Experiences in the Use of Non-Traditional Data Sources in a Rural State – South Carolina Dan Drociuk, MT(ASCP), MSPH – Director Epidemiological Response

Experiences in the Use Experiences in the Use of Non-Traditional Data of Non-Traditional Data Sources in a Rural State Sources in a Rural State

– South Carolina– South Carolina

Dan Drociuk, MT(ASCP), MSPH – DirectorDan Drociuk, MT(ASCP), MSPH – DirectorEpidemiological Response / Enhanced Surveillance Epidemiological Response / Enhanced Surveillance

SectionSectionDivision of Acute Disease EpidemiologyDivision of Acute Disease Epidemiology

South Carolina Department of Health and Environmental South Carolina Department of Health and Environmental ControlControl

OutlineOutline Part I:Part I:

• The “People”The “People” How we are organized to develop, implement, How we are organized to develop, implement,

monitor and respond to EED system needs.monitor and respond to EED system needs. Part II:Part II:

• The “Push”The “Push” How we disseminate information about EED systems How we disseminate information about EED systems

and general epidemiological activities.and general epidemiological activities. Part III:Part III:

• The “Products”The “Products” Case studies showing the interaction and intersection Case studies showing the interaction and intersection

of EED systems currently in use in South Carolina.of EED systems currently in use in South Carolina.

Part I:Part I:The “People”The “People”

A bit about South Carolina…A bit about South Carolina…

Approximate population: 4,350,500 (sans Approximate population: 4,350,500 (sans golf courses and beaches…)golf courses and beaches…)• Three MSA’s in the “Top 100”: Three MSA’s in the “Top 100”:

Columbia, Charleston, Rock Hill/CharlotteColumbia, Charleston, Rock Hill/Charlotte

• Tourism a main industry along the costal areasTourism a main industry along the costal areas

Centralized health department structureCentralized health department structure• All public health employees are state All public health employees are state

employees regardless of locationemployees regardless of location• No local boards of healthNo local boards of health

Current Systems in UseCurrent Systems in Use Palmetto Poison Center (electronic daily feeds to Palmetto Poison Center (electronic daily feeds to

public health),public health), National Retail Data Monitoring (NRDM) for OTC National Retail Data Monitoring (NRDM) for OTC

sales (using “home-grown” Csales (using “home-grown” C11, C, C22, C, C33 indicators), indicators), BioSense for DoD and VA ambulatory care BioSense for DoD and VA ambulatory care

procedures and ambulatory care diagnosis,procedures and ambulatory care diagnosis, Essence data monitored and “crossed” with Essence data monitored and “crossed” with

Biosense alerts and indicators.Biosense alerts and indicators. Sentinel providers with Influenza-like Illness Sentinel providers with Influenza-like Illness

reporting (number/wk).reporting (number/wk). Two (2) pilot hospitals providing chief-complaint Two (2) pilot hospitals providing chief-complaint

data in “home-grown” categories.data in “home-grown” categories.

Tuesday, July 5, 2005

DIVISION OF ACUTE DISEASE EPIDEMIOLOGYDixie F. Roberts, MPH, BSN, RNDivision Director

Information TechnolocySection

Jason CollinsSection Director

Reportable Disease Surveillance Section

Libby GreeneSection Director

Acute Disease Response/Enchanced Surveillance

SectionDan Drociuk

Section Director

DADE Program AreasDixie Roberts

Administrative Support Team SectionGloria McCurry

Administrative Coordinator

IT Staff:Mark Rahn

VacantVacant

HAN, etc:Jamey RudisellShana LeGrand

Surveillance Staff:Claire Youngblood

Ted LeBlancSuzy Wesley

All DADE staff & teams accountable to Section Director

for assigned routine Surveillance Activities

Response Staff:Julie Schlegel, Foodborne Epi

CoordinatorMichelle Myer, BT Epi and

Response*Amy Belflower, QA Coordinator

Marya Barker

Administrative Support Team:Rosa Wesley

Phillipine OutingSuzy Wesley

Program Area Staff:

-Dr. Tom Fabian, BT/ HRSA Medical Director

Dr. Eric Brenner, Medical Epidemiologist

Dr. Lena Bretous, Medical Epidemiologist

Dr. Shirley Jankelevich, Medical Epidemiologist

Dr. Mary Anne WenckEIS Officer

Dr. Marcia Headrick, Public Health Veterinarian

Vacant, Careful Antibiotic Use Nurse Educator

Tuesday, July 5, 2005

DIVISION OF ACUTE DISEASE EPIDEMIOLOGYDixie F. Roberts, MPH, BSN, RNDivision Director

Information TechnolocySection

Jason CollinsSection Director

Reportable Disease Surveillance Section

Libby GreeneSection Director

Acute Disease Response/Enchanced Surveillance

SectionDan Drociuk

Section Director

DADE Program AreasDixie Roberts

Administrative Support Team SectionGloria McCurry

FunctionsCarolina Health Electronic Surveillance System: (CHESS)

Develop/ operate/ maintain NEDSS based electronic surveillance system (CHESS)

Coordinate with Surveillance Section on CHESS implementation.

-Develop/ operate/ maintain CHESS-Immunization RegistryCoordinate with Immunization Division on CHESS-IR

-Health Alert NetworkDevelop and maintain capacity for rapid Public Health Emergency notification system

PHIN Standards: monitor quality assurance and PHIN compliance measures

Coordinate with Bureau of Information Systems and Health Services Information Systems to assure compliance with Agency standards.

Functions

CHESS: Surveillance Data Entry and Notifications, Data Reports, & Dissemination

· Coordinate Data Analysis & Interpretation

· Policies/Procedures

· Data Quality Assurance

· Responsible for: · List of Reportable Conditions · School and Childcare Exclusion List · Annual Report · Epi Notes · Request for Data · Web site · CHESS Training · Epi Records/Documentation

Functions

Acute Response:· Liasion with Regional Health Departments regarding epidemiological capacity/response.

· Reportable Disease Case & Outbreak Investigations/Coordination

· Policies & Procedures

· CHESS Data Collection

· Public Health Preparedness Incident Command System · DADE SOP & Implementation · Bureau of Disease Control SOP & implementation · HAN notification coordination

· On-Call System: Routine Work Day & 24/7 · Answering Service · Epidemiological Response Quality Assurance

Enhanced Surveillance: · Palmetto Poison Center data analysis · Early Aberration Reporting System · Syndromic Surveillance pilot projects · Hospital Discharge data analysis

Functions

Coordinator: · Admin. Supervision · Procurement · Personnel Items · Inventory · Network/Telephone/Space Coordination · Epi Notes · On Call Schedule

Admin. Team: · Telephone Coverage · Mail · Travel Arrangements & Reimbursements · Minutes · DHEC Forms · Meeting/Conference/Training Preparation · Data Surveillance Activities · Data Entry · Copier Maintenance & Paper · Fax Machine Maintenance & Paper · Network Printer Maintenance · TRAMS · DHEC 1129 Cards/Case Report Letters · Mailouts · Scheduling of Conference Rooms · Epi Team Database’s

Functions

Accountable for program outcomes/performance measures, grant and program budget writing, and integration of activities into the Surveillance and Response processes in the Division.

Program Area assignments are not intended to restrict involvement across the DADE Sections (functional units).

BT-CDC – Dan Drociuk NEDSS-IT (Vacant) Surveillance Sections – Libby Greene HAN-IT – Jamey Rudisell Agroterrorism & Zoonotic Disease - Dr. Marcia Headrick

BT-HRSA Dr. Tom Fabian

ELC Antibiotic Resistance – Vacant (Dixie Roberts) Hepatitis – Libby Greene Influenza – Dr. Lena Bretous WNV &Vector Borne Disease - Dr. Lena Bretous NEDSS-IT (Vacant) & Surveillance Sections – Libby Greene Foodborne Disease – Julie Schlegel

Vaccine Preventable Diseases - Dr. Shirley Jankelevich

Childcare and School Health - Michellle Myer

Regional Epi TeamsRegional Epi Teams

Services are delivered and surveillance Services are delivered and surveillance happens at the local/community levelhappens at the local/community level

Surveillance, case and outbreak investigation Surveillance, case and outbreak investigation & response starts with the Regional Epi Team& response starts with the Regional Epi Team• 6-20 members6-20 members• Mix of skills: nurses, Env. Health, PIOMix of skills: nurses, Env. Health, PIO• Established 1995 to provide trained integrated Established 1995 to provide trained integrated

team-based response to routine surveillance, case team-based response to routine surveillance, case investigations, and outbreak investigationsinvestigations, and outbreak investigations

Available for Urgent Reports 24/7 via on-call Available for Urgent Reports 24/7 via on-call rotation.rotation.

Epidemiological Responses to Epidemiological Responses to Events of Public Health Events of Public Health

SignificanceSignificance ““White powder events”White powder events” Ricin in a U.S. Postal Facility in GreenvilleRicin in a U.S. Postal Facility in Greenville Chlorine tanker train derailment, Graniteville, Chlorine tanker train derailment, Graniteville,

SCSC Numerous point-source outbreak Numerous point-source outbreak

investigationsinvestigations• Food-borne (Salmonella’s),Food-borne (Salmonella’s),• Water-borne (Legionella cluster, rash-illness),Water-borne (Legionella cluster, rash-illness),• Respiratory (Pertussis)Respiratory (Pertussis)

Hurricane Katrina Evacuation Center Hurricane Katrina Evacuation Center surveillance activities, Greenville, SCsurveillance activities, Greenville, SC

Part II:Part II:The “Push”The “Push”

Dissemination of Epi-related Dissemination of Epi-related informationinformation

DailyDaily • Provided to the South Carolina Intelligence Fusion CenterProvided to the South Carolina Intelligence Fusion Center• Reports from our Division of Acute Disease Epidemiology on-Reports from our Division of Acute Disease Epidemiology on-

call staff for overnight calls received,call staff for overnight calls received,• Summary information from our Early Event Detection Systems Summary information from our Early Event Detection Systems

(BioSense, OTC sales, Palmetto Poison Center)(BioSense, OTC sales, Palmetto Poison Center)• Previous day on-call events of public health significancePrevious day on-call events of public health significance

WeeklyWeekly • Provided via the Epidemiological Weekly Report (EWR)Provided via the Epidemiological Weekly Report (EWR)• Summary information from our Regional and Central OfficeSummary information from our Regional and Central Office

MonthlyMonthly• Meetings with Regional Epidemiology Response StaffMeetings with Regional Epidemiology Response Staff

As NeededAs Needed • Distribution via the SC Health Alert NetworkDistribution via the SC Health Alert Network• CDC and DHEC Health Alerts/Advisories/Updates CDC and DHEC Health Alerts/Advisories/Updates

Example of a Daily SCIEx Example of a Daily SCIEx reportreport

Example of a weekly EWRExample of a weekly EWR

EWR: Epidemiological Weekly EWR: Epidemiological Weekly ReportReport

The EWR is compiled weekly from The EWR is compiled weekly from Regional and DADE reports.Regional and DADE reports.• It includes basic summary information It includes basic summary information

related to an ongoing or concluding epi-related to an ongoing or concluding epi-investigations.investigations.

• Submissions usually include what is Submissions usually include what is known or hypothesized about etiology, known or hypothesized about etiology, geographic location, and numbers of geographic location, and numbers of persons affected.persons affected.


Circulation:Circulation:• The EWR is submitted to the Deputy The EWR is submitted to the Deputy

Commissioner for Health Services, Commissioner for Health Services, members of the Senior Leadership members of the Senior Leadership Team, Central and Regional Office Team, Central and Regional Office Leadership, the Office of Public Health Leadership, the Office of Public Health Preparedness, etc.Preparedness, etc.

Goal:Goal:• Provide situational awareness regarding Provide situational awareness regarding

Epi activities across the state.Epi activities across the state.


Statistics:Statistics:• In 2005, EWR’s documented 288 “new investigations” of In 2005, EWR’s documented 288 “new investigations” of

potential outbreaks or single cases of disease or events potential outbreaks or single cases of disease or events of public health significance.of public health significance.

• In 2005 documented outbreaks totaled 62 stratified as In 2005 documented outbreaks totaled 62 stratified as follows (by modes of transmission):follows (by modes of transmission):

RespiratoryRespiratory 20 (32%)20 (32%) FoodborneFoodborne 16 (26%)16 (26%) UnknownUnknown 11 (18%)11 (18%) Person-to-personPerson-to-person 7 (11%) 7 (11%) Fecal-oralFecal-oral 5 ( 8%) 5 ( 8%) ContactContact 2 ( 3%) 2 ( 3%) NosocomialNosocomial 1 ( 2%) 1 ( 2%)

2004 2005

# FB Outbreaks 13 16

% Agent Identified 92% 79%

% Source Identified 46% 29%

2004-2005 SC 2004-2005 SC Foodborne Outbreak Foodborne Outbreak

StatisticsStatistics

Part III:Part III:The “Products”The “Products”

Case Study 1:Case Study 1:

Chlorine Release in Chlorine Release in Graniteville, South Graniteville, South

Carolina Carolina

What Happened?What Happened?

At 2:39 AM, a 42-car Norfolk and At 2:39 AM, a 42-car Norfolk and Southern train derailedSouthern train derailed

A tanker car containing chlorine A tanker car containing chlorine was punctured, releasing was punctured, releasing approximately 60 tons of chlorine approximately 60 tons of chlorine

The chlorine was released in the The chlorine was released in the immediate vicinity of Avondale immediate vicinity of Avondale Mills, the commercial district, and Mills, the commercial district, and residential areas of Graniteville SCresidential areas of Graniteville SC

Objectives of a Rapid Objectives of a Rapid Epidemiological AssessementEpidemiological Assessement

AssessAssess• Extent of exposureExtent of exposure• MorbidityMorbidity• Health services usedHealth services used• Identify persons at risk for long-term Identify persons at risk for long-term

sequelaesequelae• Risk factors for severe outcomesRisk factors for severe outcomes• Location of exposureLocation of exposure

Case DefinitionCase Definition

Person treated for symptoms or Person treated for symptoms or complications from chlorine exposurecomplications from chlorine exposure

Identified byIdentified by• Hospital emergency department logsHospital emergency department logs• Physician reportingPhysician reporting

FacilityFacility

Aiken Regional Medical CenterAiken Regional Medical Center 108108 (39.7)(39.7)

Other SC hospitalsOther SC hospitals 1010 (3.7)(3.7)

Augusta, GA hospitalsAugusta, GA hospitals 154154 (56.6)(56.6)

ED Visits, N=272 ED Visits, N=272 (%)(%)

Emergency Department Emergency Department Visits within 24 HoursVisits within 24 Hours

Signs or Symptoms ReportedSigns or Symptoms ReportedSymptom (N=290)Symptom (N=290) % Reporting% Reporting

CoughingCoughing 8282

Eye burningEye burning 7777

Shortness of breathShortness of breath 7474

HeadacheHeadache 6363

Chest painChest pain 5959

NauseaNausea 5353

Nose burningNose burning 5151

"Cough up phlegm""Cough up phlegm" 5050

ChokingChoking 4646

DizzinessDizziness 4242

VomitingVomiting 3434

Number of

Events

Deaths, Hospitalizations, and Emergency Department VisitsDeaths, Hospitalizations, and Emergency Department Visits Following Train Derailment, Graniteville, SC - 2005Following Train Derailment, Graniteville, SC - 2005

Number of

Events

0

20

40

60

80

100

260

280

1 3 5 7 9 11 13 15 17 19 21 23 25

ED Visit, Not Admitted

Admitted to Hospital

Deceased, at Site of Accident

Day(s) Since Accident

0

20

40

60

80

100

260

280

1 3 5 7 9 11 13 15 17 19 21 23 25

ED Visit, Not Admitted

Admitted to Hospital

Deceased, at Site of Accident

Day(s) Since Accident

Hospitals that Treated Patients for Chlorine Exposure Hospitals that Treated Patients for Chlorine Exposure –– January 6-7, 2005January 6-7, 2005

0

5

10

15

20

25

30

35

40

2-3

am

4-5

am

6-7

am

8-9

am

10-1

1 am

12-1

pm

2-3

pm

4-5

pm

6-7

pm

8-9

pm

10-1

1 pm

12-1

am

Time

BarnwellEdgefieldLexington St. JosephsDoctorsMCGUniversityAiken

Number of

Patients

Situational Awareness Situational Awareness Issues Issues

Healthcare providers are going to treat Healthcare providers are going to treat people first, and worry about the “coding” people first, and worry about the “coding” laterlater• Review of charts showed a broad span of chief Review of charts showed a broad span of chief

complaints (n=81), primary diagnosis (n=48) complaints (n=81), primary diagnosis (n=48) and ICD-9 codes (n=51) used.and ICD-9 codes (n=51) used.

Data used for situational awareness, many Data used for situational awareness, many are going to be relying upon the data to are going to be relying upon the data to make decisions. This is a “paradigm shift” make decisions. This is a “paradigm shift” beyond being simple early event detection beyond being simple early event detection system.system.

OpportunitiesOpportunities Use of Early Event Detection systems for Use of Early Event Detection systems for

monitoring an emerging event must be flexible monitoring an emerging event must be flexible and sensitive to be able to answer the questions and sensitive to be able to answer the questions being asked, an EED must have the flexibility to being asked, an EED must have the flexibility to allow local users to create ad hoc syndrome allow local users to create ad hoc syndrome categories. categories.

The wealth of information present via an The wealth of information present via an electronic medical record only tells part of the electronic medical record only tells part of the story. The ability to identify the needs of the story. The ability to identify the needs of the people impacted greatly contributes to the overall people impacted greatly contributes to the overall situational awareness of an emerging event.situational awareness of an emerging event.

Next StepsNext Steps Within the 3-digit ZIP code area (ZIP3) 298 Within the 3-digit ZIP code area (ZIP3) 298

that surrounds Graniteville, BioSense that surrounds Graniteville, BioSense identified a data anomaly based on the identified a data anomaly based on the graphical visualization in the Respiratory graphical visualization in the Respiratory syndrome category that corresponded to syndrome category that corresponded to day 2 of the exposure. day 2 of the exposure.

However this anomaly was only apparent However this anomaly was only apparent for 1 day (1/7/05) and the source of this for 1 day (1/7/05) and the source of this anomaly has not been validated to anomaly has not been validated to determine both the source of this anomaly determine both the source of this anomaly and its relationship to chlorine toxicity.and its relationship to chlorine toxicity.


Use of Poison Control Use of Poison Control Center data Center data

Palmetto Poison CenterPalmetto Poison Center

1-800-222-12221-800-222-1222 Located in Columbia, SCLocated in Columbia, SC Serves the entire state of South CarolinaServes the entire state of South Carolina Staff consists of pharmacistsStaff consists of pharmacists and nursesand nurses Medical Director is trained in toxicology Medical Director is trained in toxicology

and emergency medicineand emergency medicine

Palmetto Poison Center Palmetto Poison Center Services ProvidedServices Provided

• 24 hours/7 days a week24 hours/7 days a week• Phone service to provide poison treatment informationPhone service to provide poison treatment information

For the public and health care professionalsFor the public and health care professionals

• Information requestsInformation requests MedicationsMedications PesticidesPesticides PlantsPlants Food poisoningFood poisoning ChemicalsChemicals

StatisticsStatistics

South CarolinaSouth Carolina• 2005: Over 37,000 calls to the Center2005: Over 37,000 calls to the Center

74% of total calls involved human poison 74% of total calls involved human poison exposuresexposures

30% involved adults over 21yo30% involved adults over 21yo 80% managed by Poison Center without further 80% managed by Poison Center without further

medical evaluation neededmedical evaluation needed

DocumentationDocumentation Every incoming call documentedEvery incoming call documented

• Follow up calls includedFollow up calls included Record includes name, phone number and zip code of Record includes name, phone number and zip code of

callercaller Patient data:Patient data:

• Age, gender weightAge, gender weight• Exposure substance, route and amountExposure substance, route and amount• Reason for exposureReason for exposure• Time of exposureTime of exposure• SymptomsSymptoms• Treatment providedTreatment provided• OutcomeOutcome

State Surveillance - DHEC State Surveillance - DHEC NotificationNotification

Require notification of Public Health for:Require notification of Public Health for:• Potential food poisoning/food tampering Potential food poisoning/food tampering

casescases• Occupational pesticide exposuresOccupational pesticide exposures• Questionable exposure to current public Questionable exposure to current public

health concerns, i.e. anthrax (‘suspicious health concerns, i.e. anthrax (‘suspicious powder calls’), West Nile Virus, chlorine powder calls’), West Nile Virus, chlorine toxicitytoxicity

• Animal bitesAnimal bites

State Surveillance - DHEC State Surveillance - DHEC NotificationNotification

Currently faxing cases and providing Currently faxing cases and providing downloads of toxidromes every 24hrs into downloads of toxidromes every 24hrs into ToxitrakToxitrak• Case information from Poison Center is Case information from Poison Center is

included in the uploadincluded in the upload• Reports can be generatedReports can be generated

Ex. How many cases had vomiting, diarrhea, fever Ex. How many cases had vomiting, diarrhea, fever in Clarendon county in the last 4 weeks; number of in Clarendon county in the last 4 weeks; number of suspected food poisoning cases from restaurants suspected food poisoning cases from restaurants per county, city or zip codeper county, city or zip code

The “Epi” of Poisonings in The “Epi” of Poisonings in SCSC

Who? Who? • 62% of calls involve children <562% of calls involve children <5

Where and When?Where and When? 92% of all accidental exposures occur in the 92% of all accidental exposures occur in the

homehome 0.8% at school0.8% at school Early evening at meal time most likely, Early evening at meal time most likely,

followed by late morning.followed by late morning.

The “Epi” of Poisonings in The “Epi” of Poisonings in SCSC

What?What?38.8%38.8% Prescription and OTC medications, Prescription and OTC medications,

e.g. analgesics, cough/cold e.g. analgesics, cough/cold

9.0%9.0% Household cleaning substancesHousehold cleaning substances

9.1%9.1% Cosmetics and personal care Cosmetics and personal care productsproducts

9.1%9.1% PlantsPlants

8.5%8.5% Insecticides, herbicides, Insecticides, herbicides, rodenticidesrodenticides

4.5%4.5% Bites/envenomationsBites/envenomations


Parris Island, South Parris Island, South Carolina – “Respiratory” Carolina – “Respiratory”

Sentinel AlertsSentinel Alerts

Disease Surveillance at Marine Corps Recruit Disease Surveillance at Marine Corps Recruit Depot (MCRD), Parris IslandDepot (MCRD), Parris Island

Marine Corps Recruit Depot, Parris Marine Corps Recruit Depot, Parris IslandIsland

Marine Corps Air Station, Beaufort SCMarine Corps Air Station, Beaufort SC Naval Hospital, Beaufort SCNaval Hospital, Beaufort SC

Personnel Assigned to NHB 728

Officers - 113

Enlisted - 330

Civilian - 263

MC - 30

NC - 45

Within 1st, 2nd, and 3rd Battalions, there are four companies. Each company contains an average of six platoons with 60 to 80 recruits in each.

360 – 480 per company.

1440 – 1920 per Battalion.

Within 4th Battalion (350-400), there are three companies, N, O, and P. Each company contains an average of two platoons with 50 to 60 recruits in each. Fourth Battalion trains only female recruits.

Recruit Training Recruit Training RegimentRegiment

Beaufort Naval HospitalBeaufort Naval Hospital

Provides general medical services to all Active Duty Navy and Provides general medical services to all Active Duty Navy and Marine Corps Personnel, as well as Retired military personnel Marine Corps Personnel, as well as Retired military personnel and all military dependents residing in the Beaufort area, a and all military dependents residing in the Beaufort area, a total population of approximately 30,000 beneficiaries.total population of approximately 30,000 beneficiaries.

Hospital

Branch Health Clinic, MCAS Branch Health Clinic, MCRD

Parris Island

1st BAS

2nd BAS

3rd BAS

4th BAS

Director ClinicalSupport Services

Director ClinicalSupport Services

Officers – 28Enlisted – 158Civilians – 22Total 208

Preventive Medicine

Methods of Disease Methods of Disease DetectionDetection

Traditional reportable disease surveillanceTraditional reportable disease surveillance• State processes.State processes.• Navy Disease Reporting System (NDRS)Navy Disease Reporting System (NDRS)

Sentinel SurveillanceSentinel Surveillance• Naval Health Research Center’s FRI surveillance at Naval Health Research Center’s FRI surveillance at

recruit training centersrecruit training centers

Astute cliniciansAstute clinicians

Syndromic surveillanceSyndromic surveillance• ESSENCE IVESSENCE IV

14 admissions to BMH in 14 admissions to BMH in September and October 2005September and October 2005

2 from 12 from 1stst Battalion Battalion• Charlie company – 2Charlie company – 2

7 from 27 from 2ndnd Battalion Battalion• Foxtrot company - 3Foxtrot company - 3• Gulf company – 4Gulf company – 4

5 from 35 from 3rdrd Battalion Battalion• Lima company - 2Lima company - 2• Kilo company – 3Kilo company – 3

Patients are admitted to BMH when a chest tube is needed

Recruit Admission to Beaufort Naval Hospital and Beaufort Memorial Hospital for Pneumonia

2005

0

5

10

15

20

25

30

Janu

ary

Febru

ary

Mar

ch

April

May

June

Ju

ly

Augus

t

Septe

mbe

r

Octobe

r

Beaufort Naval (BNH)

Beaufort Memorial(BMH)

MCRD Parris Island, Data from ESSENCE

0

50

100

150

200

250

300

350

400

450

500

7/1

0/2

005

7/2

4/2

005

8/7

/20

05

8/2

1/2

005

9/4

/20

05

9/1

8/2

005

10/

2/2

005

Pa

tie

nts

Visits/Week forRespirtatory Complaints

Medical Visits/Week forPneumonia NOS

# of Patients withPneumonia NOS

Positive GABS throatcultures/wk

Weekly Penumonia visits: MCRD Parris Island. Data From ESSENCE

0

50

100

150

200

250

300

7/10

/200

5

7/17

/200

5

7/24

/200

5

7/31

/200

5

8/7/

2005

8/14

/200

5

8/21

/200

5

8/28

/200

5

9/4/

2005

9/11

/200

5

9/18

/200

5

9/25

/200

5

10/2

/200

5

MCRD Pneumonia visits (all types) weekly incidence for every 100 Recruits

0

0.5

1

1.5

2

2.5

3

4/10

/200

5

4/24

/200

5

5/8/

2005

5/22

/200

5

6/5/

2005

6/19

/200

5

7/3/

2005

7/17

/200

5

7/31

/200

5

8/14

/200

5

8/28

/200

5

9/11

/200

5

9/25

/200

5

10/9

/200

5

Series1

Weekly incidence of positive GABS cultures MCRD PI

-0.2

0

0.2

0.4

0.6

0.8

1

1.2

1/2/

2005

2/2/

2005

3/2/

2005

4/2/

2005

5/2/

2005

6/2/

2005

7/2/

2005

8/2/

2005

9/2/

2005

10/2

/200

5

11/2

/200

5

12/2

/200

5

GABS +

Why the rise? Why the rise?

Why the rise? We Why the rise? We considered:considered:

Crowed Living Conditions.Crowed Living Conditions. Poor hygiene? Poor hygiene?

• Always a struggle, but the Marine leadership Always a struggle, but the Marine leadership is more cooperative than ever in this area.is more cooperative than ever in this area.

• Random interviews of recruits in the clinic Random interviews of recruits in the clinic indicate that they have been properly indicate that they have been properly instructed re: hand hygiene.instructed re: hand hygiene.

Recruits presenting too late? Recruits presenting too late? • Interviews of the admitted recruits indicate Interviews of the admitted recruits indicate

that they were encouraged vs. discouraged that they were encouraged vs. discouraged to seek medical care early. to seek medical care early.

Why the rise? We Why the rise? We consideredconsidered

Something in the buildings? Something in the buildings? • Mold and moisture is a problem in some buildings aboard Mold and moisture is a problem in some buildings aboard

MCRD PI. Toxic mold was discovered in one building where MCRD PI. Toxic mold was discovered in one building where all recruits are massed together for training. all recruits are massed together for training.

Slow recognition of cases by providers? Slow recognition of cases by providers? • Some recruits admitted to BMH have been ill with Some recruits admitted to BMH have been ill with

respiratory symptoms for 3-4 weeks prior to respiratory symptoms for 3-4 weeks prior to admission, and they had been seen in “medical” admission, and they had been seen in “medical” two or more times prior to admission. two or more times prior to admission.

Too high a turnover in medical staff to ensure Too high a turnover in medical staff to ensure effective leadership and staff competency?effective leadership and staff competency?• 3 SMOs in last 4 months3 SMOs in last 4 months• Nearly 100% turnover of BAS staff in Sept-Oct.Nearly 100% turnover of BAS staff in Sept-Oct.

Lab ResultsLab Results

Nine of the 17 admission to BMH Nine of the 17 admission to BMH have grown GABS from pleural fluid, have grown GABS from pleural fluid, including 5 out of last 6 admitted in including 5 out of last 6 admitted in October.October.

Nothing atypical about resistance Nothing atypical about resistance patternspatterns

Actions TakenActions Taken

Chemo prophylaxis with Bicillin Chemo prophylaxis with Bicillin provided to all recruits in high provided to all recruits in high incident Companies, to their DI’s and incident Companies, to their DI’s and to their medical staff (BAS).to their medical staff (BAS).

Presented data to MCRD ProvidersPresented data to MCRD Providers

Pneumonia Visits 7-day Moving Avg.

0

10

20

30

40

50

601

1/1

6/2

00

2

1/1

6/2

00

3

3/1

6/2

00

3

5/1

6/2

00

3

7/1

6/2

00

3

9/1

6/2

00

3

11

/16

/20

03

1/1

6/2

00

4

3/1

6/2

00

4

5/1

6/2

00

4

7/1

6/2

00

4

9/1

6/2

00

4

11

/16

/20

04

1/1

6/2

00

5

3/1

6/2

00

5

5/1

6/2

00

5

7/1

6/2

00

5

9/1

6/2

00

5

11

/16

/20

05

1/1

6/2

00

6

Series1

MCRD Recruit Population

010002000300040005000600070008000

10/2

6/20

03

12/2

6/20

03

2/26

/200

4

4/26

/200

4

6/26

/200

4

8/26

/200

4

10/2

6/20

04

12/2

6/20

04

2/26

/200

5

4/26

/200

5

6/26

/200

5

8/26

/200

5

10/2

6/20

05

12/2

6/20

05

Series1

Early Event Detection:Early Event Detection:Over-the-Counter Drug Over-the-Counter Drug

SalesSales In South Carolina as of February 2006:In South Carolina as of February 2006:

• 536 distinct sources are represented in the data536 distinct sources are represented in the data Which is approx 2.6% of the National data sourcesWhich is approx 2.6% of the National data sources

Possible Uses for OTC Sales Data:Possible Uses for OTC Sales Data:• If OTC sales data indicate an increase in use of If OTC sales data indicate an increase in use of

anti-diarrheals, this could point to a foodborne anti-diarrheals, this could point to a foodborne outbreak.outbreak.

• An increase in the use of cold/flu remedies might An increase in the use of cold/flu remedies might give information on severity of the influenza give information on severity of the influenza season or an acute respiratory event (i.e. release season or an acute respiratory event (i.e. release of chlorine).of chlorine).

Date/Day Zip Code City County Number of Stores (zip) Standard Deviation Raw Count

18-Dec-05 29657 Pickens Pickens 1 4.49 2

Sunday 29696 West Union Oconee 1 4.62 6

Stores (by zip code)

% of stores represented

Count (by zip code)

% of count represented

Date/Day County

Stores (county)

w/ > 3 SD indicator

by zip code w/ aberration

Count (county)

w/ > 3 SD indicator


18-Dec-05 Pickens 12 1 8% 7 2 29%

Sunday Oconee 5 1 20% 6 6 100%


19-Dec-05 n/a n/a n/a n/a n/a n/a

Monday

Stores (by zip

code)% of stores

represented Count (by zip

code)% of count

represented

Date/Day County

Stores (county)

w/ > 3 SD indicator


Count (county)

w/ > 3 SD indicator


19-Dec-05 n/a n/a n/a n/a n/a n/a n/a

Monday



Count (by zip code)


Date/ Day County

Stores (county)

w/ > 3 SD indicator


Count (county)

w/ > 3 SD indicator


20-Dec-05 Greenville 69 2 3% 88 3 3%

Tuesday Spartanburg 30 2 7% 37 6 16%

Anderson 21 4 19% 35 11 31%


20-Dec-05 29601 Greenville Greenville 2 24.75 3

Tuesday 29356 Landrum Spartanburg 2 3.01 6

29654 Honea Path Anderson 2 3.01 4

29669 Pelzer Anderson 2 3.21 7



Wednesday



Count (by zip code)


Date/Day CountyStores

(county)w/ > 3 SD indicator


Count (county)

w/ > 3 SD indicator



Wednesday


22-Dec-05 29669 Pelzer Anderson 2 3.14 7

Thursday



Count (by zip code)


Date/ Day CountyStores

(county)w/ > 3 SD indicator


Count (county)

w/ > 3 SD indicator


22-Dec-05

Anderson 21 2 10% 28 7 25%

Thursday



Friday 29611 Greenville Greenville 6 3.65 8

29690 Traveler's Rest Greenville 2 4.27 10



Count (by zip code)


Date/ Day County

Stores (county)

w/ > 3 SD indicator


Count (county)

w/ > 3 SD indicator


23-Dec-05 Greenville 69 8 12% 105 22 21%

Friday



Saturday 29680 Simpsonville Greenville 4 4.39 16

29303 Spartanburg Spartanburg 4 3.22 6



Count (by zip code)


Date/ Day County

Stores (county)

w/ > 3 SD indicator


Count (county)

w/ > 3 SD indicator


24-Dec-05 Greenville 69 10 14% 138 32 23%

Saturday Spartanburg 30 4 13% 52 6 12%



Sunday



Count (by zip code)


Date/ Day County

Stores (county)

w/ > 3 SD indicator


Count (county)

w/ > 3 SD indicator


25-Dec-05 Greenville 69 6 9% 63 5 8%

Sunday



Monday



Count (by zip code)


Date/ Day County

Stores (county)

w/ > 3 SD indicator


Count (county)

w/ > 3 SD indicator



Monday

Next StepsNext Steps

Currently engaged in retrospective Currently engaged in retrospective studies for all documented outbreaks studies for all documented outbreaks from 2005, by mode of transmission, from 2005, by mode of transmission, to determine if an temporal to determine if an temporal association can be made and at what association can be made and at what level. level.

Bottom-lineBottom-line

““Syndromic surveillance is another Syndromic surveillance is another “arrow in our quiver” of ways to “arrow in our quiver” of ways to detect and respond to both our detect and respond to both our routine outbreaks of public health routine outbreaks of public health significance and also those large-significance and also those large-scale events that will require scale events that will require exceedingly complex reporting and exceedingly complex reporting and situational awareness requirements”.situational awareness requirements”.

AcknowledgementsAcknowledgements

SC DHECSC DHEC Amy BelflowerAmy Belflower Claire YoungbloodClaire Youngblood Marya BarkerMarya Barker Amy RoachAmy Roach Michelle MyerMichelle Myer Mary Anne Wenck, EIS OfficerMary Anne Wenck, EIS Officer

Palmetto Poison CenterPalmetto Poison Center Jill Michaels, PharmDJill Michaels, PharmD William Richardson, MDWilliam Richardson, MD

Marine Corps Recruit Depot Marine Corps Recruit Depot (MCRD), Parris Island(MCRD), Parris Island• LT Allen D. Wright, LT Allen D. Wright,

Preventive Medicine Preventive Medicine Department, Naval Hospital Department, Naval Hospital BeaufortBeaufort

CDCCDC Leslie Z SokolowLeslie Z Sokolow Roseanne EnglishRoseanne English Haobo MaHaobo Ma

Questions?Questions?

Documents

Experiences in the Use of Non-Traditional Data Sources in a Rural State – South Carolina Dan Drociuk, MT(ASCP), MSPH – Director Epidemiological Response