Electronic Laboratory Reporting of Rabies Results and Associated NEDSS Surveillance Activities —

Nebraska, August 2011 to March 2012

Bryan F Buss, DVM MPH DACVPM

Career Epidemiology Field Officer (CEFO)

Nebraska Department of Health and Human Services

Office of the Director

Office of Public Health Preparedness and Response

Presentation Overview

Background information and overview of electronic laboratory reporting (ELR) of rabies test results

NEDSS system processes Case management of rabies laboratory reports

Case management of exposed humans

Contact tracing to link exposed persons to associated animal test results

Daily-generated NEDSS data extracts (line-lists)

ELR rabies test results

Discussion

Kansas State University Rabies Laboratory (KSU-RL)

Performs majority of rabies testing for Nebraska

Contracted to perform state-funded testing of samples

with human exposure reported

Test results and limited exposure information

captured electronically

Daily results securely messaged to DHHS via PHINMS

for Rhapsody processing and migration into NEDSS

Both positive and negative rabies test results captured

New investigation page for managing exposure cases

Electronic Laboratory Reporting of Rabies Results

Jurisdiction and Program Area assigned

Program Area = Vet/EPI (for all animal rabies tests)

NEDSS User permission (Vet/EPI role) must be enabled

to view rabies laboratory reports

Currently all LHD surveillance staff identified for

managing rabies exposures have access

Email notification generated automatically for

identified users in LHDs

Line listing of rabies reports and human exposure

investigations extracted from NEDSS daily using SAS

NEDSS Rabies Result Processing

NEDSS Alert – Email Notification

Alert provides notice that a test was received but does

not provide result

LHD staff must view report to see test result

“Upstream” Rhapsody alert for positive results being

considered

Search Based on Observation Identifier in Email

CASE MANAGEMENT OF RABIES LABORATORY REPORTS

NEDSS Documents Requiring Review

Sample Rabies Laboratory Report

Species and Breed = First and Middle Name

Point Location = Patient Address

Vaccination and Exposure History = Result Comment

Managing the Rabies Laboratory Report

Negative tests

marked as reviewed

after viewing

If investigation of exposed human will be created,

NEDSS animal patient last name is used to establish

link for contact tracing

Examples = RAB-POSITIVE-NE2012-01-25_52

RAB-NEG-NE2012-02-01_67

All positive rabies tests require an investigation,

confirmation, and electronic notification to CDC

Investigation for Positive Rabies Result

Investigation created from the ELR record by LHD

Condition = “Rabies, animal”

Positive Animal Rabies Investigation Data Captured

Investigation Start Date

Investigation Status

Investigator

Reporting Source = “Laboratory”

Earliest Date Reported to both County and State

Diagnosis Date

Confirmation Method and Date

Case Status

Comments as appropriate

Condition Specific Custom Field to report species

Positive Animal Rabies Investigation Data Captured

Completing Positive Animal Rabies Investigation

Investigation saved in NEDSS by LHD

LHD then “Creates Notification” from investigation page

Notification box then viewable at bottom of page

At this point, the process for managing an animal rabies case is complete!

MANAGING EXPOSED HUMANS Patient investigation separate from animal test result

NEDSS Animal Exposure Investigation Page Bites and Non-Bite Exposures

Patient file is created in NEDSS for exposed person

Basic demographic data collected as appropriate

Condition Selected

“Animal Exposure”

Animal Exposure Investigation Page*

*NEDSS human exposure investigation page template developed and provided by Rhode Island Department of Health

Captures demographic and clinical patient data

Seven separate tabs for collection of case information Patient

Administrative

Human Exposure or Incident Information

Animal and Wound Information

Treatment

Laboratory

Contact Records

Animal Exposure Investigation

Case Status – Administrative Tab Definitions

Confirmed – Animal exposure defined as 1) any penetration of the

skin by the teeth or any contamination of mucous membranes or

fresh, open cuts in the skin with saliva or brain material or 2) a bat

in the same room as a human who was not alert and awake the

entire time the bat was in the room or who was an unattended

young child or other individual who cannot otherwise say with

certainty “I know I wasn’t bitten.”

Probable/Suspect – Never used, values could not be removed

Event is either confirmed or not a case

Unknown – Used only when

a determination is not possible

Human Exposure or Incident Information

Captures event specific report information

Date and location of incident

Date of report and description of incident

Human Exposure or Incident Information

Additional Human Exposure Information

Index Case Question

“No” selected if only one exposed person to a single animal

“Yes” selected if additional persons exposed to same animal Number of additional persons entered and separate investigations for each individual created

Animal and Wound Information

Exposing Animal Information

Species and associated information

Wound Information

Treatment Tab

Documentation of immunosuppression if appropriate

Drop-down selections/comments to describe treatment

recommendations

Laboratory Tab

LHD clicks “Submit” when done to save the Investigation

CONTACT TRACING To link exposed persons to associated animal test results

Contact Tracing

**Note: Before a contact record is added, a message would appear in this space as below stating “Nothing Found to Display.”

“Contact Records” tab selected to “Add New Contact Record”

Search for Contact Record

“Name” search looks for text strings contained in Last or First Name

LHD searches by animal’s “NEDSS Patient Last Name” or Laboratory Observation ID (from email alert)

LHD Selects Contact Record

Green “Check Mark” is selected for the appropriate record for contact tracing.

**Note: More than one record might appear depending on the narrowness of the search.

Create Contact Record

Contact demographic information self-populates

No additional information needed in “Contact” tab

Create Contact Record

• “Contact Record” tab

• Red Asterisk on required fields

• “Jurisdiction” self-populates

• Select/assign “Investigator”

Create Contact Record

• “Status” and “Disposition” values selected

• If “Status” = “Closed” then “Disposition” is required

Contacts Named By Patient

Click “Name” to view a named Contact’s Patient File

Patient Named By Contacts View at Bottom of Animal Patient File’s Event Tab

Note: If an animal laboratory test result record is named by two or more exposed persons’ investigations, a contact record for each will be displayed here.

DAILY-GENERATED NEDSS DATA EXTRACTS (LINE-LISTS) Laboratory reports and human exposure investigations

NEDSS Rabies Laboratory Data Extract

NEDSS Rabies Laboratory Data Extract

NEDSS Human Exposure Investigation Data Extract

NEDSS Human Exposure Investigation Data Extract

ELR RABIES TEST RESULTS August 1, 2011 to March 30, 2012

Number of Rabies Tests Reported via ELR (N=768) by MMWR Week—Nebraska, August 2011–March 2012

Animal Species Total

Tested (N)

(%) (n/768)

Positive (n)

(%) (n/N)

Unsuitable (n)

(%) (n/N)

BAT 499 (65.0) 8 (1.6) 9 (1.8)

CAT 107 (13.9) 1 (0.9) 0 (0.0)

DOG 66 (8.6) 0 (0.0) 0 (0.0)

RACCOON 37 (4.8) 0 (0.0) 1 (2.7)

BOVINE 21 (2.7) 1 (4.8) 0 (0.0)

OTHER 17 (2.2) 0 (0.0) 2 (11.8)

SKUNK 12 (1.6) 7 (58.3) 0 (0.0)

SQUIRREL 5 (0.7) 0 (0.0) 0 (0.0)

HORSE 4 (0.5) 1 (25.0) 0 (0.0)

768 (100.0) 18 (2.3) 12 (1.6)

Number and Percent of Rabies Tests Reported via ELR (N=768) by Result and Species—Nebraska, August 2011–

March 2012

Total Number of Rabies Test Results (N=768) Reported via ELR—Nebraska, August 2011–March 2012

Number of Rabies Tests Reported via ELR (N=768) by Result and Species—Nebraska, August 2011–March 2012

Positive Rabies Cases (N=18) Reported via ELR by Animal Species—Nebraska, August 2011–March 2012

Proportions of Rabies Test Results Reported via ELR by Species—Nebraska, August 2011–March 2012

Vaccination Status

Dogs (%)

(n/66) Cats

(%) (n/107)

Total (%)

(n/173)

Current 23 (34.9) 11 (10.3) 34 (19.7)

None 10 (15.1) 28 (26.2) 38 (22.0)

Not current 14 (21.2) 16 (14.9) 30 (17.3)

Unknown 19 (28.8) 52 (48.6) 71 (41.0)

Totals 66 (100.0) 107 (100.0) 173 (100.0)

Vaccination Status of Rabies-Tested Dogs (n=66) and Cats (n=107)—Nebraska, August 2011–March 2012

Vaccination Status of Rabies-Tested Dogs (n=66) and Cats (n=107)—Nebraska, August 2011–March 2012

Nature of Human Exposure by Rabies-Tested Animal Species—Nebraska, August 2011–March 2012

Nature of Human Exposure (%) by Rabies-Tested Animal Species—Nebraska, August 2011–March 2012

Human Exposure by ELR-Reported Rabies Positive Animal Species (N=18)—Nebraska, August 2011–March 2012

Report of Other Animal Contact with Rabies-Tested Animals—Nebraska, August 2011–March 2012

Other Animal Contact Reported

N %

No 448 58.3

Yes 235 30.6

Unknown 85 11.1

768 100.0

Report of Other Animal Contact with Rabies-Tested

Animals by Nature of Human Exposure—Nebraska, August 2011–March 2012

Discussion

NDHHS and KSU-RL have successfully established automated ELR of animal rabies testing results

Nebraska LHDs have ready access to rabies testing results via NEDSS for managing human exposures

Anticipated enhancements include an Internet-based test requisition to electronically capture more robust exposure-related data for subsequent messaging to NDHHS NEDSS and availability for case management

We are also considering automated ELR capture of other animal laboratory results for surveillance of additional zoonotic diseases among animal populations

QUESTIONS?

Acknowledgments

• Nebraska Department of

Health and Human Services

• Thomas J Safranek

• Alison Keyser-Metobo

• Mike Nuss

• Curt Safranek

• KSU Veterinary Diagnostic

Laboratory

• Mike Moore

• Rolan Davis

• Rob McGaughey

• Cathleen Hanlon

Thanks to all local health department surveillance staff throughout Nebraska

who have indicated willingness to help manage animal exposures after the

State Public Health Veterinarian position in Nebraska was lost. Special thanks

to Anne O’Keefe and Tim Timmons for pilot work and helpful suggestions.

For more information please contact Centers for Disease Control and Prevention

1600 Clifton Road NE, Atlanta, GA 30333

Telephone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348

E-mail: cdcinfo@cdc.gov Web: http://www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Likewise, the authors’ findings and conclusions do not necessarily represent the views of the Nebraska Department of Health and Human Services.

Office of the Director

Office of Public Health Preparedness and Response

Thank-you