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2. Armed Forces Reportable Medical Events Guidelines and Case Definitions: 2017 Updates
Welcome to the October Epi Tech DCS! I am Tori Holbrook, an epidemiologist with the Epidemiology Consult Service at the USAF School of Aerospace Medicine. Today’s presentation is going to focus on updates to the Armed Forces Reportable Medical Events Guidelines and Case Definitions, which were released on 17 July 2017.
Victoria Holbrook Epidemiologist Epidemiology Consult Service USAF School of Aerospace Medicine Distribution D: DoD and Contractors Only

3. Objectives
Describe removals and additions to the 2017 Reportable Medical Events Guidelines
Understand the major changes to existing Reportable Medical Events
Recognize the effect updates to the Guidelines have on daily business processes and how to begin addressing these gaps
The objectives include: (read objectives)
We will talk a little about interpreting case definitions, however the goal of this presentation is to introduce you to the larger changes to the case definitions. At the end of the presentation we will take question, especially as they pertain to the updates and the diseases we talk about.

4. Reporting Requirements
Air Force:
AFI “Surveillance, Prevention, and Control of Diseases and Conditions of Public Health or Military Significance”
Navy:
BUMED INST C “Medical Surveillance and Medical Event Reporting”
NMCPHC-TM-PM “Medical Surveillance and Reporting”
For reference, this slide shows service-specific directive for surveillance and reporting that everyone should be familiar with.

5. Overview Summary: General Guideline Updates
Basic updates/changes to all Reportable Medical Events (RMEs)
More aligned with national reporting guidelines
Language more aligned with what a user would find in AHLTA or CHCS
Consistent, streamlined terminology
Restructured, simpler RME page formats
Added “Travel Risks” to indicate high risk transmission or occurrence settings
Alright, the updated Armed Forces Reportable Medical Events Guidelines and Case Definitions were released on 17 July. Hopefully you’ve brought a copy with you for reference during this DCS. We advise keeping a copy of the Guidelines on your office shared drive and having a printed copy in a three ring binder for quick reference. If you need a copy of the Guidelines or the List of Reportable Medical Events, contact your service hub. For the Air Force, the Guidelines are also available on the Public Health KX.
These are general updates to the guidelines as whole. (Read slide)

6. Overview Summary: General Guideline Updates
Laboratory acronym page included
“Includes”, “Excludes”, “Common Name” statements added to some diseases for guidance and clearer identification
Additional updates include (read).
These two, like many of the other more general updates, are specifically designed to make the Guidelines more user friendly.

7. Overview Summary: RME Format Improvements
2012 Guidelines
Required the user to look in several sections of the document to know if a case met the case definition
2017 Guidelines
Requirements of the case definition are all in one section
On the left of this slide you can see an example of the 2012 guidelines layout. Reading them was tended to be a process and they did not always have consistent layouts. Often the user had to read the case classification then move to the Laboratory Criteria for more information.
In the 2017 update, on the right, we cleaned up the RME format. The Case Classification is straight forward and directly states exactly what is needed to meet a case definition. And as a vocabulary note, I will use case classification and case definition interchangeably.

8. Overview Summary: RME Additions/Removals
Added:
Chikungunya Virus Disease
Novel and Variant Influenza
Post-Exposure Prophylaxis (PEP) against Rabies
Added 01 March 2017
Zika Virus
Will no longer be reported as “Any other unusual condition”
Removed:
Acute Rheumatic Fever
Streptococcus, Group A, Invasive
This slide shows the Additions and Removals to the document. As you can see, we added a few new case definitions. Although many were already reportable, they all have their own case definitions now.
We removed Acute Rheumatic Fever and Streptococcus Group A, invasive, so they no longer have disease screens in DRSi and they are not options on the drop down list.

9. Overview Summary: Disease Updates
Amebiasis – probable case classification added
Arboviral Encephalitis – non-neuroinvasive arboviral disease added; name changed to Arboviral Diseases
Cold Weather Injuries – probable case classification added
Cryptosporidiosis – clinical symptoms are no longer required for reporting
Dengue Virus Infection – suspected case classification removed
Filarial Infections – probable case classification added
Hantavirus Disease – non-pulmonary disease added
Heat Illness – heat injury category removed; probable case classification added for heat stroke
Measles – suspected case classification removed
This slide and the next are a quick summary of big changes to specific Reportable Medical Events, or RMEs. For reference, this information is on page 6 of the 2017 Guidelines. These are pretty straight forward and I will get into the details of some as we move on, but if you have questions about them please keep them for the end of the presentation.

10. Overview Summary: Disease Updates
Pertussis – probable case classification for infants added
Rocky Mountain Spotted Fever – reporting of other rickettsiosis species added; name changed to Spotted Fever Rickettsiosis
Salmonellosis – suspected case classification added
Shigellosis – suspected case classification added
Syphilis – entire disease updated including laboratory criteria
Trichinosis – suspected and probable case classifications added
Tuberculosis – suspected case classification added
Typhus Fever – removed Rickettsia species which are now included in Spotted Fever Rickettsiosis
Varicella – reporting of all beneficiaries added
Continued updates to specific RMEs. Again, this is on page 6 of the 2017 guidelines.

11. Individual RME Updates
The following slides will describe significant changes between the 2012 and 2017 case classifications, however, all RMEs have been updated.
So, although those two slides and this presentation will discuss “significant changes”, those are just a fraction of the RMEs. ALL of the RMEs have been updated. Some may be minimal, but it is important to look up every definition when you find something that may be reportable. Even if you were previously very familiar with the case definition, check and make sure the case you are investigating meets the definition.
We’re going to discuss handful of specific diseases that have big changes, are common for reporting, or are a good reflection of changes to all RMEs.

12. Arboviral disease, neuroinvasive and non-neuroinvasive
2012 Guidelines
Listed as “Encephalitis, Arboviral”
2017 Guidelines
Name changed to above
Includes Non-neuroinvasive disease (Probable and Confirmed case definitions)
If you brought copies of the guidelines, we’ll start on page 14. Old: p28
Arboviral diseases. These include most diseases transmitted by arthropods – ticks, mosquitoes, fleas, etc.
In 2012 arobviruses were listed as “Encephalitis, Arboviral” and were only reportable if they caused encephalitis (or, in other words, was neuroinvasive).
The 2017 guidelines expanded the definition. It is now called “Arboviral diseases, neuroinvasive and non-neuroinvasive”. This was expanded so that now, all cases of arboviral diseases are reportable. For example, under the 2012 guidelines, a person with West Nile would only have been reportable if they had associated encephalitis. Now, all arboviral diseases are reportable regardless of whether or not they cause encephalitis. So any case of West Nile that meets either the probable or confirmed case definition is reportable. DRSi also has a new dropdown question where you can indicate which kind of infection the case has, neuroinvasive, or nonneuroinvasive.
As you can see there is also an “Includes/Excludes” at the top. These lists aren’t exhaustive but are a helpful guide. This definition includes reporting of any arthropod-borne disease (i.e. transmitted by a mosquito, tick, flea, etc.) that does not have it’s own, stand-alone case definition. This is the catch all for other arthropod-borne diseases that aren’t that common or are newly emerging that we may not have specific definitions for yet. So, diseases like Zika, Dengue, lyme disease, Chikungunya, etc are “excluded” from this definition because they have their own case definitions.

13. Campylobacteriosis (Campylobacter species)
2012 Guidelines
Probable case definition requires only clinical compatibility and epi link to a confirmed case
Confirmed case definition only includes a positive EIA or culture
2017 Guidelines
Probable case definition adds positive lab by any method other than culture
Confirmed case definition only includes a positive culture
Next, Campylobacter. In the new guidelines we’re on page 19; Old: p15
In 2012, the guidelines listed Campy as “Campylobacter Infection”
The probable case definition, required only symptoms (i.e. clinical compatibility) and an epidemiological link to a confirmed case
Confirmed case definition required a positive EIA or culture
The 2017 updates changed the name to Campylobacteriosis
The probable case definition keeps the original “epi link”, but adds that any positive lab other than culture (PCR or EIA) is now reportable as well.
The confirmed case definition was then updated to accept only a positive culture.
There was also an addition of Critical Reporting Elements, which include to document the species, travel/deployment history, exposure circumstances, and potential high risk transmission settings (work, school, living quarters).
This update is particularly important because now all positive lab results for campy are reportable. For example, PCR is relatively common but it wasn’t reportable before, so it’s unlikely the lab is currently letting you know about them. And EIA was reportable as confirmed before, but it isn’t now. These kinds of small changes are common throughout the new updates, making it important to reference them for all reporting.

14. Novel and Variant Influenza (Influenza A virus)
2012 Guidelines
Reportable, but no case definition
2017 Guidelines
Newly added case definition
Next, page 59 for Novel and Variant Influenza.
This has always been reportable and had a screen in DRSi, but the previous guidelines did not have a case definition. Now, as you can see, there is a specific case definition. This is helpful, but there is often a lot of confusion about Novel and Variant flu and what exactly that is. There is no “list” of which strains are which because it would be constantly changing, so we definitely suggest visiting the CDCs Influenza page to read about and stay up to date on variant and novel flu viruses.
Seasonal flu differs form these because we have some level of immunity to the strains and we expect infections with them every flu season. They are always circulating in the population and we have vaccines against them. Novel flu viruses are new flus that have never before circulated in humans, so we have no corresponding immunity. For this reason, they are most likely to cause pandemics.
Variant
Influenza (flu) viruses that are known to circulate in pigs are called “swine influenza viruses” when isolated from pigs, but are called “variant viruses” when isolated from humans. Variant viruses are designated with the letter “v” (e.g., influenza A H3N2v). An important note from the CDC is that the term “variant” is not used to describe influenza viruses from animals other than pigs. For example, you may have heard in the news about 20+ cases of the H3N2v recently in Maryland among people who attended a fair and had exposure to swine, contracting the virus. Lab testing is usually able to identify these viruses. H3N2 and H1N1 are seasonal flu, but this mutation in H3N2 changed it enough for it to be a variant virus, transmitted only from pigs.
Novel
A novel influenza (flu) A virus is an influenza A virus that has caused human infection and is different from current seasonal influenza A viruses spreading among people. Novel influenza A viruses can be viruses that: 1. Originate in animals that gain the ability to infect AND spread among humans or 2. Are human viruses that change significantly so as to be different from current human seasonal influenza A viruses. These are the viruses most likely to cause a global pandemic because the human population has little to no immunity to the new form of the virus. When lab testing samples, novel flu is genetically significantly different from “normal” flu strains so your lab, state labs will be unable to subtype the sample. The lab has specific directions to follow in those cases, and it will be a big deal. Its likely the CDC will know about the results before public health.

15. Outbreak or Disease Cluster
2012 Guidelines
Additional Considerations indicate “not all outbreaks will require separate Medical Event Reports (MERs) for each case”
2017 Guidelines
Comments direct reporting of all cases in an outbreak if the etiologic agent is a MER unless otherwise directed
For example, in a Salmonella outbreak all cases should be reported individually if they meet a case definition, plus the outbreak should be reported in the Outbreak Module
Okay. Next up. Outbreak or Disease Cluster. Page 60 in the new guidelines. 53 in the old.
Outbreaks and disease clusters are reportable regardless of whether or not they are in the RME list to the Outbreak Module in DRSi.
Now, in terms of changes, the definitions between the two are pretty much identical and say: “Outbreaks should be reported when an increase in illness leads local public health to a) identify cases, b) seek causes, or c) institute control measures.” The difference is in the comments. The 2017 guidelines were updated to say that if the outbreak is caused by an agent on the RME disease list, then each case of that disease should also be reported individually. So, for example, in a Salmonella outbreak all cases should be reported individually if they meet a case definition, plus the outbreak should be reported in the Outbreak Module. An outbreak of scabies or MRSA would not be reported as individual RME’s since these are not in the Guidelines; however, they should be reported as an outbreak.
This is always true for the Air Force. For Navy attendees, if you have an outbreak of an REM you should ask your NEPMUs if individual disease reports are required.

16. Post-Exposure Prophylaxis (PEP) against Rabies
2012 Guidelines
Not in guidelines
2017 Guidelines
Newly added (1 Mar 2017)
Post-Exposure Prophylaxis against Rabies, page 65. You may already be familiar as PEP was reportable as of 01 March 2017, but it is in general new to the updated Guidelines.
The definition includes an asterisk after “exposure criteria” which directs you to the comments. Quite a few definitions have these, so if you see a super script symbol, follow it to the comments for details.

17. Salmonellosis (Salmonella species)
2012 Guidelines
Includes Probable and Confirmed case classifications
2017 Guidelines
Addition of a Suspect case classification
Next, salmonellosis! Page 72 in the new guidelines, 65 in the old.
In 2012 there were only probable and confirmed case definitions added a suspect classification which allows for the reporting of any positive lab by a method other than culture.
This seems like a small change, but like campylobacteriosis, it adds lab tests that lab personnel may not know to tell you about. Culture is a common lab test for salmonella, but even so you are most likely missing reportable cases from positive PCRs, EIAs, or DFAs.

18. Spotted Fever Rickettsiosis (Rickettsia species)
2012 Guidelines
Listed under “Rocky Mountain Spotted Fever”
Includes only R. rickettsii species
Includes only Probable and Confirmed case classifications
2017 Guidelines
Name changed to above
Includes and lists 7 additional Rickettsia species (which were previously reportable under Typhus Fever)
Includes Suspect, Probable, and Confirmed case classifications
Addition of new laboratory criteria for all case classifications
Moving on.. Spotted Fever Rickettsiosis, page 78 in the new, 63 in the old.
This definition was previously called “Rocky Mountain Spotted Fever,” but it was updated to include a number of other fevers all caused by other viruses in the Rickettsia family.
The Rocky Mountain definition only included the Rickettsia rickettsii species (because that’s the species specific to RMSF), but CDC expanded their definition, so we reflected that change. There are now seven species of Rickettsia that are reportable under this definition. We also added a suspect definition, so make sure to get familiar with the details if you are in a place where these fevers/diseases are endemic.
As a note, this change also affected the Typhus Fever case definition, but both pages specify the species of virus that are reportable under each definition.

19. Tuberculosis (Mycobacterium tuberculosis)
2012 Guidelines
Listed as “Tuberculosis, Pulmonary”
Includes Probable and Confirmed case classifications
2017 Guidelines
Includes Suspected case classification
Consolidates the Probable criteria into the Confirmed case classification
Alright. Next is Tuberculosis or TB. Page 90 in the 2017, and 79 in Latent TB is still NOT reportable. Only active infections are reportable.
In 2012 the definition was called “Tuberculosis, pulmonary” and had only a probable and confirmed case definition. The 2017 updates changed the name to just “Tuberculosis”, added a suspect case definition, and consolidated the probable and confirmed definitions into one confirmed case definition.
The suspect definition does not require any labs; only that the case meets the clinical description and has imaging studies compatible with TB. Under confirmed, the definition has been updated significantly to include more labs and different reporting criteria.

20. Varicella (Varicella-zoster virus)
2012 Guidelines
Includes reporting only Service Member cases
2017 Guidelines
Lists the common name
Includes reporting of Service Members and all beneficiaries
Almost done with diseases. Varicella (chicken pox) is next. Page is page 82.
In 2012, only cases of chicken pox in service members was reportable. The 2017 updates include all service members AND all beneficiaries. Additionally, the Critical Reporting Elements have been expanded to include documenting if the case is often in high transmission settings, like the child care center, hospitals, shipboard, etc.

21. Zika Virus 2017 Guidelines 2012 Guidelines
No longer reportable as “Any other unusual condition”
2012 Guidelines
Not in guidelines; used AFHSB case definition
Last disease. Zika, page 97.
Previously, Zika was reportable under “Any other unusual condition not listed”. But with the release of the 2017 guidelines, Zika has its own case definition and disease page in DRSi for reporting; do NOT report it under “any other unusual” any more.

22. Effects on Daily Business Processes
CHCS ad hocs
Lab personnel
Providers
So, with these changes in mind, how do they affect your daily business processes? The most prominent and pressing change is the expanded case definitions, like Salmonella, campylobacter, varicella, etc. Not only are the ad hocs from CHCS probably pulling 2012 specific labs, but lab personnel and providers may have been familiar with and accustomed to only giving you cases that matched the 2012 guidelines. But now more labs or a larger population are reportable, so it’s likely if your CHCS code has not yet been updated, you may be missing out on events that should be reported under the new definitions.
Now, the DRSi Case Finding Module and background process that feed it have been updated to reflect lab changes in the 2017 guidelines. But remember that the module only spools on 54 of the 68 reportable medical events. It does not catch everything!
Lab
Providers
DRSi Case Finding Module
CHCS reports
Finding RMEs at base level

23. Effects on Daily Business Processes
Laboratory System Support Center (LSSC)
Lt Col Warren G. Conrow: (703)
Comm Disease weekly standup
Prostaff
Lab
So the DRSi case finding module is updated, but what about the other issues? We recommend contacting the Lab System Support Center (LSSC) to update ad hoc reports. They are contracted through the Navy, but support all DoD MTF Laboratory Support needs. Note: Public health should not reach out directly to the LSSC without going through their local laboratory. Requests for LSSC support should be ed to the Clinical Laboratory Medicine Service (CLMS) Office managed by the Defense Health Agency (DHA) for approval. The Air Force LSSC representative is LtCol Warren G Conrow. Questions and eventual requests from the lab for support can be sent to CLMS though him. His contact information is included on the slide.
Additionally, a weekly Comm Disease standup to highlight changes in your most common diseases can help familiarize everyone with the new guidelines. It also ensures use of and engagement with the new guidelines, even for those who may not be responsible for reporting. Attending Pro Staff and, at the minimum, distributing the updated list of Reportable Medical Events to providers, nursing staff, and laboratory personnel can help increase the reporting of cases. That way you are made aware of cases, even if you come to find they do not meet a case definition after further evaluation.
With regard to lab personnel, if you have a representative with you, ask them the best way to inform the rest of the lab about the updates. If none are present, get in touch with your leadership and see what steps they would like to take.

24. Other Notes
Tri-Service Document – Still report Service-specific events (i.e. pediatric lead for AF)
Updates to Critical Reporting Elements and comments
Importance of Event Related Questions
A few final notes about reporting and the updates. This is a tri-service document, so there are still things that are reportable for your specific service which are not included in the guidelines. For example, in the Air Force pediatric lead is reportable per , attachment 2 and has a disease screen in DRSi! HIV is also still reportable, but NOT TO DRSi. Follow your service-specific HIV reporting instructions.
We also added updates to many of the Critical Reporting Elements and Comments, so as you use the new guidelines be sure to read those and answer the corresponding questions in DRSi with all the pertinent/available information. Those two sections and the questions in DRSi are included because they either give you, the users, important information or they provide necessary context for your service hub. Events like PEP, Zika, Hep A, and Lyme have comments that define exposure or include help with interpreting the case definition.

25. Service Specific Contact Information
Air Force: Contact your MAJCOM PH or USAFSAM/PHR
USAFSAM / PHR / Epidemiology Consult Service
Wright-Patterson AFB, Ohio
COMM: (937)   DSN: 
Navy: NMCPHC Preventive Medicine Programs and Policy Support Department
COMM: (757) ; DSN: (312)
Contact your cognizant NEPMU
NEPMU2: COMM: (757) ; DSN: (312)
usn.hampton-roads.navhospporsva.list.nepmu2norfolk-
NEPMU5: COMM: (619) ; DSN (312)
NEPMU6: COMM: (808) ; DSN: (315)
NEPMU7: COMM (int): (local): ; DSN:
Below is service-specific contact information. As a note, this powerpoint will be available, but you can download it now at the bottom of the presentation screen.
Thank you all for attending this training. At this time we will take questions over the phone or via chat box on the DCS!