Innovative Uses for ESSENCE to Improve Standard Communicable Disease Reporting Practices in MiamiDad

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Innovative Uses for ESSENCE to Improve Standard
Communicable Disease Reporting Practices in
Miami-Dade County

• Erin OConnell, MPH

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Objective

• To illustrate how ESSENCE can been utilized in
  order to improve standard communicable disease
  reporting

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Table of Contents

• Objective
• Background
• Methods
• Results
• Conclusions
• References
• Acknowledgements

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Background

• Miami-Dade County Health Department (MDCHD) has
  used Electronic Surveillance System for the Early
  Notification of Community Based Epidemics
  (ESSENCE) in 16 of the largest hospitals since
  2005
• 4 staff rotate duties and spend about 2 hours on
  syndromic surveillance activities daily
• Although ESSENCEs primary aim is to detect
  outbreaks or bioterrorism events, we wanted to
  determine its value in improving communicable
  disease surveillance and reporting

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Background

• We first considered the idea when varicella
  (chicken pox) became a newly reportable disease
  in Florida in 2006, but few cases were being
  reported although new guidelines were mailed to
  all practitioners
• In 2007, we began conducting a specialized query
  in ESSENCE for chicken pox or varicella in the
  chief complaint and contacted the hospital to
  verify if the case was confirmed and should be
  reported
• Although staff has also performed individual
  disease-related chief complaint queries
  occasionally during outbreaks or mass gathering
  events we sought to enhance our capabilities on a
  daily basis and look at a wider range of diseases

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Methods

• Since March 2008, MDCHD has performed specialized
  daily chief complaint queries for 20 reportable
  diseases and since October 2008, we now search
  for 75 diseases/conditions
• The original 20 queries included chicken pox,
  malaria, meningitis, cyclosporiasis,
  cryptosporidiosis, ciguatera, mumps, pertussis,
  hepatitis, encephalitis, botulism, smallpox,
  shigellosis, salmonellosis, anthrax, dengue
  fever, measles, mercury or food poisoning, or
  exposure
• An additional query is conducted for diarrhea and
  vomiting

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Methods

• We aimed to show how
• ESSENCE can be used in
• the following situations
• 1) Underreported diseases/
• conditions (i.e. Chicken pox)
• 2) Serious/time-sensitive diseases
• (i.e. Category A bioterrorism agents,
• meningitis)
• 3) Possible outbreaks

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Methods

• When descriptions of the queried diseases are
  found in the chief complaint, MDCHD staff
  investigates each one individually and excludes
  those that are irrelevant to the search
• When it is suspected that the chief complaint may
  be a valid case, staff then contact the Infection
  Control Practitioner (ICP) of the hospital
• Staff follow up until the disease is confirmed
  and entered into the State of Florida electronic
  disease reporting system, Merlin

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Methods

• Findings in ESSENCE queries from March to October
  2008 were compared to previous years and to
  Merlin and the MDCHD Animal Bite Database.

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Results
Disease/Conditions found in a specialized query
in ESSENCE, March- October 2008

• From March to October 2008, there were 582,463
  ED visits (mean of 2,447 per day)
• There were a total of 1,242 (0.2) ED visits
  that had one of the 20 queried reportable disease
  in the chief complaint (mean of 5 per day) and
  660/1,242 (53) were relevant

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Results
Disease/Conditions found in a specialized query
in ESSENCE, March- October 2008
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Results
1) Underreported diseases/conditions

• Chicken pox investigation
• After excluding those that were irrelevant, there
  were 205 ED visits for possible chicken pox
  between Jan 2006 and Dec 2007. However, 43 were
  reported in Merlin during those two years.
• After the implementation of the specialized
  query, there were 58 ED visits for possible
  chicken pox between March and October of 2008 and
  48 were reported in Merlin during those 8 months.
  
• Note cases in Merlin also are from private
  providers and not only from EDs

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Results
1) Underreported diseases/conditions

• Rabies PEP investigation
• In Florida, only animal bites that lead to the
  administration of post-exposure prophylaxis (PEP)
  for rabies are reportable in Merlin
• To assess the quality of animal bite
  surveillance, animal bites and rabies in ESSENCE
  were compared to MDCHDs Animal Bite database and
  Merlin
• The query included the following words rabies,
  dog, bite, animal, etc
• The MDCHD Animal Bite database includes reports
  from hospitals, the Miami-Dade County Animal
  Services Department, veterinarian clinics and
  community residents

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Results
1) Underreported diseases/conditions
ED visits and reported cases of post-exposure
prophylaxis for rabies, 2006 - 2008

• From 2007 2008, there was a 47 increase in
  reporting of post-exposure prophylaxis for rabies
  since the specialized query was implemented
• Note Cases in Merlin also are from private
  providers and not only from EDs

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Results

• 2) Serious/time-sensitive diseases
• Meningitis investigation
• ED visits with meningococcemia in the chief
  complaint, August 31, 2008

• These cases did not initiate an alert and
  therefore without the query the health
• department would not have been aware about the
  case
• The health department contacted the ICP and
  assisted with calling all the possible
• contacts to ensure they were provided the
  appropriate prophylaxis

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Number of meningitis chief complaints found in
the specialized query, all Miami-Dade County EDs,
March October 2008
Number of meningitis chief complaints found in
the specialized query at 1 hospital ED, March
October 2008
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Results

• 3) Possible outbreaks
• Outbreak investigation in a homeless shelter

• Between June 14 and 17, 2008, three small
  clusters by resident zip code and ED
• visit time were detected in a southern Miami-Dade
  County hospital with diarrhea and/or
• vomiting as chief complaints
• After staff contacted the ICP, It was discovered
  that 12 ill individuals from the same
• Zip code arrived from the same homeless shelter
  over several days

Spatial-Temporal and Chief Complaint Clustering
in an Emergency Department
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Results
3) Possible outbreaks

• Since a gastrointestinal illness alert was not
  automated because of the small number
• of persons involved, this demonstrates how
  important it is to carefully monitor
• all clusters and not only those automatically
  created by the system.

Daily ED Visits with Chief Complaints of
Diarrhea/Vomiting in Zip Code 33033, 6/1 -
6/20/2008 
Daily ED Visits to Hospital A with Chief
Complaints of Diarrhea/Vomiting, 6/1 -
6/20/2008  
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Results
3) Possible outbreaks
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Conclusions

• This study verified that ESSENCE can be useful
  not only in providing an early warning of unusual
  outbreaks in the community but also for ensuring
  that healthcare practitioners report diseases
  appropriately
• Due to the fact that only a small percentage of
  chicken pox and post-exposure prophylaxis for
  rabies cases were reported, this approach can
  improve quality control measures for
  underreported conditions
• By contacting the ICP when reportable disease
  names are found in the chief complaint, MDCHD has
  developed a stronger relationship with hospitals

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Conclusions

• Staff will continue to use these specialized
  search methods on a daily basis and hopefully
  better compliance will result through this use of
  syndromic surveillance
• A limitation for smaller health departments may
  be the limited staff and resources to investigate
  
• In addition, staff will also provide healthcare
  practitioners with information about the
  reportable disease list via email, phone, mail,
  and on-site hospital visits

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Acknowledgements

• Dr. Guoyan Zhang
• Lizbeth Londono
• Anthoni Llau
• Rene Borroto-Ponce
• MDCHD Surveillance Staff