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      A model for rapid, active surveillance for medically-attended acute gastroenteritis within an integrated health care delivery system

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          Abstract

          Background

          This study presents a novel methodology for estimating all-age, population-based incidence rates of norovirus and other pathogens that contribute to acute gastroenteritis in the United States using an integrated healthcare delivery system as a surveillance platform.

          Methods

          All cases of medically attended acute gastroenteritis within the delivery system were identified from April 1, 2014 through September 30, 2016. A sample of these eligible patients were selected to participate in two phone-based surveys and to self-collect a stool sample for laboratory testing. To ascertain household transmission patterns, information on household members with acute gastroenteritis was gathered from participants, and symptomatic household members were contacted to participate in a survey and provide stool sample as well.

          Results

          54% of individuals who met enrollment criteria agreed to participate, and 76% of those individuals returned a stool sample. Among household members, 85% of eligible individuals agreed to participate, and 68% of those returned a stool sample. Participant demographics were similar to those of the eligible population, although minority racial/ethnic groups were somewhat underrepresented in the final sample.

          Conclusions

          This study demonstrates the feasibility of conducting acute infectious disease research within an integrated health care delivery system. The surveillance, sampling, recruitment, and data collection methods described here are broadly applicable to conduct baseline and epidemiological assessments, as well as for other research requiring representative samples of stool specimens.

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          Most cited references13

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          Study of infectious intestinal disease in England: rates in the community, presenting to general practice, and reported to national surveillance. The Infectious Intestinal Disease Study Executive.

          To establish the incidence and aetiology of infectious intestinal disease in the community and presenting to general practitioners. Comparison with incidence and aetiology of cases reaching national laboratory based surveillance. Population based community cohort incidence study, general practice based incidence studies, and case linkage to national laboratory surveillance. 70 general practices throughout England. 459 975 patients served by the practices. Community surveillance of 9776 randomly selected patients. Incidence of infectious intestinal disease in community and reported to general practice. 781 cases were identified in the community cohort, giving an incidence of 19.4/100 person years (95% confidence interval 18.1 to 20.8). 8770 cases presented to general practice (3.3/100 person years (2.94 to 3.75)). One case was reported to national surveillance for every 1.4 laboratory identifications, 6.2 stools sent for laboratory investigation, 23 cases presenting to general practice, and 136 community cases. The ratio of cases in the community to cases reaching national surveillance was lower for bacterial pathogens (salmonella 3.2:1, campylobacter 7.6:1) than for viruses (rotavirus 35:1, small round structured viruses 1562:1). There were many cases for which no organism was identified. Infectious intestinal disease occurs in 1 in 5 people each year, of whom 1 in 6 presents to a general practitioner. The proportion of cases not recorded by national laboratory surveillance is large and varies widely by microorganism. Ways of supplementing the national laboratory surveillance system for infectious intestinal diseases should be considered.
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            Etiology of viral gastroenteritis in children <5 years of age in the United States, 2008-2009.

            Although rotavirus and norovirus cause nearly 40% of severe endemic acute gastroenteritis (AGE) in children <5 years of age in the United States, there are limited data on the etiologic role of other enteric viruses in this age group. We conducted active population-based surveillance in children presenting with AGE to hospitals, emergency departments, and primary care clinics in 3 US counties. Stool specimens from these children and from age-matched healthy controls collected between October 2008 and September 2009 were tested for enteric adenovirus, astrovirus, sapovirus, parechovirus, bocavirus, and aichivirus. Typing was performed by sequencing and phylogenetic analysis. Adenovirus, astrovirus, sapovirus, parechovirus, bocavirus, and aichivirus were detected in the stool specimens of 11.8%, 4.9%, 5.4%, 4.8%, 1.4%, and 0.2% of patients with AGE and 1.8%, 3.0%, 4.2%, 4.4%, 2.4%, and 0% of healthy controls, respectively. Adenovirus (type 41), astrovirus (types 1, 2, 3, 4, and 8), sapovirus (genogroups I and II), parechovirus (types 1, 3, 4, and 5), and bocavirus (types 1, 2, and 3) were found cocirculating. Adenovirus, astrovirus, and sapovirus infections were detected in 22.1% of the specimens from children <5 years of age who had medical visits for AGE and tested negative for rotavirus and norovirus. No causal role for parechovirus and bocavirus was found.
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              Acute Gastroenteritis Surveillance through the National Outbreak Reporting System, United States

              Implemented in 2009, the National Outbreak Reporting System provides surveillance for acute gastroenteritis outbreaks in the United States resulting from any transmission mode. Data from the first 2 years of surveillance highlight the predominant role of norovirus. The pathogen-specific transmission pathways and exposure settings identified can help inform prevention efforts.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Data curationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: SupervisionRole: Writing – original draftRole: Writing – review & editing
                Role: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: MethodologyRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: SoftwareRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: Writing – review & editing
                Role: Data curationRole: Formal analysisRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Project administrationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: ResourcesRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                3 August 2018
                2018
                : 13
                : 8
                : e0201805
                Affiliations
                [1 ] Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, United States of America
                [2 ] Oregon State Public Health Laboratory, Public Health Division, Oregon Health Authority, Hillsboro, Oregon, United States of America
                [3 ] Division of Viral Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
                Universita degli Studi di Parma, ITALY
                Author notes

                Competing Interests: Funding was received by Takeda Vaccines, Inc. Takeda had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This commercial funding does not alter adherence to all PLOS ONE policies on sharing data and materials.

                Author information
                http://orcid.org/0000-0002-7440-7183
                Article
                PONE-D-17-44741
                10.1371/journal.pone.0201805
                6075775
                30075030
                9df878ee-8da5-4b5e-9dd6-d1b586ae1e9b

                This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.

                History
                : 22 December 2017
                : 23 July 2018
                Page count
                Figures: 5, Tables: 3, Pages: 15
                Funding
                Funded by: CDC Foundation
                Award Recipient :
                Funded by: Takeda Vaccines, Inc
                Award ID: IISR-2015-101015
                Award Recipient :
                Funded by: Takeda Vaccines, Inc
                Award ID: IISR-2017-101938
                Award Recipient :
                MAS received institutional research funding to the Kaiser Permanente Center for Health Research for the MAAGE project from the CDC Foundation and through investigator-initiated research grants from Takeda Vaccines, Inc. (IISR-2015-101015 and IISR-2017-101938). Takeda had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The Centers for Disease Control and Prevention received no funding from Takeda.
                Categories
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                Custom metadata
                Regarding the availability of data, all data are not available in our manuscript because they contain personally identifiable information, protected by the Health Insurance Portability and Accounting Act (HIPAA) and the Kaiser Permanente Northwest Institutional Review Board. To protect participant confidentiality, a redacted version of the study data are available upon request from the corresponding author (Mark Schmidt, mark.a.schimidt@ 123456kpchr.org , Tel: 503.335. 6316) or a non-author point of contact (Mike Allison, Supervisor, Research Analystics; Michael.J.Allison@ 123456kpchr.org ; Tel: 503.528.3973).

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