Infectious Disease Outbreaks and Emerging Infectious Disease Tracking

Infectious Disease Outbreaks and Emerging Infectious Disease Tracking
Esther M. Ellis, PhD Territorial Epidemiologist USVI Department of Health

Contact Dr. Esther M. Ellis
(340) ext.3241

What is Public Health Surveillance?
Ongoing, systematic collections, analysis, and interpretation of health-related data and dissemination for use in the planning, implementation, and evaluation of public health practice

National Notifiable Disease Surveillance
Regular, frequent, timely information to prevent and control disease Reporting mandated by state law/regulation in conjunction with CDC Health care providers and laboratories report to local county health department (HD) County HD submits reports to State Reports transmitted to CDC through National Electronic Disease Surveillance System (NEDSS)

Why do Surveillance? Collect data to better understand the extent of health risk behaviors, preventive care practices and the burden of chronic diseases Monitor the progress of prevention efforts Help public health professionals and policymakers make more timely and effective decisions

Uses of Public Health Surveillance
Estimate magnitude of the problem Portray the natural history of a disease Determine distribution and spread of illness Detect outbreaks Generate hypotheses, stimulate research Evaluate control and prevention measures Monitor changes in infectious agents Detect changes in health practices Facilitate planning

Causal Pathway of Disease or Disability
Environment (pre-exposure) Hazard/agent Behavior risk factor Exposure Pre-symptomatic phase Apparent disease Death

Selected Sources of Data
Environment monitoring systems Animals/vectors Individuals Laboratories Medical records Administrative records Police records Birth/death certificates

Data Sources and Methods for Surveillance
Notifiable diseases Laboratory specimens Vital records Sentinel surveillance Registries Surveys Administrative data systems Other data sources Vital records – National infant mortality surveillance, vital records can be linked to birth records Sentinel – Monitoring of key health events through sentinel sites, events, providers vectors or animals Surveys – populations-based surveys such as the National health Interview Survey or provider-based surveys such as a hospital discharge survey Other data sources – Vaccine adverse event reporting system, the CDC drug service or others

Arboviral diseases, neuroinvasive and non-neuroinvasive:
CONDITION_NAME Anthrax Arboviral diseases, neuroinvasive and non-neuroinvasive: California serogroup virus disease, neuroinvasive California serogroup virus disease, non-neuroinvasive Chikungunya neuroinvasive disease Chikungunya non-neuroinvasive disease Eastern equine encephalitis virus disease, neuroinvasive Eastern equine encephalitis virus disease, non-neuroinvasive Powassan virus disease, neuroinvasive Powassan virus disease, non-neuroinvasive St. Louis encephalitis virus disease, neuroinvasive St. Louis encephalitis virus disease, non-neuroinvasive West Nile virus disease, neuroinvasive West Nile virus disease, non-neuroinvasive Western equine encephalitis virus disease, neuroinvasive Western equine encephalitis virus disease, non-neuroinvasive Babesiosis Botulism: foodborne infant other (wound and unspecified) Brucellosis Campylobacteriosis Chancroid Chlamydia trachomatis infection Cholera Coccidioidomycosis Cryptosporidiosis Cyclosporiasis Dengue: Dengue Dengue-like illness Dengue, severe Rubella Rubella, congenital syndrome Salmonellosis Severe Acute Respiratory Syndrome-associated Coronavirus (SARS-CoV) disease Shiga toxin-producing Escherichia coli Shigellosis Smallpox Spotted Fever Rickettsiosis Streptococcal toxic-shock syndrome Syphilis: primary secondary early latent late latent latent unknown duration Neurosyphilis late, non-neurological congenital Tetanus Toxic shock syndrome (other than Streptococcal) Trichinellosis Tuberculosis Tularemia Typhoid fever Vancomycin - intermediate Staphylococcus aureus (VISA) Vancomycin-resistant Staphylococcus aureus (VRSA) Varicella (morbidity) Varicella deaths Vibriosis Viral Hemorrhagic Fevers: Ebola hemorrhagic fever Marbug fever Crimean-congo hemorrhagic fever Lassa fever Junin (Argentine) hemorrhagic fever Machupo (Bolivian) hemorrhagic fever Sabia-associated (Braziliam) hemorrhagic fever Lujo Virus (organism) Guanarito hemorrhagic fever Yellow fever Diphtheria Ehrlichiosis/Anaplasmosis: Ehrichia chaffeensis Ehrlichia ewingii Anaplasma phagocytophilum Undetermined Giardiasis Gonorrhea Haemophilus influenzae, invasive disease Hansen disease (leprosy) Hantavirus infections: Hantavirus infection (non-HPS) Hantavirus pulmonary syndrome (HPS) Hemolytic uremic syndrome, post-diarrheal Hepatitis: Hepatitis A, acute Hepatitis B, acute Hepatitis B, chronic Hepatitis B, perinatal infection Hepatitis C, acute Hepatitis C, past or present Influenza-associated pediatric mortality Invasive Pneumococcal Disease Legionellosis Leptospirosis Listeriosis Lyme disease Malaria Measles Meningococcal disease Mumps Novel influenza A virus infections Pertussis Plague Poliomyelitis, paralytic Poliovirus infection, nonparalytic Psittacosis Q fever: Acute Chronic Rabies: Rabies, animal Rabies, human

Reportable Diseases National Electronic Disease Surveillance System (NEDSS) Efficient, interoperable, and integrated surveillance system that facilitates the electronic transfer of appropriate information from clinical information systems in the Healthcare industry to public health departments A set of criteria developed by CDC that all public health surveillance systems must meet Used to manage reportable disease surveillance data Supported by CDC funds December 18, 2014 USVI went live with NEDSS This system now allows us to conduct more accurate surveillance and analysis of notifiable diseases for our territory

National Notifiable Disease Surveillance: Your Role as a PA
Report and participate: Call the local health department Call the Department of Business and Professional Regulation Call the CDC Citizens: unfortunate experience at a restaurant

Failure to report is a 2nd degree misdemeanor with a $500
Failure to report is a 2nd degree misdemeanor with a $ fine for each offense Source:

Types of Surveillance in USVI
Reportable diseases Vital Statistics Survey Data BRFSS National Registries cancer registry Others Performance Management and Quality Improvement (PMQI), chart reviews, insurance data By improving both performance and quality, public health systems save lives, cut costs and get better results.

BRFSS The Behavioral Risk Factor Surveillance System (BRFSS) is the world’s largest, on-going telephone health survey system. Random digit telephone surveys on non-institutionalized adults’ health behavior and use of prevention services Height, weight, physical activity, smoking, alcohol use, seatbelt use, cholesterol screening, mammography, etc. Done in most states and territories CDC program

BRFSS Underlying risk factors Cardiovascular Questions
Have you ever been told by a doctor, nurse, or health professional that you have high blood pressure? Had cholesterol checked and told high by doctor, nurse, or other health professional? Has a doctor, nurse, or other health professional ever told you that you had any of the following? A heart attack, also called a myocardial infarction? Has a doctor, nurse or other health professional ever told you that you had any of the following…Angina or coronary heart disease Underlying risk factors Physical activities, nutrition, smoking, diabetes, etc.

Steps of an Outbreak Investigation
Develop hypotheses Evaluate hypotheses Refine hypotheses and carry out additional studies Implement control and prevention measures Communicate findings Establish the existence of an outbreak or new disease Verify the diagnosis Define and identify cases Describe and orient the data: time, place, and person

Outbreak vs Epidemic vs Pandemic
Used interchangeably in literature Outbreak: local increased incidence Epidemic: more widespread in geography and/ or population Naming incites a serious public response Pandemic: world wide

Develop hypotheses Evaluate hypotheses Refine hypotheses and carry out additional studies Implement control and prevention measures Communicate findings Establish the existence of an outbreak or new disease Verify the diagnosis Define and identify cases Describe and orient the data in terms of time, place, and person

Establish The Existence Of An Outbreak Or New Disease: Illness In West Africa
Flu like illness Presence of hemorrhagic symptoms Deaths Is this an “outbreak” or something new?

Establish The Existence Of A New Disease
CDC: Advanced Molecular Detection (AMD) Complete, whole genome sequencing Cheaper sequencing and more accurate than PCR and pulse gel electrophoresis Bioinformatics Biology, computers and information technology Computer analysis of genetic makeup

Risk of Emerging Disease
Highly resistant pathogens in health-care settings Multi drug resistant (MDR) Salmonella MDR and Extensive Drug Resistance (XDR) TB MDR Pseudomonas MRSA Clostridium difficile Drug resistant N. gonorrhea Carbapenem resistant enterobacteria (CRE) E. coli Kleibsiella One in 20 hospitalized patients in the United States is infected during their health care. Killer microbes that jump from animals to humans New deadly pathogens Viruses that have not previously occurred here, brought in by travelers (Chikungunya, Zika)

Establish the Outbreak
Are there more cases than would be expected? What is the incidence: in the area at this time in this season with these people With these animals/ insects/ vectors

Outbreak Decision: Consult Data Sources and Methods for Surveillance
Notifiable diseases: CDC, County Health Department Laboratory specimens Vital records Sentinel surveillance (death) Registries Surveys Administrative data systems Vaccine Adverse Event Reporting System Other data sources

2014 Ebola Outbreak Response West Africa
Centers for Disease Control and Prevention Office of Public Health Preparedness and Response

2014/2015 Ebola Outbreak This is the largest Ebola outbreak in history and the first Ebola epidemic the world has ever known CDC’s response to Ebola is the largest international outbreak response in CDC’s history

2014/2015 Ebola Outbreak Ebola Cases and Deaths
As of July 5, a total of 27,573 cases of Ebola and 11,246 deaths have been reported in 3 countries Guinea reported 3,748 cases, including 2,499 deaths Liberia reported 10,670 cases, including 4,807 deaths Sierra Leone reported 13,155 cases, including 3,940 deaths Travel-associated Cases or previously affected countries Nigeria reported 20 cases, including 8 deaths Italy reported 1 case, including 0 deaths Senegal reported 1 case, including 0 deaths Spain reported 1 case, including 0 deaths United States reported 4 cases, including 1 deaths Mali reported 8 cases, including 6 deaths United Kingdom reported 1 cases, including 0 deaths

Monitoring and Movement of People with Ebola
2014/2015 Ebola Outbreak Monitoring and Movement of People with Ebola CDC has created guidance for monitoring people exposed to Ebola and for evaluating their travel, including the application of movement restrictions when indicated Conditional release—people are monitored by a public health authority for 21 days after the last known Ebola virus exposure. People conditionally released should self-monitor for fever twice daily and notify the public health authority if they develop fever or other symptoms. Controlled movement—requires people to notify the public health authority about their intended travel for 21 days after their last known potential Ebola virus exposure. They should not travel on commercial flights, ships, long-distance buses, or trains.

Risk of Outbreaks: Food Borne Illnesses
One in 6 Americans; 48 million people sick from contaminated food yearly Cost: $77 billion per year in health care treatment, workplace, and other economic losses. Over one half billion pounds of contaminated food. 2009 outbreak salmonella linked to peanut butter across states 2011 multistate outbreak of Listeriosis linked to whole cantaloupes from Colorado

Outbreaks: Passive vs. Active Surveillance
Passive: follow clinically affected cases - Provider initiated Active: follow subclinical cases Health Department initiated CDC WHO Hospitals “Heath Fairs”

Causes of Perceived Outbreaks
Increased population in area New personnel New lab tests New reporting criteria/ case definition

Develop hypotheses Evaluate hypotheses Refine hypotheses and carry out additional studies Implement control and prevention measures Communicate findings Establish the existence of an outbreak Verify the diagnosis Define and identify cases Describe and orient the data in terms of time, place, and person

Define and Identify Cases: Case Definitions
Non infectious Cancer and toxins in water Infectious Confirmed: lab verification PulseNet (gel electrophoresis DNA “fingerprint”) Culture, PCR, IFA, IgM, IgG Suspected: typical presentation without lab confirmation Possible: fewer symptoms than typical case “Get It While You Can.”

Pulse Net

School Outbreak of Meningococcal Infection: Suspected Cases
At approximately 4:00 p.m., health department was notified that student D had died and two additional lower elementary students had been hospitalized with fever and rash (students E and F). Although these two illnesses were eventually found not to be cases of N. meningitidis infection on the basis of laboratory and clinical findings, that evidence did not become available until the following week.

Develop hypotheses Evaluate hypotheses Refine hypotheses and carry out additional studies Implement control and prevention measures Communicate findings Prepare for field work Establish the existence of an outbreak Verify the diagnosis Define and identify cases Describe and orient the data in terms of time, place, and person

Detailed Patient Data About Outbreak Documented
ID: Name, address, number Demographic: age, sex, race, occupation Clinical: hospitalization, death Risk information: exposures, contacts, etc

Detailed Patient Data About Outbreak Documented: Spatial
Geographic location Example: Marburg virus

Detailed Patient Data About Outbreak Documented Temporal (time)
Point Source Exposure to a toxin/ bacteria in individuals in the group Food poisoning at a picnic Propagated One or more cases spread to others Measles outbreaks in different areas Sporadic: no known pattern of increase

Detailed Patient Data About Outbreak Documented: Ebola
All patients had a history attending a burial in the previous few days before onset of fever. Some had lost one or more family members with similar symptoms recently

Several people were taken ill at a picnic
Several people were taken ill at a picnic. Salmonella was found in undercooked chicken these people ate. This is an example of: Point source outbreak Sporadic outbreak Propagated outbreak

Develop Hypotheses: Why did this occur now?
Familiarity with the disease process, mode of transmission, incubation, etc Ebola virus: Reason for outbreak occurrence unknown Spread through contact Instituting Viral Hemorrhagic Fever Isolation Precautions decreases incidence

Develop Hypothesis: Why Did This Happen Now?
Decrease in vaccinations Meningococcal outbreaks Improper food handling Salmonella outbreaks Animal contact Avian influenza Marburg virus MDR Overuse of antibiotics

Evaluate Hypotheses Compare facts with hypothesis Cohort
All these cases ate the same food/ at the same place All these cases had contact with others who had the same illness Cohort Study all people in a group Case controlled Compare risk exposed vs control group

Control and Prevention
Vaccine Chemoprophylaxis Isolation Antibiotics Hand washing Food handling Mosquito breeding prevention Insect repellent

Ebola Virus: Viral Hemorrhagic Fever Isolation Precautions
Wearing of protective clothing: masks, gloves, gowns, and goggles Infection-control measures: complete equipment sterilization and routine use of disinfectant Isolation of Ebola HF patients from contact with unprotected persons.

Communicate Findings Analysis and distribution of public health data via publications, presentation and reports MMWR (Morbidity and Mortality Weekly Report) NEWS/ media/ internet

Information Loop of Public Health Surveillance
Summaries, Interpretations, Recommendations Reports Health Agencies Health Care Providers Public Analysis

The list of diseases that by law must be reported to the local health department is typically compiled by the Local health Department State Health Department CDC Council of State Territorial Epidemiologists Medical Licensing Boards

Outbreak Investigation Example

911 Call Center At 01:17 hours, the 911 Call Center received a call from a visiting female for two (2) males having seizures. They ate fish tacos and vanilla ice cream. This is the first time they have experienced this. The caller also stated she has been vomiting since they came home.

2 Patients Case I: a 17 year old male Case II: a 14 year old male
Pt. lying in bed actively seizing. Vomit present on bed linens. Case II: a 14 year old male Pt. found in the same bed room lying on a comforter on the floor next to the closet actively seizing. Vomit present.

Assessment Both Patients were unresponsive
Parents stated that both brothers vomited as well as the mother. Also, that they had been at a dinner party earlier in the evening Everyone was fine at that time and no one had been sick earlier in the day. No medical history or medication

Case 3: The Dad The father left SRMC and went back to the villa on St. John. Police found him and requested EMS

Case 3: The Dad When EMS arrived Pt. A&Ox4. GCS 15.
Pt. was in the bathroom. Pt. came out sat on the couch. Saline lock in the right AC w/ an 18 g angio Pt. A&Ox4. GCS 15. Pt. stated that he feels weak and is having difficulty speaking and tremors. Pt. stated that this is abnormal for him. Pt. denied difficulty breathing, headache, vision disturbances, nausea/vomiting abdominal pain or chest pain. Also denied dizziness. Neurological Present: Abnormal Gait, Speech Slurring, Tremors

Dinner Party the Night Prior
Adult Menu Ahi tuna, sprouts, Grouper, ribbons?, almonds, thai basil Mahi Mahi, fresh conch fritters, honey crème brulee Kid’s Menu Fresh Mahi Mahi tacos w/ cabbage, flour tortillas, salsa, flank steak, blue bunny ice cream, whip cream. Catered by Ms. Julie. Number given to detectives along with list of people who attended the dinner party, 11 total. Detective Browne

Further Hx Family was on vacation staying at Sirenusa condos on St. John. They had been on island approximately five days. Cases 1, 2, and 3 went fishing prior to dinner party. Case 4 did not go. They caught Barracuda but did not eat any. 7 pm went to Moran’s condo for dinner party. Left party and returned to Sirenusa condo b/c Theresa was feeling nauseated with stomach 10pm. She also experienced mild diarrhea and emesis x1.

Tried to pinpoint the timeline from sick to seizure
Tried to pinpoint the timeline from sick to seizure. Each child presented differently. Case 1, the oldest boy’s, symptoms began with diaphoresis, nausea, muscle weakness, then seizure. Case 2, the younger son, symptoms began with headache and difficulty controlling his head and then he seized. Case 3 symptoms began with diminished fine independent finger movement in his right hand. Case 4 symptoms began with nausea, vomiting and diarrhea.

Additional History Mom denies history of topical bug spray such as DEET or Lindaine. She denies any mushroom or wild berry ingestion. She denies plant contact. Mom states that on the 18th she and her husband woke early and went on a hike while the boys remained in bed. Mom makes mention of slight nausea with the fan on in the condo, but denies significant odor or taste. Mom states that the tap water had a slight chlorine smell to it and that the family had ingested tap water from the faucet.

Initial Assessment Neurotoxin most likely a pesticide (organophosphate vs. metal vs. halide toxicity) Some other agent If ciguatera  more lethal strain not commonly seen in the ER.

Working the Case Pathways Environmental Food Ingestion Infectious ?
Chemical Pesticide Organophosphate Methyl Bromide Topical DEET Lindaine Cistern Cleaning, agent solvent Food Ingestion Fish Mushrooms Canned Food Ciguatera Water Nefarious Intentional poisoning Drugs of abuse Infectious ?

Methyl Bromide Background
Methyl Bromide was first reported to be effective as a pesticide in 1932 and registered for use in the US in 1961 Primarily used in agricultural settings for soil fumigation and in greenhouses, warehouses, and ships % phase out of methyl bromide because of its ozone-depleting properties there were 115 fatalities and 843 nonfatal cases of methyl bromide toxicity Symptoms generally appear within 48 hours of exposure Mild symptoms – headache, generalized malaise, weakness, nausea Severe symptoms – tremors, myoclonus, altered mental status, seizures, respiratory symptoms, renal failure Press release:

Objectives of Epidemiological Investigation
Environmental samples already collected by the US Environmental Protection Agency will be analyzed A survey will be done to gather additional information. During the Epi-Aid investigation, ATSDR, ACE staff and the US VI Department of Health will Identify persons who might have been exposed to the methyl bromide including: Residents Visitors and employees of condominium complex Other locations where this chemical was released Pesticide company employees Emergency responders. Interview these persons to determine exposure, acute health effects, and medical care received. Provide information about methyl bromide to those who were potentially exposed

Methyl Bromide Epidemiology
USVI DOH in collaboration with ASTDR launched an investigation Methyl Bromide had been used by the same pest control company at the same resort in October 2014. 37 additional persons identified with potential exposure to methyl Bromide during October –November 2014 and March 2015. Contact information available for 20 persons 16 persons interviewed with a standardized health questionnaire 6/16 (38%) reported post-exposure symptoms of some kind, including headache and fatigue Press release:

Methyl Bromide Epidemiology
Investigation Results No persons exposed during October-November 2014 had any adverse health effects following their potential exposure 6/9 (67%) persons exposed and interviewed during March 2015 had post-exposure symptoms Of those with symptoms: Median age 49 All had headache 4/6 (67%) had fatigue One had shortness of breath One had cough 4/6 (67%) symptoms resolved within 3 weeks 2/6 (33%) had persistent mild headache 1/6 (17%) had persistent mild cough

Methyl Bromide Discussion
Toxicity is rare (most recent case report published in 2008) Investigation highlights potential clinical and public health consequences of use of methyl bromide in a residential setting None of the persons exposed during October-November 2014 had post-exposure symptoms Exposures in October occurred after hours of ventilation Exposures in March no ventilation Prompt identification of exposure, as occurred in this situation, can prevent further exposure and subsequent illness. Difficult to correlate bromide levels in patients with clinical symptoms, as most clinical samples were obtained after initiation of hemodialysis. Providing intravenous fluids and balancing electrolytes (body salts) Maintaining oxygen status and blood pressure Treating other infections if they occur

Methyl Bromide Release at a Condominium Resort —
MMWR publication Methyl Bromide Release at a Condominium Resort — U.S. Virgin Islands, March 2015 Prathit A. Kulkarni, MD1, Mary Anne Duncan, DVM2, Michelle T. Watters, MD, PhD3, Leah T. Graziano3, Elena Vaouli, MPH3, Larry F. Cseh, MS2, John F. Risher, PhD2, Maureen F. Orr, MS2, Tai C. Hunte- Ceasar, MD4, Esther M. Ellis, PhD4

Conclusion Surveillance provides information on the health of the community Public health relies on information from medical care providers and takes prevention-oriented actions based on information received Surveillance involves taking information in, analyzing and interpreting it, and disseminating it to those who need it

Questions?

Infectious Disease Outbreaks and Emerging Infectious Disease Tracking

Similar presentations

Presentation on theme: "Infectious Disease Outbreaks and Emerging Infectious Disease Tracking"— Presentation transcript:

Similar presentations

About project

Feedback

Log in

Auth with social network:

Infectious Disease Outbreaks and Emerging Infectious Disease Tracking

Similar presentations

Presentation on theme: "Infectious Disease Outbreaks and Emerging Infectious Disease Tracking"— Presentation transcript:

Similar presentations

About project

Feedback