Acciones para abordar riesgos y oportunidades

Background: Disease burden estimates are important for planning and tracking the effectiveness of public health interventions. Infectious diseases (IDs) potentially transmitted by water result in >2500 deaths and >40,000 hospitalizations annually in the United States. However, the majority of infections are probably treated in ambulatory care settings, where precise diagnoses and modes of transmission are usually not captured. We aimed to estimate the annual acute ID burden in outpatient offices (including physician offices and hospital outpatient departments) and emergency departments (EDs). Methods: We analyzed National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey visit data from 2006-2010. We used weighted analyses to generate nationally representative estimates of the annual frequency of visits to outpatient offices and EDs for seven acute ID categories: acute gastrointestinal, acute upper respiratory tract, acute lower respiratory tract, dermatologic, opthalmologic, otitis media, and otitis externa. Results: IDs were diagnosed in 168 million ambulatory visits, or 14% of all visits. The ID visit rate was 564 visits per 1000 persons. Most (84%) of ID visits occurred in outpatient offices, and 16% occurred in EDs. In outpatient offices, upper respiratory tract infections were the most common reason for ID visits (54 million/year), followed by dermatologic

infections (25 million/year) and lower respiratory tract infections (21 million/year). In EDs, upper respiratory tract infections were the most common reason for ID visits (7 million/year), followed by gastrointestinal infections (6 million/year) and lower respiratory tract infections (6 million/year).

Gastrointestinal infections had the largest proportion (29%) diagnosed in EDs. Conclusions: About one in seven visits to ambulatory care settings resulted in an ID diagnosis. Although the proportion of ambulatory ID visits resulting from waterborne transmission is unknown, many IDs are preventable through water, sanitation, and hygiene interventions. When combined with attribution data, these estimates can be used to direct research and inform providers and policymakers of the impact of potentially preventable infectious diseases in these settings.

Board 197. Global Health Benefits from Investments in Robust Surveillance Systems

N. M. M'ikanatha1_{, D. Mazali}2_{, S. W. Boktor}1_{, J. K. Iskander}3_; 1_{Pennsylvania Dept. of Hlth., Harrisburg,}

PA, USA,2_{Muhimbili Univ. of Hlth. and Allied Sci., Dar es Salaam, Tanzania,} 3_{Office of Associate Director}

for Sci., CDC, Atlanta, GA, USA

Background: Surveillance is the cornerstone for prevention and control of emerging public health threats. The 2005 International Health Regulations (IHR) obligated all national governments to meet core surveillance requirements. By June 2012, only 40 of the 194 jurisdictions (20%) had complied with IHR. Despite the potential to galvanize support for global health investments in surveillance, outbreaks that have spread to multiple countries, such as the current Ebola virus disease (EVD) epidemic, are

inadequately described. Methods: We analyzed web-based data on EVD collected during 2000-2014 to assess the number of countries and regions involved, human illnesses, deaths, and whether the outbreak was declared a public health emergency of international concern (PHEIC). To assess the affordability of robust surveillance, for countries involved in EVD outbreaks, we obtained national gross domestic income (GDI) in 2013 US$ from World Bank indictors. Results: Nine countries in four regions reported EVD outbreaks during the study period. As of October 17, 2014, there have been 10260 EVD infections and 5046 deaths. Although the majority of cases (87.5%) occurred in 2014, 9.8% of the cases occurred in Uganda during 2001-2012. Prior to 2014, EVD outbreaks occurred in four countries in two regions, Africa and Asia. The 2014 outbreak, which was classified as a PHEIC, has spread to Spain in Europe and to the United States in North America, involving two additional regions. All countries involved in EVD outbreaks prior to 2014 had total GDI of $414.1 billion while the two that were only involved in the 2014 outbreak, Spain and the US, had combined GDI > $18.36 trillion. Conclusions: The current EVD outbreak underscores the urgent need for collaborative efforts to ensure reliable surveillance systems in all countries. During the past decade, Ebola virus outbreaks occurred in multiple countries across two regions and most recently in two additional countries in separate regions. While the current outbreak is the largest ever, previous outbreaks had caused >1000 human illnesses, predominantly in countries with limited resources. A fraction of national incomes invested in surveillance systems would meet IHR requirements as well as strengthen efforts to detect and quickly prevent the spread of pathogens such as Ebola.

Board 198. Ability of the National Influenza Surveillance, Bangladesh (NISB) to Inform Influenza Response in Bangladesh

M. Lisa1_{, K. S. Ramirez}2,3_{, P. Roy}1_{, T. Shirin}1_{, M. S. Uzzaman}1_{, M. Rahman}1_{, S. J. Chai}3_; 1_{Inst. of}

Epidemiology, Disease Control and Res. (IEDCR), Dhaka, Bangladesh, 2_{Intl. Ctr. for Diarrhoeal Diseases}

Res., Bangladesh (ICDDR,B), Dhaka, Bangladesh, 3_{CDC, Atlanta, GA, USA}

Background: The Institute of Epidemiology, Disease Control and Research (IEDCR) established the National Influenza Surveillance Bangladesh (NISB) in May 2010 to understand the burden of influenza and to monitor strains of influenza virus in the community. These parameters are important to mitigate the impact of influenza on public health. Data completeness and timeliness are important to measure whether the system can support identification of circulating strains and provide linked epidemiological data to initiate responses to outbreaks. We conducted a study to evaluate the timeliness and data completeness of NISB. Methods: We used CDC’s 2001 guidelines to evaluate surveillance systems to assess data quality and timeliness of NISB. Three case entry forms submitted to NISB from each of seven surveillance sites were randomly selected from each month from June 2013-December 2013. We also reviewed the NISB registrar book which records all samples submitted to IEDCR’s central lab. Results: The average time from sample collection to receipt at the central lab was from 24 to 36 hours for the 126 case entry forms reviewed. This is below the NISB’s Lab Protocol reference time of 72 hours or less. Laboratory testing, data analysis, and reporting were complete for every month. An updated report was found for each month on the IEDCR website. Samples were collected twice a month from all sites on scheduled days. For data quality, date of interview, specimen collection, and unique identifier were reported in 100% (126/126) of forms, patient’s demographic data in 67% (84/126), patient’s symptoms in 83% (105/126), and history of treatment and exposure in 0% (0/126) of cases. No forms were completely filled out and there was no mechanism for error checking. Conclusions: NISB is a system that provides timely sample delivery and reporting but the data is often incomplete. Timeliness supports prompt response to influenza events but missing exposure data and demographic characteristics hinders responders from using the system to improve the health of the community. Data collection completeness can be enhanced by assigning a person in every surveillance site who implements regular data quality checks of the case report forms to ensure the quality of NISB data.

Board 199. Enhancing Surveillance of Emerging Infectious Diseases Using Mobile Data Collection and Open Data Kit (ODK) Technology: A Cross-sectional Study of Febrile Patients in Kilombero, Tanzania

L. Cosmas1_{, C. Hercik}2_{, J. Verani}1_{, O. D. Mogeni}3_{, N. Wamola}3_{, W. Kohi}4_{, B. Fields}1_{, S. Mfinanga}4_{, J.}

Montgomery1_; 1_{Global Disease Detection Branch, Div. of Global Hlth. Protection, Ctr. for Global Hlth.,}

CDC, Nairobi, Kenya, 2_{Georgetown Univ., Washington DC, USA,} 3_{Kenya Med. Res. Inst.-Ctr. for Global}

Hlth.Res. (KEMRI-CGHR), Nairobi, Kenya, 4_{Natl. Inst. of Med. Res. (NIMR) Muhimbili Ctr., Daresalam,}

Background: Traditional paper-based data collection systems for disease surveillance pose many challenges related to cost, timeliness and quality of data. Recent developments of mobile devices and open source softwares have allowed for innovative methods of efficient data collection and data sharing from remote areas. Methods: In the context of surveillance for acute febrile illness in a rural setting in Tanzania, we assessed feasibility, timeliness, data quality and user acceptability of android Samsung tablets, using an Open Data Kit (ODK) application for remote data collection. Case report forms and epidemiological surveys were programmed into ODK with skip patterns and validation checks to enhance quality control. Electronic data were submitted over the internet to a secure password-protected formhub web server using the phones 3G internet. We concomitantly utilized paper-based method which was manually entered into a separate database for comparison. We later merged these two databases and conducted double-entry data comparisons so as to identify entry discrepancies. Results: From June 11th_-

July 12th_{, 2014, 205 febrile patients were enrolled and all patient data was entered both electronically and}

manually. The electronic patient data was automatically uploaded to the server and this enabled us to continuously monitor and fix issues with the data collection process as the study continued. It was so laborious to revise the paper questionnaires based on the feedback from the training than it was for the electronic system. The paper-based system was more expensive (USD 1724) than the electronic (USD 1000) system which eliminated paper printing, mailing and data entry costs. All three study clinicians expressed high user acceptability on the use of the tablets, citing programmed validation checks and automated skip patterns which reduced the average time required to complete the study surveys, while minimizing human error in data entry. Conclusions: Mobile-based data collection with open source technologies is feasible in resource-constrained settings. The real-time submission of data reduced cost, facilitated timely availability of accurate information for decision-making and improved the efficiency of data collection.

Board 200. Understanding Lyme Disease Surveillance: Burden, Alternative Approaches, and Degree of Misclassification