1. Continuing Medical Education Course Handout
FY18 Epi-Tech Surveillance Training

2. Continuing Medical Education Course Handout

3. Continuing Medical Education Course Handout

4. ANNOUNCEMENT
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5. Managing Misreporting: Common Mistakes and Misreported RMEs
Victoria Holbrook, MPH
Epidemiologist
Epidemiology Consult Service (USAFSAM/PHR)

6. Learning Objectives
Prevent misreporting by understanding what misreporting is and why accuracy in reporting is critical
Recognize common mistakes and misreported Reportable Medical Events (RMEs) to improve reporting
Understand the interpretation of case classifications and their associated labs to increase accuracy of reporting

7. Case Definitions Misreporting
Part 1: Reporting
Requirements
Case Definitions Misreporting

8. 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”
Army:
Army Regulations 40-5 "Medical Services Preventive Medicine“
Department of the Army Pamphlet "Medical Services Preventive Medicine"

9. 2017 Guidelines

10. Although slightly different, they are typically used interchangeably!
Case Definitions
Case Definition vs Case Classification?
Case Definition: the specific clinical, laboratory, and other objective criteria that define who is included as a case in the surveillance of public health conditions (i.e. RMEs)
E.g. the Mumps case definition
Case Classification: subcategories of a case definition – typically suspected, probable, and confirmed; specifies what is needed to meet the case definition of an RME
E.g. the Mumps confirmed case classification
Although slightly different, they are
typically used interchangeably!

11. Case Classifications

12. Case Classification Example
Meningococcal Disease

13. Case Classification Example
Campylobacteriosis
Chlamydia

14. Misreporting The inaccurate reporting of an RME
Can include:
Reporting an RME under an incorrect case classification
Reporting an event that does not meet any case classification
Filling out a medical event report incorrectly
Why does accuracy matter?

15. Part 2: In-Depth Case Definition Interpretation
Hepatitis A
Campylobacter
Influenza-Associated Hospitalization
Hepatitis B
Lyme Disease

16. Reading a Case Definition
Look at requirements:
Symptoms
Laboratory requirements
Lab method
Sample type
Result interpretation
Exposure history
Epidemiologically linked (i.e. sick contacts)
Travel history
Endemicity of disease

17. Hepatitis A Page 42 ONE case classification When reporting check:
Critical Reporting Elements
Comments for clarification

18. Hepatitis A What is important to notice?
Requires symptoms
Has an “or” (i.e. two ways to meet the case definition)
Specific laboratory result from a specific sample type
This case definition requires two things: 1) symptoms and 2) meeting one of the bullets

19. Hepatitis A Case must meet the clinical description
Description has an and, or requirement

20. Is this case reportable?
The following lab shows up on your spool
A look at their encounters shows that the patient presented with diarrhea and jaundice

21. Is this case reportable?
The following lab shows up on your spool
A look at their encounters shows that the patient presented with diarrhea and jaundice
Yes, as a Confirmed case
They exhibited the necessary symptoms (diarrhea plus jaundice) and a positive Hepatitis A IgM antibody (ab).

22. Is this case reportable?
Same scenario, but what if these were your lab results instead?
and the result is positive.. Is this reportable? (next slide.)

23. Is this case reportable?
Same scenario, but what if these were your lab results instead?
NO. Why?
Because this lab is a hepatitis A virus TOTAL ab test. The case definition requires a positive IgM Ab.
In this case you cannot determine if the IgM or the IgG ab is positive. Additional testing would need to be done.

24. Campylobacter Page 19 TWO case classifications When reporting check:
Critical Reporting Elements

25. Campylobacter What is important to notice?
Lab results do NOT require symptoms
Has an or
This case definition requires only one thing: 1) meeting one of the bullets

26. Is this case reportable?
The lab alerts you to the following result:

27. Is this case reportable?
The lab alerts you to the following result:
Yes, as a Probable case
The rapid Campylobacter test is positive. Rapid tests are typically EIAs. This rapid test was performed as part of the culture panel. The result is NOT culture positive for Campylobacter.

28. Influenza-Associated Hospitalization
Page 46
ONE case classification
When reporting check:
Critical Reporting Elements
Comments for clarification

29. Influenza-Associated Hospitalization
What is important to notice?
Requires symptoms
Has two and’s and one or
This case definition requires two things: 1) symptoms and 2) meeting three of the bullets

30. Is this case reportable?
On your ad hoc report you find the following result:
Additional research tells you that the patient is 35, has flu-like symptoms, and was admitted to the hospital on 27 Jan 2018

31. Is this case reportable?
On your ad hoc report you find the following result:
Additional research tells you that the patient is 35, has flu-like symptoms, and was admitted to the hospital on 29 Jan 2018
Yes, as a Confirmed case
The patient displayed symptoms, is younger than 65, had a positive flu test, and was admitted to the hospital less than 14 days after the positive test.

32. Is this case reportable?
On your ad hoc report you find the following result:
Additional research tells you that the patient is 63, has flu-like symptoms, and was seen in the ER

33. Is this case reportable?
On your ad hoc report you find the following result:
Additional research tells you that the patient is 63, has flu-like symptoms, and was seen in the ER
NO. Why?
Although they meet most criteria, they were seen in the ER but not admitted to an inpatient ward of the hospital.

34. Hepatitis B Page 43 ONE case classification When reporting check:
Two options: Acute & Chronic
When reporting check:
Critical Reporting Elements
Comments for clarification

35. Hepatitis B

36. Hepatitis B What is important?
For this example we’re going to look only at Chronic Hep B.
What is important?
The CHRONIC case case definition requires one thing: 1) meeting one of the bullets
Does NOT require symptoms
Has one and, multiple or’s

37. Is this case reportable?
You come across this Hep B panel:

38. Is this case reportable?
You come across this Hep B panel:
Yes, as a Confirmed case
The results have a negative core IgM (HBc-IgM) ab AND a positive surface antigen (HBsAG)

39. Is this case reportable?
What about this Hepatitis A+B+C Virus panel?:

40. Is this case reportable?
What about this Hepatitis A+B+C Virus panel?:
NO. Why?
The surface antigen (HBsAg) is negative, and there are no Hep B e antigen or PCR results.

41. Lyme disease Page 52 & 53 THREE case classifications
When reporting check:
Critical Reporting Elements
Comments for clarification

42. Lyme disease What is important to notice?
Does NOT require symptoms
Requires “provider diagnosis”
Includes superscripts that refer to the comments
Has one and, many or’s
This case classification requires two things: 1) provider diagnosis and 2) meeting one of the bullets
Two things I want to talk about before we get to an example – “two tiered testing” and the superscripts

43. Two-Tiered Testing

44. Lyme disease Superscripts referring to the comments
Explains laboratory details, interpretation; clarifies case definition requirements

45. Is this case reportable?
You find these results in your ad hoc and see the provider diagnosed them with Lyme:

46. Is this case reportable?
You find these results in your ad hoc:
Yes, as a Probable case
Both the first and second tier tests are positive and in the AHLTA encounter the provider diagnosed the patient with Lyme disease

47. Is this case reportable?
These results come up in your ad hoc:
Per their history, a Lyme screening test was NOT ordered, no symptoms were reported, and the doctor has not diagnosed them.

48. Is this case reportable?
These results come up in your ad hoc:
NO. Why?
The IgM WB is positive, but this result is NOT reportable without a preceding positive screening test.

49. Lyme Disease Erythema Migrans (EM)
2017 Armed Forces Reportable Medical Events Guidelines and Case Definitions
Lyme Disease
Erythema Migrans (EM)
OR Late Manifestation (LM) of Lyme Disease? (e.g. Bell’s palsy, swollen knees, Lyme carditis) No
Yes (LM)
Yes (EM)
Provider diagnosed Lyme disease? No
Yes
Known exposure* in endemic or non-endemic area?
Any clinical information available?
(+) LD total Ab screen WITH (+) IgM within 30 days of illness onset?
(Two-tier testing) No
Yes
SUSPECT
(+) LD total Ab screen WITH (+) IgM within 30 days of illness onset?
(Two-tier testing) No
Yes No
Yes
(+) LD total Ab screen WITH (+) IgM within 30 days of illness onset?
(Two-tier testing)
Start over. Or, if NO LM/EM and NO diagnosis, does not meet case definition.
(+) LD total Ab screen WITH (+) IgG?
(Two-tier testing)
PROBABLE No
Yes
Yes No
(+) LD total Ab screen WITH (+) IgG?
(Two-tier testing)
CONFIRMED No
Yes
(+) IgG?
(Single-tier testing)
Yes
PROBABLE No
Yes No
(+) LD total Ab screen WITH (+) IgG?
(Two-tier testing)
Yes
SUSPECT
(+) IgG?
(Single-tier testing)
CONFIRMED
(+) culture? No
Yes No
Yes No
(+) IgG?
(Single-tier testing)
Yes
NOT A CASE
PROBABLE
(+) culture?
CONFIRMED No
No (EM)
No (LM)
Yes
NOT A CASE
(+) culture?
SUSPECT
CONFIRMED
NOT A CASE
CONFIRMED No
Yes
* Exposure is defined as having been (≤30 days before onset of EM) in wooded, brushy, or grassy areas in a county in which Lyme disease is endemic. History of tick bite is not required. Possession of physical tick is not required.
Endemicity is defined as a county in which at least 2 confirmed cases have been acquired or established populations of the blacklegged tick are infected with B. burgdorferi.

50. Part 3: Misreporting Notes
Event Report Completion
Consistency in Reports
Conclusion

51. Medical Event Report Completion
Accuracy in reporting includes completing details like Event Related Questions in DRSi
Event Related Questions:
Reflect the Critical Reporting Elements and the case definition in the Guidelines
Answer as thoroughly as possible
Are pertinent to the event & your surveillance hub
Event related questions in DRSi. CREs give basic situational awareness to reviewers, but also provide information about likelihood of disease transmission, exposures, and often should help local public health with their investigation.
Answering these as thoroughly as possible prevents us from reaching out to ask for details (sometimes) and
Trust me, we’re asking questions we think are important.

52. Consistency – PEP against Rabies
Answers to Event Related Questions should be consistent with AHLTA records and the case definition

53. Reporting PEP against Rabies
What is wrong with this report?
The first question is answered. The second lists the species, dog. (Which, to save time, just the species of the animal is fine. Descriptions aren’t necessary!)

54. Reporting PEP against Rabies
What is wrong with this report?
One exposure criteria MUST be met in order to be reportable

55. Conclusion Case definitions Accuracy in reporting
Classifications
Symptoms
Laboratory requirements (lab method, sample type, result interpretation)
Exposure history
Ands and Ors
Accuracy in reporting
Reporting completion and consistency

56. Contact Information
Army: APHC – Disease Epidemiology Division
Aberdeen Proving Ground – MD
COMM: (410)   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:
Air Force: Contact your MAJCOM PH or USAFSAM/PHR
USAFSAM / PHR / Epidemiology Consult Service
Wright-Patterson AFB, Ohio
COMM: (937)   DSN:  T
Alright, that concludes our presentation. At this time we will take questions and comments in the chat box on DCS or over the phone! On the screen is contact information for service-specific surveillance hubs if you’d like to contact them specifically.