Finesessi7

Slide1: 

Sustaining Surveillance for West Nile Virus in New York City, 1999-2004 Annie Fine, MD New York City Department of Health and Mental Hygiene

From hysteria: 

From hysteria to humdrum

1999: 

1999

2004: 

2004

Human Cases of WNND and Number of New York Times Articles on WN virus, NYC, 1999-2004: 

Human Cases of WNND and Number of New York Times Articles on WN virus, NYC, 1999-2004

Challenges in Sustaining Surveillance and Control as WN becomes endemic: 

Challenges in Sustaining Surveillance and Control as WN becomes endemic Decreased funding Uneven medical provider awareness and reporting Decreased media interest Waning public interest/awareness Need to balance WN morbidity and mortality with other public health priorities WN virus still unpredictable and can cause outbreaks

Specific Concerns for Large Cities: 

Specific Concerns for Large Cities Need for rapid response capacity – dense population increases potential risks of outbreak Need for fine texture in determining risk to humans Need for very judicious use of adulticide Avoid exposure of large numbers of people unnecessarily Community/environmental sensitivity or opposition Diverse population Need to “do everything” – public health is local

Federal Funding to NYC for West Nile Virus Surveillance (ELC $), and human WNNDFiscal Years 1999-2004: 

Federal Funding to NYC for West Nile Virus Surveillance (ELC $), and human WNND Fiscal Years 1999-2004

NYC DOHMH expenses for arbovirus surveillance and control*, FY 99-04: 

NYC DOHMH expenses for arbovirus surveillance and control*, FY 99-04 *Does not include in kind services for human surveillance and other activities; also does not include non-DOH agency spending.

Surveillance - Human: 

Surveillance - Human Maintaining provider awareness and reporting is a challenge – Still emphasize reporting and testing of hospitalized cases and WNND Few requests for grand rounds Use health alert system Clinical presentation of WN may be subtle, need to “think WN” Many hospital-based providers were not here in 1999 NYC still actively manages suspect cases – still emphasize timely detection Offer free testing and free transportation of specimens to City PHL Little commercial testing in NYC Rolled into general disease surveillance Ended active surveillance

Surveillance – Human (cont.): 

Surveillance – Human (cont.) Since WN 1999 we have greatly improved surveillance data for aseptic meningitis and encephalitis, pick up other outbreaks Shared database with lab serves as model for other outbreak investigation databases

Aseptic Meningitis by Month, New York City, 1989-2004: 

Aseptic Meningitis by Month, New York City, 1989-2004

Surveillance - Mosquitoes: 

Surveillance - Mosquitoes Dense network of traps (83 permanent trap sites per week, 111 supplemental trap sites) over 321 square miles Over 221,000 mosquitoes ID’d in 2004 10,687 pools tested in 2004 184 pools infected with WN virus Probably “best” measure of risk to humans, but still hard to quantify Consider sampling strategies

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Brooklyn Queens Staten Island Manhattan Bronx

Surveillance – Dead Birds: 

Surveillance – Dead Birds Value for targeting control measures unclear Early warning system In densely populated area, can you use dead bird data to pinpoint areas of higher risk? Reported dead bird clusters in space and time - data has not proven extremely helpful in targeting control, though used for enhancing surveillance Value of dead bird data may change over time Dependent on public reporting (311, website) Changing seroprevalence in resident or migrant populations Depletion of corvids Turn around time is critical to usefulness but NYC discontinued in house bird testing due to costs, ltd lab capacity May need to reduce these activities substantially

Dead bird reports, positive dead birds, NYC, 2000-2004: 

Dead bird reports, positive dead birds, NYC, 2000-2004

Analysis of Surveillance Data: 

Analysis of Surveillance Data Not simple – tried time space cluster detection methods, ROC curves, other complex methods Will likely need to look at combinations of indicators rather than a single indicator Most critical need is for expert data analysis of the wealth of data we have gathered, both in NYC and in other large cities People, like birds, do move around, and in a densely populated area, using human cases as the outcome measure may make risk assessment even more difficult.

Mosquito Control: 

Mosquito Control In urban area, especially where unaccustomed to mosquito control activities, adulticiding needs to be targeted and used judiciously Heavy emphasis on larviciding Catch basins Green areas, cemeteries Aerial Proactive pesticide resistance management When to use adulticide – NOT straight-forward, controversial and difficult to evaluate effectiveness Qualitative algorithm Still some subjective elements, especially in determining boundaries of spray zones

Slide22: 

Adult Mosquito Control, NYC, 1999 - 2001 In 2001, there were only 6 spray events in 3 boroughs. Spraying was targeted to areas of WNV detection in birds, mosquitoes, and humans. Different colored areas reflect treatments on different nights from 8/14/01-9/2/01. In 2000, most of the City was treated by ground or by air. Spraying occurred within a 2 mile radius of WNV positive dead birds. Different colored areas reflect treatments on different nights from 7/19/00-9/24/00. In 1999, the whole City was treated twice by air (outer boroughs) and truck (Manhattan). Parts of northern Queens and southern Bronx were treated 4 times. 1999 2000 2001

Slide23: 

2004

Public Knowledge and Preventive Behaviors: 

Public Knowledge and Preventive Behaviors WN fatigue Perception that WN has moved “west” Public is used to spraying, environmental activism has died down Media does not carry stories More challenging to notify the public Few resources (and little interest in) for public education campaigns when disease is endemic Persistently low levels of knowledge and use of insect repellent – esp. Spanish-speaking

Public Knowledge and Preventive Behaviors (cont): 

Public Knowledge and Preventive Behaviors (cont) Target education to elderly, during high risk periods Have materials in “back pocket” Keep message SIMPLE Use students – flyers, community groups and elected officials, radio Combine the messages – spray notification and high WN activity – use protection Offer individuals e-mail notification of spray events NOV’s issued for standing water

Coordination of WN Activities: 

Coordination of WN Activities Now routine, roles well-defined Steering committee meetings once a week during mosquito season, share data WN response has served as a learning opportunity and model for DOHMH emergency response system $$ currently being used to improve public health emergency response would help in another WN outbreak

Balancing West Nile with other Public Health Priorities in NYC: 

Balancing West Nile with other Public Health Priorities in NYC 2003 New AIDS diagnoses 4946 New HIV diagnoses 4086 New TB cases 1140 Invasive Pneumococcal Disease 944 Primary and Secondary Syphilis 531 West Nile 30

Slide28: 

0.03 Cause-specific Death Rate in NYC, 2000

Conclusions: 

Conclusions WN virus has not “gone away.” Indeed, certain focal areas seem to remain at higher risk (Queens, Staten Island) from year to year As WN becomes endemic, public health needs to oppose dismantling of basic mosquito control programs and be cautious regarding decreasing resources for prevention (TB as a lesson) WN is still unpredictable and difficult to forecast Decisions about adulticiding require more quantitative risk assessment data Local and state HD’s need to be strategic about using designated funds, and leveraging other resources for WN prevention and control

Slide30: 

Next year in Hawaii

Acknowledgments: 

Acknowledgments Waheed Bajwa Edgar Butts Barbara Edwin Jessica Hartman Jacqueline Kellachan Farida Mahmood Farzad Mostashari Iqbal Poshni Ann Marie Reagan Huimin Shen

Slide32: 

1915 NYC Board of Health Report: "The city can have as much reduction of preventable disease as it wishes to pay for. Public health is purchasable; within natural limitations a city can determine its own death rate."

Correlation between positive mosquito pools and number of human cases: 

Correlation between positive mosquito pools and number of human cases

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Infected Mosquito Pools Per Site Infected Mosquito Pools (184) Legend ! ( 1 ! ( 8 ! ( 7 ! ( 5 ! ( 4 ! ( 3 2 ! ( ! ( 6 Infected Birds (43) ^ _ WNV Infected Birds Human Cases (5) 3 Cases, Imported, Arizona. 2 Case, New York City. ! . $ 1 ! O Horse Case (1) Horse Case ! ( 14 ! ( 9 Adulticide Events (14) WNV Infected Mosquitoes Nuisance Mosquitoes August 18, 2004 September 21, 2004 September 29, 2004 September 29, 2004 September 23, 2004 September 14, 2004 August 9, 2004 September 7, 2004 September 3, 2004 August 26, 2004 August 25, 2004 August 23, 2004 August 9, & 25, 2004 August 9, 2004 September 10, 2004 12/06/2004 West Nile Virus Surveillance µ West Nile Virus Activity and Adult Mosquito Control New York City 2004 ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ^ _ ! . ! O ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! ( ! . $ 1 $ 1 July 21, 2004 August 16, 2004

Human West Nile Virus in New York City Reported Suspected and Confirmed Cases and RatesJune 1 – Oct 31, 2001-2004*: 

Human West Nile Virus in New York City Reported Suspected and Confirmed Cases and Rates June 1 – Oct 31, 2001-2004* *2001-2003:Suspected Case of WN virus = encephalitis and/or unexplained motor weakness compatible with WN viral disease (any age) or aseptic meningitis (> 16 years of age); 2004: Same definition except aseptic meningitis cases of all ages are included.