Guillain-Barr

1
Guillain-Barré Syndrome Active Surveillance

• October 2009-May 2010
• Emily Mosites, MPH
• TNDOH, CEDS

2
Emerging Infections Program (EIP) GBS Surveillance

• Tennessee
• Georgia
• Connecticut
• Oregon
• California

• Colorado
• New Mexico
• Maryland
• Minnesota
• New York

3
Guillain-Barré Syndrome (GBS)

• Auto-immune disorder
• Acute onset
• Ascending generalized paralysis
• Often unknown cause, but is sometimes associated
  with recent infection

4
Symptoms

• Prickling sensation in fingers and toes
• Weakness in legs that can ascend to upper body
• Unsteady gait or inability to walk
• Can involve respiratory system
• Most patients hospitalized

5
Epidemiology

• Estimated background rate 1-2 cases per 100,000
  persons per year
• Expected in Tennessee Just over 1 case per
  week.
• GBS Cases Reported in Previous Years

Year Cases
2005 13
2006 10
2007 11
2008 6
Observed Rate 0.16 per 100,000 persons per year
6
Surveillance Objectives
Per CDC GBS Surveillance Protocol

• Rapidly detect potential cases of GBS
• Produce regular reports on cases of GBS including
  risk factor information
• Determine whether vaccination with the H1N1
  vaccine is associated with increased risk of GBS

7
Surveillance Activities

• Neurologist/Hospital Network
• Medical Records Review
• Patient Interview

8
Neurologist Network

• 166 physician offices representing 425 physicians
• 123 hospitals
• 80 clinical pharmacies
• 35 EMG laboratories

9
Network Response Rates

• 98.5 of network responded at least once since
  October
• Average 85 response rate each month

10
Medical Records Review

• History and Physical
• Neurology Consult Notes
• Labs (CSF and EMG)
• Discharge Summary

11
Case Definition

• Brighton Clinical Criteria
• Acute onset of bilateral and relatively symmetric
  flaccid weakness/paralysis of the limbs
• and
• Decreased or absent deep tendon reflexes
• and
• Monophasic illness pattern with weakness nadir
  reached between 12 hours and 28 days
• and
• Absence of an alternative diagnosis

12
Laboratory Confirmation

• Electromyography (EMG)
• Abnormal nerve conduction in limbs
• or
• Cerebrospinal Fluid (CSF) Protein
• Elevated protein level without elevated white
  blood cell count.

13
Patient Interview

• Illness within 6 weeks before onset
• Vaccination this season
• Medical history
• Preliminary response rate 87.5 of cases
  contacted

14
Tennessee Data

• 98 cases referred
• 12 out of jurisdiction (MS, GA, KY, etc)
• 21 GBS note in medical history
• 10 under evaluation
• 23 did not meet Brighton Criteria
• 29 CONFIRMED, 3 PROBABLE CASES

1.3 cases per week
15
(No Transcript)
16
GBS Case and non-case characteristics
Characteristic  Characteristic  Characteristic  Confirmed and probable N32 Non-cases N23
Sex Sex Sex
Male Male 15 (46.9) 11 (47.8)
Female Female 17 (53.1) 12 (52.2)
Mean Age Mean Age Mean Age 48.6 (5-91) 49.5 (12-77)
Race/Ethnicity Race/Ethnicity Race/Ethnicity
Black 4 (12.5) 1 (4.3)
White 21 (65.6) 16 (69.6)
Hispanic 2 (0.62) 0 (0.0)
Asian 1 (3.1) 1 (4.3)
17
(No Transcript)
18
Confirmed and probable case antecedent events
Tennessee compared to other EIP sites
TN cases N() Other EIP Site Cases N()
Total Cases 32 202
Events
H1N1 Vaccination 3 (9.4) 20 (9.9)
Seasonal Flu Vaccination 12 (37.5) 66 (32.6)
Gastrointestinal Illness 1 (3.1) 59 (29.2)
Upper Respiratory Illness or Flu-like Illness 13 (40.6) 88(43.5)
No antecedent event noted 5 (15.6) .
None of the cases with antecedent H1N1 vaccine had other symptoms within 6 weeks of GBS onset Three of the cases with antecedent seasonal flu vaccine had other symptoms within 6 weeks of GBS onset None of the cases with antecedent H1N1 vaccine had other symptoms within 6 weeks of GBS onset Three of the cases with antecedent seasonal flu vaccine had other symptoms within 6 weeks of GBS onset None of the cases with antecedent H1N1 vaccine had other symptoms within 6 weeks of GBS onset Three of the cases with antecedent seasonal flu vaccine had other symptoms within 6 weeks of GBS onset
19
Confirmed and probable case antecedent events
Tennessee compared to other EIP sites
TN cases N() Other EIP Site Cases N()
Total Cases 32 202
Events
H1N1 Vaccination 3 (9.4) 20 (9.9)
Seasonal Flu Vaccination 12 (37.5) 66 (32.6)
Gastrointestinal Illness 1 (3.1) 59 (29.2)
Upper Respiratory Illness or Flu-like Illness 13 (40.6) 88(43.5)
No antecedent event noted 5 (15.6) .
None of the cases with antecedent H1N1 vaccine had other symptoms within 6 weeks of GBS onset Three of the cases with antecedent seasonal flu vaccine had other symptoms within 6 weeks of GBS onset None of the cases with antecedent H1N1 vaccine had other symptoms within 6 weeks of GBS onset Three of the cases with antecedent seasonal flu vaccine had other symptoms within 6 weeks of GBS onset None of the cases with antecedent H1N1 vaccine had other symptoms within 6 weeks of GBS onset Three of the cases with antecedent seasonal flu vaccine had other symptoms within 6 weeks of GBS onset
Tennessee H1N1 Vaccination Coverage Estimate
(thru Jan, 2010) Under 18 34.5 18 and over
19.5 Interim Report, CDC, MMWR, April 2, 2010 /
59(12)363-368
20
Conclusions

• Network responsiveness high
• Observed matches expected rate of GBS cases per
  week
• No increasing trend or major fluctuations in
  reported cases

21
Acknowledgments

• TN Neurologists, EMG labs, clinical
• pharmacists, and HIM departments
• TN Regional Health Offices
• Rendi Murphree, PhD
• David Kirschke, MD
• CDC GBS Surveillance Coordinators