Continuing Medical Education Course Handout

1. Continuing Medical Education Course Handout FY18 Epi-Tech Surveillance Training

2. Continuing Medical Education Course Handout

3. Continuing Medical Education Course Handout

4. ANNOUNCEMENT • To Register for the Monthly Disease Surveillance Trainings: • Contact your Service Surveillance HUB to receive monthly updates and reminders • Log-on or Request log-on ID/password: https://tiny.army.mil/r/zB8A/CME • Register at: https://tiny.army.mil/r/MEHsS/EpiTechFY18 • Confirm attendance: • Please enter your full name/email into the DCS chat box to the right or email your Service hub • You will receive a confirmation email within 48 hours with your attendance record; if you do not receive this email, please contact your Service hub

5. Managing Misreporting: Common Mistakes and Misreported RMEs Victoria Holbrook, MPH Epidemiologist Epidemiology Consult Service (USAFSAM/PHR)

6. Learning Objectives • Prevent misreporting by understanding what misreporting is and why accuracy in reporting is critical • Recognize common mistakes and misreported Reportable Medical Events (RMEs) to improve reporting • Understand the interpretation of case classifications and their associated labs to increase accuracy of reporting

7. Part 1: Reporting Requirements Case Definitions Misreporting

8. Reporting Requirements • Air Force: • AFI 48-105 “Surveillance, Prevention, and Control of Diseases and Conditions of Public Health or Military Significance” • Navy: • BUMED INST 6220.12C “Medical Surveillance and Medical Event Reporting” • NMCPHC-TM-PM 6220.12 “Medical Surveillance and Reporting” • Army: • Army Regulations 40-5 "Medical Services Preventive Medicine“ • Department of the Army Pamphlet 40-11 "Medical Services Preventive Medicine"

9. 2017 Guidelines

10. Case Definitions • Case Definition vs Case Classification? • Case Definition:the specific clinical, laboratory, and other objective criteria that define who is included as a case in the surveillance of public health conditions (i.e. RMEs) • E.g. the Mumps case definition • Case Classification: subcategories of a case definition – typically suspected, probable, and confirmed; specifies what is needed to meet the case definition of an RME • E.g. the Mumps confirmed case classification Although slightly different, they are typically used interchangeably!

11. Case Classifications

12. Case Classification Example • Meningococcal Disease

13. Case Classification Example • Campylobacteriosis • Chlamydia

14. Misreporting • The inaccurate reporting of an RME • Can include: • Reporting an RME under an incorrect case classification • Reporting an event that does not meet any case classification • Filling out a medical event report incorrectly • Why does accuracy matter?

15. Part 2: In-Depth Case Definition Interpretation Hepatitis A Campylobacter Influenza-Associated Hospitalization Hepatitis B Lyme Disease

16. Reading a Case Definition Look at requirements: • Symptoms • Laboratory requirements • Lab method • Sample type • Result interpretation • Exposure history • Epidemiologically linked (i.e. sick contacts) • Travel history • Endemicity of disease

17. Hepatitis A • Page 42 • ONE case classification • When reporting check: • Critical Reporting Elements • Comments for clarification

18. Hepatitis A • What is important to notice? • Requires symptoms • Has an “or” (i.e. two ways to meet the case definition) • Specific laboratory result from a specific sample type • This case definition requires two things: 1) symptoms and 2) meeting one of the bullets

19. Hepatitis A • Case must meet the clinical description • Description has an and, or requirement

20. Is this case reportable? • The following lab shows up on your spool • A look at their encounters shows that the patient presented with diarrhea and jaundice

21. Is this case reportable? • The following lab shows up on your spool • A look at their encounters shows that the patient presented with diarrhea and jaundice Yes, as a Confirmed case • They exhibited the necessary symptoms (diarrhea plus jaundice) and a positive Hepatitis A IgM antibody (ab).

22. Is this case reportable? • Same scenario, but what if these were your lab results instead?

23. Is this case reportable? • Same scenario, but what if these were your lab results instead? • NO. Why? • Because this lab is a hepatitis A virus TOTAL ab test. The case definition requires a positive IgM Ab. • In this case you cannot determine if the IgM or the IgG ab is positive. Additional testing would need to be done.

24. Campylobacter • Page 19 • TWO case classifications • When reporting check: • Critical Reporting Elements

25. Campylobacter • What is important to notice? • Lab results do NOT require symptoms • Has an or • This case definition requires only one thing: 1) meeting one of the bullets

26. Is this case reportable? • The lab alerts you to the following result:

27. Is this case reportable? • The lab alerts you to the following result: Yes, as a Probable case • The rapid Campylobacter test is positive. Rapid tests are typically EIAs. This rapid test was performed as part of the culture panel. The result is NOT culture positive for Campylobacter.

28. Influenza-Associated Hospitalization • Page 46 • ONE case classification • When reporting check: • Critical Reporting Elements • Comments for clarification

29. Influenza-Associated Hospitalization • What is important to notice? • Requires symptoms • Has two and’s and one or • This case definition requires two things: 1) symptoms and 2) meeting three of the bullets

30. Is this case reportable? • On your ad hoc report you find the following result: • Additional research tells you that the patient is 35, has flu-like symptoms, and was admitted to the hospital on 27 Jan 2018

31. Is this case reportable? • On your ad hoc report you find the following result: • Additional research tells you that the patient is 35, has flu-like symptoms, and was admitted to the hospital on 29 Jan 2018 Yes, as a Confirmed case • The patient displayed symptoms, is younger than 65, had a positive flu test, and was admitted to the hospital less than 14 days after the positive test.

32. Is this case reportable? • On your ad hoc report you find the following result: • Additional research tells you that the patient is 63, has flu-like symptoms, and was seen in the ER

33. Is this case reportable? • On your ad hoc report you find the following result: • Additional research tells you that the patient is 63, has flu-like symptoms, and was seen in the ER • NO. Why? • Although they meet most criteria, they were seen in the ER but not admitted to an inpatient ward of the hospital.

34. Hepatitis B • Page 43 • ONE case classification • Two options: Acute & Chronic • When reporting check: • Critical Reporting Elements • Comments for clarification

35. Hepatitis B

36. Hepatitis B • What is important? • Does NOT require symptoms • Has one and, multiple or’s • The CHRONIC case case definition requires one thing: 1) meeting one of the bullets

37. Is this case reportable? • You come across this Hep B panel:

38. Is this case reportable? • You come across this Hep B panel: Yes, as a Confirmed case • The results have a negative core IgM (HBc-IgM) ab AND a positive surface antigen (HBsAG)

39. Is this case reportable? • What about this Hepatitis A+B+C Virus panel?:

40. Is this case reportable? • What about this Hepatitis A+B+C Virus panel?: • NO. Why? • The surface antigen (HBsAg) is negative, and there are no Hep B e antigen or PCR results.

41. Lyme disease • Page 52 & 53 • THREE case classifications • When reporting check: • Critical Reporting Elements • Comments for clarification

42. Lyme disease • What is important to notice? • Does NOT require symptoms • Requires “provider diagnosis” • Includes superscripts that refer to the comments • Has one and, many or’s • This case classification requires two things: 1) provider diagnosis and 2) meeting one of the bullets

43. Two-Tiered Testing

44. Lyme disease • Superscripts referring to the comments • Explains laboratory details, interpretation; clarifies case definition requirements

45. Is this case reportable? • You find these results in your ad hoc and see the provider diagnosed them with Lyme:

46. Is this case reportable? • You find these results in your ad hoc: Yes, as a Probable case • Both the first and second tier tests are positiveand in the AHLTA encounter the provider diagnosed the patient with Lyme disease

47. Is this case reportable? • These results come up in your ad hoc: • Per their history, a Lyme screening test was NOT ordered, no symptoms were reported, and the doctor has not diagnosed them.

48. Is this case reportable? • These results come up in your ad hoc: • NO. Why? • The IgM WB is positive, but this result is NOT reportable without a preceding positive screening test.

49. 2017 Armed Forces Reportable Medical Events Guidelines and Case Definitions Lyme Disease Erythema Migrans (EM) OR Late Manifestation (LM) of Lyme Disease? (e.g. Bell’s palsy, swollen knees, Lyme carditis) No Yes (LM) Yes (EM) Provider diagnosed Lyme disease? Known exposure* in endemic or non-endemic area? No Yes No Yes (+) LD total Ab screen WITH (+) IgM within 30 days of illness onset? (Two-tier testing) Any clinical information available? SUSPECT (+) LD total Ab screen WITH (+) IgM within 30 days of illness onset? (Two-tier testing) Yes No No Yes (+) LD total Ab screen WITH (+) IgM within 30 days of illness onset? (Two-tier testing) Start over. Or, if NO LM/EM and NO diagnosis, does not meet case definition. PROBABLE (+) LD total Ab screen WITH (+) IgG? (Two-tier testing) No Yes Yes CONFIRMED (+) LD total Ab screen WITH (+) IgG? (Two-tier testing) No Yes PROBABLE (+) IgG? (Single-tier testing) Yes No No Yes No (+) LD total Ab screen WITH (+) IgG? (Two-tier testing) Yes SUSPECT CONFIRMED (+) IgG? (Single-tier testing) (+) culture? No No Yes Yes No PROBABLE Yes NOT A CASE (+) IgG? (Single-tier testing) CONFIRMED (+) culture? No (LM) Yes No (EM) No NOT A CASE (+) culture? SUSPECT CONFIRMED CONFIRMED NOT A CASE Yes No * Exposure is defined as having been (≤30 days before onset of EM) in wooded, brushy, or grassy areas in a county in which Lyme disease is endemic. History of tick bite is not required. Possession of physical tick is not required. Endemicity is defined as a county in which at least 2 confirmed cases have been acquired or established populations of the blacklegged tick are infected with B. burgdorferi.

50. Part 3: Misreporting Notes Event Report Completion Consistency in Reports Conclusion