# Presentation: 836510

## Information Needs in Outbreak Management A Local PerspectiveAnnie Fine, MDMedical EpidemiologistNew York City Department of Health and Mental Hygiene

- Review recent challenging outbreaks
- Data needs for outbreak management
- What tools are currently available?
- Recommendations

## West Nile Outbreak, 1999

**West Nile Outbreak, 1999**

## West Nile NYC, 1999Challenges and Lessons Learned

- New, unexpected disease
- Regional event
- Challenging to track laboratory information
- Specimen collection, transport and result tracking
- Specimens being sent to both CDC & NYSDOH labs
- Needed multiple specimens (serum/CSF) for each pt.
- Linking epidemiologic data with laboratory data NOT trivial (no unique identifier on specimens received)
- Huge media event; demand for data 1-2x/day
- Excel and MS Access inadequate for data mgmt.

## Anthrax

- 2001

## Anthrax 2001 - Challenges

- > 600 suspect cases reported and triaged; only 8 confirmed (7 cutaneous and 1 inhalation)
- Site investigations needed at 4 major media outlets, 1 hospital, and 1 USPS distribution center
- No system available to manage huge volume of data related to laboratory specimens
**Suspect and Confirmed Cases**
**Potentially Exposed people at worksites (> 2500 nasal swabs)**
**Environmental specimens at all affected sites (> 1270 specimens)**
**> 3,000 “White powder events”**
- Need to capture, describe and easily retrieve relationships between people, sites, specific exposures, environment, courses of prophylaxis, laboratory results

## Slide 6

## SARS

- New, unexpected disease
- Laboratory diagnosis extremely challenging, esp. initially before testing available at CDC
- Communicable, high case fatality
- Complex contact tracing (home, work, and healthcare contacts)
- Need for case isolation and quarantine of contacts
- Toronto: lack of robust information system cited as major impediment to outbreak control (used Excel, then paper)

## Steps of an Outbreak Investigation

- Detection and verification of outbreak
- Active case-finding
- Case definition may change over course of outbreak
- Triage and investigation of suspect case reports
- Medical record review and physician interview
- Interview patient/family re exposure and contact data
- Collect, transport and track lab specimens
- Laboratory testing, often at PHL
- Contact tracing and management, if indicated
- Environmental investigation
- Epidemiologic analyses
- Intervention/control measures and communication

## More complex outbreaks

- Pressure for daily summary reports
- Allow data entry from multiple field sites
- Multiple jurisdictions may be affected
- Extremely dynamic, some variables standard and consistent – others situation-dependent
- Need to track patient outcomes

## More complex outbreaks

- Potentially complex analysis re. exposures
- Large volume of lab specimens with potentially inadequate documentation
- Need for stat GIS analysis and maps
- Need to link patients to specimens, patients to contacts, people to locations, specimens to locations, time dimension can be critical
- Possible need to link outbreak cases to control measures (vaccination/prophylaxis)

## Workflow Management

- Assigning interviews, chart reviews etc.
- Tracking down missing data
- Requesting and tracking specimens
- Determining case status (confirmed vs rule out)
- Case follow-up to determine outcome
- Contact tracing and management (daily status checks, prophylaxis)

## Outbreak Database Needs

- Flexible
- Scalable
- Pre-existing modules, easily modified
- Allows multiple simultaneous users
- Supports workflow management (contact tracing)
- Allows messages with other databases (e.g. lab, surveillance, CDC)

## Characteristics of an Ideal Outbreak Management System

- Easy to use and navigate
- Event-based
- Suitable for routine simple outbreaks but scalable for complex ones – training should not be a major issue during a public health emergency

## Ideal Outbreak Management System

- Versioning
- Data entry screens easily formatted
- Searchable on multiple fields (critical for minimizing duplicate record entry)
- Able to generate unique identifiers for persons or other entities

## Ideal Outbreak Management System

- User can
- initiate database for a particular outbreak
- rapidly develop and modify questionnaires/survey tools on the fly
- define new variables
- access and edit pre-existing modules (sets) of questions
- define vocabulary (as standardized as possible), field validation and skip patterns

## Ideal Outbreak Management System

- Ability to
- print questionnaire and edit/format easily (add instructions) for paper-based data collection
- message to and from PHL or other reference laboratories and integrate lab and epi data
- Should support use of bar codes
- associate contacts with cases
- track and assign actions related to a case or contact
- Geocode address fields (access to automated or semi-automated geocoding)

## Ideal outbreak management system

- Ability to
- print individual records
- generate letters, results, requests for additional specimens, orders (quarantine/isolation) using data in the system
- associate documents or photos with outbreak database
- flag records that have been created, edited, contain uploaded data
- calculate field values based on algorithms

## Ideal outbreak management system

- Secure, confidential
- User-defined roles and access
- Remote access possible
- Deployable to field for electronic data entry using laptops or handheld devices
- Deployable to the web
- Redundancy to support system in case of electronic or network failures
- Regular back-up

## Ideal outbreak management system

- Data views/analysis/queries/reports of intuitive tables, with user able to create, modify and save queries
- Data export for statistical analysis (into SAS, SPSS, MS Access, Crystal Reports)
- Deduplication
- Data import (partial or complete records)
- Metadata re. outbreaks
- Ability to view, sort, store, retrieve, reuse and edit old outbreaks, questionnaires, modules

## Currently available toolsWhat will we use for early pandemic influenza?  Or the next “new” disease?

- MSAccess
- Epi-Info
- Excel
- CDC-OMS (development paused)
- Customized solution developed for each outbreak
- Web-based data collection tools (MrInterview, SurveyMonkey)

## Slide 21

## Options for the Future

- Outbreak Management System, if development resumes
- MSAccess with sequel back-end
- Customized web-based system for each outbreak
- Commercial options???
- Others??

## Conclusions and Recommendations

- Clinical data in EHR are insufficient for outbreak management
- Need to reinstate federal support for improved tools for outbreak data management such as OMS
- State and local health departments must have strong role in designing and evaluating systems
- IT infrastructure at state and local health departments should be strengthened

## Slide 24

## NYC’s Response to SARS

- Enhanced surveillance to rapidly identify and isolate potential cases
- Triaged >300 calls regarding potential cases
- Identified 24 suspect and 3 probable cases
- No lab confirmed cases
- Identified and conducted daily monitoring of
-    > 100 contacts

## Slide 26

## Spread from Hotel M

**Hotel M****Hong Kong**

**Guangdong Province, China**

**A**

**A**

**Spread from Hotel M**
**Reported as of March 28, 2003**

**Notes:**
[Slide 9] Case A from Guangdong Province, China [Next] and two hotel guests who became ill, cases H and J, started outbreaks of SARS in three Hong Kong hospitals involving at least 95 health care workers and more than 100 contacts.  

[Next] Case B flew to Hanoi, Vietnam, was hospitalized there, and started an outbreak among health care workers and their contacts.  

[Next] Cases C, D and E, returned to Singapore and started a cluster there.  

[Next] Additional cases flew home to the U.S., 
[Next] Ireland and 
[Next] Canada.  

You will hear more about the cluster in Canada and about U.S. patients in the next talks.  

While most of these early recognized clusters suggest that contact and droplet transmission are predominant, the pattern of transmission in the hotel suggests the possibility of airborne or fomite transmission.

Now I will return to the beginnings of the outbreak in Singapore.

## Slide 28

## Anthrax Outbreak, 2001, NYCWorksite Investigations

| Site | Date
Started | Interviews | Nasal swabs | Prophylaxis
 initiated |
| --- | --- | --- | --- | --- |
| NBC | Oct 12 | 1283 | 1360 | 1283 |
| ABC | Oct 15 | 732 | 757 | None |
| CBS | Oct 18 | 357 | 352 | None |
| NY Post | Oct 19 | 175 | 111 | 23 |
| Hospital | Oct 26 | > 1000 | 20 | 1900 |