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School-based Syndromic Health Surveillance

Southwest Center for Advanced Public Health Practice

Tarrant County Public Health

Enhanced Influenza Surveillance Proposal

Presented by:Tabatha Powell, MPH

Doctoral StudentDepartment of Epidemiology

University of North Texas Health Sciences CenterSchool of Public Health

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Public health importance Detecting flu outbreaks in schools can facilitate

the development and implementation of timely public health recommendations to prevent the spread of disease to high risk populations

Burden of flu (CDC report) Preparing for pandemic flu (HHS K-12 checklist) Economic impact

– Leads to lost days at work/school– Healthcare costs

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Focusing on youth Common vehicles for transmitting influenza

to other persons in their households,

– high-risk groups (e.g., the elderly, young children, and immuno-compromised individuals)

Children biologically more susceptible; naïve immune systems

Highest rates of infection; serious illness and death in children < 2 y.o.

Environment in which children interact daily is conducive to close contact and increased transmission

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Importance of ILI data Necessary to distinguish increased absences due to

other causes; to detect underlying causes of outbreaks

Total absenteeism is not necessarily an appropriate proxy or early indicator for flu outbreaks

Provides public health with information it can use to focus its limited resources more appropriately

More precisely characterize flu and its community impact and help public health leaders marshal limited resources to control its spread

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Project goals

Short-term Process Outcomes Support early detection of flu

through development of a school-based health surveillance system

Enhance information exchange by developing an online venue (i.e. communication portal)

Strengthen the quality of surveillance data

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Project goals

Long-term Impact Outcomes Focus public health resources in response to

early detection of increased ILI and student absenteeism rates

Slow spread of flu; reduce its magnitude and impact

Serve as a model for expansion with similar initiatives in Texas

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Surveillance enhancements Reporting method Timeliness of data Data specifications Communication tools Public health response

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System overviewProgram parameter: Current method: New method:

Reporting frequency Weekly Daily

Reporting entity School district Individual schools

Reporting method to TCPH

Fax, with some via e-mail

Web-based upload of report form

Data analysis by TCPH Manual (via Excel & SPSS)

Automatic and extended in ESSENCE

Reporting to schools Manual process in which influenza activity reports are sent weekly via e-mail; additional e-mail or phone calls are placed as needed

Automatic and extensive via access to ESSENCE, with online postings of influenza activity reports weekly and with additional reports provided online or via e-mail or phone when warranted

Tools provided to schools

Limited to fact sheets and reports issued as needed

Adds access to school nurse view of the ESSENCE system and new, valuable resources in a comprehensive campaign

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Proposal Tarrant County

– Continue recruitment of public schools

– Recruit school-based health centers

– Recruit child care centers

– Lab enhancements

Dallas– Recruit schools

Denton– Recruit schools

– GIS component

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Participation Tarrant County

– More than 500 schools in 16 districts*– Seven ISDs participated (by end of May 2008)

• > 100 schools (February)

• 100 school nurses (February)

– Nearly 100 private schools• One school participated

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Each school district has its own “home page.” Though content is typically the same, it’s easy to customize it when desired or necessary.

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The report form is the “landing page’ users see after they log in.

Users have said they can complete this form in five minutes or less.

Some fields are pre-filled for ease of completion.

The CDC definition of ILI is given.

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Evaluation of pilot year Used CDC’s Framework for

Program Evaluation and Updated Guidelines for Evaluating Surveillance Systems– Logic model– Evaluation matrix

Developed by UNT HSC SPH graduate students Methodology

– Conducted key informant interviews– Administered survey to school nurses– Focused on measuring system inputs and outputs to assess

progress towards meeting process objectives

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Logic model

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Reporting trends in ILI data

Supplemental data: % of reporting by nurses

Faculty absences December February

All causes 70 71

ILI 51 60

Percentage of nurses reporting

Student Absences December January/February

April/May

Total ILI 60 60 35

ILI students seen in office 87 95 80

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Popularity of system resources Potential users interested in resources Current users view resources at a frequency

less than expected as a result of time constraints

Popularity of system resources, by views for February

Page No. of views

Share your school’s health data 3,000

Flu and ILI maps 270

Flu prevention resource page 90

ISD specific pages 74

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Public health response Absenteeism and ILI data used as supplemental data

stream to other surveillance data, including – chief complaint data from hospital EDs

– SPSN participating physician practices

– Laboratory findings

Identified 'hot zones' – Where increasing levels of absenteeism, ILI, and patients

presenting with ILI to ED and local physicians

Targeted testing of patients exhibiting ILI in 'hot zones

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Focusing resources Anticipated more effective use of antivirals

– Ability for identification of cases earlier in the course of illness to meet recommendations for use as prophy in the first 24-48 hrs following onset

Promote vaccination to prevent and reduce likelihood and magnitude of future epidemics

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Replicability Affordable

– Royalty-free, open-source portal platform (DotNetNuke)

Not time intensive to maintain Some IT knowledge necessary

– Training resources for DNN

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Next steps Revisions to report form

– Enhance functionality

Flow data into ESSENCE Include attendance clerks Develop media campaign

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Future directions ACIP recognizes the importance of this age

group in the spread of flu by recommending universal vaccination children 6mos-18yrs

Potential to be used in outbreak settings due to system’s flexibility

Move towards standardization of flu surveillance data for comparison across jurisdictions

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Contact information:Tabatha Powell, MPH : tpowell@hsc.unt.edu Dean Lampman, MBA: dflampman@tarrantcounty.com

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ReferencesReferences Peterson, D et al. An effective school-based influenza surveillance system.

Public Health Reports. 1979 Jan-Feb; 94(1): 88-92.

Lenaway, D. and A. Ambler. Evaluation of a School-Based Influenza Surveillance System. Public Health Reports. May-June 1995;110: 333-337.

Fujii, H. et al. Evaluation of the School Health Surveillance System for Influenza, Tokyo, 1999-200. Japanese Journal of Infectious Disease. 2002; 54: 97-98.

Principi, N. et al. Burden of Influenza in Healthy Children and their Households. Arch. Dis. Child. 2004;89:1002-1007.

Besculides, M. et al. Evaluation of School Absenteeism Data for Early Outbreak Detection, New York City. BMC Public Health. 2005; 5: 105.

Viboud, C. et al. Br J Gen Pract. Risk Factors of Influenza Transmission in Households. 2004 Sep; 54(506): 684-9.