1. 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

2. 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

3. 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

4. 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
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5. 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
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6. 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.
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7. 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.
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8. 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

9. 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

10. 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.
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11. 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.
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12. 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.
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13. 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.
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14. 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
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15. 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
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16. Office of Infectious Disease Services
Epidemiology
Now we will view some of the tables and epidemiological reports available in the database
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17. 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
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18. 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

19. 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

20. 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.
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21. 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
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22. 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

23. 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

24. 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