Performance audit, Department of Health Services, Bureau of Epidemiology and Disease Control Services report to the Arizona Legislature

              State of Arizona
Office
of the
Auditor General
PERFORMANCE AUDIT
Report to the Arizona Legislature
By Debra K. Davenport
Acting Auditor General
September 1999
Report No. 99-18
DEPARTMENT
OF
HEALTH SERVICES
BUREAU OF EPIDEMIOLOGY
AND DISEASE CONTROL
SERVICES
The Auditor General is appointed by the Joint Legislative Audit Committee, a bipartisan committee
composed of five senators and five representatives. His mission is to provide independent and impar-tial
information and specific recommendations to improve the operations of state and local government
entities. To this end, he provides financial audits and accounting services to the state and political
subdivisions and performance audits of state agencies and the programs they administer.
The Joint Legislative Audit Committee
Senator Tom Smith, Chairman
Representative Roberta Voss, Vice-Chairman
Senator Keith Bee Representative Robert Burns
Senator Herb Guenther Representative Ken Cheuvront
Senator Darden Hamilton Representative Andy Nichols
Senator Pete Rios Representative Barry Wong
Senator Brenda Burns Representative Jeff Groscost
(ex-officio) (ex-officio)
Audit Staff
Shan Hays—Manager
and Contact Person (602) 553-0333
Lisa Eddy—Audit Senior
Mark Haldane—Staff
Joseph McKersie—Staff
Tanya Nieri—Staff
JoAnne Dukeshire—Staff
Copies of the Auditor General’s reports are free.
You may request them by contacting us at:
Office of the Auditor General
2910 N. 44th Street, Suite 410
Phoenix, AZ 85018
(602) 553-0333
Additionally, many of our reports can be found in electronic format at:
www.auditorgen.state.az.us
2910 NORTH 44th STREET • SUITE 410 • PHOENIX, ARIZONA 85018 • (602) 553-0333 • FAX (602) 553-0051
DEBRA K. DAVENPORT, CPA
ACTING AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF THE
AUDITOR GENERAL
September 16, 1999
Members of the Legislature
The Honorable Jane Dee Hull, Governor
Dr. James Allen, Director
Department of Health Services
Transmitted herewith is a report of the Auditor General, A Performance Audit of the
Department of Health Services, Bureau of Epidemiology and Disease Control Services. This
report is in response to a May 27, 1997, resolution of the Joint Legislative Audit Committee.
The performance audit was conducted as part of the Sunset review set forth in A.R.S. ''41-
2951 through 41-2957.
This is the sixth in a series of six audit reports issued on the Department of Health Services.
In this report, we found that current disease surveillance does not ensure that the Bureau
adequately identifies disease outbreaks. Specifically, the reporting of disease-related data
from laboratories and physicians is often incomplete or delayed. Late or incomplete data can
also limit the amount of federal funding the State receives for disease control and prevention
programs. The Bureau could improve disease surveillance by periodically evaluating its
disease surveillance system, encouraging greater compliance with reporting requirements,
and obtaining information from multiple reporting sources. The Bureau could also raise
awareness of the importance of disease reporting by increasing the dissemination of
surveillance information to health care providers and laboratories.
This report also addresses how the Bureau can improve efforts to collect data on children’s
immunization rates. To more effectively gauge immunization coverage levels statewide, the
Bureau should improve the Arizona State Immunization Information System (ASIIS), a
computerized immunization registry. Additionally, the Bureau could improve efforts to
monitor school immunization rates by more thoroughly verifying school records and
working with the Arizona Department of Education to promote immunization objectives.
September 16, 1999
Page -2-
Finally, the audit found that the scope of activities within the Bureau’s Office of Environ-mental
Health is too broad. The Office is responsible for performing activities ranging from
licensing bedding manufacturers to responding to environmental emergencies, such as
chemical spills. The Bureau needs to assess the relative importance to public health of each
of its activities and identify those that could be discontinued, delegated, or transferred to
other agencies.
As outlined in its response, the Department agrees with, and has agreed to implement, all the
recommendations addressed to it.
My staff and I will be pleased to discuss or clarify items in the report.
This report will be released to the public on September 17, 1999.
Sincerely,
Debbie Davenport
Acting Auditor General
Enclosure
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OFFICE OF THE AUDITOR GENERAL
SUMMARY
The Office of the Auditor General has conducted a performance
audit of the Arizona Department of Health Services, Division of
Public Health, Bureau of Epidemiology and Disease Control
Services in response to a May 27, 1997, resolution of the Joint
Legislative Audit Committee. This performance audit was con-ducted
under the authority vested in the Auditor General by
A.R.S. §§41-2951 through 41-2957. This is the final in a series of
six audits of the Department of Health Services.
The Bureau of Epidemiology and Disease Control Services’ (Bu-reau)
mission is to monitor, control, and prevent diseases caused
by infectious and noninfectious agents, toxins, and environ-mental
hazards. To fulfill its mission, the Bureau is authorized
42.2 full-time-equivalent state employees and has 63.6 federally
funded employees. The Bureau has four program offices: the
Office of Infectious Disease Services, the Office of HIV and STD
Services, the Arizona Immunization Program Office, and the
Office of Environmental Health. Through its programs the Bu-reau
collects and analyzes disease-related data, performs out-break
and other disease investigations, inspects certain facilities
such as correctional facility kitchens for unsanitary conditions,
develops disease prevention and control efforts, and provides
the medical community with disease information useful for clini-cal
practice.
Bureau’s Disease Surveillance
System Needs Improvement
(See pages 9 through 20)
Protection of the public from communicable diseases, such as
hepatitis, HIV, and tuberculosis, depends on the Bureau’s ability
to monitor these diseases through surveillance. Disease surveil-lance
is the ongoing and systematic collection, analysis, and dis-semination
of information about diseases. Surveillance permits
the identification of disease outbreaks and at-risk groups, the
development of strategies to reduce infection, effective resource
The Bureau’s mission is
to monitor, control, and
prevent disease.
Summary
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OFFICE OF THE AUDITOR GENERAL
allocation, and improvements in clinical practice by health care
providers.
The Bureau’s surveillance system needs improvement. Although
surveillance is important, current surveillance practices do not
adequately ensure that the Bureau is able to prevent and control
disease. The Bureau’s data collection is often incomplete or de-layed.
The Bureau does not obtain reports of all disease cases
from laboratories or physicians or their authorized representa-tives,
or the reports are often received beyond the time frames
prescribed by state rules. Additionally, when reports are re-ceived,
they do not always contain complete information, and
the Bureau does not always compile them in a timely manner.
Although the Bureau handles outbreaks well once it learns of
them, incomplete data collection hinders its ability to identify
outbreaks. In 1999, for example, a measles outbreak spread un-checked
because the two cases likely to have begun the outbreak
had not been reported to the Bureau by the diagnosing physi-cians
or testing laboratories. Furthermore, late or incomplete data
presents a potentially inaccurate picture of communicable dis-ease
in the State. Additionally, late or incomplete data can affect
the amount of funding received by the State. For example, a
recent HIV case backlog resulted in inaccurate data, costing the
State an estimated $2.5 million in lost federal funding.
By addressing the several factors that contribute to deficiencies,
the Bureau can improve its disease surveillance system to more
effectively protect the public from communicable diseases. First,
the Bureau should take steps to ensure complete and timely
disease reporting by periodically evaluating the system, encour-aging
greater compliance with reporting requirements, and ob-taining
information from multiple reporting sources. Second, to
raise awareness of the importance of disease surveillance, the
Bureau should further develop its contact with the media. Fi-nally,
the Bureau should increase its dissemination of surveil-lance
data to health care providers, laboratories, and county
health departments.
Incomplete data collec-tion
hinders identifying
outbreaks.
Summary
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OFFICE OF THE AUDITOR GENERAL
Arizona Immunization
Program Office Should
Improve Efforts to Collect Data
(See pages 21 through 27)
The Arizona Immunization Program Office should improve its
efforts to collect immunization data to gauge the State’s progress
toward reaching its immunization goals. Although estimates of
statewide immunization rates for children indicate that coverage
levels have improved, rates remain low for children receiving
vaccinations from some county health departments. For exam-ple,
the figures from spring 1999 indicate that only 47 percent of
two-year-old children served by the Maricopa County Health
Department and only 43 percent of two-year-old children served
by the Pima County Health Department are fully immunized.
Immunization rates from county health departments are an im-portant
indicator of statewide coverage levels because 53 percent
of Arizona children are eligible to receive free vaccinations from
public health providers.
To more effectively monitor immunization coverage levels
statewide, the Office should improve the Arizona State Immuni-zation
Information System (ASIIS), a computerized immuniza-tion
registry. County health departments have had difficulties
submitting records to the State’s central database, obtaining pa-tient
records, and producing immunization reminder notices for
patients. In addition to the problems faced by county health
departments, the Office lacks an effective strategy to ensure that
all health providers report to ASIIS. The Office recently esti-mated
that 6 percent of private health providers do not report to
ASIIS. The Office should continue its efforts to make reporting of
immunization records easier and more thoroughly enforce re-porting
requirements.
The audit also found that although accurate tracking of school-children’s
immunization rates is important, the Office may not
be able to adequately monitor these rates. The Office cannot
ensure that all Arizona schools comply with required coverage
levels and that school immunization reports are valid. These
problems exist, in part, because the Office does not consistently
coordinate efforts with the Department of Education. However,
the Office can improve its methods for obtaining data from
Monitoring statewide
immunization rates is
important because im-munization
rates remain
low for some county
health departments.
Summary
iv
OFFICE OF THE AUDITOR GENERAL
schools by verifying school records and working with the Ari-zona
Department of Education.
Office of Environmental Health’s
Scope of Activities Should
Be Reviewed
(See pages 29 through 33)
The Office of Environmental Health’s scope of activities is too
broad. The Office is responsible for performing numerous activi-ties,
ranging from licensing bedding manufacturers to respond-ing
to environmental emergencies, such as chemical spills. In
addition, the Office performs several unmandated activities,
such as inspecting produce warehouses on the United States-
Mexico border. Auditors identified over 40 different activities for
which the Office’s 20 staff members are responsible. These ac-tivities
vary in importance with regard to protecting the public’s
health.
Although the Office delegates to county health departments
several major responsibilities, such as restaurant inspections, it is
unable to perform all of its activities. For example, although stat-ute
requires inspections of all public or semipublic buildings to
ensure sanitary conditions, the Office conducts no inspections of
public buildings. Similarly, of the 75 required inspections of chil-dren’s
camps during fiscal year 1998, the Office conducted 45.
Finally, the Office elects not to perform certain activities, such as
inspecting trailer parks and bedding manufacturers, that pose
minimal risk to public health.
The Bureau needs to assess the relative importance to public
health of each of its activities and identify those that could be
discontinued, delegated, or transferred to other agencies. Be-cause
many activities are mandated in statute, the Bureau should
develop a proposal for legislative action.
The Office’s 20 staff are
responsible for over 40
activities.
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OFFICE OF THE AUDITOR GENERAL
TABLE OF CONTENTS
Page
Introduction and Background ......................... 1
Finding I: Bureau’s Disease Surveillance
System Needs Improvement....................... 9
The Importance of
Disease Surveillance ....................................................... 9
Current Practices Limit
Effectiveness of
Surveillance Efforts......................................................... 10
Several Factors Contribute to
Deficiencies in the Bureau’s
Surveillance System........................................................ 15
Arizona’s Disease Surveillance
System Can Be Improved............................................... 17
Recommendations .......................................................... 20
Finding II: Arizona Immunization Program
Office Should Improve Efforts
to Collect Data .............................................. 21
Responsibilities of the Arizona
Immunization Program Office....................................... 21
Arizona’s Immunization
Rates Have Not Improved
in Every Area .................................................................. 22
Arizona State Immunization
Information System
Needs Improvement ...................................................... 24
The Office Does Not Ensure That
School Reporting Is Accurate ......................................... 25
Table of Contents
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OFFICE OF THE AUDITOR GENERAL
TABLE OF CONTENTS (Concl’d)
Page
Finding II: (Concl’d)
Recommendations .......................................................... 27
Finding III: The Office of Environmental
Health’s Scope of Activities
Should Be Reviewed.................................... 29
Background..................................................................... 29
Scope of Activities
Should Be Reviewed....................................................... 31
Recommendation........................................................... 33
Agency Response
Tables
Table 1 Arizona Department of Health Services
Bureau of Epidemiology and Disease Control
Statement of Revenues, Expenditures, and
Changes in Fund Balance
Years Ended June 30, 1997, 1998, and 1999
(Unaudited)................................................... 4
Table 2 Arizona Department of Health Services
Bureau of Epidemiology and Disease Control
County Health Department Immunization Levels
Percentage of Two-Year-Old Children
Fully Immunized
Fall 1994, Fall 1998, and Spring 1999............ 23
Table 3 Arizona Department of Health Services
Bureau of Epidemiology and Disease Control
Office of Environmental Health Activities
As of July 1999 .............................................. 30
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OFFICE OF THE AUDITOR GENERAL
Surveillance is the monitor-ing
of infectious diseases to
identify diseases and their
sources.
INTRODUCTION AND BACKGROUND
The Office of the Auditor General has conducted a performance
audit of the Arizona Department of Health Services, Division of
Public Health, Bureau of Epidemiology and Disease Control
Services in response to a May 27, 1997, resolution of the Joint
Legislative Audit Committee. This performance audit was con-ducted
under the authority vested in the Auditor General by
A.R.S. §§41-2951 through 41-2957. This is the final in a series of
six audits of the Department of Health Services.
The Purpose of Epidemiology
and Disease Control Services
The mission of the Bureau of
Epidemiology and Disease Control
Services is to monitor, control, and
prevent diseases carried by in-fectious
and noninfectious agents,
toxins, and environmental hazards.
It was established in 1992 as part of
the Division of Public Health Services. Under A.R.S. §36-104, the
Arizona Department of Health Services is responsible for ad-ministering
epidemiology and disease control programs. Addi-tionally,
the Department is required to collect and preserve
information relating to the prevention of diseases, such as hepa-titis,
tuberculosis, and AIDS. The Bureau carries out these tasks
and reports disease surveillance and prevention results to its
federal counterpart, the Centers for Disease Control and Preven-tion
(CDC).
Public health officials working in
epidemiology are responsible for
detecting and monitoring disease
trends. To safeguard the public’s
health, these officials obtain and
analyze disease-related data, conduct outbreak and other disease
investigations, and design and evaluate disease prevention and
Epidemiology is the study
of the factors contributing
to the causes, frequency,
and distribution of dis-eases
in a community or
given population.
Introduction and Background
2
OFFICE OF THE AUDITOR GENERAL
control efforts. State epidemiologists also provide the medical
community with information obtained through surveillance to
help health care providers with their clinical practice.
Personnel, Organization,
and Budget
The Bureau was authorized 112.3 full-time equivalent employees
to its four main offices, including seven positions assigned to the
Office of the Bureau Chief. Of these, 42.2 positions are state
funded, 63.6 are federally funded, and 6.5 are funded through
other sources, such as grants. Fourteen of the federal positions
are vacant and five of the state positions are vacant.
There are four Offices within the Bureau, which perform a wide
range of activities in the areas of epidemiology and disease con-trol.
Specifically:
n Office of Infectious Disease Services (17 FTEs)—moni-tors
the magnitude and trends of communicable diseases in
Arizona and provides technical assistance to county health
departments and other providers and agencies regarding di-agnosis,
prevention, and disease control. This office also has a
separate program for tuberculosis, which monitors the inci-dence
of tuberculosis and ensures that cases are appropri-ately
investigated and treated; and a separate program that
monitors the potential for the transmission of infectious dis-eases
that are communicable to humans from insects and
animals.
n Office of HIV and STD Services (34.3 FTEs)—provides
education, testing, counseling, treatment, and care services to
individuals with HIV/AIDS or sexually transmitted diseases
(STDs). Working with county health departments, this office
tracks the HIV/AIDS epidemic and the incidence of sexually
transmitted disease in Arizona. This office also administers
the AIDS Drug Assistance Program, which provides free
medication to uninsured, low-income persons with AIDS.
n Arizona Immunization Program Office (23.5 FTEs)—over-sees
the distribution of subsidized vaccine, promotes hepati-tis
B screening and prevention for pregnant women and their
Introduction and Background
3
OFFICE OF THE AUDITOR GENERAL
newborns, and provides information, education, and con-sultation
to enhance delivery of immunization services. The
Immunization Program Office monitors statewide immuni-zation
levels by collecting reports from schools and counties,
and maintains the Arizona State Immunization Information
System (ASIIS), which is a statewide, computerized registry
of immunization records.
n Office of Environmental Health (30.5 FTEs)—performs
numerous activities intended to prevent and control illness
related to the transmission of infectious agents or toxic sub-stances
in food and water. This office inspects various private
and public facilities, such as children’s camps, behavioral
health centers, and group homes, to prevent injury due to
unsafe conditions. Additionally, the Office of Environmental
Health performs activities to prevent illness due to environ-mental
contaminants or hazards, such as lead and pesticides.
The Bureau of Epidemiology and Disease Control Services re-ceives
both state and federal funding. The Bureau received
$22,016,259 in funding for fiscal year 1999, including state and
federal monies. Table 1 (see page 4), illustrates the Bureau’s
revenues and expenditures for fiscal years 1997 through 1999.
Introduction and Background
4
OFFICE OF THE AUDITOR GENERAL
Table 1
Arizona Department of Health Services
Bureau of Epidemiology and Disease Control
Statement of Revenues, Expenditures, and Changes in Fund Balance
Years Ended June 30, 1997, 1998, and 1999
(Unaudited)
1997 1998 1999
Revenues:
Intergovernmental1 $14,156,291 $13,487,496 $13,595,133
State General Fund Appropriations 5,951,000 6,242,400 5,956,600
Tobacco taxes 2 183,400 1,150,000 2,184,300
Charges for services 127,407 125,388 97,370
Private gifts, grants, and contracts 118,518
Other 70,548 78,909 182,856
Total revenues 20,488,646 21,202,711 22,016,259
Expenditures:
Personal services 3,444,453 3,721,236 3,614,444
Employee related 770,007 821,923 615,853
Professional and outside services 1,646,371 1,498,552 1,214,221
Travel, in-state 128,509 137,741 119,066
Travel, out-of-state 91,527 74,703 65,600
Aid to organizations 3 9,299,736 7,958,307 8,049,791
Other operating 4 4,370,216 6,017,554 7,075,454
Capital outlay 21,386 130,491 12,469
Allocated costs 426,294 1,019,065 1,407,960
Total expenditures 20,198,499 21,379,572 22,174,858
Excess of revenues over (under) expenditures 290,147 (176,861) (158,599)
Reversions to the State General Fund 14,823 1,867 399,742 5
Excess of revenues over (under) expenditures
and reversions to the State General Fund $ 275,324 $ (178,728) $ (558,341)
1 Intergovernmental revenues are primarily from federal sources.
2 In 1998, the Bureau received $1 million in tobacco tax revenue to create the Health Crisis Fund. Since 1998, the Bureau is
allocated sufficient tobacco tax revenue to replenish the Fund’s balance to $1 million at the beginning of each fiscal year.
In 1999, the Bureau received an additional $1.7 million in tobacco tax revenues to provide medicine to uninsured, low-income
persons infected with Human Immunodeficiency Virus (HIV).
3 After 1997, monies available for aid to organizations decreased. Federal support for the Federal Immunization program
was reduced. At the same time, rising costs for medical supplies reduced the amounts available to aid organizations
from the Federal Immunization and Ryan White Title II programs.
4 After 1997, increased tobacco tax revenues available for purchasing medical supplies and rising costs for medical sup-plies
significantly increased other operating expenditures.
5 Amount will not actually be reverted until June 30, 2000. Until then, it is available to pay claims that contracted vendors
failed to file in 1999. The Bureau anticipates that such claims will be made and most of the amount will be expended.
Source: The Arizona Financial Information System (AFIS) Revenues and Expenditures by Fund, Program, Organization, and
Object report, AFIS Status of Appropriations and Expenditures report, Department-provided financial information,
and State of Arizona Appropriations Report for the years ended June 30, 1997, 1998, and 1999.
Introduction and Background
5
OFFICE OF THE AUDITOR GENERAL
Audit Scope and Methodology
Audit work focused on the Bureau’s ability to adequately obtain,
analyze, and report disease-related data; accurately collect im-munization
data; and efficiently monitor environmental health.
A number of different methodologies were used to develop
findings in these three areas. Specifically:
n To determine if the Bureau adequately obtains necessary
disease-related data from health providers, a sample of 4,653
reported disease cases was reviewed. The sample comprised
all the cases entered into the Bureau’s disease database be-tween
July 1, 1998 and December 31, 1998. To determine if
laboratory reports submitted to the Bureau are timely, audi-tors
reviewed a sample of 302 infectious disease reports rep-resenting
one week of laboratory reports. Auditors also
reviewed one week of laboratory reports from each of the
Bureau’s disease surveillance systems (HIV, STD, and infec-tious
disease) for completeness. A survey of five state epide-miology
offices was conducted to obtain information about
other approaches to disease surveillance. Auditors also vis-ited
the Web sites of the surveyed states and Web sites of six
additional states to analyze reports and other publications
that these states made available through the Internet.1 Addi-tionally,
representatives of five county health departments
were interviewed regarding county responsibilities and their
relationship with the Bureau.
n To determine whether the Immunization Program Office
accurately collects data on immunization rates, annual school
immunization reports for the years 1993 through 1999 were
reviewed. Similarly, annual immunization reports for county
health departments for the years 1993 through 1999 were
analyzed to determine coverage rates for children receiving
vaccinations from public health providers. Status reports of
1 States surveyed were California, Colorado, Mississippi, New Jersey, and
Oregon. Auditors visited the Web sites of the states surveyed and also
visited Web sites for epidemiology offices in New Mexico, Nevada, New
York, Texas, Utah, and Washington. States were selected because they
are geographically or demographically similar to Arizona or were identi-fied
by public health officials as model states for disease prevention and
control.
Introduction and Background
6
OFFICE OF THE AUDITOR GENERAL
the Arizona State Immunization Information System were
also reviewed to determine the completeness of the State’s
central immunization registry. Additionally, 14 county health
departments and 1 community health center were surveyed
regarding the system. Auditors also interviewed 2 private
providers and 1 billing contractor regarding ASIIS.
n To determine if the Office of Environmental Health is able to
effectively conduct its assigned responsibilities, auditors de-termined
which of the Office’s activities are mandated or
elective; how often these activities are to be performed; and
the size of the population affected by these activities. Reports
on activities conducted were reviewed to ascertain the Of-fice’s
completion rate. Additionally, information about the
scope of activities in other state environmental health of-fices/
programs was obtained through a survey of eight
states.1
Other methods used to obtain information for all three areas
include interviews with professional associations, such as the
Agency of State and Territorial Health Officials; the Agency of
Toxic Substances and Disease Registry; the American Lung As-sociation;
and the Arizona Medical Association. Representatives
of state and federal agencies, such as the Arizona Department of
Corrections, the Arizona Department of Environmental Quality,
the Arizona Department of Education, the Centers for Disease
Control, the U.S. Department of Agriculture, and the Food and
Drug Administration were also interviewed. Finally, auditors
accompanied Bureau staff on various site visits and inspections.
Based on this audit work, the report contains findings and rec-ommendations
in three areas:
n Improving the Bureau’s disease surveillance to more ade-quately
control and prevent disease.
n Improving data collection within the Arizona Immunization
Program Office to help the State gauge its progress toward its
immunization goals.
1 States surveyed were California, Colorado, Nevada, Oklahoma, Oregon,
Texas, Utah, and Washington. These states were selected because they
are geographically or demographically similar to Arizona or were identi-fied
by public health officials as model states for environmental health.
Introduction and Background
7
OFFICE OF THE AUDITOR GENERAL
n Regularly reassessing the Office of Environmental Health’s
activities to improve effectiveness.
This audit was conducted in accordance with government
auditing standards.
The Auditor General and staff express appreciation to the
Director of the Department of Health Services, and to the Bureau
Chief and staff of the Bureau of Epidemiology and Disease
Control for their cooperation and assistance throughout the
audit.
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OFFICE OF THE AUDITOR GENERAL
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OFFICE OF THE AUDITOR GENERAL
FINDING I BUREAU’S DISEASE
SURVEILLANCE SYSTEM
NEEDS IMPROVEMENT
While protection of the public from communicable diseases de-pends
on the Bureau’s ability to effectively monitor these dis-eases,
current surveillance practices are not effective. Incomplete
and delayed data collection, inadequate data analysis, and lim-ited
data dissemination hamper the Bureau’s efforts to prevent
and control disease. Insufficient monitoring to ensure physicians
and laboratories comply with disease reporting requirements;
county health department weaknesses, such as the inability to
investigate all disease cases in a timely manner; increased de-mands
on staff; and inadequate computer systems contribute to
surveillance deficiencies. To improve its ability to protect the
public from communicable disease, the Bureau should take steps
to ensure that laboratories and physicians or physicians’ author-ized
representatives report complete and timely information
about diseases; increase its visibility; increase its dissemination of
disease information; and strengthen its surveillance technology.
The Importance of
Disease Surveillance
Disease surveillance is the ongoing and systematic collection,
analysis, and dissemination of information about communicable
diseases, such as hepatitis, HIV, and tuberculosis. It has been
called “the single most important tool for identifying infectious
diseases that are emerging, causing serious health problems, or
diminishing.”1 Surveillance data permits state health agencies to
identify disease outbreaks and at-risk groups and develop
strategies to reduce the risk of infection. It also permits effective
resource allocation and improvements in health care providers’
clinical practices. However, these outcomes depend on the sur-veillance
system’s effectiveness.
1 Association of State and Territorial Health Officials. Policy Positions.
October 1998, p. 30.
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OFFICE OF THE AUDITOR GENERAL
The Centers for Disease Control and Prevention have developed
guidelines for evaluating the effectiveness of state surveillance
systems. According to these guidelines, the system must be sen-sitive,
capturing complete and timely information on disease
cases, and useful, producing the needed information through
analysis and dissemination to prevent and control diseases.
Arizona’s communicable disease surveillance system is com-prised
of several components, including the Bureau, health care
providers, and county health departments. The Bureau is re-sponsible
for monitoring and controlling the spread of 71 com-municable
diseases and relies on health care providers,
laboratories, and county health departments to regularly report
disease information. State rules require laboratories to report
these diseases directly to the Bureau. Labs report basic case in-formation,
such as the infected individual’s name, test type, and
lab results. State rules also require that physicians report diseases
to their county health departments, which are responsible for
investigating and confirming the reported cases, and reporting
them to the Bureau. Physicians supply the counties with case
information, such as the infected individual’s address, that is not
generally provided by the laboratories but is necessary to con-duct
an investigation. Additional information, such as data on
the source of transmission, is also collected through the investi-gation
process and provided to the Bureau. The Bureau uses its
collected data to guide disease prevention and control efforts. It
also uses data to determine which reported incidents meet na-tional
case definitions and are reportable to the Centers for Dis-ease
Control and Prevention, which monitor communicable
diseases nationwide.
Current Practices Limit
Effectiveness of
Surveillance Efforts
Although disease surveillance is essential to protect the public’s
health, current surveillance practices do not adequately ensure
that the Bureau can monitor and respond to communicable dis-eases.
Laboratories and physi-cians
are required to report
communicable diseases.
11
OFFICE OF THE AUDITOR GENERAL
n First, physicians and laboratories do not always report dis-eases
as required by law, hindering the prediction of out-breaks.
n Second, many reports are submitted late.
n Third, because the Bureau does not always adequately ana-lyze
surveillance data, it is sometimes unable to identify out-breaks.
n Finally, the Bureau’s dissemination of surveillance informa-tion
is limited, leaving some health professionals without
timely access to valuable information.
Underreporting hinders the Bureau’s ability to identify out-breaks—
Both laboratories and physicians are required to report
communicable diseases to ensure that all diseases are reported
and that complete information is gathered on each case. These
matching laboratory and physician reports enable disease re-ports
to be verified by the Bureau and officially counted as cases.
Despite the importance of complete information, neither provid-ers
nor labs report every disease incident. To determine the
completeness of data collected, auditors reviewed a sample of
4,653 reported disease cases. The sample comprised all disease
reports entered into the General Communicable Disease Registry
between July 1, 1998 and December 31, 1998. The review re-vealed
that for 1,221 of the cases sampled, the Bureau had re-ceived
laboratory but not physician reports. These findings
suggest that physicians fail to report at least one-fourth of the
reportable diseases they diagnose, increasing the likelihood that
disease incidents will not be identified in a timely manner. Simi-larly,
laboratories may not report every case. According to Bu-reau
staff, laboratory reporting is far more consistent than
physician reporting; however, they too sometimes fail to report
disease cases.
Even when physicians and laboratories report diseases to the
Bureau, their reports do not always contain complete informa-tion,
which delays both the initiation of an investigation and the
determination of whether a case meets the case definition and
can be officially counted. Auditors reviewed samples of lab re-ports
from each of the surveillance sections and found that many
reports were incomplete. For instance, in a two-week sample of
Physicians do not al-ways
report many
reportable diseases.
12
OFFICE OF THE AUDITOR GENERAL
HIV laboratory-reported cases, approximately 40 percent con-tained
incomplete information. The reports were missing infor-mation,
such as the diagnosing physician’s name and phone
number, which disease investigators require to conduct case
investigations. Incomplete reports require greater staff time to
process, increase the likelihood of case reporting errors, and
delay case intervention, all of which lengthen the public’s expo-sure
to risk.
Although the Bureau manages outbreaks well once it learns of
them, incomplete or under-reporting hinders its ability to
quickly detect outbreaks. When the Bureau is unaware of a dis-ease
case, it cannot intervene to ensure treatment of the infected
individual and prevent further transmission of the disease. For
example, a measles outbreak late in 1998 spread unchecked for
almost a month, exposing many people to unnecessary risk of
infection, because the two cases likely to have begun the out-break
had not been immediately reported to the Bureau by the
diagnosing physicians or the testing laboratories. Additionally,
an outbreak of Legionnaire’s Disease occurred at a Tucson hos-pital
in 1996. While reviewing cases through hospital laboratory
databases, the Bureau discovered that an outbreak of the same
disease had occurred ten years earlier. The failure to identify the
first outbreak could have exposed the public to unnecessary risk
of infections.
Many reports are submitted late—To ensure that the Bureau can
respond promptly to disease outbreaks, rules dictate that highly
contagious or serious diseases, such as tuberculosis and rubella,
be reported within 24 hours of identification or treatment. Other
diseases, such as coccidioidomycosis (valley fever) or varicella
(chicken pox), which are less contagious or serious, must be re-ported
within a week. However, as demonstrated above in the
case of the measles outbreak, physicians do not always report in
a timely manner. Furthermore, although many laboratories
submit regular weekly reports to the Bureau, their reports of
individual disease cases may be late. Auditors reviewed a sam-ple
of 302 infectious disease cases reported by laboratories dur-ing
the first week of December 1998. The review revealed that,
on average, the Bureau received disease reports 18 days after the
laboratories produced test results.
Many laboratory re-ports
are received late.
13
OFFICE OF THE AUDITOR GENERAL
Even when the Bureau collects data within appropriate time
frames, it does not always enter it into databases in a timely
manner. Case investigation data for certain diseases is collected
on supplemental data collection forms, but the Bureau assigns
these forms a lower priority so the data is not always entered
immediately. For example, the Bureau was over a year behind in
its processing of supplemental streptococcus data when an out-break
occurred. Before the Bureau could analyze the data and
use the findings to respond to the outbreak, it had to process all
the data collection forms. The data could have been helpful for
the outbreak investigation because it differentiated between
various strains of the disease, revealing a rise in a particularly
severe strain.
Delayed or incomplete data collection may also impact funding
the State receives for some diseases. For example, a recent back-log
of Maricopa County HIV/AIDS cases awaiting investigation
had accumulated for several years and, at its peak, totaled over
2,200 cases. Because the cases had not been processed, the Bu-reau’s
disease figures understated the extent of AIDS in the State,
indicating a decline in the number of cases when, in fact, the
number was stable. Furthermore, because the cases could not be
officially counted until processed, they were not calculated into
the allocation formula for federal AIDS program dollars, poten-tially
costing the State over $2.5 million in lost funding. In 1999,
the Bureau worked with the Maricopa County Department of
Public Health Services to reduce the backlog of cases awaiting
investigation. The potential for lost funding as a result of late or
incomplete data exists with other diseases, such as sexually
transmitted diseases, whose funding is also partly dependent on
the number of reported cases.
Surveillance data is not adequately analyzed—The Bureau does
not regularly conduct in-depth analyses of its data and analyzes
little of the large quantity of collected data. When regularly com-piled
and analyzed, surveillance data permits the identification
of at-risk groups, the development of strategies for intervention
when potential and real outbreaks occur, and the education of
the public and the medical community about current risks and
prevention strategies. Without complete and timely data collec-tion
and regular analysis, the Bureau cannot consistently identify
trends or anticipate and prepare for outbreaks.
Maricopa County had a
recent backlog of 2,200
uninvestigated
HIV/AIDS cases, po-tentially
costing the
State over $2.5million.
14
OFFICE OF THE AUDITOR GENERAL
Bureau’s dissemination of surveillance information is limited—
The Bureau disseminates surveillance information through vari-ous
outlets. These include:
n public health announcements, notifying the public of out-breaks,
preventive measures, and heightened risks;
n surveillance reports with statistics on the numbers and char-acteristics
of infected individuals;
n fax alerts to health care providers during outbreaks; and
n a regular newsletter, Prevention Bulletin.
Compared to other state epidemiology agencies, the Bureau
produces only a limited number of surveillance reports and does
not widely disseminate them. For example, the Sexually Trans-mitted
Diseases section produces only one annual surveillance
report, with a distribution list of only 65 individuals, primarily
state and county health department staff. Similarly, the Infectious
Disease section does not regularly produce or distribute printed
surveillance reports on infectious diseases. In addition, although
the Bureau has access to a wide audience through the Internet, its
current Web page makes little surveillance data available.
Public health professionals have expressed a desire for more
regular and timely surveillance information from the Bureau.
Their comments suggest that the Bureau’s most widely distrib-uted
publication, Prevention Bulletin, may not meet their needs
for disease information from the Bureau. The Bulletin, with a
distribution list of almost 12,000, including all state-licensed phy-sicians,
county health departments, and other health profession-als,
contains information about recent outbreaks, immunization
drives, and other related issues. Due to its bimonthly production
schedule, however, providers sometimes learn about outbreaks
after they have ended. Providers expressed an interest in more
frequent statistical reports and regular feedback on the disease
cases they report. In addition, some county health department
representatives expressed interest in receiving more frequent
statistical reports and, in general, greater feedback on reported
data.
The Prevention Bulle-tin
may not meet health
professionals’ needs.
15
OFFICE OF THE AUDITOR GENERAL
Several Factors Contribute to
Deficiencies in the Bureau’s
Surveillance System
Several factors contribute to deficiencies in the Bureau’s disease
surveillance system. First, the Bureau does not enforce reporting
requirements for physicians and laboratories. Second, some
county health departments are unable to investigate all cases.
Third, the Bureau’s current computer systems are inadequate to
efficiently track and monitor diseases. Finally, increased de-mands
on staff cause them to spend less time analyzing data and
assessing its quality.
Bureau does not ensure that physicians and laboratories comply
with reporting requirements—The Bureau does not systemati-cally
take action to ensure that reporting is complete and timely.
First, it does not regularly monitor reporting by physicians and
laboratories to determine if and when reports are late or missing.
For example, the Bureau does not maintain complete lists of labo-ratories
required to report disease data and cannot, therefore,
determine which laboratories may not be submitting the required
weekly reports. Second, if a report is late or missing, the Bureau
does not consistently act to prevent a repeat occurrence. On occa-sion,
severely late reports and late or missing reports of serious
diseases will prompt a call from the Bureau to the physician or
laboratory; however, this practice is inconsistent. Similarly, while
the Sexually Transmitted Diseases section notifies by letter physi-cians
who fail to report or report later than required, the Bureau’s
other surveillance units do not generally follow this practice. In
addition, although failure to comply with reporting requirements
constitutes unprofessional conduct under licensing statutes, as
well as a class 3 misdemeanor, the Bureau rarely reports non-compliant
physicians for discipline to the relevant state licensing
boards, such as the Board of Medical Examiners.
Several factors make it especially challenging to monitor and
enforce physician reporting requirements. First, the medical pro-fession’s
historical independence makes any externally imposed
requirement more difficult to enforce. Physicians may view
themselves as having discretionary authority over reporting. For
example, while it is not common, some providers refuse to report
certain diseases, such as HIV, to protect patient confidentiality.
The Bureau does not
monitor reporting by
physicians and labora-tories.
16
OFFICE OF THE AUDITOR GENERAL
Second, when faced with competing demands for their time and
energy, physicians sometimes assign reporting a low priority, or,
since often it is administrative rather than clinical staff who actu-ally
handle reporting, physicians may be unaware of either state
reporting requirements or the reporting practices in their offices.
Third, as Bureau staff and some medical professionals have sug-gested,
physicians may not report because they fail to see the
purpose or benefits of reporting. Since the Bureau provides little
tangible return in the form of feedback or incentives for report-ing,
physicians may not understand the necessity of regular,
timely reporting.
Some county health departments are unable to investigate all
cases—County health departments are not always able to fulfill
their surveillance responsibilities and thus they contribute to the
problem of late and incomplete data. The counties receive dis-ease
reports from physicians, investigate and confirm cases, and
report confirmed cases to the Bureau. Yet the counties either do
not investigate or do not investigate in a timely manner many
disease cases. For example, there are about 10,000 cases of chla-mydia
annually in Maricopa County, but the County investi-gates
only an estimated one-fifth of these cases. Additionally, the
previously mentioned HIV/AIDS case backlog illustrates the
lateness of many investigations.
The Bureau’s information management systems are inade-quate—
The Bureau’s current computer systems hinder timely
data entry and analysis. The Bureau uses several computerized
databases, including four developed by the Centers for Disease
Control (CDC). However, state and county data systems are not
integrated. Most disease reports from the counties and laborato-ries
to the State are in paper form and thus, are manually proc-essed
by the Bureau. Although two counties, Maricopa and
Pima, enter certain disease data directly into a state database, the
other counties rely on Bureau staff to perform their data entry
and produce statistical summaries. Some counties and laborato-ries
are capable of and interested in reporting electronically;
however, the Bureau does not currently have the technology to
move toward electronic reporting.
Additionally, some of the Bureau’s disease databases are anti-quated
or difficult to use. For example, the CDC-provided Tu-berculosis
Information Management System requires that users
Maricopa County in-vestigates
only one-fifth
of its chlamydia cases.
17
OFFICE OF THE AUDITOR GENERAL
pass through as many as 13 different screens to enter a single
case’s data, which leads to time-consuming data entry and a
decreased likelihood that data entry will be complete and accu-rate.
Finally, existing Bureau technology limitations are compounded
by inadequate support from the Department’s Division of In-formation
Technology Services. Division staff are unavailable to
adequately maintain existing services, such as the agency’s
Internet Web site, or perform minor system improvements, such
as creating a program that would automatically generate sur-veillance
data reports or produce letters to noncompliant physi-cians.
Bureau management attributes deficiencies to increasing de-mands
placed on staff—According to Bureau management,
increasing demands on Bureau staff lessen their ability to per-form
surveillance activities, such as data analysis and data qual-ity
assessment. To begin with, staff time is being spent helping
county health departments in fulfilling their surveillance respon-sibilities.
In addition, there have been increases in disease clus-ters
and outbreaks. Finally, fewer staff are available to conduct
surveillance. For example, in the HIV section, four authorized
surveillance positions are vacant because they are unfunded.
Bureau management report that staff are often too busy re-sponding
to outbreaks and handling problems to analyze data
and produce reports. For instance, during a hantavirus outbreak,
no disease surveillance was conducted in the State because staff
resources were diverted to address the crisis.
Arizona’s Disease Surveillance
System Can Be Improved
To adequately protect the public from communicable diseases,
the Bureau should take action to improve its disease surveillance
system. First, the Bureau should take steps to ensure that physi-cians
and laboratories report information about diseases in a
complete and timely manner. Second, the Bureau should im-prove
its visibility to raise awareness of the importance of disease
surveillance. Third, the Bureau should increase its dissemination
18
OFFICE OF THE AUDITOR GENERAL
of surveillance data. Finally, the Bureau should address deficien-cies
in its surveillance technology.
The Bureau should take steps to ensure complete and timely
reporting—To ensure that its data is accurate and useful, the
Bureau should take action to increase the completeness and
timeliness of disease reporting. First, in accordance with the
Centers for Disease Control and Prevention’s guidelines for ef-fective
surveillance, the Bureau should develop a system to peri-odically
evaluate the State’s disease surveillance system. This
evaluation would enable the Bureau to regularly identify pro-viders
and laboratories whose reporting is incomplete or late.
Second, to encourage greater compliance with reporting re-quirements
by laboratories and physicians, the Bureau could
expand its practice of issuing reminder letters to noncompliant
physicians and thank-you letters to compliant physicians. Third,
the Bureau should strengthen relationships with hospitals and
health care provider groups, to improve reporting completeness
and reduce its reliance on physicians. Reliance on multiple re-porting
sources is not only recommended by the Centers for
Disease Control and Prevention but has also been successful in
other states. For instance, Mississippi’s Disease Control and En-vironmental
Epidemiology Division does not rely heavily on
physicians for reporting and, instead, maintains strong relation-ships
with hospital infection control nurses to ensure timely and
complete disease reporting.
The Bureau should improve its visibility to raise awareness of
the importance of disease surveillance—According to the public
health literature, public health agencies lack adequate self-promotion
and could benefit from greater efforts to market
themselves. The Bureau should involve its own and Department
of Health Services’ leadership in promoting the agency’s sur-veillance
efforts. The Bureau should also follow the example of
other state epidemiology agencies and develop its contact with
the media. Greater visibility could provide the Bureau an op-portunity
to communicate the importance of disease surveillance
to doctors, laboratories, and other health care providers. The
State Health Department in Oregon, which has extensive contact
with the media, including regular meetings to inform them of the
latest developments, credits its visibility as the reason for the
state’s achievement of a high level of disease reporting.
The Bureau should
consider surveying
physicians and county
health departments to
determine the type of
information needed.
19
OFFICE OF THE AUDITOR GENERAL
Dissemination of surveillance data should be improved—The
Bureau should give more feedback to health care providers,
laboratories, and county health departments. This could mean
distributing more regular reports of surveillance data or provid-ing
information on the outcomes of specific cases. It could take
the form of regular surveillance statistics, interim findings from
special studies, or reports of Bureau activities. The Bureau
should consider surveying physicians and county health de-partments
to determine the type of feedback they desire and the
usefulness of current outreach efforts, such as the Prevention
Bulletin, and develop its outreach according to survey findings.
The Bureau should also maximize the use of its Internet Web site
to ensure broad access to surveillance information. While the
Bureau’s Web site features some reports and a list of reportable
diseases, it provides less information than other, similar Web
sites. For example, other states’ sites, such as Texas, California,
and New Jersey, offer downloadable surveillance reports, the list
of reportable diseases, reporting forms, reporting requirements,
and department publications. Additionally, these Web sites offer
more current information than Arizona’s site. Access to extensive
surveillance information via the Internet is more immediate than
through other media, eliminates the need to distribute costly
printed reports, and establishes a potential foundation for the
development of electronic reporting.
The Bureau should address deficiencies in technology—Out-dated
and ineffective information management systems hinder
the Bureau’s and county health departments’ ability to conduct
surveillance efficiently. The Bureau should explore more ad-vanced
information technology. For example, electronic report-ing
of disease data by laboratories and physicians could improve
efficiency and enhance report completeness and timeliness. The
Bureau should also explore minor system enhancements it could
make in the short term, such as automatically generating sur-veillance
data reports.
20
OFFICE OF THE AUDITOR GENERAL
Recommendations
1. To ensure the completeness and timeliness of disease re-porting,
the Bureau should:
a) Develop a system to evaluate the State’s surveillance system
and identify noncompliant laboratories and physicians;
b) Expand the practice of contacting physicians and laboratories
by letter when a communicable disease report is late or miss-ing;
c) Report to the appropriate state licensing board, such as the
Board of Medical Examiners, those physicians who are chroni-cally
noncompliant with reporting requirements; and
d) Strengthen relationships with other reporting sources.
2. The Bureau should more widely and regularly disseminate
surveillance information. Specifically, the Bureau should:
a) Provide greater feedback in the form of regular surveillance re-ports,
publications, and case updates to physicians, laborato-ries,
and county health departments;
b) Consider conducting a survey to determine the kind of feed-back
desired by physicians, laboratories, and county health de-partments;
c) Evaluate the Prevention Bulletin’s contents and distribution to
ensure that it meets public health professionals’ needs for dis-ease
information from the Bureau; and
d) Improve its Internet Web site by providing online access to a
wider selection of surveillance reports, reporting forms, and
important, time-sensitive, public health information.
3 The Bureau should address deficiencies in its information
management systems. Specifically, the Bureau should:
a) Explore more advanced information technology for the State’s
disease surveillance system, such as electronic reporting of dis-ease
data by laboratories and physicians; and
b) Explore system enhancements such as automatically generat-ing
surveillance data reports.
21
OFFICE OF THE AUDITOR GENERAL
FINDING II ARIZONA IMMUNIZATION
PROGRAM OFFICE SHOULD
IMPROVE EFFORTS TO
COLLECT DATA
The Arizona Immunization Program Office should improve
efforts to collect data to gauge the State’s progress toward
reaching its immunization goals. Although estimates of state-wide
immunization rates for children indicate that coverage
levels have improved, rates remain low for children receiving
vaccinations from some county health departments. In addition,
problems with the Office’s computerized reporting system often
prevent county health departments from reporting timely and
complete immunization records. Further, the Office does not
adequately ensure the accuracy of immunization levels reported
by schools. By improving its data collection processes, the Office
may be able to more effectively monitor immunization levels
throughout the State.
Responsibilities of the Arizona
Immunization Program Office
The Arizona Immunization Program has several responsibilities
that are essential for helping the State achieve its immunization
goals. The Office is responsible for overseeing the distribution of
free vaccines to eligible providers, and promoting hepatitis B
screening for pregnant women and their newborns. Addition-ally,
the Immunization Office collects data on coverage levels for
children receiving vaccinations from county health departments
and provides this information to the health departments. As a
federal grant recipient, the Office is also required to collect data
regarding immunization levels for children attending childcare
facilities, Head Start Centers, and schools and report this data to
the Centers for Disease Control and Prevention (CDC). The Of-fice
collects data from county health departments and schools by:
Finding II
22
OFFICE OF THE AUDITOR GENERAL
n Obtaining semi-annual reports of immunization levels for
children receiving vaccinations from county health depart-ments.
n Obtaining annual immunization data reports (IDRs) from
schools, which contain immunization levels for kindergart-ners
and 6th- and 11th-graders.
Federal guidelines recommend that states achieve a 90 percent
immunization rate for two-year-old children by the year 2000 to
continue to reduce incidences of all vaccine-preventable diseases.
Collecting immunization data from county health departments
enables the Office to gauge its progress toward the 90 percent
goal. Moreover, monitoring vaccination coverage for county
health departments and schools allows the Office to identify
groups at risk of vaccine-preventable diseases, to provide feed-back
to providers, and to evaluate the effectiveness of programs
designed to increase coverage. This information also supple-ments
data collected at the national level, such as the CDC’s
National Immunization Survey, which recently estimated that
the percentage of fully immunized 19- to 35-month-old children
in Arizona increased from 74 percent in 1997 to 78 percent in
1998.
Arizona’s Immunization
Rates Have Not Improved
in Every Area
Despite recent improvements in statewide immunization rates,
many children receiving immunizations from public health pro-viders
are inadequately immunized. Immunization rates for
county health departments are an important indicator of state-wide
coverage levels because, according to Office management,
over 53 percent of Arizona children receive free vaccinations
from a county health department. Based on the semi-annual
assessments completed by the State’s county health departments
and collected by the Office, coverage levels for children using
health departments have generally improved over the past four
years, especially in rural counties (see Table 2, page 23). How-ever,
recent figures for Maricopa and Pima Counties reveal that
less than half of the children served by the State’s largest county
Immunization rates
recently increased from
74 percent to 78 per-cent.
Finding II
23
OFFICE OF THE AUDITOR GENERAL
health departments are fully immunized by age two. The most
recent figures (spring 1999) indicate that only 47 percent of two-year-
old children served by the Maricopa County Health De-partment
and only 43 percent of two-year-old children served by
the Pima County Health Department are fully immunized.
Moreover, since the fall of 1994, Maricopa County has failed to
sustain and Pima County has failed to achieve a rate of above 50
percent (see Table 2).
Table 2
Arizona Department of Health Services
Bureau of Epidemiology and Disease Control
County Health Department Immunization Levels
Percentage of Two-Year-Old Children Fully Immunized 1
Fall 1994, Fall 1998, and Spring 1999
County Fall 1994 Fall 1998 Spring 1999
Apache 49% 78% 69%
Cochise 74 73 69
Coconino 63 72 76
Gila 78 82 86
Graham 71 80 81
Greenlee 70 49 89
LaPaz 58 78 84
Maricopa 51 44 47
Mohave 75 68 73
Navajo 51 56 58
Pima 38 40 43
Pinal 46 64 64
Santa Cruz 64 89 90
Yavapai 62 75 70
Yuma 68 89 N/A2
1 According to federal guidelines, the age-appropriate vaccinations for two-year-old children include four
doses of DTaP (diphtheria, tetanus, and pertussis), three doses of polio, and one dose of MMR (measles,
mumps, and rubella).
2 According to Immunization Program Office Staff, spring 1999 figures for the Yuma County Health Depart-ment
are inaccurate because the department lost part of its database.
Source: County data assesments from the Arizona Department of Health Services, Division of Public Health,
Bureau of Epidemiology and Disease Control, Arizona Immunization Program Office.
Finding II
24
OFFICE OF THE AUDITOR GENERAL
Arizona State Immunization
Information System
Needs Improvement
County health departments have experienced difficulties using
the Arizona State Immunization Information System (ASIIS),
and the Office does not ensure that all private health providers
report immunization data to ASIIS. County health departments
have experienced problems with ASIIS that affect their ability to
submit immunization records and generate reports. In addition,
the Office lacks an effective strategy to promote and enforce the
state law requiring private providers to report to ASIIS. How-ever,
because ASIIS serves as a useful system for tracking immu-nization
records and rates statewide, the Office should continue
to work to make it easier to report immunization records and
more thoroughly enforce reporting requirements.
The Arizona State Immunization Information System is one of
many statewide, computerized immunization registries in the
country. Under A.R.S. §36-135, all health providers (public and
private) are required to submit immunization records for pa-tients
under 18 years of age to the State’s central database, which
is part of ASIIS.
County health departments experience problems using ASIIS—
Because county health departments have experienced various
problems using ASIIS, they may not be able to maintain and
submit complete and timely records. Specifically, county health
departments have had difficulties in submitting records to the
State’s central database, obtaining patient records, and produc-ing
immunization reminder notices for patients. They have also
lost data and encountered duplicate records. These problems
may have developed because the system was not designed to
handle the large volumes of data submitted by some county
health departments. Additionally, the construction and mainte-nance
of county databases is further restricted because ASIIS
software does not provide a way for computers within a county
health department to be connected to one another and thus cre-ate
a local network.
Some private providers are not reporting to ASIIS—Although
private health providers are required to submit immunization
records to the State’s database, the Office recently estimated that
ASIIS is a statewide,
computerized registry.
Finding II
25
OFFICE OF THE AUDITOR GENERAL
approximately 6 percent of private health providers enrolled in
ASIIS do not report to the system. Until recently, the Office did
not have an effective strategy to ensure that all health providers
report to ASIIS. Specifically, the Office has not consistently iden-tified
and contacted health providers who do not submit records
to ASIIS.
The Office should continue to improve ASIIS—Because immuni-zation
registries “offer the best source of accurate, real-time data
on immunization levels,” the Immunization Program Office
should continue to improve ASIIS.1 Specifically, the Office
should continue to provide technical assistance to the counties to
guarantee that their data is complete and accurate, and to ensure
that appropriate backup methods are in place at each of these
sites. The Office has recently implemented a process to remove
duplicate records from the central registry, and it should con-tinue
removing duplicate records to ensure that providers do not
encounter them when attempting to query the central registry.
Furthermore, the Office should continue with recently imple-mented
plans to systematically review lists of physicians and
health providers who administer vaccinations and fail to report
to ASIIS. By ensuring that all providers within the State enroll in
ASIIS and that enrolled providers submit accurate and timely
records, the Office may be able to increase the registry’s number
and quality of records.
The Office Does Not Ensure That
School Reporting Is Accurate
Although accurately tracking schoolchildrens’ immunization
rates is important, the Office may not be able to adequately
monitor these rates. The Office does not ensure that all Arizona
schools comply with required coverage levels and that school
immunization reports are valid. These problems exist, in part,
because the Office does not consistently coordinate efforts with
the Arizona Department of Education (ADE). However, the
Office can improve its methods for obtaining data from schools
1 Policy Positions, Association of State and Territorial Health Officials,
October 1998.
Finding II
26
OFFICE OF THE AUDITOR GENERAL
by verifying school records and working with ADE to inform
school administration about the importance of immunization
and immunization reporting. Additionally, as a CDC grantee,
the Office is required to measure school compliance levels and
conduct validation studies of school records.
Arizona schools are required by law (A.R.S. §§15-872, 15-874) to
enforce immunization requirements and submit annual immu-nization
data reports to the Immunization Program Office. The
Office collects annual immunization data reports from schools to
determine whether at least 95 percent of kindergartners and 90
percent of 6th- and 11th-graders have received age-appropriate
vaccinations and to monitor school immunization levels. In 1998,
statewide coverage levels reported to the Department were 96.8
percent for kindergartners and 98.6 percent for 6th- and 11th-graders.
The Office cannot ensure immunization levels for schools—Al-though
Arizona law requires schools to annually submit data
about their students’ immunization levels to the Immunization
Program Office, the Office does not do enough to verify that
schools comply with state requirements. For example, the Office
did not verify any of the 1998-99 school immunization data re-ports.
The Office also does not conduct many school site visits although
reports indicate that compliance rates for some schools are sig-nificantly
lower than 95 percent. In 1999, the Office conducted
only three school site visits. School site visits are useful because
they enable Office staff to review immunization records and help
administrators complete referral notices, which serve as remind-ers
for the parents/guardians of noncompliant students.
The Office lacks coordination with ADE— The Office has not
consistently worked with the Department of Education to inform
school administrators about the importance of immunizations
and immunization reporting.
Coordination with ADE could help promote school administra-tors’
awareness of immunizations and emphasize the need for
schools to report immunization data to the Office.
The Office did not verify
1998-99 school reports.
Finding II
27
OFFICE OF THE AUDITOR GENERAL
Recommendations
1. The Office should continue to improve the Arizona State
Immunization Information System by correcting design
flaws and making it easier for county health departments to
report information.
2. To ensure that the ASIIS registry is comprehensive and that
all providers submit records to the system, the Office should:
a) Continue providing technical assistance to the counties;
b) Ensure that appropriate backup methods are in place; and
c) Implement plans to systematically identify health care provid-ers
who fail to report vaccinations.
3. The Office should verify school immunization data reports
from selected schools.
4. The Office should regularly coordinate with the Arizona
Department of Education to develop strategies for promoting
the importance of immunization objectives and reporting.
28
OFFICE OF THE AUDITOR GENERAL
(This Page Intentionally Left Blank)
29
OFFICE OF THE AUDITOR GENERAL
FINDING III THE OFFICE OF ENVIRONMENTAL
HEALTH’S SCOPE OF ACTIVITIES
SHOULD BE REVIEWED
The Office of Environmental Health’s scope of activities is too
broad. The Office performs numerous duties, ranging from li-censing
bedding manufacturers to responding to environmental
emergencies, such as chemical spills. In addition, the Office per-forms
several unmandated activities intended to protect public
health. However, the Office is unable to perform all of these ac-tivities.
Bureau management should review the Office’s activities
and propose recommendations to the Legislature regarding a
revised scope of duties.
Background
Auditors identified over 40 activities for which the Office is re-sponsible
(see Table 3, page 30), all of which are apparently in-tended
to protect the public from environmental health risks,
such as poor sanitation, contaminated food, and exposure to
pollutants. State law mandates most of the activities the Office of
Environmental Health must perform. However, the Office per-forms
other activities that are not mandated by statute, such as
inspections of 88 produce warehouses in Nogales, Arizona, that
handle approximately 75 percent of the nation’s winter produce.
The Office has delegated nine of its activities to the county health
departments, including the major functions, such as restaurant
inspections. To carry out all of its discretionary activities, the
Office has 20 professional staff, including 8 who are federally
funded to complete specific tasks. Three positions are funded by
the Agency for Toxic Substances and Disease Registry to conduct
health assessments, three positions are funded by the United
States Environmental Protection Agency for lead poisoning
abatement programs, and the Centers for Disease Control and
Prevention funds two positions to develop special lead poison-ing
prevention projects. The Office’s 12 state-funded staff are
responsible for all the remaining activities.
The Office has delegated
significant functions to
county health depart-ments.
Finding III
30
OFFICE OF THE AUDITOR GENERAL
Table 3
Arizona Department of Health Services
Bureau of Epidemiology and Disease Control
Office of Environmental Health Activities
As of July 1999
Activities
Required
Yes No
Number of
Facilities or
Establishments
Delegated
to Counties
Food Safety
Inspect establishments, such as restaurants, to assure safe food
handling X 18,758 15 counties
Inspect food processors to assure safe food handling X 5,572 14 counties
Inspect institutional kitchens, such as prisons, to assure food safety X 174
Inspect bottled water facilities to assure product safety X 3 1 county
Inspect ice manufacturers to assure ice is safe to consume X 3
Assure food sold is not adulterated or misbranded X
Collect food samples during inspections and investigations
for analysis X
Respond to complaints by inspecting food and bedding
irregularities X
Evaluate county health department delegation programs X 15
Train Registered Sanitarians X
Enforce state food code X
Interpret state food code X
Review blueprints and retailer food plans X
Sponsor Sanitarians Council X
Assure that all bulked foods are dispensed, labeled, and
maintained properly X
Inspect produce warehouses in Nogales to assure
sanitary conditions X 88
Assure that foods sold as kosher are not fraudulently l abeled X
General Sanitation
License bedding manufacturers and investigate complaints X
Inspect Behavioral Health group home facilities to assure food
safety principles X 202
License and inspect children’s camps X 75
Inspect Department of Economic Security child welfare facilities X 286
Inspect sanitary condition of fertilizer manufacturers X
Inspect hotels and motels to assure sanitary conditions X 1,276 15 counties
Investigate objectionable facilities and animals X 15 counties
Inspect public pools and baths X 10,742 15 counties
Inspect public buildings to assure sanitary conditions X
Inspect public schools to assure sanitary conditions X 1,156 1 county
Inspect coach trailer parks to assure sanitary conditions X 1,844 14 counties
Toxic Substances
Provide public health perspective on environmental
emergencies, such as spills, fires, etc. X
Prepare Health Assessment Report; supported by federal
grant monies X
continued
Finding III
31
OFFICE OF THE AUDITOR GENERAL
Scope of Activities
Should Be Reviewed
With responsibility for a wide variety of activities, and a limited
number of staff to perform those activities, the Office of Envi-ronmental
Health needs to review and determine which activi-ties
are most crucial to the public health. Currently, the Office
cannot perform all of its mandated duties; however, some duties
Table 3
Department of Health Services
Bureau of Epidemiology and Disease Control
Office of Environmental Health Activities
As of July 1999
(Cont’d)
Activities
Required
Yes No
Number of
Facilities or
Establishments
Delegated
to Counties
Toxic Substances (cont’d)
Prepare Health Consultation Program; supported by
federal grant monies X
Provide outreach program regarding air quality issues X
Provide outreach program regarding indoor air quality X
Administer certification program for lead paint abatement X
Investigate serious lead poisoning cases X
Maintain Lead Poisoning Registry X
Conduct pesticide poisoning investigation X
Maintain Pesticide Poisoning Registry X
Develop statewide lead screening policy; supported
by federal grant monies X
Miscellaneous
Conduct special projects, such as adopting new state
food code X
Promulgate rules X
Review rules X
Plan and host training seminars X
Initiate and moderate task force committees X
Provide technical assistance/consultations X
Develop technical material, such as pamphlets and
other documents X
Source: Auditor General staff analysis of information provided by the Office of Environmental Health Manage-ment
and staff.
Finding III
32
OFFICE OF THE AUDITOR GENERAL
are more important to the public health than others. Therefore,
the Office should prepare recommendations for the Legislature
regarding which of its duties can be eliminated, delegated, or
transferred to other agencies.
Office cannot perform all duties—The Office cannot perform all
of its duties, even though most are mandated by statute. For
example, the Office is required to inspect public and semi-public
buildings to ensure sanitary conditions are maintained, but be-cause
staff have limited time, the Office does not perform any of
these inspections. The Office is also required to inspect Child
Welfare Facilities to support licensure by the Department of
Economic Security. In fiscal year 1998, the Office inspected 231 of
286 facilities (81 percent). Similarly, given travel time and staff
constraints, the Office inspected 45 of 75 children’s camps in
fiscal year 1998.
The Office is also unable to monitor the performance of county
health departments in carrying out the duties the Office has
delegated to them. County health departments have been dele-gated
responsibility for inspecting over 38,000 different facilities
and establishments in the State, including 18,700 restaurants;
10,700 public pools and baths; 5,600 food processors; 1,800 trailer
parks; and 1,100 school grounds. However, the Office does not
monitor the counties’ performance of these duties.
Some duties more critical than others—Although there are more
duties than can be performed by existing Office staff, not all of
these duties are equally important in terms of their potential
impact on public health. For example, the Office does not inspect
licensed bedding manufacturers, even though such inspections
are mandated, because bedding represents a minimal public
health risk. However, the Office considers revising the State’s
food code an important public health activity. The Office also
considers inspections of produce warehouses, which are not
mandated, an important public health activity because of the
possible use of contaminated well water to process the produce.
The Office has identified duties for which the public health im-pact
is not clearly established. For example, the duty to inspect
kosher foods to ensure authenticity is an issue of consumer fraud
In fiscal year 1998 the
Office inspected only 81
percent of Child Welfare
Facilities.
Some Office duties have
minimal impact on
public health.
Finding III
33
OFFICE OF THE AUDITOR GENERAL
rather than public health. The Office also believes trailer park
inspections, in the absence of a complaint, represent a minimal
public health impact.
Office needs to review and prioritize all duties—Although the
Office has identified some activities as a low priority, the Office
has not systematically prioritized its various duties nor sought to
have less critical mandates removed by eliminating, delegating
or transferring them to other agencies. The Office should assess
the relative public health impact for all of its duties. It should
then prepare a proposal for legislative consideration to eliminate
those mandated duties with little or no public health impact.
This would allow the Office to focus its limited resources on the
most important duties and remove regulatory requirements
from statute.
Recommendation
1) The Office should determine those duties that have the great-est
impact on public health, and present the Legislature with
a proposal outlining those mandated activities that could be
eliminated, delegated, or transferred to other agencies.
OFFICE OF THE AUDITOR GENERAL
(This Page Intentionally Left Blank)
OFFICE OF THE AUDITOR GENERAL
AGENCY RESPONSE
OFFICE OF THE AUDITOR GENERAL
Page 1 of 6
Response to the Performance Audit of the
Arizona Department of Health Services
Bureau of Epidemiology and Disease Control Services
Overview:
The Arizona Department of Health Services (ADHS) agrees in general with the findings of the audit
team.
Finding I - “Bureau’s Disease Surveillance System Needs Improvement”
The Bureau generally agrees with Finding I and recognizes the deficiencies of the current infectious
disease surveillance system. The reasons behind the problems are complex. It is important to note that
during the period from 1993 through 1998 the state’s population has increased 21%; the number of
annual communicable disease reports has increased by 77%; the number of laboratory reportable
conditions has increased by 230%; but the number of surveillance staff has remained the same.
Compounding this issue is the fact that in none of the 15 county health departments have their
communicable disease surveillance and control staff increased to be able to meet these needs at the
local level. The growing spectrum of diseases of public health importance, Arizona’s rapid population
growth, and the changing demographics in the State have overwhelmed the Bureau’s ability to address
adequately the current disease surveillance needs. These resource constraints increasingly limit the
Bureau’s capabilities in the areas of disease surveillance.
In addition to the need for appropriate resources and adequate staffing, an effective disease surveillance
system is closely interwoven with laboratory support, county health departments’ ability to investigate
and follow-up on case reports, health care providers’ willingness to comply with reporting
requirements, and the ability of large health care institutions to detect changes in infection rates and to
report them to the Bureau. For example, on page 12, the observation is made that “While reviewing
cases through hospital laboratory databases, the Bureau discovered that an outbreak of the same
disease had occurred ten years earlier. The failure to identify the first outbreak could have exposed the
public to unnecessary risk of infections.” In this instance, the hospital’s infection control program did
not recognize the increased rate in their hospital infections, and consequently, the hospital did not report
the cases to the Bureau. Not only is it physically impossible for the Bureau to monitor the databases of
all health care providers, this would be perceived as a significant intrusion by the state into the internal
operations of the health care provider.
It is noted on page 17 that existing Bureau technology limitations are compounded by inadequate
support from the Department’s Division of Information and Technology Services (DITS). We would
like to point out that the data registries that form the foundation of the Bureau’s disease surveillance
systems were developed by the federal Centers for Disease Control and Prevention (CDC) and their
use is mandated by CDC reporting requirements. Unfortunately, the data registries cannot be
Page 2 of 6
supported by DITS because DITS did not develop the computer software for the data registries and
does not have the source code.
With regard to vacancies in the Bureau, we have found, as have others, that the state’s salary structure
is not highly competitive nationally, leading to difficulties in recruiting and retaining qualified staff.
Finding I Recommendations
1. To ensure the completeness and timeliness of disease reporting, the Bureau should:
a. Develop a system to evaluate the State’s surveillance system and identify noncompliant
laboratories and physicians;
The finding of the Auditor General is agreed to and the audit
recommendation will be implemented.
b. Expand the practice of contacting physicians and laboratories by letter when a
communicable disease report is late or missing;
The finding of the Auditor General is agreed to and the audit
recommendation will be implemented.
c. Report to the appropriate state licensing board, such as the Board of Medical
Examiners, those physicians who are chronically noncompliant with reporting
requirements; and
The finding of the Auditor General is agreed to and the audit
recommendation will be implemented.
d. Strengthen relationships with other reporting sources.
The finding of the Auditor General is agreed to, and the audit
recommendation will be implemented.
2. The Bureau should more widely and regularly disseminate surveillance information. Specifically,
the Bureau should:
Page 3 of 6
a. Provide greater feedback in the form of regular surveillance reports, publications, and
case updates to physicians, laboratories, and county health departments;
The finding of the Auditor General is agreed to and the audit
recommendation will be implemented.
b. Consider conducting a survey to determine the kind of feedback desired by physicians,
laboratories, and county health departments;
The finding of the Auditor General is agreed to and the audit
recommendation will be implemented.
c. Evaluate the Prevention Bulletin’s contents and distribution to ensure that it meets
public health professionals’ needs for disease information from the Bureau; and
The finding of the Auditor General is agreed to and the audit
recommendation will be implemented.
d. Improve its Internet Web site by providing online access to a wider selection of
surveillance reports, reporting forms, and important, time-sensitive, public health
information.
The finding of the Auditor General is agreed to and the audit
recommendation will be implemented.
3. The Bureau should address deficiencies in its information management systems. Specifically,
the Bureau should:
a. Explore more advanced information technology for the State’s disease surveillance
system, such as electronic reporting of disease data by laboratories and physicians; and
The finding of the Auditor General is agreed to and the audit
recommendation will be implemented.
Comment: A major barrier to electronic reporting is the fact that no single
commercial software is available to interface with the various laboratory reporting
systems. Additionally, each laboratory is likely to have a different computer data
system. Some state health departments have received CDC funds to explore the
feasibility of such electronic reporting; however, it does not appear that any major
progress has been made to date on this issue by CDC. Another concern
associated with electronic reporting that first must be addressed is the maintenance
Page 4 of 6
of patient confidentiality.
b. Explore system enhancements such as automatically generating surveillance data
reports.
The finding of the Auditor General is agreed to and the audit
recommendation will be implemented.
Finding II “Arizona Immunization Program Office Should Improve Efforts to Collect
Data”
(A) Arizona’s Immunization Rates Have Not Improved in Every Area
The Bureau agrees in general with the statements in this section, but certain clarifications should be
made. For example, on page 23 it is stated that only 47 % of two-year-old children served by
Maricopa County Department of Public Health (MCDPH) and only 43% of two-year-old children
served by Pima County Health Department are fully immunized. It should be explained that every child
who receives even a single immunization by a county health department is included in that county’s
immunization database. County health departments conduct numerous special immunization outreach
activities at various locations, including shopping malls, Women, Infants and Children (WIC) offices,
schools, day care centers, etc., and these events may be the one and only immunization contact that the
child will have with the county’s immunization program. The child’s other immunizations may be given
by the child’s primary health care provider. Even if a child has received only one of a possible 16
immunizations from a county health department, that child must be included in the county’s immunization
database. Although the child may be fully immunized, the county’s database will continue to list this
child as receiving only one vaccination. Because of this reporting artifact, the Bureau believes the actual
immunization coverage levels are significantly higher than the rates given in this report. Once the
Arizona State Immunization Information System (ASIIS) becomes fully functional, we believe this issue
can be resolved.
(B) Arizona State Immunization Information System (ASIIS) Needs Improvement
The Bureau generally agrees with the conclusions provided in this section.
(C) The Office Does Not Ensure That School Reporting is Accurate
The Bureau generally agrees with the recommendations of this section. However, it should be noted
that a reliability and validity study on the 1998-1999 school immunization data was not conducted
because the CDC grant that funds this activity requires a biennial study and does not provide funding to
conduct annual studies. A reliability and validity study was conducted for the 1997-1998 school year
and another study is scheduled for the 2000-2001 school year. As noted in the report, the school
Page 5 of 6
1998 immunization data demonstrated coverage levels at an all-time high of 97% for Kindergartens
(72,616 students), and 99% for 6th and 11th grades (121,865 students). The Bureau feels that these
coverage results are excellent.
It should be noted that the Bureau has and will continue to coordinate activities with the Arizona
Department of Education (ADE). However, it is the Bureau’s understanding that funding is no longer
available in ADE for immunization compliance activities and any assistance from ADE will be through
ADE staff only as availability permits.
Finding II Recommendations
1. The Office should continue to improve the Arizona State Immunization Information System
[ASIIS] by correcting design flaws and making it easier for county health departments to
report information.
The finding of the Auditor General is agreed to and the audit recommendation
will be implemented.
2. To ensure that the ASIIS registry is comprehensive and that all providers submit records to the
system, the Office should:
a. Continue providing technical assistance to counties;
b Ensure that appropriate backup methods are in place; and
c. Implement plans to systematically identify health care providers who fail to report
vaccinations.
The finding of the Auditor General is agreed to and the audit recommendation
will be implemented.
3. The Office should verify school immunization data reports from selected schools.
The finding of the Auditor General is agreed to and the audit recommendation
will be implemented.
4. The Office should regularly coordinate with the Arizona Department of Education to develop
strategies for promoting the importance of immunization objectives and reporting.
The finding of the Auditor General is agreed to and the audit recommendation
will be implemented.
Page 6 of 6
Finding III: “The Office of Environmental Health’s Scope of Activities Should Be
Reviewed.”
The Bureau generally agrees with the findings of this section.
Finding III Recommendation
1. The Office should determine those duties that have the greatest impact on public health, and
present the Legislature with a proposal outlining those mandated activities that could be
eliminated, delegated, or transferred to other agencies.
The finding of the Auditor General is agreed to and the audit recommendation
will be implemented.
Comment: The Bureau has requested as recently as last year statutory revisions that
would have removed the mandate to license and inspect bedding manufacturers and
would have repealed the statutory requirements for the sale of bulk foods. The Bureau
hopes to be successful in repealing those and other mandates that have little or no
impact on public health in the next legislative session.
Other Performance Audit Reports Issued Within
the Last 12 Months
98-13 Private Enterprise Review Board
98-14 Adult Services
98-15 Podiatry Board
98-16 Board of Medical Examiners
98-17 Department of Health Services—
Division of Assurance and Licensure
98-18 Governor’s Council on Develop-mental
Disabilities
98-19 Personnel Board
98-20 Department of Liquor
98-21 Department of Insurance
98-22 State Compensation Fund
99-1 Department of Administration,
Human Resources Division
99-2 Arizona Air Pollution Control
Commission
99-3 Home Health Care Regulation
99-4 Adult Probation
99-5 Department of Gaming
99-6 Department of Health Services—
Emergency Medical Services
99-7 Arizona Drug and Gang Policy
Council
99-8 Department of Water Resources
99-9 Department of Health Services—
Arizona State Hospital
99-10 Residential Utility Consumer
Office/Residential Utility
Consumer Board
99-11 Department of Economic Security—
Child Support Enforcement
99-12 Department of Health Services—
Division of Behavioral Health
Services
99-13 Board of Psychologist Examiners
99-14 Arizona Council for the Hearing
Impaired
99-15 Arizona Board of Dental Examiners
99-16 Department of Building and
Fire Safety
99-17 Department of Health Services’
Tobacco Education and Prevention
Program
Future Performance Audit Reports
Department of Health Services—Sunset Factors
Arizona State Board of Accountancy
Department of Environmental Quality