ISDS Annual Conference Proceedings 2013. This is an Open Access article distributed under the terms of the Creative Commons Attribution- Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 87 (page number not for citation purposes) ISDS 2013 Conference Abstracts Using Syndromic Surveillance to Investigate Tattoo- related Skin Infections in NYC Mollie Kotzen*1, 2, Robert Mathes1, Lillian Lee1 and Don Weiss1 1Bureau of Communicable Disease, New York City Department of Health and Mental Hygiene, Long Island City, NY, USA; 2New York University, New York City, NY, USA Objective To investigate tattoo-associated skin infections due to Mycobac- terium chelonae using Emergency Department (ED) syndromic surveillance. Introduction In 2012, an outbreak of Mycobacterium chelonae infections in tattoo recipients in Rochester, NY was found to be associated with premixed tattoo ink contaminated before distribution.1 In May 2012, a case of M. chelonae was reported in a New York City (NYC) resident who received a tattoo with ink alleged to have been diluted with tap water. When a second case of M. chelonae in a tattoo recipient was reported in March 2013, an investigation was initiated. M. chelonae is not reportable in NYC other than in clusters re- ported by providers or laboratories. To determine if there were addi- tional tattoo-associated M. chelonae infections, we searched for cases using NYC ED syndromic surveillance. Methods ED syndromic data is de-identified and received daily from 49 of the 52 acute care hospitals in NYC.2 Patient chief complaints are routinely scanned for key words and coded into syndromes (e.g. in- fluenza-like illness, asthma). Chief complaint data containing the key word “tattoo” for the period January 1, 2008 – December 31, 2012 were selected for analysis. The data were analyzed to describe trends and identify ED visits suspicious for skin infection (chief complaints containing the words “cellulitis,” “infected,” “redness,” etc.). ED visits that met our criteria in the five months preceding the recent M. chelonae report were selected for interview (November 2012-March 2013). Names and contact information associated with the chief complaint data were obtained from hospital staff. A ques- tionnaire including symptoms and duration, location of tattoo, name of tattoo parlor, and artist information was administered to evaluate possible M. chelonae cases requiring referral to a dermatologist for di- agnosis. NYC laboratories were contacted to inquire about skin or soft tissue cultures from 2012 or 2013 in which M. chelonae was isolated. Results A total of 577 tattoo-related ED visits (TREDV) representing 43 (88%) hospitals were identified during 2008-2012. A 26% increase in the proportion of TREDV per total ED visits among ages 18-64 was noted from 2008-2012. Chi square for trend was not significant (p=0.11). Three-hundred eighty (66%) of these visits were identified with additional chief complaint wording suggestive of infection. Thirty-one TREDV were identified in the five-month period pre- ceding the second reported case of M. chelonae. ED visits were dis- tributed among 19 NYC hospitals (range 1-4 visits/hospital). The median age of patients was 24 (range 16-48) and 65% (20) were women. For 18 (58%) patients, the chief complaint was coded as in- fection, 10% (3) for rash, 10% (3) for swelling, 7% (2) for pain and 16% (5) for other (allergic reaction, redness, warmth, not specified). Interviews were conducted for 14 (45%) of the TREDV. Rea- sons for unsuccessful interviews included no reply to three phone call attempts and wrong or disconnected phone numbers. ED pa- tients interviewed did not differ significantly from those who could not be reached on age, sex, or borough of residence. Thirteen (93%) interviewed patients had resolution of symptoms or a noninfectious diagnosis. One patient who had persistent symptoms was referred for additional medical care and was diagnosed with Staphylococcus aureus. From January 2012 through March 2013, NYC laboratories re- ported 13 isolates of M. chelonae from skin or soft tissue specimens, none of which were from patients with recent tattoos. Conclusions Using ED syndromic surveillance data, we determined that one case of tattoo-related M. chelonae was not part of an unrecognized outbreak or cluster of cases. In response to this concern about M. chelonae infections in tattoos, the Health Department sent a letter to all licensed tattoo artists in New York City advising them not to dilute tattoo inks with tap water. Syndromic surveillance is an option for finding cases when the event under surveillance is described by a unique and specific word or phrase, such as tattoo. This method can be similarly used for situations where diseases are either not report- able or when cases may be otherwise difficult to capture. Keywords tattoo; Mycobacterium chelonae; syndromic surveillance References 1. Giulieri S, Cavassini M, Jaton K. Mycobacterium chelonae Illnesses Associated with Tattoo Ink. N Engl J Med. 2012; 367(24): 2357-8. 2. Heffernan R, Mostashari F, Das D, Karpati A, Kulldorff M, Weiss D. Syndromic Surveillance in Public Health Practice, New York City. Emerg Infect Dis. 2004; 10(5):858-864. *Mollie Kotzen E-mail: mkotzen@health.nyc.gov scholcommuser Stamp scholcommuser Rectangle scholcommuser Rectangle scholcommuser Text Box Online Journal of Public Health Informatics * ISSN 1947-2579 * http://ojphi.org * 6(1):e172, 2014