PIHOA-SPC-WHO-FNU-RAPID-CDC Joint EpiTech-Data for Decision Making Training Program Data for Decision Making I: Disease Outbreak Surveillance & Response Meeting Report: Palau, June 2014 Location: Palau Community College, Republic of Palau, Western Pacific Dates: June 30-July 5, 2014 Additional Sponsors: Association of State and Territorial Health Officers, Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET), Palau Ministry of Health, CDC Office of Public Health Preparedness & Response Course Objectives: 1) Reinvigorate of EpiNet teams in the USAPI through building of knowledge and skills of EpiNet team members and linking of emergency preparedness program officers to disease outbreak teams in their jurisdictions 2) Strengthen capacity of teams through development of standard operating procedures for routine communicable disease surveillance at jurisdiction level 3) Obtain academic course credit for students toward formal credentials in applied epidemiology through Fiji National University 4) Build a mid-level Epi-tech track to complement advanced applied epidemiology training to be offered within a Pacific SHIP/FETP fellowship program Facilitators: Afeke Kambui, Association of State and Territorial Health Officials (ASTHO); Janice McMichael, US Centers for Disease Control and Prevention (CDC); Sevil Huseynova, World health Organization (WHO); 1
Haley Cash, Palau Ministry of Health; Dawn Fitzgibbons, Palau Ministry of Health; Mark Durand, PIHOA; Thane Hancock, PIHOA Participants: 19 Participants from the U.S. Associated Pacific Islands including CNMI, Guam, Palau, Yap, and Pohnpei, 1. Suzette Brikul, Palau 2. Doris Cruz, CNMI 3. Wincener David, Pohnpei 4. Kate Decherong, Palau 5. Kiah Farr, Palau 6. Jolie Gurtmag, Yap 7. Grace Lapid Rosadino, Guam 8. Teliwy Liwy, Pohnpei 9. Oshiro Lorin, Palau 10. Monaliza Melayong, Palau 11. Israella Reklai, Palau 12. Mindy Sugiyama, Palau 13. Rosalita Tadao, Palau 14. Hilda Tafledep, Yap 15. Tebuka Toatu, SPC (Pohnpei) 16. Irish Tutii, Palau 17. Alyssa Uncangco, Guam 18. Elchesel Wilfred, Palau 19. Willa Wong, Palau Background: EpiNet is the response arm of the Pacific Public Health Surveillance Network. These teams were established by the health authorities in all 22 of the Pacific Island countries and territories in 2001. The multidisciplinary teams coordinate surveillance and field response activities for their jurisdiction; in addition the Epinet teams establish and maintain relevant surveillance and response protocols for target diseases. From 2001, EpiNet teams built epidemiologic capacity for the entire Pacific including the establishment and management of surveillance systems and responding to outbreaks such as dengue and SARS. In 2010 and 2012, the Declaration of Health Emergency for NCDs and the heightened threats of dengue and influenza outbreaks in the Northern Pacific demonstrated a need to improve the epidemiologic capacity of the region, both for outbreak prone diseases (via EpiNet teams) and for other public health surveillance officers, including those responsible for NCDs. 2
The EpiTech-Data for Decision Making series for the Pacific is a collaborative project of PIHOA, the Secretariat for the Pacific Community (SPC), the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO), the Fiji National University (FNU) and AusAID-funded Response and Analysis for Pacific Infectious Diseases Project (RAPID) of Hunter-New England Health District. A version of Module 1 (of 5) of CDC s Data for Decision Making curriculum was used for this workshop. This module was recently updated by technical staff from SPC and RAPID, and had been pilot tested in previous workshops. This was the fourth time that Module 1 has been delivered in the Pacific in the past 12 months. The Data for Decision Making curriculum is a set of 5 courses (four instructional and one independent project) that originated with a set of US Centers for Disease Control and Prevention workshop modules and was converted to an accredited applied epidemiology curriculum in the early 2000s through the then Fiji School of Medicine, Department of Public Health (by Dr. Naren Singh of the then Fiji School of Medicine, and Dr. Mike O Leary, of WHO). In 2013, a revision of the course package was undertaken in partnership by a group of epidemiologists from Fiji National University School of Medicine, Nursing, and Health Sciences Department of Public Health (FNU), Secretariat for the Pacific Community, PIHOA, WHO, RAPID project of Hunter-New England Health District/Univ. of Newcastle, WHO, and CDC. Students must formally register with FNU for each course. Course faculty will have appointments with FNU (as adjunct faculty for epidemiologists working for regional associations). Student performance will be measured against course learning objectives through end of course examinations and student projects. Full time faculty at FNU will perform final assessment of student based on examinations and projects, and award course credit. Students who pass all 5 courses will be awarded a post-graduate certificate in applied epidemiology from FNU. With 4 additional courses students can be awarded a post graduate diploma and with an additional 4 courses, a Master s degree. Courses passed can also count toward Bachelor degrees for those who do not yet have a BA or BS. The 5 courses are as follows: DDM1- Outbreak Surveillance and Response DDM2- Basic Applied Epidemiology and Data Analysis DDM3- Advanced Applied Epidemiology and Data Analysis DDM4- Public Health Surveillance DDM5- Surveillance Project or Research Project Work Shop Details: The workshop was conducted at the Palau Community College Conference Hall. In order to achieve the goals the following objectives and methods were utilized: Objectives: 3
1. To be aware of (and link in with) important networks for surveillance in the Pacific (e.g., PPHSN) and the services they provide 2. List the reasons that health agencies investigate reported outbreaks. 3. Explain Why do epidemics/outbreaks occur? and why investigate outbreaks? 4. List the conditions that present as outbreaks in the Pacific region, perhaps by countries. 5. Define the terms cluster, outbreak, epidemic, endemic, hyperendemic, pandemic, holoendemic, sporadic. 6. Describe types of outbreaks and investigation scenarios 7. Given the initial information of a possible disease outbreak, describe how to determine whether an epidemic exists. 8. Outline the steps involved in an investigation of Outbreak/epidemic 9. Define and calculate attack rates. 10. Write a case definition, refine it and state the effect of increasing or decreasing the elements of case definition and identify the population at risk ie. realize at which stage in the outbreak to use sensitive or specific case definitions. 11. State what a line listing is and what it is used for? 12. Given information about a community outbreak of disease, execute the initial steps of an investigation and develop biologically plausible hypotheses by analyzing time/place and person characteristics of the epidemic. 13. Identify and draw different types of epidemic curves and discuss the sources of outbreak. 14. Decide when to investigate further. 15. Outline the control or management and prevention of epidemics, including use of the Pacific Outbreak Manual as a reference. 16. Write a report of the outbreak/epidemic investigation and list the categories of persons that need to be communicated with during an outbreak investigation. 17. To understand the principles of risk communication. 18. To be able to write a PacNet message that includes the appropriate information. 19. Present an overview of surveillance and outbreak investigation. Methods: Multiple teaching methods were utilized to deliver the course content and achieve the identified objectives. These included: 1) Lectures: a. Course Overview and Background b. Course Expectations and What is an EpiNet Team c. Introduction to IHR, Pacific Outbreak Manual and syndromic Surveillance d. Descriptive epidemiology Part I e. Descriptive epidemiology Part II f. Disease surveillance g. Displaying data h. Outbreak Investigation 4
i. Outbreak response and control j. Disease surveillance and control: Beyond outbreaks 2) Group work/exercises a. Descriptive epidemiology activity b. Jurisdiction Project: (1) Mapping reportable surveillance in your country/jurisdiction (2) Mapping syndromic surveillance in your country/jurisdiction (3) Development of standard operating procedures for reportable and/or syndromic surveillance c. Mystery outbreak investigation/case study d. Outbreak response and control- Case Study 1 (Rash and Fever) e. Outbreak response and control- Case Study II (ILI with Chicken Die-Off) 3) Group presentations- evaluation a. Presentation and constructive critique on jurisdiction project b. Presentation on Situational Report developed from own data 4) Written examination- evaluation a. 90 minute written exam 5
Agenda: Time Activity (approximate time) Activity type Facilitator Material needed/used Mon June 30 8:00-8:30 Registration (Light Breakfast) Name badges, FNU course applications 8:30 Minister of Health, Opening Greg Ngirmang 8:35-10:00 Welcome & Invocation (10 min) Full group, discussion Durand Introductions (20 min) Full group, facilitated Durand None Course overview and background: PPHSN, EpiNet teams and FETP continuum (20 min) Presentation Durand Distribute new edition Pacific Outbreak Manual Tue July 1 Expectations on this course. What are important/ideal knowledge and skills for EpiNet teams? (40 min) Full group. Facilitated discussion/intro. Hancock 10:00-10:30 MORNING TEA 10:30-11:30 Introduction to: IHR, Pacific Outbreak Manual, Syndromic Surveillance Full group, lecture Husynova 11:30-12:30 Descriptive epidemiology, Part 1 Full group, lecture Cash PP13 Module 1 descriptive epi 12:30-13:30 LUNCH 13:30-14:00 Descriptive epidemiology, Part 2 Full group, lecture Cash PP13 Module 1 descriptive epi 14:00-15:00 Descriptive epidemiology - activity Group work 1 (by 5) All facilitators, led by Hancock PP13 Module 1 Activity 15:00-15:30 AFTERNOON TEA 15:00-17:00 Descriptive epidemiology - activity Group work 1 (by 5) (continued) All facilitators, led by Hancock PP13 Module 1 Activity 8:25-8:30 Monday recap Course participants 8:30-9:30 Disease surveillance (60 min) Fitzgibbons PP13 Module 2 Disease surveillance 9:30-10:30 Reportable and syndromic surveillance in your country: detection - confirmation - action.(jurisdiction project, choose one: > Reportable disease mapping > Syndromic surveil strengthening > Reportable & Syndromic SOPs Group work 2 (by country) 10:30-11:00 MORNING TEA 11:00-12:00 Work jurisdiction project, continued 12:00-13:00 LUNCH 13:00-14:30 Work jurisdiction project, continued Group work 2 (by country) Group work 2 (by country) 14:30-15:00 AFTERNOON TEA 15:00-17:00 Presentation of group work - Jurisdiction project Full group, interactive Husynova All facilitators, led by Fitzgibbons & Durand All facilitators, led by Fitzgibbons & Durand All facilitators, led by Fitzgibbons & Durand 1) Syndromic Surveillance Maps from DDM1 in Guam, 2013 2) Reportable disease lists for each jurisdiction, 3) Template for surveillance standard operating procedures 6
Time Activity (approximate time) Activity type Facilitator Material needed/used Wed 20 Aug 8:25-8:30 Tuesday recap Course participants 8:30-9:15 Displaying data Full group, lecture Cash CDC displaying data. 9:15-10:00 Alden Outbreak investigation and SPC Outbreak investigation Full group, lecture Durand lectures 10:30-11:00 MORNING TEA 11:00-12:00 Outbreak investigation case study & Excel orientation Group work 4 (by 5) Hancock Scenario: Fever in Chuuk 12:00-1:00 Lunch 1:00-3:00 All facilitators, led by Outbreak investigation-own data Group work 4 (by 5) Hancock Own computer, excel, own data 3:00-3:30 Afternoon Tea Thu 20 Aug 3:30-4:30 Outbreak investigation-own data All facilitators, led by continued Group work 4 (by 5) Hancock Own computer, excel, own data 4:30-5:00 Wellness workout Group play Cash Comfortable cloths, workout shoes 8:25-8:30 Wednesday recap Plenary Course participants 8:30-10:30 Outbreak investigation-own data presentations Full group, interactive Husynova 10:30-11:00 MORNING TEA 11:00-12:00 Outbreak response and control Full group, lecture Fitzgibbons CDC Slides (Alden response and control measures) 12:00-1:00 LUNCH Fri 20 Aug 1:00-2:00 All facilitators led by Response and control -case study 1 Group work Hancock 2:00-3:00 All facilitators led by Response and control case study 2 Group work Fitzgibbons 3:00-3:30 AFTERNOON TEA 3:30-5:00 Practice written exam & review Hancock 8:25-8:30 Thursday recap Plenary Course participants 8:30-10:25 Tutoring for exam prep & coaching for jurisdiction project, as needed Group work All facilitators 10:25-10:30 Course evaluation Individual work Fitzgibbons 10:30-11:00 MORNING TEA 11:00-12:30 Written Exam Individual work All facilitators 12:30-13:30 LUNCH 13:30-14:15 Disease Surveillance & Controlbeyond outbreaks Full group, lecture Durand 14:30-15:00 AFTERNOON TEA 15:00-16:00 Return scored exams/closing ceremony Plenary Fitzgibbons Rash & Fever Diarrhea outbreak 7
Workshop Evaluation: Participant evaluation of the workshop was conducted through a form developed and analyzed by Janice McMichael. The form was based on previous evaluation work by Beverly Paterson of RAPID. Her summary findings are: Overall Course: 8
Responses to the three opened ended questions regarding the course are as follows: Questions Is there anything that was covered during the course that you are still unsure about? What did you like most about the course? Summary of Responses 1. No. Will use pivot table every week to get the hang of it. It makes less work than I need to do usually. 2. Everything was OK, is just that this is my first time to work on syndromic surveillance or outbreak investigation. 3. The 4 different types of epi curves (3) 4. None -- all topics were well covered 5. Just need to be more familiarize with the types of epi curves and graphs 6. Am not involved with my state epinet. Came without any knowledge, I think of all that was covered, I got good knowledge. I probably can't remember everything, but got all the slides with me to refer when doubting. 7. Pivot table 8. International Health Regulations 9. I would like to know more about control measures in regards to specific diseases. 10. A bit of confusion with the different types of epi curves. 11. Not really. 1. Epi curve & situation reports 2. Analyzing data into pivot table and determining the type of source it may have been. 3. Creating a situation report and the mapping. 4. The exercises - I learned better with hands-on and have a good understanding of the subject. (3) 5. Group work and presentations 6. The use of Excel pivot tables 7. Getting our own Pacific Outbreak Manual book. 8. Understanding the meaning of epidemiology and the investigation exercise we did for the outbreaks. 9. More than 5 facilitators; whole pacific region coming together to learn together and from each other. 10. Exercises of pivot table 11. Excel exercises and generating situation reports on outbreaks. 12. Activities for each presentation. 13. Everything (2) 14. Syndromic and outbreak investigations 15. I enjoyed the interative components in which we were able to investigate 'mystery' outbreaks/situations 16. Going over the steps of investigating an outbreak; situational reports. 9
Questions How can we improve the course? Summary of Responses 1. All in all, it was very good. I have taken DDM2. But for the other participants who are new to this and spoke to me said that the pace was a bit too fast for them. Maybe next time, get the people with the same knowledge/understanding together. 2. As a rookie to this course, I am very much satisfied with this, so no comment on this part. 3. Probably involve more laboratory staff in the next training to strengthen laboratory public health components which is weak in the majority of jurisdictions as well as I n other Pacific Islands. 4. Change venue next time in Palau 5. Up to facilitators after reviewing the outcome of the courses already offered. 6. Put in more time. 7. More exercises on the topics. 8. It was a great course. Improved my knowledge & skills tremendously. No necessary improvements to suggest. 9. More exercises and real life scenarios that could be used to improve our existing work. 10. Give practice presentations before actually doing the ones to be graded, otherwise everything was good. 11. All presentation and exam on the last day. Class/homework on preparing presentations. During presentation, facilitators to give good feedbacks on presentations to be improved and to go back and present to state. 12. Nothing - You are doing good. Thank you. Excel Skills: 10
Generally participants reported improvement in the ability to work with data in Excel. Examples of responses to the opened-ended response are as follows: Questions What were the key things you learned about Excel that you will use in your workplace? Summary of Responses 1. Pivot tables (10) 2. Proper ways to display long-term data using data for epi curve; proper tables to use during certain outbreaks; how to work with pivot tables from line listings 3. Cleaning data, making charts, pivot tables, shortcuts (formulas), creating graphs (2) 4. Working on pivot table and generating epi curve and other charts; strengthen lab investigation processes through the use of charts to summarize and organize lab data. 5. More data cleaning and graphing 6. How to manipulate data (i.e., formulas) 7. Creation of an epi curve; proper display of data via graphs and charts; manipulation of keys/functions 8. Different types of epi curves and displaying data 11
Understanding Syndromic Surveillance: Students demonstrated an even larger improvement in understanding syndromic surveillance than the gain of Excel skills. Examples of responses to the opened-ended response are as follows: Questions What were the key things you learned about syndromic surveillance that you will use in your workplace? Summary of Responses 1. Continuous and timely reporting 2. Steps during outbreak investigation; differences between syndromic surveillance and notifiable surveillance; guidelines during outbreaks; how to create (analyze) data by epi curves (2) 3. Making a chart out of the syndromic surveillance 4. Linking syndromic surveillance to lab based surveillance. 5. Ways to monitor disease syndromes looking at present health situation provided opportunities for rapid response and to control illnesses. 6. Line list and making a case definition 7. Advantages and disadvantages 8. The importance of having a consistent and complete surveillance data 9. In my future workplace, it will be useful to have knowledge about what syndromes are under close surveillance. 10. Algorithm of syndromic surveillance 11. Areas where they are collected and doing case definition. 12. Learned a lot but not sure if I will use any in my work. 13. Routine syndromic surveillance, follow-ups on lab results; good communication with doctors and nurses 14. Routine and systematic 15. Don't really work with syndromic surveillance, but it helps 12
Knowledge of Outbreak Investigations: The participants also reported substantial knowledge gain with regards to outbreak investigations. Examples of responses to the opened-ended response are as follows: Questions What were the key things you learned about outbreak investigations that you will use in your workplace? Summary of Responses 1. Situation reports (5) 2. How to make a case definition; the difference between sensitive and specific case definition; questions helpful to certain investigations. 3. Situation reports, graphs - epi curve 4. Responding to a report of a disease outbreak 5. It's primary importance to confirm outbreaks by looking at features, who is infected, control of outbreak 6. Pacific Outbreak Manual (2) 7. Some general guidelines for response to outbreak; steps in an outbreak investigation 8. Good communication with doctors/nurses; mapping how to deal with an outbreak; active epinet team; situation reports 9. Steps on dealing with an outbreak. (2) 10. In my future workplace, it will be very beneficial to know who to add in our outbreak investigations 11. Line list and case definition 12. Implement control measures at any given time. (2) 13. Strengthen lab capacity and promote their important role in outbreak surveillance 13
Participant Outcomes: All participants were evaluated on three sets of criteria the presentation of the analysis of their jurisdictional project, the presentation on their situational report, and a written exam. The analysis of the participant grades was performed by Thane Hancock. Total Number of Participants: 19 Mean Score: 83% Range: 64%-96% Grading breakdown and evaluation criteria: 1) Jurisdictional Surveillance Project (20%) Mean Score: 82% Range: 65%-95% Participants were allowed to choose from one of the three following projects: 1. A completed surveillance standard operating procedure and improvement action plan, including: identification of data sources for notifiable diseases and syndromic illness defining of data products, timeframes, distribution list defining of threshholds for action and action steps 2. Reportable disease surveillance system mapping and strengthening project 14
process map of current reportable/notifiable disease surveillance system identification of weaknesses/gaps in existing system action plan for improving current system 3. Syndromic disease surveillance system mapping and strengthening project process map of current reportable/notifiable disease surveillance system identification of weaknesses/gaps in existing system action plan for improving current system Participants were evaluated on the completed project and its report in a 10 minute PowerPoint presentation. Evaluation criteria (Syndromic/Notifiable Disease Surveillance Mapping): 1. Clearly set forth which syndromes and/or diseases are covered by these systems. 2. Clearly diagrams the flow of information from initial collection to initial response. 3. Clearly set forth what data sources are, who, how, when, to access them and how often. 4. Clearly demonstrates the lines of communication. 5. Clearly demonstrates responsibilities for initiating response. 6. Uses the map to identify strengths and weaknesses of the system (e.g. terms of Acceptability, Timeliness, Simplicity, and Representativeness) 7. Consider ways to leverage strengths and minimize the impact of weaknesses. Evaluation criteria (Standard Operating Procedures): 1. Clearly set forth which syndromes and/or diseases are covered by these SOPs. 2. Clearly set forth what data sources are, who, how, when, to access them and how often. 3. Clearly set forth the contents, frequency, time frame, and distribution for routine communicable disease reports. 4. Clearly set forth the alert triggers to use for the data collected and what action steps the surveillance officer will take when an alert trigger is reached, and policies for releasing information to the public about an outbreak, reporting to and enlisting health from outside agencies. 5. Clearly set forth the representatives and terms of reference for the local communicable disease response (EpiNet) team, upkeep of notifiable disease list, in-service training activities and updates to community stakeholders like reporting physicians and veterinarians. 6. Clearly set forth other duties of surveillance officers such as policies to assure after hours coverage for emergency reporting of outbreaks. 15
2) Outbreak Situational Report (20%) Use own data to create charts and tables to generate own Situational Report (SitRep) Present and discuss SitRep in PowerPoint to class and instructors for critique See example below Mean Score: 84% Range: 73%-95% Evaluation criteria: 1. Provides a clear summary of the outbreak to include overview, outbreak response, demographics, symptoms/signs, laboratory, summary and discussion. 2. Displays a clear and accurate epidemic curve on the Situation Report. 3. Utilizes clear and appropriate graphics to support the Situation Report. 4. Constructs clear and useful display of data aside from epidemic curve. 5. Describes the Situation Report clearly and accurately. 3) Written Exam (60%) 90 minutes Collection of multiple choice, short answer, calculations and matching Mean Score: 82% Range: 47%-98% No retest was offered 16
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Conclusions/Next Steps: The workshop appears to have been successful in achieving its four main goals. 1) Reinvigorate of EpiNet teams in the USAPI through building of knowledge and skills of EpiNet team members and linking of emergency preparedness program officers to disease outbreak teams in their jurisdictions This was the fourth time that DDM1 was delivered in the Pacific in the past 12 months. It was the second time the course was delivered in the USAPI. It was well received, and training benefitted from including facilitators and participants who had been involved in the Pacific Islands Preparedness and Emergency Response (PIPER) Regional Meeting. Each participant received training in the wide variety of skills used in outbreak identification and response. The Pacific Outbreak Manual was utilized as the foundation resource throughout the workshop. This allowed participants to gain familiarity with the manual and how to use it to help guide the outbreak preparedness and response activities. 2) Strengthen capacity of teams through development of standard operating procedures for routine communicable disease surveillance at jurisdiction level All teams were successful in developing and/or refining their syndromic or notifiable disease surveillance through establishing SOPs or mapping the systems. During the mapping, strengths and weaknesses of each system were recognized and the steps to improve the weakness identified. There were many ah-ha moments for participants as they dove into the nuts and bolts of their systems. 3) Obtain academic course credit for students toward formal credentials in applied epidemiology through Fiji National University All participants were given the opportunity to register with FNU to receive course credit. Paperwork was completed and submitted to FNU with the assistance of PIHOA. Guidance was provided by FNU during the development of the training and evaluation to help ensure the course meets all accreditation requirements. FNU is currently reviewing work submitted to determine if credit can be given to passing participants. 4) Build a mid-level Epi-tech track to complement advanced applied epidemiology training to be offered within a Pacific SHIP/FETP fellowship program The workshop allow for more students to have the opportunity to participate in DDM1. This is generally the first module in the Epi-Tech track of training. It reaffirms that the DDM series delivers the appropriate knowledge and skills for training EpiNet team members. A cohort of USAPI EpiNet team members is developing from which individuals for further training can be identified. The training was again demonstrated success bringing together partners in Pacific public health and epidemiology. As mentioned in other reports, the close collaboration and commitment 18
between these partners to develop, deliver, and evaluate the training is extraordinary. During the training it benefits the participants to have all partners involved, and after the training, strengthens communication and cooperation in regional public health work. It is a model that should be utilized more frequently. Next Steps: 1) Partners -PIHOA, WHO, CDC, SPC, RAPID, FNU- together to: a. continue to collaborate and pilot test revisions of other DDM modules, b. deliver the other 3 DDM modules to EpiNet team members, c. provide further input for Pacific FETP (SHIP) development and be ready to provide mentoring to SHIP fellows once the program is up and running, 2) Follow-up with FNU on the accreditation of the courses and registration of participants, 3) Support other deliveries of DDM1 in the Pacific region as requested by PICTs, 4) Continue to expand epidemiology competencies in NCD surveillance and response; 5) Consider continuing the one-page SitRep template in further deliveries of DDM1. Submitted: W. Thane Hancock July 28, 2014 19
Appendix A: SitRep Example Not this data is unofficial, inaccurate, and not for publishing or further distribution 20