Addressing the Challenges of Implementing Systematic, Meaningful Disease-Specific Case-Based Control Measures

Leah Eisenstein, MPHJanet Hamilton, MPHKatherine 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

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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

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Public Health SURV and EI Functions and Associated Performance Measures

Function Performance Measure(s)Conduct public health surveillance and detection SURV – Disease reporting

Conduct public health and epidemiological investigation

EI – Outbreak investigation reportsEI – Exposure investigation reportsEI – Outbreak investigation reports with minimal elementsEI – 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

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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 2011

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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

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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

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Pilot I Findings

• 6 CHDs participated

• 59 cases reported

• Only 4 cases of PHEP- required diseases

Disease Total

Salmonellosis 51

STEC 3

Giardiasis 1

Hepatitis A 1

Varicella 1

Pertussis 1

Rabies, possible exposure

1

Total 59

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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 1st CM

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CMs for 1st Merlin Screen: Jan 5, 2011

Control MeasureBotulism

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.)

X X

Recommended isolation or restriction of movements of case or contacts (e.g., excluded from work or daycare)

X X X

Recommended prophylaxis or vaccination of contacts exposed persons X X X X X

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1st Merlin Screen: Pilot II11

Pilot II FindingsControl Measures for Confirmed, Probable, and Suspect Cases

Jan 5 to Apr 21, 2011

DiseaseNumber 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 0 - -- 0.0

Hepatitis A 28 25 89% 1.8

Measles 5 5 100% 0.5

Meningococcal disease 20 20 100% 0.2

STEC 95 78 82% 2.7

Salmonellosis 802 597 74% 2.0

Shigellosis 552 458 83% 0.9

Tularemia 0 - -- 0.0

Total 1,502 1,183 79% 1.6

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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

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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

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• 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

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Disease Appropriate Timeframe

(in Calendar Days)

Botulism 1

Hepatitis A 7

Measles 1

Meningococcal disease 1

Salmonellosis 1

Shigellosis 4

STEC 3

Tularemia 2

Current Measure Parameters

Appropriate Timeframes by Disease

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CMs for 2nd Merlin Screen: Aug 16, 2011

CMs Implemented within Appropriate Timeframe17

Disease Total cases Cases with CM(s)

Cases with CM(s) within appropriate

timeframe#(%) #(%)

Botulism 0 -- --Hepatitis A 118 110(92%) 100(85%)Measles 0 -- --Meningococcal Disease 47 47(100%) 44(94%)STEC 424 395(93%) 284(67%)Salmonellosis 6,672 5,597(84%) 2,726(41%)Shigellosis 1,781 1,590(89%) 1,348(76%)Tularemia 0 -- --Total 9,042 7,739(86%) 4,502(50%)

Disease Total cases Cases with CM(s)

Cases with CM(s) within appropriate

timeframe#(%) #(%)

Botulism 0 -- --Hepatitis A 30 27(90%) 22(73%)Measles 7 7(100%) 6(86%)Meningococcal Disease 19 19(100%) 19(100%)STEC 147 140(95%) 106(72%)Salmonellosis 1,378 1,153(84%) 570(41%)Shigellosis 206 186(90%) 155(75%)Tularemia 0 -- --Total 1,787 1,532(86%) 878(49%)

2012

2013

Low percentage

Low percentage

Decrease from 2012

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

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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

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Program Accountability and Improvement

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• 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

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QUESTIONS?

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