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The validity of chief complaint and discharge diagnosis on emergency department-based syndromic surveillance

ACADEMIC EMERGENCY MEDICINE 2004年第12期11卷 1262-1267页

作者： Fleischauer, AT Silk, BJ Schumacher, M Komatsu, K Santana, S Vaz, V Wolfe, M Hutwagner, L Cono, J Berkelman, R Treadwell, T Ctr Dis Control & Prevent Bioterrorism Preparedness & Response Program Natl Ctr Infect Dis Atlanta GA 30333 USA Emory Univ Rollins Sch Publ Hlth Ctr Publ Hlth Preparedness & Res Atlanta GA 30322 USA Maricopa Cty Dept Publ Hlth Dept Epidemiol Biodef Preparedness & Response Phoenix AZ USA Arizona Dept Hlth Serv Infect Dis Epidemiol Sect Phoenix AZ 85007 USA Natl Ctr HIV STD & TB Prevent Div HIV AIDS Prevent Ctr Dis Control & Prevent Atlanta GA USA

Objective: Emergency department (ED)-based syndromic surveillance systems are being used by public health departments to monitor for outbreaks of infectious diseases, including bioterrorism;however, few systems have been validated. The authors evaluated a "drop-in" syndromic surveillance system by comparing syndrome categorization in the ED with chief complaints and ED discharge diagnoses from medical record review. Methods: A surveillance form was completed for each ED visit at 15 participating Arizona hospitals between October 27 and November 18, 2001. Each patient visit was assigned one of ten clinical syndromes or "none." For six of 15 EDs, K statistics were used to compare syndrome agreement between surveillance forms and syndrome categorization with chief complaint and ED discharge diagnosis from medical record review. Results: Overall, agreement between surveillance forms and ED discharge diagnoses (kappa = 0.55;95% confidence interval [CI] = 0.52 to 0.59) was significantly higher than between surveillance forms and chief complaints (K = 0.48;95% CI = 0.44 to 0.52). Agreement between chief complaints and ED discharge diagnoses was poor for respiratory tract infection with fever (kappa =0.33;95% CI = 0.27 to 0.39). Furthermore, pediatric chief complaints showed lower agreement for respiratory tract infection with fever when compared with adults (kappa = 0.34 [95% CI = 0.20 to 0.47] vs. K = 0.44 [95% CI = 0.28 to 0.59], respectively). Conclusions: In general, this syndromic surveillance system classified patients into appropriate syndrome categories with fair to good agreement compared with chief complaints and discharge diagnoses. The present findings suggest that use of ED discharge diagnoses, in addition to or instead of chief complaints, may increase surveillance validity for both automated and drop-in syndromic surveillance systems.

关键词： bioterrorism preparedness syndromic surveillance emergency departments chief complaint discharge diagnosis evaluation

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Implementing syndromic surveillance: A practical guide informed by the early experience

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JOURNAL OF THE AMERICAN MEDICAL INFORMATICS ASSOCIATION 2004年第2期11卷 141-150页

作者： Mandl, KD Overhage, JM Wagner, MM Lober, WB Sebastiani, P Mostashari, F Pavlin, JA Gesteland, PH Treadwell, T Koski, E Hutwagner, L Buckeridge, DL Aller, RD Grannis, S Harvard Univ Childrens Hosp Informat Program Ctr BiopreparednessDiv Emergency MedSch Med Boston MA 02115 USA Indiana Univ Sch Med Reganstrief Inst Indianapolis IN USA Univ Pittsburgh Ctr Biomed Informat Real Time Outbreak & Dis Lab Pittsburgh PA USA Univ Washington Sch Med Dept Med Educ & Biomed Informat Seattle WA USA Univ Massachusetts Dept Math & Stat Amherst MA 01003 USA New York City Dept Publ Hlth Div Epidemiol New York NY USA Walter Reed Army Inst Res Silver Spring MD USA Univ Utah Salt Lake City UT USA Intermt Hlth Care Salt Lake City UT USA Ctr Dis Control & Prevent Bioterrorism Preparedness & Response Program Natl Ctr Infect Dis Atlanta GA USA Palo Alto Vet Hlth Care Syst Palo Alto CA USA Quest Diagnost Inc Teterboro NJ USA Stanford Univ Stanford Med Informat Stanford CA 94305 USA Los Angeles Cty Publ Hlth Acute Communicable Dis Unit Los Angeles CA USA

Syndromic surveillance refers to methods relying on detection of individual and population health indicators that are discernible before confirmed diagnoses are made. In particular, prior to the laboratory confirmation of an infectious disease, ill persons may exhibit behavioral patterns, symptoms, signs, or laboratory findings that can be tracked through a variety of data sources. Syndromic surveillance systems are being developed locally, regionally, and nationally. The efforts have been largely directed at facilitating the early detection of a covert bioterrorist attack, but the technology may also be useful for general public health, clinical medicine, quality improvement, patient safety, and research. This report, authored by developers and methodologists involved in the design and deployment of the first wave of syndromic surveillance systems, is intended to serve as a guide for informaticians, public health managers, and practitioners who are currently planning deployment of such systems in their regions.

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Epidemiologic clues to bioterrorism

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PUBLIC HEALTH REPORTS 2003年第2期118卷 92-98页

作者： Treadwell, TA Koo, D Kuker, K Khan, AS CDCP CDC Natl Ctr Infect Dis Bioterrorism Preparedness & Response Program Atlanta GA 30333 USA CDCP Epidemiol Program Off Atlanta GA 30333 USA Fed Bur Invest Acad Washington DC USA CDCP Natl Ctr Infect Dis Div Parasit Dis Atlanta GA 30333 USA

Public health investigators have successfully carried out epidemiologic investigations of outbreaks of disease for many years. By far the majority of these outbreaks have occurred naturally. With the recent illnesses resulting from deliberate dissemination of B. anthracis on an unsuspecting population, public health investigation of diseases must now include consideration of bioterrorism as a potential cause of outbreaks of disease. The features of naturally occurring outbreaks have a certain amount of predictability in terms of consistency with previous occurrences, or at least biological plausibility. However, with a deliberately introduced outbreak or infection among a population, this predictability is minimized. In this paper, the authors propose some epidemiologic clues that highlight features of outbreaks that may be suggestive of bioterrorism. They also describe briefly the general process of involvement of agencies at various levels of government, public health and non-public health, depending on the extent of an outbreak or level of suspicion. I would rather live in a world where my life is surrounded by mystery than live in a world so small that my mind could comprehend it. Harry Emerson Fosdick.

关键词： bioterrorism EPIDEMIOLOGY

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World Trade Center Rescue Worker Injury and Illness Surveillance, New York, 2001

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AMERICAN JOURNAL OF PREVENTIVE MEDICINE 2003年第2期25卷 79-87页

作者： Berríos-Torres, SI Greenko, JA Phillips, M Miller, JR Treadwell, T Ikeda, RM Ctr Dis Control & Prevent Div Violence Prevent Natl Ctr Injury Prevent & Control Atlanta GA 30333 USA Ctr Dis Control & Prevent Bioterrorism Preparedness & Response Program Natl Ctr Infect Dis Atlanta GA 30333 USA City New York Dept Hlth & Mental Hyg New York NY USA

Background: The September 11, 2001, terrorist attacks on the World Trade Center in New York City, New York, prompted an unprecedented rescue and recovery response. Operations were conducted around the clock, involved over 5000 workers per day, and extended into months following the attacks. The City of New York Department of Health and Mental Hygiene and the Centers for Disease Control and Prevention implemented prospective surveillance to characterize rescue worker-related injury and illness and to help guide public health interventions. Methods: From September 11 to October 11, 2001, personnel reviewed medical records at four Manhattan hospital emergency departments (EDs), and healthcare providers completed data collection forms at five temporary Disaster Medical Assistance Team (DMAT) facilities located at the site. Rescue workers included construction workers, police officers, firefighters, emergency medical service technicians, or Urban Search and Rescue workers. Data collected included demographic characteristics, injury type, illness, and disposition. Results: Of 5222 rescue worker visits, 89% were to DMAT facilities and 12% to EDs. Musculoskeletal conditions were the leading cause of visits (19%), followed by respiratory (16%) and eye (13%) disorders. Incidence rates were estimated based on total injuries and/or illnesses reported times 200,000 (100 equivalent full-time workers in I year at 40 hours per week X 50 weeks per year), then divided by the total number of hours worked. Eye disorders (59.7) accounted for the highest estimated injury and illness rate, followed by headache (46.8). One death, 52 hospital admissions, and 55 transports were reported. Findings underscored the need to coordinate distribution and enforcement of personal protective equipment use, purchase of diagnostic equipment to diagnose corneal abrasions, and distribution of health advisories. Conclusions: This system provided objective, timely information that helped guide public health

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The role of an advanced practice public health nurse in bioterrorism preparedness

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PUBLIC HEALTH NURSING 2003年第6期20卷 422-431页

作者： Mondy, C Cardenas, D Avila, M Los Angeles Cty Dept Hlth Serv Acute Communicable Dis Control Program Bioterrorism Preparedness & Response Unit Los Angeles CA USA

The 2001 anthrax events have vividly illustrated that terrorism involving the release of a biological agent is a major public health emergency requiring an immediate and well-coordinated response. If healthcare professionals and emergency responders are to be prepared to manage such attacks, unprecedented cooperative efforts at the national, state, and local levels are necessary. To aid such efforts, advanced practice public health nurses (PHNs) must exercise their ability to collaborate with a variety of disciplines and communities. Using the Los Angeles County Public Health Nursing Practice Model, advanced practice PHNs can be trained to deal effectively with acts of bioterrorism. This model defines the practice of public health nursing as working on a population-based level to create conditions under which healthy people can live within healthy communities. This article will discuss the threat of bioterrorism and describe how the Public Health Nursing Practice Model can be applied to assist advanced practice PHNs in the development of a public health plan for preparedness and response to bioterrorism. Six specific interventions that enable advanced practice PHNs to affect populations at the community and systems level will be discussed along with the implications of bioterrorism for advanced practice public health nursing.

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bioterrorism Web site resources for infectious disease clinicians and epidemiologists

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CLINICAL INFECTIOUS DISEASES 2003年第11期36卷 1458-1473页

作者： Ferguson, NE Steele, L Crawford, CY Huebner, NL Fonseka, JC Bonander, JC Kuehnert, MJ Ctr Dis Control & Prevent Off Hlth Commun Natl Ctr Infect Dis Atlanta GA 30333 USA Ctr Dis Control & Prevent Div Healthcare Qual Promot Natl Ctr Infect Dis Atlanta GA 30333 USA Ctr Dis Control & Prevent Bioterrorism Preparedness & Response Program Natl Ctr Infect Dis Atlanta GA 30333 USA Ctr Dis Control & Prevent Informat Resources Management Off Atlanta GA 30333 USA Ctr Dis Control & Prevent Off Director Off Commun Atlanta GA 30333 USA Northrop Grumman Mission Syst Los Angeles CA USA

Finding bioterrorism-related information on the World Wide Web can be laborious. We hope to help readers find such information more easily by summarizing essential information in a consistent framework. A panel of 7 Centers for Disease Control and Prevention reviewers identified Web sites and evaluated them for sponsorship, mission, content usefulness, online ease of use, and adherence to commonly accepted quality criteria. Of 1100 potential sites identified, 81 were chosen for target content of interest, and 43 were selected for inclusion. The results were classified into general purpose/portal sites;biological agent information;laboratory, infection control, epidemiology, and mental health information;and emergency contact sources, news and updates, event preparedness resources, information for first-responder settings, clinical and public education materials, and research resources. Agents covered included anthrax, smallpox, plague, botulism, tularemia, and viral hemorrhagic fever.

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Clinical features that discriminate inhalational anthrax from other acute respiratory illnesses

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CLINICAL INFECTIOUS DISEASES 2003年第3期36卷 328-336页

作者： Kuehnert, MJ Doyle, TJ Hill, HA Bridges, CB Jernigan, JA Dull, PM Reissman, DB Ashford, DA Jernigan, DB Ctr Dis Control Natl Ctr Infect Dis Div Healthcare Qual Promot Atlanta GA 30333 USA Ctr Dis Control Natl Ctr Infect Dis Div Viral & Rickettsial Dis Atlanta GA 30333 USA Ctr Dis Control Natl Ctr Infect Dis Div Bacterial & Mycot Dis Atlanta GA 30333 USA Ctr Dis Control Natl Ctr Infect Dis Bioterrorism Preparedness & Response Program Atlanta GA 30333 USA Ctr Dis Control & Prevent Div Publ Hlth Surveillance & Informat Epidem Intelligence Serv Branch Epidemiol Program Off Atlanta GA USA Ctr Dis Control & Prevent Div Appl Publ Hlth Training Epidem Intelligence Serv Branch Epidemiol Program Off Atlanta GA USA

Inhalational anthrax (IA) is a rapidly progressive disease that frequently results in sepsis and death, and prompt recognition is critical. To distinguish IA from other causes of acute respiratory illness, patients who had IA were compared with patients in an ambulatory clinic who had influenza-like illness (ILI) and with hospitalized patients who had community-acquired pneumonia (CAP) at the initial health care visit. Compared with patients who had ILI, patients who had IA were more likely to have tachycardia, high hematocrit, and low albumin and sodium levels and were less likely to have myalgias, headache, and nasal symptoms. Scoring systems were devised to compare IA with ILI or CAP on the basis of strength of association. For ILI, a score of greater than or equal to4 captured all 11 patients with IA and excluded 664 (96.1%) of 691 patients with ILI. Compared with patients who had CAP, patients with IA were more likely to have nausea or vomiting, tachycardia, high transaminase levels, low sodium levels, and normal white blood cell counts. For CAP, a score of greater than or equal to3 captured 9 (81.8%) of 11 patients with IA and excluded 528 (81.2%) of 650 patients with CAP. In conclusion, selected clinical features of patients with IA differ from those of patients with ILI and are more similar to those of patients with CAP.

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bioterrorism preparedness for the public health and medical communities

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MAYO CLINIC PROCEEDINGS 2002年第7期77卷 619-621页

作者： Meyer, RF Morse, SA Natl Ctr Infect Dis Rapid Response & Adv Technol Lab Bioterrorism Preparedness & Response Program Atlanta GA 30333 USA

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Threat of a biological terrorist attack on the US food supply: the CDC perspective

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LANCET 2002年第9309期359卷 874-880页

作者： Sobel, J Khan, AS Swerdlow, DL Ctr Dis Control & Prevent Foodborne & Diarrheal Dis Branch Div Bacterial & Mycot Dis Natl Ctr Infect Dis Atlanta GA 30333 USA Ctr Dis Control & Prevent Bioterrorism Preparedness & Response Program Natl Ctr Infect Dis Atlanta GA 30333 USA

Deliberate contamination of food with biological agents has already been perpetrated in the USA. The US food supply is Increasingly characterised by centralised production and wide distribution of products. Deliberate contamination of a commercial food product could cause an outbreak of disease, with many illnesses dispersed over wide geographical areas. Dependent on the biological agent and contaminated food, such an outbreak could either present as a slow, diffuse, and initially unremarkable increase in sporadic cases, or as an explosive epidemic suddenly producing many illnesses. preparedness for a bioterrorist event affecting the food supply, therefore, entails augmentation of the traditional public-health infrastructure to enhance disease surveillance, accelerate capacity of laboratory detection, rapidly investigate and control outbreaks, and develop capacity for response to mass-casualty disasters.

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Seroincidence of Helicobacter pylori infection in a cohort of rural Bolivian children:: Acquisition and analysis of possible risk factors

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CLINICAL INFECTIOUS DISEASES 2002年第9期35卷 1059-1065页

作者： Glynn, MK Friedman, CR Gold, BD Khanna, B Hutwagner, L Iihoshi, N Revollo, C Quick, R Community & Child Hlth Project La Paz Bolivia Natl Ctr Trop Dis Santa Cruz CA USA Emory Univ Sch Med Dept Pediat Div Pediat Gastroenterol Atlanta GA 30322 USA Emory Univ Sch Med Div Bacterial & Mycot Dis Foodborne & Diarrheal Dis Branch Atlanta GA 30322 USA Emory Univ Sch Med Bioterrorism Preparedness & Response Program Atlanta GA 30322 USA

High seroprevalence rates for Helicobacter pylori are reported in developing countries, yet few seroincidence studies exist that determine age of initial acquisition and risk factors for H. pylori seroconversion. Two H. pylori serosurveys were conducted in August 1996 and November 1997. Of 188 children aged 21 months to 6 years who were seronegative in the first survey, 44 (23%) had seroconverted at follow-up, yielding an 18% annual seroincidence. The largest increase in seroincidence occurred between children aged 2 years (10%) and children aged 3 years (32%). Use of a lidded, narrow-mouthed water vessel was protective against seroconversion (odds ratio [OR], 0.3;95% confidence interval [CI], 0.1-0.8), and the presence of another H. pylori-seropositive sibling in the household was a risk factor for seroconversion (OR, 3.1;95% CI, 1.3-8.7). Although not a randomized intervention trial, this study suggests that the use of a narrow-mouthed water vessel may prevent the transmission of H. pylori in households in developing countries.

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