E-mail: cdcinfo@cdc.gov | Web: www.cdc.govThe findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

*Some counties have local clinics or hospitals contact migrant and complete evaluations

Mail to LHD**

Immigrant evaluated

Input data into EDN

Worksheetcompleted

Contact Migrant*

Form sent to IDPH/CDPH/

CCDPH

EDN

Illinois (IDPH)

Cook Co. (CCDPH)

Chicago (CDPH)

Jurisdictions

**LHD = local health department

OverseasPanel

Physicianexam

Electronic Disease

Notification

CDCQuarantine

Station review

Health Department

Port of EntryCBP1 Immigration

processing(500,0002)

Condition of public health

concern(24,0002)

1CBP=Customs and Border Protection2Annually, newly arriving immigrants

National Center for Emerging and Zoonotic Infectious DiseasesDivision of Global Migration and Quarantine

60% of TB cases reported in U.S. in 2010 occurred in foreign-born persons

All applicants for permanent residency and refugees complete pre-immigration medical evaluation

Some inactive TB overseas found to be active after entering the United States

CDC recommends re-evaluation of immigrants with TB conditions within 30 days of arrival

Complete EDN Data Flow

CDC surveillance system that tracks U.S.-bound migrants requiring medical follow-up

Notifies states of newly arriving migrants

Captures data from domestic follow-up medical evaluations

Accessed through CDC Secure Data Network

Replaced Information on Migrant Population (IMP) System, to which states did not have access, in October 2008

Background

Electronic Disease Notification (EDN)

System

EDN Data Flow in Illinois

Evaluate migrant follow-up in EDN to determine timeliness and completeness

Determine where improvements can be made to ensure migrants with TB conditions receive prompt follow-up

Explore why there are low rates of data entry into EDN’s follow-up module by Illinois

Make recommendations to improve rates of follow-up and EDN data entry

Objectives

Use of EDN in Illinois was evaluated using the 2001CDC Updated Guidelines for Evaluating Public Health Surveillance Systems.

Attributes considered included:− Simplicity, Data Quality,

Acceptability, Sensitivity, Representativeness, Timeliness, Stability, Usefulness

Methods

Participation• All immigrants and refugees with TB

conditions– U.S. arrival between October 1, 2008-

September 30, 2010– Illinois destination address

Data Collection EDN data extraction on Oct 15, 2010

(baseline)– High-priority variables identified by

IDPH Medical record review to obtain

unrecorded data– Collected high-priority variables and

entered into EDN– Compared data in EDN at baseline

and after data entry User interviews regarding EDN

– Conducted in-person or over phone (n=9)

Data Analysis Completed using SAS 9.2 Data Quality

– Percent complete at baseline and after data entry

Acceptability– Proportion of worksheets complete

by county at baseline and after data entry

Timeliness – Median days between time

intervals Stability

– Median time intervals over a 3-month period during and after the 2009 H1N1 pandemic• During H1N1 pandemic (April

22nd- July 22nd 2009)• After H1N1 pandemic (April 22nd

– July 22nd 2010)– Kruskal-Wallis non-parametric test

Representativeness– Comparison of distribution of TB

follow-up worksheet completion status at baseline and after data entry

Sensitivity– Completed follow-up evaluations

recorded in EDN at baseline compared to follow-up evaluations actually completed

EDN interview results were compiled to assess simplicity, stability, usefulness, and acceptability

Simplicity – EDN User Interviews EDN users with direct access (Direct Users)

– 100% (3/3) easy to use– 100% (3/3) easy to learn– 66.7% (2/3) not easy to gain initial access

Local health departments without EDN access (Non-Direct Users)– 100% (5/5) easy to fill out form– 60% (3/5) have problems sending back worksheet

Data Quality After data entry, number of started worksheets,

completed worksheets and completed evaluations in EDN dramatically increased

Figure 1: Complete* Worksheets in EDN at Baseline and After Data Entry (N = 1807)

Acceptability Overall low acceptabilityCompletion Rate by County Worksheet completion rate at baseline

– Mean rate: 23.5%– Range: 0% to 61.7% by county

Worksheet completion rate after data entry– Mean rate: 93.5% – Range: 64.8% to 100.0% by county

EDN User Interviews EDN user interviews indicated low willingness to use

system 62.5% (5/8) did not perform related activities on a

regular basis (direct and non-direct users) 60% (3/5) felt like filling out form takes away from

other duties (non-direct users)

Results

Representativeness There was a significant difference in distribution of

worksheet status at baseline and after data entry (p<0.01).

Figure 2: Distribution of Worksheet Status in EDN at Baseline and After Data Entry (N=1807)

Timeliness The time interval from disposition to EDN entry is

where most improvement can be made in Illinois

Table 1: Timeliness of Steps in EDN Process

Sensitivity Assessed by comparing:

– Number of completed evaluations documented in EDN at baseline

– Number total of completed evaluations after data entry (gold standard)

Of total follow-up evaluations completed, 36.3% documented in EDN at baseline

Time Intervals* N Median Days IQR**

Arrival to EDN State Notification

FY 2009FY 2010

915892

388

19 – 575 - 15

State Notification to Initiation 653 20 9-44Arrival to Initiation

FY 2009FY 2010

513522

2620

13-6412-40

Initiation to Disposition 987 24 5-67Disposition to EDN Entry*** 320 78 32.5-184

*Excluded negative time intervals**IQR = Inter-quartile range; used to control for data accuracy issues***Used baseline data only

Stability All time intervals were significantly longer during H1N1

pandemic Biggest time difference is disposition to physician

signature, with 118.5 days during and 29 days after H1N1

Table 2: Comparison of time intervals during and after the H1N1 pandemic

EDN User Interviews on Stability EDN system itself is fully operational, but stability of

follow-up is affected by lack of resources– 100% direct EDN users stated system was operating

fully 75-100% of the time– 62.5% EDN users (direct and non-direct) stated

related activities not a priority when resources are limited

Usefulness 66.7% said EDN did NOT provide adequate data for

surveillance of analysis 100.0% said EDN did NOT produce adequate feedback or

reports on data in EDN

Users’ Suggestions for Making EDN More Useful Users to CDC/Division of Global Migration and Quarantine

(DGMQ)– Provide summary reports on worksheets

completed/worksheets outstanding– Supply regular surveillance reports– Send reminders for pending worksheets– Create online instructions on completion of worksheet

Local Health Departments (LHD) to Illinois State– Make worksheet electronic to send back through email– Send reminders/mechanism to track “pending”

worksheets– Incorporate into Illinois National Electronic Disease

Surveillance System– Train healthcare providers on filling form out, sending

form back, requesting replacement forms, etc.

Median Times (days) During H1N1

After H1N1

p-value

Arrival to Initiation of exam*no time limit 27.0 19.0 0.01

Initiation within 90 days of arrival 27.0 14.0 0.01

EDN Notification to Initiation*no time limit 27.0 14.5 0.001

Initiation within 90 days of arrival 20.5 12.5 0.28

Disposition to physician signature* 118.5 29.0 0.01

Physician signature to EDN Entry** 38.0 19.0 0.02

*Medians calculated only for migrants with U.S. arrival during specified time frame **Medians calculated only for completed evaluations during specified time frame

General Conclusions Use of EDN’s follow-up module is low in Illinois Does not accurately portray follow-up evaluation

efforts As changes to EDN occur, additional guidance,

training, and resources for health departments may improve use of the follow-up module

ConclusionsStrengths of EDN Only national system to track first-time migrants

with TB conditions Standard system for all jurisdictions Electronic system provides real-time data sharing Easy and straightforward to use once initial access

obtained Fully operational 75-100% of timeWeaknesses of Use of EDN in

Illinois Data quality– Low proportion of data entered in Illinois

Timeliness of follow-up evaluation data entry Follow-up data entry is unstable, especially when

resources are low

CDC/DGMQ Improve online guidance on how to fill out

worksheet Consider electronic version of worksheet for non-

direct users Send feedback, summary and surveillance reports

to users Develop reminder system for pending or

incomplete reports

Recommendations

Illinois Consider resources needed to improve follow-up

data entry Allow EDN access at local level Provide guidance and recurring training for LHD

– Especially on how/when to fill out worksheets for those who never initiate a follow-up evaluation

Develop reminder and tracking system for LHD

This study was supported in part by an appointment to the Applied Epidemiology Fellowship Program administered by the Council of State and Territorial Epidemiologists (CSTE) and funded by the Centers for Disease Control and Prevention (CDC) Cooperative Agreement Number 5U38HM000414

AcknowledgementsNeha Shah, MD & Josh Jones, MD, Chicago Department of Public HealthDemian Christiansen, DSc, Cook County Department of Public HealthMichael Arbise & Peter Ward, Illinois Department of Public Health

Contact Information Teal R. Bell, MPHCDC/CSTE Applied Epidemiology Fellow Quarantine and Border Health Service BranchDivision of Global Migration and QuarantineTel: 404-718-1188TRBell@cdc.gov

Evaluation of the Use of the Centers for Disease Control and Prevention’s Electronic Disease Notification System Tuberculosis Follow-up in Illinois

T. Bell, MPH , a,b N. Molinari, PhDa, M. Selent, DVM, a S. Blumensaadt, c B. Puesta, c R. Philen, MD, a D. Lee, MPH, a N. Cohen, MDaa Centers for Disease Control and Prevention, Atlanta, Georgia, United States, b Council of State and Territorial Epidemiologists, Atlanta, Georgia, United States c Centers for Disease Control and Prevention, Chicago Quarantine Station, Chicago, Illinois

*Indicated by high-priority variablesWorksheet started = at least one high-priority variable filled outCompleted worksheet = a worksheet containing all high-priority variables according to dispositionCompleted evaluation = disposition of “completed evaluation,” starting and completing treatment if applicable

26.5% 23.5%17.5%

94.2% 93.5%

48.4%

0

200

400

600

800

1000

1200

1400

1600

1800

Worksheets started in EDN

Completed worksheets in EDN

Completed Evaluations in EDN

Freq

uenc

y

BaselineAfter Data Entry

73.6%

5.8%

2.9%

0.8%

5.9%

45.1%

17.6%

48.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Baseline After Data Entry

Perc

ent

Complete Worksheet: Evaluations Completed

Complete Worksheet: Evaluations Not Completed Incomplete Worksheet in EDN

Worksheet not started