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Although no cases of E.coli 0157:H7 have been found in Mississippi, the recent outbreak has served to remind physicians about the importance of disease surveillance and reporting. Without it, officials could not have tracked the source or warned consumers, and more sickness and even death might have been the results.

Because of one astute physician in Florida, the first case of inhalational anthrax was found and tracked. Because of another, the first Contra virus in the United States was uncovered. Yet, according to some estimates, only 10 percent of the reportable diseases are actually being reported.

Dr. Mills McNeill, epidemiologist and director of the Mississippi Public Health Laboratory, State Department of Health, said systems in place are ensuring and encouraging more reporting from the field.

"We strive to improve our reporting on a continual basis and have a number of things in place to do that," McNeill said. "Historically, the Department of Health relied on passive reporting whereby we published a reportable disease list and waited for people to call us. Now, post 9/11, we've moved to a more proactive disease protection mode."

The relatively new National Electronic Disease Surveillance System (NEDSS) and bioterrorism preparedness initiatives support integration of electronic data from various sources.

One new method is the introduction of syndromic disease surveillance, as in, for example, the tracking of influenza-like illness (ILI). Since most ILIs are never confirmed in a lab but are diagnosed clinically, a number of stops have been put into place to track them.

"Most or many bioterrorism agents present early on as an influenza-like illness. When you start seeing that, particularly if it's not during flu season, that would raise concerns that you may be dealing with a terrorism event. If we're seeing the percentage of ILIs go up in flu season, chances are good it's the flu," McNeill said.

Two systems in Mississippi being used to track and report those are the Bioterrorism ILI Surveillance Program and the National Sentinel Physician Surveillance (NSPS).

Under the bioterrorism program, information is gathered from hospital logs, patient sign-in logs, emergency room logs and labs from around the state. The data are compiled on a weekly basis to watch for trends of ILI around Mississippi. The Sentinel system involves private physicians around the state who have volunteered to provide information on their clinical practices once a week, which is then compiled and sent to the CDC. Both are proactive mechanisms to enable better detection of outbreaks at a time when intervention is most effective.

CDC press officer Dave Daigle called the discovery of the recent E.coli outbreak an example of how well an additional reporting network, PulseNet, is working.

"This was a great success for our PulseNet," Daigle said. "It sends a DNA fingerprint of disease from state labs to us here. The Council of State and Territorial Epidemiologists meet once a year to decide what diseases should go on the reportable list, but each state can add to that list and decide what they want to report. We saw a strain pop up in Wisconsin and the same strain appeared from Washington, two different states with the identical strain, so we were able to identify and track it very quickly."

Hattiesburg urologist Dr. Randolph Ross said while some people are diagnosed with E.coli, all E.coli is not reportable.

"Everyone has some E.coli bacteria in their colon, but usually they may be a little ill for a few days and then it passes, and they won't even need to go to the doctor. For it to be reportable, it has to be a certain strain. Usually the infectious disease doctors and labs make the report, but all labs should be required to as a backstop. Physicians would welcome that," Ross said.

McNeill said while systems in place will enhance tracking and reporting procedures, it's the grassroots clinicians who come face to face with the diseases that should make sure they get reported.

"We go out and do lots of presentations to hospital staff and practitioners, so there's a high degree of awareness of the importance of reporting," McNeill said. "But, I would be quick to add it's still incumbent upon the clinical astuteness of practicing physicians to serve as the front line for all of these systems. They are still the best eyes and ears out there to follow through."

According to the CDC, there are five challenges with the automated reporting system: sensitivity, specificity, completeness, coding standards, and end-user acceptance.

Sensitivity is often reduced because of failure to forward reports from the county of diagnosis to the country of residence, ongoing adjustments to the data extraction program, difficulties deciphering reportable diseases from the test results, and problems in the transmission of data files.

Specificity is also compromised. With automated reporting, while there's an increase in reportable diseases, there is also an increase in non-reportable conditions being reported. Even unnecessary negative reports, duplicate or false-positive reports are increased.

Reports sometimes come in incomplete and lacking sufficient data needed by health departments.

Although both the Systemized Nomenclature of Human and Veterinary Medicine and Health Level Seven (HL7) standards are available, many labs use their own coding which makes that data arrive in multiple formats and difficult to decipher.

Lastly, cooperation between practitioners on the front end is required when making determinations for reportable and non-reportable conditions.

For a list of Mississippi's reportable diseases, visit www.msdh.state.ms.us.


December 2006

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