GeoSentinel: The Use of International Travelers as Sentinels for Global Infectious Diseases Events: David O. Freedman, MD Professor of Medicine & Epidemiology Center for Geographic Medicine Division of Infectious Diseases University of Alabama at Birmingham GeoSentinel: The Use of International Travelers as Sentinels for Global Infectious Diseases Events


GeoSentinel:The Global Surveillance Network of the ISTM and CDC: GeoSentinel: The Global Surveillance Network of the ISTM and CDC A worldwide communications and data collection network of travel/tropical medicine clinics


Slide3: What is GeoSentinel? Provider based surveillance of international travelers and migrants. Does not cover endemic diseases in local populations 33 travel/tropical medicine clinics globally (since 1996) 145 Network Members on all 6 continents (since 2002)


Why GeoSentinel?: Why GeoSentinel? 1992 IOM Report and all subsequent analyses Travelers are key element in spread of emerging ID Travel & migration continue to increase Travelers are sentinels visiting all countries Can be sampled upon return at relatively few points Detect pathogens at point of entry to domestic populations Value of aggregating global data centrally 1 case of unusual illness from Bolivia at 1 GeoS clinic compared to 5 cases from Bolivia from 5 GeoS clinics in 5 countries


Provider-based Sentinel Surveillance: Provider-based Sentinel Surveillance Surveillance-Response Alarming sentinel events Surveillance-ongoing trends Analysis of morbidity and estimating risk Diagnosing the ill-returnee; the clinician perspective Advising the Prospective Traveler; the traveler perspective Defining associations between patient characteristics and disease


How does GeoSentinel Work?: How does GeoSentinel Work?


Diagnoses: Comprehensive and Flexible: Diagnoses: Comprehensive and Flexible Comprehensive 500 available diagnosis codes in table New codes added as needed 77,062 final diagnoses for 57,825 patients


Provider-based Sentinel Surveillance: Provider-based Sentinel Surveillance Surveillance-Response Alarming sentinel events Surveillance-ongoing trends Analysis of morbidity and estimating risk Diagnosing the ill-returnee; the clinician perspective Advising the Prospective Traveler; the traveler perspective Defining associations between patient characteristics and disease


GeoSentinel Response Capabilities: GeoSentinel Response Capabilities Rapid Query-Response loop 33 GeoSentinel Sites 145 GeoSentinel Network Members ISTM members (TravelMed; 1800 members in 55 countries Partners (WHO, ProMed, IDSA, TropMed, CDC, etc) Outgoing Alerts/Advisories Broadcast radius is situation dependent Collaboration with public health partners


Leptospirosis - EcoChallenge, 2000: Leptospirosis - EcoChallenge, 2000 September 11, 2000; London site Queries by e-mail concerning ill returnees from Eco-Challenge, Sabah 2000 Query-Response to GeoS sites: Cases from NYC and Toronto. Elapsed time=8 hours. Participants worldwide still within incubation period. Wide broadcast of GeoSentinel Alert to to ISTM, ProMed, IDSA, TropMed. Elapsed time=14 hours. GeoSentinel sites interface directly with public health authorities in USA, UK, Australia and Canada to contact all at risk individuals. Elapsed time=48 hours.


GeoS Query-Response – Initial Events During SARS: GeoS Query-Response – Initial Events During SARS


The Signal from TorontoGlobal, not just Asian Implications: The Signal from Toronto Global, not just Asian Implications


GeoSentinel Respiratory Illness in Travelers1 (1/1997 – 12/2002): GeoSentinel Respiratory Illness in Travelers1 (1/1997 – 12/2002) 1 Travelers – excludes recent immigrants and expatriate residents without recent international travel 2 East Asia – includes includes Hong Kong, China, Thailand, Singapore, Vietnam, Taiwan 3 Upper respiratory illness – includes acute or chronic sinusitis, otitis (all types), pharyngitis, laryngitis, glossitis, stomatitis, rhinitis, tonsillitis, pertussis, and nonspecific upper respiratory infection 4 Lower respiratory illness – includes acute or chronic bronchitis, influenza, pneumonia (atypical/diffuse, bacterial/lobar), acute respiratory distress syndrome, asthma unspecified, legionellosis, pleurisy, mycobacterial infection, pulmonary eosinophilia


Slide17: Impact on Travel Medicine Recommendations Globally


Alarming Events Strategy: Alarming Events Strategy Fixed list of flagged diagnoses Any such record entered into the central database triggers an immediate alarm Immediate notification of a Project Director for decision on response Temporary flagged diagnoses added based on situations arising


Interesting Leads / Threads Maintained onNetwork Members Restricted Access Website: Interesting Leads / Threads Maintained on Network Members Restricted Access Website


Provider-based Sentinel Surveillance: Provider-based Sentinel Surveillance Surveillance-Response Alarming sentinel events Surveillance-ongoing trends Analysis of morbidity and estimating risk Diagnosing the ill-returnee; the clinician perspective Advising the Prospective Traveler; the traveler perspective Defining associations between patient characteristics and disease


Slide21: Trends by Month Data collected continuously 60 diagnosis/syndromes plotted routinely


Rapid Institution of Enhanced SurveillanceExample: Weekly trend analysis during SARS: Rapid Institution of Enhanced Surveillance Example: Weekly trend analysis during SARS


Small n, limited geographic distribution: Small n, limited geographic distribution *Most likely place of exposure as noted by physician in red


GeoSentinel Promed Postings: GeoSentinel Promed Postings Malaria - Israel ex Thailand. 20-MAY-2006. Archive: 20060520.1431 Chikungunya - Indian Ocean Update (05): Spread to Europe [3] France (Marseilles), Switzerland (Geneva) and Germany (Munich). 04-MAR-2006. Archive: 20060304.0695 Malaria - Haiti, Canada ex Haiti. 11-NOV-2005. Archive: 20051111.3292 Trypanosomiasis - USA ex Tanzania (Serengeti): RFI. 13-JUL-2005. Archive: 20050713.1989 Wound infections, tsunami-related - Asia. 10-JAN-2005. Archive: 20050110.0079 Malaria ex Dominican Republic [2] Canadian case of malaria imported from the Dominican Republic 02-DEC-2004. Archive: 20041202.3217 Hantavirus pulmonary syndrome, imported - USA. 30-MAY-2002. Archive: 20020530.4363 Dengue/DHF updates (16): 26 Apr 2002 [2] Thailand: out of season dengue outbreak in travellers to Koh Phangan. 26-APR-2002. Archive: 20020426.4039 Pediatric VAQTA Hepatitis A Vaccine Recall - USA. 14-DEC-2001. Archive: 20011214.3027 Anthrax bioterrorism: background & perspectives. 17-OCT-2001. Archive: 20011017.2556 West Nile virus protection. 31-AUG-2001. Archive: 20010831.2070 Respiratory illness - USA ex Mexico (Acapulco) (04) [1]. 12-APR-2001. Archive: 20010412.0727 Trypanosomiasis, African - Tanzania. ProMED-mail. 06-NOV-2000. Archive: 20001106.1935


Provider-based Sentinel Surveillance: Provider-based Sentinel Surveillance Surveillance-Response Alarming sentinel events Surveillance-ongoing trends Analysis of morbidity and estimating risk Diagnosing the ill-returnee; the clinician perspective Advising the Prospective Traveler; the traveler perspective Defining associations between patient characteristics and disease


GeoSentinel data collection: GeoSentinel data collection Data from patient (anonymous) Travel itinerary Data from provider Presenting symptoms Patient classification Diagnosis Data entry on secure web site Standardized data collection form


GeoSentinel Dataset, June 2006: GeoSentinel Dataset, June 2006 Number of Patients in GeoSentinel (n = 57,825) Place of Likely Exposure in Patients Seen After Travel


Slide29: Proportionate Morbidity no. of patients with given diagnosis (or group of diagnoses) all ill travelers to a destination Risk All incident cases all travelers to a destination


Slide30: Freedman DO, Weld LH, Kozarsky PE, Fisk T, Robins R, von Sonnenburg F, Keystone JS, Pandey P, Cetron MS; GeoSentinel Surveillance Network. Spectrum of disease and relation to place of exposure among ill returned travelers. N Engl J Med. 2006;354:119-30.


Slide32: GeoSentinel Reporting Rate # of GeoS patients with a diagnosis (or group of diagnoses) WTO estimate of all travelers to a destination GeoSentinel Reporting Rate Ratio GeoS reporting rate for region or country of interest GeoS reporting rate for low-risk reference region or country Risk All incident cases all travelers to a destination


Malaria Risk by Region: Malaria Risk by Region , Reference group Clin Infect Dis 2004:39;1104-1112


Gastrointestinal Infection by Region: Gastrointestinal Infection by Region Gastrointestinal infection reporting rate and reporting rate ratios (RRR) by region of travel, GeoSentinel 2000-2005. Submitted for publication. * Number of travelers to the region in 2000-2005 reported to WTO. † Number of cases of gastrointestinal infections after travel with exposure in the region as reported to GeoSentinel 2000-2005.


Gastrointestinal Infection by Country: Gastrointestinal Infection by Country Gastrointestinal infection reporting rate ratios (RRR) for selected countries (only one country visited), GeoSentinel 2000-2005. Submitted for publication. * Number of travelers to the region in 2000-2005 reported to WTO. † Number of cases of gastrointestinal infections after travel with likely exposure in the region reported to GeoSentinel 2000-2005.


Rare Diagnoses in 42,000 Ill Travelers 1996-2004: Rare Diagnoses in 42,000 Ill Travelers 1996-2004 No Cases: Ebola, Japanese encephalitis, rabies, tetanus, diphtheria, plague, tularemia, murine typhus, Rift Valley fever, poliomyelitis, free-living amebic meningitis, anthrax, or yellow fever 4 Cases or Fewer: Angiostrongylus cantonensis (1), A. costaricensis (1), hantavirus infection (1), cholera (1), melioidosis (1), Lassa fever (2), Ross River virus infection (1), ehrlichiosis (2), African trypanosomiasis (2), trichinellosis (2), legionnellosis (3), acute American trypanosomiasis (Chagas’ disease) (3), coccidioidomycosis (3), paracoccidiomycosis (1), chronic brucellosis (3), West Nile fever (3), rubella (4), and meningococcal meningitis (4)


What Sentinel Networks Can and Can’t Do: What Sentinel Networks Can and Can’t Do Physician verified diagnoses Don’t describe all illness in all travelers Focus is on medically important, not mild or self-limited illness Focus is on illness presenting at specialized centers Attribution of place of exposure not possible in all ill travelers Multi-country itineraries, some diseases with long or variable incubation periods Easy to narrow to region, not always to country Perceived “risky” destinations may be over-represented Patients seen after-travel must be analyzed separately from those seen during travel


Provider-based Sentinel Surveillance: Provider-based Sentinel Surveillance Surveillance-Response Alarming sentinel events Surveillance-ongoing trends Analysis of morbidity and estimating risk Diagnosing the ill-returnee; the clinician perspective Advising the Prospective Traveler; the traveler perspective Defining associations between patient characteristics and disease


Slide39: GeoSentinel Project Staff Project Directors D. Freedman - U. of Alabama at Birmingham P. Kozarsky - Emory University C. Reed - Div. of Global Migration & Quarantine, NCID/CDC ISTM Staff E. Axelrod - Data Manager A. Plier (UAB) - Program Manager B. Bagwell - Financial Management, Travel Coordination Div. of Global Migration & Quarantine, NCID/CDC M. Cetron - Special Consultant L. Weld - Statistician M. Russell - Epidemiologist I. Srinivasan - CDC IT support


Slide40: GeoSentinel Site Directors D. Meisch; Ho Chi Minh A. McCarthy; Ottawa S. McLellan; New Orleans T. Nutman; Bethesda P. Pandey; Katmandu C. Perret; Santiago W. Piyaphanee; Bangkok B. Sack; Baltimore H. Sagara; Yokohama E. Schwartz; Jerusalem M. Shaw; Auckland W. Stauffer; St. Paul R. Steffen; Zürich F. von Sonnenburg; Munich A. Wilder-Smith; Singapore M. Wittner; Bronx E. Barnett; Boston G. Brown; Melbourne G. Carosi; Brescia L. Chen; Cambridge B. Connor; New York J. Delmont; Marseille D. Freedman; Birmingham D. Hale; Salt Lake City N. Jenks; Peekskill, NY J. Keystone; Toronto P. Kozarsky; Atlanta E. Jong; Seattle C. Licitra; Orlando L. Loutan; Geneva M. Lynch; Fresno S. MacDonald; Beijing