Public Health - December 2008
Tex Med . 2008;104(12):37-40.
By Crystal Conde
Edward Sherwood, MD, FACP, was the interim health authority of the Austin/Travis County Health Department in 2003 when a hospital laboratory reported an Austin resident tested positive for typhoid fever. Days later, another case came to the department's attention.
What was unusual and worrisome was that neither patient had visited another country. Salmonella typhi , the bacterium that causes typhoid fever, is not endemic to the United States. Dr. Sherwood explains that most people who contract typhoid fever get it while visiting abroad.
Through disease reporting and notification by the Texas Department of State Health Services (DSHS), Austin health officials quickly learned of one case of typhoid fever in San Antonio and three more in Houston. None of the patients had traveled outside the country.
With six patients suffering from typhoid fever and no way of knowing how widespread the illness would become, public health officials obtained permission from the two Austin patients to introduce them to each other. After talking, they identified three restaurants where they'd both eaten, but only one they had eaten at within the typical 18-day incubation period of the illness. Upon investigation, it turned out all six who tested positive for typhoid fever had eaten raw oysters prior to the illness's onset.
DSHS traced the supply back to an oyster lease in Galveston Bay. DSHS tested samples of frozen oysters from the same harvest area and time frame and took specimens from oyster plant workers. The oysters and workers tested negative for S. typhi .
DSHS was unable to identify the source of the oyster contamination and reasoned it could have happened during harvesting or at the lease site.
Dr. Sherwood, chair of the Texas Medical Association Committee on Infectious Diseases and chief of staff of the Central Texas Veterans Health Care System, says the typhoid fever cases illustrate health care professionals' important role as lookouts in preventing the spread of illnesses. He says physicians, not just laboratories and hospitals, have an opportunity to protect the public's health in the face of a disease outbreak.
"If there weren't mandated reporting, no one would have known anything was going on," he said.
Dr. Sherwood stresses that physicians shouldn't wait for test results to come back to report a disease, but should do so when they suspect something.
For example, the Austin/Travis County Health Department learned of a case of measles in 2003. The highly contagious disease requires public health authorities to isolate exposed patients to prevent it from spreading.
"The problem is the case was reported to us when the laboratory confirmation came back, which was three weeks after the patient was sick," Dr. Sherwood said. "Obviously, someone thought it could be measles, because the testing was ordered. However, public health didn't find out until it was confirmed. By then, the cows are out of the barn; it's too late."
Fortunately, no one else contracted measles because of the late reporting.
Adolfo Valadez, MD, DSHS assistant commissioner for prevention and preparedness services, says it's critically important for physicians to identify and report unusual diseases, as well as unusual manifestations or occurrences of nonexotic diseases, such as an increase in influenza. (See " Program Tracks Flu Statewide.")
"Physicians are often the first line of defense against infectious diseases, whether in a primary care clinic, private practice, hospital, or emergency room. Health departments can't investigate outbreaks or other events unless they know something is amiss," he said.
Spreading the News
Unusual diseases generally can be reported with a simple phone call or fax to the local health authority or local health department. Both have a mechanism for health care professionals to report 24 hours a day, seven days a week. In counties without a local health department, physicians can send reports to the DSHS health service region.
Contact information for local health departments is available on the DSHS Web site at www.dshs.state.tx.us/regions/lhds.shtm and for the health service regions at www.dshs.state.tx.us/regions.
Texas law requires reporting of a number of infectious diseases and conditions to local health departments and DSHS. The list of reportable illnesses and conditions is available at www.dshs.state.tx.us/idcu/investigation/conditions.
According to Dr. Valadez, DSHS updates the list when needed, depending on emerging threats or changes in public health significance. DSHS formally reviews the list every four years.
He specifies that even if a disease isn't on the list of reportable illnesses and conditions, physicians must report it if it meets the criteria in the Texas Administrative Code. "In addition to individual case reports, any outbreak, exotic disease, or unusual group expression of disease that may be of public health concern should be reported by the most expeditious means," a provision of the code says.
Jennifer Jackson, RN, DSN, director of Public Health Nursing at the Williamson County and Cities Health District, says the majority of illness reports her department receives come from school nurses. Laboratories and hospitals follow, with physician offices trailing.
She says doctors often are busy and may lack an in-office infection control practitioner, like at each hospital serving the region. In addition, her department has a program that asks hospitals to monitor their intensive care units and notify the department of any unusual illnesses on a weekly basis.
Dr. Valadez says DSHS doesn't assess reporting by physicians or health care facilities. Instead, the department focuses its efforts on pursuing direct reporting from clinical laboratories and hospitals and using electronic laboratory reporting to make it easier to report and to provide results faster.
"The faster results get to health care providers, the sooner interventions to stop infectious diseases can begin," he said.
Physicians should establish relationships with local health authorities and health departments and know whom to contact and how to send a report to make sure they're fulfilling their role as lookouts, Dr. Valadez says. Communicating effectively and regularly with the local health department or authority can help physicians stay informed on public health issues other than infectious disease.
The departments can provide information on and help investigate drugs, vaccines, suspect food items, water contamination, and other problems and can make the connections to any state and federal entities that need to be involved. They also may work closely with poison control centers.
Aside from preventing the spread of disease, physicians have another motivation for reporting. Failing to report a notifiable infectious disease is a Class B misdemeanor. But Dr. Valadez is unaware of any person or entity ever being penalized for not reporting.
"We prefer to work with our physician and health care provider community to educate them on the importance of reporting these conditions and help them improve reporting practices," he said. "The goal is to work with physicians to improve patient care, prevention, and treatment of disease, not to punish doctors."
Identifying the Unusual
Recognizing the out-of-the-ordinary is the first step in spotting an unusual infectious disease. Dr. Valadez says most practicing physicians are highly skilled in this area, and their observations may lead to a definitive diagnosis through laboratory and other clinical testing; further research and/or referral; or consultation with local, regional, or state health department officials.
During the summer, a cryptosporidiosis outbreak affected Central Texas. Ms. Jackson says her department kept in contact with physicians as reports came in, and faxed or e-mailed practitioners to let them know about the signs and symptoms of the disease. As part of its educational outreach, the department also contacted local parks and recreation departments, homeowners associations, and others with public pools to instruct them on the Centers for Disease Control and Prevention's (CDC's) guidelines that require hyperchlorination at pools testing positive for cryptosporidiosis.
"While it doesn't eliminate kids getting sick from crypto, it helps when everybody's coordinating efforts. The doctors are looking for it, the pools [are being] hyperchlorinated, and then the labs and hospitals are reporting to us," she said.
TMA's Committee on Infectious Diseases will focus on staying abreast of the presentations of unusual illnesses that some physicians have never seen and perhaps last heard about in medical school. Dr. Valadez says including courses in infectious disease in the required annual continuing medical education (CME) is probably the most efficient way to strengthen a physician's background. Many general state and national CME programs include infectious disease components.
Physicians also may request e-mail notification of new editions of the DSHS Epilink , an online public health news journal (www.dshs.state.tx.us/idcu/epilink) that features infectious disease topics relevant to Texas. In addition, CDC offers free online CME courses on infectious disease topics that can be accessed online ( www2a.cdc.gov/ce/availableactivities.asp).
Crystal Conde can be reached by telephone at (800) 880-1300, ext. 1385, or (512) 370-1385; by fax at (512) 370-1629; or by email at Crystal Conde .
TMA Gets You Drug Alerts Fast
The Texas Medical Association has arranged for physicians to receive Food and Drug Administration (FDA) alerts as soon as the FDA issues them.
TMA President Josie Williams, MD, says the association worked with the FDA, the American Medical Association, and the Texas Medical Liability Trust to make the Health Care Notification Network (HCNN) available to physicians. HCNN sends drug and medical device recalls and safety alerts to physicians online, replacing the current paper process that is slow and error-prone, she says.
In addition, here's what you can expect from HCNN:
- You can designate practice staff members to receive copies of the HCNN alerts automatically.
- Your privacy is protected by the not-for-profit board that governs the HCNN.
- There is no advertising or spam.
- Your data from the network will not be sold or shared.
- You can opt out at any time.
- HCNN is free to physicians and paid for by those who use the network for alert delivery, the manufacturers, and the FDA.
- If you do not open the e-alert, you will receive a paper alert via U.S. mail.
Registration for the service is online at www.hcnn.net/registration/tma/registration.aspx .
"I encourage you to enroll now in a new, free service that will improve patient safety and your liability protection," Dr. Williams said.
Get more information and sign up at www.texmed.org/hcnn.
Program Tracks Flu Statewide
The Texas Department of State Health Services (DSHS) implements the Centers for Disease Control and Prevention's (CDC's) U.S. Influenza Sentinel Provider Surveillance Network. Participants provide data on influenza-like illnesses each week to help CDC monitor the impact of influenza and guide prevention and control activities, vaccine strain selection, and patient care.
During the 2007-08 influenza season, 132 Texas health care professionals participated in reporting data on influenza-like illness to CDC every week. CDC compares the percentage of patient visits reported to sentinel providers for influenza-like illness with the national baseline of 2.2 percent. This allows the center to survey influenza activity around the nation.
Participation in the program involves reporting the total number of patient visits for influenza-like illness by age group (0-4, 5-24, 25-64, older than 65), along with the total number of patient visits. Physicians submit the data once a week to CDC via the Internet or fax.
DSHS says a majority of participants report that the entire process takes less than 20 minutes each week. In addition, sentinel providers can submit specimens from a subset of patients for virus isolation, free of charge. And, they receive feedback on the data submitted, summaries of regional and national influenza data, and free subscriptions to CDC's Morbidity and Mortality Weekly Report and Emerging Infectious Diseases journal.
Physicians interested in enrolling in the program can request a form from Irene Brown, sentinel influenza coordinator in the DSHS Infectious Disease Control Unit, by calling (512) 458-7111, ext. 6878, or emailing firstname.lastname@example.org .
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