1. Foodborne, Waterborne and Zoonotic Infections Division

2. Syndromic Surveillance Using OTC Medication Sales…How Useful Is It? Victoria L. Edge Foodborne, Waterborne and Zoonotic Infections Division Infectious Disease and Emergency Preparedness COMOH/APHEO Education Session for Syndromic Surveillance 1 st February 2007

3. Foodborne, Waterborne and Zoonotic Infections Division Objectives C. Understand the role of, and interactions between, public health representatives at different gov’t levels and pharmacists A. Understand how OTC data are collected and categorised – the importance of researching historical data. B. Understand the difference between using spatio-temporal patterns of OTC sales as an early warning system and for routine surveillance.

4. Foodborne, Waterborne and Zoonotic Infections Division On the Agenda… OTC data surveillance Public Health Agency of Canada’s (PHAC) use of OTC data Features & Utility Challenges Advantages

5. Foodborne, Waterborne and Zoonotic Infections Division OTC Data Surveillance

6. Foodborne, Waterborne and Zoonotic Infections Division A. S. A.P. Alternative Surveillance Alert Project https://www.cnphi-rcrsp.ca/cnph

7. Foodborne, Waterborne and Zoonotic Infections Division Early warning of community outbreaks. Investigate significant historical Canadian outbreaks. Waterborne : Walkerton, OntarioE.coli O157 and Campylobacter Battlefords, Saskatchewan Cryptosporidium

8. Foodborne, Waterborne and Zoonotic Infections Division Walkerton, Ontario Spring 2000 Waterborne outbreak: E.coli O157 and Campylobacter

9. Foodborne, Waterborne and Zoonotic Infections Division A. S. A.P. Alternative Surveillance Alert Project Meeting with area pharmacists and PHU representatives Collection of data – only one pharmacy able to provide electronic data (in weekly format) Compared with confirmed (lab) cases from outbreak investigation and also with IGI–related ER visits data

10. Foodborne, Waterborne and Zoonotic Infections Division Culture confirmed cases (onset+4days) and Weekly Totals of OTC Start of outbreak period 13 th May Ref: Edge et al., 2004. Can J Pub Health 95(6):446-450 Walkerton, March-June 2000

11. Foodborne, Waterborne and Zoonotic Infections Division Battlefords, Saskatchewan Spring 2001 Waterborne outbreak: Cryptosporidium

12. Foodborne, Waterborne and Zoonotic Infections Division OTC medications related to IGI epidemic curve realized in a retrospective investigation of a waterborne outbreak of Cryptosporidium. North Battleford, Saskatchewan Spring 2001 MAR 21 Water system compromised APR 25 Boil Water Advisory (Ref: Stirling R, et al. 2001. ) http://www.health.gov.sk.ca/info_center_pub_health_can_epi_report_NB.pdf MAR 21 Water system compromised APR 25 Boil Water Advisory (n=110)

13. Foodborne, Waterborne and Zoonotic Infections Division A. S. A.P. Alternative Surveillance Alert Project How PHAC uses OTC data

14. Foodborne, Waterborne and Zoonotic Infections Division A. S. A.P. Alternative Surveillance Alert Project Key Observations from Initial Research: Keep ‘human involvement’ to a minimum Keep it simple : for public health officials for retailers and pharmacists Define benefit: for public health for retailers and pharmacists

15. Foodborne, Waterborne and Zoonotic Infections Division A. S. A.P. Alternative Surveillance Alert Project PHAC’s Objectives: Create and test a system of OTC-sales based surveillance operating at the national level Collect data electronically & automatically from major retailers Feed all data electronically into one location Analyse at different jurisdictional levels as required

16. Foodborne, Waterborne and Zoonotic Infections Division Features & Utility

17. Foodborne, Waterborne and Zoonotic Infections Division Web-based Data Collection, Analysis and Reporting https://www.cnphi-rcrsp.ca/cnph “Canadian Early Warning System” (CEWS)

18. Foodborne, Waterborne and Zoonotic Infections Division Currently: 6 (almost 7!) major retailers providing data for all of their locations across Canada; (~2200 locations representing ~50% of all major retailers’ pharmacies) PHAC providing wkly reports/alerts to pilot PHUs Pilot PHU users have access to web-based monitoring (via CNPHI-CEWS) Interaction with PH officials and Pharmacy reps

19. Foodborne, Waterborne and Zoonotic Infections Division DATA: UPC level daily sales volumes by pharmacy location Adult and Paediatric: anti-diarrhoeal, anti-nauseant, rehydration; cough and cold products, vaporisers, thermometers

20. Foodborne, Waterborne and Zoonotic Infections Division TO DO: Enlist more retailers Evaluate on-line system by PH & pharmacy officials in next year

21. Foodborne, Waterborne and Zoonotic Infections Division Challenges…and Advantages What’s the Word at the Public Health Region Water Cooler?

22. Foodborne, Waterborne and Zoonotic Infections Division “OTC data are not that useful for primary detection.” “ER visit data are better at earlier detection of disease outbreaks.” “OTC data are non-specific.” “Rural areas are poorly represented (if at all) by OTC data.“

23. Foodborne, Waterborne and Zoonotic Infections Division HOWEVER,… In combination with other information… With thanks: Dr. Hazel Lynn, Alanna Leffley Grey Bruce Health, ECADS research team - OTTAWA

24. Foodborne, Waterborne and Zoonotic Infections Division A final comment… The very process of investigating OTC sales-based surveillance has increased the level of communication between pharmacy and public health officials.

25. Foodborne, Waterborne and Zoonotic Infections Division Acknowledgements: Public Health Agency of Canada (esp. P Muchaal, J Aramini, S Mukhi) Walkerton area pharmacists (esp. K. Brown) Public Health Units: Grey-Bruce, Wellington-Dufferin-Guelph, Kingston Frontenac Lennox & Addington, Waterloo Region, City of Hamilton, Winnipeg Region) CRTI funding for CNPHI PharmaPlus and Rexall (KATZ Group Canada Ltd), Shoppers Drug Mart, Wal-Mart, Loblaw, London Drugs, Safeway Canadian Association of Chain Drug Stores (CACDS) University of Guelph ECADS and the Grey Bruce Health Unit