26 Sep Technology played key role in E. coli alerts
Madison, Wis. – To the casual observer, responders contained the recent E. coli outbreak quickly, but in the eyes of many public health professionals, the automated system used to identify the disease and coordinate alerts has plenty of room for improvement.
Still, information technology played a key role in alerting public health officials of the recent outbreak, and it will play an even greater role in future public health crises, according to Wisconsin and national health experts.
Unusual numbers of E. coli cases began appearing in hospitals around the country in late August, and by mid September public health officials were investigating a nationwide outbreak. Within days, the investigation pointed to spinach grown in three counties in California, and several producers issued voluntary product recalls.
To date, 175 people in 25 states have been infected, including 93 hospitalizations and one death, according to the U.S. Food and Drug Administration.
A relatively limited spinach contamination may not inspire as much fear as an avian flu pandemic, but it opens a window into the ongoing effort by health officials to control disease outbreaks more effectively with information technology.
“Outbreaks are only recognized as outbreaks when they come to the attention of public health agencies,” said Dr. Seth Foldy, former health commissioner for the City of Milwaukee. “Occasional, sporadic cases of E. coli infections happen all the time, and it’s not possible to chase every one of them as though it were an outbreak.”
So the public health agency has to recognize that more than the usual number of cases are occurring. The earlier it can do that, the faster it can respond with an outbreak investigation.
“The reporting of infectious diseases to public health departments by laboratories and physicians is mandated by law,” Foldy said, “but it is known to be very slow and very incomplete.”
Disease radar: updating surveillance
An effort to equip the state’s emergency health responders with more rapid disease tracking and communication systems has just left the gate with the installation of the Wisconsin electronic disease surveillance system (WEDSS).
The system, which could utilize electronic laboratory reporting (ELR) functions, would enable communication from the trenches. Hospitals and clinics seeing cases appear at their door could quickly and automatically transfer information about disease findings to public health departments at the local, state, and federal levels for monitoring trends and sending alerts.
The WEDSS project, the state’s offshoot of the ongoing national initiative, NEDSS, entered its implementation and configuration phase last week. According to WEDSS project manager, Aasa Schmit, this phase could be completed before the end of the year. Pilot programs in the City of Milwaukee and Brown and Burnett Counties have not yet started using the system.
“No live data has been entered into the system and no outbreaks so far have been managed by the system,” Schmit said in an e-mail to WTN.
Fingerprinting: ID the bug
Once a health agency is aware of an abnormal number of disease cases in a community, it must determine whether the cases are related by deriving a genetic fingerprint from the bacteria or virus. This is accomplished with a labor-intensive laboratory informatics technique called pulsed field gel electrophoresis.
Wisconsin played a key role in this identification stage of the E. coli situation and made the genetic information available to other states, a point Gov. Jim Doyle emphasized in his statement on the outbreak.
“In the E. coli case, the bugs mutate constantly,” Foldy said. “But if you’re seeing the same genetic pattern appearing around the country, you can use this evidence to link the cases to a single point source.”
Once health officials possess the genetic fingerprints, they turn to a Web-based database to compare findings rapidly. The database operates through PulseNet, a national network of public health and food regulatory agency laboratories coordinated by the Centers for Disease Control and Prevention.
PulseNet provides a “relatively new, totally electronic tool to compare patterns and genetic fingerprints of these organisms to identify infections by identical pathogens in disparate geographic areas,” explained Herb Bostrom, director of the Wisconsin Bureau of Communicable Diseases.
“We posted patterns and Oregon picked up on them and called the CDC. New Mexico was next, and that’s how the outbreak was determined,” Bostrom said.
Containing the bug
With the culprit pathogen in their crosshairs, health responders must then pinpoint the contamination source. This requires a case-finding operation and compiling detailed information from victims to establish the largest data set possible.
In the case of a food-borne illness, that data must then be linked to information from the FDA, which allows CDC officials to target the manufacturing facility or field where the disease originated.
Alerting doctors
In more than a third of all hospitals across the country, a Web-based tool created by Milwaukee-based EMSystem, a provider of emergency response communication solutions, has been used to facilitate the alert and investigation process.
It enables automated mass e-mail, fax, text message, and Web-posting notifications to be sent to enrolled primary care doctors and other emergency health responders. In this case, it would warn them to be on the lookout for certain diseases.
“Many of our regions used the application to get information out about the E. coli outbreak,” said Elaine Schweitzer, director of customer relations for EMSystem. “It’s a Web-based application, which really serves emergency medicine very well because no matter where you’re managing an event, if you can get on the Internet, you can get to the application. It’s a rapid form of communication in real time, and it’s constantly updatable.”
During the onset of the outbreak, Foldy, a practicing subscriber physician, received a text message on his cell phone notifying him that Milwaukee clinics were recording an unusual number of cases of “E. coli O157:H7” and recommending that patients with certain symptoms be tested.
“They blast the message to obtain more action, a higher index of suspicion, and better reporting by physicians,” Foldy said.
Schweitzer said that although the system receives generally positive user responses at user meetings each year, EMSystem works to improve the functionality of its applications and explore ways to help hospitals communicate more readily about bed and specialty patient care availability.
Rapid response
Rapid detection was important for a number of reasons, particularly because E.coli has varying affects on different age groups.
According to the CDC, E. coli causes an estimated 73,000 cases of infection and 61 deaths in the United States each year. Infection often leads to bloody diarrhea and vomiting.
Although most healthy adults can recover completely from the recent strain within a week, young children and the elderly are more likely to develop a form of kidney failure called hemolytic uremic syndrome (HUS), which can lead to serious kidney damage or death.
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