Surveillance guidelines of reportable diseases

Transcription

1 Surveillance guidelines of reportable diseases Measure A Submitter: Norton County Health Department, KS (PHAB Beta Test Site) Demographic Information: Population served: 5,600, frontier FTEs: 8 State structure: decentralized Board authority: advisory, governing, policy-making Required documentation: 1. Protocols describing the processes used to determine when events rise to significance for an AAR review 2. List of significant events that occurred, including outbreaks, environmental public health risks, etc. 3. Completed AAR for two events which document successes, issues, and recommended changes in investigation/response procedures and other process improvements Submitter justification: This document was created by the state health department (SHD) to be used as a resource for local health departments (LHDs) in conducting disease investigations. The goal was to provide a Cliff s Notes of disease investigation and provide more consistency in how these investigations are conducted in Kansas. This guidance helped fill a need specifically for our LHD as well as for other LHDs in Kansas. Note: none of the beta test sites received accreditation status or an indication of the likelihood of accreditation status through the testing process, and therefore this documentation does not reflect items that have officially been approved by PHAB for the purposes of meeting a standard or measure.

2 Surveillance Guidelines of Reportable Diseases in Kansas A Tool for Local Health Departments and Regional Coordinators April 2010

3 Contents Introduction 3 Section 1: Background Information 5 Public health surveillance 5 Surveillance of infectious diseases 6 Methods of surveillance 7 Surveillance systems 8 Public health responsibility in Kansas 10 Section 2: Collecting and analyzing data of individual cases 11 Investigate case 11 Report the case to KDHE 11 Contact KDHE via the Epidemiology Hotline, if needed 11 Enter the case and related information into KS-EDSS 11 Search and review cases in KS-EDSS 12 Review KS-EDSS for newly assigned cases 12 Review County of Residence 12 Review the Case Classification of each case 12 Review the Supplemental Form 13 Review data for completeness and accuracy 14 Verify information required for submission to CDC 14 Create a line list 15 Analyze the data on the line list 19 Interpret the findings 20 Section 3: Detection of clusters, outbreaks, or unusual events 21 Analysis of surveillance data by time, place, and person 21 Analyzing KS-EDSS data by time 22 Yearly Report by Month/Week 22 Diseases 5 Year History Report 24 Epi Curve Report 25 Analyzing KS-EDSS data by person 27 Diseases by Demographics Report 28 Analyzing KS-EDSS data by place 29 Disease by Geographic Area Report 29 Interpreting results 31 Section 4: Presenting and disseminating public health data 33 Tables 33 Graphs 35 Charts 36

4 Contents (continued) Section 5: Surveillance Performance Reports 38 Performance reports for local health departments and preparedness regions 38 Section 6: Supporting documents 41 Kansas Statutes K.S.A K.S.A K.S.A Kansas Regulations (2007 List of Reportable Diseases in Kansas) (Isolation and quarantine of specific infectious and contagious diseases) 46 Sections of the KS-EDSS User Guide 2.0 (October 2008): Section 3.0 Entering a New Human Case 50 Section 4.0 Editing Cases 56 Section 5.0 Searches 61 Section 6.0 Reports 72 Section 9.0 Supplemental Forms 87

5 Introduction Purpose The Surveillance Guidelines of Reportable Diseases in Kansas have been developed to assist communicable disease investigators and regional coordinators with public health surveillance activities at the local and regional levels. The Surveillance Guidelines are meant to enhance current processes, to improve the use of the Kansas Electronic Disease Surveillance System (KS- EDSS), and to strengthen public health response efforts throughout the state. These guidelines establish a process of ensuring that reportable diseases and other issues of public health importance in Kansas are efficiently and effectively monitored on a routine basis. Methods for collecting, analyzing, and disseminating reportable disease data on individual cases and for detecting clusters and outbreaks are discussed. Surveillance performance reports are also discussed, including reviewing data for completeness and accuracy and identifying unusual patterns and clusters, trends, and potentially new or unusual diseases. Format The Surveillance Guidelines have been divided into six sections. Section 1 provides a brief background of public health surveillance and the surveillance of infectious diseases in Kansas. Section 2 describes the process for collecting and analyzing data for individual cases. Section 3 discusses methods and tools used to detect clusters and outbreaks. Section 4 explains how investigators can present and disseminate public health data. Section 5 outlines useful surveillance performance reports for local health departments, regions, and KDHE. Section 6 includes supporting documentation referenced throughout the Surveillance Guidelines. 3

6 Developed by Cheryl Bañez Ocfemia, MPH Kansas Department of Health and Environment Office of Surveillance and Epidemiology 1000 SW Jackson, Suite 210 Topeka, KS Epi Hotline: (877) Acknowledgments Kansas Association of Local Health Departments 300 SW 8 th Avenue Topeka, KS (785) Resources Information and excerpts from the following two documents are included in these guidelines. KS-EDSS User Guide Principles of Epidemiology in Public Health Practice, 3 rd edition 4

7 Section 1: Background information Public Health Surveillance The Centers for Disease Control and Prevention (CDC) define public health surveillance as the ongoing, systematic collection, analysis, and interpretation of health-related data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control 1. Public health surveillance is essential to identify health problems and health hazards in the community; diagnose and investigate the causes; and develop, evaluate, and implement control and prevention measures needed to respond to issues of public health concern. Additionally, public health surveillance is linked to the Core Public Health Function of Assessment and to Essential Public Health Services #1 Monitor health status to identify community health problems and #2 Diagnose and investigate health problems and health hazards in the community

8 Source: Surveillance of Infectious Diseases The ongoing collection of infectious disease data provides information needed to make decisions that influence and support public health practice. Data obtained through infectious disease surveillance are used to measure the burden of disease; monitor disease trends; detect infectious disease outbreaks and unusual disease events; direct immediate public health action; assess the impact of control and prevention measures; support planning and policy efforts; prioritize the allocation of public health resources; and provide a basis for epidemiologic studies. In the United States, the Centers for Disease Control and Prevention (CDC) maintains responsibility for the collection and publication of data of nationally notifiable diseases 2. The Council of State and Territorial Epidemiologists (CSTE), with input from the CDC, reviews this list annually and revises the list as needed. To provide uniform criteria for reporting surveillance data, the CSTE and the CDC also developed the Case Definitions for Infectious Conditions 2 The current list of Nationally Notifiable Infectious Diseases is available at ncphi/disss/phs/infdis.htm. 6

9 Under Public Health Surveillance. An alphabetical list of the current Case Definitions may be found at Though the CDC maintains surveillance data at the national level, reporting of nationally notifiable diseases by state health departments to the CDC is voluntary. However, reporting of infectious diseases at the state-level is mandated by state laws, and the list of reportable diseases in each state differs. The Kansas Department of Health and Environment (KDHE) maintains the list of reportable diseases for Kansas, which is specified in K.A.R The current list of reportable diseases in Kansas is attached; an electronic version can be found at DISEASE_FORM.pdf. Methods of Surveillance There are four general forms of surveillance methods: passive, active, sentinel, and syndromic. Passive surveillance is the most commonly used method of surveillance. This surveillance method is provider-initiated ; it relies on health care providers, hospitals, and laboratories to submit information about reportable diseases to the local or state health department. No public health action is taken until public health authorities are notified of a reportable disease or condition. During outbreak situations, public health investigators may conduct stimulated or enhanced passive surveillance by sending a notification to the medical community about the situation and requesting reports of similar cases. Active surveillance involves outreach by public health authorities to medical partners and groups in the community. This surveillance method is health department-initiated ; it includes regular phone calls or visits to physicians, laboratories, hospitals, and other entities, including child care and long-term care facilities, to actively identify cases during outbreaks or events of public health importance. Active surveillance is usually limited to specific diseases over a limited period of time. Sentinel surveillance is a method of collecting data on a sample of the population in order to learn something about the overall population. This surveillance method is useful in studying the burden of a disease that is not reportable and relies on select providers, hospitals, and laboratories to report the condition of interest. A good example of sentinel surveillance is the collection of influenza-like illness (ILI) data from a network of providers throughout the state to follow ILI activity. Syndromic surveillance is a method that relies on the collection of general syndromes or presumptive diagnoses as opposed to specific clinical or laboratory diagnostic criteria. This surveillance method most often involves the review of emergency department data as a means for the early detection of public health events in the community. For example, an increase of gastroenteritis seen at emergency departments could indicate a potential foodborne illness outbreak. However, syndromic surveillance is not specific, may identify individuals who are not of interest, and requires analysis of complex data. 3 K.A.R is in accordance with K.S.A and K.S.A

10 Surveillance Systems Surveillance systems are designed and maintained to monitor health events, to identify changes or patterns, and to investigate underlying causes or factors. State and national surveillance systems have been developed to provide comprehensive monitoring of health events using consistent collection and reporting procedures. 4 In Kansas, as stated in K.S.A , hospital administrators, physicians, and certain other persons are required by law to submit information about individuals affected by reportable infectious diseases to the LHD or KDHE. Clinical laboratories are required to report to KDHE, though some also report to the LHDs. The LHDs, in turn, are required to submit the information to KDHE. The surveillance data on reportable diseases are entered and stored in the secure, webbased, Kansas Electronic Disease Surveillance System, known as KS-EDSS. KS-EDSS allows for the secure sharing of sensitive health-related data between KDHE and public health staff at the local and regional levels. The Office of Surveillance and Epidemiology (OSE) at KDHE maintains KS-EDSS, manages the statewide infectious disease data, and publishes the annual Summary of Reportable Infectious Diseases in Kansas 5. OSE also forwards pertinent KS-EDSS data to the National Notifiable Disease Surveillance System (NNDSS) at the CDC on a weekly basis. Reporting to the NNDSS is voluntary, but is essential to conducting public health surveillance on notifiable diseases at the national level. Kansas receives funding from the CDC to participate in this system. Data on selected notifiable infectious diseases are published weekly in the Morbidity and Mortality Weekly Report ( MMWR) and at year-end in the annual MMWR Summary of Notifiable Diseases, United States 6. 4 The National Public Health Performance Standards Program. Local Public Health Performance Assessment Instrument, Version The annual Summary of Reportable Infectious Diseases in Kansas may be found at 6 MMWR documents are located at 8

11 Simplified Diagram of Surveillance of a Health Problem 7 7 Centers for Disease Control and Prevention. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR 2001;50(No. RR-13) 9

12 Public Health Responsibility in Kansas In addition to reporting, K.S.A gives LHDs the responsibility of monitoring and conducting follow-up on infectious diseases identified in their respective counties. Investigation and tracking of reportable diseases at the local level should be conducted by a communicable disease staff member at the county health department or by the regional coordinator. KDHE maintains responsibility of reportable diseases statewide and assists with the follow-up of infectious disease events. Every public health professional also has the crucial responsibility of maintaining confidentiality of the individuals affected by an infectious disease. Identifying information should never be released unless absolutely necessary to properly protect the public s health. Extreme consideration should be taken to ensure that information is released only on a need-to-know basis. Excerpts from HIPAA Privacy Rule and public health: guidance from CDC and the U.S. Department of Health and Human Services MMWR 2003;52(Supl) New national health information privacy standards have been issued by the U.S. Department of Health and Human Services (DHHS), pursuant to the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The new regulations provide protection for the privacy of certain individually identifiable health data, referred to as protected health information (PHI). Balancing the protection of individual health information with the need to protect public health, the Privacy Rule expressly permits disclosures without individual authorization to public health authorities authorized by law to collect or receive the information for the purpose of preventing or controlling disease, injury, or disability, including but not limited to public health surveillance, investigation, and intervention. Public health practice often requires the acquisition, use, and exchange of PHI to perform public health activities (e.g., public health surveillance, program evaluation, terrorism preparedness, outbreak investigations, direct health services, and public health research). Such information enables public health authorities to implement mandated activities (e.g., identifying, monitoring, and responding to death, disease, and disability among populations) and accomplish public health objectives. Public health authorities have a long history of respecting the confidentiality of PHI, and the majority of states as well as the federal government have laws that govern the use of, and serve to protect, identifiable information collected by public health authorities. 10

13 Section 2: Collecting and analyzing data of individual cases The surveillance of infectious diseases in Kansas includes the collection, analysis, and dissemination of reportable disease data. The following steps should be performed on a routine basis to ensure timely and appropriate public health action, prompt reporting of notifiable diseases, and the management of clean, complete, and accurate data. Surveillance of individual cases 1) Investigate case 2) Report the case to KDHE a) Contact KDHE via the Epidemiology Hotline, if needed b) Enter the case and related information into KS-EDSS 3) Search and review cases in KS-EDSS a) Review KS-EDSS for newly assigned cases b) Review County of Residence c) Review the Case Classification of each case d) Review the Supplemental Form 4) Review data for completeness and accuracy a) Verify information required for submission to CDC b) Create a line list c) Analyze the data on the line list d) Interpret the findings NOTE: The Sections of the KS-EDSS User Guide 2.0 that are referenced below have been attached. The complete version of the User Guide can be found at Investigate Case When a local health department is notified of a case of a reportable disease, the communicable disease (CD) investigator should investigate the case as specified in the Disease Investigation Guidelines (DIGs). The Kansas DIGs can be downloaded from disease_protocols.htm. Report the case to KDHE All cases should be reported to KDHE in a timely manner either by phone, fax, or entry into KS- EDSS. Contact KDHE via the Epidemiology Hotline, if needed If the disease event should be reported within four hours as indicated on the List of Reportable Diseases in Kansas, the CD investigator should contact the Epidemiologist on-call at (877) A copy of the current list is attached. 11

14 Enter the case and related information into KS-EDSS In March 2008, KDHE assumed responsibility of entering all laboratory results into KS- EDSS. However, the KS-EDSS Case Records can be created at the local level even without the laboratory information. The communicable disease investigator should enter the case information into KS-EDSS and, if appropriate, complete the supplemental form. For information about entering a case into KS-EDSS, refer to Sections , and in the KS-EDSS User Guide. NOTE: LHDs that do not have access to KS-EDSS can submit case information to KDHE via fax at (877) Search and review cases in KS-EDSS The following steps should be conducted when reviewing KS-EDSS cases. These steps are most often performed by the CD investigator at the local health department; however, these can also be fulfilled by the regional coordinator. Review KS-EDSS for newly assigned cases Because KDHE and other LHDs can create new case records, a search in KS-EDSS should be conducted at least daily to ensure that all newly assigned cases for the county are identified. For more information about accessing and viewing existing cases in KS- EDSS, refer to Sections in the KS-EDSS User Guide. Review County of Residence County of Residence should be reviewed at least daily to make sure that the cases have been assigned to the appropriate county. If a case resides in another county, the county and state of residence should be changed and the appropriate agency should be notified by telephone or so follow-up can be initiated. Notification by telephone or e- mail is necessary to ensure that the appropriate county does not overlook the case. For more information about the County of Residence, refer to Section in the KS-EDSS User Guide. Review the Case Classification of each case As mentioned in Section 1, the CSTE/CDC case definitions provide a standardized method of reporting notifiable diseases to CDC. These surveillance case definitions describe clinical and laboratory criteria that should be met to classify a case as a suspect, probable, or confirmed case or as not a case. The case definitions are available at index.htm. There is also a link in KS- EDSS at the bottom of the Case Reporting tab. The CSTE/CDC case definitions generally include only confirmed and probable case status for most diseases (some include suspect ). Because of the need to assign case status for every case in a consistent manner, KDHE has developed a supplemental document for standardized case classifications. This document includes additional criteria for probable, suspect, and not a case classifications for many diseases that lack these criteria in the CSTE/CDC case definitions. This document is located at 12

15 ase_classifications.pdf. The Case Classification of each case should be reviewed at least weekly to make sure that cases are appropriately classified. (See image on next page.) Data for all confirmed cases and probable cases for vaccine-preventable diseases are forwarded to the CDC every week for inclusion in the weekly MMWR publication. For more information about the case definitions, refer to Addendum A: KS-EDSS Case Definitions in the KS-EDSS User Guide. Review the Supplemental Form The Supplemental Form includes information that is necessary to appropriately classify a case, assess potential exposures associated with illness, and to identify factors requiring an immediate public health response. If a form is available for a disease and it has been entered, data from the Supplemental Form should be reviewed at least weekly to make sure that the form is complete. The investigator should also review the form for potential sources of infection or the potential for spread to others to ensure that appropriate follow-up is conducted. For example, if the form states that the individual ate cheese made with unpasteurized milk, the investigator should determine if others are ill. The variable labeled Supplemental Form Status should also be correctly marked on the Case Reporting screen. (See image on next page.) For more information about Supplemental Forms, refer to Section 9.0 in the KS-EDSS User Guide. 13

16 KS-EDSS Screenshot of a case report Review data for completeness and accuracy At least weekly, the following steps should be conducted to ensure completeness and accuracy of KS-EDSS data that are needed for appropriate public health follow-up and response: Verify information required for submission to the CDC Data for the following variables are sent to the CDC on a weekly basis for the nationally notifiable diseases. The CD investigator or the regional coordinator should review these variables at least weekly for completeness and accuracy; a response should be selected for all cases. Date of birth Report date Age Onset date Age type Hospitalized Sex Died Race Ethnicity Case classification Outbreak associated Imported 8 8 Indicates if the case was locally acquired or imported into the state or U.S. 14

17 Create a line list The New Search function can be run in KS-EDSS to get a listing of the required CDC variables for all cases by county or region. For the following steps, refer to the screenshot provided on page 15. 1) Click New Search on the Left Navigation Sidebar. The search page appears. This feature allows the user to search by any and all fields available in the core component of KS-EDSS for a case, such as patient name, a range of dates, disease name, referring physician, and fields from the lab report section. The user can specify as few or as many of the fields as needed by clicking in the fields and making selections. As a general rule, the more variables specified, the more specific the search will be; the fewer variables, the broader the search will be. 2) If you want to save your search, choose a name for your Search. 3) Under Disease Name, choose Select All. 4) Under Case Classification, choose Select All. 5) For Report Date, enter the desired time frame. 6) Under the heading Patient Address, select County and choose the desired county. If the user would like to search by BT Hospital Region, click the CONTINUE button at the bottom to proceed to a second page with more variables. 7) Click SEARCH at the bottom of the page to run the query (if you want to save the search hit SAVE & FINISH). All the fields for the KS-EDSS cases that meet the selected criteria (that you have permission to view) will appear in a case listing. 8) Click EXPORT at the top of the case listing to export the data into a spreadsheet. 9) Click SAVE to download and save the spreadsheet to a folder. By default, the file is named Temporary.csv. 10) Locate the file named Temporary.csv and open the file to view a line list of disease cases for a given timeframe and geographic location. 11) For ease, keep only the columns with the fields of interest. The following variables provide important information for all diseases: Investigation ID Disease Name Case Classification Outbreak Onset Date Report Date 15

18 Died Supplemental Form Status Imported Hospitalized Address County Sex Race Ethnicity Date of Birth Age Age Unit For more information about performing temporary searches, saving searches, sorting data, and exporting data in KS-EDSS, refer to Sections in the KS-EDSS User Guide. NOTE: A Case Listing report can also be generated in KS-EDSS for some of the variables listed above. The "Case Listing" report displays a simplified, patient-level list of all cases that fall within a specified time period, geographic area, and disease group as defined by the report parameters. Variables of interest to be included in the report are selected using the "Display Columns" check boxes. Refer to Section in the KS-EDSS User Guide for information about the Case Listing report. 16

19 KS-EDSS screenshots To create a line list: Click New Search and select the desired fields. Click CONTINUE at the bottom of this screen to go to the next page to choose a BT Hospital Region. To export the line list to a spreadsheet: Click EXPORT and then save the file. 17

20 Example Line List This table includes all cases for Region A that were reported for the week of January 1, 2009 and January 7, Only the columns with the fields of interest (including the fields required for submission to the CDC) were kept; the other columns were deleted. Investigation ID Disease Name Case Classification Outbreak Y/N Onset Date Report Date Died Supplemental Form Status Imported Hospitalized Address County Sex Race Ethnicity Date of Birth Age Age Unit Shigellosis Confirmed N 1/2/09 IND A Male White Hepatitis C virus infection Confirmed N 1/2/09 IND B Male Black or African American Not Hispanic or Latino 9/3/05 3 Years Not Hispanic or Latino 8/16/54 54 Years Hepatitis B; chronic Confirmed N 1/2/09 IND N B Female Unknown Unknown 8/7/81 27 Years Salmonellosis Confirmed N 12/26/08 1/2/09 IND N A Female White Hispanic or Latino 10/23/08 2 Months Varicella Probable N 12/15/08 1/5/09 FP IND Y C Female White Unknown 3/2/31 77 Years Hepatitis C virus infection Confirmed N 1/6/09 IND C Male White Not Hispanic or Latino 5/1/62 46 Years Pertussis (Bordetella pertussis) Suspect N 12/31/08 1/6/09 IND N A Male White Hispanic or Latino 12/22/97 11 Years Rocky Mountain Spotted Fever Probable N 1/7/09 IND A Female Unknown Unknown 8/22/62 46 Years Streptococcus pneumonaie, invasive Confirmed N 1/7/09 IND N D Male White Not Hispanic or Latino 9/23/36 72 Years Hepatitis B; acute Probable N 1/7/09 IND Y A Male Unknown Unknown 1/17/58 50 Years 18

21 Analyze the data on the line list Refer to the example line list report located on the previous page. With a line list, the CD investigator or regional coordinator can easily sort the data and identify the cases that are missing information for the variables selected. Further public health follow-up may be done to ensure that the information is complete and accurate. For analysis of the data, descriptive methods can be used. Frequencies (counts) and percentages provide useful information about the cases and the need for public health action. Simple frequencies and percentages can be calculated based on the information provided on the line list, including the following: Total number of case reports within a certain time frame The number and percent of cases by disease name The number and percent of cases classified as suspect, probable, confirmed or not a case The number and percent of cases that are associated with an outbreak The number and percent of cases that are imported The number and percent of cases with information for onset date, died, supplemental form status, hospitalized, sex, race, ethnicity, date of birth, and age After reviewing the example line list report on the following page, these results were obtained: Ten cases have been reported in KS-EDSS between January 1 to January 7, 2009 for Region A. The diseases for the 10 cases are as follows: o 2 (20%) Hepatitis C virus infection o 1 (10%) each of Shigellosis, Hepatitis B chronic infection, Varicella, Pertussis, Rocky Mountain Spotted Fever, Streptococcus pneumoniae invasive, and Hepatitis B acute infection. There does not appear to be any issues with the Case Classification based on the information provided. All cases are marked as N for the variable Outbreak and IND (indigenous) for the variable Imported. All cases have complete information for age type, birthdate, and sex. Onset date information is missing for 7 (70%) of the cases. Died information is missing for all cases. Supplemental Form Status is marked for only one of the cases. Hospitalized information is missing for 4 (40%) of the cases. Race information is marked as Unknown for 3 (30%) of the cases. Ethnicity information is marked as Unknown for 4 (40%) of the cases. 19

22 The Shigellosis case involved a 3 year old male; onset date is also missing. The Salmonellosis case involved a 2 month old Hispanic female. The Varicella case involved a 77 year old female who was hospitalized. The Hepatitis B acute case involved a 50 year old male. Interpret the findings Analysis of the surveillance data provides important information that guides public health action. Referring to the example, analysis of the data provides the following: More emphasis should be placed on retrieving died, hospitalized, race, and ethnicity information during case investigations. Seventy percent of the cases are missing information for Onset Date. For some diseases (e.g., Hepatitis B virus, Hepatitis C virus, Rocky Mountain Spotted Fever), date of onset of illness may be difficult to determine. For diseases like Shigellosis and Pertussis, onset date is important in determining potential sources of infection and estimating the period of communicability. Further investigation is warranted for the Shigellosis and Salmonellosis cases. o Both enteric diseases occurred in children. o Do the cases attend day care, school, or participate in another form of out-ofhome care? If so, did the children attend while ill? Are other children at these facilities reporting illness? o Do the cases have young siblings? If so, are these siblings experiencing illness? Do the siblings attend out-of-home care? o Do the parents of the cases provide direct patient care or work in a nursing home, day care, or food establishment? If so, are the parents experiencing illness? For the Varicella case, what is the current health status of the hospitalized 77 year old female? For the Hepatitis B acute case, the supplemental form status is incomplete. Has a case investigation been initiated to determine susceptible contacts and the need to recommend post-exposure prophylaxis or vaccination? 20

23 Section 3: Detection of clusters, outbreaks, or unusual events Because the detection of clusters, outbreaks, or unusual events relies on the review of aggregate surveillance data, case-level information should be entered into KS-EDSS in a timely manner and should be complete and accurate. Outbreaks the occurrence of more cases than expected can be uncovered by reviewing and comparing exposure information on the supplemental forms for individual cases. Outbreaks may also be detected when health department staff perform regular, timely analysis of surveillance data to identify increases in reported cases or an unusual clustering of cases by time and place. For clarity, the Principles of Epidemiology in Public Health Practice provides the following statements to define an epidemic, an outbreak, and a cluster: An epidemic is the occurrence of more cases of disease than expected in a given area or among a specific group of people over a particular period of time. Usually, the cases are presumed to have a common cause or to be related to one another in some way. An outbreak is an epidemic limited to localized increase in the incidence of disease. A cluster is an aggregation of cases in a given area over a particular period without regard to whether the number of cases is more than expected. Analysis of surveillance data by time, place, and person Events of public health importance can be detected through analysis of surveillance data by time, place, and person. Several reports are available in KS-EDSS that organize disease data for analysis and presentation. CD investigators at the local health departments can use the reports to detect outbreaks or manage outbreak data in their respective county. Regional coordinators can use these reports to detect outbreaks or manage outbreak data in the region and make comparisons among the counties within the region. Reports are accessed by clicking REPORTS on the green menu bar at the top of the screen. The Left Navigation Sidebar changes to show the available reports. Depending on what the investigator wants to know, one report may be better than another. In some instances, several different reports may be generated to produce useful results. The more an investigator reviews and understands the data for their county or region, the easier it becomes to recognize aberrations or unusual events and to detect clusters and outbreaks. The following reports will be discussed in this Section. YEARLY REPORT BY MONTH/WEEK DISEASES 5 YEAR HISTORY EPI CURVE DISEASE BY DEMOGRAPHICS DISEASE BY GEOGRAPHIC AREA 21

24 NOTE: All reports can be saved as *.pdf files and shared as needed. Refer to Section 6.0 in the KS-EDSS User Guide for more information about Reports. KS-EDSS Screenshot Analyzing KS-EDSS data by time Basic analysis of surveillance by time is often performed to characterize trends and detect changes in disease incidence. YEARLY REPORT BY MONTH/WEEK In KS-EDSS, a YEARLY REPORT BY MONTH/WEEK can be generated to display a table of year-to-date count information for a specific disease, disease group, or all diseases for a particular year and geographic area. The count information can be displayed by month or by CDC s MMWR week, and comparisons by month and week can be made. The YEARLY REPORT BY MONTH/WEEK should be used at least weekly. Different reports should be generated with the following criteria: Weekly and monthly counts of all diseases with Confirmed case classification by county and region Weekly and monthly counts of all diseases with Probable case classification by county and region Weekly and monthly counts of all diseases with Suspect case classification by county and region 22

25 NOTE: The report aggregates all data based on the selected criteria. Separate tables need to be generated in order to review counts by month or week, by individual disease, by case classification, and by individual county or region. KS-EDSS Screenshot of Yearly Report by Month/Week Example: YTD Table of Diseases for a Given Year (partial report) Year 2008 Display Interval: By MMWR Geographic Area: The State of Kansas Case Classification: [Confirmed] Disease Names: [Salmonellosis (Salmonella spp.)] Analysis and interpretation: An abrupt increase or a gradual buildup in the number of cases for a particular disease can be detected by comparing the number of cases during the current week to the number reported during previous weeks. In the example above, the number of Salmonellosis cases increased from one case during MMWR week 1 to five cases during MMWR week 2. Because the report generated the counts for Salmonellosis cases reported statewide, the increase most likely is not indicative of an outbreak. Nonetheless, the increase should signal the investigator to consider reviewing the Salmonellosis case records and the supplemental forms to identify any commonalities. 23

26 DISEASES 5 YEAR HISTORY REPORT Other useful analyses include (1) comparing the number of cases during the current period to the number reported during the same period for the last 5 years and (2) comparing the cumulative number of cases reported to date during the current year to the cumulative number reported to the same date during the last 5 years. In KS-EDSS, a DISEASES 5 YEAR HISTORY report can be generated to make these comparisons. The DISEASES 5 YEAR HISTORY REPORT should be generated at least monthly or when an outbreak of a specific disease is suspected or has been detected. At a minimum, a report with the following criteria should be generated: Monthly counts of all diseases with Confirmed case classification by county and region NOTE: The report aggregates all data based on the selected criteria. Separate tables need to be generated in order to review counts by specific months or specific weeks, by individual disease, by case classification, and by individual county or region. KS-EDSS Screenshot of Diseases 5 Year History Report 24

27 Example: Table of Diseases Comparing A Given Timeframe for Past 5 Years Year: Display Interval: By Year Geographic Area: The State of Kansas Case Classifications: [Confirmed] Disease Names: [Salmonellosis (Salmonella spp.)] Analysis and interpretation: In this example, the number of Salomonellosis cases reported annually appears to have increased in 2007 and The investigator analyzing the data should ask, Why? Was there a change in the CDC/CSTE case definition which led to more cases being classified as confirmed? Was there a change in laboratory methods, increasing the number of gastroenteritis illnesses diagnosed as Salmonellosis? Was there an outbreak that influenced the number of cases reported? The best explanation for the increase in the number of Salmonellosis cases reported is that Kansas residents were associated with two multi-state Salmonellosis outbreaks that occurred in 2007 and 2008 and one multi-county Salmonellosis outbreak in Kansas in EPI CURVE REPORT Increases in incidence can also be analyzed using graphs. An epidemic curve is a histogram that displays the number of cases of disease during an outbreak or epidemic by times of onset. The y-axis represents the number of cases; the x-axis represents date and/or time of onset of illness. The EPI CURVE report in KS-EDSS displays graphs the number of new cases of a selected disease against the selected time period defined by the report parameters. The graph information can be further broken down by time interval. This report does not offer HTML output. Only the PDF report includes both the graph and data. The CSV report includes the data, but the user must use other software, such as a spreadsheet or database program, to create and view the graph. The EPI CURVE REPORT should be generated when an outbreak of a specific disease is suspected or has been detected. Principles of Epidemiology in Public Health Practice provides a list of reasons why epi curves are useful and informative investigative tools: The epi curve shows the magnitude of the epidemic over time as a simple, easily understood visual. It permits the investigator to distinguish epidemic from endemic disease. Potentially correlated events can be noted on the graph. The curve shows where you are in the course of the epidemic still on the upswing, on the down slope, or after the epidemic has ended. This information forms the basis for predicting whether more or fewer cases will occur in the near future. 25

28 The shape of the epidemic curve may provide clues about the pattern of spread in the population, e.g., point versus intermittent source versus propagated. 9 The curve can be used for evaluation, answering questions like: How long did it take for the health department to identify a problem? Are intervention measures working? Outliers (cases that don t fit into the body of the curve) may provide important clues. If the disease and its incubation period are known, the epi curve can be used to deduce a probable time of exposure and help develop a questionnaire focused on that time period. NOTE: Because all outbreaks are different, selecting the time criteria that produces the best epi curve is often a matter of trial-and-error. If an outbreak of a disease is clustered in time, viewing the data between specific dates may be more appropriate. If an outbreak of a diseases seems more spread out over time, viewing the data by week or month may be better. KS-EDSS screenshot of the Epi Curve Report 9 Common-source or point-source outbreaks are characterized by a sharp rise in the number of cases that slowly tapers off. Most illness appears within one incubation period. Propagated outbreaks are characterized by progressive peaks, approximately one incubation period apart. Continual-source outbreaks are characterized by a gradual rise in cases that often plateaus. 26

29 Example: Epi-Curve Graph Time Period: August 2008 Time Breakdown: by MMWR Week Reportable Condition: Salmonellosis (Salmonella spp.) Geographic Area: The State of Kansas Case Classifications: [Confirmed] MMWR Week Tota Analysis and interpretation: In the epi curve example, a substantial increase in Salmonellosis cases statewide from MMWR week 31 to MMWR week 32 is apparent. This visual display assists investigators in using surveillance data to quickly identify an unusual occurrence in disease and that public health action is warranted. The curve also demonstrates that the number of cases statewide continued to rise over the next four MMWR weeks and abruptly dropped by MMWR week 36. Analyzing KS-EDSS data by person Age and sex are the most commonly collected and analyzed person characteristics. Because race and ethnicity data are not as consistently collected, data analysis by these two characteristics are not always performed. Other person characteristics that may be useful for analysis include attendance at school or daycare, type of occupation, and travel history. 27

30 DISEASES BY DEMOGRAPHICS REPORT In KS-EDSS, the DISEASES BY DEMOGRAPHICS report displays a table of count or percentage information for all diseases that fall within a specified time period and geographic area as defined by the report parameters. The count or percentage information can be further broken down by two different variables. The DISEASES BY DEMOGRAPHICS report should be generated at least weekly. Different reports should be generated with the following criteria: Weekly counts of all diseases by Sex and Age Group NOTE: The DISEASES BY DEMOGRAPHICS Report can also be used to generate the count of cases for all diseases broken down by Race, Ethnicity, Case Classification ( Confirmed, Probable, and Suspect ), Investigation Status, and Month. KS-EDSS Screenshot of Disease by Demographics Report 28

31 Example: Disease by Demographics Time Period from 8/2/08 to 8/31/08 Display Variable 1: Sex Display Variable 2: Age Group Report Type: Count Geographic Area: State Wide Analysis and interpretation: The report above reveals that of the 56 Salmonellosis cases reported statewide during August 2008, 14 (25%) of the cases occurred in persons less than 5 years of age. Additionally, 9 (64%) of the 14 cases are female; no difference by sex is observed when all 56 cases are included. Diarrheal illness, such as Sallmonellosis, can be easily spread person-to-person in day care settings and households with young children. Young children are also more likely to be asymptomatic carriers. Further follow-up should be done to make sure that appropriate public health control and prevention measures have been implemented. The number of Salmonellosis cases should also be closely monitored to detect additional cases or outbreaks in the affected communities. Analyzing KS-EDSS data by place Analysis of cases by place is often displayed in a table or a map. KS-EDSS data can be analyzed by county, city, zip code, hospital BT region, BT Local Health Department or statewide. DISEASE BY GEOGRAPHIC AREA REPORT The DISEASE BY GEOGRAPHIC AREA report displays a table of count information for all diseases that fall within the selected time period and geographic area as defined by the report parameters. The count or rate information can be displayed by geographic boundaries and areas. The DISEASE BY GEOGRAPHIC AREA Report should be generated at least weekly. A report should be generated with the following criteria: Weekly and monthly counts of all diseases with Confirmed case classification by county and region Weekly and monthly counts of all diseases with Probable case classification by county and region Weekly and monthly counts of all diseases with Suspect case classification by county and region 29

32 KS-EDSS Screenshot of Disease by Geographic Area Report Example: Partial Table of Disease by Geographic Location Time Period: August 2008 Report Type: Counts Geographic Breakdown: By Region Geographic Area: The State of Kansas Case Classifications: [Confirmed] Analysis and interpretation: The table above reveals that two of the largest regions (Kansas City Metro Region and South Central Metro Region) have more Salmonellosis cases reported during August Though it is expected that more cases will be reported in these areas of the state, further analysis is warranted. Are these case counts more than expected for each area? If the counts are not more than would be normally expected, case counts by county for 30

33 each of these regions could provide additional information. All the Salmonellosis cases could be occurring in one the counties, possibly indicating a localized cluster or outbreak. Interpreting results When an increase in disease incidence is observed or the disease pattern in a certain population at a specific time and place differs from its expected pattern, further investigation or increased emphasis on public health control and prevention measures is usually indicated. The level of public health action taken is often dictated by available resources, competing priorities, etc. For some diseases (e.g. botulism, inhalational anthrax, measles), one case of an illness is often sufficient reason to initiate an investigation and quickly implement appropriate public health measures. Sometimes aberrations in surveillance may be a result in which surveillance was conducted as opposed to a true change in disease occurrence. Principles of Epidemiology in Public Health Practice lists the following as common reasons for artifactual changes: Changes in local reporting procedures or policies (e.g., a change from passive to active surveillance). Changes in case definition (e.g., AIDS in 1993). Increased health-seeking behavior (e.g., media publicity prompts persons with symptoms to seek medical care). Increase in diagnosis. New laboratory test or improved diagnostic procedure. Increased physician awareness of the condition, or a new physician is in town. Increase in reporting (i.e., improved awareness of requirement to report). Duplicate reporting. Outbreak of similar disease, misdiagnosed as disease of interest. Laboratory error. Batch reporting in which reports from previous periods are held and reported all at once during another report period (e.g., reporting all cases received during December and the first week of January during the second week of January). Because the primary responsibility of public health officials is to protect the health of the public, most consider an apparent increase in disease as real and respond appropriately, until proven otherwise. 31

34 Excerpt from Principles and Practice of Public Health Surveillance by Teutsch SM, Churchill RE The real art of conducting surveillance lies in interpreting what the data say. Data need to be interpreted in the context of our understanding of the etiology, epidemiology, and natural history of the disease or injury. The interpretation should focus on aspects that might lead to improved control of the condition. By proceeding from the simple to the complex, investigators can use surveillance as a basis for taking appropriate public health action. Epidemics can be recognized, preventive strategies applied, and the effect of such actions can be assessed. The key to interpretation lies in knowing the limitations of the data and being meticulous in describing them. One axiom to be always kept in mind is that, because of the descriptive nature of surveillance data, correlation does not equal causation. 32

35 Section 4: Presenting and disseminating public health data Routine analysis of public health surveillance data ensures that issues of public health importance are efficiently and effectively monitored. When the results are shared with public health partners, the usefulness and scientific value of surveillance is validated and the information loop of public health surveillance is completed. Tables One basic, simple way of sharing analytical results is through the use of tables. Using rows and columns, tables demonstrate patterns, exceptions, differences, and other relationships among different variables. Tables can be used to organize almost any quantitative information. Additionally, tables usually serve as the basis for creating other visual displays of data, such as graphs and charts, in which much of the detail would not be included. To increase the effectiveness of a table and ensure ease-of-use, follow these guidelines when constructing the table 10 : Use a clear and concise title that describes person, place and time what, where, and when of the data in the table. Label each row and each column and include the units of measurement for the data (e.g., years). Show totals for rows and columns, where appropriate. If percentages (%) are shown, also give their total (should always equal 100 percent). Identify missing or unknown data either within the table or in a footnote below the table. 10 Principles of Epidemiology in Public Health Practice, 3 rd edition 33

36 Explain any codes, abbreviations, or symbols in a footnote (e.g., HBV = Hepatitis B Virus). Note exclusions in a footnote. Note the source of the data below the table or in a footnote if the data are not original. One-variable table The one-variable table is the simplest frequency distribution table. In this type of table, the first column shows the values or categories of the variable represented by the data, such as disease. The second column shows the number of persons or events in each category. Additional columns, such as percentage or cumulative percentages, may also be included. One-Variable Examples: Reported Cases of Salmonellosis by Year Kansas, * Year Number of Cases Total 3567 * Summary of Reportable Infectious Diseases in Kansas, 2007 Reported Cases of Salmonellosis by Age Kansas, 2007* Age Group (years) Number of Cases Percent (%) Unknown 1 0 Total * Summary of Reportable Infectious Diseases in Kansas,

37 Two-variable tables Data can also show counts by an additional variable. For example, the Salmonellosis data can be displayed by age-group and sex. Two-variable Example: Reported Cases of Salmonellosis by Age and Sex Kansas, 2007* Number of Cases Age Group (Years) Male Female Unknown Total Unknown Total *Summary of Reportable Infectious Diseases in Kansas, 2007 Graphs Another format that is useful when conveying results is a graph. Graphs assist readers to visualize patterns, trends, aberrations, similarities, and differences in data. Graphs are often used to present data to others who are not familiar with the data. Graphs can be created using a spreadsheet application, such as Microsoft Office Excel or Corel WordPerfect Office Quattro Pro. To ensure simplicity and clarity, many of the guidelines for tables should be followed when constructing a graph 11 : Ensure that a graphic can stand alone by clear labeling of title, source, axes, scales, and legends; Clearly identify variables portrayed (legends or keys), including units of measure; Minimize number of lines on a graph; Generally, portray frequency on the vertical scale, starting at zero, and classification variable on horizontal scale; Ensure that scales for each axis are appropriate for the data presented; Define any abbreviations or symbols; Note exclusions in a footnote. Note the source of the data below the table or in a footnote if the data are not original. 11 Principles of Epidemiology in Public Health Practice, 3 rd edition 35

38 Example Graph: (Data are taken from the example table on page 34) Salmonellosis Cases Reported in Kansas Number of Cases Year Charts Bar charts use bars of equal width to display discrete data that can be compared, such as race or age groups. The bar chart can be portrayed with the bars either vertical or horizontal. The decision to make a vertical or horizontal bar chart is usually made based on the length of text labels longer labels fit better on a horizontal chart than a vertical one. Charts can be created using a spreadsheet application, such as Microsoft Office Excel or Corel WordPerfect Office Quattro Pro. When constructing bar charts, follow these guidelines to properly display the data 12 : Arrange the categories that define the bars or groups of bars in a natural order, such as alphabetical or increasing age, or in an order that will produce increasing or decreasing bar lengths. Choose whether to display the bars vertically or horizontally. Make all of the bars the same width. Make the length of bars in proportion to the frequency of the event. Do not use a scale break, because the reader could easily misinterpret the relative size of different categories. Show no more than five bars within a group of bars, if possible. Leave a space between adjacent groups of bars but not between bars within a group. Within a group, code different variables. 12 Principles of Epidemiology in Public Health Practice, 3 rd edition 36

39 Example Bar Chart: (Data are taken from the example table on page 34) Age Distribution of Salmonellosis Cases Reported in Kansas Number of Cases Age Groups (Years) 37

40 Section 5: Surveillance Performance Reports Communicable disease investigators and regional coordinators can utilize the tools described in Sections 2-4 to manage and review the surveillance data for their respective agencies, counties, and regions. Surveillance performance reports for local health departments and preparedness regions If performed on a weekly and monthly basis, the following reports can be useful in conducting surveillance activities at the local and regional levels. Each county and each region can decide who the most appropriate person to run these reports is for their county and/or region. Surveillance performance report Year-to-date counts of disease using KS-EDSS reports Weekly, monthly, and yearly comparison of counts of disease using KS-EDSS reports Note: Disease occurrence is often analyzed by time and place simultaneously. These reports can provide an indication of whether an unusual cluster or pattern of disease is occurring. Additional reports, like the EPI CURVE report, can be generated and shared as needed. Surveillance Performance Report The detection of clusters and outbreaks depends on timely, complete, and accurate data in KS-EDSS. This report will help the local investigators manage the KS-EDSS data for their county. A copy of this report can be found on page Run a New Search in KS-EDSS (as described in Section 2) and create a line list for the county of interest. Include the following variables on the line list: Investigation ID, Disease Name, Case Classification, Outbreak, Onset Date, Report Date, Died, Supplemental Form Status, Imported, Hospitalized, Address County, Sex, Race, Ethnicity, Date of Birth, Age, Age Unit. Additional variables may be added, if needed. 2. Summarize the data using the suggested report provided on the next page. Calculate the percentage of cases with complete information. 3. Review the line list data for potential clusters or unusual events (as described in Section 2). 4. Indicate how many clusters or unusual events were observed. Was an epidemiologic investigation conducted for each cluster or outbreak? Was an epidemiological link or source identified? Was there a disease that had 0 cases reported in the previous time period, but had 1 or more cases reported in the current period? 5. Provide additional comments under Comments. 6. Share information from the line list and summary report with local health department staff and partners as needed. 38

41 SURVEILLANCE PERFORMANCE REPORT Data Completeness and Accuracy Detection of clusters, outbreaks, and unusual events Data for County Health Department for the period of / / through / / KS-EDSS Data Element % of cases with complete information Date of birth Sex Race Ethnicity Onset date Hospitalized Died Imported Outbreak associated Supplemental form completed, if applicable Total number of diseases reported in KS-EDSS for County Confirmed = Probable = Suspect = Total = Total number of clusters or unusual events observed for County = Comments / Observations Prepared by Contact Number Date 39

42 Year-to-date counts of disease As discussed in Section 3, KS-EDSS reports can be generated to show disease occurrence by time and place. The YEARLY REPORT BY MONTH/WEEK, DISEASES BY DEMOGRAPHICS, and DISEASE BY GEOGRAPHIC AREA reports in KS-EDSS can help local investigators quantify what has been reported in their county and region on a weekly basis. Weekly, monthly, and yearly comparison of counts of disease As discussed in Section 3, comparisons by week, month, and year can help determine if there are more cases than would normally be expected or seen for a particular county or region. The YEARLY REPORT BY MONTH/WEEK and the DISEASES 5 YEAR HISTORY reports in KS-EDSS can help local investigators make comparisons, monitor and track clusters and detect outbreaks by county and by region. 40

43 Section 6: Supporting documents Kansas Statutes K.S.A K.S.A K.S.A Kansas Regulations (2007 List of Reportable Diseases in Kansas) (Isolation and quarantine of specific infectious and contagious diseases) 46 Sections of the KS-EDSS User Guide 2.0 (October 2008): Section 3.0 Entering a New Human Case 50 Section 4.0 Editing Cases 56 Section 5.0 Searches 61 Section 6.0 Reports 72 Section 9.0 Supplemental Forms 87 41

44 Chapter 65.--PUBLIC HEALTH Article 1.--SECRETARY OF HEALTH AND ENVIRONMENT, ACTIVITIES Reporting to local health authority as to infectious or contagious diseases; persons reporting; immunity from liability; confidentiality of information; disclosure. (a) Whenever any person licensed to practice the healing arts or engaged in a postgraduate training program approved by the state board of healing arts, licensed dentist, licensed professional nurse, licensed practical nurse administrator of a hospital, licensed adult care home-administrator, licensed physician assistant, licensed social worker, teacher or school administrator knows or has information indicating that a person is suffering from or has died from a reportable infectious or contagious disease as defined in rules and regulations, such knowledge or information shall be reported immediately to the county or joint board of health or the local health officer, together with the name and address of the person who has or is suspected of having the infectious or contagious disease, or the name and former address of the deceased individual who had or was suspected of having such a disease. In the case of a licensed hospital or adult care home, the administrator may designate an individual to receive and make such reports. The secretary of health and environment shall, through rules and regulations, make provision for the consolidation of reports required to be made under this section when the person required to make the report is working in a licensed hospital or adult care home. Laboratories certified under the federal clinical laboratories improvement act pursuant to 42 code of federal regulations, 493 shall report the results of microbiologic cultures, examinations, immunologic essays for the presence of antigens and antibodies and any other laboratory tests which are indicative of the presence of a reportable infectious or contagious disease to the department of health and environment. The director of the division of health may use information from death certificates for disease investigation purposes. (b) Any person who is an individual member of a class of persons designated under subsection (a) of this section and who reports the information required to be reported under such subsection in good faith and without malice to a county or joint board of health, a local health officer or the department of health and environment shall have immunity from any liability, civil or criminal, that might otherwise be incurred or imposed in an action resulting from such report. Any such person shall have the same immunity with respect to participation in any judicial proceeding resulting from such report. (c) Information required to be reported under subsection (a) of this section shall be confidential and shall not be disclosed or made public, upon subpoena or otherwise, beyond the requirements of subsection (a) of this section or subsection (a) of K.S.A , except such information may be disclosed: (1) If no person can be identified in the information to be disclosed and the disclosure is for statistical purposes; (2) if all persons who are identifiable in the information to be disclosed consent in writing to its disclosure; (3) if the disclosure is necessary, and only to the extent necessary, to protect the public health; (4) if a medical emergency exists and the disclosure is to medical personnel qualified to treat infectious or contagious diseases. Any information disclosed pursuant to this paragraph shall be disclosed only to the extent necessary to protect the health or life of a named party; or (5) if the information to be disclosed is required in a court proceeding involving child abuse and the information is disclosed in camera. History: L. 1901, ch. 285, 2; R.S. 1923, ; L. 1953, ch. 283, 1; L. 1976, ch. 262, 1; L. 1979, ch. 189, 1; L. 1998, ch. 35, 1; L. 2000, ch. 162, 17; Feb. 1,

45 Chapter 65.--PUBLIC HEALTH Article 1.--SECRETARY OF HEALTH AND ENVIRONMENT, ACTIVITIES Duties and powers of local health officers; contagious diseases; confidentiality of information; disclosure, when. (a) Any county or joint board of health or local health officer having knowledge of any infectious or contagious disease, or of a death from such disease, within their jurisdiction, shall immediately exercise and maintain a supervision over such case or cases during their continuance, seeing that all such cases are properly cared for and that the provisions of this act as to isolation, restriction of communication, quarantine and disinfection are duly enforced. The county or joint board of health or local health officer shall communicate without delay all information as to existing conditions to the secretary of health and environment. The local health officer shall confer personally, if practicable, otherwise by letter, with the person in attendance upon the case, as to its future management and control. The county or joint board of health or local health officer is hereby empowered and authorized to prohibit public gatherings when necessary for the control of any and all infectious or contagious disease. (b) Any disclosure or communication of information relating to infectious or contagious diseases required to be disclosed or communicated under subsection (a) of this section shall be confidential and shall not be disclosed or made public beyond the requirements of subsection (a) of this section or subsection (a) of K.S.A , except as otherwise permitted by subsection (c) of K.S.A History: L. 1901, ch. 285, 3; R.S. 1923, ; L. 1953, ch. 283, 2; L. 1974, ch. 352, 8; L. 1976, ch. 262, 2; L. 1979, ch. 189, 2; July Chapter 65.--PUBLIC HEALTH Article 1.--SECRETARY OF HEALTH AND ENVIRONMENT, ACTIVITIES Rules and regulations of secretary for isolation and quarantine; publication; definition. (a) For the protection of the public health and for the control of infectious or contagious diseases, the secretary of health and environment by rules and regulations shall designate such diseases as are infectious or contagious in their nature, and the secretary of health and environment is authorized to adopt rules and regulations for the isolation and quarantine of such diseases and persons afflicted with or exposed to such diseases as may be necessary to prevent the spread and dissemination of diseases dangerous to the public health. (b) As used in K.S.A , , , , and , and amendments thereto, "infectious or contagious disease" means any disease designated by the secretary of health and environment as an infectious or contagious disease in accordance with subsection (a) but the infectious or contagious disease acquired immune deficiency syndrome or any causative agent thereof shall not constitute an infectious or contagious disease for the purposes of K.S.A , , , , and , and amendments thereto, because such disease is subject to the provisions of K.S.A through and amendments thereto. History: L. 1917, ch. 205, 1; R.S. 1923, ; L. 1953, ch. 283, 6; L. 1965, ch. 506, 25; L. 1974, ch. 352, 11; L. 1976, ch. 262, 7; L. 1988, ch. 232, 9; July 1. 43

46 Kansas Department of Health and Environment Kansas Administrative Regulation Designation of infectious or contagious diseases. (a) The following diseases shall be designated as infectious or contagious in their nature, and cases or suspect cases shall be reported within seven days, unless otherwise specified, in accordance with K.S.A and K.S.A , and amendments thereto. (1) Amebiasis; (2) anthrax (report by telephone within four hours to the secretary); (3) arboviral disease, including West Nile virus, western equine encephalitis (WEE) and St. Louis encephalitis (SLE); (4) botulism (report within four hours to the secretary); (5) brucellosis; (6) campylobacter infections; (7) chancroid; (8) Chlamydia trachomatis genital infection; (9) cholera; (10) cryptosporidiosis; (11) cyclospora infection; (12) diphtheria; (13) ehrlichiosis; (14) Escherichia coli enteric infection from E. coli 0157:H7 and other shiga toxin-producing E. coli, also known as STEC; (15) giardiasis; (16) gonorrhea; (17) Haemophilus influenzae, invasive disease; (18) hemolytic uremic syndrome, postdiarrheal; (19) hepatitis B in pregnancy (report the pregnancy of each woman with hepatitis B); (20) hepatitis, viral; (21) hantavirus pulmonary syndrome; (22) influenza deaths in children under 18 years of age; (23) legionellosis; (24) leprosy or Hansen s disease; (25) listeriosis; (26) Lyme disease; (27) malaria; (28) measles or rubeola (report by telephone within four hours to the secretary) (29) meningitis, bacterial (indicate causative agent, if known, and report by telephone within four hours to the secretary); (30) meningococcemia (report by telephone within four hours to the secretary); (31) mumps (report by telephone within four hours to the secretary); (32) pertussis or whooping cough (report by telephone within four hours to the secretary); (33) plague or Yersinia pestis (report by telephone within four hours to the secretary); (34) poliomyelitits (report by telephone within four hours to the secretary); (35) psittacosis; (36) rabies, animal and human (report by telephone within four hours to the secretary); (37) Rocky Mountain spotted fever; (38) rubella, including congenital rubella syndrome (report by telephone within four hours to the secretary); 44

47 (39) salmonellosis, including typhoid fever; (40) severe acute respiratory syndrome (SARS) (report by telephone within four hours to the secretary); (41) shigellosis; (42) streptococcal invasive, drug-resistant disease from group A Streptococcus or Streptococcus pneumoniae; (43) syphilis, including congenital syphilis; (44) tetanus; (45) toxic-shock syndrome, streptococcal and staphylococcal; (46) any transmissible spongioform encephalopathy (TSE) or prion disease (indicate causative agent, if known); (47) trichinosis; (48) tuberculosis, active and latent (report active disease by telephone within four hours to the secretary); (49) tularemia; (50) varicella or chickenpox; (51) yellow fever; and (52) any exotic or newly recognized disease, and any disease unusual in incidence or behavior, known or suspected to be infectious or contagious and constituting a risk to the public health (report by telephone within four hours to the secretary). (b) The occurrence of a single case of any unusual disease or manifestation of illness that the health care provider determines or suspects could be caused by or related to a bioterrorism act shall be reported within four hours by telephone to the secretary. The term bioterrorism act, as used in this article, shall mean a dispersion of biological or chemical agents with the intention to harm. Each bioterrorism act shall be reported within four hours by telephone to the secretary. The following shall be considered bioterrorism agents when identified in the course of a possible bioterrorism act: (1) Anthrax; (2) plague; (3) smallpox; (4) tularemia; (5) botulism; (6) viral hemorrhagic fever; (7) Q fever or Coxiella burnetii; (8) brucellosis; and (9) any other infectious or toxic agent that can be intentionally dispersed in the environment. (Authorized by K.S.A and ; implementing K.S.A and ; effective May 1, 1982; amended May 1, 1986; amended Dec. 24, 1990; amended April K.A.R , 1993; amended Jan. 12, 1996; amended Dec. 1, 1997; amended Feb. 18, 2000; amended, T , Nov. 20, 2003; amended March 5, 2004; amended April 28, 2006.) 45

48 Final Amended Regulation Article 1 - Diseases Kansas Department of Health and Environment KAR Kansas Department of Health and Environment Requirements for isolation and quarantine of specific infectious and contagious diseases; exception; definition. (a) Any of the requirements specified in this regulation for isolation and quarantined may be altered by the secretary of health and environment or the local health officer if the secretary or local health officer determines that an alteration is necessary for the greater protection of public health, safety, or welfare. The requirements for isolation or quarantine, or both, so altered shall be based on current medical knowledge of the infectious agent of the disease for which isolation or quarantine, or both, re ordered and may include consideration of the following factors: (1) The incubation period; (2) the communicable period; (3) the mode of transmission; and (4) susceptibility. (b) For the purposes of this regulation the phrase enteric precautions shall mean thorough hand washing after attending to infectious cases or touching the feces of an infected person, disinfection of articles that have been in contact with infectious cases or feces, and sanitary disposal of feces. (c) For the purposes of this regulation the phrase susceptible person shall mean someone for whom there is no history of disease that has been documented by a licensed physician, no laboratory evidence of immunity, or no documentation acceptable to the secretary that demonstrates current immunity against the disease. (d) The following isolation and quarantine precautions, as defined in K.A.R , shall be observed: (1) Amebiasis. Each infected food handler shall be excluded from that person s occupation until three negative stools have been obtained. Both the second and the third specimens shall be collected at least 48 hours after the prior specimen. (2) Chickenpox (varicella). Each infected person shall remain in isolation for six days after the first crop of vesicles appears or until the lesions are crusted, whichever comes first. Each susceptible contact of an infected person in a school, child care facility, or family day care home shall be vaccinated within 24 hours of notification to the secretary or excluded from the school, the child care facility, or the family day care home until 21 days after the onset of the last reported illness in the school, child care facility, or family day care home. (3) Cholera. Enteric precautions shall be followed for the duration of acute symptoms. (4) Diphtheria. Each infected person shall remain in isolation for 14 days or until two consecutive negative pairs of nose and throat cultures are obtained at least 24 hours apart and not less than 24 hours after discontinuation of antibiotic therapy. Each household contact and other close contact shall have nose and throat specimens tested and be monitored for seven days from time of last contact for symptoms. Healthy carriers with diphtheria shall be treated. Those contacts who are food handlers or work with children shall be excluded until nose and throat cultures are negative. 46

49 (5) Gonorrhea. Each infected newborn and prepubertal child shall be isolated for 24 hours following initiation of treatment with antibiotics. (6) Hepatitis A. Each infected person shall be excluded from food handling, patient care, and any occupation involving the car of young children and the elderly until 14 days after the onset of illness. (7) Meningitis caused by Haemophilus influenza. Each infected person shall remain in respiratory isolation for 24 hours after initiation of antibiotic therapy. (8) Meningitis, meningococcal. Each infected person shall remain in respiratory isolation for 24 hours after initiation of antibiotic therapy. (9) Mumps. Each infected person shall remain in respiratory isolation for five days from the onset of illness. Each susceptible contact of an infected person in a school, day care facility, or family day care home shall be vaccinated within 24 hours of notification to the secretary or excluded from the school, child care facility, or family day care home until 26 days after the onset of the last reported illness in the school, child care facility, or family day care home. (10) Pediculosis (headlice). Each student infested with lice shall be excluded from school, child care facility, or family day care home until treatment with an antiparasitic drug is initiated. (11) Pertussis (whooping cough). Each infected person shall remain in respiratory isolation for three weeks if untreated, or for five days following initiation of antibiotic therapy. Each susceptible contact of an infected person in a school, child care facility, or family day care home shall be vaccinated within 24 hours of notification to the secretary or complete a five day course of antibiotic therapy. Each susceptible contact of an infected person who does not receive the vaccination shall be excluded from the school, child care facility, or family day care home until 21days after the onset of the last reported illness in the school, child care facility or family day care home. (12) Plague (pneumonic). Each infected person shall remain in respiratory isolation until completion of 48 hours of antibiotic therapy. Each close contact who does not receive chemoprophylaxis shall remain in quarantine for seven days. (13) Poliomyelitis. Each infected person shall remain in isolation for 10 days from the onset of illness. Enteric precautions shall be followed for six weeks. (14) Rubella (German measles): Each infected person shall remain in respiratory isolation for seven days after the onset of rash. Each susceptible contact of an infected person in a school, day care facility, or family day care home shall be vaccinated within 24 hours of notification to the secretary or excluded from the school, child care facility, or family day care home until 21 days after the onset of the last reported illness in the school, child care facility, or family day care home. (15) Rubeola (measles). Each infected person shall remain in isolation for four days after the onset of rash. Each susceptible contact of an infected person in a school, child care facility, or family day care home shall be vaccinated within 24 hours of notification to the secretary or excluded from the school, child care facility, or family day care home until 21 days after the onset of the last reported illness in the school, child care facility, or family day care home. (16) Salmonellosis (nontyphoidal). Enteric precautions shall be followed for the duration of acute symptoms. Each infected person with diarrhea shall be excluded from food handling, patient care, and any 47

50 occupation involving the care of young children and the elderly until no longer symptomatic. Any asymptomatic and convalescent infected person without diarrhea may be excluded from, and may return to this work by the order of the local health officer or the secretary. (17) Scabies. Each child or student infected with scabies shall be excluded from the school, child care facility, or family day care home until treated with an antiparasitic drug. (18) Shiga-toxin producing Escherichia coli (STEC). Enteric precautions shall be followed for the duration of acute systems. Each infected person shall be excluded from food handling, patient care, and any occupation involving the care of young children and the elderly, until two negative stool cultures are obtained at least 24 hours apart and no sooner than 48 hours following discontinuation of antibiotics. No infected child shall attend a child care facility, or a family day care home until two negative stool cultures are obtained at least 24 hours apart and no sooner than 48 hours following discontinuation of antibiotics. (19) Shigellosis. Enteric precautions shall be followed for duration of acute symptoms. Each infected person shall be excluded from food handling, patient care, and any occupation involving the care of young children and the elderly until two negative cultures are obtained at least 24 hours apart and no sooner than 48 hours following discontinuation of antibiotics. Kansas Department of Health and Environment KAR , page 5 (20) Staphylococcal disease. Each infected food handler shall be excluded from that person s occupation until the purulent lesions are healed or until each wound is covered with an impermeable cover such as a finger cot, and a single-use glove is worn over the impermeable cover. (21) Streptococcal disease, hemolytic; including erysipelas, scarlet fever, streptococcal sore throat. Each infected person shall remain in isolation for 10 days if untreated or for 24 hours following initiation of antibiotic therapy. (22) Tinea capitis and corporis (ringworm): Each infected child or student shall be excluded from the school, child care facility, or family day care home until treated by a health care provider. (23) Tuberculosis, active disease. Each infected person shall remain in respiratory isolation until all of the following conditions are met: (A) Three sputa obtained on consecutive days are negative by microscopic examination. (B) The person has received standard multi-drug anti-tuberculosis therapy for at least two weeks. (C) The person shows clinical improvement. (24) Typhoid fever. Enteric precautions shall be followed for the duration of acute symptoms. Each infected person shall be restricted from food handling, patient care, and any occupation involving the care of young children and the elderly until three negative stool cultures, and three negative urine cultures in patients with schistosomiasis, have been obtained. Both the second and the third specimens shall be collected at least 24 hours after the prior specimen. The first specimen shall be collected no sooner than 48 hours following discontinuation of antibiotics, and not earlier than one month after onset. If any one of these tests is positive, cultures shall be repeated monthly until three consecutive negative cultures are obtained. (25) Sexually transmitted diseases. Each infected person shall follow isolation or quarantine measures established by the local health officer for persons who are confirmed or suspected of being infected with a sexually transmitted disease if these persons are recalcitrant to proper treatment. 48

51 (Authorized by K.S.A and ; implementing K.S.A ; effective May 1, 1982, amended May 1, 1986; amended Sept. 5, 1997; amended July 16, 1999; amended P-.) 49

52 3.0 Entering a New Human Case To enter a new human case, use the following procedure. 3.1 Choose NEW HUMAN CASE Click NEW HUMAN CASE on the Left Navigation Sidebar. The following screen will appear (see Figure 3.1). Fig Fuzzy Searches Before entering a patient into KS-EDSS, you must search the system to see if the case already exists. This prevents duplicates in the system, and ensures that your county numbers are reported accurately to the Center for Disease Control (CDC). The best method to search for a case is to use a fuzzy search. To do this, enter the first 2-3 letters of the last name in the Last Name field and the first 2-3 letters of the first name in the First Name field (a minimum of two letters in the Last Name field is required). For example, if you were searching for John Smith, you would enter smi under the Last Name field and jo under the First Name field. After hitting ENTER, a list of names that fall under these search parameters will appear on the KS-EDSS screen. Note: While you could also enter the date of birth and/or county, in general, the looser the search you perform, the more likely it is that you will avoid entering duplicates. More strict searches may not list patient records that have a typographical error in the name or an incorrect date or birth. By performing a fuzzy search, you reduce the risk of duplicating a patient in the database. It s possible that someone else may have entered your patient s name incorrectly or that the report you have misspells the name. By performing a fuzzy search more of these errors can be caught and eliminated. 50

53 Fig Entering Patient Information When you have performed your search, you will be taken to a screen listing possible matches. You may sort the cases by any of the columns in the blue, underlined column header (See Fig.3.2). For instance, if you click on Last Name, the cases will re-sort by last (This is recommended). If your patient is listed, click the CREATE CASE button located in the row of information beside the patient name. If the patient is not listed, click the CREATE NEW CASE button at the top of the screen. Either choice will take you to the New Patient screen. However, when you hit CREATE CASE, the patient s demographic information will be filled in since he or she is already in the system. Note: Make sure you verify that the patient demographic information that has been prepopulated into the new case fields is complete when you use the CREATE CASE option. The Patient Address information does not always populate completely in the new case record. If you are a local-level user, it is very important that you make sure the County field is populated under the Patient Address section. If no county is entered, you will be unable to view the case you have created once you hit SAVE & FINISH. If there is no county of residence listed in the case, the system will be unable to determine which county the case should be assigned to, and will automatically assign the case to the KS-EDSS Coordinator. If this occurs, permission restrictions will prevent local-level users from viewing the case. Please do not re-enter a case if you cannot locate one you just created. Contact the KS-EDSS Coordinator at KSEDSSadmin@kdhe.state.ks.us or (785) They will locate the case in the system and re-assign it to your county. Surveillance Guidelines on Reportable Diseases in Kansas March

54 There are three pages of information you must complete before the case is in the system. If you do not complete all three pages and hit SAVE & FINISH before exiting these pages, your data will not be saved, and over the information will have to be re-entered First Patient Information Screen This screen contains demographic information about the patient, including his or her name, date of birth, sex, race, etc. It also identifies what disease the patient has. Under the Disease Name field are two buttons: SUPP FORM (HTML) and PRINT SUPP FORM (PDF). Information on how to fill out supplemental forms can be found in Section 9. Fig.3.3 When you are entering data, some fields are required. You must fill them in if you wish to continue on to the next page. Other fields are optional. You may fill them in if you have the information, or you may leave them blank and fill them in later. Please do not leave information out of an investigation just because a field is not required. A field should only be left blank if you are unable to get the information during the course of your investigation, or if it does not apply to that particular case. Required fields are designated with red type and/or an asterisk (*). Optional fields are designated with black type. If you do not fill in a required field, KS-EDSS will not let you move forward. It will prompt you to fill in any missing required fields. When you have completed this screen click the CONTINUE button at the bottom of the page. The second patient information screen will appear. Surveillance Guidelines on Reportable Diseases in Kansas March

55 Note: When you are entering the patient s address, make sure you enter it in the Patient Address section not the Mailing Address section. The Mailing Address section should only be used if the patient s mailing address is different from his or her physical address (for example, a P.O. Box address). Leaving the Patient Address section blank but filling in the Mailing Address section prevents the system from properly assigning the case to the correct county. Note: If you do not enter a county in the County field of the Patient Address section, the case will be assigned to the KS-EDSS Coordinator with KDHE, and you will not be able to view it if you do not have statewide level permissions (see Section 3.2). Always enter a county, even if the rest of the address information isn t known. When in doubt, enter your own county. That way you will have access to the case Edit screens. Enter the correct address once you have that information. Note: The Report Date field denotes the date on which your office received notification of the case, not the date the referring authority made the referral. This field is equivalent to the Report Received field in HAWK. Though this field is automatically populated in KS-EDSS, it can be changed if you are entering a new case that was reported on an earlier date Second Patient Information Screen This screen contains the treatment history for the patient including hospitalizations, reporting information, and the primary attending physician. Fig. 3.4 The only required field in this screen is Name of Reporting Facility (See Fig.3.4). This field is a dropdown menu. Choose OTHER if the reporting facility does not appear on the list and contact KDHE at if you would like the facility to be added to the system. Surveillance Guidelines on Reportable Diseases in Kansas March

56 When you are have completed this screen, click the CONTINUE button at the bottom of the page. The third and final patient information screen will appear Third Patient Information Screen The final screen contains information on the patient s occupation (especially for those jobs that pose high risks of spreading infectious diseases), travel history, and an open text box for notes. Fig.3.5 There are no required fields in this screen, but enter any information you have received during your investigation. When you have finished entering information on this page, click the SAVE & FINISH button at the bottom of the screen. This will automatically take you to the case Edit screens. If it does not, either the case has not saved or your user permissions are not allowing you to see the case (refer to section 3.3). Surveillance Guidelines on Reportable Diseases in Kansas March

57 Note: Remember you must create a new case every time a patient is reported with a disease. For example, if a patient is in the system with Hepatitis A case, and later the patient contracts Hepatitis C, click the CREATE CASE button next to his or her name and fill out the three patient information screens. This is a separate disease event, so it needs its own case entered in KS-EDSS. 3.3 Assigning Cases Every time a new case is entered into KS-EDSS it is assigned to a KS-EDSS user at the county level. Local health department disease investigators are automatically assigned cases that fall under their purview. They also automatically receive an notification from the system alerting them that a new case has been assigned to them. Note: The notification feature is not currently working for new cases. Notifications are only sent when changes are made to an existing case. This will be fixed in a future build. Investigators who do not wish to have cases automatically assigned to them or who do not want an notification alerting them every time they are assigned a new case, should have their supervisors contact the KS-EDSS Coordinator at KSEDSSadmin@kdhe.state.ks.us. Keep in mind that notifications are an all-or-nothing feature. For instance, you cannot chose to receive them for new cases but to not receive them for changes made to existing cases. Local health department administrators are in charge of who gets automatically assigned cases and receives notifications in their health department. To request changes administrators should contact the KD-EDSS Coordinator at KDHE. Cases can be reassigned to a different investigator after they have been entered. Any investigator with permissions to view a case can edit it, even if they are not the assigned investigator. However, only the investigator assigned to the case will receive notifications regarding that case. Information on how to reassign cases is available in Section 4.3. Note: If a case is entered without its county being designated, it is assigned to the KS-EDSS Coordinator, who will assign it to a local investigator after determining to what county the case belongs. Remember, if you are a regional or local-level user, it is very important that you make sure the County field is populated under the Patient Address section. If no county is entered, you will be unable to view the case you have created. If there is no county of residence listed in the case, the system will be unable to determine which county the case should be assigned to, and will automatically assign the case to the KS-EDSS Coordinator. If this occurs, permission restrictions will prevent local-level users from viewing the case. Please do not re-enter a case if you cannot locate one you just created. Contact the KS-EDSS Coordinator at KSEDSSadmin@kdhe.state.ks.us or (785) They will locate the case in the system and re-assign it to your county. Surveillance Guidelines on Reportable Diseases in Kansas March

58 4.0 Editing Cases Often a case needs to be edited after it is entered in the system because information changes or more data is acquired. Please see Addendum B for additional information on locating and editing cases that were migrated from HAWK. 4.1 Getting into the Edit Cases Screen To edit a case, you must locate it in the system. There are several ways to do this, including performing a search, using specific criteria that will enable the case to be found. Information on how to perform searches can be found in Section 5. If you are the investigator assigned to the case you can locate it through your All Open investigations or My Open Investigations saved searches. When you login to KS-EDSS, you are automatically given a list of cases to which you have access. Fig. 4.1 Scroll down until you find the case you re looking for. Then click the EDIT button to the right of the case you wish to edit. Note: The system automatically sorts the case listings by INVESTIGATION STATUS. Sort by REPORT DATE to bring the most recent cases in the system to the top of the case listing screen. This may be done by selecting the down arrow on the first drop-down box to the right of the Case Listings label. Select Report Date and then click the SORT button to the right of the drop-down box. 56

59 Note: You can create a saved search and set it as your default search. This means that the list of cases meeting that search criteria will be the first screen you see each time you log in to KS- EDSS instead of the All Open Investigations list. (See section for more details). 4.2 Tabs The Edit Case screen features a number of tabs at the top. These are designed to look like the tabs on a series of folders. Each tab takes you to a different screen to edit specific data on the case. Fig. 4.2 Surveillance Guidelines on Reportable Diseases in Kansas March

60 When you first enter the Edit Case screen, the Case Reporting tab is highlighted, indicating that is the section of the case you are in. To move to another tab, click on the label of the tab you wish to view. The tab label is a link that will bring that screen to the forefront Case Reporting Tab The Case Reporting tab allows you to make changes to the disease event, case classification, the name of the patient, and other information directly related to the case itself. See Figure 4.2 for an overview of this screen. Note: Please see Addendum A form more information on properly using the Case Classification field. Surveillance Guidelines on Reportable Diseases in Kansas March

61 When you are finished making changes, click the SUBMIT CHANGES button at the bottom of the screen. If you do not click this button before moving on, a pop-up window with the message You are about to leave this page without saving your changes will appear on your screen (See Fig. 4.3). Select OK to stay on the Case Reporting tab or CANCEL to move to another area in the system without saving your changes. Fig. 4.3 The RESET button allows you to clear all the fields on the page so you can start over. CANCEL takes you out of the Edit Case screen without making any changes to the case. Note: Once you click SUBMIT CHANGES, CANCEL will not undo them. They must be manually removed by editing. The RE-ASSIGN CASE button can be found at the top of the Case Reporting tab, to the right of the investigator s name and jurisdiction. For more information on this feature read Section 4.9. The CONTACT TRACING link is located at the top center of the Case Reporting tab. Clicking on this link will open screens that allow you to enter detailed information on case contacts. For more information on CONTACT TRACING read Section 9.2. The CASE DEF button creates a new window with a searchable database of disease definitions. The PRINT INVESTIGATION button opens a new tab or window with a summary of the case. This allows you to create a hard copy of all the information on the case in question (See Fig.4.2). Surveillance Guidelines on Reportable Diseases in Kansas March

62 Note: The PRINT INVESTIGATION feature does not currently print all fields in the case. For instance, the Mailing Address fields do not print. Also, the information pulled from the Lab Reports tab only prints the case listing of the labs instead of all the information from each individual lab. If you want to print labs you must do each separately. This feature will be fixed in future KS-EDSS builds so that the summary will include all completed fields for the case. Surveillance Guidelines on Reportable Diseases in Kansas March

63 5.0 Searches Searches allow you to look through KS-EDSS to find a specific case or a series of cases using data from any or all of the fields from the Edit Case screens. 5.1 Temporary Searches A temporary search is a simple search to find a particular case. Click NEW SEARCH on the Left Navigation Sidebar to begin (See Fig.5.1). Fig

64 The search page appears. This feature allows you to search by any and all fields available in a case, such as: patient name, a range of dates, disease name, referring physician, and fields from the lab report section. You can specify as few or as many of these as you like by clicking in the fields and making choices. As a general rule, the more variables you specify, the more specific your search will be; the fewer variables, the broader the search will be. Surveillance Guidelines on Reportable Diseases in Kansas March

65 Fig.5.2 Any variables you do not select are treated as though you chose SELECT ALL in that field. At the bottom of the page, the CONTINUE button will take you to a second page with more variables. If you don t need any other criteria for your search, there is no need to click CONTINUE; you may click SEARCH to run your query. On the second page, the BACK button will take you back to the first page of variables. There are four pages of possible variables. Surveillance Guidelines on Reportable Diseases in Kansas March

66 Once you have selected all your variables, click SEARCH at the bottom of the page. All cases in the system that meet your criteria (that you have permission to view) will appear in a case listing. Note that this screen looks exactly like other case listing screens, such as the one you saw when you first logged into KS-EDSS, however the dropdown box will show TEMPORARY. Scroll down to find the case you want to work with, and then click the EDIT button in that row to open it. Fig.5.3 For example, if you wanted to find all the Varicella (chicken pox) cases in your county for October 2007, you would click NEW SEARCH on the Left Navigation Sidebar. You would scroll down in the Disease Name field and select VARICELLA (CHICKEN POX). In the Report Date fields type in 10/1/2007 in the From box and 10/31/2007 in the To box. Under the Patient Address section in the County field, click the arrow and select your county from the dropdown menu. Finally, click SEARCH. All the cases of chicken pox in your county during October of 2007 that you have permission to view will be displayed. You could make this search more specific by entering more variables. If you chose ACTIVE in the Investigation Status field, for example, your search would only find active cases of Varicella for the time period you specified. Surveillance Guidelines on Reportable Diseases in Kansas March

67 For example, if you wanted to find all the Varicella (chicken pox) cases in your county for October 2007, you would click NEW SEARCH on the Left Navigation Sidebar. You would scroll down in the Disease Name field and select VARICELLA (CHICKEN POX). In the Report Date fields type in 10/1/2007 in the From box and 10/31/2007 in the to box. Finally, under Patient Address in the County field, you would click the arrow and select your county from the dropdown menu. When you click SEARCH, all the cases of chicken pox in your county during October of 2007 that you have permission to view will be displayed. Note: A temporary search will remain available as a search option in your dropdown list of searches (On the main CASES screen) until you run another NEW SEARCH, or until you logout of the system. 5.2 Saved Searches Keep in mind that if you want to repeat a temporary NEW SEARCH, you have to go in and specify the variables each time you want to perform it. A saved search allows you to set up a search with certain variables that you can perform over and over again Creating a Saved Search To creat a saved NEW SEARCH, click NEW SEARCH on the Left Navigation Sidebar. At the top of the screen there is a field labeled Name of Saved Search. You must give a search a name in order to save it. Click in the field and type in a name. Enter the variables for your search just as if this was a temporary search (See section 5.1). Fig.5.4 When you have named your search and specified all your variables, instead of clicking SEARCH at the bottom of the page, click SAVE & FINISH. Your search will now be saved, and you can run it again and again. If you have not named your search and you click on SAVE Surveillance Guidelines on Reportable Diseases in Kansas March

68 & FINISH you will get an error message Search name is required directing you to correct the error before proceeding. Note: Clicking SAVE & FINISH does not run your search. It only saves it in the system. When you click the SAVE & FINISH button, you will be taken to the Searches page. See Section for information on running a saved search Finding and Running Saved Searches To access your saved search(es), click SEARCHES on the Left Navigation Sidebar. This will bring up a screen with all of your saved searches on it. If you haven t created any saved searches, there will be two searches listed here: All Open Investigations, which lists all the open cases in the system that you have permission to view, and My Open Investigations, which will bring up all the open cases assigned to you. Note: Open investigations are cases with an Investigation Status of New or Active. Fig.5.6 To run a search, click the SEARCH button next to its name. It will bring up a case listing according to the criteria you set. You can also run a saved search from the Cases page. Click CASES on the Left Navigation Sidebar. At the top right hand corner of the Cases page is a dropdown menu that shows the current search. Click the down arrow to get a list of your saved searches. Select the one you want to perform, then click SEARCH to the right of the dropdown menu. A new case listing that matches the criteria of the selected search will be loaded. Surveillance Guidelines on Reportable Diseases in Kansas March

69 Fig Editing Searches You can change the criteria of a saved search at any time by adding, subtracting, or updating variables. On your SEARCHES screen, click the EDIT button next to the search name you want to edit. This will bring up the New Search screen with that all the variables you have previously selected. You can then enter new variables, unselect others, or change ones you have already set. For example, you might want to change the dates of the search to make it more current. When you are finished editing the search, click SAVE & FINISH. Your search will be updated, and you will be taken back to the Searches screen, where you can run the updated search. Note: If you edit a saved search and then click SEARCH instead of SAVE & FINISH, the system will pull up a case listing that matches the newly selected criteria. However, it will not save the changes; instead it will treat the search as a temporary search. If the system does not direct you to the Searches screen, you have not saved your search. Surveillance Guidelines on Reportable Diseases in Kansas March

70 5.2.4 Default Searches Every user has a default search in KS-EDSS. This is the search the system automatically performs to bring up the case listing screen you see when you log in. Fig.5.8 You can change the default search, but you can only have one default search at a time. To set a search as your default, click SEARCHES on the Left Navigation Sidebar. Click EDIT next to the search you want to make your default. This will take you to the NEW SEARCH screen with the variables you have previously selected. In the upper right-hand corner of the screen is a box labeled, Default Search. Click the box. A checkmark appears (See Fig.5.9). Fig.5.9 When you see the checkmark, scroll down to the bottom of the page and click SAVE & FINISH. You will be returned to the Searches screen. Your new default search will have an X in the column labeled Default (See Fig.5.8). This search will now be performed every time you log in. Surveillance Guidelines on Reportable Diseases in Kansas March

71 5.2.5 Deleting Searches If you do not need a search anymore, it can be deleted. Click SEARCHES in the Left Navigation Sidebar and click DELETE next to the search you want to delete. Default searches cannot be deleted (thus there is no DELETE button in the row of the default search. See Fig.5.10). If you wish to delete a search you have set as your default, you must first designate another search as your default. Click EDIT next to the search you wish to make the default and follow the procedure outlined in Section for setting default searches. When you are finished, click DELETE next to the search you wish to eliminate. Fig Sorting Data When a search case listing is displayed, it can be organized a number of different ways. At the top of the screen next to the Case Listings label there are two dropdown fields. Clicking the down arrow on the left dropdown menu allows you to sort cases according to INVESTIGATION STATUS, DISEASE, PATIENT NAME, REPORT DATE, INVESTIGATOR, or JURISDICTION. Select the option you want to sort by, and then click SORT to the right of the dropdown menu. The case listing will be reorganized according to the option you chose. Surveillance Guidelines on Reportable Diseases in Kansas March

72 Fig Exporting Data If you need a hard copy of the data with which you are working, you can export it to a spreadsheet. On the Left Navigation Sidebar click SEARCHES. When the Saved Searches screen comes up, select SEARCH in the row of the search you wish to export. This will run a case listing according to that search s criteria. Fig.5.12 Surveillance Guidelines on Reportable Diseases in Kansas March

73 Near the top of the screen on the right-hand side is a button labeled, EXPORT. When clicked, it creates a pop-up window asking you if you want to open or save the file. Click OPEN to open a spreadsheet at your workstation displaying the data from all the cases in the search. Click SAVE to save the data as a spreadsheet on your computer. You will then be prompted to choose a location on your computer for the file. Make sure it is a secure location and that you remember where you saved it! Clicking CANCEL will close the pop-up window without the spreadsheet opening or saving to your computer. Once you have the file open (or saved) on your computer, you have the option to print it or import the file into a SAS program for analysis. Surveillance Guidelines on Reportable Diseases in Kansas March

74 6.0 Reports Several reports are available, organizing disease data in KS-EDSS for analysis and presentation. 6.1 The Reports Section Reports are accessed by clicking REPORTS on the green menu bar at the top of the screen. The Case Listing report will automatically display when you navigate to this section of the system. Fig.6.1 The REPORTS label is now brighter than the CASE INVESTIGATION and LOGOUT labels to indicate you are in the Reports section of the system. The Left Navigation Sidebar changes to show the available reports: CASE LISTING DISEASE BY DEMOGRAPHICS YEARLY REPORT BY MONTH/WEEK DISEASES 5 YEAR HISTORY DISEASE BY GEOGRAPHIC AREA ANIMAL RABIES REPORT EPI CURVE HUMAN WEST NILE VIRUS REPORT 72

75 6.2 Report Output Reports can be viewed in three formats. You must select which format you want when you run the report HTML The HTML (HyperText Markup Language) displays the data in standard Web page format by opening the data in a new tab or window in your browser. This is a good option if you do not have Adobe Acrobat. It allows you to quickly view the information. However, the presentation is not as clean as a PDF file (See Section 6.2.2). Note: The Epi Curve report is not available in the HTML format PDF The PDF (Portable Document Format)file is non-editable and can be read by Adobe Acrobat. If you have Adobe Acrobat on your computer, this output is superior to HTML. It is much cleaner and easier to read. Choosing PDF as your output format will automatically launch Acrobat Reader on your computer. You will need at least Version 6.0 to view output in this format CSV The CSV (Comma-Separated Values) file is a text format in a spreadsheet format. A window will pop up asking if you want to open a spreadsheet file or save one to your computer. This function works exactly like exporting data from a search (See Section 5.4). 6.3 Running Reports All reports, excluding the Case Listing report and Human West Nile Virus Report, present only aggregate count data and have no restrictions on users. The Case Listing report and Human WNV Report present patient-level data; your role must have the appropriate permission to view that level of data for you to view/export this report Running Reports To run a report, click the name of the report on the Left Navigation Sidebar. On the following screen, select the variables you want to search just as you would with the New Search feature in the Case Investigation section (See Section 5.1). Note: Some reports may have required fields (see Section 2.3) such as starting and ending dates. Required fields are designated with red type and/or an asterisk (*). Note: Some reports have radio dial choices. A radio dial is a white circle that fills in green when you selected. Doing so deselects any other radio dial in that section. For example, when selecting a geographic region, you can search by Zip code or by county, but not both. Click the Surveillance Guidelines on Reportable Diseases in Kansas March

76 radio dial for the choice you want, and then make any more specific choices in the box accompanying the radio dial. Fig.6.2 When you have selected all your variables, scroll down to the bottom of the screen and click VIEW HTML REPORT, VIEW PDF REPORT, or VIEW CSV REPORT. A fourth button, RESET, clears all the fields and allows you to start over. Surveillance Guidelines on Reportable Diseases in Kansas March

77 6.4 Specific Report Information Notes on the specific reports follow below Case Listing The "Case Listing" report displays a patient-level list of all cases that fall within a specified time period, geographic area, and disease group as defined by the report parameters. Choose which variable to include in your report output by selecting or deselecting the "Display Columns" check boxes (See Fig.6.2). Note: Lab-related Display Columns in this report are only available in CSV output. Below is an example of a Case Listing report (created without identifying information) in HTML format: Fig.6.3 Surveillance Guidelines on Reportable Diseases in Kansas March

78 Note: Investigation IDs are hyperlinked to cases when the report is viewed in HTML or PDF format. This means that if you click on the Investigation ID link the case will open in a new tab or window in your browser Disease by Demographics The "Diseases by Demographics" report displays a table of count or percentage information for all diseases that fall within a specified time period and geographic area as defined by the report parameters. The count or percentage information can be further broken down by demographic information by selecting the appropriate display variables. Fig.6.4 Note: The screen for this report looks different than the standard KS-EDSS format. The VIEW PDF REPORT and VIEW HTML REPORT buttons are flipped. Otherwise, it works exactly the same as other reports Surveillance Guidelines on Reportable Diseases in Kansas March

79 Figure 6.5 is an example of a Disease by Demographics report in HTML format: Fig Yearly Report by Month/Week The "Yearly Report by Month/Week" report displays a table of year-to-date count information for all diseases that fall within the selected year and geographic area as defined by the report parameters. The count information can be displayed by month or week. Figure 6.6 is an example of a Yearly Report by Month/Week report in HTML format: Fig.6.6 Surveillance Guidelines on Reportable Diseases in Kansas March

80 6.4.4 Diseases 5 Year History The "Diseases 5 Year History" report displays a comparison table of count information for all diseases reported for the present and preceding four years within the geographic area as defined by the report parameters. The count information can be displayed by year, month or week. Fig.6.6 Surveillance Guidelines on Reportable Diseases in Kansas March

81 Figure 6.7 is an example of a Disease 5 Year History report in HTML format: Fig.6.7. Surveillance Guidelines on Reportable Diseases in Kansas March

82 6.4.5 Disease by Geographic Area The "Disease by Geographic Area" report displays a table of count information for all diseases that fall within the selected time period and geographic area as defined by the report parameters. The count or rate information can be displayed by geographic boundaries and areas. Fig.6.8 Surveillance Guidelines on Reportable Diseases in Kansas March

83 Figure 6.9 is an example of a Disease by Geographic Area report in HTML format: Fig.6.9 Surveillance Guidelines on Reportable Diseases in Kansas March

84 6.4.6 Animal Rabies Report The "Animal Rabies" report displays a table of count information for all incidences of rabies that fall within the selected time period and county (or all counties). Fig.6.10 Note: The screen for this report looks different than the standard KS-EDSS format. The VIEW PDF REPORT and VIEW HTML REPORT buttons are flipped. Otherwise, it works exactly the same as other reports Figure 6.11 is an example of an Animal Rabies report in HTML format: Fig.6.11 Surveillance Guidelines on Reportable Diseases in Kansas March

85 6.4.7 Epi Curve The "Epi Curve" report displays a graph in which the number of new cases of a selected disease is plotted against the selected time period defined by the report parameters. The graph information can be further broken down by time interval. This report does not offer HTML output. Only the PDF report includes both the graph and data. The CSV report includes the data, but you must use other software, such as a spreadsheet or database program, to create and view the graph. Fig.6.12 Surveillance Guidelines on Reportable Diseases in Kansas March

86 Figure 6.13 is an example of an Epi Curve report in PDF format: Fig.6.13 Report 8: Epi-Curve Graph Time Period: 06/01/ /31/2006 Time Breakdown: by Day Reportable Condition: Geographic Area: The State of Kansas Case Classifications] Day Total Human West Nile Virus Report The "Human West Nile Virus" report displays a patient-level list of all the West Nile Virus cases that fall within a specified time period, geographic area, and disease group as defined by the report parameters. Choose which variable to include in your report output by selecting or deselecting the "Display Columns" check boxes (See Fig.6.14). Surveillance Guidelines on Reportable Diseases in Kansas March

87 Fig.6.14 Surveillance Guidelines on Reportable Diseases in Kansas March

88 Note: Lab-Related Display Columns in this report are only available in CSV output. Figure 6.15 is an example of a Human West Nile Virus Report in HTML format: Fig.6.15 Note: Investigation IDs are hyperlinked to cases when the report is viewed in HTML or PDF format. This means that if you click on the Investigation ID link the case will open in a new tab or window in your browser. Surveillance Guidelines on Reportable Diseases in Kansas March

89 9.0 Supplemental Forms Some diseases have supplemental information that is required by CDC (See Appendix A for a list of diseases with supplemental forms). A supplemental form is available when a case for one of these diseases is created in KS-EDSS. The forms must be filled out when a case is investigated, or the case will not be considered complete. 9.1 Adding a Supplemental Form Supplemental form data should always be added to a case from the Edit screens. Run a search for the case you need to edit (See Section 5.1), and then click the EDIT button for that case. The buttons to access supplemental forms are found on the Case Reporting tab directly below the Disease Name field (See Fig.9.1). Fig Accessing Supplemental Forms Click the SUPP FORM (HTML) button. A message box will pop up that says, Any data changes will be lost. Presses cancel to return. Press OK to continue. If you have made changes on the Case Reporting tab and you have not hit SUBMIT CHANGES at the bottom of the screen, these changes will be lost if you select OK. If you have not made changes, choose OK and you will be forwarded to a white screen that says, If your browser does not automatically navigate to the next page click the Continue button. This should only appear for a couple of seconds before the supplemental form screen loads. Otherwise, follow those instructions to load the supplemental form screen. 87

90 Note: To print the supplemental from you would select the PRING SUPP FORM(PDF) button instead of the SUPP FORM(HTML) button. This will open in Adobe Acrobat with a version of the supplemental form containing all the information that has been input on the HTML version of the form. You cannot enter data directly on the PDF version, nor can you save a copy. However, this is useful if you need to fax the form, or would like a paper copy for a case record. To exit the PDF version of the form you will always click the CANCEL button on the top of the form (See Fig.9.2). You will return to the Case Reporting tab. Fig.9.2 If there is no supplemental form for your disease, you ll receive an error page (See Fig.9.3). Simply click the BACK button at the bottom of the screen (NOT THE ONE AT THE TOP OF YOUR BROWSER) to return to the Case Reporting tab. You may also use the RETURN TO KS-EDSS link in the Left Navigation Sidebar to return to the Case Reporting tab. This can be found at the very bottom of the Left Navigation Sidebar (you may have to scroll down the page to see this link). Surveillance Guidelines on Reportable Diseases in Kansas March

91 Fig Multiple Forms For some diseases, you have a choice of supplemental forms. When you click SUPP FORM (HTML) (or PRINT SUPP FORM (PDF)) the system will take you to a screen with a dropdown list of associated forms. You should always choose the form that is most specific to your investigation. For example, if you are in a HEPATITIS A case and click SUPP FORM (HTML), a screen asking you to select either the HEPATITIS A form or the ENTERIC DISEASE form will load. You would choose HEPATITIS A since that is more specific to your individual case. However, you should also fill out the other supplemental form with any information you have that doesn t fit the specific form. Continuing with the Hepatitis A example, if there is enteric disease information that does not fit the HEPATITIS A form, enter it on the ENTERIC DISEASE form. When you fill out two supplemental forms, choose the most specific form first. Any information that doesn t fit can then be entered on the less specific form. If you still have more case information that does not fit on either supplemental form, please enter this into the Notes tab in the main case record. Surveillance Guidelines on Reportable Diseases in Kansas March

92 Fig Bi-directional Data Some data in KS-EDSS is bi-directional. When certain fields in the Patient Information screens are populated, the system will automatically enter the information into the corresponding supplemental form field too. Thus, when you open a supplemental form for your case, certain fields will already be populated. You can make changes to the supplemental form fields, and doing so will save the changes in both locations when you hit SUBMIT. For example, the patient s full name, demographic information, and date of birth will automatically appear in the supplemental form, so you do not have to enter them again. The following fields are bi-directional: Case Type Disease Classification Last Name First Name Age Date of Birth Race Ethnicity Sex Patient Address Daytime Phone Evening Phone Person Providing Report Occupation Required Fields Surveillance Guidelines on Reportable Diseases in Kansas March

93 Just like with other screens in KS-EDSS, supplemental forms have required fields. Many of these are the bi-directional fields listed in section If there are required fields not filled in on the supplemental form, you must complete them to save information on the form. Although not every field is required, you should attempt to complete every field that is applicable to your case. Supplemental information on these forms is data that the CDC wants collected, and therefore should not be viewed as optional. Note: Some supplemental lab information that does not have a place on the Lab Reports tab and is requested by CDC will be found on the supplemental forms, but this is rare. Any pertinent lab information that is not found on either the Lab Reports tab or the supplemental form should be entered on the Notes tab Filling out the Form Many fields on the supplemental forms are radio dial choices (See Fig.9.5). A radio dial is a white circle that fills in green when you selected. Doing so deselects any other radio dial in that field. If you click the wrong radio dial in a field, simply click the correct one to change it. Fig.9.5 Checkboxes are also used (See Fig.9.6). These white squares fill in with a checkmark when you click them. These fields are often accompanied by the phrase, Check all that apply. Checkboxes work just like radio dials except that you can make more than one choice. Click in a box to check it. Click in as many boxes as appropriate. To uncheck a box, click in the checked box and the checkmark will disappear. Surveillance Guidelines on Reportable Diseases in Kansas March

94 Fig.9.6 Note: Please follow the format suggestions given in a field when entering data in the supplemental form (See Fig.9.6). If you do not enter data in the correct format you will get an error message and will be unable to save any of the information on the supplemental form until you have corrected your error. When you are finished filling out the form, click SUBMIT at the bottom of the page. This will take you back to the Case Reporting tab of the case you are working on. If you click SUBMIT and you are not returned to this screen, scroll to the top of the page and check for an error message. You must choose SUBMIT to save your data. If you exit the supplemental form any other way, such as selecting the RETURN TO KS-EDSS button, your data will not save. Note: Error messages in the supplemental forms are not always specific to the fields where an error has been made, and therefore can be difficult to fix. Please contact the KS-EDSS Coordinator if you are having trouble fixing an error in a form. If at all possible, do not exit the form without correcting the error so that your data is saved. Once you return to the Patient Information screens, any bi-directional data (see Section 9.1.3) filled out in the supplemental form will be populated into the corresponding fields in the appropriate tabs. Surveillance Guidelines on Reportable Diseases in Kansas March

95 9.2 Supplemental Form Searches This feature allows users to export data from the supplemental form fields for use in data analysis Getting to the Supplemental Form Search Screens Select a case from your case listing that you know has a supplemental form associated with it (See Appendix A). Click on the EDIT button for that case to bring up the Case Reporting tab. Select the SUPP FORM(HTML) button under the Disease Name field. This will load the supplemental form (See section 9.1). From the Left Navigation Sidebar select the QUERY BY EXAMPLE link. This will load the Form builder environment (Fig.9.7). Fig.9.7 Surveillance Guidelines on Reportable Diseases in Kansas March

96 Note: Though not currently available, in a future build you will be able to select NEW SUPPLEMENTAL FORM SEARCH on the Left Navigation Sidebar to load the Form builder environment (See Fig.9.8). Fig Setting up the Query Make the following selections on the Query by Example page (See Fig.9.9): Form Type = Data Collection Form Owner Category = Case Category Owner Subcategory = Select the disease name. Form = Select the form from which you will be exporting data from the list of supplemental forms associated to the previously selected disease. Surveillance Guidelines on Reportable Diseases in Kansas March

97 Fig.9.9 Select the QUERY button at the bottom of the Query by Example screen. The system displays the supplemental form and the associated fields Selecting Search Criteria The supplemental form fields allow you to select your search criteria with as much or as little detail as you prefer. Enter or highlight the search criteria in which you are interested. Any field that is formatted as a dropdown box on the supplemental form will appear as a list in the query. You may select more than one option from the list by holding down CTRL on your keyboard as you click multiple selections from the list with your mouse. After you have chosen all of your search criteria, select SUBMIT at the bottom of the screen (See Fig.9.10). Fig.9.10 Surveillance Guidelines on Reportable Diseases in Kansas March

98 9.2.4 Query Results The system displays the case counts that match the search criteria and allows you to export the results either as CSV, HTML or XML format (See Fig.9.11). You also have the option to save the query. If you chose the CSV option your results will open as a zip file with three spreadsheets. One spreadsheet will have the data from the Case History fields on the supplemental form. Another spreadsheet contains the data from the Patient Demographic fields and the spreadsheet labeled start.csv contains the data from the remainder of the fields in that supplemental form. All three spreadsheets have a column with the Investigation ID so that they may be linked together easily. Note: The Save Query feature is not working in the current version of KS-EDSS. Also note that the column labels in the spreadsheets are not exactly the same as the fields on the supplemental forms. And finally, some of the drop down boxes are not properly exporting information to the spreadsheets. All of these issues will be resolved in later builds. Fig.9.11 Surveillance Guidelines on Reportable Diseases in Kansas March