Epidemiology Newsletter
Office of Epidemiology February 2002 Utah Department of Health
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Olympic Surveillance

Disease surveillance and response is an ongoing function of the Office of Epidemiology and Utah’s local health departments. The influx of peoples from around the world and the heightened concern about bioterrorism during the recent Olympic Games required and enhanced disease surveillance and response plan be in place. Such a plan was developed by the local health departments (LHD) with Olympic related activities and the Utah Department of Health (UDOH) to monitor disease activity, to detect emerging diseases, outbreaks or unusual patterns of disease, and to effectively respond to outbreaks, natural or intentional. [Note: The six LHD’s with Olympic related activities include Davis, Salt Lake, Summit, Utah, Wasatch, and Weber-Morgan]

The major components of the Plan included:

  • Surveillance of Encounters at Urgent Care Facilities

  • Enhanced (active) Surveillance for Notifiable Diseases

  • Surveillance of Encounters at Olympic Designated Medical Clinics

  • Other Sentinel Surveillance Systems

  • Sentinel Intelligent Observers

Surveillance of Encounters at Urgent Care Facilities included hospital-based emergency departments and “drop-in” urgent care clinics. This was a “syndromic” surveillance system that identified visits for conditions suggestive of potential public health problems and identified cases compatible with diseases of public health concern. For some conditions, investigations were triggered for a single event (e.g., botulism-like syndrome), while other investigations were to initiated if an unusual number of events occurred. Ten syndromes were identified for tracking based upon communicable disease outbreaks of particular concern during the Olympics, and on the likely clinical presentations of victims that might indicate a bioterrorist event (Table 1).

Syndrome

Case Definition

Comments/guidance
Respiratory infection with fever One of: cough, sore throat, pharyngitis, bronchitis, pneumonia, pneumonitis, bronchopneumonia, bronchiolitis, shortness of breath, chest pain, or chest x-ray showing an infiltrate or mediastinal abnormality

plus: fever (“fever” or temperature > 100F/ 37.8C recorded in chart)

 Documentation of fever can be either as reported by the patient or documented at the visit.
Bloody diarrhea One of: diarrhea, loose or frequent stools, dysentery, gastroenteritis

Plus: blood in stool

 Documentation of “blood" is sufficient, without having any test to confirm the blood. Blood in stool may also be reported as a positive test for fecal occult blood. A primary gastrointestinal bleed (e.g., bleeding ulcer) may present with diarrhea due to the blood in the gut. If apparent in the note, such a case wouldn’t be included.
Gastroenteritis (diarrhea, vomiting)

without blood

 One of: diarrhea, loose or frequent stools, vomiting, gastroenteritis

Without: blood in stool, or a non-gastrointestinal cause of the symptom

 It may not be apparent, but a visit where it is evident that vomiting is due to a drug, such as cancer chemotherapy, would not be included. Nausea alone is not sufficient for this syndrome.
Febrile illness with rash One of: rash, dermatitis, exanthema

Plus: fever (“fever” or temperature > 100F/37.8C recorded in chart)Or: diagnosis of measles, rubella, fifth’s disease or exanthema rubitum, chickenpox, varicella, or of course smallpox)

 Rashes may be described as erythematous, macular, papular, vesicular, pustular, or combinations of those terms. Any of those would be included in this syndrome.

Documentation of fever can be either as reported by the patient or documented at the visit.

Surveillance sites were in the six LHD affected by the Olympics and were made up of 23 hospital-affiliated emergency departments and 19 “drop-in” urgent care facilities. Identification of cases was based upon the review of logs at each facility of the chief complaint and preliminary diagnosis for the preceding 24 hour period. Local Health Department staff conducted investigations for syndromes identified as sentinel events. Chart reviews were conducted where the log entry was suspicious but insufficient to confirm the presence of one of the target syndromes. When the number of events exceeded the expected number observed within a facility, health district, or in the six LHD as a group, an investigation was initiated.

Data was received by UDOH in one of two ways; entered by LHD staff either at the facility or at the LHD and transmitted to the UDOH as an email attachment, or transmitted in a tab-delimited form to UDOH by staff at the facility. Analysis was conducted at the LHD, based upon their resources to do so, and at the UDOH.

Enhanced (active) Surveillance for Notifiable Diseases was an enhancement of currently conducted surveillance for notifiable diseases where designated laboratories and clinical sites were contacted by LHD or UDOH staff three times per week to request information about persons with selected diseases of concern during the Olympics (Table 2).

Diseases/Conditions for Laboratory Surveillance

Diseases/Conditions for Enhanced Clinical Site Surveillance
Respiratory Diseases:Laboratory confirmed influenza, PertussisTuberculosis, Diphtheria Respiratory conditions:Pertussis, Tuberculosis, InfluenzaPneumonia, Diphtheria
Vaccine-preventable rash illnesses:MeaslesRubella Vaccine-preventable rash illnesses:
( “rash illness surveillance ”rather than specific conditions)Measles, Smallpox
Enteric Diseases:Salmonella, Shigella, E. ColiHepatitis A, Campylobacter, Cryptosporidiosis Food borne and enteric diseases:Botulism, HepatitisDiarrheal illness - bloodyGastroenteritis - non-bloody diarrhea or vomiting
CNS illnesses:Meningococcal meningitisViral encephalitis CNS illnesses:Bacterial meningitisViral encephalitis
Bioterrorism-related:Anthrax, PlagueSmallpox, Tularemia, Brucellosis Other:

Primary or secondary syphilis, Sepsis or unexplained shock

Unexplained death with fever

Notifications of possible cases received by UDOH from laboratories were communicated to the appropriate LHD for investigation and any case identified by the LHD was transmitted to UDOH. Sharing of information was conducted on the same day cases were identified.

Surveillance of Encounters at Olympic Designated Medical Clinics collected information from clinics located at the Olympic Village, each athletic venue, and at the International Olympic Committee hotel. These facilities primarily served members of the Olympic Family (athletes, officials). Encounter forms for each visit included the conditions tracked at the selected urgent care facilities and ED’s in addition to conditions associated with injury and trauma. Data from these forms were sent to UDOH daily and evaluated along with the other syndromic surveillance data.

Other Sentinel Surveillance Systems included the annual Influenza surveillance, worksite absenteeism surveillance, BASIS (a system for detecting an airborne biologic agent), Poison Control Center, and the University of Utah Clinical Data warehouse. These systems/agencies were alerted to contact UDOH if anything unusual was identified.

Sentinel Intelligent Observers that were identified included: Office of the Medical Examiner, Poison Control Center, Emergency Department and Urgent Care Facility staff (not otherwise included in surveillance activities), hospital infectious disease and infection control staff, Pharmacists, Veterinarians, and hospital intensive care unit physicians and nurses. Information received from these sites was considered as part of the enhanced notifiable disease surveillance.

Data collected and evaluated to date suggest no unusual public health problems occurred during the Olympics. Influenza activity was detected both through regular and enhanced notifiable disease surveillance and syndromic surveillance (as respiratory illness with fever). A final analysis of all the data will be completed over the next several months. Look for a summary this summer!

The Epicenter

In addition to the Olympic surveillance that was put in place to protect the public’s health, the Epicenter, served as a communications hub for the agencies involved with the Environmental and Public Health Alliance (EPHA). These agencies include the six counties with Olympic-related activities; three state agencies (the Utah Departments of Environmental Quality, Agriculture and Food, and Health); and five federal partners (the Food and Drug Administration, the U.S. Department of Agriculture, the Centers for Disease Control and Prevention, the Environmental Protection Agency and the Department of Health and Human Services). The primary goal of the Epicenter was to ensure that communication between agencies would be uninterrupted in the event of an emergency. Twelve phone lines (six incoming and six outgoing), two facsimile machines, an 800 MHz radio, a ham radio, and a satellite telephone line ensured that communication was possible through a variety of mechanisms. The Epicenter was also used to facilitate routine communications between agencies during the Games. Other operations included preparing a daily report that summarized activities of all the EPHA organizations, and providing a central location where people could gather to discuss ongoing problems. After the 2002 Winter Olympic and Paralympic Games are over, the equipment in the Epicenter will be securely stored away, and the room will be available again as a conference room. However, in the event of a future emergency, the equipment can be taken out of storage and the Epicenter can be in full operational mode in 30 minutes or less. This enhanced ability to rapidly respond to an emergency will serve as the Epicenter’s legacy.

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Utah Department of Health, Bureau of Epidemiology
Monthly Morbidity Summary - February 2002 - Provisional Data

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The Epidemiology Newsletter is published monthly by the Utah Department of Health, Division of Epidemiology and Laboratory Services, Office of Epidemiology, to disseminate epidemiologic information to the health care professional and the general public.

Send comments to:
The Office of Epidemiology, Box 142104, Salt Lake City, UT 84114-2104 or call (801) 538-6191

Approval 8000008: Appropriation 3705

Rod Betit, Executive Director, Utah Department of Health
Charles Brokopp, Dr.P.H., Director, Division of Epidemiology and Laboratory Services
Gerrie Dowdle, MSPH, Manager, Surveillance and Disease Control Program, Managing Editor
Connie Dean, Community Health Technician, Surveillance and Disease Control Program, Production Assistant

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