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

This presentation discusses the use of non-traditional data sources in South Carolina for epidemiological surveillance and response. It highlights the organization, dissemination of information, and case studies of current systems in use. The case study of a chlorine release in Graniteville, SC is also presented.

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

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  1. Experiences in the Use of Non-Traditional Data Sources in a Rural State – South Carolina Dan Drociuk, MT(ASCP), MSPH – Director Epidemiological Response / Enhanced Surveillance Section Division of Acute Disease Epidemiology South Carolina Department of Health and Environmental Control

  2. Outline • Part I: • The “People” • How we are organized to develop, implement, monitor and respond to EED system needs. • Part II: • The “Push” • How we disseminate information about EED systems and general epidemiological activities. • Part III: • The “Products” • Case studies showing the interaction and intersection of EED systems currently in use in South Carolina.

  3. Part I:The “People”

  4. A bit about South Carolina… • Approximate population: 4,350,500 (sans golf courses and beaches…) • Three MSA’s in the “Top 100”: • Columbia, Charleston, Rock Hill/Charlotte • Tourism a main industry along the costal areas • Centralized health department structure • All public health employees are state employees regardless of location • No local boards of health

  5. Current Systems in Use • Palmetto Poison Center (electronic daily feeds to public health), • National Retail Data Monitoring (NRDM) for OTC sales (using “home-grown” C1, C2, C3 indicators), • BioSense for DoD and VA ambulatory care procedures and ambulatory care diagnosis, • Essence data monitored and “crossed” with Biosense alerts and indicators. • Sentinel providers with Influenza-like Illness reporting (number/wk). • Two (2) pilot hospitals providing chief-complaint data in “home-grown” categories.

  6. Regional Epi Teams • Services are delivered and surveillance happens at the local/community level • Surveillance, case and outbreak investigation & response starts with the Regional Epi Team • 6-20 members • Mix of skills: nurses, Env. Health, PIO • Established 1995 to provide trained integrated team-based response to routine surveillance, case investigations, and outbreak investigations • Available for Urgent Reports 24/7 via on-call rotation.

  7. Epidemiological Responses to Events of Public Health Significance • “White powder events” • Ricin in a U.S. Postal Facility in Greenville • Chlorine tanker train derailment, Graniteville, SC • Numerous point-source outbreak investigations • Food-borne (Salmonella’s), • Water-borne (Legionella cluster, rash-illness), • Respiratory (Pertussis) • Hurricane Katrina Evacuation Center surveillance activities, Greenville, SC

  8. Part II:The “Push”

  9. Dissemination of Epi-related information • Daily • Provided to the South Carolina Intelligence Fusion Center • Reports from our Division of Acute Disease Epidemiology on-call staff for overnight calls received, • Summary information from our Early Event Detection Systems (BioSense, OTC sales, Palmetto Poison Center) • Previous day on-call events of public health significance • Weekly • Provided via the Epidemiological Weekly Report (EWR) • Summary information from our Regional and Central Office • Monthly • Meetings with Regional Epidemiology Response Staff • As Needed • Distribution via the SC Health Alert Network • CDC and DHEC Health Alerts/Advisories/Updates

  10. Example of a Daily SCIEx report

  11. Example of a weekly EWR

  12. EWR: Epidemiological Weekly Report • The EWR is compiled weekly from Regional and DADE reports. • It includes basic summary information related to an ongoing or concluding epi-investigations. • Submissions usually include what is known or hypothesized about etiology, geographic location, and numbers of persons affected.

  13. EWR: Epidemiological Weekly Report • Circulation: • The EWR is submitted to the Deputy Commissioner for Health Services, members of the Senior Leadership Team, Central and Regional Office Leadership, the Office of Public Health Preparedness, etc. • Goal: • Provide situational awareness regarding Epi activities across the state.

  14. EWR: Epidemiological Weekly Report • Statistics: • In 2005, EWR’s documented 288 “new investigations” of potential outbreaks or single cases of disease or events of public health significance. • In 2005 documented outbreaks totaled 62 stratified as follows (by modes of transmission): • Respiratory 20 (32%) • Foodborne 16 (26%) • Unknown 11 (18%) • Person-to-person 7 (11%) • Fecal-oral 5 ( 8%) • Contact 2 ( 3%) • Nosocomial 1 ( 2%)

  15. 2004-2005 SC Foodborne Outbreak Statistics

  16. Part III:The “Products”

  17. Case Study 1:Chlorine Release in Graniteville, South Carolina

  18. What Happened? • At 2:39 AM, a 42-car Norfolk and Southern train derailed • A tanker car containing chlorine was punctured, releasing approximately 60 tons of chlorine • The chlorine was released in the immediate vicinity of Avondale Mills, the commercial district, and residential areas of Graniteville SC

  19. Objectives of a Rapid Epidemiological Assessement • Assess • Extent of exposure • Morbidity • Health services used • Identify persons at risk for long-term sequelae • Risk factors for severe outcomes • Location of exposure

  20. Case Definition • Person treated for symptoms or complications from chlorine exposure • Identified by • Hospital emergency department logs • Physician reporting

  21. Emergency Department Visits within 24 Hours ED Visits, N=272 (%)

  22. Signs or Symptoms Reported

  23. Deaths, Hospitalizations, and Emergency Department Visits Following Train Derailment, Graniteville, SC - 2005 ED Visit, Not Admitted ED Visit, Not Admitted Admitted to Hospital Admitted to Hospital Deceased, at Site of Accident Deceased, at Site of Accident 1 3 5 7 9 11 13 15 17 19 21 23 25 280 280 260 260 100 100 Number of Events Number of Events 80 80 60 60 40 40 20 20 0 0 1 3 5 7 9 11 13 15 17 19 21 23 25 Day(s) Since Accident Day(s) Since Accident

  24. Hospitals that Treated Patients for Chlorine Exposure – January 6-7, 2005 40 Barnwell Edgefield 35 Lexington St. Josephs 30 Doctors 25 MCG Number of Patients University 20 Aiken 15 10 5 0 2-3 am 4-5 am 6-7 am 8-9 am 2-3 pm 4-5 pm 6-7 pm 8-9 pm 12-1 pm 12-1 am 10-11 am 10-11 pm Time

  25. Situational Awareness Issues • Healthcare providers are going to treat people first, and worry about the “coding” later • Review of charts showed a broad span of chief complaints (n=81), primary diagnosis (n=48) and ICD-9 codes (n=51) used. • Data used for situational awareness, many are going to be relying upon the data to make decisions. This is a “paradigm shift” beyond being simple early event detection system.

  26. Opportunities • Use of Early Event Detection systems for monitoring an emerging event must be flexible and sensitive to be able to answer the questions being asked, an EED must have the flexibility to allow local users to create ad hoc syndrome categories. • The wealth of information present via an electronic medical record only tells part of the story. The ability to identify the needs of the people impacted greatly contributes to the overall situational awareness of an emerging event.

  27. Next Steps • Within the 3-digit ZIP code area (ZIP3) 298 that surrounds Graniteville, BioSense identified a data anomaly based on the graphical visualization in the Respiratory syndrome category that corresponded to day 2 of the exposure. • However this anomaly was only apparent for 1 day (1/7/05) and the source of this anomaly has not been validated to determine both the source of this anomaly and its relationship to chlorine toxicity.

  28. Case Study 2:Use of Poison Control Center data

  29. Palmetto Poison Center • 1-800-222-1222 • Located in Columbia, SC • Serves the entire state of South Carolina • Staff consists of pharmacists and nurses • Medical Director is trained in toxicology and emergency medicine

  30. Palmetto Poison Center • Services Provided • 24 hours/7 days a week • Phone service to provide poison treatment information • For the public and health care professionals • Information requests • Medications • Pesticides • Plants • Food poisoning • Chemicals

  31. Statistics • South Carolina • 2005: Over 37,000 calls to the Center • 74% of total calls involved human poison exposures • 30% involved adults over 21yo • 80% managed by Poison Center without further medical evaluation needed

  32. Documentation • Every incoming call documented • Follow up calls included • Record includes name, phone number and zip code of caller • Patient data: • Age, gender weight • Exposure substance, route and amount • Reason for exposure • Time of exposure • Symptoms • Treatment provided • Outcome

  33. State Surveillance - DHEC Notification • Require notification of Public Health for: • Potential food poisoning/food tampering cases • Occupational pesticide exposures • Questionable exposure to current public health concerns, i.e. anthrax (‘suspicious powder calls’), West Nile Virus, chlorine toxicity • Animal bites

  34. State Surveillance - DHEC Notification • Currently faxing cases and providing downloads of toxidromes every 24hrs into Toxitrak • Case information from Poison Center is included in the upload • Reports can be generated • Ex. How many cases had vomiting, diarrhea, fever in Clarendon county in the last 4 weeks; number of suspected food poisoning cases from restaurants per county, city or zip code

  35. The “Epi” of Poisonings in SC • Who? • 62% of calls involve children <5 • Where and When? • 92% of all accidental exposures occur in the home • 0.8% at school • Early evening at meal time most likely, followed by late morning.

  36. The “Epi” of Poisonings in SC What? 38.8% Prescription and OTC medications, e.g. analgesics, cough/cold 9.0% Household cleaning substances 9.1% Cosmetics and personal care products 9.1% Plants 8.5% Insecticides, herbicides, rodenticides 4.5% Bites/envenomations

  37. Case Study 3:Parris Island, South Carolina – “Respiratory” Sentinel Alerts

  38. Personnel Assigned to NHB 728 Officers - 113 Enlisted - 330 Civilian - 263 MC - 30 NC - 45 Disease Surveillance at Marine Corps Recruit Depot (MCRD), Parris Island • Marine Corps Recruit Depot, Parris Island • Marine Corps Air Station, Beaufort SC • Naval Hospital, Beaufort SC

  39. Recruit Training Regiment 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.

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