Skip to main content

Monitoring the Transfer of Patients with Rocky Mountain Spotted Fever from Tribal Lands to Facilities in Maricopa County, Arizona

Public Health Problem (100 words)

Rocky Mountain Spotted Fever (RMSF), a bacterial tick-borne rickettsial illness, initially causes nonspecific symptoms (e.g., fever, rash, nausea, and vomiting).  In 2003, RMSF was identified on tribal lands in Arizona where the brown dog tick is the primary vector1.

Individuals with suspected RMSF are often transferred from tribal lands to Maricopa County hospitals.  Prior to transfer, doxycycline, the recommended first line antibiotic, is initiated.  Given misperceptions about doxycycline causing teeth staining in children under 8 years of age2, lifesaving treatment may be interrupted upon arrival to Maricopa County, particularly for this age group. 

Success Story Narrative (400 words)

In 2012, an RMSF transfer protocol was created to ensure continuation of care when a patient was transferred from a tribal health care facility to one in Maricopa County.  The protocol focused on improving communication between the tribal jurisdiction, Arizona Department of Health Services (ADHS), and Maricopa County Department of Public Health (MCDPH).  Although communication did improve following its implementation, some transferred individuals with suspected RMSF spent days in Maricopa County facilities before MCDPH was notified, leading to possible interruptions in doxycycline administration.  This motivated MCDPH to pursue active surveillance methods, and syndromic surveillance was identified as a method to address this need.

A myESSENCE dashboard and an RMSF query were created in the National Syndromic Surveillance Program’s (NSSP) BioSense Platform, ESSENCE (Electronic Surveillance System for the Early Notification of Community-based Epidemics).  The query was designed to capture patients who had a residential tribal zip code, were treated at a Maricopa County facility which is part of the RMSF transfer protocol and had RMSF-related terms in the chief complaint or reason for admission.  The RMSF terms included, but were not limited to, “rocky mountain”, “rash”, “fever”, “petechiae”, “vomiting”, “nausea”, “thrombocyt*”, “low platelet”, “hyponatremia”, “low sodium”, “transfer”, “tick”, and “tickbite”.  In order to identify new cases, the dashboard is checked each business day.

From May through July 2018, an average of 2 cases were flagged each business day.  Once received, cases were triaged into two categories: not a case or suspect.  If the records indicated the case was admitted due to trauma or injury, they were categorized as not a case.  However, if tick, RMSF, or other RMSF-related key words were listed, the case was considered suspect and investigated further.  Since RMSF can be easily mistaken for other diseases, such as viral gastroenteritis, upper respiratory tract infection, or urinary tract infection3, cases were not ruled out purely on alternate diagnoses alone and were also investigated further. 

On June 8, 2018, ESSENCE flagged a suspected RMSF case, an infant who had been transferred to a Maricopa County hospital on June 6.  The medical records indicated he was scheduled for discharge within hours of being flagged on ESSENCE.  The infant had progressively improved on doxycycline, however, the medical records indicated he would be discharged without completing the CDC-recommended treatment (5-7 days of doxycycline for uncomplicated cases)4.  MCDPH identified this gap and promptly advocated for the continuation of treatment; a potentially life-saving intervention.

Outcomes And Impact (400 words)

Due to its rarity and the fact that RMSF is not locally-acquired in Maricopa County, many physicians in the county’s urban facilities do not immediately suspect RMSF as a cause of illness in their patients.  Additionally, RMSF acquired on Arizona tribal lands does not always present with rash—unlike cases of RMSF found elsewhere in the United States—potentially leading to a missed diagnosis of RMSF.  For these reasons, prompt communication from the originating facility and health departments is extremely helpful; it assists the receiving provider in making a timely diagnosis and an appropriate treatment plan.

The RMSF transfer protocol was established to improve patient outcomes by coordinating health care between facilities on tribal lands and in Maricopa County.  It relied on passive surveillance and adequate communication between facilities and health departments.  Although communication improved after the protocol was implemented, a time delay was still present, indicating there were still opportunities for improvement.

The near-real-time data received through the NSSP BioSense Platform and ESSENCE tool allowed MCDPH to take an active role in monitoring the unique situation that RMSF presents in Maricopa County.  As a result of its use, MCDPH provided potentially life-saving guidance.  In this case, MCDPH epidemiologists identified a patient in the syndromic surveillance data who was transferred from tribal lands to a facility in Maricopa County.  The healthcare provider was informed that the patient was at risk for RMSF, and the treatment plan was updated accordingly. 

In parallel, MCDPH received word from ADHS about the patient through the original passive surveillance protocol.  However, that communication was not received until after the patient was discharged.  Ultimately, lab results were not available until three weeks after patient discharge, and although the results concluded the patient did not have RMSF, he was not left at risk for severe RMSF-related outcomes during this waiting period. Syndromic surveillance provided the timeliest information and might have prevented severe outcomes associated with RMSF.  Adding syndromic surveillance to the RMSF transfer protocol improved situational awareness for MCDPH.

Lessons Learned (400 words)

The BioSense Platform and ESSENCE are valuable tools for public health practice.  Identifying at-risk patients and reaching out to physicians in a timely manner not only provides opportunities for education regarding proper treatment, it improves patient care—and may save lives.  With this new technology, MCDPH improved an existing protocol and provided potentially life-saving guidance. 

Further, MCDPH implemented a novel method for identifying a population with known health disparities using syndromic surveillance data.  It is recognized that, compared to the larger population of the United States, tribal communities have been historically underserved, and consequently suffer from poorer health outcomes.  Through ZIP codes and specific keywords, MCDPH identified patients with possible RMSF infections from tribal lands.  This syndromic surveillance activity is one effort MCDPH implemented to address the systemic inequalities that negatively impact Arizona tribal populations. 

Having access to data in a timely manner is essential for good patient care.  As more Maricopa County facilities report data daily to the NSSP BioSense Platform, MCDPH will be able to monitor for possible RMSF infections in individuals who are transferred from tribal lands to facilities across the county, aiding in the protection and well-being of those cared for in Maricopa County.

Submitting Author Name
Jennifer Collins
Submitting Author Title
Epidemiologist
Submitting Author Organization
Maricopa County Department of Public Health
Submitting Author Phone
(602) 372-8414
Submitting Author Email
Jennifer.Collins@maricopa.gov
Referenced File
Submitted by jecollins72 on