Epidemiology and the Practice of Public Health

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Epidemiology and the Practice of Public Health

• WVU Department of Community Medicine
• October 20, 2004

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Robert W. White II, RS, MPH

• Regional Epidemiologist
• Monongalia County Health Department
• Morgantown, WV
• 598-5132

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Bureau for Public Health Infectious Disease
Epidemiology Program Who We Are
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Bureau for Public Health Infectious Disease
Epidemiology Program Who We Are
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Bureau for Public Health Infectious Disease
Epidemiology Program Who We Are
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(No Transcript)
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BPH Issues - Website

• http//www.wvdhhr.org/bph/oehp/sdc/a-z/a-z-idep.ht
  m
• Reporting information
• What diseases to report
• How to report (forms / protocols)
• Disease information
• Information sheets
• Protocols
• Data

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BPH Issues - Confidentiality

• HIPAA
• Letter from Commissioner
• Covered in the Communicable Disease Rule (64 CSR
  7) information cannot be released except under
  specified circumstances
• Section 64-7-14 (pg 13)

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BPH Issues Proposed Reportable Disease Rule

• Proposed
• Updated reporting requirements for BT agents,
  SARS, monkeypox, enterovirus, pediatric death due
  to influenza
• Deletion of requirement to report herpes, aseptic
  meningitis
• New sections on outbreaks, BT, special
  surveillance projects
• Proposed language on the web

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Surveillance Issues Case Definitions

• National case definitions located at
• www.cdc.gov/epo/dphsi/casedef/case_definitions.htm
  
• Standard criteria for use by every reporting
  source and health department in doing
  surveillance

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BPH Issues - AMR

• Four outbreaks of CA-MRSA in 2003
• Outbreak report
• Encourage reporting of
• Outbreaks of CA-MRSA - within 24 hours (required
  by communicable disease rule)
• Cases of CA-MRSA (voluntary)
• Cases of Invasive Streptococcus pneumoniae and
  antimicrobial resistance profile (required)

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BPH Issues AMR (2)

• GET SMART campaign
• CDC-designed information campaign
• Easy to participate
• Electronic copies on our website
• We invite your participation
• ICP
• Laboratory Director
• Pharmacy Director
• Medical Staff Director
• Anyone!

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BPH Issues -- Timeliness of Reporting (3)

• Pertussis
• Contacts must be traced and started on
  prophylaxis ASAP
• Symptomatic contacts should be identified, begun
  on therapy, and isolated during the first 5 days
  of treatment

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BPH Issues -- Timeliness of Reporting (4)

• Foodborne
• Do not need laboratory confirmation by OLS to
  report
• Delayed investigation results in
• Decreased recall of food history and other risk
  factors
• Delayed recognition of clusters and outbreaks
• Lost opportunities to confirm the etiologic agent

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BPH Issues Completeness of Reporting

• PAPER
• WV BPH Confidential Reportable Disease Case
  Report Form (Yellow Card)
• Patient
• Onset of symptoms
• Demographic information
• Full name and address - helps us refer the
  investigation to the proper county (or state!)
• Physician
• Full name, address, phone facilitates the
  investigation
• Attach copy of appropriate labs
• NEDSS
• Completely fill out the provider section

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BPH Issues Timeliness of Reporting

• Hepatitis A (24 hours)
• LHD must offer immune globulin to contacts within
  2 weeks after exposure
• Hepatitis B (24 hours)
• LHD must offer hepatitis B immune globulin (HBIG)
  to
• Sexual contacts within 2 weeks of the last
  contact and
• Needle-sharing contacts within 1 week of last
  exposure

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Bacterial Isolates that Should be Referred to OLS

• Staphylococcus aureus with glycopeptide-Intermedia
  te (GISA/VISA) or glycopeptide resistant
  (GRSA/VRSA) susceptibilities
• CA-MRSA
• Streptococcus pneumoniae, invasive
• Tularemia
• Vibrio cholerae
• Yersinia pestis

• Bacillis anthracis
• Clostridium botulinum
• Corynebacterium diphtheriae
• Enterhemorrhagic E coli
• Haemophilus influenzae
• Listeria monocytogenes
• Mycobacterium tubersulosis
• Neisseria meningitidis
• Salmonella typhi
• Shigella sp

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Viral / Serological Specimens that Should be
Confirmed by OLS

• Arboviral encephalitis
• Hantavirus
• Mumps (IgM)
• Poliomyelitis

• Rabies, animal or human
• Rubella (IgM)
• Rubella (IgM)
• Smallpox

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BPH Issues - Foodborne Disease

• Salmonella, Shigella, Campylobacter, Listeria,
  Enterotoxigenic E coli
• Serotyping
• PFGE
• Typing of shigatoxin-producing E coli
• Do not wait for OLS confirmation to report a
  positive from your laboratory
• If you report, we begin the epi investigation
  immediately.

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10 Things I Didn't Learn in School or Real Life
Epidemiology
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Introduction

• How my education prepared me for this job
• How real life differs from the model
• How things can really go wrong (even when you
  have good intentions)

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1. When is information not that necessary?

• 1977 Halloween Party Outbreak
• 23 sick students
• Allergic reaction to hay
• CDC advised blood samples on all 23 ill patients
• Science Doesnt Overcome 23 Crying Children

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2. Just What is Swine Flu?

• Mass immunization clinics held throughout the
  county
• Marion County Armory was the site
• But what does a Sanitarian do ? Register
  patients and run for coffee
• Be ready to do whatever is needed

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3. Are you ever off the record?

• Superfund Clean-up site in Marion County
• Public meeting on testing and remediation
• Spoke to some individuals in the hallway prior
  meeting (one was a reporter)
• Headlines the following day- Sanitarian says
  Its All Just Part of the Plan
• Know Your Audience

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4. How do you get away from the rioting crowd?

• Community sewage problems in South Fairmont
• Public hearing set
• Another Sanitarian and I didnt think the meeting
  would be well attended - we put out maps showing
  the problem locations
• Help- 250 angry residents

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5. How gross can it get?

• Family with recurring diarrhea
• Physician asked if HD would collect water sample
• 37 miles and 4 dirt roads one way
• Opened the hand dug well- a family of mice had
  drowned
• Excuse me while I ..

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6. Should you always do what the boss says?

• Shigella outbreak in Morgantown
• I had been a Regional Epi for 1 week
• News station wanted to go with a live outdoor
  remote broadcast
• 15 seconds before broadcast the wind and rain
  started
• Reporter looked at me and said, Tell me
  everything you know, you have 2 minutes live.
• The boss isnt always right

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7. How long does it take to wrap up an
investigation?

• Food borne outbreak at a Christmas party at a
  medical center
• Outbreak team responded well and had under
  control within 1 day
• B. Cereus as the culprit but couldnt find the
  source- six months later employee volunteered
  information
• Its not over till its over

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8. Is the Doctor Always Right?

• Meningitis outbreak in jail
• Set up a meeting with the corrections officers- I
  got there first and began giving handouts from
  CDC website
• Physician showed 30 minutes late and wanted to go
  on TV with his message.
• You may know more butdont show up the
  DoctorStill have him stick to the script

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9. What is Validity (and will I ever use it in
real life)?

• Working on a major food borne outbreak at an
  elementary school
• Surveyed 4th and 6th graders as to what they ate
  for lunch for the week
• One student answered that he ate lunch every day
  at school, then said he had been sick all week
  and hadnt been to class
• Now I know what Validity is

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10. How far will you go to complete the job?

• Food borne outbreak at a medical center luncheon
  (Mardi Gras)
• Completed surveys, sampled leftovers, and wrapped
  most of the investigation
• Evidence pointed to drinks, particularly ice
  rings made in Pennsylvania
• In the darkness of night I was invited into a PA
  home, sampled the well and snuck back into WV for
  lab testing (Whatever it takes)

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In Conclusion

• Make sure the information is worth the effort
• Be ready to do what is necessary
• Know your audience and adjust the message
• Dont cause undo hardship on yourself
• Dont bring in notions of whats right and wrong
• Realize that orders can be changed
• It takes time to solve problems
• Everybody makes mistakes
• Text books dont tell the whole story
• Its sometimes better to beg forgiveness than to
  ask for permission

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Mark Twain (1835 - 1910)

• I have never let my schooling interfere with my
  education.
• Mark Twain (1835 - 1910)