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

Meghan M. Weems, MPH June 4, 2012

Electronic Disease Notification (EDN)

Immigrant, Refugee, and Migrant Health Branch

Division of Global Migration and Quarantine

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

Overview

•Background•The evolution of EDN•Direction forward

EDN Background• Immigrants and refugees

required to undergo TB screening/medical examinations before entering US.

• Over 670 panel physicians (overseas physicians), designated by the US Department of State, perform these screenings.

~450,000 new immigrants and refugees arrive in the US each year with their medical examination documentation.

• These medical documents—for all refugees and only immigrants with medical conditions such as TB—are collected at one of 20 CDC quarantine stations .

EDN Background Cont.• Refugees and immigrants with culture- or

smear-positive TB are treated prior to arrival in the US.

• After arrival, CDC’s Electronic Disease Notification system (EDN) notifies nearly 500 TB and Refugee Health coordinators in health departments of the results of overseas medical examinations.

• Heath departments can enter results of post-arrival TB evaluations into EDN (TB follow up).

• In October 2008, EDN completely replaced the previous paper-based system.

Notification History

AIS*

1995 20102000 2005

IMP* EDN200719991995

2008—100% centralization

DGMQ Quarantine Stations mail to U.S. Health Depts

EDN sends electronic notification

AIS—Alien Information SystemIMP—Information of Migrant PopulationEDN—Electronic Disease Notification

*limited medical data collected

Broad Partnerships• Division of TB Elimination (CDC)• State and local health departments–Refugee Health Coordinators– TB Controllers

• Federal partners–Department of State–Department of Homeland Security

• International Organization for Migration (IOM)

• Resettlement Agencies

EDN Information Flow

Department of State Medical Forms

(DS Forms)• Forms used under 1991 and 2007 TB Technical Instructions–DS 2053/2054 Medical

Examination for Immigrant or Refugee Applicant–DS 3024/3030 Chest X-Ray and

Classification Worksheet–DS 3026 Medical History and

Physical Examination Worksheet–DS 3025 Vaccination

Documentation Worksheet

DS-2054—Medical Examination

The Evolution of EDN

EDN User Community• Nearly 500 active users• Health Departments in all 50 States

(state, county, and local) & Washington, D.C.–263 jurisdictions

• TB Controllers (199)• TB/Refugee Health Coordinators

(176)• Refugee Health Coordinators (110)

EDN Users 2006-2011

2006 2007 2008 2009 2010 20110

50

100

150

200

250

300

Number of Users

Number of Jurisdictions Added

EDN Users Cont. • 11 states have local jurisdictions

(171 total)• Arizona- 1 County• California- 61 Counties• Colorado- 1 County• Florida- 67 Counties• Georgia- 1 County• Idaho- 3 Health Districts• Illinois- 1 City, 1 County• Michigan- 4 Counties• New York- 1 City• Oregon- 3 Counties• Texas- 27 Counties and Health

Districts

• Newly added jurisdictions in 2011 (10)• Midland County TX• DeKalb County GA• Public Health District 3 Idaho• Public Health District 4 Idaho• Public Health District 5 Idaho• Wayne County MI• Detroit City MI• Kent County MI• Oakland County MI• Maricopa County AZ

• States with first time local jurisdictions (4)• Georgia• Idaho• Michigan• Arizona

EDN Jurisdictions- 2012

EDN Jurisdictions

• Current local jurisdiction setups:• Major Metro – High-volume counties

have direct access; state controls lower volume counties (AZ, CO, GA, ID, IL, MI, OR)

• Complete Split – State is completely segmented into counties/regions, state-level users are only supervisory (CA, FL, TX)

Local Jurisdiction Access

• TB follow-up rates were greater in states where local and city health departments had access to EDN than those who did not (chi-square p <0.01).

Table. Reporting Rates Stratified by Access Type Access Type Mean Reporting (%)Local Access 80.0No Local Access 70.6• Excludes all U.S. territories• Numbers are based on arrival data from October 2010 to March 2011.

Notification Data for 2011• US Total- 73,493• Average time from arrival to notification- 5 days• FY 2010- average time was 11 days

• Immigrants- 18,412• Average time from arrival to notification- 5 days• FY 2010- average time was 13 days

• Refugees- 51,097• Average time from arrival to notification- 5 days• FY 2010- average time was 11 days

Days from Arrival to Notification 2009-2011

2009 2010 20110

5

10

15

20

25

30

35

40

45

Median Days- Total

Median Days- Immigrant

Median Days- Refugee

EDN Data January-December 2011

Visa Type n* All TB Conditions %

Refugee 51,097 4,205 8.23

Asylee 3,984 183 4.59

Immigrant 18,412 17,846 96.93

TOTAL 73,493 22,234 30.2

*Number of EDN notifications

Top 5 Birth Countries for US-bound Immigrants and Refugees- 2011

• Immigrants– Philippines–Mexico– China– Dominican

Republic– India

• Refugees– Cuba–Myanmar– Bhutan– Iraq– Nepal

Top 10 Birth Countries of US-bound Immigrants and Refugees- 2011

Areas of Progress

• EDN Improvements

• Continued partnerships

Recent EDN Improvements • Easier access to EDN

– System upgrade—Microsoft SQL server upgraded to alleviate stalls

– Single password access with 1 year expiration• Users no longer required two passwords to

access the EDN web-interface. The 30 day password expiration was removed.

• System activity reports– Percentage of TB worksheets started– Sub-migrations to and from

Recent EDN Improvements cont.• Alien information page now includes

some Pre Departure Medical Form (PDMS) data– Anti-Malarial and Anti-Helminthic

treatment– Pre Departure vaccination information

• Added Hansen’s Disease module– Federal Hansen’s disease users will

receive notifications of refugee/immigrants diagnosed with Hansen’s disease.

Continued Partnerships• EDN Workgroup• IOM (International Organization for

Migration)• Department of State (DOS): Refugee

Processing Center (RPC), Bureau of Population, Refugees and Migration (PRM), Consular Affairs (DOS)

• Department of Homeland Security (DHS): Custom Border Protection (CBP)

EDN Workgroup• Began as NTCA EDN Workgroup• Re-structured– Current Members• 2 co-chairs TB and refugee health

coordinator• 10 representatives representing US

regions• DTBE and DGMQ Federal participants

• Purpose a forum to address user needs/concerns and to provide accountability for improvements

• Meet every other month• Created subgroup to discuss TB follow up

form

EDN Worksheet Sub-Workgroup• Sub-workgroup created May 5, 2011

• Goals–Discuss and finalize goals of TB

follow-up data collection• Guide revision process

–Update current TB worksheet to increase• Consistency and accuracy of data collection• User friendliness • Overall EDN reporting

–Develop standardized protocol for secondary migration

IOM Data• Data feed ~65% of

refugee data comes from IOM’s MiMOSA database

• Providing additional data to better assist US health coordinators– Information refugee

camp, language, ethnicity, etc.

– Pre-departure treatment against intestinal parasites and malaria, and pre-departure vaccinations

Refugee Processing Center

• Receive scan documents for 100% of refugees within 24-48 hours of arrival

• Coupled with ~65% electronic refugee data from IOM

• Outcome=Improved notification time

Consular Affairs and CBP• Collaborate with US Department of State

and Custom Border Protection (CBP) on Consular Electronic Application Center (CEAC) project• To provide electronic medical data from overseas panel

physicians• Decreased need for manual data entry at

CDC• Improved accuracy of data• Faster notification times• A work in progress

Direction forward• Continue to improve notification time

• Improve data quality–Data from panel physicians

• Establish new users– Encourage local health department

access– Users in Puerto Rico, Virgin Islands,

Guam, etc.

Direction forward continued• Fulfill DTBE/DGMQ MOU

- Implement new TB follow up form• Implement recommendations to improve

TB follow-up reporting–New access types for local health

departments– System reports

• Continue active collaboration with Federal partners

EDN Team• Medical Director Rossanne Philen, MD, MS, CAPT USPHS

• Program Coordinator Meghan M. Weems, MPH

• Public Health Advisor Kendra Cuffe, MPH

• Data Entry Center (DEC) Manager Nekeia Gray, BS

• Data Entry Center Staff Ashley Mizell, Iris Gaye, Willie Bradley, Rhonda Rhodes-Price, Keisha Thomas, Dale Atkinson, Tanya Garcia, Mytrice Grier, Matrilla King, Sharon Davenport, Kourtney Powers, Jason Rochon

• Informatics team Daniel Wenger, Charlie Miller, Wei-Lun Juang, Dan Reed

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

Thank you!

Meghan M. WeemsMWeems@cdc.gov

EDN Helpdeskedn@cdc.gov

1-866-226-1617