June 11, 2008
Paul McGaha, D.O., M.P.H.
Texas Department of State Health Services
Promote the importance of active
Identify mandated notifiable
Review Class A agents
Identify reporting partners and their
Understand reporting mechanism
Identify case definitions
Understand HIPAA and Public Health
Your are a paramedic in Trinity
County. You make transports to
three different hospitals that day.
Three different previously health
adults with severe pustular rashes
and fever were transported. All
patients were admitted. Should you
inform anyone of the possible
Perspective on Importance
―The ability to control infectious diseases
requires an effective and comprehensive
public health surveillance and response
capacity. Public health surveillance is an
essential prerequisite for establishing local,
national, regional and global priorities;
planning, mobilizing and allocating resources;
early detection of epidemics; as well as
monitoring and evaluating disease prevention
and control programs.‖
Public Health Actions
The mission of Disease Surveillance is to
monitor communicable diseases.
The Surveillance unit maintains the mandatory
reportable disease system and is responsible for
collecting, analyzing, interpreting and reporting
infectious disease data.
The Disease Control unit is responsible for
infectious disease control activities, case follow-
up, patient and provider education and disease
Goal of Surveillance
To reduce morbidity and
mortality through the control
and/or prevention of disease.
Process of Public Health
PUBLIC HEALTH ACTION
Uses of Public Health Surveillance
Estimate magnitude of the problem
Determine geographic distribution of
Portray the natural history of a disease
Detect epidemics/ define a problem
Evaluate control measures
Monitor changes in infectious agents
Estimate Magnitude of Problem
Source: Texas DSHS
Determine Distribution of Problem
Portray Natural History of Disease
Source: Texas DSHS
Detect Epidemics/Define a Problem
Source: Texas DSHS
Evaluate Control Measures
Monitor Changes in Infectious Agents
Your 18 month old child attends a
day care center. Several children at
the center have had a severe cough.
You hear of one child that has been
hospitalized. To your knowledge, the
day care center director has not
notified the local health department.
What should you do?
Facilitate Preventive Measures
Coordinating prophylaxis treatment as
Work with schools to promote consistent
Public Health message - MRSA and
Promote education to public and
Participating in exercises and tabletops
Components of the Surveillance
Sources of Data
Several Texas laws (Health & Safety Code,
Chapters 81, 84, and 87) require specific
information regarding notifiable conditions
be provided to the Texas Department of
State Health Services (DSHS). Health care
providers, hospitals, laboratories, schools,
and others are required to report patients
who are suspected of having a notifiable
condition (Chapter 97, Title 25, Texas
Administrative Code ).
Are the Hoof Beats Horses or
In addition to reporting the communicable
diseases required by law, health care
providers and the public are encouraged
to report to the health department any
strange or unusual occurrence of disease.
A heightened level of vigilance and
reporting helps to minimize the likelihood
that important risks to health will be
DSHS Region 4/5N
24/7 Disease Reporting
You are a school nurse and you have
noted that 15 students in a second
grade class are absent with a
diarrheal illness. What should you
Anthrax is a serious disease caused by Bacillus anthracis,
a bacterium that forms spores. There are three types of
– skin (cutaneous)
– lungs (inhalation)
– digestive (gastrointestinal)
The symptoms (warning signs) of anthrax are different
depending on the type of the disease:
Cutaneous: The first symptom is a small sore that
develops into a blister. The blister then develops into a
skin ulcer with a black area in the center. The sore,
blister and ulcer do not hurt.
Gastrointestinal: The first symptoms are nausea, loss
of appetite, bloody diarrhea, and fever, followed by bad
Inhalation: The first symptoms of inhalation anthrax
are like cold or flu symptoms and can include a sore
throat, mild fever and muscle aches. Later symptoms
include cough, chest discomfort, shortness of breath,
tiredness and muscle aches.
Inhalation Anthrax is not known to spread from
one person to another.
Antibiotics are used to treat all three types of
anthrax. Early identification and treatment are
Prevention after exposure. Treatment is
different for a person who is exposed to anthrax,
but is not yet sick. Health-care providers will use
antibiotics (such as ciprofloxacin, levofloxacin,
doxycycline, or penicillin) combined with the
anthrax vaccine to prevent anthrax infection.
Treatment after infection. Treatment is usually
a 60-day course of antibiotics. Success depends
on the type of anthrax and how soon treatment
What is plague?
Plague is a disease caused by Yersinia pestis (Y.
pestis), a bacterium found in rodents and their
fleas in many areas around the world.
Image Bubonic plague
courtesy of CDC
Pneumonic vs. Bubonic Plague
Is pneumonic plague different from bubonic plague?
Yes. Both are caused by Yersinia pestis. Pneumonic plague can
be transmitted from person to person; bubonic plague cannot.
Pneumonic plague affects the lungs and is transmitted when a
person breathes in Y. pestis particles in the air. Bubonic plague
is transmitted through the bite of an infected flea or exposure
to infected material through a break in the skin. Symptoms
include swollen, tender lymph glands called buboes. Buboes
are not present in pneumonic plague.
What are the signs and symptoms of pneumonic plague?
Patients usually have fever, weakness, and rapidly developing
pneumonia with shortness of breath, chest pain, cough, and
sometimes bloody or watery sputum. Nausea, vomiting, and
abdominal pain may also occur. Without early treatment,
pneumonic plague usually leads to respiratory failure, shock,
and rapid death.
How quickly would someone get sick if exposed to
plague bacteria through the air?
Someone exposed to Yersinia pestis through the air—
either from an intentional aerosol release or from close
and direct exposure to someone with plague
pneumonia—would become ill within 1 to 6 days.
Can pneumonic plague be treated?
Yes. To prevent a high risk of death, antibiotics should
be given within 24 hours of the first symptoms. Several
types of antibiotics are effective for curing the disease
and for preventing it. Available oral medications are a
tetracycline (such as doxycycline) or a fluoroquinolone
(such as ciprofloxacin). For injection or intravenous
use, streptomycin or gentamicin antibiotics are used.
Early in the response to a bioterrorism attack, these
drugs would be tested to determine which is most
effective against the particular weapon that was used.
What are the symptoms of smallpox?
The symptoms of smallpox begin with high fever, head and body
aches, and sometimes vomiting. A rash follows that spreads and
progresses to raised bumps and pus-filled blisters that crust, scab,
and fall off after about three weeks, leaving a pitted scar.
If someone comes in contact with smallpox, how long does
it take to show symptoms?
After exposure, it takes between 7 and 17 days for symptoms of
smallpox to appear (average incubation time is 12 to 14 days).
During this time, the infected person feels fine and is not
Is smallpox fatal?
The majority of patients with smallpox recover, but death may
occur in up to 30% of cases. Many smallpox survivors have
permanent scars over large areas of their body, especially their
face. Some are left blind.
Is there any treatment for smallpox?
Smallpox can be prevented through use of the
smallpox vaccine. There is no proven treatment
Viral Hemorrhagic Fever
Viral hemorrhagic fevers (VHFs) refer to
a group of illnesses that are caused by
several distinct families of viruses. In
general, the term "viral hemorrhagic
fever" is used to describe a severe
syndrome. Characteristically, the
overall vascular system is damaged,
and the body's ability to regulate itself
VHFs are caused by viruses of four
distinct families: arenaviruses,
filoviruses, bunyaviruses, and
What are the symptoms of viral
hemorrhagic fever illnesses?
Specific signs and symptoms vary by the type of
VHF, but initial signs and symptoms often include
marked fever, fatigue, dizziness, muscle aches, loss
of strength, and exhaustion. Patients with severe
cases of VHF often show signs of bleeding under the
skin, in internal organs, or from body orifices like
the mouth, eyes, or ears. However, although they
may bleed from many sites around the body,
patients rarely die because of blood loss. Severely ill
patient cases may also show shock, nervous system
malfunction, coma, delirium, and seizures. Some
types of VHF are associated with renal (kidney)
How are patients with viral
hemorrhagic fever treated?
Patients receive supportive therapy,
but generally speaking, there is no
other treatment or established cure
for VHFs. Ribavirin, an anti-viral
drug, has been effective in treating
some individuals with Lassa fever or
Q. What are the signs and symptoms of
A. The signs and symptoms people develop depend
on how they are exposed to tularemia. Possible
symptoms include skin ulcers, swollen and painful
lymph glands, inflamed eyes, sore throat, mouth
sores, diarrhea or pneumonia. If the bacteria are
inhaled, symptoms can include abrupt onset of
fever, chills, headache, muscle aches, joint pain, dry
cough, and progressive weakness. People with
pneumonia can develop chest pain, difficulty
breathing, bloody sputum, and respiratory failure.
Tularemia can be fatal if the person is not treated
with appropriate antibiotics.
Q. Can tularemia be effectively treated with
A. Yes. Early antibiotic treatment is recommended
whenever it is likely a person was exposed to tularemia or
has been diagnosed as being infected with tularemia.
Several types of antibiotics have been effective in treating
tularemia infections. The tetracycline class (such as
doxycycline) or fluoroquinolone class (such as ciprofloxacin)
of antibiotics are taken orally. Streptomycin or gentamicin
are also effective against tularemia, and are given by
injection into a muscle or vein.
Q. Can someone become infected with the tularemia
bacteria from another person?
A. People have not been known to transmit the infection to
You are driving down Highway 69 in
Wood County. In a pasture next to
the highway, you notice 20 cattle
along with several birds have died.
Should you do anything?
What about influenza?
Influenza (the flu) is a serious
Each year in the United States, on
5% to 20% of the population gets the flu;
More than 200,000 people are
hospitalized from flu complications, and;
About 36,000 people die from flu.
What about influenza? (Cont.)
Avian (or bird) flu (AI) is caused by
influenza viruses that occur naturally
among wild birds. Low pathogenic AI
is common in birds and causes few
problems. Highly pathogenic H5N1 is
deadly to domestic fowl, can be
transmitted from birds to humans,
and is deadly to humans. There is
virtually no human immunity and
human vaccine availability is very
What about influenza? (Cont.)
Pandemic flu is virulent human
flu that causes a global
outbreak, or pandemic, of
serious illness. Because there is
little natural immunity, the
disease can spread easily from
person to person. Currently,
there is no pandemic flu.
Sources of Data
Who Should Report?
Physicians/Practioners (hospital and
Other individuals and institutions
Types of Reporting
PassiveSurveillance- receive reports
―passively‖, e.g., hospital mails
ActiveSurveillance- Public health
actively pursues reports by calling
health care providers, etc.
Region 4/5 North
Angelina Cities and County
Cherokee County Health
Gregg County Health
Jasper-Newton Public Health
Northeast Texas Public Health
Texarkana-Bowie County Family
Call reports to the staff that
covers your county!!
Know who you should report to- local
health department or regional health
Know your Health Authority and their
role in Public Health Intervention.
Think globally- report
Report the right disease to the right person at the
Know how quickly the disease should be
reported. Call, fax or electronically report
A case definition is different from a
clinical diagnosis. You can access
case definitions at www.cdc.gov.
The disease reports have
investigations completed and then
are entered into National Electronic
Surveillance System (NEDSS).
This information helps is put into
MMWR- you can get a weekly
feedback from a state perspective.
MMWR- you can get an email copy free
Peer review and medical journals
What About HIPAA?
The Health Insurance Portability and
Accountability Act of 1996 (HIPAA) privacy
regulations implemented standards for
how information that identifies a patient
can be used and disclosed. (Title 45, Code
of Federal Regulations (CFR), Parts 160
and 164) The regulations apply to
"covered entities" including health-care
plans, health-care clearinghouses, and
health-care providers. These privacy
standards go into effect on April 14, 2003.
What does this mean?
What does this mean? (cont.)
Gastroenteritis at a University in Texas
This case study is based on a real-life outbreak investigation
undertaken in Texas in 1998
On the morning of March 11, the Texas Department of Health
(TDH) in Austin received a telephone call from a student at
a university in south-central Texas. The student reported
that he and his roommate, a fraternity brother, were
suffering from nausea, vomiting, and diarrhea. Both had
become ill during the night. The roommate had taken an
over-the-counter medication with some relief of his
symptoms. Neither the student nor his roommate had seen
a physician or gone to the emergency room.
The students believed their illness was due to food they had
eaten at a local pizzeria the previous night. They asked if
they should attend classes and take a biology midterm
exam that was scheduled that afternoon.
What questions (or types of questions) would you
ask the student?
WHAT is the person’s problem?
WHO else became ill, their characteristics (e.g.,
age, sex, occupation), and the nature of their
illnesses (e.g., symptoms, whether any persons
were hospitalized or died)?
WHEN did the affected person(s) become ill?
WHERE are the affected persons located?
(including names and telephone numbers)
WHY (and HOW) do they think they became ill?
(e.g., risk factors, suspected exposures,
suspected modes of transmission, hints from who
else did and did not become ill)
What would you advise the student
about attending classes that day?
You probably should refer the
student to his personal physician or
the Student Health Center for a
While symptomatic, the students
would probably be most comfortable
staying in their dorm room
Do you think this complaint should be
Ideally, all reports of possible outbreaks of
foodborne illnesses should be investigated
– prevent other persons from becoming ill
(either from the same food or method of
– identify potentially problematic
foodhandling practices, and
– add to our knowledge of foodborne
How big is the threat?
The most important diseases/complaints to investigate are
those that are a severe threat to the public’s health or
where a timely control response is critical. Top priorities
an outbreak associated with a commercially distributed food
severe (life-threatening) illnesses such botulism or E. coli
confirmed clusters of a similar illness that appear to be
associated with a specific food preparer or food service
instances where a large number of people appear to be
indications of adulterated food presenting an imminent
foodborne illness in a foodhandler
TDH staff were skeptical of the student’s report but felt that a
minimal amount of exploration was necessary. They began by
making a few telephone calls to establish the facts and determine
if other persons were similarly affected. The pizzeria, where the
student and his roommate had eaten, was closed until 11:00 A.M.
There was no answer at the University Student Health Center, so
a message was left on its answering machine.
A call to the emergency room at a local hospital (Hospital A)
revealed that 23 university students had been seen for acute
gastroenteritis in the last 24 hours. In contrast, only three
patients had been seen at the emergency room for similar
symptoms from March 5-9, none of whom were associated with
At 10:30 A.M., the physician from the University Student Health
Center returned the call from TDH and reported that 20 students
with vomiting and diarrhea had been seen the previous day. He
believed only 1-2 students typically would have been seen for
these symptoms in a week. The Health Center had not collected
stool specimens from any of the ill students.
Do you think these cases of gastroenteritis
represent an outbreak at the university? Why or
An outbreak is the occurrence of more cases of a
disease than expected for a particular place and
time. In a 2-day period, over 40 cases of
gastroenteritis occurred among students at the
university (assuming that individual students did
not visit both the Student Health Center and the
emergency room). This compares with the
handful of students that would normally have
been seen for these symptoms at the two
facilities in a week. Therefore, it is highly likely
that these cases represent an outbreak.
On the afternoon of March 11, TDH staff
visited the emergency room at Hospital A
and reviewed medical records of patients
seen at the facility for vomiting and/or
diarrhea since March 5. Based on these
records, symptoms among the 23
students included vomiting (91%),
diarrhea (85%), abdominal cramping
(68%), headache (66%), muscle aches
(49%), and bloody diarrhea (5%). Oral
temperatures ranged from 98.8°F
(37.1°C) to 102.4°F (39.1°C) (median:
List the broad categories of diseases that
must be considered in the differential
diagnosis of an outbreak of acute
There are two broad classifications for
Infections are a consequence of the
growth of a microorganism in the body
Intoxications are caused by ingestion of
food already contaminated by toxins
Graphic Depiction of Outbreak
By March 12, seventy-five persons with vomiting or
diarrhea had been reported to TDH. All were students
who lived on the university campus.
Onset of gastroenteritis among students, University X, Texas,
March 1998. (N=72) (Date of onset was not known for three ill
Among persons who ate at the deli
bar during the implicated meals,
cases were three times more likely
than controls to eat American cheese
and mayonnaise. They were also 1.5
times more likely to have eaten ham.
Although food handlers are often victims of food
borne disease outbreaks because they consume the
contaminated food themselves, the facts in this
outbreak suggest this food handler might have been
the source of infection for the students:
The diarrheal illness in her child preceded the
outbreak and occurred at the probable time the
students were exposed (i.e., began three days
before the outbreak and continued through March
The food handler prepared ingredients and
sandwiches served at the deli bar during the time
that her child was ill.
Finally, norovirus was isolated from the child’s stool
and was identical to that obtained from ill students
and the deli ham.
Early Detection---- Rapid Response
When in doubt call!!! Don’t assume
that disease reporting has occurred.
LocalHealth Department or
Your tool kit has some of the most
common notifiable diseases in East
CDC - Center for Disease Control:
Texas Department of State Health
World Health Organization: