regional epidemiology unit: update - pihoa: pacific island ... · zika in republic of the marshall...

Regional Epidemiology Unit:

UpdatePIHOA Meeting

Majuro, Marshall Islands

March 22, 2015

A Mark Durand [email protected]

Haley Cash [email protected]

W Thane Hancock [email protected]

mailto:[email protected]



362 Possible Cases 14 Lab-confirmed

(6 pregnant)

Zika in American SamoaJan 1 - Mar 2016

0

5

10

15

20 Suspect cases by diagnosis date

Zika in Republic of the Marshall

Islands, 2015-2016

26 Possible Cases2 Lab Confirmed Cases

(1 Pregnant)

Demographic information on patients who visited a Public Hospital for NCD-related diagnosis, FSM, 2013.

= Confirmed Cases (#)

= Possible Cases (lab

pending)

Zika in the USAPI, Key Points:

1) Zika will come to your place

2) Could be subtle and easy to miss when it comes

3) Serious threat to the unborn child

4) Many unknowns:

Why now?

Long term neurological effects (unborn child, infants,

children/adults)

Sexual and other transmission

Performance of lab tests for Zika

Dynamics of outbreaks in small islands

Outline

• Introduction to Surveillance

• Workforce Development

• DDM, SHIP, OR

• Data Collection in the USAPIs

• Selection of Core Indicators

• Plans for Data Collection and Analysis

• Mechanisms for Reporting/Dissemination

• Links to Action

• Summary of Progress

• Future Goals and Plans

Public Health Surveillance

• The regular and systematic collection, analysis, and

interpretation of health-related data with timely

dissemination for the planning, implementation, and

evaluation of public health practice.

Note: Same process applies to other routine reporting

Derived from: World Health Organization. (April 2015). WHO | Public health

surveillance. Retrieved April 27, 2015.

http://www.who.int/topics/public_health_surveillance/en/. And Centers for Disease

Control. Comprehensive Plan for Epidemiologic Surveillance. Atlanta: US

Department of Health and Human Services, Public Health Service; 1986

Identify health

problem(s)

Collect / Compile

Data

Analyze / Interpret

DataReport /

Disseminate Data

Monitor / Evaluate

System

So it can be

used for

decision-

making!

Regular &

Systematic

Purpose of Surveillance

Communicable

Diseases

NCDs

Timely

Response

Monitor

Trends and

Evaluate

Surveillance of Health Information

• Public Health Surveillance Systems

• no single data-collection or research

method can provide the broad range of

information required by countries

• utilize several different data sources

• create a complete picture using multiple

lenses

Key Products for Surveillance

DATA

Reporting

Template

Think about

standardized

frameworks and what

you really need/want

How to collect what

data, how often,

and who is going to

do it

Effectively present data

you’ve collected to

inform and evaluate

ACTION

Surveillance

Plan

Workforce Development

A good surveillance systems are dependent

upon staff who can:

• Operate existing, well-designed data systems

• Assure good quality data inputs

• Use Excel and EpiInfo

• Produce standard, high quality reports

• Understand and can explain reports

DDM & SHIP*

*DDM= Data for Decision Making

(program for making certified Epi-technicians)

*SHIP= Strengthening Health Interventions in the Pacific

(full program to applied epidemiologist fellowship --

masters degree level)

Certificate

(Epi-tech)

Diploma

(Senior

Epi-tech)

Masters

(Field

Epidemiologi

st)

DDM803: Outbreak

Surveillance and

Response

DDM802:

Public

Health

Surveillance

DDM804:

Surveillance

or research

project

DDM801:

Basic

epidemiolog

y and data

analysis

DDM805:

Intermediate

epidemiolog

y and data

analysis

OR 3:

Paper

writing

OR 2:

Data

cleaning

and

analysis

OR 1:

Protocol

Writing

+/-

Optional

thematic

modules

Teaching

DDM

Four

studies/

projects

In-country

residency -

knowledge

transfer,

active

engagement

“From work, at work, for work”

Training delivered to build both systems & skills

Epi Technicians

• Operate existing, well-designed data systems

• Assure good quality data inputs

• Use Excel and EpiInfo

• Produce standard, high quality reports

• Understand and can explain reports

(Cannot design health information systems analyze complex data)

Partners:

Pacific Islands Health Officers Association

Fiji National University

RAPID Project of Hunter New England Health District, Australia

Secretariat of the Pacific Community

University of Guam

World Health Organization

US Centers for Disease Control & Prevention

ASTHO

DDM Independent Project Highlights

• NCD Monitoring and Surveillance Plans

• CD Standard Operating Procedures (SOPs)

• NCD Annual data dashboard template

• CD weekly report template

• Compact indicator SOPs

• Compact indicator annual data dashboard

• Program-specific SOPs for patient tracking

• High-quality annual profiles (e.g. NCD, food safety, Leprosy)

• Hospital and outpatient encounter database reports


DATA

Reporting

TemplateSurveillance

Plan


DATA

So, what should we be collecting?

Core Indicators

NCD Data Collection• Adult Surveillance

• BRFSS, STEPS, Community Health Assessment Surveys

• Cancer registry

• Various SAMHSA NOMs surveys

• Clinical Indicators • Vary by jurisdiction

• Usually reliant on CDEMS software or EMRs

• CDEMS limited to small fraction of NCD care. EHRs not yet adapted to monitor care

• Youth Surveillance• YRBS, GYTS

• Rapid youth survey in Pohnpei and Kosrae in 2015

• Vital Statistics • Ideally, all births and deaths would be certified

• Issues with underlying COD codes, inconsistent reporting

• Missing data (outlying islands)

• Recent SPC workshop to develop state and national vital statistics reports

Purpose of Surveillance

Communicable

Diseases

NCDs

Timely

Response

Monitor

Trends and

Evaluate

Core Indicator Scorecard

USAPI

NCD

Core

Surveillance

Indicators

Tobacco Alcohol ↑BMI Diseases

(adult)

Deaths

(30-69 years)

Cig

s-

yo

uth

Cig

s-

adult

Ch

ew

-Y

ou

th

Ch

ew

-adult

Yo

uth

Ad

ult

Yo

uth

Adult

HT

N

DM

↑Cholesterol

All

Cause

Ca

rdio

va

scu

l

ar

Ca

nce

r

Dia

be

tes

Ch

ron

ic

Lung

Am Samoa ↓ N ↓ ↑ N N N N N

CNMI ↓ N ↓ N ↓ N ↑ ↑ ↑ N ↓

Chuuk

Kosrae

Pohnpei

Yap N N N N N ↓ N ↓ N

Guam ↓ ↓ ↑ N ↓ N N N N N N ↑ N ↑ ↑ ↑

Palau ↑ N ↓ N ↓ N N N ↑ ↑ ↑ N N

RMI ↑ ↓ ↑ ↓ N

How can we fill in our surveillance gaps?

CNMI NCD Hybrid Survey

• Tobacco, alcohol, NOMs

• Betel nut, e-cigarettes

• Nutrition

• F&V, sugary drinks, processed meats

• Physical activity

• Oral Health

• Cancer Screening

• Health care

• Measurements

• BMI, BP, glucose, cholesterol

Benefits to this survey

• Ongoing adult surveillance

• Using local resources

• Building local capacity

• Data ownership

• Quality data collection- customization

• Breaking down the silos

• Serve as a model for other Pacific jurisdictions

FSM Rapid High School Survey

• Conducted in Pohnpei and Kosrae this fall

• All high school students included

• Run by local State Health Departments

• Indicators included:

• Tobacco smoking and chewing (30 day use)

• Betel Nut (30 day use)

• Alcohol (30 day use)

• BMI (measured)

• School name, classroom, grade, gender, age


DATA

Reporting


Plan


Surveillance

Plan

Children

(2-8yrs)

Youth

(11-18yrs)

Adults

(18yrs+)

Mortality

(30-69yrs)

Clinical Services

Policy Uptake

CHL Survey

Every 2 years

YRBS

Every 2 years

Adult Hybrid Survey

Every 5 years

Epidemiology Unit- Death

certs w/ NCHS codes

Yearly (rolling 5 yr avg)

EHRs

Yearly

NCD Coalition, yearly

• Overweight/Obesity

• Vegetable intake


• 30 day tobacco use

• Overweight/obesity

• 30 alcohol use


• Current tobacco use

• Overweight/obesity

• Binge drinking

• NCD prevalence:

• Hypertension (by BP)

• Diabetes (by blood sugar)

• High cholesterol (by blood cholesterol)

• Premature adult mortality (30-69yrs)

• Cardiovascular disease mortality (30-69yrs)

• Diabetes mortality (30-69yrs)

• Cancer mortality (30-69yrs)

• Chronic lung disease mortality (30-69yrs)

• % hypertensive patients w/ controlled BP

• % diabetic patients w/ controlled blood sugar

• % Early renal failure patients w/ case

management and guildeline directed care

• % RHD patients w/ clinical evaluations

15 Core Policies (PIHOA)

Category Indicators Source/Frequency

*last conducted in 2004

*needs to be analyzed

*needs to be analyzed

Physician- Charts in medical record- Completes diagnosis

section in PEF- Completes Confidential

Morbidity Report on PEF if indicated

ER or Outpatient Department- Paper Medical Record

initiated/retrieved- Patient Encounter Form

(PEF) generated

Public Health Response- Confirm cases- Establish immediate response

needs- Mobilize immediate response

by:- Epidemiologist- CDU staff- Clinical and PH nurses- DEH staff

Belau National Hospital Lab• In house-test completed• Reference lab results

Lab Order

RDDS Lab Report

AND

Reportable Disease SurveillanceDatabase

Epidemiologist

EpiNet Team

CDU Case Investigation

DEH Case Investigation Remediation

WHO, SPC, CDC


DATA

Reporting


Plan


Reporting

Template

For Further Information Rose Zabala (671)735-7304

References:

1- YRBS, BRFSS, GDOE BMI data, Guam Comprehensive

Wellness Program Employee Interest Survey

2- BRFSS

3- Policies from Guam Legislature

Acknowledgements: NCD Consortium Action Teams

Guam NCD Action Team Status

Guam NCD Consortium

Data & Surveillance Action Team

Measurement Baseline

2011

Current

2013

Change Target

(NCD Plan)

Youth Current Smoking 21.9% 20.2% * 18%

Adult Current Smoking 30.5% 26.5% * 25%

Youth Current Drinking 24.7% 23.5% * 22.2%

Youth Binge Drinking 13.6% 12.7% * 12.2%

Adult Current Drinking 41.8% 40.9% * 37.6%

Adult Binge Drinking 18.3% 20.9% 16.5%

Adult Heavy Drinking 6.8% 7.0% * 6.1%

Adult Participating in 150 Minutes or More of

Aerobic Physical Activity Per Week

48.0% 48.7% * 52.8%

High School Students Not Physically Active at

Least 60 Minutes Per Day on 5 or More Days

62.6% 62.7% * 56.3%

High School Students Not Physically Active at

Least 60 Minutes Per Day on All 7 Days

78.2% 76.5% * 70.4%

Youth Obesity 23.6% 23.2% 21.2%

Adult Obesity 27.4% 27.0% 24.7%

Fruit and Vegetable Consumption 16.2% 21.3% -

NCD Risk Factors, Youth and Adults1

Proposed Policies and Initiatives 3

TOBACCO:

Increase tobacco taxes by 100% by December 2018. In

Progress

To remove all Exception in Tobacco Control Mandate. In

Progress

Establish Tobacco Cessation Resources as part of the Worksite

Wellness Program.

In

Progress

Measurement Baseline

2011

Current

2013

Change

Ever diagnosed with diabetes (adults) 9.9% 14.1%

Ever diagnosed with other types of cancer (adults) 1.8% 2.7% *

Ever diagnosed with a stroke (adults) 3.2% 2.6% *

Ever diagnosed with hypercholesterol (adults) 33.1% 38%

Ever diagnosed with hypertension (adults) 20.8% 29.6%

ALCOHOL:

Responsible Alcohol sales and Services Act. Completed

Increase number of policies and laws that encourage healthy

environmental conditions.

In

Progress

Establishing Standardized protocols for clinicians to conduct

alcohol screening and referrals.

In

Progress

Progress

Getting Better

Getting

Worse

PHYSICAL ACTIVITY:

Improve infrastructure that promotes physical activity In

Progres

s

Increase Physical Education Requirements in Schools In

Progres

s

Implement Worksite Wellness Programs In

Progress

NUTRITION:

Promote initiatives that increase availability of and accessibility to

fruits and vegetables.

In

Progress

Establish local public/private partnerships to initiate interventions

to reduce salt intake.

In

Progress

Establish policies that promote breastfeeding. In

Progres

sDiabetes, Cancer, Stroke, Hypercholesterol, Hypertension 2

* Use caution when interpreting

the change as it may not be

statistically significant. Produced by:

Paulino, Y., PhD., Paulino, H., Uncangco, A., Rosadino, G.Note: This is a summary based on the 2015 Data

and Surveillance Highlights (DASH)

Link to Action

15 NCD

Policies

Environment

Youth Risks

- Tobacco

- Alcohol

- Obesity

Adult Risks

- Tobacco

- Alcohol

- Obesity

Diseases:

CVD

Cancer

DiabetesCOPD(HTN)(Lipids)

Deaths

- COPD

-Heart+Stroke

- Cancer

- Diabetes

Link to Action

USAPI NCD Scorecard

Functional NCD M&S

Plan

NCD Policy

Mapping

Done

Good quality

annual NCD

profiles

CNMI Partly done Yes No

FSM National Yes No No

Chuuk No No No

Kosrae Yes No No

Pohnpei Yes Yes Yes

Yap Yes Yes Yes

Guam Partly done Yes Yes

Palau Partly done No Yes

RMI Partly done Partly done No

Am Samoa Yes Yes Yes

Functional CD

Surveillance SOPs

Reliable &

High Quality

Weekly CD

reports

Well

organized

EpiNet

outbreak

response

teams

CNMI No No No

FSM National No No Yes

Chuuk No No No

Kosrae No No No

Pohnpei Yes Yes Yes

Yap No No Yes

Guam Yes Yes Yes

Palau Partly done Yes Yes

RMI Partly done Partly done Partly done

Am Samoa Yes Yes Yes

USAPI CD Scorecard

Summary of Progress

• DDM

• 2 courses completed in Pohnpei

• 1 course completed in Kosrae and Yap

• OR courses 1 and 2 complete

• NCD Adult data collection

• CNMI over 50% complete with NCD Hybrid Survey

• Training and data collection in Palau in May

• NCD Youth data collection

• Rapid High School Survey completed in Pohnpei and Kosrae

Use of Electronic Tools

• Kosrae CHC

• Re-design of work flow, forms, data entry screens and job aids to

facilitate delivery of preventive services and to capture performance

indicators

• Pohnpei DHS-CHC

• Pilot Electronic Health Records project

• New Opportunity Available

• Informatics Project for facilitation of preventive services delivery

and capture of performance indicators- health agencies with

existing EHRs

Recent/Ongoing Extension Services

• Post-typhoon response in CNMI

• Zika response in American Samoa

• Zika response in RMI

• Event-based surveillance in Guam for Pacific Arts Festival

• RMI placement of PIHOA staff

• Performance-based budgeting indicators

• Clinical guidelines for NP Training

• Management consultation

• NIH Grant Application (PIHOA/UH/CMI)

Future Goals / Plans• DDM

• Complete DDM in Pohnpei, Yap, and Kosrae by end of 2016

• Begin in American Samoa in May

• Complete OR course in August 2016

• Hybrid Survey

• Begin data collection in Palau in May

• Begin planning in American Samoa

• FSM Rapid High School Survey

• Complete in Chuuk and Yap

• Develop necessary NCD M&S Plans and Annual Data Dashboards

• Strengthen tools and use of tools

• EHRs for monitoring of clinical indicators

• Continued extension services

• Continued assistance with outbreak response

• Consider developing mechanism for annual NCD mortality reporting

Thank you!

• A Mark Durand [email protected]

• Haley Cash [email protected]

• Thane Hancock [email protected]




regional epidemiology unit: update - pihoa: pacific island ... · zika in republic of the marshall...

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