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When Something Smells Fishy

Posted By Sara Ramey, Wednesday, March 26, 2014
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It started with a call from an astute provider (as it usually does), an infectious disease physician, who had noticed a few cases of skin and soft tissue infections among older women from Chinatown. The lesions were described as erythematous, tender subcutaneous nodules on the fingers and hands, and one patient was subsequently diagnosed with Mycobacterium marinum. M. marinum is a bacteria that often causes cutaneous infection after contact with both fresh and salt water, especially due to aquarium exposures or fish or shellfish associated injuries. At least a few of the initial cases in New York City (NYC) reported handling fresh whole fish, purchased live or on ice from one of our local markets. Over the next few weeks, we started to hear about more cases - from other providers as well as from the routine reports we receive from CDC’s Infectious Disease Pathology Branch as dermatology providers in NYC were submitting biopsy specimens for immunohistochemical staining.

So we ramped up our outbreak response – developing our case definitions for suspect, probable and confirmed cases; sending a health alert to medical providers and laboratories requesting that they call us if they were seeing similar cases; setting up a more formal triage system to screen the initial provider calls; conducting more active casefinding by calling primary care providers, dermatologists, pathologists and hand surgeons, especially those who practice in one of the three Chinatown areas of the city; developing a structured questionnaire and database to better characterize the clinical illness and potential risk exposures; alerting public health partners via an EpiX alert to see if anyone else was seeing similar cases; getting any available isolates to our laboratory for molecular typing; working with our environmental colleagues at the city and state to begin traceback investigations and environmental testing; and alerting our federal partners, including the CDC, FDA and USDA.
Though we are still in the midst of this investigation, some clues are falling into place. We are now up to about 60 cases, with most being female, between the ages of 50-80, of Chinese ethnicity who reported purchasing fresh whole fish from a tank or on ice. About 2/3 recalled having a cut or injury prior to symptom onset. But a number of different markets are involved, and we are just beginning the traceback investigation. However, unlike other foodborne outbreak investigations, there is no federal or state regulatory agency to work with who oversees the interstate sale of live fish for food consumption. So we needed to step into this regulatory void, and use our public health authority to conduct the environmental investigations at both the markets and the distributors.
I have been overseeing communicable disease outbreak investigations in NYC for over 20 years now. It still amazes me that though the approach to each one is very similar, there is always something new to learn -- whether a new infectious disease etiology or a novel mode of transmission or just learning about a new setting or practice that I was unfamiliar with (in this case, the apparently well-established interstate trade of live fish for food). Our tools for outbreak detection and response have improved so dramatically since I first started here as an EIS officer in 1992 ---- with electronic laboratory reporting, syndromic surveillance, more robust IT systems for managing our surveillance and outbreak data, enhanced analytic methods to detect aberrations in our data, improved laboratory molecular diagnostics and electronic networks to communicate more rapidly with our provider and laboratory partners.
But more times than not, it’s the basics we depend on – the astute provider calling us and setting in motion the initial outbreak response steps that I first learned during my EIS training to determine if something unusual is occurring and whether there is a common exposure. With a city of over 8 million people and 50,000 providers, we still mostly rely on that one call from a provider seeing just a few cases that she or he considers unusual enough to alert us that something larger may be going on citywide. And it’s why that in addition to continuing our investments in improving our electronic surveillance infrastructure, it’s just as critical that we continue to foster relationships with our healthcare provider partners and always remind them of how powerful a single phone call can be in allowing us to detect the next big outbreak.
Marcelle Layton, MD
Assistant Commissioner Bureau of Communicable Disease
New York City Department of Health

Tags:  infectious disease  member spotlight  outbreak 

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