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How Sick Is That?
Sneezing, sniffles, fever, gastrointestinal turmoil, and a sore throat that won’t quit. It’s not just a bug: It’s data.
I don’t puke. Some people up-chuck at the slightest provocation. Not me. I’m not a puker.
I do not say this to brag, but simply to impress upon you how memorable it was when, sometime between midnight and dawn on Monday, September 14, 2009, I awoke with the feeling that “maybe” I was “coming down with something”—followed seconds later by the realization that there were no maybes about it, and that I was about to hurl like a freshman after a fraternity kegger. Which I did.
I will spare you the details of the cleaning-up and the exhausted clamber back into bed. Suffice it to say, that opening volley was just the beginning. For the rest of the night I took stock of the miseries as they swept over my prone body: muscles so sore they screamed, roiling guts, and a headache that made me pull my shoulders up to my ears and pray for death to take me.
What did I have? How did I get it? And who had I already given it to? I lay there pondering the possibilities between peristaltic assaults. For starters, I had, in the preceding 48 hours, been cheek-by-jowl with the weekend crowd at Kings Island. I had also dined out once, prepared food for a half-dozen people in my own home, and had—this was the worst thought—planted kisses on my grandchildren. Had I served family and friends a heaping helping of food poisoning or spread sickness among hundreds of amusement park visitors from all over southwestern Ohio? Were the adults who’d sat at my table destined to go through the same misery? Were the babies I’d anointed with my toxic breath already in an emergency room?
I called my doctor when morning arrived, expecting grave concern. The global pandemic of H1N1 was making its way across the nation, and even if I didn’t have that, I felt certain that I must be a festering pool of something. But my physician’s measured response suggested to me that he did not think there was sufficient cause to summon a Hazmat team for the disposal of my bedclothes. I don’t recall his exact explanation, but here’s what it came down to:
I had a bug.
Something ordinary. I was not at death’s door, nor was I a 21st century Typhoid Mary, spreading pestilence in my wake. He offered to phone in a prescription for the nausea and told me to drink Gatorade to stay hydrated. “You’ll feel better by tomorrow afternoon,” he said.
And I did. Almost like clockwork, I rose from my bed of pain the following midday and felt—if not perfectly fine—infinitely better. And rather sheepish at having catastrophized about something that turned out to be, well, nothing. At least nothing special in the world of disease.
Which is not to say that an unremarkable sickness like mine—or one such as your own household might be experiencing this very minute, as we enter the phlegm-coated heart of winter—goes unnoticed. Thanks to technology (and to the threat of bioterrorism), our sniffles and sneezes and intestinal vicissitudes are part of a landscape of malaise that’s being watched like a stock ticker to help health care specialists figure out the Who, What, Where, Why, When, and How to Stop It of illness.
Your first grader goes to the school nurse with a booger-clogged nose. Your neighbor stops at an all-night grocery to buy a new thermometer. You take your gurgling innards to the emergency room because your mother-in-law’s cabbage rolls aren’t sitting well. These things would hardly seem like worthy cinematic scenes in a remake of The Andromeda Strain. But in the world of public health, somebody’s watching.
Pretty sick, right?
It is early November, and the kids are all right. At least, that’s how it looks on the computer screen.
I’m in the office of Ted Folger, director of epidemiology and assessment for the Hamilton County Public Health Department, and we’re examining data from HealthWatch, an online surveillance system that tracks absenteeism in local schools. HealthWatch alerts the health department about a particular school when an unusually high proportion of the students don’t show up for class. “Ten percent is taken as normal,” says Folger. But, he allows, it’s a figure that epidemiologists must temper with input about whatever else might be going on at a school. Such as? “Senior skip day,” he says wryly.
We’re looking at a report from a suburban school (which shall remain nameless; confidentiality is part of the deal when schools agree to participate in HealthWatch). Today, the data does not indicate that absenteeism is higher than usual. The nurse’s report on kids’ symptoms indicates there’s hacking and coughing, but, Folger says, “The increase in respiratory illnesses are normal.” Around here, enteric (i.e., intestinal) diseases dominate in summer and respiratory symptoms rule in winter. Fall is the time of year when the switch-over begins.
HealthWatch doesn’t diagnose anything. It provides data that, combined with observations from school nurses about the symptoms they’re seeing when kids come through the door, can help the health department quickly spot a health problem, swoop in to ID the illness, and figure out ways to keep it from spreading. It was created in 2009 to prepare for the H1N1 influenza outbreak. “We knew that [H1N1] would disproportionately effect school-age children,” Folger says, so HealthWatch was used to point to the schools where the illness might be breaking out. Now it’s an established part of the county’s “syndromic surveillance” that keeps tabs on what ails us.
The big picture of all things infectious is Hamilton County’s most recent Communicable Disease Report, which came out last August. It covers everything from Amebiasis (that’s amebic dysentery, in layman’s terms) to Yersiniosis (a rare disease, but a good reason not to eat raw meat). It takes time to gather, confirm, and certify this information, so the most recent report only covers 2004–2008. In contrast, syndromic surveillance is a snapshot of what’s happening right now.
Folger takes me to another recent online eye-on-malaise: a report from a suburban hospital’s emergency room generated a few days before our meeting. All the patients are de-identified, but each one is described, along with his/her complaints. There’s an “SOB [shortness of breath] and Cough”; also an “SOB, panic.” There are patients coming through the door with ILI (influenza-like illness), abdominal pain, fever, and other assorted concerns. The area’s hospital emergency departments transmit this information to the county’s EpiCenter system, and EpiCenter issues alerts when there are higher than expected visits for a particular complaint. Epidemiologists can drill down into the information, slice it and dice it by symptom, by neighborhood, by hospital, by gender or age, looking for “who is getting what,” Folger says. “Then we try to figure out what is driving it.” And, of course, what to do about it.
Case in point: Last summer, data from EpiCenter and other systems helped identify the swimming pools in the region linked to a cryptosporid-iosis outbreak. Cryptosporidium is a nasty parasite that can bring on diarrhea and dehydration in healthy individuals; for those with poor immunity, it can be very serious. And it spreads readily where kids and water mix. “A kid goes to a lake on vacation, takes in a gulp and becomes infected with crypto,” explains Folger. “Then they go back to the pool and have a diarrheal accident. Now all the children are swimming in feces!”
Folger, who is putting the finishing touches on a PhD in epidemiology and biostatistics, is the father of a toddler and has a second baby on the way, so his infection scenario may be somewhat colored by parenthood. But to his point: crypto parasites are chlorine-resistant and they persist in stool for a long time, so a kid who goes into the water with a soiled bottom or a mom who rinses her hands in the wading pool after changing a diaper can be an effective delivery system. “I love taking my daughter to the pool,” Folger adds with a note of glum irony.
There was a major crypto outbreak here in 2005; so when the first case appeared last summer, the health department asked physicians to start testing their symptomatic patients immediately and began interviewing the parents of infected kids about the pools where they swam. As the data rolled in, the department posted signs at pools connected to the infections—not something pool managers were thrilled about, but they cooperated, Folger says. He shows me a map pinpointing the aquatic hotspots. Traditional media and family-centric social media helped educate people about crypto (don’t swim if you’ve been sick in the past two weeks; don’t change diapers poolside; wash your kids with soap before letting them dive in). Some pools were closed temporarily and the water super-chlorinated in hopes of killing off the resilient parasite. In 2005, the disease shifted from pools to daycare centers by summer’s end; the department worked to short-circuit that transfer during the outbreak in 2011. If your kid’s nursery school got rid of the water table this fall, this may be the reason.
When school is in session, HealthWatch data can be used alongside EpiCenter for a more nuanced picture of the disease landscape. In the fall of 2011, for example, there was a HealthWatch alert about a school with high absenteeism. So an epidemiologist went to EpiCenter, searched by zip code, and found that there were higher than expected pediatric ER visits for respiratory complaints involving children from that school’s neighborhood. A call to the hospital’s infection control specialist revealed that those sick students had parainfluenza—a not-so-scary virus for school kids, but dangerous for infants. Connecting the dots made it possible to alert local doctors about the outbreak.
You can thank 9/11 for EpiCenter. The system was adopted in Hamilton County (and in many other places) in the wake of that terrible event—built as an early warning system for bioterrorism. It’s the epidemiological equivalent of the DEW Line, with data instead of radar scanning the horizon for symptoms that might be the first clue of, say, an anthrax attack.
The information provided by syndromic surveillance doesn’t necessarily speak for itself. For example, there’s a database about over-the-counter drug store and grocery purchases—thermometers, cough medicine, Pepto-Bismol, et cetera. Hypothetically, an alert about bottles of Pedialyte flying off the shelves in Hyde Park on November 1 could be a heads-up that an intestinal virus is poised to tear through east side toddlers like a tsunami. Or that a bioterrorist with a syringe is injecting pathogens into juice boxes. Or it could just be the result of widespread Halloween candy pigging-out. Without built-in “subject matter experts,” Folger says, it’s hard to tell what’s going on with OTC purchases. Essential are what Folger calls “sentinel clinicians”—the ER docs and nurses, hospital infection specialists, local physicians, and school nurses who are actually seeing the runny noses and strange rashes, and who can help the health department quickly suss out what a spike in symptoms might mean. “School nurses are the front line,” says Folger. “And they’re slowly disappearing.”
It doesn’t always take vast numbers to get the attention of officials; sometimes one will do it. Last fall Pat Allingham, a public health nurse and director of disease prevention for Hamilton County, got a middle-of-the-night call from a hospital about a young woman who’d arrived with a suspected case of Neisseria meningitides—a serious bacterial meningitis. She got on the phone with the patient’s family, found that the woman’s sweetheart and child were at risk for infection, and put them on antibiotics immediately.
“Different diagnoses have different laws that guide our response,” Allingham says. Reportable diseases are those communicable infections that are of high public health concern. Food-borne botulism, for example, must by law be reported to the health department immediately; ditto anthrax, rabies, and any one of the epic ills that wiped out whole populations back before vaccines and antibiotics existed—cholera, measles, diphtheria, smallpox. What happens next depends on the law, the disease, and how much investigators are able to find out.
Allingham began her nursing career back in the 1970s, back when government support for public heath programs was broad and deep. “We visited every newborn and new mother and every pregnant woman,” she says. These days her one-on-one interviews are often focused on matters that are even more intimate than childbirth.
Take the case of the church festival salmonella outbreak. In the summer of 2010, the health department got a call from a person claiming that she and her family got sick from something they ate at a church festival. The symptoms—vomiting, stomach pain, diarrhea—sounded like it might have been a norovirus. A norovirus is a common intestinal menace. Highly contagious, you can catch it from another person—or from the food they’ve handled. It’s not a disease your doctor needs to report to the health department, but when someone says they got “a little food poisoning” or “a stomach bug,” odds are it’s a norovirus. Still, Allingham can’t assume that because there are other food-borne illnesses that are too dangerous to dismiss. So she phoned the church secretary—“Who knows everything,” Allingham jokes—and asked if there were any reports of illness after the fete. “And the secretary says, ‘Oh my gosh, I’ve had about 20 calls!’”
The church provided the names of everyone who was—literally—bellyaching as well as a list of every food served that weekend. Then Allingham and her staff set about contacting the households, running through a long list of questions about what each family had been up to (Camping? Fishing? Petting zoo?), what they’d been eating (Runny eggs? Shellfish? Rare hamburger?) and inquiries about their symptoms—the vomiting, the diarrhea, the abdominal pain. Then she had to request a stool sample. These are never easy conversations to have. “It’s a science and an art,” Allingham says.
Her office talked to 60 people after the church festival; only three agreed to provide a sample. The samples established that the problem was not a relatively benign norovirus—it was the bacterial infection salmonella. That meant rapidly re-interviewing households, talking to family members who didn’t get sick about what they didn’t eat, and by process of elimination identifying the source—a pulled pork sandwich. The pulled pork vendor was located, but since the meat was all gone, the Case of the Tainted Barbecue was over.
It’s a process that’s repeated in some form whenever there’s suspicion of a food-borne illness. And it doesn’t always end so quietly. In September, children from a family in Butler County got E. coli from Tyson’s ground beef, setting off an investigation that involved the county, the state, and the USDA—an investigation that ultimately prompted a recall of 131,300 of pounds of meat in 14 states. It happened as the illness and death toll was rising from the listeriosis outbreak caused by tainted Colorado cantaloupes, and for a moment it looked like it might be another catastrophe besetting the U.S. food chain. “You take a deep breath and think, ‘We could be in the middle of something severe,’” says Patricia Burg, director of the Butler County Health Department. Amazingly, no other cases were reported.
Burg says modern technology helped: “[Recall information] can be shared so easily across states that we can get a handle on it.” And perhaps anxiety about listeria had already put everyone on high alert. “When the recall was announced, the news media was on it immediately,” she says. “We were very fortunate.”
Database technology has transformed our ability to pinpoint contagions. But computers haven’t taken all the mystery out of epidemiology. Consider Southwest Ohio’s STD problem.
Between 2004 and 2008, Hamilton County saw an increase in the rate of gonorrhea—even though the sexually transmitted infection was decreasing in the United States at the time. The county also has the dubious distinction of having the highest chlamydia rate in the state—about 6,000 cases diagnosed in 2010, according to Dr. Lawrence Holditch, medical director of the Cincinnati Health Department, which handles STD statistics for the region.
Neither trend is good news, but the most worrisome conundrum is syphilis. In 2009, the county leapt from having 72 cases to 197 in a year. In 2010 there were 257 acute cases of syphilis—including eight babies born with it, at grave risk for disability and death. “We should have none,” says Holditch grimly. “It’s very concerning.”
The local syphilis surge is especially puzzling, Holditch says, because the pattern is unusual. Nationally, when the disease is on the rise it’s usually associated in large part to male-to-male transmission. And often sex for money or drugs plays a role. But investigators say that’s not the case here. “In Hamilton County, it’s much more heterosexual, and disproportionately impacting the African-American community,” he says. It’s young adults and “party sex,” as he describes it.
In 2010, the situation in Hamilton County was concerning enough that the Centers for Disease Control sent two teams of investigators here for several weeks to attempt to help the city health department get a handle on the outbreak. Holditch says investigators have gone door to door in targeted neighborhoods offering free testing; the department works with WIZ-FM to get information to that station’s listeners and is using social media tools such as text messaging to alert partners. Then there’s the old-fashioned shoe leather/phone call attempts to make contact with people who may have been exposed—“sometimes to the point of making ourselves quite obnoxious,” Holditch says.
For the moment, Holditch can only conjecture about the reason for the sudden rise: Perhaps it has to do with young adults being less concerned about HIV and failing to practice safe sex. Or maybe it’s the ease of hooking up in the age of social media. “Maybe,” he says, “in times of economic instability, all forms of recreational activity go up.” That still doesn’t explain why here and why us, but syphilis has a tendency to throw public health gurus curveballs. “In 1990 there was a big outbreak here and nationally,” he says. It’s two decades later “and no one has been able to explain that.”
When we talked in the fall, Holditch told me the case count for the year was 178; “So,” he said with a touch of don’t-want-to-jinx-it caution, “a downward trend.”
Remember my misery on that September night when I was—I swear—as sick as Gwyneth Paltrow right before she bit the dust in Contagion? Considering my symptoms, Ted Folger speculates that I probably had a norovirus—one of the ubiquitous stomach bug/food poisoning/touch-of-something illnesses.
I am willing to concede that it could have been something thoroughly ordinary. But, I wonder, was it “going around” in sufficient numbers to get noticed? Even if my diligent (OK, semi-hysterical) call to the doctor and my palliative purchase of Gatorade didn’t register on the we’re-sick-o-meter, surely there were other people who had what I had—enough of them who were miserable enough to show up in emergency rooms barfing and dehydrated and causing a spike in EpiCenter’s survey of the landscape.
Folger pulls up a report from the fall of 2009—a graph from September, when I was sick. He can find nothing unusual in terms of gastrointestinal complaints; no alarm bells set off by headache-debilitated hoards either. Yes, people were showing up in the emergency room with those symptoms, but they were barfing and cradling their noggins in predictable, average numbers.
Then he switches to data tracking different symptoms: respiratory complaints. We follow the steep graph line from a gentle rise in the summer to a steep ascent in September to its apex in October 2009, when 450 people were showing up each day in emergency rooms.
That’s when H1N1 peaked here, he says. That’s what sick looks like.
Originally published in the January 2012 issue.