The North Carolina Division of Public Health (NC DPH) developed a program to increase surveillance for potential bioterrorist or infectious disease events by placing public health epidemiologists in 10 of the state's largest hospital systems. Increased partnerships between public health and hospitals, along with the enhanced surveillance skills epidemiologists bring to large healthcare systems, led to a program with great potential for responding quickly to an emerging health crisis.
The Public Health Epidemiologist (PHE) program began in 2003, partly as a response to the discovery that the first patient suffering from intentional inhalational anthrax infection in 2001 had spent time in North Carolina before traveling to Florida. As public health officials tried to determine the origin of the infection, NC DPH personnel determined they needed a prompt way within hospital settings to retrieve infectious disease cases that could signal a bioterrorism attack or a communicable disease cluster.
NC DPH used funding from its "Public Health Preparedness and Response for Bioterrorism" cooperative agreement to place and maintain 10 PHEs in hospitals across the state. Hospitals selected for the program were intended to offer the greatest reach in geopolitical location, emergency department volume, hospital bed size, and participation in a network with a large referral base.
PHEs' main responsibility involves bridging the gap between analyzing the large amounts of clinical data gathered by hospitals and serving the communications and surveillance needs of health departments. PHEs examine hospital data for indications of community-based infections and bioterrorist events, use their surveillance skills to aid in public health investigations, and educate healthcare professionals about public health surveillance. PHEs are able to draw data from various hospital sources and thus play a significant role in developing plans to mitigate a bioterrorism attack.
Hospital-based PHEs generally operate under the guidance of a hospital epidemiologist and an infection control manager and communicate directly with the NC DPH Communicable Disease Branch . PHEs use North Carolina's statewide syndromic surveillance system – NC DETECT (North Carolina Disease Event Tracking and Epidemiologic Collection Tool) to daily review hospital Emergency Department visits for infectious diseases, community acquired infections of special interest, and other events of public health significance.
Other data sources include hospital admission logs, hospital laboratory results, and physician notes. PHEs also conduct case investigations based on their data results and inquiries into patients' exposure histories. Not only do they share any suspicious or concerning findings with infection control and preparedness staff from the hospital, local and state health departments, they also provide a weekly report of hospital-based surveillance.
Because PHEs often conduct surveillance for diseases or clusters of cases that might otherwise go unrecognized, they must be innovative about how they search for clues that something clinically unusual is occurring. This is especially true as they examine data records for cases of potential bioterrorism. PHEs search for key words in patient records that, if occurring in significant numbers, might indicate a bioterrorist event. For instance, PHEs might closely examine results obtained from a search for "fever and rash" to rule out smallpox. Likewise, because a bioterrorism attack would probably not be immediately obvious in a healthcare setting, PHEs might search for a term like "mediastinal widening on chest X-ray," rather than searching deliberately for "anthrax."
The PHE program has proven to be beneficial both to the relationship between public health and healthcare systems and to their respective abilities to identify patterns of illness in the community. PHEs have been able to identify clusters of encephalitis in adults and children and help with a shigellosis outbreak investigation within several schools. Likewise, PHEs were responsible for identifying suspected cases of mycobacterium tuberculosis and meningococcal meningitis.
The PHE program has had a profound effect on surveillance for infectious disease and agents of bioterrorism, while also influencing organizational preparedness. PHEs have encouraged the development of several new approaches to healthcare preparedness since the beginning of the program, including an automated laboratory reporting system in their hospital, healthcare facility response plans for bioterrorism and infectious disease outbreaks, and the improvement of NC DETECT.
A survey conducted by the North Carolina Preparedness and Response Research Center (NC PERRC) in 2010 found that PHEs spend 20 percent of their time conducting public health investigations in coordination with local health departments. Nearly 13 percent of their time is spent communicating between clinicians, hospital workers, and public health professionals. The PHE program serves as important sentinel for potential health crises, while also building bridges between the information and response needs of public health and healthcare systems.