Building a Public Health Community of Practice

1
Building a Public Health Community of
Practice How to Take Biosurveillance to the Next
Level and Reap its Broad Benefits APC Training
Conference February 19, 2008 Prepared and
presented by Bill Stephens, MS, APC
Manager Dean Lampman, MBA, Regional Surveillance
Coordinator Kay Sanyal-Mukherji, MPH, Workforce
Development Specialist
2
Agenda
Topic
Time

• Pre-test 10
• Communities of public health practice overview 25
  
• Biosurveillance fundamentals and best
  practices 25
• Health partnerships applied response
  protocols 30
• Break 15
• Interactive group session 1 15
• Interactive group session 2 15
• Discussion of group sessions / conclusion 20
• Post-test 10

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Pre-test
4
Learning objectives

• At the end of this session, participants will be
  able to
• Describe three functional areas of
  biosurveillance where syndromic surveillance
  applies and clinician-only input is insufficient.
• Identify the primary purposes of biosurveillance
  and how it can benefit public health and other
  stakeholders in a public health community of
  practice.
• List and apply several key decision-making
  criteria contained in biosurveillance system
  response protocols that are used to evaluate and
  respond to public health threats.

5
The context for public health information
systems

• Healthcare in the U.S. under fire for a variety
  of reasons
• Poor quality of care, errors resulting in more
  deaths annually than highway accidents, breast
  cancer or AIDS
• Presence of disparities in access to care and in
  health outcomes
• National disasters, terrorism or infectious
  disease public health threats
• Rapidly increasing costs of healthcare

• One response American Health Information
  Community (AHIC)

• Federally chartered 9-13-05
• Advisory committee
• Provides input to HHS

• Goal is to achieve common interoperability
  framework for health IT with input from a broad
  range of stakeholders on achieving widespread
  adoption

• Work performed by four workgroups
• Population Health and Clinical Care Connections
• Biosurveillance Data Steering Group
• Consumer Empowerment
• Chronic Care
• Electronic Health Records

6
Context for public health information systems
continued

• 12-06 Pandemic and All-Hazards Preparedness Act
  (PAHPA)
• Broad implications for HHSs preparedness and
  response activities
• New Assistant Secretary for Preparedness and
  Response (ASPR)
• Establish quadrennial National Health Security
  Strategy and support new programs (e.g., advanced
  development of medical countermeasures)
• 11-07 Homeland Security Presidential Directive
  21 (HSPD-21)
• Establish biosurveillance capability for early
  warning of a biological attack or disease
  outbreak w/ ongoing near real-time updates
• Formulate comprehensive plan for promoting
  community public health and medical preparedness
  to help those building resilient communities
• Develop disaster medical capability that can
  immediately re-orient and coordinate resources
  within all sectors to satisfy community needs
• Foster medical countermeasure stockpiling and
  distribution so that communities can distribute
  and dispense countermeasures in 48 hours

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AHIC Its different and powerful

• Why is this group different than any of the
  hundreds of others who regularly gather under
  different banners and acronyms for the same
  purpose? Spoken bluntly, the answer is market
  power. Around this table sits representatives of
  the federal and state agencies that pay for and
  regulate a major piece of the 1.7 trillion
  dollars a year spent on health care in America.

Dr. Michael O. Leavitt Secretary, DHHS
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AHICs key objective
Creating a robust health IT environment that
brings together

• Public Health Information
• Electronic Health Records (EHR)
• Personal Health Records (PHR)
• Open source, open standards for data and security
  /privacy
• Interoperable Health Information Exchanges (HIE)

9
AHIC priorities and use case roadmap
The AHIC MDS enables achievement of the
requirements in the biosurveillance use case.
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HIEs will link public health and clinical care
entities

• Population Health and Clinical Care Connections
  Workgroup recommendations include
• -- 1.0 Develop a business case for data
  information exchange between public health and
  clinical care as well as develop a communications
  plan to improve the understanding of the need for
  this exchange
• -- 1.3 Support the establishment of a
  proof-of-concept demonstrating the added value of
  sharing data from clinical care to public health
  through health information exchanges.
• -- 1.4 Develop a plan to encourage the
  integration of state funded public health
  surveillance programs and health information
  exchanges.
• Harmonized biosurveillance use case defined to
  provide input to HITSP standards including
• A framework or functional area matrix for
  public health and healthcare
• Biosurveillance data standards via a Minimum Data
  Set (MDS)
• Lab reporting standards for EHR and public health

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Why focus on the biosurveillance use case?

• Primarily, it provides the baseline for the
  broadest possible response to recommendation 1.0
  from the PHCCC workgroup
• Secondarily, it integrates data requirements
  (MDS) across the functional areas matrix (FAM) in
  which public health and healthcare generally will
  share information in the brave new world of
  health information exchanges.
• Open source software and industry standards are
  making it work

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What is biosurveillance?
The BDSG adopted ASTHOs definition of
biosurveillance in fall 2006 Biosurveillance is
often referred to as syndromic surveillance
however the ability to detect events early
requires a broader set of information than that
of syndromes. While theres no single
agreed-upon definition, theres agreement that
such biosurveillance systems need to take
advantage of integrated data from multiple
sources including public health information as
well as electronic health information not
traditionally monitored by public health.
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What is biosurveillance?

• Biosurveillance systems must leverage two major
  surveillance methods
• Well-established public health surveillance
  methods and sources used for the tracking,
  monitoring, and reporting of health-related
  information, such as epidemiologic investigations
  of infectious disease outbreaks or environmental
  conditions are needed to ensure a broad coverage
  of data sources, to use as baselines comparisons,
  and to support the accuracy and reliability of
  the biosurveillance findings.
• Early event detection and situational awareness
  - the use of an automated system to evaluate case
  and suspected case reporting along with
  statistical surveillance and data visualization
  of pre-diagnostic and diagnostic data to support
  the earliest possible detection of events that
  may signal a public health emergency - are
  essential components for near real-time detection
  of natural or man-made health events.

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Functional areas for health information
Source Office of the National Coordinator,
Health IT
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Functional areas for health information (contd)
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Functional areas for health information (contd)
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Functional areas where syndromic surveillance
applies

• Early event detection
• Outbreak management
• Partner communication and alerting

And where clinician input alone is insufficient
because

• The scale of these tasks exceeds clinicians
  capabilities
• Clinicians are not properly trained for these
  tasks
• Early detection requires no significant time lag,
  which is common in clinical confirmation (e.g.,
  for lab tests)
• Support for these claims and more reasons
  presented in next section

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What is a community of public heath practice?

• People and organizations working together who may
  share resources in an effective, efficient way
  working towards separate but related solutions.
• Partners
• Hospitals and physicians
• Schools, school-based clinics and daycares
• EMS providers, law enforcement and other first
  responders
• Long-term care facilities and mental health care
  providers
• Public information officers and the media
• Academics, vendors, subject-matter experts, where
  applicable
• Insurance companies

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What is a community of public heath practice?
(cont.)

• Resources and practices
• Surveillance data and systems
• And their accompanying response protocols
• Networks/grids, IT assets and solutions,
  including
• Applications
• Databases
• Forums
• Medical facilities and laboratories
• Governance models RHIOs, HIEs

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Current North Central Texas Surveillance
Communications ModelA Loose Federation
Hospitals ----------------------- THR Baylor HCA
Tenet Others
State Public Health ------------------------ Regio
n 2/3 Office (Arlington, TX)
Local Public Health ------------------------ Dalla
s County Collin County Denton County Wichita
County
Hospital Council ----------------------- Serves
hospitals Provides reports Leads
exercises Maintains EM Systems

Regional EPI Group
ICPs and ICP Committees
APC / TCPH ---------------------- Maintains HIE
and supporting tools Leads collaboration, but
cannot set policy beyond Tarrant County
Federal Public Health ------------------------ CD
C (Atlanta, GA)

Comments Strength The model works.
Collaboration is occurring. Each participant
maintains a high degree of control over their own
event alert response protocols. Weakness The
model lacks formal HIE governance. The high
degree of autonomy of each participant limits the
ability of the region to quickly develop a
consistent response protocol. Gaps may exist
that are difficult to pinpoint and also
challenging to overcome.
Legend
required reporting relationship
voluntary reporting relationship
some required some voluntary reporting
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Communities of public health practice overview
QUESTIONS
What questions may we answer at this point?
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Agenda
Topic
Time

• Pre-test 10
• Communities of public health practice overview 25
  
• Biosurveillance fundamentals and best
  practices 25
• Health partnerships applied response
  protocols 30
• Break 15
• Interactive group session 1 15
• Interactive group session 2 15
• Discussion of group sessions / conclusion 20
• Post-test 10

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Syndromic surveillance definition, purpose

• Syndromic surveillance has been defined as "the
  timely collection, analysis, and investigation of
  health-related data that precede diagnosis."

• Syndromic surveillance is used to
• Trace disease patterns over time
• Describe patterns of disease in geographic
  locations and demographics at any time
• Detect changes in community health status,
  especially for the early detection of outbreaks
• Reduce morbidity and mortality (improve health
  status)

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Is early detection important?
With a pandemic possible, it seems vital!
Any community that fails to prepare, with the
expectation that the federal government (or for
that matter, the state government) will be able
to step forward and come to their rescue at the
final hour, will be tragically wrong -- not
because we will lack a collective wallet, but
because there is no way that you can respond to
every hometown in America at the same time. --
HHS Secretary Leavitt, April 20, 2006
1918 Pandemic Worst epidemic ever 20 to 40
million deaths
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Isnt clinician input enough?
Wheres Doctor Smith?
Definitely not! For many reasons

• Automated surveillance doesnt sleep, doesnt get
  bored, doesnt play golf, and is good at the math
  
• Many physicians are not trained in infectious
  disease or public health

Hes seeing patient Green.

• Systems that rely on human input have poor
  compliance rates
• Even if a disease is detected that is legally
  required to be reported, studies show that lt 10
  of such cases are actually reported
• Timely clinical detection is unlikely for CDC
  Category A agents
• Incorrect clinician diagnosis rate gt 50
  incorrect response rate 75
• Most pathogens require tests typically not on
  hand or routinely ordered
• The best case, anthrax, may show positive from a
  routine test in 18 hours

See handout Challenges to Rapid Clinical
Detection of Select Agents, by Dr. David
Siegrist, 6-26-06
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Biosurveillance transcends early event detection
Situational awareness requires deep data in a
window of opportunity

• Initial detection (identify event rapidly)
• Quantification (how many are ill?)
• Localization (where is this happening?)
• Investigation (demographics, etiology,
  conveyance, travel histories, etc.)

• Subsequent detection (identify more cases)
• Outbreak management (confirm, track cases)
• Countermeasures (isolation, vaccination)
• Target (illness, deaths recede)

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Biosurveillance transcends early event detection
Situational awareness requires broad data across
outbreak health cycle

• Exposure occurs, but feels fine initially
• Headache, fever (pharmacies)
• Develops cough (call hotline)

• Sees provider (care visit, absent)
• Calls ambulance, admitted (EMS / ED)
• Critical, ICU, lab tests (diagnosed)
• Expires (reported)

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Infectious disease outbreak health cycle
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Partner participation benefits

• Early awareness is preparedness
• Consider potential for pandemic, bioterrorism,
  etc.
• Supports infection control goals
• Shows community patterns (MRSA)
• Enhances image of provider
• Fosters collaboration with others and public
  health on health problem solving

• Chance to influence project directions
• When open systems apply, low or no cost
• Likely ancillary IT / operational benefits

32
How partners share data with public health

• Sign data use agreement (aka contract) with
  HIPAA coverage for data elements (AHIC MDS) to
  be shared
• Contract can be amended if data elements change

• Assess network connections and transfer methods,
  which are typically VPN and HL7, but can vary
• Identify and link to interfaces (often done w/
  interface engine)
• Send test files, work out mapping issues
• Total project time varies, but usually can be
  accurately estimated and isnt huge.

Its not rocket science!
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Biosurveillances scope of work (per CDC)

• Purpose is to
• Establish near real-time electronic nationwide
  public health situational awareness capability
  via interoperable network of systems (e.g., NHIN)
• Share data to enhance rapid response to, and
  management of, potentially catastrophic
  infectious disease outbreaks and other public
  health emergencies. 
• Requires simultaneous provision of data to all
  levels of public health
• Successful HIEs (aka community of public health
  practice) must
• Standardize information storage and messaging
  formats
• Resolve varying local, state, and federal
  regulations  
• Address privacy concerns
• Accurately identify patients

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Biosurveillances scope of work (continued)

• Activities to be addressed
• Minimum Data Set (MDS) for biosurveillance
• Evaluate availability and usefulness for
  situational awareness
• Interoperability standards
• Bidirectional communication
• Data quality and accessibility

• Data evaluation and assessment to detect,
  characterize and track a public health threat
• Evidence of effectiveness, costs and scalability

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• Facility data
• 1-5 Base data
• 6-23 Daily data
• Patient data (24-33)
• Clinical data (34-43)
• Lab data (44-58)

AHIC MDS Gold standard
10
MDS 58 elements
Patient data
Facility data
23
Clinical data
Lab data
15
Facility (23) 40 Other (35) 60
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MDS situational awareness, anything lt only
offers early warning BioSense seeks MDS inputs,
CDC seeks to validate MDS utility
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targeted in 08
TBD (possible threat?)
existing
TBD
schools
Evolving Case Study North Texas
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51 data feeds, 120 users
The starting point was hospitals
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ESSENCE applications impact

• User view allows collaboration with public health
• Has proven valuable for hospital ICPs, others
• One of several systems used for N. Texas
  surveillance
• Differs from RODS in how it generates, sends
  alerts

• Offers good slicing, dicing capabilities for
  analysis
• Used by Dallas County to identify heat
  emergencies
• Offers physician data, school absenteeism modules
• Continuously enhanced to address user feedback

ESSENCE lets us view whats happening in our
multi-hospital system. We can monitor in real
time patients being seen and admitted, an
impossible task otherwise. Its user friendly,
and best of all, its at no cost to us. --
Judy Prescott, Manager, Epidemiology, Baylor
University Medical Center
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EpiAgent enhances local situational awareness

• EpiAgent is a PHIN-compliant next-generation
  surveillance tool from General Biodefense

• A clinical event monitor, it applies a case-based
  analytical model and offers rule-based analysis
  of clinical data (e.g. MDS)
• Can automatically detect individual instances of
  targeted items
• Anthrax (existing rules)
• Varicella, aka chicken pox (existing rules)
• MRSA (future rules)
• Cases found can send alerts automatically to
  authorized users
• Authorized users can include hospitals and public
  health
• Ideal complement to syndromic surveillance
  systems, which have proven effective with case
  counts of 100, 500, 1,000 and 5,000

A key expansion point is hospitals
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Next steps for participating hospitals

• Support provision of more data for situational
  awareness
• This applies regardless of the phasing of any MDS
  project
• Champion project to share AHIC MDS data
• Keep staff and management aware of the benefits
• Encourage system use, identify areas for
  improvement
• Improve data quality (pursue standards of data
  entry)
• Make staff aware theyre feeding an analytical
  system
• Improve data analysis and response (apply
  protocols)
• Be available when called on by public health
  staff

Were making it easy by asking for test data!
EpiAgent demo can open the treasure chest!
41
Contact presenters for demo
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LEFR system key features

• Portal uses audible alerting to prompt agency
  monitors when new notifications are posted
• Color coding of notifications conveys relative
  urgency of events
• Supporting text is concise, action oriented
  brevity avoids scrolling
• Show more links provide details complete
  event history accessible
• Users can also add their comments to
  notifications or send their own messages (not
  tied to a notification)

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Contact presenters for demo
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Data Flow Within School Health Surveillance System
Open source ETL tool (Mirth)
XML DB on open source portal
Data entry form on open source portal (DNN)
Royalty-free ESSENCE DB at TCPH
Royalty free ESSENCE application
Efficient, affordable, replicable method
45
Users click on their choices among a series of
images with large to small geographic coverage
46
Users can click on the next or previous links to
see other images in the series and click the
close link to return the main maps page.
47
This page provides access to flu prevention
resources school nurses can use. More resources
or topics could be added.
48
Biosurveillance fundamentals and best practices
QUESTIONS
What questions may we answer at this point?
49
Agenda
Topic
Time

• Pre-test 10
• Communities of public health practice overview 25
  
• Biosurveillance fundamentals and best
  practices 25
• Health partnerships applied response
  protocols 30
• Break 15
• Interactive group session 1 15
• Interactive group session 2 15
• Discussion of group sessions / conclusion 20
• Post-test 10

50
Why response protocols matter

• Clear guidelines needed to review and summarize
  large amounts of data, daily
• Approaches or steps to review data and analyze
  the importance of anomalies in data
• Prompt inquiries that need to be completed in
  hours or days, depending on estimated degree of
  urgency
• Example Phone consultation with physician at a
  hospital
• Essential for determining relative value of
  different approaches in outbreak detection in
  each system
• Provides information useful to determine
  efficiency of system in detecting outbreaks in
  the initial stages

51
Why response protocols matter

• They can help maximize the functionality and
  value of a surveillance system
• A standard framework can help distinguish
  statistical anomalies from more important public
  health events
• Can translate to time and cost savings for PH in
• Investigating alerts
• Systems development, maintenance and upgrades

52
Response protocols framework

• Anomaly detection
• Anomaly characterization
• Validation of anomaly
• Assessing public health significance of findings
• Other factors of importance

53
Anomaly detection

• Systems use statistical algorithm to determine if
  actual case counts exceed expected counts for
  syndromes
• Helps epidemiologists spot suspicious disease
  clusters
• Healthcare providers send information on unusual
  disease clusters and incidence that system can
  evaluate
• Detection should occur at multiple levels to
  discover anomalies that may be missed in a single
  jurisdiction

54
Anomaly detection

• Check quality and completeness of data
• Onset of exposure, symptoms, behavior
• Timeliness, capture of data
• Completion of data processing
• Application of pattern recognition
• Sufficient records available
• Generation of automated alert

55
Anomaly characterization

• Anomaly should be described fully w/ respect to
  person, place, and time (descriptive
  epidemiology)
• Use geographic and demographic information
• Clinical data should be evaluated and summarized
• More information may be needed to fully
  characterize

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Anomaly characterization

• Key questions to explore
• How widespread is the pattern?
• Are similar patterns found elsewhere?
• How many days has anomaly lasted?
• Has geographical spread changed over time?
• Does anomaly affect certain demographics?

57
Anomaly validation

• Anomalies expected or unusual?
• Seasonal or temporal (e.g. ILI)
• Environmental causes
• Disease trends
• Corroborate data sources
• Holiday, day-of-week effects
• Same pattern prior year?

BioSense protocol
(protocol continued on next slide)
58
Assessing public health significance of findings

• Public health significance?
• Extent of variance from usual frequency
  distribution
• Atypical from known patterns
• Magnitude, continuity of increase given syndrome
  group
• Sustained for multiple days?

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Other factors of importance

• Unique attributes of the data stream to assess
• Lag time between occurrence of an event and time
  it is available to the system for detection of
  anomaly
• Clinical value of the data
• One data stream or source may be chosen as
  primary indicator of change and other data
  sources as secondary
• Compare anomaly w/ other surveillance systems

60
Considerations in drafting response protocols

• Most tasks in response protocols overlap
• Concept similar to early stages of outbreak
  investigation
• Procedures for response protocols will vary based
  on
• Surveillance system the protocol supports
• Jurisdiction in which it operates
• Agency preferences
• Communication of findings and response should be
• Consistent for anomalies/events of similar
  nature/importance
• Easily and routinely monitored
• Shared across all levels and jurisdictions

61
Constraints in drafting response protocols

• Variables that effect the design of a common
  protocol

• Agency size
• Experience
• Training
• Degree of risk
• Time pressures
• Data quality (lag time)
• Jurisdiction
• Department level

62
Agency protocol 1 Tarrant County

• Factors that constitute a concern
• Unusual epidemiology
• High number of excess cases
• Multiple sites with excess
• Sustained increase
• Detection of anomaly that is of concern
• Consultation with chief epidemiologist
• Review medical records and/or follow-up with
  patients
• Lab testing
• Consultation with key public health officials
• Send alerts to health providers
• Outbreak confirmed outbreak investigation

63
Agency protocol 2 CDC BioSense

• Protocol steps
• Identify anomalies
• Prioritize anomaly list
• Characterize anomaly
• Make a decision
• Determine action

64
Sample protocol usage scenario 1 Bubbas
unhappy campers

• Background
• Clinician in Weatherford, TX notices several of
  her patients coming in with common symptoms
• 43 patients presented at hospital with diarrhea,
  nausea, vomiting, and some with fever
• No final diagnosis, but she suspects something

• Action
• She contacts director of LHD with information
• Sanitarian is director of LHD
• LHD does not have staff or surveillance system to
  investigate

65
Sample protocol usage scenario 1 Bubbas
unhappy campers

• Sanitarian contacts regional health department

• RHD queries ESSENCE to analyze chief complaints
• Finds similar counts with symptoms under the GI
  (gastrointestinal) syndrome
• MAP portal in ESSENCE is based on GIS
  technology

• Counts high in Weatherford only, not nearby areas

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67
Sample protocol usage scenario 1 Bubbas
unhappy campers

• Investigators check ESSENCE data against OTC
  sales
• Increase in sales of Pepto-Bismol and similar
  products

• Investigators note that theres unusual health
  event occurring in the Weatherford area hospital

68
Sample protocol usage scenario 1 Bubbas
unhappy campers

• Epidemiologists from RHD sent to work with
  clinician to investigate

• Clinician reveals that some patients have
  returned with fevers
• Epis review medical charts and order lab tests

69
Sample protocol usage scenario 1 Bubbas
unhappy campers

• Epis, sanitarian interview all patients
• Finding all ate at same place (Bubbas Chicken
  Shack) on same day
• All ate the daily fried chicken special
• Sanitarian investigates
• Finding food was contaminated
• Restaurant shut down for investigation

70
Sample protocol usage scenario 1 Bubbas
unhappy campers

• Tests come back positive for Campylobacter
• Bacterium spread through contamination,
  especially through undercooked poultry
• Can cause chronic diarrhea

• PH director at RHD sees a need for intervention
  and issues a media release

71
Sample protocol usage scenario 1 Bubbas
unhappy campers

• LHD and RHD issue a public health alert and media
  statement

• Few additional victims come forward
• All victims are given effective antibiotics

72
Sample protocol usage scenario 1 Bubbas
unhappy campers

• Bubba self-medicates at his favorite watering
  hole
• Quite late the next day, Bubbas hurting again,
  so he takes still more meds

73
Sample protocol usage scenario 2 What to ask
say if the anthraxswer is blowin in the wind
74
Sample protocol usage scenario 2 What to ask
say if the anthraxswer is blowin in the wind

• Background

• While monitoring the LE/FR Surveillance System in
  May, 2007, the Arlington (Texas) Police
  Department a notices yellow advisory involving
  increased respiratory complaints
• Advisory concentrated in their location and
  adjacent locations
• Advisory issued by Tarrant County Public Health,
  which cited significant increase in respiratory
  problems
• Advisory indicates that the precise cause of the
  problems is being investigated and more
  information will be forthcoming

75
Sample protocol usage scenario 2 What to ask
say if the anthraxswer is blowin in the wind

• Action
• LHD contacts Police Department to indicate that
  public health is aware of the situation and is
  investigating
• Public healths LE/FR system advisory
  notification indicates
• The respiratory problem is significant and
  widespread in the county
• For officers safety, and with bioterrorism a
  possibility not yet ruled out, its time to don
  PPE (i.e., N95 masks)
• Same message goes to other agencies that may
  enter into affected areas
• Police Department sends message to all agency
  users in system
• Police Department alerts other community
  stakeholders (its partners) that lack LE/FR
  warns them to take preventive action

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77
Sample protocol usage scenario 2 What to ask
say if the anthraxswer is blowin in the wind

• Tarrant County Public Health continues to
  investigate
• Queries respiratory complaints in highlighted
  regions
• Findings similar clusters in that area
• Compares data to last years data same time
  period
• Determines counts are higher than previous year
• Compare against other data sources
• Similar rise in OTC sales of respiratory
  medication
• Time period is not typical for respiratory
  problems

78
Sample protocol usage scenario 2 What to ask
say if the anthraxswer is blowin in the wind

• Other factors examined
• Weather reports
• Pollen counts have been extremely high for most
  of the month
• Counts are exceedingly high throughout last week
  of the month
• Lab data from care givers
• Anthrax not indicated

MAY 2007
79
Sample protocol usage scenario 2 What to ask
say if the anthraxswer is blowin in the wind

• The respiratory problems were due to allergies
• Local Health Authority determines no threat
• Alert precautions to front-line personnel lifted
• Stakeholders in community of practice are briefed

80
Sample protocol usage scenario 3 Saved by the
school bell

• Background
• October 2007 in school Web portal
• School nurse notices that many students are
  absent or coming into office with common symptoms
• Symptoms of sneezing, coughing, runny nose, and
  fever consistent with flu

81
Sample protocol usage scenario 3 Saved by the
school bell

• Action
• Nurses enter absenteeism data
• LHD makes use of school portal to communicate w/
  school nurses
• LHD surveillance lead asks nurses to send flu
  resources home w/ students

• Nurses report similar findings
• LHD investigates w/ ESSENCE using school and
  other health data

82
Sample protocol usage scenario 3 Saved by the
school bell

• ESSENCE has ER data
• Using both sources, they query chief complaints
  and limit age to those in elementary school

• Map portal shows zip codes with the significant
  clusters

83
Sample protocol usage scenario 3 Saved by the
school bell

• The original school was found in the zip code
  with a significantly large cluster
• Adjacent areas showing small clusters
• LHD target zip codes with large clusters for
  samples

• Through local physician offices, LHD obtains lab
  results for several samples chosen
• Lab tests reveal FLU

84
Sample protocol usage scenario 3 Saved by the
school bell

• LHD sent messages to all schools telling them to
  take preventive action
• Original school installs new antibiotic scrubbing
  solution to mitigate the spread
• Other schools follow suit

• Health Authority calls for broadened flu shot
  distribution
• Flu shots distributed in areas that show most
  signs of flu

85
Health partnerships applied response protocols
QUESTIONS
What questions may we answer at this point?
86
Agenda
Topic
Time

• Pre-test 10
• Communities of public health practice overview 25
  
• Biosurveillance fundamentals and best
  practices 25
• Health partnerships applied response
  protocols 30
• Break 15
• Interactive group session 1 15
• Interactive group session 2 15
• Discussion of group sessions / conclusion 20
• Post-test 10

87
Agenda
Topic
Time

• Pre-test 10
• Communities of public health practice overview 25
  
• Biosurveillance fundamentals and best
  practices 25
• Health partnerships applied response
  protocols 30
• Break 15
• Interactive group session 1 15
• Interactive group session 2 15
• Discussion of group sessions / conclusion 20
• Post-test 10

88
Interactive group session 1
89
Agenda
Topic
Time

• Pre-test 10
• Communities of public health practice overview 25
  
• Biosurveillance fundamentals and best
  practices 25
• Health partnerships applied response
  protocols 30
• Break 15
• Interactive group session 1 15
• Interactive group session 2 15
• Discussion of group sessions / conclusion 20
• Post-test 10

90
Interactive group session 2
91
Agenda
Topic
Time

• Pre-test 10
• Communities of public health practice overview 25
  
• Biosurveillance fundamentals and best
  practices 25
• Health partnerships applied response
  protocols 30
• Break 15
• Interactive group session 1 15
• Interactive group session 2 15
• Discussion of group sessions / conclusion 20
• Post-test 10

92
Discussion of interactive group sessions
93
In conclusion

• Clinician-only input is insufficient for several
  reasons
• Biosurveillance systems have broad, major
  benefits
• Response protocols apply key decision-making
  criteria
• General guidelines are helpful, may not be
  sufficient
• Actual responses may occur in various forms, ways
• A community of public health practice engages
  many
• Response protocols require effective
  communication

It takes a village community of public health
practice.
94
In conclusion

• Staff experience key factor in readiness,
  protocol development
• LHD should always assess community-level health
  problems
• Usually, LHDs will lead community health problem
  solving
• Not all health problems turn out to be what they
  first look like
• Findings and response should be shared broadly
  and promptly
• Health status should be monitored at various
  granularity levels
• One plan does not fit all

95
References and resources to learn more

• These handouts are part of your conference
  materials
• AHIC MDS and preconditions
• Copy of these slides and full scenarios upon
  which exercises were based
• Challenges to Rapid Clinical Detection of Select
  Agents (D. Siegrist)
• List of references and resources with active
  hyperlinks
• Region Has Radar for Outbreaks (Fort Worth
  Star-Telegram)
• Syndromic Surveillance on the Epidemiologists
  Desktop Making Sense of Much Data (K.
  Hurt-Mullen et al)
• Tarrant County Public Health and CDC BioSense
  response protocols
• Tarrant County syndromic surveillance efficacy
  test report (Siegrist et al)
• Contact information for presenters

96
You can also request our forthcoming CD

• All handouts on prior slide and
• Surveillance implementation guide
• More on LE/FR and school portals
• A report on the NEDSS program
• More TBD? Give us your input!
• Methods to order
• Sign up sheet here
• E-mail request later

Building a Community of Public Health Practice A
Compendium of Biosurveillance Resources
97
References and resources to learn more

• Book Handbook of Biosurveillance, M. Wagner et
  al., Elsevier, May, 2006. Details
  www.elsevier.com/wps/find/bookdescription.cws_home
  /707451/description
• Useful Websites and pages
• American Health Information Community
  www.hhs.gov/healthit/community/background/
• CDC Biosense www.cdc.gov/biosense/ and CDC PHIN
  www.cdc.gov/phin/
• CDC syndromic surveillance resources
  www.cdc.gov/epo/dphsi/syndromic.htm
• Johns Hopkins Applied Physics Lab (ESSENCE
  developer) www.jhuapl.edu/
• HIMSS HIT Dashboard www.hitdashboard.com/
• HIPAA and decision tool www.hipaa.org and
  www.hhs.gov/ocr/hipaa/decisiontool/
• Health Level 7 www.hl7.org/
• Homeland Security Presidential Directive 21
  www.fas.org/irp/offdocs/nspd/hspd-21.htm
• Mirth project (open source HL7 interface engine)
  www.mirthproject.org/
• Office of the National Coordinator
  www.hhs.gov/healthit/onc/mission/
• PAHPA www.hhs.gov/aspr/conference/pahpa/2007/pahp
  a-progress-report-102907.pdf
• Regenstrief Institute www.regenstrief.org/
• University of Pittsburghs RODS Lab (RODS
  developer) https//www.rods.pitt.edu/site/
• Southwest Center for Advanced Public Health
  Practice (APC) www.texasapc.net
• Tarrant County Public Health www.tarrantcounty.co
  m/eHealth/site/default.asp

98
Post-test
99
Agenda
Topic
Time

• Pre-test 10
• Communities of public health practice overview 25
  
• Biosurveillance fundamentals and best
  practices 25
• Health partnerships applied response
  protocols 30
• Break 15
• Interactive group session 1 15
• Interactive group session 2 15
• Discussion of group sessions / conclusion 20
• Post-test 10

i
Thank you for your attention and participation!