1. College Health Surveillance Network James C. Turner, MD Professor of Internal Medicine Executive Director Department of Student Health National Social Norms Institute University of Virginia Sarah Van Orman, MD Executive Director University Health Services University of Wisconsin-Madison Evelyn Wiener, MD Executive Director Student Health Service University of Pennsylvania 1

2. Funded in part by CDC and UVa/NSNI. Established a 19 school (one additional pending) network using EMR uploads of depersonalized (e.g. [MR # X 2.17] / 37.10) data to central server. Each school IRB approval or institutional data sharing agreement. College Health Surveillance Network (CHSN) 2

3. 607,835 currently enrolled students 19 four-year public and private not-for-profits Types of institutions (Research 1 IHE) Census region representation: – Northeast: 6 – South: 7 – Midwest: 4 – West: 2 (3 rd pending IRB) Demographics similar to DOE data on Research 1 IHE’s. Two schools started during spring/summer 2011. College Health Surveillance Network (CHSN) 3

4. Gender CHSN National** **National Cohort of Research 1 IHE’s

5. Age CHSN*National** * Note on Age Variables - 2 IHEs in the Network submit student age data to IPEDS every other year, so age numbers for 2 regions reflect Fall 2009 enrollments rather than Fall 2010. As such, percentages are estimations. ** National Cohort of Research 1 IHE’s

6. Level of Student CHSNNational** **National Cohort of Research 1 IHE’s

7. Ethnicity CHSNNational** **National Cohort of Research 1 IHE’s

8. Preliminary Data Analysis Analyses of ICD9 and CPT codes during this presentation should be considered preliminary. A new school will add 2011 data once IRB approval is received. Data management procedures are evolving as the data base grows-may require reanalysis in the future. 8

9. Epidemiology 2011 (n=468,678 visits) 15 most common categories 1.URI, pharyngitis, other respiratory symptoms - 775 visits / 10,000 enrolled 2.Screenings (STI, Pap Smear, TB, hypertension) 3.Depression 4.Back disorders (back pain, sciatica) 5.Adjustment Reaction 6.General symptoms (fatigue, chronic fatigue, malaise, insomnia, hypersomnia) 7.Menstrual disorders 8.Ear disorders 9.Urinary tract symptoms 10.Eating Disorders 11.Contact dermatitis 12.HPV 13.Conjunctivitis 14.Digestive system Symptoms 15.Vaginitis 9

10. Epidemiology 2011 (n= 182,268 patients) 15 most common categories of patients: 1.URI, pharyngitis, other respiratory symptoms Multivariate analysis: Males to females OR 1.473, (95% CI: 1.422, 1.526) Hawaii/Pacific Islanders to White OR 1.447 (95% CI: 1.232, 1.699) West to Northeast OR 1.889, (95% CI: 1.783, 2.002) South to Northeast OR 0.820, (95% CI: 0.783-0.858) 2.Screenings (STI, Pap Smear, TB, hypertension) 3.General symptoms (fatigue, chronic fatigue, malaise, insomnia, hypersomnia) 4.Ear disorders 5.Menstrual disorders 6.Urinary tract symptoms 7.Contact dermatitis 8.Back disorders (back pain, sciatica) 9.Conjunctivitis 10.Digestive system symptoms (nausea, vomiting, heartburn) 11.Depression 12.Vaginitis 13.HPV 14.Gastritis 15.Adjustment disorder 10

11. Epidemiology 2011 Visits per Patient by DX 1.Eating Disorders5.57 2.Depression2.68 3.Adjustment Disorder2.56 4.Back Disorder1.98 5.HPV1.74 6.Anxiety Disorder1.47 7.Respiratory Disorder1.39 8.Menstrual Disorder1.29 9.Ear Disorder1.24 10.General Symptoms1.24 11

12. Epidemiology 2011 Mental health visits individuals (n=468,678) (n=182,268) 1.Depression 16,289 6,257 2.Eating disorders10,700 2,015 3.Anxiety 5,937 3,331 4.Alcohol 4,412 846 12

13. * Includes ICD-9 codes: Depression, major, full remission - 296.26 Depression, major, mild - 296.21 Depression, major, moderate - 296.22 Depression, major, partial remission - 296.25 Depression, major, severe - 296.23 DEPRESSION, not elsewhere classified - 311 Depressive disorder, major, recurrent episode - 296.3 Depressive disorder, Major, single episode - 296.2 13

14. Influenza 1/1/11-3/31/12 14

15. Epidemiology 2011 (n=182,268) Diagnoses of interest ( individuals ): 1.HPV 4,788 2.Mononucleosis 2,183 3.Strep Throat 1,590 4.Genital Herpes Simplex 477 5.HIV (AIDS or + test) 43 6.Mumps 5 7.Meningococcal 2 8.Measles 0 15

16. Epidemiology 2011 (n=182,268) Diagnoses of interest ( individuals ): 1.Concussion 997 2.DM 701 3.HTN 1.All ages 1360 2.<25 360 3.25-40 832 4.Obesity/Overweight 1105 16

17. UTILIZATION OF HEALTH SERVICES 17

18. Methodology January 1, 2011-December 31, 2012 19 Campuses, Medical Services – Week 1-17 607, 835 Students – Week 18-30 121,567 Students – Week 31-53 607, 835 Students 18

19. All E & M codes CHSN-Calculated number of evaluation and management codes per student in population; surrogate for visits. ACHA Benchmarking Study-Visits per enrolled student 19 MedicalPreventiveMental Health CHSN1.70.10.39 ACHA-Overall1.3------0.37 ACHA-Public1.1------0.24 ACHA-Private1.7------0.58

20. Epidemiology 20 Sept., 2011-Dec., 2011Jan., 2011-Dec., 2011 Acute Injury Rate per 10,000848/10,0002602/10,000 Percent of Population with at least one visit 6.9%20.4%

21. Epidemiology 21 Sept., 2011-Dec., 2011Jan., 2011-Dec., 2011 Upper Respiratory and/or Influenza Diagnoses Total Visits47572 Rate per 10,000775/10,000 Percent of Population with at least one visit 6.4%18.8%

22. Gender Sept. 1, 2011-Dec. 31, 2011 Observed “visits”/10,000 Students 22 OverallFemaleMaleRatio (F:M) Medical3512434726191.66:1 Mental Health 84410506241.68:1

23. Ethnicity Sept. 1, 2011-Dec. 31, 2011 Observed “visits”/10,000 Students 23 WhiteAsianHispanicAfrican American Medical2426313823182718 Mental Health 699634461692

24. Vaccinations: Non-influenza 24

25. Influenza Vaccinations 25

26. Vaccinations: Rate per 10,000 *MMR, HPV, DTP, TDaP, Td, HiB, Hep B, Meningococcal, Varicella, Pneumovax, 26

27. Pre-entrance Immunization Data Pilot Project 27 Three schools with pre-entrance immunization data residing in electronic files Pre-entrance immunizations Fall 2010 and Fall 2011 35,043 matriculating students Fall 2010: 19, 956 students 11,923 undergraduates 8,033 graduate/professional students Fall 2010: 15,087 students 9,950undergraduates 5,137 graduate/professional students Separate electronic files in EMR Requires special abstraction programming

28. 28 VACCINE YEAR RELEVANT ACIP RECOMMENDATIONS Hepatitis B2005Routine immunization of all previously unvaccinated adolescents HPV 2007 2012 Routine vaccination of females ages 11 to 26 Routine vaccination of males aged 11 to 12, catch-up for males 13 to 21 MMR1989Recommendation for two-dose schedule MCV-4 2000 2005 2011 Recommendation for MPSV4 vaccine Single dose MCV-4 vaccine Second dose MCV-4 at age 16 Tdap 2005 2010 Single dose of Tdap (interval of at least 5 years from last Td encouraged) Single dose of Tdap when indicated (regardless of interval from last Td) Varicella 1995 2007 One dose for children 1 to 12 yrs old, two doses for persons > 13 yrs old Two doses for all, catch up dose for persons with only one dose as child

29. Vaccine PA requirement post-secondary schools VA requirement post-secondary schools WI requirement post-secondary schools Hepatitis BNo state mandate FT students in 4-year public institutions No state mandate HPVNo state mandate MCV-4 Students in campus housing or written waiver FT students in 4-year public institution or written waiver No state mandate MMRNo state mandate FT students in 4-year public institution No state mandate TdapNo state mandate FT students in 4-year public institution ( Td ) No state mandate VaricellaNo state mandate

30. ALLOWED EXEMPTIONS MEDICAL RELIGIOUSPHILOSOPHICAL TemporaryPermanent PENNSYLVANIA ✔✔✔✔ VIRGINIA ✔✔✔ WISCONISN ✔✔✔✔

31. Vaccination requirements (University of Pennsylvania) VaccineStateUniversity of Pennsylvania Hepatitis BNo state mandate3 doses or (+) immune titers HPVNo state mandateNot required MCV-4 Students in college owned housing or written waiver Required for undergraduates living on campus (or waiver); booster required if 1 st dose < age 16 MMRNo state mandate2 doses or (+) immune titers TdapNo state mandate1 dose VaricellaNo state mandate2 doses or (+) immune titers

32. Vaccination requirements (University of Virginia) Vaccine StateUniversity of Virginia Hepatitis B 3 doses 3 doses or (+) immune titers HPV No state mandate Recommended: Women ages 11-26, men ages 11 -21 MCV-4 1 dose Required or waiver, booster required if 1 st dose < age 16 MMR 2 doses2 doses or (+) immune titers Tdap 1 dose Td Required of health sciences students, recommended others Varicella No state mandate Proof of disease, 2 shots, or (+) immune titers

33. Vaccination requirements (University of Wisconsin) VaccineStateUniversity of Wisconsin Hepatitis BNo state mandateRecommended HPVNo state mandateRecommended MCV-4No state mandateRecommended MMRNo state mandateRecommended TdapNo state mandateRecommended VaricellaNo state mandateRecommended

34. MATRICULATING STUDENTS (2010)MATRICULATING STUDENTS (2011) UNDERGRADUATE GRADUATE/PROFES SIONAL UNDERGRADUATE ENROLLMENT GRADUATE/PROFES SIONAL No.% % % % Total 11923803399505137 Female 644554435754526553264151 Male 547846367646468547249549 Hep B (3 doses) 993583386748865787293757 Hep B (2 doses) 2143263330732735 Hep B (1 dose) 1242224326033918 HPV (women/3 doses) 259440385924334641316 HPV (women/3 doses) 27156622435652 HPV (women/1 dose) 42778924398702 MMR (2 doses) 1010085455157896590351568 MMR (1 dose) 2532438517723357 34

35. MATRICULATING STUDENTS (2010)MATRICULATING STUDENTS (2011) UNDERGRADUATE GRADUATE/PROFES SIONAL UNDERGRADUATE ENROLLMENT GRADUATE/PROFES SIONAL No.% % % % Total 11923803399505137 Female 644554435754526553264151 Male 547846367646468547249549 Hep B (3 doses) 993583386748865787293757 Hep B (2 doses) 2143263330732735 Hep B (1 dose) 1242224326033918 HPV (women/3 doses) 259440385924334641316 HPV (women/3 doses) 27156622435652 HPV (women/1 dose) 42778924398702 MMR (2 doses) 1010085455157896590351568 MMR (1 dose) 2532438517723357 35

36. MATRICULATING STUDENTS (2010)MATRICULATING STUDENTS (2011) UNDERGRADUATE GRADUATE/PROFES SIONAL UNDERGRADUATE ENROLLMENT GRADUATE/PROFES SIONAL No.% % % % Total 11923803399505137 Female 644554435754526553264151 Male 547846367646468547249549 MCV4 (2 doses) 2-2190222-240.5 MCV4 (1 dose) 907576243630586659217842 Tdap 748763253732743476266452 VAR (2 doses) 28042446263337344469 VAR (1 dose) 1000162994952102866 Hep A (2 doses) 3550308931136013684616 Hep A (1 dose) 11941958971001104579 36

37. MATRICULATING STUDENTS (2010)MATRICULATING STUDENTS (2011) UNDERGRADUATE GRADUATE/PROFES SIONAL UNDERGRADUATE ENROLLMENT GRADUATE/PROFES SIONAL No.% % % % Total 11923803399505137 Female 644554435754526553264151 Male 547846367646468547249549 MCV4 (2 doses) 2-2190222-240.5 MCV4 (1 dose) 907576243630586659217842 Tdap 748763253732743476266452 VAR (2 doses) 28042446263337344469 VAR (1 dose) 1000162994952102866 Hep A (2 doses) 3550308931136013684616 Hep A (1 dose) 11941958971001104579 37

38. FACTORS Congruency with guidelines Institutional support Resources Systems – Electronic records – Processes to chase non-compliant students 38

39. Enforcement strategies 39

40. CHALLENGES Part-time students Summer students Dependents Faculty and staff Visitors 40

41. MORE CHALLENGES Religious/philosophical exemptions Dependence on technology Expense Global exposure Currency with updated recommendations State and/or institutional restrictions 41

42. College Health Surveillance Network Challenges to Implementation IRB/data sharing agreements Achieving agreement among health centers about use of codes and provider consistency Differing EMR software among schools Pre-entrance immunization and lab result data exist in separate files Timely uploads of monthly data

43. Meeting the Challenges IRB/data sharing agreements: Templates & proactive monitoring of process Achieving agreement: Active involvement of Medical Directors Differing EMR software: Sharing abstraction programs among schools with same software Pre-entrance data: Abstraction of these data is a new project. Timely uploads: Automated reminder system; regular emails with highlights from data

44. Expand the network to 150-160 schools, 2.5M enrolled students, all ten HHS regions (at least 5 schools per region). Establish sub-population datasets – Pre-entrance electronic immunization records – Laboratory reports – Counseling center reports – Mortality data – Real time reports for syndromic surveillance College Health Surveillance Network Future