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120 Enhanced Provider Education and Dengue Surveillance in Florida Veterans Affairs Healthcare Facilities, 2009-2010

Saturday, April 2, 2011
Trinity Ballroom (Hilton Anatole)
Cynthia A. Lucero, MD, CIC , Department of Veterans Affairs, Office of Public Health Surveillance and Research, Palo Alto, CA
Stephen Benoit, MD, MPH , Centers for Disease Control and Prevention, Office of Surveillance, Epidemiology and Laboratory Services, Atlanta, GA
Luis M. Santiago, MPH , Centers for Disease Control and Prevention, Division of Vector-Borne Diseases, Dengue Branch, San Juan, PR
Danielle Stanek, DVM , Florida Department of Health, Bureau of Environmental Public Health Medicine, Tallahassee, FL
Patricia Schirmer, MD, CIC , Department of Veterans Affairs, Office of Public Health Surveillance and Research, Palo Alto, CA
Achintya Dey, MA , Centers for Disease Control and Prevention, Office of Surveillance, Epidemiology and Laboratory Services, Atlanta, GA
Maria Rangel, MD, PhD , Department of Veterans Affairs, Office of Public Health Surveillance and Research, Palo Alto, CA
Gina Oda, MS, CIC , Department of Veterans Affairs, Office of Public Health Surveillance and Research, Palo Alto, CA
Mark Holodniy, MD, CIC , Department of Veterans Affairs, Office of Public Health Surveillance and Research, Palo Alto, CA

Background: In 2009 dengue was detected in Florida, the first outbreak in the continental U.S. outside Texas-Mexico border since 1945. Low awareness and limited surveillance were noted as possible contributors to sustained transmission. Dengue is a reportable disease in Florida, but Veterans Affairs (VA) facilities are not required to report to local health officials, limiting public health awareness and prevention efforts. Due to these concerns, VA partnered with CDC BioSense, CDC Dengue Branch and Florida Dept. of Health (FL DOH) to better address dengue among VA patients in Florida.

Objective: To increase dengue awareness among VA providers and improve surveillance and response by sharing relevant clinical information from these illnesses with FL DOH and CDC. 

Methods: VA utilized resources developed by CDC Dengue Branch to create educational materials for providers. VA ESSENCE biosurveillance system evaluated outpatient and emergency department visits for dengue ICD-9 diagnosis codes from Jan. 2009-Sept. 2010 at all 50 Florida VA facilities. CDC BioSense reviewed 2010 data from 30 South Florida VA facilities for dengue codes and code combinations suggestive of dengue (e.g. fever + thrombocytopenia). Cases were also reported by VA Infection Preventionists (IPs). VA epidemiologists reviewed medical records of potential cases and completed standardized chart extraction forms which were sent to CDC and FL DOH, who then communicated with county officials. 

Results: Educational materials were developed and distributed to clinicians in July 2010. Combining all case finding methods, 18 laboratory-confirmed dengue cases were identified (7 in 2009, 11 in 2010). ESSENCE identified 22 patients with codes for dengue and 15 (68%) had lab-confirmed dengue. BioSense detected 28 patients with codes or code combinations suggestive of dengue and 13 (46%) had lab-confirmed dengue. IPs reported 3 additional confirmed cases not identified by either electronic system. Of the 18 cases, 7 had exposures outside of Florida. All remaining patients were residents of or reported travel only to Key West, FL (Fig.1). Six patients were hospitalized, 2 required ICU care, none died. Median age was 61 years (range 27-74) and 83% were male. None developed dengue hemorrhagic fever. The most common signs and symptoms were fever (78%), joint/muscular pain (78%), thrombocytopenia (61%), rash (56%), headache (39%), and cough (22%).

Conclusions:   In this collaborative effort, an educational campaign and enhanced dengue surveillance were instituted for VA facilities in Florida. Cases in the first 9 months of 2010 were increased compared to 2009. Continued efforts to educate providers and monitor transmission in this region are needed.  This federal-state-local health reporting collaboration is an excellent model for improving inter-agency communication and response for other diseases of public health significance.