Event Detection in a Vulnerable Population

1. Event Detection in a Vulnerable Population Erin L. Murray, MSPH Georgia Division of Public Health Robert J. Finton, MSPH Fulton County Department of Health & Wellness I would like to take this time to describe an increase in invasive Streptococcus pneumoniae infections in the Atlanta homeless population detected by syndromic surveillanceI would like to take this time to describe an increase in invasive Streptococcus pneumoniae infections in the Atlanta homeless population detected by syndromic surveillance

2. Background –Atlanta Homeless Services Several homeless shelters operated throughout city with variety of services Day services Meals Mail collection Medical clinics Overnight shelter accommodations Atlanta homeless also utilize emergency departments in Fulton County The city of Atlanta, volunteer organizations, and the faith-based community operate several homeless shelters throughout the city. A variety of services are offered, including day services like meals, mail collection, and medical clinics, as well as overnight accommodations. In addition to the medical services provided at these shelters, the Atlanta homeless utilize emergency departments in Fulton County. The city of Atlanta, volunteer organizations, and the faith-based community operate several homeless shelters throughout the city. A variety of services are offered, including day services like meals, mail collection, and medical clinics, as well as overnight accommodations. In addition to the medical services provided at these shelters, the Atlanta homeless utilize emergency departments in Fulton County.

3. Background –Active Surveillance in GA Hospitals Emerging Infections Program (EIP) >100 clinical laboratories Syndromic Surveillance 29 Georgia Emergency Departments (ED) These emergency departments, and the hospitals they are affiliated with, may participate in two active surveillance systems that are operated in the state of Georgia. The Emerging Infections program, which involves more than 100 clinical laboratories, which are primarily affiliated with hospitals and syndromic surveillance, which currently has 29 participating Emergency Departments statewide Note: 40% of ED visits statewide 4000 visits/day These emergency departments, and the hospitals they are affiliated with, may participate in two active surveillance systems that are operated in the state of Georgia. The Emerging Infections program, which involves more than 100 clinical laboratories, which are primarily affiliated with hospitals and syndromic surveillance, which currently has 29 participating Emergency Departments statewide Note: 40% of ED visits statewide 4000 visits/day

4. Background –Emerging Infections Program (EIP) Network of CDC and 11 state health departments Conduct active population-based surveillance Active Bacterial Core Surveillance (ABCs) Invasive diseases caused by emerging, vaccine-preventable, and drug-resistant bacterial diseases FoodNet Foodborne and waterborne diseases the Emerging Infections Program is a network consisting of CDC and 11 state health departments that conduct active population-based surveillance for a variety of organisms. It does this through the Active Bacterial Core Surveillance system, or ABCs, and FoodNet. The ABCs system conducts active population-based surveillance for invasive diseases caused by emerging, vaccine-preventable, and drug-resistant diseases, and includes Group A and B streptococcus, Heamophilus influenzae type B, Neisseria meningitidis, and Streptococcus pneumoniae FoodNet focuses on foodborne and waterborne diseases. the Emerging Infections Program is a network consisting of CDC and 11 state health departments that conduct active population-based surveillance for a variety of organisms. It does this through the Active Bacterial Core Surveillance system, or ABCs, and FoodNet. The ABCs system conducts active population-based surveillance for invasive diseases caused by emerging, vaccine-preventable, and drug-resistant diseases, and includes Group A and B streptococcus, Heamophilus influenzae type B, Neisseria meningitidis, and Streptococcus pneumoniae FoodNet focuses on foodborne and waterborne diseases.

5. Background – Syndromic Surveillance in GA 22 emergency departments enrolled in March 2007 2 in Fulton County Data received daily for previous 24 hour period (midnight to midnight) Chief complaints categorized into 26 non-mutually exclusive syndromes 4 Priority Syndromes Fever Flu Rash Fever Diarrhea Vomit At the time of this event, the state of Georgia’s emergency department-based syndromic surveillance system had 22 hospital EDs participating statewide, representing approximately 30% of all ED visits. 2 of these facilities were located in Fulton County. Data from these emergency departments are received daily and include the ED visits that occurred during the previous day. Patient chief complaints are categorized into 26 non-mutually exclusive syndromes. Because of the large number of syndromes, 4 have been designated as priority syndromes and are monitored more closely than the others and include Fever Flu, Rash Fever, Diarrhea, and Vomit. The secondary syndromes consist of those designed to capture notifiable diseases, bioterrorist agents, and non-infectious conditions. At the time of this event, the state of Georgia’s emergency department-based syndromic surveillance system had 22 hospital EDs participating statewide, representing approximately 30% of all ED visits. 2 of these facilities were located in Fulton County. Data from these emergency departments are received daily and include the ED visits that occurred during the previous day. Patient chief complaints are categorized into 26 non-mutually exclusive syndromes. Because of the large number of syndromes, 4 have been designated as priority syndromes and are monitored more closely than the others and include Fever Flu, Rash Fever, Diarrhea, and Vomit. The secondary syndromes consist of those designed to capture notifiable diseases, bioterrorist agents, and non-infectious conditions.

6. Background – Syndromic Surveillance in GA Data analyzed using CuSum (EARS) – 3 levels State Health District Hospital Districts responsible for monitoring their hospitals State takes secondary role Multi-District anomalies Within District anomalies Data are analyzed using Cusum from the CDC’s Early Aberration Reporting System at three different geographic levels – the state, the health district, and the hospital. Georgia’s 18 Health Districts are depicted on the map. The primary responsibility for monitoring the data lies with the Health Districts, and they are only responsible for monitoring data from the hospitals located in their District. The state takes a secondary role in the data monitoring. But because they have access to all of the participating districts’ and hospitals’ data, their primary focus is looking for anomalies that may involve multiple health districts, but they do occasionally also notice unusual data anomalies within a district and notify the district epidemiologist about them. Data are analyzed using Cusum from the CDC’s Early Aberration Reporting System at three different geographic levels – the state, the health district, and the hospital. Georgia’s 18 Health Districts are depicted on the map. The primary responsibility for monitoring the data lies with the Health Districts, and they are only responsible for monitoring data from the hospitals located in their District. The state takes a secondary role in the data monitoring. But because they have access to all of the participating districts’ and hospitals’ data, their primary focus is looking for anomalies that may involve multiple health districts, but they do occasionally also notice unusual data anomalies within a district and notify the district epidemiologist about them.

7. Background – Syndromic Surveillance in GA Results available daily via Syndromic Surveillance secure web interface Counts Line list Time series Demographic distributions Interactive map To aide in the daily data monitoring activities, the state of Georgia has developed a syndromic surveillance web interface. This interface is dynamic and allows for the data to be viewed in several different ways, including counts, line lists, graphs, by demographics, and geographically through an interactive map. The interface plays a large role in helping the data monitor determine if something unusual is going on and often allows the monitoring epidemiologist to conclude that the CuSum flag is unlikely to represent a real outbreak without contacting the infection control practitioner at the hospital involved. Ultimately, very few CuSum flags actually result in follow-up with the hospital. The remainder of this presentation, however, will focus on one of the few CuSum flags that was deemed worthy of follow-up. To aide in the daily data monitoring activities, the state of Georgia has developed a syndromic surveillance web interface. This interface is dynamic and allows for the data to be viewed in several different ways, including counts, line lists, graphs, by demographics, and geographically through an interactive map. The interface plays a large role in helping the data monitor determine if something unusual is going on and often allows the monitoring epidemiologist to conclude that the CuSum flag is unlikely to represent a real outbreak without contacting the infection control practitioner at the hospital involved. Ultimately, very few CuSum flags actually result in follow-up with the hospital. The remainder of this presentation, however, will focus on one of the few CuSum flags that was deemed worthy of follow-up.

8. The Event – Bloody Respiratory Syndrome March 12, 2007 C1C2C3 flags identified 8 total events statewide on March 11 6 at Hospital A Most visits on single day at single ED ever On Monday, March 12, C1, C2, and C3 CuSum flags were noted for the bloody respiratory syndrome, one of the bioterrorism related syndromes. While this syndrome is not routinely given a lot of attention, the fact that there were 8 events statewide was considered very unusual. Further inspection revealed that 6 of the visits occurred at the same hospital, Hospital A. This was the largest number of visits for the bloody respiratory syndrome at a single facility on a single day ever recorded since the inception of Georgia’s syndromic surveillance system in January 2005. On Monday, March 12, C1, C2, and C3 CuSum flags were noted for the bloody respiratory syndrome, one of the bioterrorism related syndromes. While this syndrome is not routinely given a lot of attention, the fact that there were 8 events statewide was considered very unusual. Further inspection revealed that 6 of the visits occurred at the same hospital, Hospital A. This was the largest number of visits for the bloody respiratory syndrome at a single facility on a single day ever recorded since the inception of Georgia’s syndromic surveillance system in January 2005.

9. Bloody Respiratory SyndromeMarch 12 All had similar chief complaint 2 from same zip code Fulton County Department of Health & Wellness (FCDH&W) immediately notified An inspection of the line list data showed that all 6 visits at Hospital A had similar chief complaints of coughing up blood and that 2 of them were from the same Atlanta zip code. Because of the number of bloody respiratory visits and the spatial clustering of two of the cases, the Fulton County Department of Health & Wellness was notified An inspection of the line list data showed that all 6 visits at Hospital A had similar chief complaints of coughing up blood and that 2 of them were from the same Atlanta zip code. Because of the number of bloody respiratory visits and the spatial clustering of two of the cases, the Fulton County Department of Health & Wellness was notified

10. Bloody Respiratory SyndromeMarch 12 FCDH&W contacted Infection Control Practitioner (ICP) at Hospital A Two from same zip code reported same address Day shelter for homeless Both discharged as rule out tuberculosis One returned and was admitted The Epidemiologist in Fulton County concurred that this was unusual and warranted further follow-up with the Infection Control Practitioner at Hospital A. The ICP reported that the two cases from the same zip code had also reported the same address – a day shelter for the homeless. Both had been discharged with a working diagnosis of rule out tuberculosis, but one had since returned and been admitted. The Epidemiologist in Fulton County concurred that this was unusual and warranted further follow-up with the Infection Control Practitioner at Hospital A. The ICP reported that the two cases from the same zip code had also reported the same address – a day shelter for the homeless. Both had been discharged with a working diagnosis of rule out tuberculosis, but one had since returned and been admitted.

11. Bloody Respiratory SyndromeMarch 13 Culture results available Both positive for Streptococcus pneumoniae (non-sterile sites) ICP contacted GA EIP to inquire about possibility of other cases 4 cases of invasive S. pneumoniae with same day shelter address reported Onset from late-February and mid-March, 2007 On March 13, cultures on both of these patients came back positive for Streptococcus pneumoniae. While these two specimens had been taken from non-sterile sites, the test results prompted the ICP to contact the Georgia Emerging Infections Program to see if any invasive Streptococcus pneumoniae cases had been reported from the same homeless shelter address. This search uncovered 4 cases with onset in the previous 3 weeks. On March 13, cultures on both of these patients came back positive for Streptococcus pneumoniae. While these two specimens had been taken from non-sterile sites, the test results prompted the ICP to contact the Georgia Emerging Infections Program to see if any invasive Streptococcus pneumoniae cases had been reported from the same homeless shelter address. This search uncovered 4 cases with onset in the previous 3 weeks.

12. Invasive S. pneumoniae Notified CDC of cluster of invasive S. pneumoniae among homeless Review of all Atlanta invasive S. pneumoniae cases in 2007 (Jan-Mar) 10 cases with addresses reported as known homeless shelters The Georgia Division of Public Health notified the CDC of this cluster and they undertook a review of all invasive Streptococcus pneumoniae cases reported in metropolitan Atlanta during 2007 and cross referenced them with known homeless shelter addresses. A total of 10 cases among the homeless were identified at this time The Georgia Division of Public Health notified the CDC of this cluster and they undertook a review of all invasive Streptococcus pneumoniae cases reported in metropolitan Atlanta during 2007 and cross referenced them with known homeless shelter addresses. A total of 10 cases among the homeless were identified at this time

13. Invasive S. pneumoniae All hospitalized 8 at Hospital A 2 at Hospital B 7 had HIV 2 deaths 6 isolates with known serotypes 5 different S. pneumoniae serotypes No person-to-person transmission of S. pneumoniae All 10 cases had been hospitalized, 8 at hospital A and 2 at another hospital, hospital B 7 were known to be infected with HIV and 2 of the infections resulted in death Interestingly, of the 6 cases whose serotypes were known, 5 different Streptococcus pneumoniae serotypes were represented. This suggested that person-to-person spread of Streptococcus pneumoniae was not occurring as had been previuosly thought to this point. This new information prompted a further retrospective look at cases of invasive Streptococcus pneumoniae in patients reporting addresses of known homeless shelters to determine if what was being seen was normal or if there had been a recent increase in infections. All 10 cases had been hospitalized, 8 at hospital A and 2 at another hospital, hospital B 7 were known to be infected with HIV and 2 of the infections resulted in death Interestingly, of the 6 cases whose serotypes were known, 5 different Streptococcus pneumoniae serotypes were represented. This suggested that person-to-person spread of Streptococcus pneumoniae was not occurring as had been previuosly thought to this point. This new information prompted a further retrospective look at cases of invasive Streptococcus pneumoniae in patients reporting addresses of known homeless shelters to determine if what was being seen was normal or if there had been a recent increase in infections.

14. Invasive S. pneumoniae in Homeless An increase in the number of cases of invasive Streptococcus pneumoniae among homeless persons was found between 2005 and 2007. In 2005, only 4 cases had been reported A total of 13 cases were reported during 2006 and 10 cases had already been reported during the first 3 months of 2007, when only 4 cases were expected to have been reported during this time period. CLICK An increase in the number of cases of invasive Streptococcus pneumoniae among homeless persons was found between 2005 and 2007. In 2005, only 4 cases had been reported A total of 13 cases were reported during 2006 and 10 cases had already been reported during the first 3 months of 2007, when only 4 cases were expected to have been reported during this time period. CLICK

15. Invasive S. pneumoniae in Homeless A further breakdown of the 2006 data showed that 3 of the 13 cases had onset dates in December. A further breakdown of the 2006 data showed that 3 of the 13 cases had onset dates in December.

16. The Investigation Hypothesis Invasive S. pneumoniae infections represent secondary infection from viral primary infection Possibly influenza March 16 – formal investigation initiated Fulton County Department of Health & Wellness Georgia Division of Public Health Centers for Disease Control and Prevention Georgia Emerging Infections Program Service Provider A Because of the large number of cases that had occurred over the last 4 months and their overlap with the influenza season, it was hypothesized that the invasive streptococcus pneumoniae infections were actually representing secondary bacterial infections resulting from primary viral infections, quite possibly influenza On March 16, it was decided that a formal investigation would occur and would involve the collaborative efforts of the Fulton County Department of Health & Wellness, the Georgia Division of Public Health, the Centers for Disease Control and Prevention, the Georgia Emerging Infections Program, and Service Provider A, a health care provider for the homeless Because of the large number of cases that had occurred over the last 4 months and their overlap with the influenza season, it was hypothesized that the invasive streptococcus pneumoniae infections were actually representing secondary bacterial infections resulting from primary viral infections, quite possibly influenza On March 16, it was decided that a formal investigation would occur and would involve the collaborative efforts of the Fulton County Department of Health & Wellness, the Georgia Division of Public Health, the Centers for Disease Control and Prevention, the Georgia Emerging Infections Program, and Service Provider A, a health care provider for the homeless

17. Investigation Objectives Determine if significant increase in invasive S. pneumoniae occurred among homeless during 2006-07 influenza season Determine if influenza or another viral antecedent was circulating among homeless Recommend interventions to interrupt transmission of agents involved The objectives for the investigation were to establish surveillance for streptococcus pneumoniae in the Atlanta homeless population Determine if influenza or another viral pathogen was circulating among homeless persons And recommend interventions to interrupt the transmission of the agents involved Prospective and Retrospective surveillance among inpatients and outpatients was used to address these objectives The objectives for the investigation were to establish surveillance for streptococcus pneumoniae in the Atlanta homeless population Determine if influenza or another viral pathogen was circulating among homeless persons And recommend interventions to interrupt the transmission of the agents involved Prospective and Retrospective surveillance among inpatients and outpatients was used to address these objectives

18. Methods – S. pneumoniae Surveillance Focus on inpatients Most homeless persons with community acquired pneumonia are hospitalized Prospective Included respiratory virus testing March 17-30 - surveillance at hospital A March 22-30 - surveillance at hospital B Retrospective October 1, 2006 - March 16, 2007 Surveillance efforts for invasive streptococcus pneumoniae were focused on inpatients since most homeless persons with community acquired pneumonia are hospitalized. Prospective surveillance for new cases of streptococcus pneumoniae began at Hospital A on March 17th, and began at hospital B on March 22nd. The prospective surveillance also included testing for respiratory viruses Retrospective surveillance for cases not previously identified covered the time period from October 1, 2006 through March 16, 2007  Surveillance efforts for invasive streptococcus pneumoniae were focused on inpatients since most homeless persons with community acquired pneumonia are hospitalized. Prospective surveillance for new cases of streptococcus pneumoniae began at Hospital A on March 17th, and began at hospital B on March 22nd. The prospective surveillance also included testing for respiratory viruses Retrospective surveillance for cases not previously identified covered the time period from October 1, 2006 through March 16, 2007

19. Methods –Influenza-like Illness (ILI) Surveillance Outpatient clinics of Service Organization A Prospective March 21-30, 2007 Respiratory virus testing Any respiratory symptoms, e.g., cough, sore throat, etc. Retrospective November 1, 2006 - March 20, 2007 ILI visits Acute respiratory infections (ICD-9 codes 460.0–466.19) Pneumonia and influenza (ICD-9 codes 480.0–487.1) Influenza-like illness surveillance among the homeless was conducted at the outpatient clinics of service organization A Prospective surveillance was conducted from March 21st to the 30th and included testing for respiratory viruses on patients presenting with any respiratory symptoms Retrospective surveillance was conducted from November 1, 2006 through March 20, 2007 A visit was considered to be for an influenza-like illness if the diagnosis included any of the ICD-9 codes for acute respiratory infections, pneumonia, or influenza Influenza-like illness surveillance among the homeless was conducted at the outpatient clinics of service organization A Prospective surveillance was conducted from March 21st to the 30th and included testing for respiratory viruses on patients presenting with any respiratory symptoms Retrospective surveillance was conducted from November 1, 2006 through March 20, 2007 A visit was considered to be for an influenza-like illness if the diagnosis included any of the ICD-9 codes for acute respiratory infections, pneumonia, or influenza

20. Results – Prospective and Retrospective S. pneumoniae Surveillance 23 cases of invasive S. pneumoniae identified in homeless persons 1 new case from prospective surveillance No laboratory evidence of coincident viral respiratory infection 16 had HIV/AIDS A total of 23 cases of invasive streptococcus pneumoniae in homeless persons were identified between October 1, 2006 and March 30, 2007. One of these was detected during the prospective surveillance period, but did not have laboratory evidence of a coincident respiratory virus infection but nearly three quarters of the cases were identified as having HIV/AIDS A total of 23 cases of invasive streptococcus pneumoniae in homeless persons were identified between October 1, 2006 and March 30, 2007. One of these was detected during the prospective surveillance period, but did not have laboratory evidence of a coincident respiratory virus infection but nearly three quarters of the cases were identified as having HIV/AIDS

21. Results – Prospective and Retrospective Outpatient Surveillance 10%-20% of visits due to ILI Sentinel Providers (2%-5%) Laboratory Results 1 influenza B virus 3 coronavirus 1 also positive for rhinovirus Outpatient surveillance for influenza-like illness revealed that visits due to ILI ranged from 10 to 20% between November 1, 2006 and March 30, 2007 This was substantially higher than what was seen in the general population by Georgia sentinel providers, but ILI case definitions likely differed Respiratory virus testing that occurred during the prospective surveillance identified 1 influenza B virus infection and 3 coronovirus infections 1 of the coronavirus infections was co-infected with a rhinovirus Outpatient surveillance for influenza-like illness revealed that visits due to ILI ranged from 10 to 20% between November 1, 2006 and March 30, 2007 This was substantially higher than what was seen in the general population by Georgia sentinel providers, but ILI case definitions likely differed Respiratory virus testing that occurred during the prospective surveillance identified 1 influenza B virus infection and 3 coronovirus infections 1 of the coronavirus infections was co-infected with a rhinovirus

22. Investigation Limitations Prospective surveillance <2 weeks Investigation began when influenza season ending Only 1 new invasive S. pneumoniae case detected Only 1 influenza isolate identified The primary limitations of this investigation were the length and timing of the prospective surveillance activities These activities took place for less than a 2 week period And were begun as influenza activity in Georgia was waning Thus, only 1 new invasive streptococcus pneumoniae case was detected and Only 1 influenza isolate was identified Which made meeting the study objectives difficult. The primary limitations of this investigation were the length and timing of the prospective surveillance activities These activities took place for less than a 2 week period And were begun as influenza activity in Georgia was waning Thus, only 1 new invasive streptococcus pneumoniae case was detected and Only 1 influenza isolate was identified Which made meeting the study objectives difficult.

23. Investigation Findings Previously unrecognized burden of invasive S. pneumoniae in homeless Contribution of specific viral antecedent cases S. pneumoniae not established High burden of respiratory illness in homeless population However, the study did reveal that the cluster detected by syndromic surveillance uncovered a previously unrecognized burden of invasive streptococcus pneumoniae in the Atlanta homeless population Although a specific viral antecedent to these infections was not able to be established The investigation also indicated that there is a high burden of respiratory illness among homeless persons However, the study did reveal that the cluster detected by syndromic surveillance uncovered a previously unrecognized burden of invasive streptococcus pneumoniae in the Atlanta homeless population Although a specific viral antecedent to these infections was not able to be established The investigation also indicated that there is a high burden of respiratory illness among homeless persons

24. Investigation Recommendations Continue prospective surveillance for invasive S. pneumoniae among homeless Promote hand-hygiene among homeless Consider providing pneumococcal vaccine to HIV-positive homeless persons Provide influenza vaccine to entire homeless community In order to address the burden of respiratory illness and invasive pneumococcal disease in the homeless, several recommendations came out of this investigation Prospective surveillance for invasive streptococcus pneumoniae should be continued among homeless persons. Hand-hygiene among the homeless should be promoted, possibly by the distribution of alcohol-based hand-sanitizers at points-of-access to services, for example, upon shelter entry or exit Providing pneumococcal polysaccharide vaccine to unvaccinated homeless persons infected with HIV should be considered And influenza vaccine should be made accessible to the entire homeless community early in the influenza season In order to address the burden of respiratory illness and invasive pneumococcal disease in the homeless, several recommendations came out of this investigation Prospective surveillance for invasive streptococcus pneumoniae should be continued among homeless persons. Hand-hygiene among the homeless should be promoted, possibly by the distribution of alcohol-based hand-sanitizers at points-of-access to services, for example, upon shelter entry or exit Providing pneumococcal polysaccharide vaccine to unvaccinated homeless persons infected with HIV should be considered And influenza vaccine should be made accessible to the entire homeless community early in the influenza season

25. Investigation Benefits Fostered multi-jurisdictional and multi-agency collaboration Provided immediate evaluation of the health status of many registered homeless Refined how providers work together to expand public health services to homeless Additionally, there were several benefits to public health in Georgia that resulted from this investigation. It fostered multi-jurisdictional and multi-agency collaboration It provided an immediate evaluation of the health status of many of the registered homeless in the City of Atlanta. And it refined how service providers work together to expand public health services to the homeless. Additionally, there were several benefits to public health in Georgia that resulted from this investigation. It fostered multi-jurisdictional and multi-agency collaboration It provided an immediate evaluation of the health status of many of the registered homeless in the City of Atlanta. And it refined how service providers work together to expand public health services to the homeless.

26. Investigation Benefits Expanded relationship between public health and homeless service providers Increased notifiable disease reporting from homeless health care providers Allows for planning of future health promotion efforts in this population Additionally, it expanded the relationships between local public health and health care service providers to the homeless, which subsequently increased notifiable disease reporting from these health care providers. It also opened the door for the planning of future health promotion efforts and established routes for their implementation in this underserved population Additionally, it expanded the relationships between local public health and health care service providers to the homeless, which subsequently increased notifiable disease reporting from these health care providers. It also opened the door for the planning of future health promotion efforts and established routes for their implementation in this underserved population

27. Summary – Syndromic Surveillance Alerted public health of event in community May have otherwise gone unnoticed Allowed for immediate response Allowed for development of public health prevention strategies for homeless Example of how GA using syndromic surveillance to assist local public health In summary, syndromic surveillance alerted public health of an event occurring in the community that may have otherwise gone unnoticed. It allowed for an immediate response and the development of public health prevention strategies targeted towards the Atlanta homeless population This event provides a great example of how the Georgia Division of Public Health is using syndromic surveillance to assist public health practitioners at the local level in detecting and responding to events of public health significance in their communities In summary, syndromic surveillance alerted public health of an event occurring in the community that may have otherwise gone unnoticed. It allowed for an immediate response and the development of public health prevention strategies targeted towards the Atlanta homeless population This event provides a great example of how the Georgia Division of Public Health is using syndromic surveillance to assist public health practitioners at the local level in detecting and responding to events of public health significance in their communities

28. Acknowledgements Fulton County Department of Health & Wellness Robert J. Finton, MSPH Priti Kolhe, MSHA Steven R. Katkowsky, MD Wayne Ford, MPH Jamie Howgate, MPH Shamimul Khan, MPH Centers for Disease Control and Prevention Roopal Patel, MD (EIS) Scott Epperson, MPH Hospital A Nancy White, RN, CIC Jessica Garcia, MPH Service Organization A Mae Morgan, MD, MPH Georgia Division of Public Health Wendy Cameron, MPH Petra Wiersma, MD (EIS) Katie Arnold, MD, MPH Cherie Drenzek, DVM, MPH Susan Lance, DVM, MPH Karl Soetebier, MPW Georgia Emerging Infections Program Monica Farley, MD Wendy Baughman, MPH Hospital B Betsy Hackman, RN, CIC Connie Bryant, RN, CIC Paul Malpie, MD Georgia Public Health Laboratory

30. Questions?

31. Case Definitions CAP Chest x-ray confirmed Community Acquired Pneumonia in homeless person admitted to Hospital A or Hospital B IPD Isolation of S. pneumoniae from a normally sterile site from a homeless person admitted to Hospital A and Hospital B

32. Methods – Respiratory Virus Surveillance Inpatient and Outpatient Influenza A and B viruses Respiratory syncytial virus (RSV) Human metapneumovirus (hMPV) Parainfluenza viruses 1,2, and 3 (PIV1-3) Adenovirus Coronaviruses Rhinoviruses

33. Results - Prospective and Retrospective S. pneumoniae Surveillance

34. Results –Respiratory Disease Surveillance 10% and 20% of clinic visits for ILI