Skill Sets Sometimes Forgotten for Epidemiological Response Marilyn Felkner, DrPH, epidemiologist Infectious Disease Surveillance and Epidemiology Branch

Epidemic of antibiotic-resistant, “flesh-eating, ” sometimes systemic and rapidly fatal bacteria transmitted by person-to- person contact but not generally airborne.

Role of environmental contamination is uncertain. Bacteria are spreading through all segments of the community with schools and correctional facilities among the most frequent sites of outbreaks.

What’s an epidemiologist to do?

Similar to the real life situation with methicillin resistant Staphylococcus aureus (MRSA)

What Texas Department of State Health Services has done: High School Athletic Departments as Sentinel Surveillance Sites for Community Associated Methicillin Resistant Staphylococcal Infections An Investigation and Characterization of Skin and Soft Tissue Infections at a Texas County Jail Methicillin Resistant Staphylococcus aureus Nasal Carriage Rate in Texas County Jail Inmates

8 Simple Rules for Epidemiological Response 1. There is “the study population” and there is the population you end up studying

8 Simple Rules for Epidemiological Response 2. Who you gonna call? 3. When you call, will they answer?

8 Simple Rules 4. You can’t abstract data if the chart is missing. 5. You can’t abstract data that were never recorded.

8 Simple Rules is not important to everyone (maybe not anyone) else. 6. What’s important to you

8 Simple Rules 7. Just say “no” is more than a slogan, it’s a way of life.

8 Simple Rules 8. What’s important to you may change.

There is “the study population” and there are the people you end up studying Athletes in Texas high schools Who you gonna call? Coaches? School nurses? Licensed athletic trainers?

There is “the study population” and there are the people you end up studying Athletes in Texas high schools with licensed athletic trainers, I.e. 4A and 5A high schools (enrollment >900 students) who participated in fall sports Who you gonna call? Who sees the athletes, all the athletes, and nothing but the athletes?

When you call, will they answer? Texas high schools designated 4A or 5A minus no current contact information, minus unable to contact an LAT or the LAT declined to respond 447-(48-213) = 186 (41.6%)

When you call (or or mail) will they answer? 45/144 (31%) Telephone: 56/158 (35%) Mail: 85/145 (59%)

You can’t abstract data if the chart is missing Inmates in wound line listing minus missing records = 925 (80.6%)

You can’t abstract data that were never recorded Change in Temp Date of change in Temp Wound location Wound size Change in wound size Date of change in wound size Booking Date Date of Initial Visit Number of Visits Complaint Temperature Wound Location Wound Size

What’s important to you is not important to everyone (maybe not anyone) else All inmates booked from July 2004 – April 2005 minus inmates the health care workers didn’t have time to screen ~33,750 – 33, 096 = 654

Just say “no” is more than a slogan, it’s a way of life Inmates screened by HCWs minus unable to participate usually due to being non-English minus declined to participate 654 – (35-216) = 403 (61.6%)

What’s important to you may change (so save your lab specimens) MRSA positive specimens minus overgrown or nonviable specimens minus specimens no longer available 18 – (2 + 9) = 7

8 Simple Rules for Epidemiological Response There is “the study population” and there are the people you end up studying Become acquainted with the “community” and how it is organized. Who you gonna call? Know both the key informants for the type of information that you want and the people who can make your project happen. When you call, will they answer? Know the best method of contact for your informants.

8 Simple Rules You can’t abstract data if the chart is missing. Assess primary data before relying on it. You can’t abstract data that were never recorded. Pilot your data collection instrument in the actual situation.

8 Simple Rules What’s important to you is not important to everyone (maybe not anyone) else. Respect your community partners, their expertise, and other demands they have. Just say “no” is more than a slogan, it’s a way of life. Assume lack of cooperation and compensate before the study begins. What’s important to you may change. Stay current on advances in the field you are studying and adapt.

What Texas Department of State Health Services has done: Barr B, Felkner M, Diamond PM. High School Athletic Departments as Sentinel Surveillance Sites for Community Associated Methicillin Resistant Staphylococcal Infections. Tex Med. 2006;102: Felkner M, Rohde R, Baldwin T, Rivera-Valle AM, Newsome LP. Methicillin Resistant Staphylococcus aureus Nasal Carriage Rate in Texas County Jail Inmates. J Correctional Healthcare. 2007; in press.

Acknowledgements Department of State Health Services –Sky Newsome, BS, CHES –Tamara Baldwin, BS –Ana Maria Valle-Rivera, PhD

Acknowledgements University of Texas at Austin –Alice Cates –Rochelle Kingsley –Emily –Greg Leos –Chanel Sams –Leanne Field, PhD

Acknowledgements University of Texas Health Science Center- Houston, School of Public Health – Beth Barr, MPH –Pamela M. Diamond, PhD

Acknowledgements Texas State University at San Marcos –Rodney E. Rohde, MS, SV (ASCP) –Kimberly Barron, BS, CLS – Clinical Laboratory Science Classes of

Acknowledgements Correctional facility staff and inmates Licensed athletic trainers in Texas 4A and 5A high school