Creation of a Multifunctional Database to Aid in Pertussis Outbreak Management Shoana M. Anderson, MPH Office of Infectious Disease Services Arizona Department of Health Services The goal of this presentation is to provide an overview of a database which was created to assist our local health department with a school-based pertussis outbreak. The presentation will proceed as follows: Purpose of the database Background information on case investigation and treatment methods Screen shots of the database Highlights/Positives of the database Considerations/Problems of the database Summary

Office of Infectious Disease Services Purpose To assist county with management of cases To create one-click epidemiologic reports to assist in outbreak analyses Provided integration and organization of multiple sources of information This database was created to assist the county with outbreak investigation and epidemiological analysis of a school-based pertussis outbreak Office of Infectious Disease Services

Flow of Cases and Data Physicians Schools Yavapai County Health Dept State Health Dept CDC Labs Public Cases checked against CDC case definitions Cases reported to CDC via NETSS Majority of NP Swabs Case investigations Case treatment and contact prophylaxis Daily data entry Individual with cough or suspicion of pertussis One important feature of this outbreak is that almost all cases were seen at the county health department. This assisted in the following ways: Initial interviews were conducted at the time of the first swab. Often cases and contacts were recommended for treatment/prophylaxis at this time, limiting the amount of follow-up Almost all data was generated at the county health department; therefore cases could be entered into the database in a timely fashion, typically within 24 hours Assessing scope of the outbreak. Since nearly all coughing patients were sent to the county health department, daily visits provided the relative presence of pertussis/coughing-illness in the community. Office of Infectious Disease Services

Integration of Case Classification and Treatment Protocols Suspect: Cough and an association with an outbreak school Possible: 7 days of cough; OR Cough of any length and apnea/paroxysm/PT vomit Probable: 14 days of cough ONLY (not lab-confirmed or epi-linked) These are the classifications which were used by the county and include a combination of treatment/prophylaxis definitions and case definitions used to count cases. The county did adopt an outbreak clinical case definition of two weeks of cough, in addition to deciding to epi-link cases to outbreak schools. Suspect and Possible cases were identified to monitor potential cases and to provide a protocol for treatment. An individual with any length of cough and an association to Confirmed: 14 days of cough and epi-linked to a case; OR Culture and/or PCR positive for B. pertussis Office of Infectious Disease Services

Case Investigation and Treatment Protocols Initial Interview (Treatment of Cases) Case Status NP Swab Treatment of cases Suspect Possible Probable Confirmed Initial 7-day Interview (Prophylaxis of Contacts) Prophylaxis of contacts Treatment of cases (if not done) NP Swab (if not done) Possible Ruled-Out Suspect These are the classifications which were used by the county and include a combination of treatment/prophylaxis definitions and case definitions used to count cases. These definitions were used to guide the case management process, in combination with the two following rules: No swabs taken after 14 d of cough No one was treated after 21 d of cough Therefore a 7-day interview was established to ensure treatment/prophylaxis of highly suspect cases and contacts, who were not treated/prophylaxed during the initial interview. The final interview was conducted at 14+ days mainly for case counting purposes, but also to monitor for diseases in contacts. 14-day Interview (Case Classification) Probable Confirmed Ruled-Out Possible Case Classification Office of Infectious Disease Services

Office of Infectious Disease Services Database Overview This is the main screen of the database. The database is divided into three sections encompassing: data entry, management of cases, and epidemiology. Office of Infectious Disease Services

Office of Infectious Disease Services Case Management Case Management: Main Screen This portion of the database was created to assist the county health staff with individual case investigation and management of outbreak sites. We will view sample reports from this section in the following slides. Office of Infectious Disease Services

Office of Infectious Disease Services Case Management Interview Call List NOTE: Dummy Data are used for all variables shown throughout the presentation. The interview call lists were generated daily to provide counties with a list of individuals who were eligible for either 7-day or final interviews. These call lists were generated based on the interview methodologies described previously. Office of Infectious Disease Services

Cases by School/Work Location Case Management Cases by School/Work Location Report of Cases by School/Site Provides enhanced visualization of the number, types, and names of cases associated with various outbreak sites and assisted with evaluations of outbreak sites. Specific schools/locations could be selected and viewed. Partial names of schools would be accepted. Office of Infectious Disease Services

List of Contacts by Case Case Management List of Contacts by Case List of Contacts for Each Case Allows for rapid visualization of all contacts associated with a particular case. Specific cases could be selected or all cases and contacts could be viewed. Office of Infectious Disease Services

Office of Infectious Disease Services Main Screen I briefly would like to return to the Main Screen. We just completed a brief overview of the Case Management section and will now view the Epidemiology portion of the database. Office of Infectious Disease Services

Office of Infectious Disease Services Epidemiology Epidemiology: Main Screen The epidemiology section is divided into to groups: line lists and cross-tabulation tables. First, I will give an overview of the different line lists available in the database followed by examples of line list reports. Office of Infectious Disease Services

Office of Infectious Disease Services Line Lists Line List: Main Screen Access to the multiple line lists available in the database which include alphabetical lists, as well as lists by case status and lab results. The following are examples of a couple of line lists. Office of Infectious Disease Services

Office of Infectious Disease Services Line Lists Line List, Detail Detailed Line List Alphabetical line list containing detailed information for each case in the database Office of Infectious Disease Services

Line List, Culture Positive Line Lists Line List, Culture Positive List of Culture Positive Cases Provides an alphabetical line list of all culture confirmed cases Office of Infectious Disease Services

Office of Infectious Disease Services Epidemiology Now we will view some of the tables and epidemiological reports available in the database Office of Infectious Disease Services

Case Totals by Classification Epidemiology Case Totals by Classification Case Totals by Classification Provides an up-to-date report on the number of cases occurring in the outbreak for each case classification Office of Infectious Disease Services

Cases by Onset Date (Epi-Curve) Epidemiology Cases by Onset Date (Epi-Curve) Cases by Onset Date Generates the tables need to create epi-curves/graphs of cases by onset date. Data is automatically exported to an excel file for graphing. The following graphs are examples of data that can be easily generated using this report. Office of Infectious Disease Services

Epi-Curve Epidemiology Pertussis Cases and Pending Investigations The inclusion of suspect and ruled-out cases facilities additional analyses of the data. These assist in defining the scope of the outbreak, allocating resources, and organizing staff. These graphs demonstrate the different types of epi-curves which can be generated using the database. The first graph includes cases of pertussis, only; due to the two week delay in case counting, epi-curves of cases typically lag behind the actual spread. Inclusion of non-cases allows county health staff to assess the current breadth of the outbreak. Office of Infectious Disease Services

Office of Infectious Disease Services Epidemiology Cases by Site Table: Cases by Site It is also possible to generate tables of case classification by school or work/site, which allows county official to further track and monitor the outbreak. Office of Infectious Disease Services

Office of Infectious Disease Services Highlights Daily call lists for management of cases Reports displaying epidemiology of the outbreak Menu-driven database for ease of use and data entry Drop down menus to prevent data entry errors Ability to monitor suspect and ruled-out cases, which further describe the scope of the outbreak The major highlights of the database include: -Call lists to enhance case investigations -Access to rapid, standard epidemiologic reports to monitor the outbreak -Inclusion of all classification types including suspect and ruled-out facilitated visualization of the outbreak and staffing needs In addition, the ease of use resulted in less training needs for the majority of county users Office of Infectious Disease Services

Office of Infectious Disease Services Limitations Need for daily data management Miscoded data may affect case management and epidemiologic reports Delays in data entry will affect case management and epidemiologic reports Requires double entry Symptomatic contacts entered into case database Cases must be entered into NETSS Strong understanding of data needs prior to establishing reports Requires at least one individual with strong knowledge of MS Access to manage data, create new reports, and update drop-down menus. Due to the design limitations of the database, dual entry is required for both contacts who later develop symptoms and cases to be entered into NETSS (the state/national surveillance system). The structure and intended use of the database resulted in fairly rigid reports which were not easily changed. Therefore, a strong understanding and agreement of report needs should be established prior to report generation. Office of Infectious Disease Services

Office of Infectious Disease Services Summary Useful database for assisting local health departments with epidemiology and case management Particularly useful in counties with less outbreak experience Ability to track suspect and ruled-out cases Need for personnel with database and data management skills to modify database and monitor the data Office of Infectious Disease Services

Office of Infectious Disease Services Acknowledgements Yavapai County Health Department Stephen Everett Spencer Guest Sandra Halldorson Marcia Jacobson Debbie Savoini Brian Supalla Administrative and Nursing staff Centers for Disease Control and Prevention Kris Bisgard Pam Srivastava Rachel Woodruff Gary Sanden Arizona Department of Health Services Andie Denious Susan Goodykoontz Ken Komatsu Cheryl McRill Cindi Snider Office of Infectious Disease Services