Addressing the Challenges of Implementing Systematic, Meaningful Disease-Specific Case-Based Control Measures Leah Eisenstein, MPH Janet Hamilton, MPH Katherine McCombs, MPH To protect, promote & improve the health of all people in Florida through integrated state, county, & community efforts.

Public Health Emergency Preparedness (PHEP) Cooperative Agreement Performance Measures CDC provides significant funding through PHEP Cooperative Agreement for states to build capacity 15 preparedness capabilities defined, including Public Health Surveillance (SURV) and Epidemiological Investigation (EI) 6 performance measures defined and required for SURV and EI 2

Project Summary Objective: standardized, operational process for collecting data on the proportion of cases where select control measure(s) were initiated within appropriate timeframe Key steps: Define control measures, appropriate timeframes Define data collection process 3

Public Health SURV and EI Functions and Associated Performance Measures FunctionPerformance Measure(s) Conduct public health surveillance and detection SURV – Disease reporting Conduct public health and epidemiological investigation EI – Outbreak investigation reports EI – Exposure investigation reports EI – Outbreak investigation reports with minimal elements EI – Exposure investigation reports with minimal elements Recommend, monitor, and analyze mitigation actions SURV – Disease control Improve public health SURV and EI systems Disease control: proportion of cases of selected reportable diseases with public health CMs initiated within appropriate timeframe 4

Operationalizing Data Collection Florida decided to use existing web-based, reportable disease surveillance system (Merlin) to capture data Large volume of cases in Florida De-centralized model with 67 county health departments (CHDs) doing case investigations Needed centralized way to manage data without creating separate process of system Initiated work on defining CMs in May 2010 Approach was extensively vetted, revised, and implemented by Aug

Overall Approach Step 1: worked with statewide Quality Improvement and Enteric Workgroups to get feedback on possible CMs Step 2: piloted CMs with 6 CHDs Step 3: created data collection screen in Merlin and piloted with all 67 CHDs for 7 months Step 4: reviewed data collected in Merlin, solicited feedback from QI and Enteric Workgroups, modified data collection screen 6

Pilot I: 6 CHDs Used paper form Included additional diseases Data collected July 12-30, 2011 Did not specify which CMs were appropriate for which diseases 7

Pilot I Findings 6 CHDs participated 59 cases reported Only 4 cases of PHEP- required diseases DiseaseTota l Salmonellosis51 STEC3 Giardiasis1 Hepatitis A1 Varicella1 Pertussis1 Rabies, possible exposure 1 Total59 8

Pilot I Findings Confused about term “initiate” Does attempting phone call count as initiating education to contacts? Answer options not interpreted consistently within/between diseases If case couldn’t be reached, some CHDs used “initiated”, some used “not done” Date of investigation (existing Merlin field) was most often the same as the date as initiation of 1 st CM 9

CMs for 1 st Merlin Screen: Jan 5, 2011 Control Measure Botulism Hepatitis A Measles Meningococcal disease STEC Tularemia Salmonellosis Shigellosis Provided prevention education to case (or case’s guardian/care giver) or contacts Identified contacts or exposed persons (exposed to either the case or the environmental source) Recommended environmental measures to prevent future exposure (e.g., boil water notice, facility inspection or closure, etc.) XX Recommended isolation or restriction of movements of case or contacts (e.g., excluded from work or daycare) XXX Recommended prophylaxis or vaccination of contacts exposed persons XXXXX 10

1 st Merlin Screen: Pilot II 11

Pilot II Findings Control Measures for Confirmed, Probable, and Suspect Cases Jan 5 to Apr 21, 2011 Disease Number of cases reported Number of cases with ≥1 intervention measure Percent of cases with ≥1 intervention measure Mean days from CHD notification to earliest intervention measure Botulism Hepatitis A282589%1.8 Measles55100%0.5 Meningococcal disease20 100%0.2 STEC957882%2.7 Salmonellosis %2.0 Shigellosis %0.9 Tularemia Total1,5021,18379%1.6 12

Adjusted Approach CMs and answer options still interpreted inconsistently between CHDs Another round of input from statewide QI and enteric workgroups and state epidemiologist Limited CMs to interventions we thought had public health impact CHDs find great value in providing disease information to cases (realistically limited impact on disease transmission) Example: decided providing transmission prevention information to cases IF the person was still symptomatic at interview 13

Adjusted Approach Attempted to make answer options more specific and mutually exclusive Instead of using yes/no/NA for whether contacts were identified: Yes, and exposed individuals were identified Yes, but no other exposed individuals were identified No Ultimately decided to base measure on implementation rather than initiation of CMs Initiation without implementation not deemed an effective means of disease control Not consistent with PHEP performance measure guidance 14

Collect CM data on all confirmed, probable, suspect cases for the selected diseases Use time between CHD notified date and date interviewed “Appropriate timeframes” for implementing CMs 15 DiseaseAppropriate Timeframe (in Calendar Days) Botulism1 Hepatitis A7 Measles1 Meningococcal disease1 Salmonellosis1 Shigellosis4 STEC3 Tularemia2 Current Measure Parameters Appropriate Timeframes by Disease

16 CMs for 2 nd Merlin Screen: Aug 16, 2011

CMs Implemented within Appropriate Timeframe 17 Disease Total cases Cases with CM(s) within appropriate timeframe #(%)# Botulism0-- Hepatitis A118110(92%)100(85%) Measles0---- Meningococcal Disease47 (100%)44(94%) STEC424395(93%)284(67%) Salmonellosis6,6725,597(84%)2,726(41%) Shigellosis1,7811,590(89%)1,348(76%) Tularemia0-- Total9,0427,739(86%)4,502(50%) Disease Total cases Cases with CM(s) within appropriate timeframe #(%)# Botulism0-- Hepatitis A3027(90%)22(73%) Measles77(100%)6(86%) Meningococcal Disease19 (100%)19(100%) STEC147140(95%)106(72%) Salmonellosis1,3781,153(84%)570(41%) Shigellosis206186(90%)155(75%) Tularemia0-- Total1,7871,532(86%)878(49%) Low percentage Decrease from 2012

Additional Features Created Merlin report so CHDs can query and view data 18

Future Activities Determining reasonable percentage targets, based on data collected thus far Incorporating the measure into existing state-level CHD Snapshot Performance Measures Making small changes to processes within Merlin to streamline data entry Revising the dates used to determine the endpoint of the measure 19

Program Accountability and Improvement 20 Broad programmatic aim of measure: improve timeliness of appropriate interventions to limit the spread of disease in human populations and communities However, this measure does NOT address whether or not CMs reduce disease CHD staff are not optimistic that they can improve the timeliness of interventions (particularly for the higher volume diseases, which is very dependent upon cases being responsive to CHD contact efforts

Conclusions Identifying, operationalizing, and systematically monitoring meaningful CMs was challenging Additional guidance and standard disease-specific control measures with definitions would have been useful The relatively low volume of the PHEP-required diseases results in small numbers with unstable proportions, particularly at the local level CHDs perceived some CMs as important, even with little proof of public health impact Example: educating people on how they were infected Better communication between states could result in more systematic nationwide collection and use of meaningful disease control data 21

QUESTIONS? To protect, promote & improve the health of all people in Florida through integrated state, county, & community efforts.