Continuing Medical Education Course Handout

Transcription

1 Continuing Medical Education Course Handout FY19 Epi-Tech Surveillance Training Friday, October 05, Monday, September 30, 2019 DCS, APG, MD Provided By U.S. Army Medical Command Activity ID Course Director CME Planner John Ambrose Mimi C. Eng Accreditation Statement This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of U.S. Army Medical Command and ARMY PUBLIC HEALTH CENTER. The U.S. Army Medical Command is accredited by the ACCME to provide continuing medical education for physicians. Credit Designation The U.S. Army Medical Command designates this Live Activity for a maximum of 5 AMA PRA Category 1 Credit(s) TM. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This is a required handout. It must be disseminated to each learner prior to the start of the activity. 1

2 Continuing Medical Education Course Handout Statement of Need/Gap Analysis The purpose of this CME activity is to address the identified gap(s): 1. Disease identification - verification of disease by established case definitions have been utilized by the local health departments, Centers for Disease Control and Prevention, World Health Organization, and the Department of Defense. With the every changing list of reportable medical events and new emerging infections, case definitions change rapidly. Army epidemiologist conduct verification studies that monitor the efficiency of reporting by local public health experts and have concluded that completeness percentages for reportable medical events range as low as 35% for select diseases. 2. Outbreak reporting - Recent evidence have demonstrated that outbreak reporting and communication between public health agencies is poor. In fact, the Army failed to report six outbreaks in the DRSi between June 2016 and September Surveillance techniques - Surveillance of common communicable diseases continues to be a problem among local MTFs. In fact, cases of campylobacter were not investigated in 2015 for PACOM MTFS, while 2016 cases of salmonella were not investigated. Civilian public health agencies are required to conduct investigations into all reportable medical events. However, DoD facilities often do not take initiative to conduct this investigation. Learning Objectives 1. Based on case presentation, enhance your ability to improve case finding and surveillance practices within your local MTF. Target Audience / Scope of Practice Target Audience: The intended audience for this educational activity includes preventive medicine physicians, community health nurses, public health nurses, and epidemiology technicians. Scope of Practice: This activity will improve the performance of preventive medicine personnel who conduct surveillance activities in inpatient and outpatient settings. 2

3 Continuing Medical Education Course Handout Disclosure of Faculty/Committee Member Relationships It is the policy of the U.S. Army Medical Command that all CME planning committee/faculty/authors disclose relationships with commercial entities upon invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Faculty Members Gilmore, Jessica - No information to disclose. Committee Members Ambrose, John Brown, Jodi Eng, Mimi Gibson, Kelly Graham-Glover, Bria Holbrook, Victoria Kebisek, Julianna Riegodedios, Asha Rudiger, Courtney - No information to disclose. - No information to disclose. - No information to disclose. - No information to disclose. - No information to disclose. - No information to disclose. - No information to disclose. - No information to disclose. - No information to disclose. Acknowledgement of Commercial Support There is no commercial support associated with this educational activity. 3

4 Announcement To register for the Monthly Disease Surveillance Trainings: Contact your service surveillance HUB to receive monthly updates and reminders Log-on or request log-on ID/password: Register at: Confirm attendance: Please enter your full name/ into the DCS chat box to the right or your service hub You will receive a confirmation within 48 hours with your attendance record; if you do not receive this , please contact your service hub 4

5 Child Blood Lead Program S S g t J e s s i c a G i l m o r e N C O I C, S u r v e i l l a n c e a n d R e s e a r c h S u p p o r t E p i C o n s u l t S e r v i c e D i v i s i o n U S A F S A M 5

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7 Learning objectives Understand the sources and adverse medical effects of lead exposure to educate base population and prevent further cases Interpret blood lead labs and ensure blood lead cases above CDC reference value are reported appropriately Identify ways to improve patient assessment for blood lead exposures 7

8 Outline Guidance Medical effects of lead exposure Blood lead screening assessments Reporting procedures/afdrsi Public health call to action References Contact Information Lab testing Investigation 8

9 Guidance Current CDC reference value > 5 micrograms per deciliter (µg/dl) as of AF: AFI Attachment 2 Childhood Blood Lead Screening Army: OTSG/MEDCOM Policy Memo (Signed 17 Oct. 2018) Army Regulation (AR) (Industrial Hygiene), Chapter 7-33a describes the childhood lead poisoning prevention (CLPP) program Department of the Army Pamphlet Chapter 7-14a(2)(a-d), Clinical services supporting childhood lead poisoning prevention AR , Chapter 3-4a AR , Appendix C-51 AR 200-1, Chapter 4-2f(4)(b) Navy: BUMED INSTRUCTION D Childhood Lead Poisoning Prevention, 30 Aug

10 Army Public Health Call to Action OTSG/MEDCOM Policy Memo (Signed 17 Oct 2018) Clinicians assess the risk for exposure to lead at well-child examinations beginning at 6 months of age through 6 year of age. Report incidents of confirmed BLLs > 5μg/dL to Army DRSi MTFs should ensure that mechanisms are in place to communicate BLL results to clinicians and preventive medicine personnel. 10

11 Medical effects of lead exposure No safe blood lead level Any lead in blood has shown to have affect on IQ and cognitive development In 2014, CDC reported 8,056 new cases of elevated BLL s reported among children < 5 years Route of exposure for lead poisoning is mostly through inhalation and ingestion but can occur less commonly through dermal absorption The developing fetus and children < 6 years are more sensitive to lead exposure than adults because of the immaturity of the blood-brain barrier, increased gastrointestinal absorption, and hand-to-mouth behaviors, all of which increase exposure Lead can cause harm to all body systems, but particularly: kidneys, nervous system, reproductive system and can cause high blood pressure 11

12 Medical effects of lead exposure Symptoms include: Developmental concerns (IQ, hearing loss, growth) Loss of appetite/weight loss Fatigue Abdominal pain Vomiting/Nausea Lead toxicity of the central nervous system is irreversible Death Encephalopathy Increased risk of hypertension in adulthood Developmental toxicity (delayed puberty, decreased growth & hearing) Developmental toxicity (decreased IQ levels & academic abilities, attention-related & anti-social behaviors Acute lead encephalopathy developed at blood lead levels > 20 µg/dl characterized by symptoms: coma, seizures, bizarre behavior, ataxia, apathy, incoordination, vomiting, alteration in the state of consciousness, and subtle loss of recently acquired skills 12

13 Blood lead screening assessments: Policy IAW AFI attachment MTF medical providers will conduct universal childhood blood lead testing when required by state/local regulations. Otherwise, medical providers will conduct targeted or risk-based screening IAW CDC Guidelines (next slide) IAW AFI attachment MTF providers will conduct targeted screening through risk assessment questionnaires beginning at 6 12 mos and periodically between 24 mos to 6 yrs. Local policy might have additional requirements. IAW OTSG/MEDCOM Policy Memo para 5.c Clinicians will conduct screening beginning at 6 months of age through 6 year of age. Clinicians will follow state/local policy. IAW BUMEDINST D, Navy providers should assess risk for lead exposure during well child visits from age 6 months through 6 years using NAVMED 6200/2 ( ) Lead Exposure Risk Assessment Questionnaire or a similar tool. Children found to be at increased risk based on this assessment should be screened. 13

14 Blood lead assessments: Universal Screening and Targeted Testing Per American Academy of Pediatrics (AAP) guidelines, children 6 months 6 years (inclusive) should be screened for risk of lead exposure via a parental questionnaire. Children with risk factors identified on questionnaire should receive targeted BLL testing. Some states require universal blood testing for certain children, e.g. Medicare recipients or for children whose residence is in an area with historically high exposure to lead. Each state health department has different questions based on local sources of lead exposure. Child is considered high risk if answering yes to any question on a parental risk questionnaire 14

15 Targeted blood lead screening assessments: MH Genesis Blood Lead Screening Questionnaire Ex 15

16 Targeted blood lead screening assessments: Navy Ex 16

17 State-specific lead exposure parental questionnaires (Texas) 17

18 State-specific lead exposure parental questionnaires (Maryland) 18

19 Lab testing If a capillary test is positive, patient should be retested with venous test to confirm. Recommended schedule for obtaining a confirmatory venous sample Venous blood test has a low likelihood for contamination and is the preferred specimen for analysis. All children with confirmed venous blood lead levels > 20 µg/dl require medical evaluation. The urgency of further medical evaluation depends on the blood lead level and whether symptoms are present. Asymptomatic children with blood lead levels > 45 µg/dl should receive chelation therapy. Symptomatic lead poisoning or a venous blood lead concentration > 70 µg/dl is a medical emergency, requiring immediate inpatient chelation therapy * The higher the BLL on the screening test, the more urgent the need for confirmatory testing. 19

20 Investigation: CDC recommendations 20

21 AF investigation requirements AFI attachment 2 MTF provider will refer all patients > 5 µg/dl to PH PH initiates investigation Environmental assessment of detailed history Home or parent workplace visit to identify potential sources of lead exposure Coordinates with BE for lead sampling based on epi data IAW CDC/OSHA guidelines Consider BLL screenings on family members PH will provide lead toxicity investigation findings to patient s medical provider 21

22 Army investigation requirements IAW OTSG/MEDCOM Policy Memo (Signed 17 Oct. 2018) paragraph b. Guided by CDC recommendations (from slide 20) Investigation usually refers to an environmental risk assessment of the house Installation PM assets must contact off-post public health assets to ensure appropriate investigation is done. Army PH conducts a case review following confirmed elevated BLL. Case review includes: review of patient s electronic medical record and f/u with Preventative Medicine Services/Public Health Department to confirm that environmental investigations are conducted. Army PH confirms investigations of elevated BLLs and any housing remediation are complete. 22

23 Navy investigation requirements Clinician Confirm BLL 5 μg/dl Notify family Monitor health status Administer treatment as indicated Recommend environmental assessment MTF Commanding Officer Report incident to command responsible for the management of the housing Report incident to Preventive Medicine Preventive Medicine Report to MTF Director of Public Health Report to civilian public health authorities according to state and local regulations Collaborate with Housing in investigating incident Confirm investigation and remediation is completed 23

24 Investigation: sources of lead 24

25 Investigation: occupations associated with lead Painters Home remodels/renovators Construction workers Auto body repairs Plumbers/pipe fitters Police Officers Firing range instructors Pottery making California Department of Health study, Jan 2014; protecting-workers-from-lead-exposure 25

26 Reporting procedures/drsi Follow local/state requirements to report elevated blood levels Some states require to report ALL blood lead tests performed Other states require to report blood lead tests > CDC reference value AF and Army Public Health reports all BLLs above the current CDC reference value to DRSi. (AFI , Attachment OTSG/MEDCOM Policy Memo , paragraph f.2) Navy Preventative Medicine personnel do not have a requirement to report 26

27 AFDRSi 1. Select Lead poisoning from the diagnosis drop down menu 2. Method of Confirmation-Serology 3. Case Classification Status-Confirmed 4. MER Status-Final 5. Laboratory tests 1 Blood Lead Level above the current CDC reference value Serology Confirmed Final 6. Comments Positive 5 Blood Lead level, comments to investigation if applicable, links to this case if applicable 27

28 ADRSi 1. Select Lead poisoning from the diagnosis drop down menu 2. Method of Confirmation-Serology 3. Case Classification Status-Confirmed 4. MER Status-Final 5. Laboratory tests Blood Lead Level above the current CDC reference value Positive Serology Confirmed Final 6. Comments Blood Lead level, comments to investigation if applicable, links to this case if applicable

29 Navy reporting requirement Labs and clinicians report BLLs 5 μg/dl to local Preventive Medicine NMCPHC Epi Data Center reviews blood lead lab reports recorded in CHCS Produces routine reports to enable program evaluation at the HQ level Navy previously required reporting to NMCPHC via Navy DRSi Review showed poor compliance Did not enable HQ program monitoring, reporting burden provided little value Navy requirement to report in DRSi dropped Central monitoring of clinical lab results commenced 29

30 AF lead surveillance, Epi Consult Service analyzed lab lead results for all AF bases and also compared to the cases that were actually reported in AFDRSi. Only 6 cases out of 29 elevated BLL s were reported in 2016 Only 8 cases out of 27 elevated BLL s were reported in 2017 For further details on the lead report, review the Summer 2018 PH Report on the KX ocuments/publications/public%20health %20Report_Summer% pdf Table 2: Elevated Blood Lead Cases Reported in AFDRSi among those under 18 years old, RME <6 yrs <18 <6 6 <18 yrs yrs yrs Lead Poisoning Pediatric Lead Screen

31 Army lead surveillance results 2010 Aug 2018 Army Pediatric Lead Report CY Year # of tests # of children tested , ,478 10, ,063 10, ,782 11, ,624 10, Total 86,837 83,517 Children tested Elevated BLLs Prevalence Aug ,838 83, per per Jan 2018 Aug per

32 Navy lead surveillance results NMCPHC Epi Data Center analyzed HL7 formatted chemistry blood lead results (from CHCS) for all DON beneficiaries 6 years Annual and quarterly DON reports support HQ program assessment efforts. CY17 annual report found 39 elevated BLLs in children 17 years of age (see table). Table 1. Blood Lead Level (BLL) Counts by Age Group, DON Pediatric Beneficiaries, CY 2017 BLL Ranges Age Group (Years) <5 µg/dl 5-9 µg/dl µg/dl 20 µg/dl Totals <2 4, , , , Totals 6, ,871 Data from Health Level 7 Chemistry (HL7 Chemistry) Prepared by the EpiData Center, Navy and Marine Corps Public Health Center on 21 February : 21 DON beneficiaries 6 years with elevated BLLs 5 μg/dl (out of 3,772 children tested) : 317 DON beneficiaries 6 years with elevated BLLs 5 μg/dl 32

33 Public health call to action Prevention is the best treatment! Brief Prostaff on importance of lead toxicity How many medical providers test for lead? What is their criteria to test? Does it follow CDC Guidelines? How does the medical provider educate to patient/parent of patient on lead exposure and toxicity levels? Refer to CDC lead homepage for education/prevention materials. See reference slide Liaise with your state health department on local sources of lead exposure and modify the screening questionnaire appropriately 33

34 Public health call to action: Lab recommendations Consult with your lab officer to help with adhoc setup to spool CHCS for ALL blood lead tests Air Force If lab is unable to modify the CHCS spooling code, they may contact the Laboratory Support (LSSC) on PH's behalf. PH should NOT reach out directly to the LSSC without first going through the lab The AF LSSC contact is: Major Tatanya Cooper, (703) Army should work with clinicians in assuring that all patients > 5 µg/dl are reported to appropriate personnel. Navy should work with their Medical Center s IT Dept. Brief lab on PH/Prev Med reporting/investigation requirements of lead poisoning 34

35 Public health call to action For the parent/guardian assigned to an Occupational Health shop: Ensure Occupational Health Shops that have lead exposure follow OSHA stds (CFR ) Review shop training programs on lead exposure and prevention of bringing lead home Ensure measures to prevent lead exposure to young family members are in place: Lead removing soap or wipes provided at work Showers at work site, if applicable Change clothes and shoes before heading home Washing lead exposed clothes at work site (using lead removing laundry detergent) 35

36 Questions? 36

37 References AFI ; AF reporting, AFDRSI; PH KX; Navy Guidance; BUMEDINST D: Tri-Service Workflow: CDC Lead homepage; CDC NIOSH; CDC publication: Preventing Lead Poisoning in Young Children; CDC publication: Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials; WHO publication: Childhood Lead Poisoning; MMWR edition 58: August 7, 2009, Recommendations for Blood Lead Screening of Medicaid-Eligible Children aged 1 5 Years: An Updated Approach to Targeting a Group at High Risk; MMWR edition 58: August 21, 2009, Childhood Lead Poisoning Associated with Lead Dust Contamination of Family Vehicles and Child Safety Seats Maine 2008; MMWR edition 61: August 10, 2012, Lead in Drinking Water and Human Blood Lead Levels in the United States; MMWR edition 66: January 20, 2017, Childhood blood lead levels in children <5 years United States, ; CFR : Oregon Department of Health; BORATORIES/Pages/index.aspx Questions Slide Picture- Symptoms Picture-Adair County Health Dept; Graph on lead removing wipes Health of the Force: Creating a healthier force for tomorrow; US Army Public Health Center Lead based pictures- 37

38 Contact Information Army: APHC Disease Epidemiology Division Aberdeen Proving Ground MD COMM: (410) DSN: Navy: NMCPHC Preventive Medicine Programs and Policy Support Department COMM: (757) ; DSN: (312) Contact your cognizant NEPMU NEPMU2: COMM: (757) ; DSN: (312) usn.hampton-roads.navhospporsva.list.nepmu2norfolk- NEPMU5: COMM: (619) ; DSN (312) NEPMU6: COMM: (808) ; DSN: (315) NEPMU7: COMM (int): (local): ; DSN: Air Force: Contact your MAJCOM PH or USAFSAM/PHR USAFSAM / PHR / Epidemiology Consult Service Wright-Patterson AFB, Ohio COMM: (937) DSN: usafsam.phrepiservic@us.af.mil 38