Leah Eisenstein, MPH Janet Hamilton, MPH Katherine McCombs, MPH

1. 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.

2. 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 SURVand EI

3. 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

4. Public Health SURV and EI Functions and Associated Performance Measures • Disease control: proportion of cases of selected reportable diseases with public health CMs initiated within appropriate timeframe

5. 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

6. 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

7. 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

8. Pilot I Findings • 6 CHDs participated • 59 cases reported • Only 4 cases of PHEP- required diseases

9. 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 1stCM

10. CMs for 1st Merlin Screen: Jan 5, 2011

11. 1st Merlin Screen: Pilot II

12. Pilot II Findings Control Measures for Confirmed, Probable, and Suspect Cases Jan 5 to Apr 21, 2011

13. 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

14. 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

15. Current Measure Parameters • 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 Appropriate Timeframes by Disease

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

17. CMs Implemented within Appropriate Timeframe 2012 Low percentage 2013 Decrease from 2012 Low percentage

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

19. 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

20. Program Accountability and Improvement • 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

21. 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

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