The Perspective

From Cards to Computers: Tools of Outbreak Investigation

Throughout the history of public health, the goal of an outbreak investigation has always been to identify the source and end the outbreak. The basic how-to is the same. Interview, interview, interview. Define case defintions and parameters. Identify trends. Review test results. Notify appropriate entities. Eliminate the source. End the outbreak. What’s different today is the technology and speed of how the outbreak investigation is done.

Public health has gone from post cards, regular mail, facsimile, dial-up modems, floppy disks and dot matrix printers to electronic reporting, social media, and sophisticated computer programs to identify an outrbreak or epidemic.

The Early Years

Years ago, it was acceptable for physicians to mail – yes, mail – post cards with information to the local health authority. In states with remote locations, like Alaska, short wave radios were used to report illnesses – and that could only be accomplished during a 30-minute window that allowed the physician to communicate. “You could have a lag time of three or four months before you knew about an outbreak,” said Dr. John Middaugh, interim chief health officer. “It took a lot longer to establish that an outbreak was occuring.” He said that during his time as the state epidemiologist with the State of Alaska, he and his colleagues would sometimes read about illnesses related to a local community event in the newspaper.

The 5”x8” card was the go-to tool that held many clues. Handwritten interview notes on the cards provided both patient and other information related to an illness such as onset, symptoms, etc. The time-consuming task of developing case definitions and then identifying patients who met case definitions and were included in the outbreak meant lots of sorting through paperwork and using tools like punch cards. Disease registries were developed from these handwritten cards and there were rooms full of patient files. Locating patient records as part of the outbreak investigation was, at times, very difficult and time consuming.

Present Day Reporting

Today, the health district receives information about reportable illnesses electronically. Physicians can use online tools to directly report information about their patients’ illnesses, tests are more accurate and can be done more quickly. The health district has even used social media outlets to help in a disease investigation conducted in 2011 when it received reports of illnesses following the Las Vegas Marathon. Modern reporting systems and more accurate tests allow epidemiologists to identify an outbreak in days rather than months.

The health district now has national databases that can assist with identifying an outbreak. The best example is the national Legionnaires’ Disease database maintained by the Centers for Disease Control and Prevention. This database helps to identify a source for the illness following patient diagnoses. The health district can take measures to end the outbreak at the source. In the case of Legionnaires, that would likely be a hotel’s water systems.

A Glimpse into the Future

Since 2010, the health district has been working on the TriSano system, a project that is helping modernize electronic systems for disease investigation and epidemiologic analysis. It allows epidemiology staff to quickly investigate and understand infectious diseases. Dr. Middaugh described it as the ‘Rolls Royce’ of sytems because it can help to identify disease patterns in the community and analyze data from hospitals or labs. TriSano is expected to transform what can be accomplished in the field of public health. The long term goal of the health district is to adapt the TriSano system so it can be used in the HIV/AIDS, STD and TB programs as well.

But, the personal touch has not been abandoned. . . disease investigators still interview patients via telephone and sometimes even in person. Staff still must communicate with patients and physicians on a personal level. And yes, they still use a pen and a piece of paper.

We hope you have enjoyed our final issue of the "Retro Perspective," which commenorates the health district's 50th anniversary. Look for new issues of the "Perspective" in 2013. We wish you a happy and healthy New Year!

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