Guillain-Barré SyndromeGuillain-Barré Syndrome Active SurveillanceActive Surveillance

October 2009-May 2010October 2009-May 2010

Emily Mosites, MPHEmily Mosites, MPH

TNDOH, CEDSTNDOH, CEDS

Emerging Infections Emerging Infections Program (EIP) GBS Program (EIP) GBS SurveillanceSurveillance

TennesseeTennessee

GeorgiaGeorgia

ConnecticutConnecticut

OregonOregon

CaliforniaCalifornia

ColoradoColorado

New MexicoNew Mexico

MarylandMaryland

MinnesotaMinnesota

New YorkNew York

Guillain-Barré Syndrome Guillain-Barré Syndrome (GBS)(GBS)

Auto-immune disorderAuto-immune disorder

Acute onsetAcute onset

Ascending generalized paralysisAscending generalized paralysis

Often unknown cause, but is sometimes Often unknown cause, but is sometimes associated with recent infectionassociated with recent infection

SymptomsSymptoms Prickling sensation in fingers and Prickling sensation in fingers and

toestoes

Weakness in legs that can ascend Weakness in legs that can ascend to upper bodyto upper body

Unsteady gait or inability to walkUnsteady gait or inability to walk

Can involve respiratory systemCan involve respiratory system

Most patients hospitalizedMost patients hospitalized

EpidemiologyEpidemiology

Estimated background rate: 1-2 cases per Estimated background rate: 1-2 cases per 100,000 persons per year100,000 persons per year

Expected in Tennessee: Just over 1 case Expected in Tennessee: Just over 1 case per week.per week.

GBS Cases Reported in Previous YearsGBS Cases Reported in Previous Years

YearYear CasesCases

20052005 1313

20062006 1010

20072007 1111

20082008 66

Observed Rate= 0.16 per 100,000 persons per year

Surveillance ObjectivesSurveillance Objectives

Rapidly detect potential cases of GBSRapidly detect potential cases of GBS

Produce regular reports on cases of GBS Produce regular reports on cases of GBS including risk factor informationincluding risk factor information

Determine whether vaccination with the H1N1 Determine whether vaccination with the H1N1 vaccine is associated with increased risk of vaccine is associated with increased risk of GBSGBS

Per CDC GBS Surveillance Protocol

Surveillance ActivitiesSurveillance Activities

Neurologist/Hospital NetworkNeurologist/Hospital Network

Medical Records ReviewMedical Records Review

Patient InterviewPatient Interview

Neurologist NetworkNeurologist Network

166 physician offices representing 425 166 physician offices representing 425 physiciansphysicians

123 hospitals123 hospitals

80 clinical pharmacies80 clinical pharmacies

35 EMG laboratories35 EMG laboratories

Network Response RatesNetwork Response Rates

98.5% of network responded at least once 98.5% of network responded at least once since Octobersince October

Average 85% response rate each monthAverage 85% response rate each month

Medical Records ReviewMedical Records Review

History and PhysicalHistory and Physical

Neurology Consult NotesNeurology Consult Notes

Labs (CSF and EMG)Labs (CSF and EMG)

Discharge SummaryDischarge Summary

Case DefinitionCase Definition

Brighton Clinical Criteria:Brighton Clinical Criteria:

Acute onset of bilateral and relatively symmetric Acute onset of bilateral and relatively symmetric flaccid weakness/paralysis of the limbs flaccid weakness/paralysis of the limbs

andand

Decreased or absent deep tendon reflexes Decreased or absent deep tendon reflexes

andand

Monophasic illness pattern with weakness nadir Monophasic illness pattern with weakness nadir reached between 12 hours and 28 days reached between 12 hours and 28 days

andand

Absence of an alternative diagnosisAbsence of an alternative diagnosis

Laboratory ConfirmationLaboratory Confirmation

Electromyography (EMG):Electromyography (EMG):

Abnormal nerve conduction in limbsAbnormal nerve conduction in limbs

oror

Cerebrospinal Fluid (CSF) Protein:Cerebrospinal Fluid (CSF) Protein:

Elevated protein level without elevated white Elevated protein level without elevated white blood cell count.blood cell count.

Patient InterviewPatient Interview

Illness within 6 weeks before onsetIllness within 6 weeks before onset

Vaccination this seasonVaccination this season

Medical historyMedical history

Preliminary response rate: 87.5% of cases Preliminary response rate: 87.5% of cases contactedcontacted

Tennessee DataTennessee Data

98 cases referred98 cases referred12 out of jurisdiction (MS, GA, KY, etc)12 out of jurisdiction (MS, GA, KY, etc)

21 GBS note in medical history21 GBS note in medical history

10 under evaluation 10 under evaluation

23 did not meet Brighton Criteria23 did not meet Brighton Criteria

29 CONFIRMED, 3 PROBABLE CASES29 CONFIRMED, 3 PROBABLE CASES~ 1.3 cases per week

TN GBS cases admitted per week, October 2009-April 2010

0

5

10

15

20

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24-O

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7-Nov

21-N

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5-Dec

19-D

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2-Ja

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16-J

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30-J

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13-F

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27-F

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13-M

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Week Admitted

Cas

es

GBS Case and non-case characteristics

Characteristic 

Confirmed and probable

N=32Non-cases

N=23

Sex

Male 15 (46.9) 11 (47.8)

Female 17 (53.1) 12 (52.2)

Mean Age 48.6 (5-91) 49.5 (12-77)

Race/Ethnicity

Black 4 (12.5) 1 (4.3)

White 21 (65.6) 16 (69.6)

Hispanic 2 (0.62) 0 (0.0)

Asian 1 (3.1) 1 (4.3)

Confirmed and probable case antecedent events: Tennessee compared to other EIP sites

TN cases N(%)Other EIP Site Cases

N(%)

Total Cases 32 202

Events

H1N1 Vaccination 3 (9.4)* 20 (9.9)

Seasonal Flu Vaccination 12 (37.5)** 66 (32.6)

Gastrointestinal Illness 1 (3.1) 59 (29.2)

Upper Respiratory Illness or Flu-like Illness 13 (40.6) 88(43.5)

No antecedent event noted 5 (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

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 Cases 32 202

Events

H1N1 Vaccination 3 (9.4)* 20 (9.9)

Seasonal Flu Vaccination 12 (37.5)** 66 (32.6)

Gastrointestinal Illness 1 (3.1) 59 (29.2)

Upper Respiratory Illness or Flu-like Illness 13 (40.6) 88(43.5)

No antecedent event noted 5 (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

ConclusionsConclusions

Network responsiveness highNetwork responsiveness high

Observed matches expected rate of GBS Observed matches expected rate of GBS cases per weekcases per week

No increasing trend or major fluctuations No increasing trend or major fluctuations in reported casesin reported cases

AcknowledgmentsAcknowledgments

TN Neurologists, EMG labs, clinicalTN Neurologists, EMG labs, clinical

pharmacists, and HIM departmentspharmacists, and HIM departments

TN Regional Health OfficesTN Regional Health Offices

Rendi Murphree, PhDRendi Murphree, PhD

David Kirschke, MDDavid Kirschke, MD

CDC GBS Surveillance CoordinatorsCDC GBS Surveillance Coordinators