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Implementation of Adult Herpes Zoster (HZ) Surveillance in West Philadelphia, 2006

Implementation of Adult Herpes Zoster (HZ) Surveillance in West Philadelphia, 2006. Niya Spells, BA (niya.spells@phila.gov), Priya Abraham, BS, Dana Perella, MSPH, Mia Renwick, MPH, Barbara Watson, MbChB Varicella Active Surveillance Project (VASP)

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Implementation of Adult Herpes Zoster (HZ) Surveillance in West Philadelphia, 2006

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  1. Implementation of Adult Herpes Zoster (HZ) Surveillance in West Philadelphia, 2006 Niya Spells, BA (niya.spells@phila.gov), Priya Abraham, BS, Dana Perella, MSPH, Mia Renwick, MPH, Barbara Watson, MbChB Varicella Active Surveillance Project (VASP) Philadelphia Department of Public Health This research was supported by cooperative agreement U66/CUU 311179-2-02, National Immunization Program, Centers for Disease Control and Prevention. The presenter has no conflicts of interest to disclose.

  2. Up to 1,000,000 cases/year in the United States.1 >67% of cases occur in people >50 years.2 Lifetime incidence: 20%-30%.1 ~ 50% of persons >85 experience zoster The Incidence of Herpes Zoster 1. Schmader KE. Clin Geriatr Med 2007 23:615-632. 2.Strauss SE, Oxman MN. In:Freedberg IM, Eisen AZ, Wolff K, et al, eds. Fitzpatrick’s Dermatology in General Medicine. 5th ed. Vol 2. New York, NY: McGraw-Hill; 1999:2427-2450. 3. Arvin AM. In: Knipe DM, Howley PM, eds. Field Virology. 4th ed. Vol 2. New York, NY: Lippencott Williams & Wilkins; 2001:2731-2767.

  3. Objective • To describe Adult Herpes Zoster (HZ) and Post Herpetic Neuralgia (PHN) surveillance in West Philadelphia, and present initial results on: • Surveillance Methods and Expansion Process • Baseline Incidence • Baseline Clinical Characteristics

  4. Why is Adult Herpes Zoster Surveillance Needed? • To evaluate the shingles vaccination program’s impact on HZ incidence and disease severity among adults.

  5. West Philadelphia Active Surveillance Area • Area: 7 zip codes/ 26 square miles • Population: ~269,000 residents • ~1/5 of the population of Philadelphia • ~27% age 50+ • Higher Proportion of Female Adults aged > 50 years • Majority African American/Non-Hispanic (~77%) VASP West Philadelphia Surveillance Area

  6. Traditional Sources Contacted state and local professional organizations to obtain comprehensive HCP lists to identify potential sites. Cross-referenced these sites with current MS-Access database. Performed on-site orientation with new sites The Expansion Process, 2005 Electronic Sources • Monthly Hospital Billing Reports for residents city-wide with HZ Diagnosis (053.X) • Daily Reports from Hospital ERs for residents city-wide with HZ Chief Complaints and/or Discharge Diagnoses

  7. West Philadelphia Active Surveillance Sites *Represent different departments within each facility: ER, Infection Control, Oncology, Medical Records, Internists /Outpatient clinics **Includes dermatologists, family planning clinics, pain clinics, and infectious disease specialists. ***Schools, daycares, homeless shelters, recreation centers, prisons

  8. Active Surveillance • Identify contacts, establish and maintain relationships with sites • Send bi-monthly reminders to report cases via fax and email • Call non-reporting sites • Conduct site visits to collect reports and assess problems

  9. Case Investigation • Acute information collected: • Rash description • Pain severity, including impact on activities of daily living (ADL) • Complications • Healthcare sought • Treatment HZ • Household VZV transmission links • Underlying conditions • VZV disease / vaccination history • Demographics • HZ Case Definition: Vesicular rash in a dermatomal distribution with healthcare provider diagnosis OR diagnosis verification by medical record review. • Assessment of Post Herpetic Neuralgia (PHN) conducted 4 months after rash healed for those with ongoing pain. • PHN Case Definition: Ongoing pain at site of rash more than 90 days after rash onset.

  10. 154 Confirmed Adult HZ Cases 68% Unilateral Rash Along Single Dermatome Majority (90%) with positive or uncertain history of varicella 1 case developed rash 16 days after vaccination 23% Immuno-compromised All Diagnosed by a Health Care Professional 88% Received Anti-Viral Medication 2006 HZ Surveillance Results Dermatomal Distribution of Zoster Among Confirmed Cases, 2006

  11. Adult Herpes Zoster Cases and Rates by Age Group, West Philadelphia, 2006 Number of Cases Rate per 100,000 population Total Number of Cases = 154

  12. HZ Cases and Rates by Age Group and Gender in West Philadelphia, 2006

  13. Medical Facilities Visited For HZ, 2006 3% Other Specialty 8% Hospital 13% Primary Care Provider 8% Long Term Care 7% Health Center 3% Eye Specialist 58% ER 18% Immunocompromised 72% Other Chronic Conditions 51% Severe Pain N=152

  14. Pain Severity by Age Group in West Philadelphia, 2006 Percentage of Cases

  15. Prescription Pain Medications by HZ Pain Severity, 2006 Percentage of Cases

  16. PHN by Age Group, 2006 Percentage of Cases

  17. Other HZ-Related Complications by Immune Status, 2006 *Fisher’s Exact test. NS: No significant difference detected (p-value≥0.05)

  18. Transmission of VZV to Household Members • 117 HZ cases with household member information obtained • 46 (39%) lived alone • 46 (39%) lived with one household member • Nearly all adults ≥20 years of age (43, 93%) • Secondary transmission of VZV only occurred in one household

  19. Key Findings from the 1st Year of Active Adult HZ Surveillance • New surveillance sites provided additional HZ case reports among West Philadelphia residents aged ≥70 years. • Over one-half of HZ cases reported to VASP in 2006 sought care at an ER. • Majority (77%) reported having a condition requiring regular healthcare provider visits and likely have a primary care provider. • Household transmission of VZV from HZ cases aged ≥50 years was rare.

  20. Strengths HZ is reportable by City Ordinance Existing sites have been educated to report HZ for several years City-wide electronic surveillance captures West Philadelphia residents seeking care outside of the surveillance area Limitations Surveillance relies primarily on HZ cases who seek care Ensuring reporting completeness will be harder to achieve among adults Accuracy of reporting may vary by site type Obtaining clinical information from the elderly is difficult Strengths and Limitations of HZ Surveillance in West Philadelphia

  21. Future Implications • Provide baseline clinical characterization of HZ for the evaluation of the shingles vaccination program • Establish role of Adult HZ in VZV transmission

  22. Acknowledgements • CDC VASP Staff • Aisha Jumaan, PhD, MPH • Jessica Leung, MPH • Riduan Joesoef, MD, PhD • Meredith Reynolds, PhD • Sandra Dos Santos Chaves, MD, MSc • Participating Active Surveillance Sites in West Philadelphia

  23. QUESTIONS

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