1. Guillain-Barré Syndrome Active Surveillance October 2009-May 2010 Emily Mosites, MPH TNDOH, CEDS

2. Emerging Infections Program (EIP) GBS Surveillance TennesseeGeorgiaConnecticutOregonCaliforniaColorado New Mexico MarylandMinnesota New York

3. Guillain-Barré Syndrome (GBS) Auto-immune disorder Auto-immune disorder Acute onset Acute onset Ascending generalized paralysis Ascending generalized paralysis Often unknown cause, but is sometimes associated with recent infection Often unknown cause, but is sometimes associated with recent infection

4. Symptoms Prickling sensation in fingers and toes Prickling sensation in fingers and toes Weakness in legs that can ascend to upper body Weakness in legs that can ascend to upper body Unsteady gait or inability to walk Unsteady gait or inability to walk Can involve respiratory system Can involve respiratory system Most patients hospitalized Most patients hospitalized

5. Epidemiology Estimated background rate: 1-2 cases per 100,000 persons per year Estimated background rate: 1-2 cases per 100,000 persons per year Expected in Tennessee: Just over 1 case per week. Expected in Tennessee: Just over 1 case per week. GBS Cases Reported in Previous Years YearCases 200513 200610 200711 20086 Observed Rate= 0.16 per 100,000 persons per year

6. Surveillance Objectives Rapidly detect potential cases of GBS Rapidly detect potential cases of GBS Produce regular reports on cases of GBS including risk factor information Produce regular reports on cases of GBS including risk factor information Determine whether vaccination with the H1N1 vaccine is associated with increased risk of GBS Determine whether vaccination with the H1N1 vaccine is associated with increased risk of GBS Per CDC GBS Surveillance Protocol

7. Surveillance Activities Neurologist/Hospital Network Neurologist/Hospital Network Medical Records Review Medical Records Review Patient Interview Patient Interview

8. Neurologist Network 166 physician offices representing 425 physicians 166 physician offices representing 425 physicians 123 hospitals 123 hospitals 80 clinical pharmacies 80 clinical pharmacies 35 EMG laboratories 35 EMG laboratories

9. Network Response Rates 98.5% of network responded at least once since October 98.5% of network responded at least once since October Average 85% response rate each month Average 85% response rate each month

10. Medical Records Review History and Physical History and Physical Neurology Consult Notes Neurology Consult Notes Labs (CSF and EMG) Labs (CSF and EMG) Discharge Summary Discharge Summary

11. Case Definition Brighton Clinical Criteria: Acute onset of bilateral and relatively symmetric flaccid weakness/paralysis of the limbs and Decreased or absent deep tendon reflexes and Monophasic illness pattern with weakness nadir reached between 12 hours and 28 days and Absence of an alternative diagnosis

12. Laboratory Confirmation Electromyography (EMG): Abnormal nerve conduction in limbs or Cerebrospinal Fluid (CSF) Protein: Elevated protein level without elevated white blood cell count.

13. Patient Interview Illness within 6 weeks before onset Illness within 6 weeks before onset Vaccination this season Vaccination this season Medical history Medical history Preliminary response rate: 87.5% of cases contacted

14. Tennessee Data 98 cases referred 12 out of jurisdiction (MS, GA, KY, etc) 21 GBS note in medical history 10 under evaluation 23 did not meet Brighton Criteria 29 CONFIRMED, 3 PROBABLE CASES ~ 1.3 cases per week

16. GBS Case and non-case characteristics Characteristic Confirmed and probable N=32 Non-cases N=23 Sex Male15 (46.9)11 (47.8) Female17 (53.1)12 (52.2) Mean Age48.6 (5-91)49.5 (12-77) Race/Ethnicity Black4 (12.5)1 (4.3) White21 (65.6)16 (69.6) Hispanic2 (0.62)0 (0.0) Asian1 (3.1)1 (4.3)

18. Confirmed and probable case antecedent events: Tennessee compared to other EIP sites TN cases N(%)Other EIP Site Cases N(%) Total Cases32202 Events H1N1 Vaccination3 (9.4)*20 (9.9) Seasonal Flu Vaccination12 (37.5)**66 (32.6) Gastrointestinal Illness1 (3.1)59 (29.2) Upper Respiratory Illness or Flu-like Illness13 (40.6)88(43.5) No antecedent event noted5 (15.6). * None of the cases with antecedent H1N1 vaccine had other symptoms within 6 weeks of GBS onset **Three of the cases with antecedent seasonal flu vaccine had other symptoms within 6 weeks of GBS onset

19. Confirmed and probable case antecedent events: Tennessee compared to other EIP sites Tennessee H1N1 Vaccination Coverage Estimate (thru Jan, 2010): Under 18: 34.5% 18 and over: 19.5% Interim Report, CDC, MMWR, April 2, 2010 / 59(12);363-368 TN cases N(%)Other EIP Site Cases N(%) Total Cases32202 Events H1N1 Vaccination3 (9.4)*20 (9.9) Seasonal Flu Vaccination12 (37.5)**66 (32.6) Gastrointestinal Illness1 (3.1)59 (29.2) Upper Respiratory Illness or Flu-like Illness13 (40.6)88(43.5) No antecedent event noted5 (15.6). * None of the cases with antecedent H1N1 vaccine had other symptoms within 6 weeks of GBS onset **Three of the cases with antecedent seasonal flu vaccine had other symptoms within 6 weeks of GBS onset

20. Conclusions Network responsiveness high Network responsiveness high Observed matches expected rate of GBS cases per week Observed matches expected rate of GBS cases per week No increasing trend or major fluctuations in reported cases No increasing trend or major fluctuations in reported cases

21. Acknowledgments TN Neurologists, EMG labs, clinical pharmacists, and HIM departments TN Regional Health Offices Rendi Murphree, PhD David Kirschke, MD CDC GBS Surveillance Coordinators