Comparing Syndromic Surveillance and Poison Center Data for Snake Bites in Missouri

Objective

This study intends to use two different surveillance systems available in Missouri to explore snake bite frequency and geographic distribution.

Introduction

In 2010, there were 4,796 snake bite exposures reported to Poison Centers nationwide (1). Health care providers frequently request help from poison centers regarding snake envenomations due to the unpredictability and complexity of prognosis and treatment. The Missouri Poison Center (MoPC) maintains a surveillance database keeping track of every phone call received. ESSENCE, a syndromic surveillance system used in Missouri, enables surveillance by chief complaint of 84 different emergency departments (ED) in Missouri (accounting for approximately 90% of all ED visits statewide). Since calling a poison center is voluntary for health care providers, poison center data is most likely an underestimation of the true frequency of snake envenomations. Comparing MoPC and ESSENCE data for snake envenomations would enable the MoPC to have a more accurate depiction of snake bite frequency in Missouri and to see where future outreach of poison center awareness should be focused.

Methods

Archived data from Toxicall®, the MoPC surveillance system, was used to query the total number of snake bite cases from 01/01/2007 until 12/31/2011 called into the MoPC center by hospitals that also participate ESSENCE. Next, ESSENCE data was used to estimate the total number of snake envenomations presenting to EDs in Missouri. This was accomplished using the same date range as well as searching for key terms in the chief complaints that would signify a snake bite. The results of each datasearch were compared and contrasted by Missouri region.

Results

The Toxicall® search showed a total of 324 snake bite cases. The initial ESSENCE data query showed a total of 1983 snake bite cases. After certain data exclusions, there was a total of 1763 ESSENCE snake bite visits. This suggests that approximately 18% of all snake bite visits reported in Missouri ESSENCE were called into the MoPC. The results are demonstrated by Missouri region in Figure 1. This figure also shows that the greatest number of ESSENCE visits for snake bites were reported by Southwest region hospitals whereas the Eastern region hospitals placed the greatest number of calls to MoPC regarding snake bites.Open in a separate windowFigure 1:ESSENCE Snake Bites Cases Compared to Toxicall® Snake Bite Cases in Missouri by Region

Conclusions

The total number of snake bite cases from Missouri ESSENCE ED visits is much greater than the number of snake bites cases called into the MoPC by ESSENCE participating hospitals. This underutilization of the poison center demonstrates the increased need for awareness of the MoPC’s free services. In Missouri, the MoPC should target hospitals in the Southwest region for outreach in particular based on these findings. Poison centers are staffed by individuals trained in all types of poisonings and maintain a list of consulting physicians throughout the United States experienced in management and treatment of venomous snake bites (2). Any healthcare facility would benefit from MoPC assistance. Finally, syndromic surveillance allows for quick and easy data compilation, however there are some difficulties when attempting to search for a particular condition. Communication and partnership between two different public health organizations will be beneficial toward future public health studies.     

Surveillance for Radiation-Related Exposures Reported to the National Poison Data System

Objective

To describe radiation-related exposures of potential public health significance reported to the National Poison Data System (NPDS).

Introduction

For radiological incidents, collecting surveillance data can identify radiation-related public health significant incidents quickly and enable public health officials to describe the characteristics of the affected population and the magnitude of the health impact which in turn can inform public health decision-making. A survey administered by the Council of State and Territorial Epidemiologists (CSTE) to state health departments in 2010 assessed the extent of state-level planning for surveillance of radiation-related exposures and incidents: 70%–84% of states reported minimal or no planning completed. One data source for surveillance of radiological exposures and illnesses is regional poison centers (PCs), who receive information requests and reported exposures from healthcare providers and the public. Since 2010, the Centers for Disease Control and Prevention (CDC) and the American Association of Poison Control Centers (AAPCC) have conducted ongoing surveillance for exposures to radiation and radioactive materials reported from all 57 United States (US) PCs to NPDS, a web-based, national PC reporting database and surveillance system.

Methods

We collaborated with the American Association of Poison Control Centers (AAPCC), Poisindex® and Thomson Reuters Healthcare to develop an improved coding system for tracking radiation-related exposures reported to US PCs during 2011 and trained PC staff on its usage. We reviewed NPDS data from 1 September 2010 – 30 June 2012 for reported exposures to pharmaceutical or nonpharmaceutical radionuclides; ionizing radiation; radiological or nuclear weapons; or X-ray, alpha, beta, gamma, or neutron radiation. CDC medical toxicology and epidemiology staff reviewed each reported exposure to determine whether it was of potential public health concern (e.g. exposures associated with an ongoing public health emergency, several reported exposures clustered in space and time). When further information was needed to classify the potential public health importance of a call, CDC and AAPCC staff contacted the regional PC where each call originated. When exposures were spatially and temporally clustered, we reviewed news stories in the public media for evidence of an associated radiation incident.

Results

Of 419 exposures reported during the study period, 25 were associated with a radiation-related incident. Of these, 4 were related to an exposure to x-ray radiation from an industrial radiography incident, 11 were related to a transportation accident involving potential contamination with radioactive material, and 10 were related to the Fukushima Daiichi Japan nuclear reactor disaster. Public health, hazardous materials, or hospital radiation safety staff were involved in responding to each of these events. We also identified 26 reported exposures associated with a regional radiation anti-terrorism exercise. The reported exposures were followed-up and removed from analysis once we determined they were part of the exercise. The remaining (n=368; 88%) were either requests for information, confirmed non-exposures, or exposures deemed unrelated or non-significant.

Conclusions

The capability to monitor self- or clinician-reported exposures to radiation and radioactive materials is available in NPDS for state and local public health use in collaboration with their regional PC and may improve public health capacity to identify and respond to radiological emergencies. Next steps include testing the system’s capability to accurately classify and rapidly respond to a cluster of calls to PCs reporting radiation exposures associated with a “dirty bomb” exercise during July, 2012.     

Towards Interoperability for Public Health Surveillance: Experiences from Two States

Objective

To characterize the use of standardized vocabularies in real-world electronic laboratory reporting (ELR) messages sent to public health agencies for surveillance.

Introduction

The use of health information systems to electronically deliver clinical data necessary for notifiable disease surveillance is growing. For health information systems to be effective at improving population surveillance functions, semantic interoperability is necessary.Semantic interoperability is “the ability to import utterances from another computer without prior negotiation” (1). Semantic interoperability is achieved through the use of standardized vocabularies which define orthogonal concepts to represent the utterances emitted by information systems. There are standard, mature, and internationally recognized vocabularies for describing tests and results for notifiable disease reporting through ELR (2). Logical Observation Identifiers Names and Codes (LOINC) identify the specific lab test performed. Systematized Nomenclature of Medicine-Clinical Terms (SNOMED CT) identify the diseases and organisms tested for in a lab test.Many commercial laboratory and hospital information systems claim to support LOINC and SNOMED CT on their company websites and in marketing materials, and systems certified for Meaningful Use are required to support LOINC and SNOMED CT. There is little empirical evidence on the use of semantic interoperability standards in practice.

Methods

To characterize the use of standardized vocabularies in electronic laboratory reporting (ELR) messages sent to public health agencies for notifiable disease surveillance, we analyzed ELR messages from two states: Indiana and Wisconsin. We examined the data in the ELR messages where tests and results are reported (3). For each field, the proportion of field values that used either LOINC or SNOMED CT codes were calculated by dividing the number of fields with coded values by the total number of non-null values in fields.

Results

Results are summarized in

上海市普陀区社区卫生服务中心门诊伤害监测分析

目的掌握普陀区伤害流行现状,了解伤害防治的侧重点,为建立完善的伤害监测系统提供依据。方法在普陀区建立以社区卫生服务中心为基础的伤害病例报告网络及监测系统,并加强报告单位的质量管理检查,落实伤害报告制度。结果普陀区门诊伤害病例中,多发年龄段为以中老年女性为主,伤害原因集中在跌落、跌倒,占66.48%。男性伤害多发于街道和公路,女性则以家中为主。结论普陀区伤害防治重点人群应为中老年女性。同时,应把本区的二、三级医院纳入监测系统以完善本区地伤害病例报告监测系统。     

浙江省公共卫生监测区传染病监测样本地区合理性评价

目的分析监测区传染病报告发病率与全省疫情报告发病率的一致性,评价浙江省卫生监测区样本地区抽样设计的合理性.方法利用1991～2000年疫情资料分别统计监测区与全省疫情的总报告发病率和分疾病系统、分地区类别的报告发病率,进行相关分析.结果监测区传染病总报告发病率高于全省疫情13.65%,两个系统传染病报告发病率呈相关关系(r＝0.9637 t＝10.21 p＜0.01);除二类农村外,其余4类地区监测区所得的报告发病率分别高于全省疫情8.18%、20.53%、3.22%、7.70%,相关系数分别为0.8664、0.9293、0.8866、0.9896,具有很强的相关性;肠道、血源与性传播传染病监测结果:监测区年均报告发病率高于大疫情12.83%、16.46%,具有很强相关性.结论监测区监测结果与全省结果一致,卫生监测区地区样本抽样设计是合理的.     

社区卫生服务中心人力资源现状分析与建议：以南京市建邺区为例

目的了解南京市建邺区社区卫生服务中心人力资源状况,探索改善社区卫生服务中心人力资源配置的有效措施。方法对南京市建邺区7家社区卫生服务中心的人力资源状况进行调查。结果部分社区卫生服务机构人员配备不足,结构不合理,缺少中高级职称人才,女性偏多。收入低、工作量大、社会地位低是影响人员稳定和工作积极性的主要因素。结论各级行政部门应建立合理的人员配置评定体系;应加大投入力度,加强人才队伍建设;应制定合理的社区卫生服务机构考核细则等。     

2006年威海市突发公共卫生事件信息监测分析

[目的]分析威海市突发公共卫生事件信息,规范各类突发公共卫生事件的报告、处置,提高应对突发公共卫生事件的能力。[方法]利用国家突发公共卫生事件信息报告管理系统,采用描述性流行病学方法分析威海市突发公共卫生事件信息。[结果]2006年威海市共报告突发事件及相关信息103起,确认分级的突发事件10起。其中,较大突发事件2起,一般突发事件8起,其余93起为未分级突发事件。共波及22916人,病例448例,死亡4例。传染病事件13起,食物中毒事件3起,环境因素事件87起。环翠区报告最多,45起,占43.69%。报告发生突发事件农村82起,占79.61%。12月发生88起,占85.44%。448例病例中,男性174例,女性274例;年龄以2~29岁年龄组居多,占80.58%;职业分布以学生为主,占51.79%。[结论]突发公共卫生事件多数发生农村、学校及流动人口聚集区,死亡病例主要发生在农村,应切实落实相应预防和控制措施,减少突发公共卫生事件的发生。     

Public Health Surveillance in Pilot Drinking Water Contamination Warning Systems

Objective

This paper describes the lessons learned from operation and maintenance of the public health surveillance (PHS) component of five pilot city drinking water contamination warning systems (CWS) including: Cincinnati, New York, San Francisco, Philadelphia, and Dallas.

Introduction

The U.S. Environmental Protection Agency (EPA) designed a program to pilot multi-component contamination warning systems (CWSs), known as the “Water Security initiative (WSi).” The Cincinnati pilot has been fully operational since January 2008, and an additional four pilot utilities will have their own, custom CWSs by the end of 2012. A workshop amongst the pilot cities was conducted in May 2012 to discuss lessons learned from the design, implementation, operation, maintenance, and evaluation of each city’s PHS component.

Methods

When evaluating potential surveillance tools to integrate into a drinking water contamination warning system, it is important to consider design decisions, dual use applications/considerations, and the unique capabilities of each tool. The pilot cities integrated unique surveillance tools, which included a combination of automated event detection tools and communication and coordination procedures into their respective PHS components. The five pilots performed a thorough, technical evaluation of each component of their CWS, including PHS.

Results

Four key lessons learned were identified from implementation of the PHS component in the five pilot cities. First, improved communication and coordination between public health and water utilities was emphasized as an essential goal even if it were not feasible to implement automated surveillance systems. The WSi pilot project has helped to strengthen this communication pathway through the process of collaborating to develop the component, and through the need to investigate PHS alerts.Second, the approximate location of specific cases associated with PHS alerts was found to be an essential feature that allowed a cross-comparison to water pressure zones when attempting to locate the source of possible contamination. More specific location data (e.g., latitude and longitude) leads to a more efficient investigation, however, just narrowing the case location down to a specific hydraulic region within the water distribution system is extremely useful.Third, the ability to quickly visualize spatial distribution of cases via a visual interface was reported to be valuable to investigators during alert investigations. Most pilots implemented a CWS dashboard, in the form of a central graphical display, which presents the alerts and was used by the water utility and public health to obtain an understanding of geospatial relationships between cases, alerts and water pressure zones.Finally, public health and water utility representatives from several of the WSi pilots acknowledged that their automated surveillance tools currently have limited capabilities for detection of chemical contaminants (which may result in a sudden onset of symptoms), with the main deficiency being the timeliness of the alerts relative to the window of opportunity to respond in a meaningful and effective manner. While they currently focus on detection of traditional waterborne diseases, these tools could potentially be adapted to also detect chemical contaminants.

Conclusions

The results of the pilots have demonstrated that it is important to construct and formalize standard operating procedures, so that public health personnel and water utilities have a standard communication protocol. As a basic step to a PHS component, it is important to establish a relationship between utilities and public health. In addition to the efforts of the WSi pilots, research is currently being conducted by the U.S. EPA to analyze health seeking behavior of symptomatic individuals, because all PHS tools rely on data generated from behavior pursued by the affected population during a public health incident. Results from analysis of both emergency department data and poison control center follow-up phone data are currently underway.     

Peer Reviewed: Public Health Surveillance for Mental Health

Public health systems have relied on public health surveillance to plan health programs, and extensive surveillance systems exist for health behaviors and chronic disease. Mental health has used a separate data collection system that emphasizes measurement of disease prevalence and health care use. In recent years, efforts to integrate these systems have included adding chronic disease measures to the Collaborative Psychiatric Epidemiology Surveys and depression measures to the Behavioral Risk Factor Surveillance System; other data collection systems have been similarly enhanced. Ongoing challenges to integration include variations in interview protocols, use of different measures of behavior and disease, different interval reference periods, inclusion of substance abuse disorders, dichotomous vs continuous variables, and approaches to data collection. Future directions can address linking surveillance efforts more closely to the needs of state programs, increasing child health measurements in surveys, and improving knowledge dissemination from survey analyses.     

日本急性传染病和突发公共卫生事件综合监测及应对体系介绍与启示

采用文献研究方法,通过卫生服务体系六模块理论,分别从服务提供、领导力与治理、信息系统、卫生人力、筹资和技术等方面对日本急性传染病和突发公共卫生综合监测和应对体系进行介绍。提示我国在应对急性传染病和突发公共卫生事件时,应重视事前预防,充分发挥卫生部门的决策支撑作用;加强智库建设,保证资金到位;加强信息共享,拓宽信息来源渠道,整合技术性贸易措施等     

医疗机构突发公共卫生事件监测能力现状分析及改善对策

本研究采用分层抽样的方法,对黑龙江省19家医疗机构的299名相关的医疗服务人员进行了调查,调查采用了定性与定量相结合的研究方法,以了解医疗机构突发公共卫生事件监测能力的现状,比较不同层级、部门等医务人员的监测能力差异,以及影响医疗机构医务人员监测报告能力的因素,并提出了相关的政策建议,以完善医院在突发公共卫生事件监测系统中的作用。     

公共卫生监测理论对职业卫生监测工作的启迪

职业病防治工作不仅是社会关注热点问题,也是公共卫生领域的重点工作。防治职业病,保护和促进劳动者健康,是职业卫生工作的最终目标,而职业卫生监测是连接疾病与预防的重要桥梁。职业卫生监测所反馈的信息,对职业病防治工作具有重要的指导作用。在近二十年里,对职业卫生监测的关注度大大增加,这一方面是得益于政府部门对工业化发展和公共卫生能力建设的重视,同时也是由于劳动力资源紧缺、用工成本增加、劳动者赔偿成本增高、人口老龄化等诸多现实因素的刺激作用。