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08 September
2014
Page 1 of 12 ProQuest
Hospitalization Records as a Tool for Evaluating Performance of Food- and
Water-Borne Disease urveillance !stems" # $assac%usetts &ase tud!
#ut%or" Mor, Siobhan M; Jr, !fre" #eMaria; $aumo%a, &!ena $
ProQuest "o'ument !in(
#'stract" )e out!ine a frame*or( for e%a!uating foo"+ an" *ater+borne sur%ei!!an'e s,stems
using hospita!i-ation re'or"s, an" "emonstrate the approa'h using "ata on sa!mone!!osis,
'amp,!oba'teriosis an" giar"iasis in persons age" ./5 ,ears in Massa'husetts0 1or ea'h
infe'tion, an" for ea'h reporting 2uris"i'tion, *e generate" smoothe" stan"ar"i-e" morbi"it,
ratios 3SM45 an" sur%ei!!an'e to hospita!i-ation ratios 3S645 b, 'omparing obser%e" sur%ei!!an'e
'ounts *ith e7pe'te" %a!ues or the number of hospita!i-e" 'ases, respe'ti%e!,0 )e e7amine" the
spatia! "istribution of S64 an" re!ate" this to the mean for the entire state0 8hrough this approa'h
muni'ipa!ities that "e%iate" from the t,pi'a! e7perien'e *ere i"enti9e" an" suspe'te" of un"er+
reporting0 4egression ana!,sis re%ea!e" that S64 *as a signi9'ant pre"i'tor of SM4, after
a"2usting for popu!ation age+stru'ture0 8his 'on9rms that the spatia! :signa!: "epi'te" b,
sur%ei!!an'e is in part in;uen'e" b, in'onsistent testing an" reporting pra'ti'es sin'e
muni'ipa!ities that reporte" fe*er 'ases re!ati%e to the number of hospita!i-ations ha" a !o*er
re!ati%e ris( 3as estimate" b, SM450 Perio"i' assessment of S64 has potentia! in assessing the
performan'e of sur%ei!!an'e s,stems0
Full te(t" bstra't
)e out!ine a frame*or( for e%a!uating foo"+ an" *ater+borne sur%ei!!an'e s,stems using
hospita!i-ation re'or"s, an" "emonstrate the approa'h using "ata on sa!mone!!osis,
'amp,!oba'teriosis an" giar"iasis in persons age" ./5 ,ears in Massa'husetts0 1or ea'h
infe'tion, an" for ea'h reporting 2uris"i'tion, *e generate" smoothe" stan"ar"i-e" morbi"it,
ratios 3SM45 an" sur%ei!!an'e to hospita!i-ation ratios 3S645 b, 'omparing obser%e" sur%ei!!an'e
'ounts *ith e7pe'te" %a!ues or the number of hospita!i-e" 'ases, respe'ti%e!,0 )e e7amine" the
spatia! "istribution of S64 an" re!ate" this to the mean for the entire state0 8hrough this approa'h
muni'ipa!ities that "e%iate" from the t,pi'a! e7perien'e *ere i"enti9e" an" suspe'te" of un"er+
reporting0 4egression ana!,sis re%ea!e" that S64 *as a signi9'ant pre"i'tor of SM4, after
a"2usting for popu!ation age+stru'ture0 8his 'on9rms that the spatia! :signa!: "epi'te" b,
sur%ei!!an'e is in part in;uen'e" b, in'onsistent testing an" reporting pra'ti'es sin'e
muni'ipa!ities that reporte" fe*er 'ases re!ati%e to the number of hospita!i-ations ha" a !o*er
re!ati%e ris( 3as estimate" b, SM450 Perio"i' assessment of S64 has potentia! in assessing the
performan'e of sur%ei!!an'e s,stems0
<itation: Mor SM, #eMaria Jr0 , $aumo%a &$ 320145 6ospita!i-ation 4e'or"s as a 8oo! for
&%a!uating Performan'e of 1oo"+ an" )ater+=orne #isease Sur%ei!!an'e S,stems: Massa'husetts
<ase Stu",0 P>oS ?$& @345: e@AB440 "oi:1001AB1C2ourna!0pone000@AB44
&"itor: Dishnu <hatur%e"i, <a!ifornia #epartment of Pub!i' 6ea!th, Enite" States of meri'a
4e'ei%e": $o%ember 20, 201A; ''epte": Mar'h /, 2014; Pub!ishe": pri! 1/, 2014
<op,right: F2014 Mor et a!0 8his is an open+a''ess arti'!e "istribute" un"er the terms of the
<reati%e <ommons ttribution >i'ense, *hi'h permits unrestri'te" use, "istribution, an"
08 September
2014
Page 2 of 12 ProQuest
repro"u'tion in an, me"ium, pro%i"e" the origina! author an" sour'e are 're"ite"0
1un"ing: 1un"ing for this resear'h *as pro%i"e" b, the $ationa! Gnstitute of &n%ironmenta! 6ea!th
S'ien'es 3&S 01A1B150 8he fun"er ha" no ro!e in stu", "esign, "ata 'o!!e'tion an" ana!,sis,
"e'ision to pub!ish, or preparation of the manus'ript0
<ompeting interests: 8he authors ha%e "e'!are" that no 'ompeting interests e7ist0
Gntro"u'tion
1oo"borne i!!ness aHe'ts an estimate" 4B08 mi!!ion peop!e in the Enite" States ea'h ,ear, 'ausing
more than 128,000 hospita!i-ations an" A,000 "eaths I1J, I2J0 Simi!ar!,, *aterborne i!!ness is
estimate" to aHe't 1@05 mi!!ion resi"ents ea'h ,ear IAJ0 8he tota! hea!th+re!ate" 'ost of foo"borne
i!!ness is !i(e!, to be as mu'h as KBB bi!!ion per ,ear I4J, *hi!e hospita!i-ation 'osts asso'iate"
*ith three 'ommon *aterborne pathogens a!one 'ost the hea!th'are s,stem an estimate" K5A@
mi!!ion annua!!, I5J0
Gn the Enite" States, sur%ei!!an'e for noti9ab!e "iseases + in'!u"ing those transmitte" %ia foo" an"
*ater + fa!!s *ithin the man"ate of !o'a! an" state go%ernments0 8hese sur%ei!!an'e s,stems
t,pi'a!!, re!, on passi%e reporting b, !aboratories an" hea!th'are pro%i"ers *ho notif, !o'a! hea!th
authorities *hen 'ases are "iagnose"0 Gn Massa'husetts, "iseases are reportab!e to the !o'a!
boar" of hea!th 3=?65, of *hi'h there are A510 =?6s re'ei%e '!ini'ian or !aborator, reports
through a %ariet, of means, an" are responsib!e for 'omp!eting in%estigations to '!assif, 'ases as
'on9rme", probab!e, or not a 'ase0 8o impro%e performan'e of sur%ei!!an'e s,stems, automate"
e!e'troni' !aborator, reporting metho"s are in'reasing!, being use" in Massa'husetts an"
e!se*here I/J+I8J0 1urthermore, nationa! sur%ei!!an'e s,stems are e7pan"ing the number an"
range of pro7ies e%a!uate" to better 'hara'teri-e the bur"en of infe'tion an" performan'e of
pub!i' hea!th sur%ei!!an'e I@J, I10J0
<ases "ete'te" through passi%e sur%ei!!an'e represent on!, a fra'tion of the :true: number of
'ases that o''ur in the popu!ation be'ause: 315 most patients ha%e mi!" s,mptoms of short
"uration an" so "o not see( me"i'a! 'are; 325 of those that "o a''ess '!ini'a! 'are, man, *i!! not
ha%e the !aborator, test performe" to "etermine a spe'i9' etio!og,; an" 3A5 of those *ho see(
me"i'a! 'are in *hom an etio!ogi' "iagnosis is 'on9rme", not a!! *i!! be reporte" to the
sur%ei!!an'e s,stem3s5 I11J0 Gmportant!,, points 325 an" 3A5 represent potentia! areas *here
targete" inter%entions b, pub!i' hea!th authorities 3e0g0 training =?6 members an" ph,si'ians5
might be reasonab!, e7pe'te" to ,ie!" impro%ements in sur%ei!!an'e, pro%i"e" 2uris"i'tions un"er+
as'ertaining 'ases 'an be i"enti9e"0 8his remains 'ha!!enging in the absen'e of "ata on the :true:
number of 'ases in ea'h reporting 2uris"i'tion0
Gn this paper *e out!ine a frame*or( for e%a!uating 2uris"i'tion performan'e b, 'omparing
sur%ei!!an'e an" hospita!i-ation re'or"s for the same i!!ness0 )hi!e hospita!i-ations represent a
fra'tion of the tota! number of 'ases of i!!ness in the popu!ation, gastrointestina! i!!ness se%ere
enough to reLuire hospita!i-ation shou!" resu!t in a "iagnosti' e%a!uation !i(e!, to i"entif, an
etio!ogi' agent shou!" it be present0 Esing Massa'husetts as a 'ase stu",, *e sho* that
'omparison of sur%ei!!an'e an" hospita!i-ation "ata 'ou!" be a usefu! too! for i"entif,ing
geographi' areas that "e%iate from the t,pi'a! e7perien'e an" might be un"er+as'ertaining 'ases
of reportab!e "isease0
Materia!s an" Metho"s
08 September
2014
Page A of 12 ProQuest
8heoreti'a! frame*or(
8o formu!ate the ana!,ti'a! p!an *e "esigne" a theoreti'a! frame*or( that 'onsi"ers the natura!
histor, of enteri' infe'tions, sur%ei!!an'e s,stem attributes, an" hea!th 'are uti!i-ation0 8he
spe'trum of gastrointestina! "isease is freLuent!, "es'ribe" as an :i'eberg: or :p,rami":0 8he
shape of the p,rami" + that is the re!ati%e number of 'ases that are mi!", mo"erate an" se%ere,
for an, parti'u!ar pathogen + is not usua!!, (no*n0 8,pi'a!!,, as,mptomati' an" mi!" 'ases of
"isease are "iM'u!t to enumerate *ithout !aborator, stu"ies to 'on9rm an etio!ogi' "iagnosis0
Gnstea", most sur%ei!!an'e s,stems re!, on "ete'tion of 'ases that see( me"i'a! assistan'e an"
are subseLuent!, "iagnose" *ith infe'tion be'ause of a positi%e !aborator, test, a subset of *hi'h
*i!! be hospita!i-e" "ue to se%ere i!!ness0 1or a pathogen of mo"erate %iru!en'e, a re!ati%e!, sma!!
proportion of those that see( me"i'a! attention *i!! be hospita!i-e"0 8hus, the ratio bet*een the
number of 'ases reporte" through sur%ei!!an'e an" the number of hospita!i-ations obser%e" o%er
the same time perio" for the same infe'tion 3sur%ei!!an'e to hospita!i-ation ratio, S645 shou!" be
*e!! in e7'ess of 10 Gn the i"ea! s'enario, the magnitu"e of the ratio represents bio!ogi'a!
pro'esses on!,0 1or instan'e, infe'tion *ith high %iru!en'e organisms or pathogens that are of
signi9'ant interest, su'h as Sa!mone!!a 8,phi, might be e7pe'te" to resu!t in hospita!i-ation in
man, 'ases, espe'ia!!, in the e!"er!,, an" reporting of most 'ases i"enti9e"0 Gn this situation the
S64 *i!! approa'h 10 !ternati%e!,, %ariations in the ratio might re;e't artifa'ts of the sur%ei!!an'e
s,stem0 1or e7amp!e, in'omp!ete reporting *i!! arti9'ia!!, "e'rease this ratio if not a!! i"enti9e"
'ases are reporte"; in the *orst 'ase s'enario, this ratio ma, fa!! be!o* 1 if not a!! hospita!i-e"
'ases are reporte"0
#ata
)e use" tempora!!, aggregate" "ata from Massa'husetts to e7amine the uti!it, of hospita!i-ation
re'or"s as a too! for e%a!uating foo"+ an" *aterborne sur%ei!!an'e s,stems0 )hi!e the ana!,sis
fo'use" on sur%ei!!an'e an" hospita!i-ation for sa!mone!!osis, *e abstra'te" "ata on other foo"+
an" *aterborne infe'tions to e7p!ore potentia! "iHeren'es bet*een pathogens0 !imite" "ataset
'omprising sur%ei!!an'e re'or"s for the perio" Januar, 1@@1 to #e'ember 2004 3Januar, 1@@5+
#e'ember 2004 for <r,ptospori"ium5 *as obtaine" from the Massa'husetts #epartment of Pub!i'
6ea!th 3M#P65, #i%ision of &pi"emio!og, an" Gmmuni-ation0 <riteria for reporting to M#P6 "uring
that time perio" in'!u"e": iso!ation of a spe'i9' mi'roorganism from an, '!ini'a! spe'imen
3<amp,!oba'ter, Sa!mone!!a an" Shige!!a5; "emonstration of immunog!obu!in M antibo", to
hepatitis %irus in the b!oo"; or "emonstration of parasites or antigen in stoo!, intestina! ;ui" or
sma!!+bo*e! biops, spe'imens 3<r,ptospori"ium an" Niar"ia5 I12J0 !! re'or"s for Massa'husetts
resi"ents age" ./5 ,ears *ere e7tra'te" from the "atabase, in'!u"ing muni'ipa!it, of resi"en'e0
6ospita!i-ation "is'harge "ata *as obtaine" from the <enters for Me"i'are an" Me"i'ai" Ser%i'es
3<MS5 for the 'orrespon"ing 14 ,ear perio"0 8he Me"i'are Pro%i"er na!,sis an" 4e%ie* "atabase
'ontaine" information on age, se7, "ate of hospita!i-ation or emergen', room %isitation, -ip 'o"e
of resi"en'e an" up to 10 "iagnosti' 'o"es 3'!assi9e" b, the Gnternationa! <!assi9'ation of
#isease, @th e"ition, *ith <!ini'a! Mo"i9'ation IG<#+@+<MJ50 )e e7tra'te" a!! re'or"s for
Massa'husetts resi"ents age" ./5 ,ears 'ontaining 'o"es for noti9ab!e foo"+ an" *ater+borne
"iseases, name!, infe'tion *ith <amp,!oba'ter 3G<#+@+<M 00804A5, <r,ptospori"ium 300B02,
00B04, 00B08, 00B0@5, Niar"ia 300B015, hepatitis 300B00, 00B015, non+t,phoi" Sa!mone!!a 300A0O5,
Sa!mone!!a 8,phi 3002005, an"Cor Shige!!a 30040O50 n e7pan"e" 'ase "e9nition *as use" for
08 September
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'r,ptospori"iosis base" on prior e%i"en'e of mis'!assi9'ation of this infe'tion I1AJ0
na!,sis
nnua! in'i"en'e of infe'tion *as 'a!'u!ate" for ea'h noti9ab!e "isease an" for ea'h "ata sour'e
3sur%ei!!an'e an" hospita!i-ation5 using e!"er!, popu!ation "ata "eri%e" from the 1@@0 an" 2000
"e'ennia! 'ensus0 8he e!"er!, popu!ation *as estimate" b, !inear interpo!ation bet*een 'ensus
,ears, *ith the reporte" annua! in'i"en'e %a!ues base" on the e!"er!, popu!ation at the mi"point
of the stu", perio" 31@@BC1@@8; 1@@@C2000 for <r,ptospori"ium sur%ei!!an'e50 8he 'ru"e S64 *as
'a!'u!ate" for ea'h noti9ab!e "isease b, "i%i"ing the obser%e" number of 'ases reporte" through
sur%ei!!an'e 3So5 b, the obser%e" number of hospita!i-e" 36o5 'ases0
1or "iseases *ith suM'ient 'ounts + name!,, sa!mone!!osis, 'amp,!oba'teriosis an" giar"iasis + the
obser%e" number of 'ases reporte" through sur%ei!!an'e 3So5 an" the obser%e" number of
hospita!i-e" 'ases 36o5 *ere aggregate" b, muni'ipa!it,0 8o e7p!ore spatia! "iHeren'es in re!ati%e
ris( as "epi'te" b, the sur%ei!!an'e s,stem, *e 'a!'u!ate" the 'ru"e stan"ar"i-e" morbi"it, ratio
3SM45 for ea'h muni'ipa!it, b, "i%i"ing the obser%e" 3So5 an" the e7pe'te" 3Se5 number of
reporte" 'ases 3SoCSe5 I14J0 &7pe'te" %a!ues 3Se5 *ere 'a!'u!ate" b, mu!tip!,ing the e!"er!,
popu!ation 3age" ./5 ,ears5 in ea'h muni'ipa!it, b, the mean in'i"en'e for the entire state of
Massa'husetts0 8he !atter *as 'a!'u!ate" b, "i%i"ing the tota! number of 'ases reporte" through
sur%ei!!an'e b, the tota! popu!ation age" ./5 ,ears in Massa'husetts0
Mar(o% <hain Monte <ar!o 3M<M<5 metho"s *ere emp!o,e" to 'onstru't =a,esian 're"ib!e
inter%a!s to re;e't the "egree of un'ertaint, for point estimates of SM40 Smooth point estimates
an" un'ertaint, measures *ere 'ompi!e" b, a !arge number of simu!ations imp!emente" in the
M<M< mo"e!ing a!gorithm, app!,ing a stan"ar" Poisson+gamma mo"e! as fo!!o*s I15J, I1/J:
*here ,i is the obser%e" number of 'ases reporte" through sur%ei!!an'e 3So5 in to*n i, ei is the
e7pe'te" number of 'ases reporte" through sur%ei!!an'e 3Se5, an" Pi is the ratio bet*een ,i an"
ei in to*n i0 8hus, Pi is an estimate of the mean SM4 in to*n i0 Mo"e! 'on%ergen'e *as assesse"
through e7amination of tra'e p!ots an" Ne!men+4ubin statisti's0 Posterior estimates of the mean
an" asso'iate" @5Q =a,esian 're"ib!e inter%a! *ere generate" for the entire state an" for ea'h
to*n0 8he !atter *ere mappe" using r'NGS soft*are 3%ersion @0A01; &sri, 4e"!an"s <50 =,
'on%ention, a to*n *as "eeme" to ha%e a higher or !o*er ris( than e7pe'te" if the @5Q 're"ib!e
inter%a! for the SM4 e7'!u"e" 1 3obtaine" *hen obser%e" an" e7pe'te" %a!ues are the same50
Simi!ar!,, the ratio bet*een the obser%e" number of reporte" an" hospita!i-e" 'ases 3SoC6o5 *as
'a!'u!ate" from the aggregate" "ata, pro%i"ing a 'ru"e estimate of the S64 in ea'h muni'ipa!it,0
8o generate un'ertaint, measures for S64, *e repeate" the abo%e M<M< pro'e"ures using the
obser%e" number of hospita!i-e" 'ases 36o5 in p!a'e of the e7pe'te" %a!ue, ei0 8hus, in this
'onte7t, Pi is an estimate of the mean S64 in to*n i0 1or this mo"e!, ana!,sis *as !imite" to on!,
those muni'ipa!ities *ith .1 hospita!i-e" 'ase0 Posterior estimates of the mean S64 an"
un'ertain!, measures *ere generate" an" mappe" as "es'ribe" abo%e0 muni'ipa!it, *as
"eeme" to be suspe't of un"er+reporting if the point estimate for S64 *as be!o* the state
a%erage an" the @5Q 're"ib!e inter%a! for the muni'ipa!it, "i" not o%er!ap *ith the @5Q 're"ib!e
inter%a! for the entire state0 8he number an" per 'ent of muni'ipa!ities *ith suspe'te" un"er+
reporting *as estimate" for ea'h infe'tion0
1ina!!,, 'orre!ation an" mu!tip!e regression ana!,ses *ere 'on"u'te" to assess spatia! simi!arit,
08 September
2014
Page 5 of 12 ProQuest
an" the e7tent to *hi'h spatia! heterogeneities in SM4 'an be pre"i'te" b, S64, a"2usting for
"iHeren'es in e!"er!, popu!ation age+stru'ture0 8his approa'h assumes that: a5 for a gi%en
infe'tion, spatia! heterogeneit, in re!ati%e ris( "ete'te" through sur%ei!!an'e in'!u"es both :true:
%ariation in in'i"en'e an" artifa'ts re!ate" to "iHeren'es in testing pro'e"ures an" reporting an"
is "epi'te" b, SM4 R SoCSe; an" b5 for a gi%en infe'tion an" *ithin an age+stan"ar"i-e"
popu!ation, the re!ationship bet*een the number of 'ases reporte" through sur%ei!!an'e an" those
that are hospita!i-e" re;e'ts spatia! heterogeneit, in testing pro'e"ures an" man"ator, reporting
3'ontributing to %ariab!e "ata Lua!it,5 an" is "epi'te" b, S64 R SoC6o0 Simi!arit, bet*een spatia!
"istributions of these t*o measures 'ou!" therefore be in"i'ati%e of a uniLue !atent spatia!
pro'ess0 Positi%e asso'iations "epi'te" b, 'orre!ation 'oeM'ients bet*een SM4 an" S64 in"i'ate
*hether !o*er re!ati%e ris( 'oin'i"e *ith un"erreporting in referen'e to man"ator, reLuirements0
1or a!! regression mo"e!s, smoothe" estimates of SM4 an" S64 for ea'h 2uris"i'tion *ere !og+
transforme" an" use" as the "epen"ent an" in"epen"ent %ariab!es, respe'ti%e!,0 Mo"e!s *ere
a"2uste" for the proportion of e!"er!, persons age" B5+84 ,ears an" 85 ,ears an" abo%e in ea'h
2uris"i'tion 3at the 2000 "e'ennia! 'ensus50 ?bser%ations *ith !arge resi"ua!s *ere e7amine" an"
e7'!u"e" from subseLuent ana!,ses if the, *ere "eeme" potentia!!, in;uentia!0 Qua!it, of 9t *as
reporte" as a"2uste" 420
#ata ana!,sis *as performe" in 4 3%ersion 201A00; 4 1oun"ation for Statisti'a! <omputing, Dienna
ustria5 *ith M<M< imp!ementation performe" in )in=ENS I1BJ 3%ersion 1040A5 using the
42)in=ENS pa'(age I18J0 8his stu", *as re%ie*e" an" e7empte" b, the Gnstitutiona! 4e%ie*
=oar" at 8ufts Me"i'a! <enter an" 8ufts Eni%ersit, 6ea!th S'ien'es <ampus0 Ese of the
sur%ei!!an'e an" hospita!i-ation "ata *as permitte" through "ata sharing agreements bet*een
8ufts an" M#P6 an" <MS, respe'ti%e!,0
4esu!ts
$oti9ab!e "isease 'ounts an" annua! rate of "isease b, etio!og, an" "ata sour'e are sho*n in
8ab!e 1 a!ong *ith the 'ru"e S64 for ea'h infe'tion0 <amp,!oba'ter an" non+t,phoi" Sa!mone!!a
*ere the most 'ommon etio!ogies, *hi!e t,phoi" *as 3e7pe'te"!,5 the !east 'ommon0
8ab!e 10 $oti9ab!e foo"+ an" *aterborne "iseases in Massa'husetts, 1@@1+2004S0
Sa!mone!!osis
=et*een 1@@1 an" 2004, at !east one 'ase of hospita!i-ation "ue to Sa!mone!!a *as obser%e" in
1@@CA51 muni'ipa!ities in Massa'husetts0 mong 152 muni'ipa!ities *here there *ere no
Sa!mone!!a hospita!i-ations, the number of 'ases reporte" to M#P6 range" from 0 to B 3me"ian:
050 1igures 1 an" 2 sho* the smoothe" estimates of the S64 for sa!mone!!osis b, muni'ipa!it,0 ?n
a%erage, appro7imate!, 10B 'ases of sa!mone!!osis *ere reporte" to M#P6 for e%er, 1
hospita!i-ation *ith this pathogen I@5Q <G: 105A, 108BJ0 1our 32Q5 muni'ipa!ities *ere suspe'te"
of un"er+reporting for this pathogen0
I1igure omitte", see P#1J
1igure 10 Sur%ei!!an'e to hospita!i-ation ratio 3S645 for sa!mone!!osis0
1or ea'h muni'ipa!it, point estimates an" 're"ib!e inter%a!s for the posterior estimates of the
mean 3SoC6o5 are sho*n in gre,0 8he mean estimate of the S64 for the entire state 3so!i" !ine5 an"
asso'iate" 're"ib!e inter%a! 3"ashe" !ines5 are in"i'ate" as hori-onta! !ines0 Muni'ipa!ities that ha"
signi9'ant!, !o*er S64 'ompare" to the state mean are in"i'ate" *ith a b!a'( triang!e0
08 September
2014
Page / of 12 ProQuest
I1igure omitte", see P#1J
1igure 20 Sur%ei!!an'e to hospita!i-ation ratio 3S645 for sa!mone!!osis0
Muni'ipa!ities are 'ategori-e" a''or"ing to Luinti!es0 1or 'on9"entia!it, reasons the four
2uris"i'tions that are suspe'te" of un"er+as'ertaining 'ases ha%e not been i"enti9e"0
1igure A sho*s the re!ationship bet*een the smooth estimates of the SM4 an" S64 for
sa!mone!!osis0 8here *as a mo"erate positi%e re!ationship bet*een the t*o ratios 3pT0000150
"2usting for "iHeren'es in popu!ation stru'ture, for e%er, 10Q "e'rease in S64, SM4 "e'rease"
b, 20B4U002AQ 3pT00001, a"2uste" 42 R 002B50
I1igure omitte", see P#1J
1igure A0 <omparison bet*een the stan"ar"i-e" morbi"it, ratio 3SM45 an" the sur%ei!!an'e to
hospita!i-ation ratio 3S645 for sa!mone!!osis0
8he nu!! h,pothesis for the SM4 is in"i'ate" as a hori-onta! !ine 3SM4 R 150 8he mean estimate of
the S64 for the entire state is in"i'ate" as a %erti'a! !ine0 Point estimates that are VAS# of the
respe'ti%e mean are in"i'ate" 3WXW50 &7'!usion of four out!iers "i" not substantia!!, a!ter the
9n"ings 3rho R 0050, pT0000150
?ther infe'tions
s sho*n in 8ab!e 1, appro7imate!, @ 'ases of hepatitis *ere reporte" for e%er, hospita!i-ation
*ith this infe'tion0 Gn 'ontrast, the number of hospita!i-ations *ith 'r,ptospori"iosis e7'ee"e" the
tota! number of reporte" 'ases 3S64T15, in"i'ating o%era!! substantia! un"er+reporting of this
parti'u!ar infe'tion0
?n a%erage, appro7imate!, A 'ases of 'amp,!oba'teriosis *ere reporte" to M#P6 for e%er, 'ase
hospita!i-e" *ith this infe'tion 3@5Q <G: 20B2, A05550 8*ent, out of 1B2 3110/Q5 muni'ipa!ities *ith
.1 <amp,!oba'ter hospita!i-ation *ere suspe'te" of un"er+reporting for this pathogen0 1or
giar"iasis appro7imate!, 2 'ases *ere reporte" for e%er, 'ase hospita!i-e" 3@5Q <G: 105/, 20505;
none of the B2 muni'ipa!ities *ith .1 Niar"ia hospita!i-ation *ere 'onsi"ere" suspe't0
1igures 4 an" 4= sho* the re!ationship bet*een the SM4 an" S64 for 'amp,!oba'teriosis an"
giar"iasis, respe'ti%e!,0 Simi!ar to sa!mone!!osis, *e foun" a mo"erate positi%e asso'iation
bet*een the t*o ratios for both infe'tions 3pT00001 for both infe'tions50 1or e%er, 10Q "e'rease
in S64, SM4 "e'rease" b, appro7imate!, 208/U00AAQ for <amp,!oba'ter 3pT00001, a"2uste" 42
R 00AA5 an" 40A4U005AQ for Niar"ia 3YpT00001, a"2uste" 42 R 00485 a"2usting for "ifferen'es in
popu!ation stru'ture0
I1igure omitte", see P#1J
1igure 40 <omparison bet*een the stan"ar"i-e" morbi"it, ratio 3SM45 an" the sur%ei!!an'e to
hospita!i-ation ratio 3S645 for 'amp,!oba'teriosis 35 an" giar"iasis 3=50
8he nu!! h,pothesis for the SM4 is in"i'ate" as a hori-onta! !ine 3SM4 R 150 8he mean estimate of
the S64 for the entire state is in"i'ate" as a %erti'a! !ine for both infe'tions0 Point estimates that
are VAS# of the respe'ti%e mean are in"i'ate" 3WXW50 &7'!usion of out!iers "i" not substantia!!,
a!ter the 9n"ings 3<amp,!oba'ter: rho R 005A, pT00001; Niar"ia: rho R 00/0, pT0000150
#is'ussion
Sur%ei!!an'e "ata on foo"+ an" *aterborne infe'tions are inherent!, in'omp!ete be'ause infe'tion
08 September
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t,pi'a!!, presents as mi!", se!f+!imiting "isease in the ma2orit, of those aHe'te" an" reLuires
submission of a !aborator, spe'imen for 'on9rmation0 8he e7tent to *hi'h sur%ei!!an'e s,stems
"ete't su'h i!!nesses is "iM'u!t to assess in the absen'e of "ata on the :true: number of 'ases in
the popu!ation0 s a resu!t it is "iM'u!t to as'ertain *hether geographi' "iHeren'es in reporte"
'ases represent true signa!s 3%ariations in in'i"en'e5 or s,stemati' measurement error stemming
from '!ini'a! 3testing5 an" non+'!ini'a! 3reporting5 fa'tors0 =, 'omparing the number of reporte"
'ases *ith the number of hospita!i-e" 'ases for the same infe'tion *e i"enti9e" muni'ipa!ities
that signi9'ant!, "e%iate" from the t,pi'a! e7perien'e in the state an" might be un"er+
as'ertaining 'ases0 8he names of these 2uris"i'tions ha%e not been ma"e pub!i' for 'on9"entia!it,
reasons0 )e 'an re%ea! that 2uris"i'tions ;agge" as ha%ing a !o* S64 *ere primari!, o!"er
in"ustria! 'ities *ith signi9'ant pub!i' hea!th resour'e restraints that *ou!" ten" to e7p!ain
performan'e0 8his s'enario *as true for man, of the muni'ipa!ities in the !o*est Luinti!e of S64
3see 1igure 250
Gn spatia! epi"emio!og, resear'h, stan"ar"i-e" morbi"it, ratios are a 'ommon metho" for
representing re!ati%e "iHeren'es in "isease ris( a'ross geographies I14J0 )e app!ie" this
metho"o!og, to stan"ar"i-e sur%ei!!an'e 'ounts *ith respe't to the e!"er!, popu!ation, a!!o*ing
'omparison bet*een ea'h muni'ipa!it, an" the mean rate reporte" for the state0 pp!i'ation of
Mar(o% <hain Monte <ar!o simu!ation enab!e" generation of 're"ib!e inter%a!s for a p!ausib!e
range of %a!ues for ea'h muni'ipa!it,, *hi!e a!so minimi-ing the in;uen'e of "ata from sma!! areas
I14J, I1/J0 )e foun" mar(e" %ariation in SM4 for sa!mone!!osis a'ross the state of Massa'husetts,
ranging from 0052 3!o* in'i"en'e re!ati%e to mean5 to 108/ 3high in'i"en'e re!ati%e to mean50 Gt is
p!ausib!e that this spatia! heterogeneit, "epi'te" b, SM4 is "ue to the %ar,ing ris( of foo"+borne
an" *aterborne "isease a'ross Massa'husetts, stemming from "iHeren'es in e7posure !e%e!s 3e0g0
'onta't rates, pathogen "ose5 or "istribution of popu!ation at ris( 3e0g0 :o!"er: muni'ipa!ities50
Gn"ee", an ana!,sis of en%ironmenta! fa'tors asso'iate" *ith the rate of reporte" proto-oan
infe'tions "emonstrate" !in(s *ith the t,pe of *ater sour'e, in'ome, an" 'ro*"e"ness, *hi'h are
une%en!, "istribute" a'ross the state I1@J, I20J0 )e postu!ate ho*e%er that + *hen app!ie" to
passi%e sur%ei!!an'e "ata + SM4 ma, be 'onfoun"e" b, in'onsistent testing an" reporting
pra'ti'es a'ross muni'ipa!ities0 )hi!e testing an" reporting pro'e"ures shou!" be stan"ar"i-e"
a'ross the state an" base" on 'omprehensi%e pub!ishe" gui"e!ines I12J, resour'e 'onstraints an"
%ariations in hea!th'are a''ess "i'tate that these gui"e!ines are "iHerentia!!, app!ie"0 8he e7tent
to *hi'h su'h %ariation 'onfoun"s the spatia! :signa!: "epi'te" b, sur%ei!!an'e is "iM'u!t to
assess in the absen'e of e7terna! "ata against *hi'h these 9n"ings 'an be %eri9e"0
Gn this paper *e intro"u'e the sur%ei!!an'e to hospita!i-ation ratio 3S645 as a 'omp!imentar,
te'hniLue to ai" in i"enti9'ation of muni'ipa!ities that might be un"er+as'ertaining 'ases of
reportab!e "isease0 En!i(e the SM4, *hi'h "epi'ts %ariations in :true: in'i"en'e re!ati%e to the
state mean as *e!! as 3potentia!5 artifa'ts 'reate" b, %ariab!e testing an"Cor reporting pra'ti'es,
*e suggest that "iHeren'es in S64 a'ross muni'ipa!ities shou!" prin'ipa!!, re;e't on!, the !atter
for an, gi%en infe'tion an" popu!ation 3assuming hospita!i-ation rates are 'onsistent a'ross
muni'ipa!ities50 Gt is p!ausib!e that "iHeren'es in popu!ation age+stru'ture 'ou!" 'ontribute to
spatia! %ariation in S64 3e0g0 !o*er S64 in muni'ipa!ities *ith more persons age" 85 ,ears an"
o!"er50 n e7amination of the popu!ation age+stru'ture in muni'ipa!ities *ith the 15 highest an"
15 !o*est S64s "i" not support this 'on'!usion ho*e%er 3see 1igure S150
08 September
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)e foun" that S64 *as a signi9'ant pre"i'tor of SM4; muni'ipa!ities that reporte" fe*er 'ases
re!ati%e to the number of hospita!i-ations ha" a !o*er re!ati%e ris( 3as estimate" b, SM45,
a"2uste" for popu!ation age+stru'ture0 Gmportant!,, this 9n"ing *as 'onsistent a'ross a!! three
infe'tions stu"ie"0 8his obser%ation supports our assumption that the spatia! :signa!: "epi'te" b,
sur%ei!!an'e is in part in;uen'e" b, in'onsistent testing an" reporting pra'ti'es a'ross the state
an" that S64 ma, be he!pfu! in "is'erning *hi'h 2uris"i'tions ma, be un"erperforming in terms of
i"entif,ing 'ases of reportab!e "isease0
)e foun" that S64 %arie" 'onsi"erab!, b, "isease, 'onsistent *ith our h,pothesis that this ratio
a!so re;e'ts pathogen spe'i9' pro'esses 3e0g0 "iHeren'es in %iru!en'e50 1or instan'e, the 'ru"e
S64 %arie" from 005 for 'r,ptospori"iosis 3more hospita!i-e" than reporte"5 to @01 for hepatitis
infe'tion 3more reporte" than hospita!i-e"50 8he !o* S64 for 'r,ptospori"iosis '!ear!, in"i'ates
un"er+reporting or inabi!it, to fo!!o* up positi%e !aborator, resu!ts for 'on9rmation of the 'ase,
sin'e + per the Massa'husetts gui"e!ines I12J + a!! of the hospita!i-e" 'ases shou!" ha%e been
reporte" to the =?60 8he S64 of @01 for hepatitis !i(e!, re;e'ts both the !imite" morbi"it,
asso'iate" *ith infe'tion, an" possib!, the re'ogni-e" prob!em of fa!se positi%e !aborator, resu!ts
arising from the use of :hepatitis pane!s: in e!"er!, patients *ith abnorma! !i%er fun'tion tests
I21J0
1e* stu"ies report simu!taneous "ata for sur%ei!!an'e an" hospita!i-ation 'ases against *hi'h the
'ru"e S64s 'a!'u!ate" here 'an be 'ompare"0 Gnferen'e from "ata presente" in t*o stu"ies
un"erta(en in the genera! popu!ation in #enmar( I22J an" in states parti'ipating in 1??#$&8 in
the Enite" States I2AJ ,ie!" estimates of A0/ an" 50/ for sa!mone!!osis, respe'ti%e!,0 >i(e*ise,
these stu"ies suggest that the S64 for 'amp,!oba'teriosis is 50/ an" /0@0 8hese stu"ies agree
*ith our 9n"ing of a !o*er S64 for Sa!mone!!a 'ompare" to <amp,!oba'ter 3108 %s A01 in
Massa'husetts5, a!beit *ith higher o%era!! %a!ues reporte" in these other stu"ies0 8he reason for
the !atter ma, re!ate to the fa't that our stu", fo'use" on an e!"er!, popu!ation that is more !i(e!,
to be hospita!i-e" fo!!o*ing infe'tion0 8his h,pothesis is supporte" b, a <a!ifornia stu", from
*hi'h *e 'an infer that the S64 for sa!mone!!osis among persons age" T5, 5+/4 an" ./5 ,ears
*as 402, A0/ an" 102, respe'ti%e!, I24J0 Gn"ee", e%en *ithin the ./5 ,ears age 'ategor, *e foun"
that S64 "e'!ine" steep!, *ith in'reasing age 3see 8ab!e S150 Gn sum, our 9n"ings suggest that
pathogen+ an" popu!ation+spe'i9' 3age+stan"ar"i-e"5 assessment of S64 is *arrante" an"
reLuires further resear'h0
>imitations
8here are se%era! !imitations to this stu",0 8he use of hospita! "is'harge "ata to e%a!uate pub!i'
hea!th sur%ei!!an'e s,stems is not a ne* proposition; resear'hers ha%e "emonstrate" the uti!it, of
su'h "ata *hen e%a!uating sur%ei!!an'e for infe'tious I10J, I25J, non+infe'tious I2/J,
en%ironmenta! hea!th out'omes I2BJ0 $e%erthe!ess, the a''ura', an" 'omp!eteness of "ata
'ontaine" in Me"i'are, hospita! "is'harge an" other a"ministrati%e "atabases has been 'a!!e" into
Luestion in respe't to %arious infe'tious "iseases I28J+IA0J0 8he e7tent to *hi'h these 'on'erns
ho!" true for gastrointestina! infe'tions is not (no*n0 Gt is possib!e that "iagnoses ma"e on the
basis of !aborator, resu!ts obtaine" after a"mission are not 'o"e" in the "is'harge re'or"0 )e
in'!u"e" a!! 10 "iagnosti' 'o"es in our stu", sin'e + per the Massa'husetts gui"e!ines I12J +
noti9ab!e pathogens shou!" be reporte" *hene%er the, are "ete'te", e%en if the, are not the
primar, reason for i!!ness0 ma2orit, of Me"i'are re'or"s use" in this stu", 'ontaine" the
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"iagnosti' 'o"es of interest in position 1 or 2 3see 8ab!e S250 1urther resear'h is nee"e" to
'hara'teri-e the a''ura', an" 'omp!eteness of "iagnosti' 'o"ing for gastrointestina! infe'tions0 Gn
this stu",, ana!,sis *as !imite" to the perio" 1@@1+2004, re;e'ting a%ai!abi!it, of "ata un"er "ata
sharing agreements bet*een 8ufts Eni%ersit, an" the o*ners of the "ata0 Gt is un!i(e!, that the
9n"ings *ou!" be in%a!i"ate" b, in'!usion of more re'ent "ata0
?ur stu", fo'use" on persons age" /5 ,ears an" o!"er, o*ing to the fa't that Me"i'are re'or"s
in'!u"e information on Z@/Q of the ES e!"er!, popu!ation IA1J0 8he, therefore pro%i"e e7'e!!ent
'o%erage of the popu!ation un"er sur%ei!!an'e in this age range0 Enfortunate!,, Me"i'are
"atabases "o not permit app!i'ation of these metho"s to a ,ounger 'ohort sin'e enro!!ment of
su'h persons in the program is base" on ha%ing a "isabi!it,0 )hi!e the rate of testing an"
"iagnosis *ere biase" b, the greater !i(e!ihoo" of being si'(er, hospita!i-e" an" ha%ing a test
"one in the e!"er!, popu!ation, *e maintain that *ithin an age strata, the re!ationship bet*een
sur%ei!!an'e 'ounts an" the number of peop!e hospita!i-e" shou!" remain fair!, 'onsistent for
ea'h pathogen0
Gt is !i(e!, that "ata from the e!"er!, "o not re;e't the o%era!! performan'e of a sur%ei!!an'e
s,stem0 8he spe'trum of en%ironmenta! e7posures in e!"er!, "iHers from the genera! popu!ation
an" + gi%en the se%erit, of infe'tion + the, might ha%e a greater !i(e!ihoo" of being "iagnose"
espe'ia!!, *hen i!! enough to be hospita!i-e"0 Se%era! e7perts ha%e 'a!!e" for targete" monitoring
of gastrointestina! i!!ness in this parti'u!ar sub+popu!ation gi%en that the, are espe'ia!!,
%u!nerab!e to se%ere out'omes of gastrointestina! i!!ness IA2J+IA4J0 ""itiona!!,, pub!ishe"
gui"e!ines support routine stoo! 'u!tures on a!! patients a"mitte" to the hospita! *ith 'ommunit,+
a'Luire" "iarrhea an" a!! /5 ,ears of age or o!"er *ith pre+e7isting 'on"itions *ho "e%e!op
"iarrhea B2 or more hours after a"mission IA5J0 Gt therefore seems reasonab!e to un"erta(e
measures to strengthen "isease sur%ei!!an'e a'ti%ities for this spe'i9' popu!ation0
)hi!e it is 'on%entiona! to 'onsi"er an SM4 R 1 as the nu!! %a!ue 3obtaine" *hen obser%e" an"
e7pe'te" %a!ues are the same5, "e9ning appropriate 'ut+points for S64 *as more 'ha!!enging
be'ause the re!ationship bet*een the number of hospita!i-e" an" reporte" 'ases *as un(no*n at
the outset0 )e "e9ne" a muni'ipa!it, as potentia!!, un"er+reporting if the upper !imit of the @5Q
're"ib!e inter%a! for the muni'ipa!it, "i" not o%er!ap *ith the !o*er !imit for the entire state0 8his
is a 'onser%ati%e approa'h an" ma, ha%e resu!te" in mis'!assi9'ation0 )ith further resear'h it
shou!" be possib!e to "e9ne appropriate :'ut+oH: %a!ues for S64, fa'i!itating impro%e" "ete'tion
of muni'ipa!ities that "e%iate substantia!!, from the t,pi'a! e7perien'e0 Gn an, 'ase state hea!th
"epartments ma, 'hoose to raise or !o*er su'h thresho!" "epen"ing on their nee"s an" resour'es
3e0g0 in%estigate muni'ipa!ities in !o*est Luinti!e50
1uture "ire'tions
)e propose to further e7p!ore the usabi!it, of routine!, 'o!!e'te" hea!th "ata, su'h as sur%ei!!an'e
an" hospita!i-ation re'or"s in an integrati%e manner0 Pro%en su''essfu!, these integrate" metri's
'an be emp!o,e" perio"i'a!!, using tempora!!, aggregate" "ata an" e%entua!!, a"apte" to
monitor performan'e of sur%ei!!an'e s,stems in :rea! time:0 Su'h a metri' *ou!" be simi!ar to the
Stan"ar"i-e" Gnfe'tion 4atio, *hi'h is use" in infe'tion 'ontro! epi"emio!og, an" ai"s in
ben'hmar(ing in'i"en'e of hospita!+a'Luire" infe'tion 36G5 in sing!e hospita!s against nationa!
a%erage rates of 6G IA/J+IA8J0 )e suggest that su'h an integrate" approa'h to gastroenteritis
sur%ei!!an'e might ha%e a potentia! to assess the impa't of 'hanges in '!ini'a! a!gorithms 3su'h as
08 September
2014
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e7pansion of manage" 'are5 an" testing metho"s on "isease sur%ei!!an'e, eHe'ts of popu!ation
migration patterns on hea!th 'are uti!i-ation IA@J, an" state+*i"e inter%ention strategies or nation+
*i"e po!i', 'hange impa'ts I40J0
<on'!usions
8he <enters for #isease <ontro! an" Pre%ention 3<#<5 out!ines a frame*or( for e%a!uating pub!i'
hea!th sur%ei!!an'e a'ti%ities, a state" purpose of *hi'h is to "e%e!op re'ommen"ations for
impro%ing "ata Lua!it, I41J0 8he e7pansion of the use of e!e'troni' hea!th re'or"s promises more
"ire't an" 'omp!ete reporting of noti9ab!e "iseases *ith abi!it, to supp!ement an" e%a!uate
tra"itiona! sur%ei!!an'e s,stems I@J, I10J, I42J0 Gn'orporating assessment of S64 "uring perio"i'
e%a!uations of sur%ei!!an'e a'ti%ities 'ou!" pro%i"e an ob2e'ti%e an" pra'ti'a! means to i"entif,
2uris"i'tions that ma, be un"er+as'ertaining 'ases of reportab!e "isease0 =en'hmar(ing
performan'e of muni'ipa!ities to the rest of the state 'ou!" he!p gui"e attention to 2uris"i'tions
that ma, nee" assessment for resour'es an" priorit, setting0
Supporting Gnformation
1igure S10
Sur%ei!!an'e to hospita!i-ation ratio 3S645 for sa!mone!!osis, b, age+'ategor,0 =ars represent the
15 !o*est an" 15 highest ran(ing muni'ipa!ities 3'orrespon"ing to 1igure 250 )ithin the ./5 age
'ategor,, the proportion age" /5+B4 ,ears 3"ar( gre,5, B5+84 ,ears 3me"ium gre,5 an" 85 ,ears
an" o!"er 3!ight gre,5 are sho*n0
38G15
8ab!e S10
Sa!mone!!osis in Massa'husetts, b, age 'ategor,, 1@@1+20040 #ata re;e't the number of 'ases in
persons /5 ,ears o!" an" o!"er reporte" through the state sur%ei!!an'e s,stem an" the number of
hospita!i-e" 'ases as "o'umente" b, the <enter for Me"i'are an" Me"i'ai" Ser%i'es "atabase0
3#?<O5
8ab!e S20
Sa!mone!!osis hospita!i-ations in Massa'husetts, b, "iagnosti' 'o"e position, 1@@1+20040 #ata
re;e't the 9rst o''urren'e of a non+t,phoi" Sa!mone!!a G<#+@+<M 'o"e 300A0O5 in 1 of 10 'o"e
positions in persons /5 ,ears o!" an" o!"er, as "o'umente" b, the <enter for Me"i'are an"
Me"i'ai" Ser%i'es "atabase0
u')ect" Me"i'are; #isease; Pub!i' hea!th; ge; Popu!ation; 1oo"; Me"i'ai"; Juris"i'tion; G!!nesses;
>aboratories; 6ospita!i-ation; $oso'omia! infe'tions; Gntegrate" approa'h;
*ocation" Massa'husetts, Enite" States++ES
Pu'lication title" P>oS ?ne
+olume" @
Issue" 4
Pu'lication !ear" 2014
Pu'lication date" pr 2014
08 September
2014
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,ear" 2014
ection" 4esear'h rti'!e
Pu'lis%er" Pub!i' >ibrar, of S'ien'e
Place of pu'lication" San 1ran'is'o
&ountr! of pu'lication" Enite" States
Pu'lication su')ect" Me"i'a! S'ien'es, S'ien'es: <omprehensi%e )or(s
ource t!pe" S'ho!ar!, Journa!s
*anguage of pu'lication" &ng!ish
Document t!pe" Journa! rti'!e
D-I" http:CC"70"oi0orgC1001AB1C2ourna!0pone000@AB44
ProQuest document ID" 151/@54/BB
Document .R*" http:CCsear'h0proLuest0'omC"o'%ie*C151/@54/BB[a''ounti"R2854B
&op!rig%t" F 2014 Mor et a!0 8his is an open+a''ess arti'!e "istribute" un"er the terms of the
<reati%e <ommons ttribution >i'ense, *hi'h permits unrestri'te" use, "istribution, an"
repro"u'tion in an, me"ium, pro%i"e" the origina! author an" sour'e are 're"ite": Mor SM,
#eMaria Jr0 , $aumo%a &$ 320145 6ospita!i-ation 4e'or"s as a 8oo! for &%a!uating Performan'e of
1oo"+ an" )ater+=orne #isease Sur%ei!!an'e S,stems: Massa'husetts <ase Stu",0 P>oS ?$&
@345: e@AB440 "oi:1001AB1C2ourna!0pone000@AB44
*ast updated" 2014+04+21
Data'ase" ProQuest <entra!
///////////////////////////////////////////////////////////////

&ontact ProQuest
<op,right 2014 ProQuest >><0 !! rights reser%e"0 + Terms and &onditions
08 September
2014
Page 12 of 12 ProQuest