Retail Clinics as Potential Reporters for Influenza Surveillance

Reported Cases of Influenza INTRODUCTION 40 42 44 46 48 50 52 Oct Nov

Influenza – the disease Viral respiratory disease Seasonal pattern Range of severity 35, 000

Diagnosis Clinical Signs and Symptoms Influenza-like Illness (ILI) Rapid Diagnostic tests Identify Influenza A

Influenza Surveillance in Texas 3 Main Components ①Laboratory Surveillance Data ②ILI information collected from

Influenza Surveillance in Travis County Two groups of clinicians reporting weekly LOCAL REPORTERS ILINet

Desirable qualities of influenza reporters REPORTERS Report weekly Submit specimens to DSHS Reliable DATA

Retail Clinics • Located in retail settings • No appointment needed • Fixed prices

US Retail Clinics, February 2009 Source http: //www. ncsl. org/default. aspx? tabid=13959 and Merchant

Potential advantages of retail clinic participation in influenza surveillance Electronic medical records May capture

Purpose GOAL 1: Describe influenza surveillance in Travis County GOAL 2: Investigate the feasibility

Reported Cases of Influenza Methods 40 42 44 46 48 50 52 Oct Nov

Goal 1: Describe Influenza Surveillance in Travis County Categorize and map current reporters 1.

Goal 2: Investigate the feasibility of adding retail clinics as influenza reporters Identify and

Reported Cases of Influenza Results 40 42 44 46 48 50 52 Oct Nov

Influenza Surveillance Sources for Austin/Travis County by Reporter Type, October 2010 Reporter Type LOCAL

Average Number of ILINet Providers Reporting Weekly and Number of Registered ILINet Providers during

Percent of Patients with ILI Influenza and ILI Activity Detected by Travis County Data

Percentage of Total ILI Cases Reported by ILINet Providers in the US, in Texas,

Number of ILI Cases Reported by Travis County ILINet Providers During the Last 3

Identification of Retail Clinics in Central Texas Company A – pharmacy chain 7 stores

Retail Clinics and Current Influenza/ILI Reporters in Travis and Surrounding Counties, October 2010 LOCAL

Survey Results Desirable Qualities of Influenza Reporters REPORTERS ü Report weekly DATA REPORTED üNumber

Survey Results Desirable Qualities of Influenza Reporters REPORTERS ü Submit specimens to DSHS DATA

Survey Results Desirable Qualities of Influenza Reporters DATA ü Capture a potentially underrepresented demographic

Summary of Desirability of Retail Clinics as Influenza Reporters in Travis County REPORTERS Report

Percent of Patients with ILI Reported by ILINet Providers in Travis County and All

Reported Cases of Influenza Conclusions 40 42 44 46 48 50 52 Oct Nov

Conclusions: Travis County Influenza Surveillance 1. Diverse reporters 2. Reporters located primarily along IH-35

Conclusions: Travis County Influenza Surveillance 5. Age distribution of Travis County ILINet data is

Conclusions: Retail Clinics 1. 2 companies in Central Texas 2. Majority along IH- 35

Limitations 1. Age group information not collected by local reporters 2. ILI information not

Recommendations Utilize retail clinics for surveillance Recruit more ILINet reporters to meet CDC/DSHS recommendations

Future Studies Investigate retail clinic reporting of notifiable conditions. Explore feasibility of using Google

Acknowledgements Texas Department of State Health Services: Carol Davis Lesley Brannan Tracy Haywood Irene

Thank you! Funding generously provided by an Association of Schools of Public Health/Association of

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Retail Clinics as Potential Reporters for Influenza Surveillance in Travis County, Texas By: Alexander Domingo Public Health Internship Program School of Biological Sciences The University of Texas at Austin Mentor: Carol Davis, MSPH, CPH Emerging and Acute Infectious Disease Branch Texas Department of State Health Services Mentor: Heather Cooks-Sinclair, MS Division of the Medical Director Austin/Travis County Health and Human Services

Reported Cases of Influenza INTRODUCTION 40 42 44 46 48 50 52 Oct Nov Dec 1 3 Jan 5 7 Feb 9 11 13 15 17 19 Mar Apr May

Influenza – the disease Viral respiratory disease Seasonal pattern Range of severity 35, 000 deaths/year

Diagnosis Clinical Signs and Symptoms Influenza-like Illness (ILI) Rapid Diagnostic tests Identify Influenza A and B Require little training and equipment Provide results within an hour Rapid Diagnostic Kit

Influenza Surveillance in Texas 3 Main Components ①Laboratory Surveillance Data ②ILI information collected from regional centers and ILINet providers ③Rapid test data from clinics, laboratories, and hospitals from regional centers. Weekly summary report sent to CDC

Influenza Surveillance in Travis County Two groups of clinicians reporting weekly LOCAL REPORTERS ILINet Report rapid test results and ILI cases directly to ATCHHSD Report ILI cases by age group to CDC Two Real-time Syndromic Surveillance Sources RODS NRDM Web-based chief complaint database Over-the-counter drug and health care product sales

Desirable qualities of influenza reporters REPORTERS Report weekly Submit specimens to DSHS Reliable DATA REPORTED • Number of ILI cases and total number of patients • Rapid test results Patient demographics for children and elderly patients Captures a potentially underrepresented demographic in the community Inclusion of data about mild, moderate and severe cases across all reporters Sources: C. Davis and H. Cooks-Sinclair

Retail Clinics • Located in retail settings • No appointment needed • Fixed prices • Limited menu of services • Care providers: NP, PA, and in some cases MD/DO

US Retail Clinics, February 2009 Source http: //www. ncsl. org/default. aspx? tabid=13959 and Merchant Medicine, LLC

Potential advantages of retail clinic participation in influenza surveillance Electronic medical records May capture populations with ILI that would not be captured otherwise Mild --Moderate--Severe-- > Fatal NRDM Data Physician Offices Hospital Urgent Care Retail Clinics Vital Statistics

Purpose GOAL 1: Describe influenza surveillance in Travis County GOAL 2: Investigate the feasibility and utility of adding retail clinics as influenza reporters

Reported Cases of Influenza Methods 40 42 44 46 48 50 52 Oct Nov Dec 1 3 Jan 5 7 Feb 9 11 13 15 17 19 Mar Apr May

Goal 1: Describe Influenza Surveillance in Travis County Categorize and map current reporters 1. 2. Collect and analyze historical surveillance data Number of reporters in last 3 seasons Influenza/ILI activity detected by data sources ILI activity by age group

Goal 2: Investigate the feasibility of adding retail clinics as influenza reporters Identify and map all retail clinics in Travis County 1. 2. Describe local retail clinic characteristics Design and administer a survey 3. Analyze historical ILI data from local retail clinics

Reported Cases of Influenza Results 40 42 44 46 48 50 52 Oct Nov Dec 1 3 Jan 5 7 Feb 9 11 13 15 17 19 Mar Apr May

Influenza Surveillance Sources for Austin/Travis County by Reporter Type, October 2010 Reporter Type LOCAL REPORTERS Hospital 2 Urgent Care Clinic 2 ILINet 1 Pediatrician 1 Family Practice 1 Retail Store 1 NRDM 15 University Health Center Community Health Center RODS 1 11

LOCAL REPORTERS ILINet RODS

Average Number of ILINet Providers Reporting Weekly and Number of Registered ILINet Providers during the Past 3 Influenza Seasons in Travis County 8 7 7 7 6 6 5 Average Number of Providers Reporting per Week 4, 2 Number of Providers Registered during Season 4 2, 9 3 2, 1 2 1 0 2007 -2008 -2009 Influenza Season 2009 -2010

Percent of Patients with ILI Influenza and ILI Activity Detected by Travis County Data Sources, May-December 2009 18, 00 16, 00 14, 00 12, 00 10, 00 8, 00 6, 00 4, 00 2, 00 0, 00 Travis County ILINet All TX Counties Except Travis ILINet 21 22 23 24 25 26 27 28 29 30 Number of Positive Constitutional Tests Chief Complaints Jun 1200 1000 800 600 400 200 0 31 32 Jul 33 34 35 36 37 38 39 40 41 Aug Sep 42 43 44 45 46 47 48 49 50 51 Oct Nov Rapid Test A LOCAL REPORTERS 21 22 23 200 24 25 26 27 Jun 150 Dec Rapid Test B 28 29 30 31 32 Jul 33 34 35 36 Aug 37 38 39 40 41 Sep 42 43 44 45 46 47 48 49 50 Oct Nov Dec RODS 100 51 50 0 21 22 23 24 25 26 27 28 29 30 Jun Jul 31 32 33 34 Aug 35 36 37 38 Sep 39 40 41 42 43 44 45 46 47 48 49 50 Oct Nov Dec 51 52

Percentage of Total ILI Cases Reported by ILINet Providers in the US, in Texas, and in Travis County by Patient Age Group, October 2008 -October 2009 Percent of Total ILI Cases Reported 100, 0% 87, 0% 90, 0% 80, 0% 70, 0% 54, 3% 60, 0% 50, 0% 46, 5% 0 -4 yrs 5 -24 yrs 40, 0% 30, 0% 26, 2% 23, 6% 20, 0% 10, 0% 3, 7% N = 642, 735 US ILINet 25 -64 yrs 27, 7% 65+ yrs 12, 8% 5, 2% N = 32, 868 10, 9% 2, 1% N = 1525 0, 0% All Texas Counties Travis County ILINet Except Travis ILINet

Number of ILI Cases Reported by Travis County ILINet Providers During the Last 3 Influenza Seasons by Age Group and Provider Type Total Number of ILI Cases Reported 1000 Student Health 900 Pediatrician 800 Nursing Home Family Practice 700 Community Health Center 600 500 400 300 200 100 0 0 -4 5 -24 25 -64 2007 -2008 65+ 0 -4 5 -24 25 -64 2008 -2009 65+ 0 -4 Age Group and Influenza Season 5 -24 25 -64 2009 -2010 65+

Goal 2: Investigate the feasibility of adding retail clinics as influenza reporters Identify and map all retail clinics in Travis County 1. 2. Describe local retail clinic characteristics Survey development and implementation 3. Analyze historical ILI data from local retail clinics

Identification of Retail Clinics in Central Texas Company A – pharmacy chain 7 stores Company B – grocery store chain 5 stores

Retail Clinics and Current Influenza/ILI Reporters in Travis and Surrounding Counties, October 2010 LOCAL REPORTERS ILINet RODS

Survey Results Desirable Qualities of Influenza Reporters REPORTERS ü Report weekly DATA REPORTED üNumber of ILI cases and total number of patients Question Retail Clinic Company A Retail Clinic Company B 1. Does your clinic regularly track number of patients with ILI/Influenz a? No, but stored Same as A in EMR system daily with all other diagnoses. 2. Does your Yes, daily using Same as A clinic track EMR system total number of patients seen? If so, at what frequency?

Survey Results Desirable Qualities of Influenza Reporters REPORTERS ü Submit specimens to DSHS DATA üRapid test results Question Retail Clinic Company A 3. Would Maybe your company be willing to submit specimens to DSHS? 4. How does your clinic diagnose patients with influenza? Retail Clinic Company B Yes Combination Same as A of clinical and point-of-care rapid test results

Survey Results Desirable Qualities of Influenza Reporters DATA ü Capture a potentially underrepresented demographic in community ü Inclusion of data about mild, moderate and severe cases across all reporters Question Retail Clinic Company A Retail Clinic Company B 5. What percentage of your patients are medically underserved, in your estimation? 20– 30% 25 -30% 6. In your estimation, what percent of influenza patients that you see have mild, moderate, or severe disease? Mild: 60 % Moderate: 40% Severe: Refer to ER Mild: 75% Moderate: 25% Severe: Same as A

Summary of Desirability of Retail Clinics as Influenza Reporters in Travis County REPORTERS Report weekly Submit specimens to TDSHS Reliable ? DATA COLLECTED Number of ILI cases and total number of patients Rapid test results Demographic data representative of the community Inclusion of data about mild, moderate and severe cases across all reporters Patient demographics for infants, children and elderly patients

Goal 2: Investigate the feasibility of adding retail clinics as influenza reporters Identify and map all retail clinics in Travis County 1. 2. Describe local retail clinic characteristics Survey development and implementation 3. Analyze historical ILI data from local retail clinics

Percent of Patients with ILI Reported by ILINet Providers in Travis County and All Other Counties in Texas, and Number of Cases of ILI recorded by Retail Clinic B, October 2008 -May 2009 12, 00 All TX Counties Except Travis 10, 00 8, 00 Travis County ILINet 6, 00 4, 00 2, 00 0, 00 40 41 42 43 44 45 46 47 48 49 50 51 Oct Nov 52 53 1 2 Dec 3 4 5 6 Jan 7 8 9 Feb 10 11 12 13 14 Mar 15 16 17 18 Apr 19 20 May 180 Number of ILI Cases 160 140 Retail Clinic B ILI 120 100 80 60 40 20 0 40 41 42 43 44 45 46 47 48 49 50 51 Oct Nov 52 53 Dec 1 2 3 4 5 6 7 Jan Feb MMWR Week and Month 8 9 10 11 Mar 12 13 14 15 Apr 16 17 18 19 20 May

Percentage of Total ILI Cases Reported by ILINet Providers in the US, in Texas, and in Travis County and Recorded by Retail Clinic Company B by Patient Age Group, October 2008 -October 2009 N = 1908 N = 32, 868 N = 1525

Reported Cases of Influenza Conclusions 40 42 44 46 48 50 52 Oct Nov Dec 1 3 Jan 5 7 Feb 9 11 13 15 17 19 Mar Apr May

Conclusions: Travis County Influenza Surveillance 1. Diverse reporters 2. Reporters located primarily along IH-35 and MOPAC 3. Ave. no. ILINet providers reporting per week less than CDC recommendations; declining in the last two years 4. ILI and influenza activity reported by Travis County temporally similar to that reported in Texas

Conclusions: Travis County Influenza Surveillance 5. Age distribution of Travis County ILINet data is not representative of statewide or nationwide data Over-representation of young adult data from a university health center Under representation of infants and young children and those over 65 years of age

Conclusions: Retail Clinics 1. 2 companies in Central Texas 2. Majority along IH- 35 and MOPAC, 3 in west Travis County 3. Adding 7 retail clinics in Travis County will nearly double numbers of current weekly reporters 4. Detection of ILI activity comparable with Texas ILINet providers 5. Retail clinics meet almost all Travis County criteria for desirable reporters Over-representative of adults and under-representative of infants, young children, and elderly.

Limitations 1. Age group information not collected by local reporters 2. ILI information not readily available for time period analyzed 3. Rapid test positive results missing from retail clinic data 4. No historical data from clinic company A

Recommendations Utilize retail clinics for surveillance Recruit more ILINet reporters to meet CDC/DSHS recommendations Focus on pediatricians and geriatric care

Future Studies Investigate retail clinic reporting of notifiable conditions. Explore feasibility of using Google Flu trends as a data source

Acknowledgements Texas Department of State Health Services: Carol Davis Lesley Brannan Tracy Haywood Irene Brown Austin-Travis County Health and Human Services: Heather Cooks-Sinclair University of Texas at Austin: Nancy Elder; Dr. Diane Kneeland Dr. Leanne Field

Thank you! Funding generously provided by an Association of Schools of Public Health/Association of Public Health Laboratories “Pathways to Public Health Careers and Internships Grant” from The Centers for Disease Control and Prevention