Public Health Information Network (PHIN) Series I

1. is for Epi Epidemiology basics for non-epidemiologists Public Health Information Network (PHIN) Series I

3. Series I Sessions

4. Session I – V Slides VDH will post PHIN series slides on the following Web site: http://www.vdh.virginia.gov/EPR/Training.asp NCCPHP Training Web site: http://www.sph.unc.edu/nccphp/training

5. Site Sign-in Sheet Please submit your site sign-in sheet and session evaluation forms to: Suzi Silverstein Director, Education and Training Emergency Preparedness & Response Programs FAX: (804) 225 - 3888

6. Series ISession V “Epidemiology Specialties Applied”

7. What to Expect. . . Today Learn about the application and practice of three Epidemiology specialties: • Disaster Epidemiology • Environmental Epidemiology • Forensic Epidemiology

8. Session Overview • Disaster Epidemiology • North Carolina case study: Hurricanes • Impact of natural disasters • Rapid Needs Assessment methods and technology • Environmental Epidemiology • Virginia regulations • Environmental investigations • Restaurant inspections

9. Session Overview (cont’d.) • Forensic Epidemiology • Public Health Perspective • Law Enforcement Perspective • Joint Operations

10. Today’s Learning Objectives • Be able to distinguish Disaster, Environmental, and Forensic Epidemiology specialties • Recognize the common Epidemiological methods used among the three featured specialties • Recognize the special considerations or conditions faced by Epidemiologists in each specialty • Appreciate how the context of law, media, business, and communities impacts Epidemiology practice

11. Today’s Presenters Mark Smith, PhD, MS, MA Director Health Surveillance and Analysis Unit Guilford County Health Department, NC Gary Hagy, MSEH Director Division of Food and General Environmental Services Virginia Department of Health Jennifer Horney, MPH, MA Assistant Director NC Center for Public Health Preparedness

12. Disaster Epidemiology Mark Smith, PhD, MS, MA Director Health Surveillance and Analysis Unit Guilford County Health Department North Carolina

13. Public Health Grand Roundshttp://www.publichealthgrandrounds.unc.edu • Click on “Archived Programs” • Broadcast title: “Disasters, People, and Public Health: Are You Ready?” • September 1999, Hurricane Floyd • Immediate and long-term impact • Major components of a disaster response plan • Mental health aspects for victims and responders

14. North Carolina’s Evolving Public Health Response to Natural Disasters Rapid Needs Assessments after Hurricane Isabel and Charley

15. Overview • NC’s Public Health Regional Surveillance Team (PHRST) Structure • Rapid Needs Assessments (RNAs) • GIS and GPS Technology • Hurricane Isabel: 2003 • RNA methods and lessons learned • Hurricane Charley: 2004 • Evolution of RNA methods and lessons learned

16. NC Office of Public Health Preparedness and Response Public Health Regional Surveillance Teams (PHRST)

17. Regional Team Members • Physician-Epidemiologist • Nurse-Epidemiologist • Industrial Hygiene consultant • Administrative Assistant • Veterinarian liaison (NC Dept. Agriculture) • Three Pharmacist consultants shared

18. Rapid Needs Assessment After Natural Disasters • Identify need for food, water, power, shelter, access to medical care • Determine the magnitude of the need in order to plan and implement relief efforts. Purpose

19. Rapid Needs Assessment Background • RNA methodology developed by WHO and CDC • Used after hurricanes and other disasters, e.g., Ankara earthquake (1999), ice storm in Maine (1998), and hurricane in the Dominican Republic (1998) • Two-stage random sampling methodology allows generalization to sample area from only 210 surveys

20. Needs Assessment Sample Selection • Select a sample area • storm path, damage reports, service areas • Randomly select 30 population weighted geographic clusters in sample area • Randomly select 7 households within each geographic cluster • 210 total surveys, 10 survey teams

21. Hurricane Isabel: September 18, 2003

22. Rapid Needs Assessment:Hurricane Isabel • Thirty census clusters selected for a survey sample across 14 counties • Ten assessment teams comprised of Public Health Regional Surveillance Team (PHRST) staff, UNC Chapel Hill School of Public Health students, and state agency volunteers deployed to “forward base” in Greenville • Organized deployment using Incident Command System (ICS) structure

23. Rapid Needs Assessment Objective was to collect data about: • External or flood damage to homes • Access to household utilities • Incidence of hurricane-related illness and injury • Access to food and water • Access to medical care or medication • Immediate needs

24. Survey Instrument • One-page survey instrument • 24 questionnaire items • 33 data fields • Accompanied by a one-page “explanatory notes” form for interviewers

25. Interview Process

26. Interview Process Overview • Assessment teams deployed in official vehicles to assigned census block area • From starting point, moved sequentially along roadways to collect data from seven households per cluster • Data collection was paper-based • Total of 210 interviews completed

27. Isabel RNA Results • 2% flooded (95% CI 0.2 - 4.5) • 32% damaged (95% CI 23 - 42) • 65% no electricity • 30% using a generator

28. Isabel RNA Results • 43% bottled water supply • 13% no access to 3-day food supply • Household projections • 40,00 using bottled water • 12,000 no access to 3-day food supply

29. Lessons Learned

30. Lessons Learned • Need for better randomization in second stage • Use of paper questionnaires required double data entry

31. Can new technologies address these issues? Options: • Perhaps Geographic Information Systems (GIS) could be used in the 2nd stage randomization. • Skip the paper and enter the data directly into the computer, a handheld computer.

32. What is GIS? • Set of tools that collect, store, retrieve, transform, and display spatial data • Used to construct maps that communicate spatial data • Raster-based: Data and image stored in a regularized grid made of pixels [Satellite] • Vector-based: Data and image stored separately in map layers (points, lines, polygons) – [Epi Map, ArcView] • Map layers share a common coordinate system (e.g., x - y)

33. GIS Mapping Example: John Snow’s Broad Street Pump Investigation

34. GPS (Global Positioning System)

35. Field Data Collection EPI Info GIS Wireless: WIFI 802.11 or Bluetooth Field Team 4 Field Team 5 Field Team 1 Field Team 2 Field Team 3 Field data collection using IPAQ Pocket PCs equipped with GPS, GIS software and data collection forms.

36. Hurricane Charley: August 9-14, 2004

37. Changes in RNA Methodology • Electronic field data collection • Use of GIS to randomly select households for interviews • Use of GIS and GPS to route interviewers to field data collection sites

38. Hurricane Charley RNA Assessment Area Map made in Arcview 9.0

39. Selection of Census Block Groups Map made in Arcview 9.0

40. Using Random Number Generator to Select 30 Geographic Clusters Census Block Group Identifier Census Block Group map layer has population data In Excel, create cumulative population field to randomize “proportional to population” Use random number generator in Excel to generate 30 numbers, select Census Block Groups 1st Stage Randomization in Excel

41. Identifying Individual Census Block Groups Map made in Arcview 9.0

43. HP IPAQ Pocket PC running ArcPad GIS software ArcPad Routing Function

44. ArcPad programmed to automatically insert cluster # in database for complex samples analysis ArcPad form programmed to automatically insert census block group population in survey Assigns a unique case ID or incident #

45. Field Data Collection EPI Info GIS Wireless: WIFI 802.11 or Bluetooth Field Team 4 Field Team 5 Field Team 1 Field Team 2 Field Team 3 Field data collection using IPAQ Pocket PCs equipped with GPS, GIS software and data collection forms.

46. Hurricane Charley RNA Results • 203 surveys completed • Training, data collection, analysis, report writing completed in 24 hours • Findings showed little impact from the hurricane • Estimated 1.4% of households without power • 6% of homes damaged but habitable • 2.5% of homes flooded with 1-12 in. water

47. Lessons Learned • Prepare data collection forms in advance, if possible • Provide mobile GIS training to potential field data collectors • Consider alternatives for second-stage randomization procedure; i.e., tax parcels

48. Conclusions • RNA’s fulfill vital public health function • Use of Incident Command System (ICS) vital to rapid deployment of resources • Handheld computers, GIS and GPS adds value to field data collection in RNA • Eliminates double data entry • Provides routing and direction-finding for field teams • Improved randomization through GIS • Ability to quickly analyze and map data

49. Question & Answer Opportunity Mark Smith msmith@co.guilford.nc.us (336) 641 - 6844

50. Moderator Commentary Disaster Epidemiology in The Context of The Series