School and Child Health Surveillance System

State: TX Type: Model Practice Year: 2011

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"The Tarrant County Public Health School and Child Health Surveillance System supports the needs of public health epidemiologists, school nurses and childcare facility staff to monitor and respond appropriately to community health threats in Tarrant County, a large, diverse county with 1.7 million residents, including approximately 260,000 children less than 18 years of age. Initially completed in October 2007 with an open source content management system (DotNetNuke), the Web portal allows both school nurses and childcare facility staff to share health data, including absenteeism and absences related to influenza-like illness, by completing a form that requires less than five minutes to fill out. Besides ILI, the system supports case reporting of Methicillin-Resistant Staphylococcus Aureus (MRSA), a potentially life-threatening skin condition problematic in schools. 

The data received is available for ad hoc analysis and entry into Tarrant County's ESSENCE biosurveillance system, which can analyze school absenteeism with ESSENCE's valuable alerting, charting and mapping capabilities. TCPH also uses the system to share a wealth of information and resources with school nurses and childcare facility staff, including news materials, action items, ESSENCE-derived maps showing the spread of ILI in the region, county and county quadrants, and flu prevention resources organized by language (English and Spanish), target audience, child's age level and user (school or childcare center).

The practice's primary goal is to strengthen partnerships with schools and build or enhance relationships with childcare centers.The supporting objectives are to: 1) Facilitate fully electronic, automated data collection, analysis and communications tools. 2) Make the collection and analysis of child health data more robust and easily managed than it has been historically. 3) Use the system to help public health become better prepared to respond swiftly and correctly to community health patterns. Because the system uses DotNetNuke (DNN), an open source content management system (no licensing fee), the cost to produce the system was less than $500. Initial expenses were for several low-cost software modules that addressed the news, photo gallery and online forms functions in a more robust manner than DNN delivers ""out of the box."" Funds were obtained from the Southwest Center for Advanced Public Health Practice (APC), a NACCHO grantee. Additional funds were obtained from the Texas Department of State Health Services (DSHS) for program expansion.

Currently (November 2010), new and more robust reporting forms are in the final stages of testing. The enhancements will benefit the nearly 200 public schools (and one private school) that use the School Health Surveillance System, representing just under half of the county's schools, as well as the approximately 15 childcare facilities pilot testing the Child Health Surveillance System and more expected to use it. All users will soon be able to view, download and edit their reports, examine charts, and conduct cross-tab analyses of the online data. Discussion capabilities (a blog) will also be introduced. Cost for these enhancements, about $10,000, was covered by a DSHS flu surveillance grant. All objectives for the system were met. Users surveys indicate a strong level of satisfaction with the system. School nurses say they value the information TCPH is providing via the system. TCPH epidemiologists have said the system is a useful complement to other health surveillance data and that the system has yielded early evidence of emerging health threats, including both seasonal flu and H1N1, while also generating frequent and complete reporting of MRSA cases on school campuses, where the condition is commonly found. Compared to prior methods used, core school health data gathered is now more timely (daily reporting vs. weekly), more granular (campus-specific data vs school district aggregate data), and more complete"

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Tarrant County Public Health Department
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School and Child Health Surveillance System
"The Tarrant County Public Health School and Child Health Surveillance System supports the needs of public health epidemiologists, school nurses and childcare facility staff to monitor and respond appropriately to community health threats in Tarrant County, a large, diverse county with 1.7 million residents, including approximately 260,000 children less than 18 years of age. Initially completed in October 2007 with an open source content management system (DotNetNuke), the Web portal allows both school nurses and childcare facility staff to share health data, including absenteeism and absences related to influenza-like illness, by completing a form that requires less than five minutes to fill out. Besides ILI, the system supports case reporting of Methicillin-Resistant Staphylococcus Aureus (MRSA), a potentially life-threatening skin condition problematic in schools.  The data received is available for ad hoc analysis and entry into Tarrant County's ESSENCE biosurveillance system, which can analyze school absenteeism with ESSENCE's valuable alerting, charting and mapping capabilities. TCPH also uses the system to share a wealth of information and resources with school nurses and childcare facility staff, including news materials, action items, ESSENCE-derived maps showing the spread of ILI in the region, county and county quadrants, and flu prevention resources organized by language (English and Spanish), target audience, child's age level and user (school or childcare center). The practice's primary goal is to strengthen partnerships with schools and build or enhance relationships with childcare centers.The supporting objectives are to: 1) Facilitate fully electronic, automated data collection, analysis and communications tools. 2) Make the collection and analysis of child health data more robust and easily managed than it has been historically. 3) Use the system to help public health become better prepared to respond swiftly and correctly to community health patterns. Because the system uses DotNetNuke (DNN), an open source content management system (no licensing fee), the cost to produce the system was less than $500. Initial expenses were for several low-cost software modules that addressed the news, photo gallery and online forms functions in a more robust manner than DNN delivers ""out of the box."" Funds were obtained from the Southwest Center for Advanced Public Health Practice (APC), a NACCHO grantee. Additional funds were obtained from the Texas Department of State Health Services (DSHS) for program expansion. Currently (November 2010), new and more robust reporting forms are in the final stages of testing. The enhancements will benefit the nearly 200 public schools (and one private school) that use the School Health Surveillance System, representing just under half of the county's schools, as well as the approximately 15 childcare facilities pilot testing the Child Health Surveillance System and more expected to use it. All users will soon be able to view, download and edit their reports, examine charts, and conduct cross-tab analyses of the online data. Discussion capabilities (a blog) will also be introduced. Cost for these enhancements, about $10,000, was covered by a DSHS flu surveillance grant. All objectives for the system were met. Users surveys indicate a strong level of satisfaction with the system. School nurses say they value the information TCPH is providing via the system. TCPH epidemiologists have said the system is a useful complement to other health surveillance data and that the system has yielded early evidence of emerging health threats, including both seasonal flu and H1N1, while also generating frequent and complete reporting of MRSA cases on school campuses, where the condition is commonly found. Compared to prior methods used, core school health data gathered is now more timely (daily reporting vs. weekly), more granular (campus-specific data vs school district aggregate data), and more complete"
With society’s continued dependence on out-of-home childcare, it is critical that we better understand and assess the risk of infectious diseases in the daycare setting. TCPH and the APC have aligned their approach to child health surveillance with CDC research priorities that are intended to improve and enhance existing influenza surveillance and explore the potential for early warning of an impending influenza outbreak in an uncommonly tapped source of public health data, especially childcare centers but also schools. The stage was set nearly 15 years ago to promote the partnership between clinical research, schools, childcare centers, and public health to further explore avenues for reducing the burden of infectious diseases in pre-school and school-aged populations. In 1994, at the International Conference on Child Day-Care Health, Dr. Michael Osterholm spoke on factors that interplay between children, the childcare environment, and infectious disease transmission to others in the household and community. Research by Dr. Osterholm and many others show that children play a significant role in transmitting flu (and other diseases) because of the nature of the virus and the means by which it spreads. Children share cups, do not cover their coughs or sneezes correctly, if at all, and promote the spread of viruses and bacteria readily among those in close, consistent contact with them, such as other children and staff in a daycare setting.The flu virus can perpetuate in children greater than 10 days following symptom onset. The highest attack rates of influenza illness and the highest rates of infection occur among children less than three years of age, ranging from 23 percent to 48 percent per year. School-aged children are common vehicles for transmitting influenza to other persons in their households, including those categorized into high-risk groups (e.g., the elderly, young children, and immuno-compromised individuals). Influenza-like illness or laboratory-confirmed influenza infection accounted for up to 19 percent of medical office visits and up to 29 percent of emergency room visits with rates ranging from 50-95 visits to medical clinics per 1,000 children per year. Rates of serious illness and hospitalization are highest among children under two years old.
Agency Community RolesTCPH is responsible for all aspects of the School Health Surveillance System and ancilllary Child Health Surveillance System. The agency was involved in its initial planning and implementation and led dialogue with lead nurses at the various Tarrant County independent school districts that resulted in the portal's construction and launch. Flu Surveillance Coordinator Mary Izaguirre continues to maintain our agency’s vital relationships with school nurses. She is responsible for posting the ESSENCE-derived daily flu maps that nurses can view in the portal, weekly TCPH surveillance reports, news items and action items. She responds to any problems or questions that emerge. At the beginning of each school year, she contacts district lead nurses to obtain updated nurse rosters and makes any necessary changes, such as new student enrollment numbers, in the portal’s school accounts. She also downloads and analyzes the data, including both flu data and MRSA case reports. Other TCPH team members ensure that the data is entered into ESSENCE to leverage that system’s alerting, charting and mapping capabilities. TCPH team members also prepare certificates of appreciation for distribution to participating school nurses and coordinate an annual user survey to determine the system’s usefulness, benefits and needed enhancements. TCPH staff members collaborate with the APC on technical work to enhance the system to meet user needs and, when necessary, on efforts to obtain grant funding for program or technical enhancements. TCPH staff members collaborate with subject matter expert Tabatha Powell, MPH, on annual program evaluations and in discussion of evaluation findings that typically lead to system enhancements. TCPH has also provided content for trainings of daycare centers that are being coordinated with Campfire First Texas Council as part of an effort to build support for more thorough participation by childcare facilities in the Child Health Surveillance System. TCPH staff members determined what types of data could and should be collected from both schools and childcare centers and also what resources could be shared that can help schools and childcare centers take appropriate steps to prevent the spread of community diseases (including but not limited to flu). Costs and ExpendituresThe Tarrant County Public Health School and Child Health Surveillance System supports the needs of public health epidemiologists, school nurses and childcare facility staff to monitor and respond appopriately to community health threats in Tarrant County, a large, diverse county with 1.7 million residents, including approximately 260,000 children less than 18 years of age. Initially completed in October 2007 with an open source content management system (DotNetNuke), the Web portal allows both school nurses and childcare facility staff to share health data, including absenteeism and absences related to influenza-like illness, by completing a form that requires less than five minutes to fill out. Besides ILI, the system supports case reporting of Methicillin-Resistant Staphylococcus Aureus (MRSA), a potentially life-threatening skin condition problematic in schools. The data received is available for ad hoc analysis and entry into Tarrant County's ESSENCE biosurveillance system, which can analyze school absenteeism with ESSENCE's valuable alerting, charting and mapping capabilities. TCPH also uses the system to share a wealth of information and resources with school nurses and childcare facility staff, including news materials, action items, ESSENCE-derived maps showing the spread of ILI in the region, county and county quadrants, and flu prevention resources organized by language (English and Spanish), target audience, child's age level and user (school or childcare center). The practice's primary goal is to strengthen partnerships with schools and build or enhance relationships with childcare centers. The supporting objectives are to: 1) Facilitate fully electronic, automated data collection, analysis and communications tools. 2) Make the collection and analysis of child health data more robust and easily managed than it has been historically. 3) Use the system to help public health become better prepared to respond swiftly and correctly to community health patterns. Currently (November 2010), new and more robust reporting forms are in the final stages of testing. The enhancements will benefit the nearly 200 public schools (and one private school) that use the School Health Surveillance System, representing just under half of the county's schools, as well as the approximately 15 childcare facilities pilot testing the Child Health Surveillance System and more expected to use it. All users will soon be able to view, download and edit their reports, examine charts, and conduct cross-tab analyses of the online data. Discussion capabilities (a blog) will also be introduced. Cost for these enhancements, about $10,000, was covered by a DSHS flu surveillance grant. All objectives for the system were met. Users surveys indicate a strong level of satisfaction with the system. School nurses say they value the information TCPH is providing via the system. TCPH epidemiologists have said the system is a useful complement to other health surveillance data and that the system has yielded early evidence of emerging health threats, including both seasonal flu and H1N1, while also generating frequent and complete reporting of MRSA cases on school campuses, where the condition is commonly found. Compared to prior methods used, core school health data gathered is now more timely (daily reporting vs. weekly), more granular (campus-specific data vs school district aggregate data), and more complete (ILI cases reported, not just absenteeism). Moreover, school nurses and participating childcare centers now view themselves as integral parners with public health. The system has been deemed a promising practice for pandemic influenza preparess by the Center for Infectious Disease Research and Policy (CIDRAP). A subject matter expert, Tabatha Powell, MPH, has evaluated the system in each of the first three years of its use. She applied the CDC's framework for evaluation of syndromic surveillance systems ImplementationInitially, Tarrant County identified four objectives for its project: 1) Slow the spread of flu by enhancing information exchange with schools (and later childcare centers), 2) Support early detection of ILI by making it easier for schools (and later childcare centers) to report absenteeism data and ILI, 3) Provide easy access to various resources that can help system users promote disease prevention and health promotion activities and 4) Focus public health resources in response to early detection of increased ILI and student absenteeism rates. Tarrant County addressed these objectives by developing its royalty-free, Web-based, open-source portal. Specific tasks fundamental to achieving the objectives were: 1) System design and development, 2) System review and revision, 3) System launch and use tracking. Key tasks in system review and revisions included initial communication about the project and detailed project discussions. School nurses, principals, and superintendents were notified of the system’s development and anticipated implementation date via dissemination of letters. A School Nurse Advisory Committee (SNAC) was formed and convened to provide feedback on system layout, design, and content. Meetings with individual school districts were also conducted. System launch occurred via e-mail notification and the provision of user account information to each school district. System log reports were used to track usage; the reports revealed the number of reports submitted by nurses, the frequency with which nurses viewed the various Web pages available to them, and other useful data. The timeframe required for this project was nine months. The time allotted for specific tasks was as follows: Three months for system design and development (March-May); three months for system review and revision (June-August); and three months for system launch and use tracking (September-November). While this timeframe worked, it should be noted that Tarrant County had already developed good working relationships with school districts and lead nurses. Replication of the project might be more time consuming if a health department needs to establish or enhance those relationships.
The primary goal of the practice is to strengthen partnerships with schools and build or enhance connections with childcare centers. The first supporting objectives is to facilitate fully electronic, automated data collection, analysis and communications tools. Our program evaluations reflected CDC guidance on the steps in the evaluation framework for surveillance systems and included a logic model that outlined the resources, activities, and intended short, moderate, and long-term process and impact outcomes. An evaluation matrix delineated the measures and markers used in the quantitative components of the evaluation. The primary focus of the SHSS pilot year evaluation and approach emphasized the need to assess specific attributes of the surveillance system that both TCPH and the APC felt were crucial to the acceptance, use, and success of the program; the initial evaluation also assessed the progress of the project to meet the process objectives by measuring the inputs and outputs of the system. The evaluation assessed the potential of the system with regards to certain aspects that can improve and enhance surveillance to more effectively and appropriately allocate public health resources, detect potential flu outbreaks, and provide public health disease prevention and health promotion information. Data collection involved numerous data sources that were accessed and referenced in each of the three formal annual program evaluation reports. For system performance and system use measures, the site log and event viewer reports, found in the administrative area of the Web portal, were run to obtain data on system use. Discussions with project staff and review of files and records were conducted to assess recruitment and training, data management, and public health response. An overview of system use provided background on school nurse reporting trends and popularity of resources provided on the portal. Through the analysis and monitoring of ILI and absenteeism data, the evaluation assessed whether the data were used to focus resources for targeted specimen sampling, vaccinations, and public health messaging to prevent and reduce the spread of the disease. TCPH was 100 percent successful in implementing activities that support this objective, as evidenced by program participation. School participation increased 14 percent from 152 schools in the first year to 177 in the third. Number of reports received now exceeds 11,000, up from 4,194 in year one. TCPH senior leaders and system users received evaluation results. Some lessons learned: Difficulties with log-in procedures identified during the first-year evaluation were addressed prior to SHSS re-launch during year two. User names and passwords now reflect the Independent School District (ISD)’s unique school identifier; this eliminated use of user-id and password combinations that were more difficult for school nurses to remember and apply. On the report form itself, TCPH and the APC implemented features that prevent users from entering date information inconsistently and from entering alpha values when numerical values are required. This addressed “data cleaning” issues that made public health use of the system more cumbersome than necessary. Subsequent report form changes included allowing childcare facilities and school nurses to change their enrollment data, which was initially not an editable field in the form. Future versions of the form will further simplify it by not having visible fields for certain basic information such as the name of the reporting facility (school name or childcare center) where such information is readily available from the user profile once a user is logged in. TCPH and its APC recognized that there were limitations to their system and staff members have been transparent about those limitations with system users. The focus has remained intently on making major, significant improvements by transforming a paper- and faxed-base
Tarrant County believes project stakeholders are committed to perpetuating the system: External users: Annual school nurse user surveys have revealed strong support for this system and system has grown steadily since 2007. The H1N1 flu outbreak validated the importance of flu as a health threat and gave credence to the importance of the system and the data it yields. Relationships with schools and campus nurses have been satisfactorily maintained with certificates of appreciation and meetings in which epidemiologists have discussed use of the system and efforts to enhance it. The system is free for schools to use and certain enhancements now being implemented will make it easier for nurses to view, download and edit their data and understand the aggregate data. System use among childcare facilities is not yet robust enough to provide statistically meaningful reports, but a partnership with Camp Fire First Texas Council, which provides training for childcare facilities, may change that. Camp Fire expects to find ways to make system use increasingly beneficial for childcare facilities and may use the portal for exclusive delivery of certain services or information. Internal users: Epidemiologists continue to find the system complementary to other biosurveillance data sources. Emerging enhancements will make it easier for them to analyze system data. The system costs essentially nothing to maintain since it uses an open source content management system and Web hosting is provided by the Texas Association of Local Health Officials (TALHO). Funding: The Tarrant County Advanced Practice Center (APC) has released its School Health Surveillance Guidance Kit to help other health departments interested in replicating this practice by building similar systems. In doing so, health departments will be fulfilling certain requirements of the Public Health Preparedness (PHEP) Capabilities, which the Centers for Disease Control and Prevention (CDC) has defined as standards to achieve under a new five-year PHEP cooperative agreement that takes effect in August 2011. Replicating the practice would address public health surveillance and epidemiological investigation capabilities as detailed in the PHEP guidance. Tarrant County intends to sustain the system with the same hands-on relationship building it counted on to start the program – the individual efforts of its epidemiologists to work with school district lead nurses and individual campus nurses. Plans have been defined to conduct work that will make the system more fully and tightly integrated with biosurveillance systems (e.g. ESSENCE) that epidemiologists use routinely to track and respond to community health patterns. Tarrant County also plans to leverage its partnership with Camp Fire First Texas Council to build a more robust base of support for the system among local childcare facilities. The principle there is to have Camp Fire use the portal exclusively to deliver certain programs, products or services. In this way, childcare facilities are expected to gain exposure to and familiarity with the system and its many benefits. Some health departments are already planning to use the system for alerting and communications about a broad range of notifiable diseases. Tarrant County anticipates (and other health departments interested in replicating this practice can also anticipate) that continued use and enhancement of school and child health surveillance systems will fulfill certain functions and tasks within targeted capabilities of the new PHEP cooperative agreement – specifically those relating to public health surveillance and epidemiological investigation.
 
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