December 17, 2004
Epi Update Managing Staff:
"The reason for collecting, analyzing and disseminating information on a disease is to control that disease. Collection and analysis should not be allowed to consume resources if action does not follow."
Foege WH., International Journal of Epidemiology 1976; 5:29-37
Florida Youth Risk Behavior Survey Results Published
The survey data show that in 2003:
Among the 66 percent of high school students who reported riding a bicycle during the past 12 months, 79 percent never wore a helmet and 8 percent rarely wore a helmet.
Less than half (44 percent) of Florida high school students always wore a seatbelt and 26 percent wore a seatbelt most of the time. The corresponding Healthy People 2010 objective is to increase the use of safety belts to 92 percent.
Thirty percent of high school students rode in a car or other vehicle one or more times during the past 30 days with someone who had been drinking alcohol. The corresponding Healthy People 2010 objective is to reduce to 30 percent the proportion of high school students who report that they rode during the previous 30 days with a driver who had been drinking alcohol.
During the 30 days prior to the survey administration, one in nine (11 percent) high school students drove a car or other vehicle at least one time after they had been drinking alcohol. Male and non-Hispanic White students had higher prevalences of reporting this behavior than their counterparts, and the prevalence of this behavior increased with increasing grade level.
Readers can review detailed information from this report online at the bureau?s Website at http://www.doh.state.fl.us/disease_ctrl/epi/topics/pubs.htm.
Melissa Murray is coordinator of research services within the Chronic Disease Surveillance Section of the Bureau of Epidemiology. She can be reached at 850.245.4444, ext. 2445.
Syndromic Tracking and Reporting System
The Syndromic Tracking and Reporting System (STARS) used by the Pinellas County Health Department was established throughout the county in July 2003. The system was created through grant money received by the Hillsborough County Health Department and the data is maintained on a server in that facility. The program monitors the chief complaints of incoming emergency room patients at 10 out of the 13 county hospitals with the intent of providing the health department with an early warning signal of potential public health threats to the community. The main goal of STARS is to detect non-specific conditions or symptoms in a population that may indicate a naturally occurring or man-made outbreak.
Data entry and reporting goals were set before the implementation of STARS, when LEADERS was still being used. These goals included:
§ Less than 4 hour lapse between patient arrival and data entry time;
§ Less than 2% of records entered in the ?No Box Checked? category;
§ At least 90% of the ER visits entered into the system.
The goal of less than 1% of entries being duplicated was added to the original set when an accurate system for duplicate detection was recognized.
The following graphs display how well Pinellas hospitals fared when it came to meeting the goals set at the beginning of the year. The goal is indicated in red on the graph.
Figure 1 shows that, overall, the hospitals have improved the average report time. These results were compared with the data from the 2002-2003 LEADERS program and it was found that, for the months recorded, the hospitals have improved by over 50%. This is shown in Table 1 below.
Hospital personnel may not check off a box because it is not understood that leaving a form blank does not mean it is in the ?None of the Following? category. Proper training of the hospital personnel who fill out the forms leads to more consistent data reporting. A future goal is to ensure that the hospital staff understand the importance of STARS in the community and recognize the national focus of syndromic surveillance. The total number of entries for each hospital over the past year is shown in Table 2 below. This equals an average of 590 entries per day into the STARS database.
Much of the data for the data entry rate graph is incomplete because one or more hospitals did not report a census number. The Florida Department of Health?s ER census reporting feature in Merlin was introduced to hospital contacts as a way to ensure an accurate and timely census reading each month.
The duplicate entry rate has also remained fairly constant over the past year. Addition of the correction function when entering data has identified some entries that were not duplicates, but corrections. This has reduced the number of duplicates slightly, but the majority of hospitals still do not use this function.
Overall, Pinellas County hospitals have improved from July of 2003 to June of 2004. Maintaining consistency throughout the county is an important factor that is being addressed through quality assurance checks. Every 6 months each hospital has the reporting and data entry portions of their STARS process reviewed for accuracy. The goal for each hospital is to improve its accuracy from the previous QA check. The goal of this QA check is to hold the clinical staff who fill out the forms and the data entry staff who enter the forms accountable for their work.
The STARS program has improved the interagency collaboration between the local health department and area hospitals. One example of this is when three persons presented as a group to a local ER with gastroenteritis symptoms. After the initial workup the physician contacted the health department personnel via phone to inform them of the situation before cultures were completed. This action allowed the health department to begin interviews and public health interventions a few days earlier than if reporting had occurred when test results were in. The physician was aware that the health department was looking for these types of situations because of the STARS forms that are usually filled out.
Another example was an unexplained death with fever at a local hospital that was reported through the STARS program. After a record review the medical examiner was contacted for follow-up on the case. Exposure to a bioterrorism or environmental agent was not suspected and a contagious disease did not cause the death. The health department was able to follow-up on this case in real-time with the medical examiner, instead of waiting for a report to be submitted months later.
There is potential for this type of case to be related to a bioterrorism event, and working with the medical examiner and the hospital decreases the response time. This system is especially beneficial if a health emergency occurs in the county; the STARS system can be used to monitor the current health situation and focus resources where they are most needed.
This early reporting system benefits both the health department and the hospitals. Any trend seen in the data can be reported to all local hospital ICNs and ER managers so they can educate their personnel on safeguarding themselves. For example, an increase in respiratory syndrome cases in the fall could indicate the start of the flu season. An email to local hospitals would encourage staff to receive the flu vaccine to protect them from ill patients.
An increase in the same syndrome in the spring may prompt an email to increase vigilance regarding travel history and patient contacts. These trends may not be noticed on a scale of one hospital, but having the data from 10 hospitals creates a more pronounced trend. Figure 5 shows the number of respiratory syndromes reported for all hospitals.
An increase in respiratory syndrome cases was reported to local hospitals in November 2003. An email was sent to hospital ICNs and ER managers to promote flu vaccination and use of standard precautions. The community can benefit from this surveillance because, armed with this knowledge, the health department and hospitals are able to better serve the citizens of Pinellas County. A higher level of security exists when community members know their hospitals are monitoring their well-being and the health department will investigate an aberration.
The STARS data entry relies on personnel, so there is potential for incorrect entries. For example, there were 68 unexplained deaths reported but only one actual unexplained death. The other 67 reports were all data entry error and each incident required calling the hospital immediately to gather information and verify the report. This takes time for health department staff and hospital personnel.
Another weakness of the system is that not all hospitals in Pinellas County participate in the program. Three hospitals, which constitute a significant portion of the total number of ER visits in the county, do not report in the STARS program. There was a large outbreak in Pinellas County during the reviewed time frame, but since all of the symptomatic patients went to a hospital that does not report, the health department had no advance warning.
There is a fourth hospital that does not report in the STARS program but it is not a public hospital. The area VA Hospital does have emergency care for veterans, but does not receive members of the general population. It is unknown if the addition of these cases would positively impact the outcome from the program since it is a specific demographic.
Future goals of the STARS program include the creation of a hospital satisfaction survey, which will assist health department personnel in identifying areas of the program that may need improvement. A STARS user group meeting was held last year to receive feedback from the participating hospitals and will be scheduled again in the coming year.
Another goal is increasing the number of hospitals reporting from 10 to 13, by including the Morton Plant/ Mease Healthcare hospitals. Several meetings have been attended with Morton Plant/ Mease Healthcare personnel, including personnel from the ER, senior management and information technology. The continuation of this process is important because 100% participation by county hospitals would create a more reliable system with an enhanced picture of the health of the community as a whole.
Finally, implementation of the data bridge system, which would eliminate the paperwork currently required of each hospital, is a goal for the coming year. The Hillsborough County Health Department has received funding through the HRSA grant funding stream and is working with an outside agency to establish this data bridge in STARS hospitals.
While the focus of the STARS program this past year has been the proper implementation of the system in a hospital setting, the focus for the coming year shifts more towards improvement of the system as a whole. The uncertainty of being able to predict a natural or man-made disaster emphasizes the importance of this system. Increasing productivity through comprehensive hospital participation and the data bridge system will provide a tool that can accurately and effectively monitor the health of the community.
Suzanne DeKay is an epidemiologist at the Pinellas County Health Department Office of Public Health Preparedness. She can be reached at 727.824.6900, ext. 11190.
Trust for America's Health Names Florida One
To receive this rating, Florida achieved a passing score in nine out of ten indicators. The scoring was base on ten indicators within three broader categories defined as funding, back to health basics, and all-hazards. The ten indicators were:
The TFAH team consisted of public health experts who created the key indicators as a way of measuring the capabilities, improvements and vulnerabilities of each state as they relate to bioterrorism preparedness. Their report, published just this month, found that nearly 60% of states do not have an adequate number of scientists on hand to test for anthrax or the plague. They also noted that competition for limited resources appears to affect the cooperative relationship between local, state and federal health agencies. In their recommendations, the team listed four areas in which states are encouraged to seek improvement: A requirement for states to demonstrate how federal funds are used for the Bioterrorism Act of 2002; more emphasis on basic health system components; a resolution of liability laws that currently overwhelm the manufacture and approval of vaccines; and greater use of practice drills for bioterrorism events.
In a December 14 press release, Dr. John Agwunobi, secretary of the Florida Department of Health, said, "Although much work remains to be done in Florida...it is encouraging to see how much progress has been made by almost all the states of our nation." After thanking the governor and the legislature for their support, he added, "I pledge to strive for continued enhancements in our response system."
Trust for America's Health is a non-profit organization founded in 2001. Its mission is to protect the health and safety of all communities from current and emerging health threats by strengthening the fundamentals of public health defenses. It receives funding from the Robert Wood Johnson Foundation, the Pew Charitable Trusts and other major donors. To read the entire 72-page report entitled Ready or Not?: Protecting the Public's Health in the Age of Bioterrorism 2004, go to:
Jaime Forth is managing editor of, and a contributing writer to, Epi Update. She can be reached at 850.245.4444, ext. 2004.
Field Investigators Course Set for January 24
The Florida Center for Public Health Preparedness is sponsoring a one-day course entitled Field Investigator Response and Surveillance Training on January 24, 2005 at World Golf Village in St. Augustine.
Continuing education credits will be given for certified health education specialists, nurses and physicians, pharmacists, psychologists, social workers, licensed mental health counselors, and marriage and family therapists. Only 36 participants will be accepted.
The deadline for registration is January 10, 2005. An on-line pre-work sheet must be completed after registration.
For more information or to register, email Pam Price at firstname.lastname@example.org or phone her at 813.974.3718.
Mosquito-borne Disease Update December 5-11, 2004
Eastern Equine Encephalomyelitis (EEE) virus activity: There were nine seroconversions to EEE virus in sentinel chickens from Bay (2), Leon (4) and Walton (3) counties. In addition, there were three seroconversions to unspecified alphavirus in Walton county. One horse in Okaloosa County was reported with EEE virus infection. So far this year, 34 counties have reported EEE activity.
St. Louis Encephalitis (SLE) virus activity: None this week. Four counties have reported SLE activity this year.
Highlands J (HJ) Virus activity: There were two seroconversions to HJ virus in sentinel chickens from Jackson and Walton counties this week. Thirteen counties have reported HJ this year.
Cooler weather in many parts of the state is helping to reduce mosquito populations. Where they are still present, people are urged to take precautions against getting bitten. Dead birds should be reported to www.wildflorida.org/bird/. See the web page for more information: www.MyFloridaEH.com.
Samantha Rivers, Caroline Collins, Kristen Payne and Calvin DeSouza are the arbovirus surveillance team at the Bureau of Community Environmental Health in Tallahassee and can be reached at 850.245.2437. Dr. Carina Blackmore is the state public health veterinarian and can be reached at 850.245.4444, ext. 4732.
This Week on EpiCom
|The Bureau of Epidemiology encourages Epi Update readers to not only register on the EpiCom system at https://www.epicomfl.net but to sign up for features such as automatic notification of certain events and contribute appropriate public health observations related to any suspicious or unusual occurrences or circumstances. EpiCom is the primary method of communication between the Bureau of Epidemiology and other state medical agencies during emergency situations.
Pete Garner is administrator of the Bureau of Epidemiology Surveillance Systems Section in
Click here to review the most recent disease figures provided by the Florida Department of Health Bureau of Epidemiology.
D'Juan Harris is a GIS specialist in the Surveillance Systems Section of the Bureau of Epidemiology.
FL Department of Health My Florida