute kidney injury in children
Photo/Figure courtesy of Madhura Sundararajan
*Diarrhea may range from mild and non-bloody to stools that are virtually all blood

7. Epidemiology Resource Center (ERC)
Conduct surveillance to monitor disease trends
Investigate communicable disease
Maintain Communicable Disease Reporting Rule (410 IAC 1-2.5)
List of diseases available at:
We maintain the Communicable Disease Reporting Rule which outlines the reporting requirements for physicians, hospitals, and laboratories, along with disease specific requirements for exclusion of ill individuals
The list of diseases reportable, by law, to the health department include immediately reportable, and others that must be reported within 24 or 72 hours can be found at the link provided here

8. Transmission and Contributing Factors
Fecal-oral
Foodborne (undercooked meats, raw produce)
Direct person-to-person can occur in families, child care centers, and custodial institutions
Waterborne from contaminated drinking water and recreational waters
Consumption of undercooked meats, cross-contamination
Consumption of raw or unpasteurized products
Contact with animals
Contact with those infected

9. When to Consider HUS Evidence of anemia following a diarrheal illness
Evidence of renal injury following a diarrheal illness
Evidence of low platelet count following diarrheal illness
Nephrology consultation
High-risk age range (younger children)
Dehydration
Severe GI illness requiring hospitalization or transfer
Any of the above in conjunction with STEC O157 or non-O157 positive lab result

10. Contacts for Infectious Diseases
ISDH Epidemiology Resource Center:
ISDH After Hours Line:
CDC/EOC Physician Line:
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