# Presentation: 657662

## COCA Conference Call:Disaster SurveillanceDec. 18, 2007

**	****Continuing Education Credits DISCLAIMER:****In compliance with continuing education requirements, all presenters must disclose any financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use. ****CDC, our planners, and the presenters for this seminar do not have financial or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or product under investigational use.**** **

## Disaster Surveillance 

**Amy Wolkin**
- Centers for Disease Control and Prevention
- National Center for Environmental Health
**Rebecca Noe****  **
- Centers for Disease Control and Prevention
- National Center for Infectious Disease

## Presentation Overview

**Disaster surveillance**
**Hurricane Katrina**
**- Public Health Response**
**- Morbidity Surveillance Activities**
**CDC’s Disaster Surveillance Workgroup (DSWG)**
**- Inception**
**- Work to Date / Accomplishments**
**- Future Activities**

## Objectives

**Review potential public health impacts of a natural disaster and describe disaster surveillance. **
**Discuss challenges in disaster surveillance and describe data sources and critical data elements needed in disaster surveillance. **
**Describe the Centers for Disease Control and Prevention’s agency role in a natural disaster and their methods for coordinating federal, state, and local disaster activities. **

## What is a disaster?

**Disaster: a serious disruption of the functioning of society, causing widespread human, material or environmental losses, that exceeds the local capacity to respond, and calls for external assistance **
**	****	****	****	****	****UN DHA, WHO, Gunn**

## “...disasters are defined by what they do to people, otherwise they are simply interesting geological or meteorological phenomena.” – Eric Noji

**Disasters from a Public Health Perspective**

## Why are disasters a public health problem?

- Unexpected number of deaths, injuries and illnesses that exceed available health resources
- May destroy local health infrastructure and emergency response capabilities
- May cause adverse effects to the environment
- May cause large populations to move

## Disaster Epidemiology

**Disaster epidemiology is the use of epidemiology to assess the short- and long-term adverse health effects of disasters and to predict consequences of future disasters. **
**Surveillance is a disaster epidemiology tool**

## Surveillance

**Public Health Definition: ****“The ongoing, systematic collection, analysis, interpretation, and dissemination of data about a health-related event for use in public health action to reduce morbidity and mortality and to improve health.”**

## Importance of Active Surveillance During a Disaster

**Supplement regular reporting mechanisms**
**Rapidly detect outbreaks  and define health problems**
**Identify groups at risks for adverse health events**
**Determine needs of special populations **

## Importance of Active Surveillance During a Disaster (2)

**Optimize the relief response**
**Monitor the effectiveness of the relief effort**
**Respond to public concerns and media inquiries**
**Facilitate planning for future disasters**

**Hurricane Katrina, 2005**

## Human Impact of Katrina  

-   **Total 1,464**** ****fatalities in New Orleans (NO)**
** ****> 1 million people evacuated**
**- ~ 800,000 people displaced**
**- ~ 300,000 in evacuation centers**
** ****~ 100,000 people remained **
**- Civil unrest**
**- Health hazards**
**- Infrastructure failure**

- Source: Louisiana Department of Health and Hospitals, Hurricane Katrina, Deceased Reports
- Source: The Federal Response to Hurricane Katrina, Lessons Learned, February 2006

## Federal Public Health Response

**National Disaster Medical System**
**Disaster Medical Assistance Teams (DMATS)**
** ****Provide patient medical care**
** ****6000 persons deployed in 102 teams **
** ****> 165,000 patients treated**** **

## Federal Response (2)

** ****American Red Cross (ARC)**
**- Provide shelter, food, health, mental health services**
**- > 200,000 “Volunteers” staffed 1,200 evacuation   ****	****centers in 30 States**
-  **Health and Human Services (HHS)**
**- Provide medical, epidemiology/surveillance teams**
**- USPHS, CDC including EISOs, other agencies**

## CDC Morbidity Surveillance during Katrina

** ****Data reported by 12 states, regularly by Gulf states**
** ****Data sources **
**	****- Healthcare Facilities (HCF) ****include****	****    ****	**** ****	****  hospitals, emergency departments, clinics, DMATs, and ****	****	****  military treatment units.**
**	****- Evacuation Centers (EC) **
** ****Partners : Health Departments, ARC, DMATS,  **
**  ****USPHS**

## Enhanced Surveillance in New Orleans

**Healthcare Facilities (HCF)**
**Individual Morbidity Form**** **
**- 30 illness disease syndromes**
**- 4 mental health conditions**
**- 15 injury trauma conditions with detailed etiology**
**- Medication refills**
**- Severity and disposition**

## Healthcare Facility (HCF) Daily Surveillance 

-  **Forms collected from HCFs or completed by EISO at HCF**
**Labor Intensive**
**- 8 hospitals**
**- 6 DMATS**
**- 5 Clinics**
**- 10 military facilities**
**- Paper Form ******** EpiInfo**
** ****Incidence of syndromes reported to LDHH and CDC**
**Transitioned to automated syndromic surveillance**

## Results - Health Care Facilities 6 Weeks after Katrina 

| Condition/Symptom | % |
| --- | --- |
| Infectious diseases - diarrhea, ARI, wounds | 18 |
| Injuries- MVC, trauma, falls | 26 |
| Chronic disease conditions and medication refills | 32 |

**~ 25,000 case report forms**

## CDC Surveillance Among Katrina Evacuees in Louisiana

**Evacuation Centers (EC) **
**~ 500 established in Louisiana**
**Modified CDC aggregate surveillance form**
**- 9 illness disease syndromes**
**- 3 mental health conditions**
**- 5 environmental/trauma conditions**
**Data Analysis **
**	****- Incidence of syndromes monitored daily **

## Results – Evacuation Centers 6 Weeks after Katrina

| Condition/Symptom | % |
| --- | --- |
| Acute/infectious including ILI, Rash  | 69% |
| Chronic conditions | 31% |
| Surveillance coverage - EC population | 33% |

**~ ****3,000 aggregate surveillance forms**

**No significant outbreaks detected**

**~ 40,000 patient visits**

## Other Katrina Evacuee Surveillance Systems which Regularly Reported to CDC

**Arkansas, Mississippi, and Texas **
**Data sources**
**	****- Number of HCF reporting fluxed from 5-21**
**	****- Number of EC reporting fluxed from 2-76**
**Data reported varied**
**	****- Numerator: 3 vs. 1 GI condition                                         **
**	****- Denominator:  # Patient visits and # Evacuees/facility**
**       **

## Integrate surveillance data 
Number and specificity of conditions under surveillance
Location of surveillance 
Population under surveillance
Forms used for data collection

**Integrate surveillance data **
**Number and specificity of conditions under surveillance**
**Location of surveillance **
**Population under surveillance**
**Forms used for data collection**

**Daily Rate of Diarrhea or Vomiting**

**% Cases of Watery Diarrhea **

## Lessons Learned

**Surveillance provided valuable information**
**	****- No significant outbreaks detected**
**	****- Defused rumors**
**	****- Measured burden of chronic conditions**
**However**
**No “standardized” forms available**
**No “standardized” denominator **

## Lessons Learned (2)

**Time-intensive data collection and entry**
**Different health care settings wanted different reports**
**Federal, State, and local partnerships needed to coordinate surveillance activities **
*****Establish prior to landfall***

## CDC Disaster Surveillance Workgroup (DSWG)

**Inception and early work**

## Why Establish a CDC DSWG?

**Different Data Sources and Elements**

**Data Collection Methods**

**Data Analysis**

**Why Establish a CDC DSWG?**

- Lack of Standardization

**Data Interpretation**

## Why Does CDC Need Standardized Data?

**In collaboration with States, provide national picture to**
**Target deployments**
**Prevent and control outbreaks**
**Reassure the public/politicians**
**Monitor effectiveness of relief activities**

## DSWG Goals

**Provide technical resources to partners**
**- Identify critical post-hurricane health outcomes and standardized data collection tools**
**- Facilitate data management, and rapid processing, and reporting of surveillance information **
**Expand use of disaster surveillance tools **
**Distribute tools to increase use to encourage that multi-setting, multi-jurisdictional information is comparable**
**Evaluate tools and guidelines to improve situational awareness and response activities**

## Inception of the DSWG

**NCIPC**
**	****- Unintentional**
**	****- Violence**
**	****- Mental Health**

**Chronic **
**	****- Disaster WG**
**	****- Reproductive**
**       ****Health**

**NIOSH**
**  ****- Injury**
**  ****- Illness**

**NCEH and NCID**

**Federal and State **
**Partners**

## DSWG Early Work

**Evaluated previous disaster surveillance efforts**
**Determined critical data needs**
**Facilitated revisions of morbidity forms**
**Process**
**Cross-CIO “after action” meetings**
**Bi-monthly DSWG meetings for ~ 6 month period**
**“****Homework” between meetings—completed by individual DSWG members from NCIPC, Mental Health, Chronic, NIOSH, NCID, CEFO/States**

## DSWG Accomplishments  

**Completed revisions of forms **
**- Input from CIOs and SE States**
**- Revised data elements**
**- “Standardized” surveillance forms**
**Revised ARC - ****Health Services Shelter Morbidity Report Form**
**Initiated NDMS collaborations **
**Awarded internal CDC funding**

## CDC Revised Individual Surveillance Form

**Patient-level data**
**	****- Infectious and non-**
**	****   ****infectious conditions**
**Clinical care settings (e.g. ERs, DMATs)**
**Adequate resources**
**Need detailed data**

## CDC Revised Aggregate Surveillance Form

**Facility-level data**
**	****- ****Infectious conditions**
**	****- Beds/Staff available**
**Evacuation centers or shelters**
**Few resources**

## DSWG Forms Instructions

**Complete in triage or emergency room**
**Data collection by health professional-provider, nurse, or medical/nursing student**
**Data Source-patient self-report or medical chart review**
**Form Variables **
**	****- Check off all that apply**
**	****- No hierarchy of syndromes**
**	****- Flexible analysis - build syndromes categories**

## Natural Disaster Individual Clinical Care Form

**Natural Disaster ****Individual**** Clinical Care Form**

## Slide 37

## Slide 38

## Slide 39

## DSWG ActivitiesSummer 2007

**NDMS visit to CDC ****- demo of their electronic medical record (EMR)**
**EMR includes**
**	****	****- Chief complaint = 32 injury, illness, ****	****	****   mental health, chronic syndromes **
**	****	****- These syndromes ****comparable to   ****	**** ****	****   DSWG**** individual form’s data elements **
**Pilot test tools in collaboration GA DPH and CEFO program**

## Pilot Test July/Aug 2007

**Goals**
**Determine sensitivity and specificity**
**Clinical Syndromes**
**Outcome Variables **
**Assess effectiveness of advanced technologies at local level **
**Objectives**
**Validate and evaluate Individual Clinical Form**
**Evaluate and compare data collection technology**
**Paper to Epi-Info **
**Hand-held PDA (RDC)**
**Scannable Forms **

## If a Hurricane hit tomorrow...what would CDC need from clinical responders...

**Recognize clinical data = public health data**
**Use standardized forms (e.g. Individual state’s  form, DSWG, ARC, or NDMS)**
**Know how report any unusual clusters or communicable diseases to PH authorities**
**Provide feedback to improve surveillance efforts**

## DSWGFuture Activities

**No one-size-fits-all approach**
**Choosing a tool **
**Methodological approach**
**What questions need answering**
**What resources are available**
**What information sources exist**
**What is timeframe needed for results**
**What baseline data or systems are available**
**Incorporate wider State involvement**

## Available DSWG-developed Tools

**Natural Disaster Individual Morbidity and Mortality Report Form**
**(available in Spanish) **
- _[http://www.emergency.cdc.gov/disasters/surveillance/](http://www.emergency.cdc.gov/disasters/surveillance/resources.asp)_
- _[resources.asp](http://www.emergency.cdc.gov/disasters/surveillance/resources.asp)_
**Aggregate Morbidity Report Form **
**(available in Spanish)**
- _[http://emergency.cdc.gov/disasters/pdf/Aggregate%20Natural%20Disaster%20Morbidity%20Report%20Form_DSWG1.4.pdf](http://emergency.cdc.gov/disasters/pdf/Aggregate%20Natural%20Disaster%20Morbidity%20Report%20Form_DSWG1.4.pdf)__ _
**Individual Report Form – Rapid Data Collector (PDA,**
**notebook, web), EPI-Info, Scannable**

**Notes:**
Spanish available
Intranet in the works

## For more information on DSWG 

**Email **_[DSWG@cdc.gov](mailto:DSWG@cdc.gov)_** for a DSWG Fact Sheet**
**Email **_[coca@cdc.gov](mailto:coca@cdc.gov)_** with any specific questions**

**Thank you**

## 	
	Continuing Education guidelines require that the attendance of all who participate in COCA Conference Calls be properly documented. ALL Continuing Education credits (CME, CNE, CEU and CHES) for COCA Conference Calls are issued online through the CDC Training & Continuing Education Online system http://www2a.cdc.gov/TCEOnline/. 
	Those who participate in the live COCA Conference Calls and who wish to receive CE credit must complete the online seminar evaluation by January 17, 2008. The course code for live COCA Conference Calls is EC1265. Those who participate in the COCA Conference Calls once they are archived and who wish to receive CE credit must complete the online seminar evaluation by December 18, 2008. The course code for archived COCA Conference Calls is WD1265. CE certificates can be printed from your computer immediately upon completion of your online evaluation. A cumulative transcript of all CDC/ATSDR CE’s obtained through the CDC Training & Continuing Education Online System will be maintained for each user. 

**	****Continuing Education guidelines require that the attendance of all who participate in COCA Conference Calls be properly documented. ALL Continuing Education credits (CME, CNE, CEU and CHES) for COCA Conference Calls are issued online through the CDC Training & Continuing Education Online system **_[http://www2a.cdc.gov/TCEOnline/](http://www2a.cdc.gov/TCEOnline/)__. _
**	****Those who participate in the live COCA Conference Calls and who wish to receive CE credit must complete the online seminar evaluation by January 17, 2008. The course code for live COCA Conference Calls is EC1265. Those who participate in the COCA Conference Calls once they are archived and who wish to receive CE credit must complete the online seminar evaluation by December 18, 2008. The course code for archived COCA Conference Calls is WD1265. CE certificates can be printed from your computer immediately upon completion of your online evaluation. A cumulative transcript of all CDC/ATSDR CE’s obtained through the CDC Training & Continuing Education Online System will be maintained for each user.**** **

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