Technical Guidance: Duplicate Review

National HIV Surveillance System (NHSS)

Attachment 4c.
Duplicate Review Technical Guidance

Technical Guidance for HIV
Surveillance Programs
Duplicate Review

HIV Incidence and Case Surveillance Branch
Atlanta, Georgia

Contents
Background ................................................................................................................................... 3
Intrastate Duplicate Review .......................................................................................................... 3
Structural Requirements .............................................................................................................. 3
Process Standards ........................................................................................................................ 4
Outcome Standard ....................................................................................................................... 5
Interstate Duplicate Review .......................................................................................................... 5
National Data Processing and RIDR Report Generation ............................................................ 7
Structural Requirements .............................................................................................................. 8
Process Standards ........................................................................................................................ 8
Outcome Standard ..................................................................................................................... 10

2
National HIV Surveillance System Technical Guidance – Duplicate Review, December 2018

Background
HIV surveillance systems must provide a reliable measure of the number of persons in need of
HIV prevention and care services at the local, state and national levels. An accurate HIV
surveillance system is one that minimizes the degree to which it overcounts or undercounts
reported cases of HIV infection and maximizes the reliability with which data for a given
person are linked over time. Failing to properly link an incoming surveillance report to an
existing case leads to overcounting and incomplete case information; incorrectly linking an
incoming surveillance report to an existing case may lead to undercounting and data
contamination.
Because doctors, hospitals, laboratories, and other reporting entities may be required to report
all diagnoses of HIV infection, duplicate case reports within a state (intrastate) or between
states (interstate) may not be identified during routine case entry into the surveillance database.
To prevent overcounting and undercounting of cases, identification of potential intrastate and
interstate duplicate case reports, merging case reports that have been deemed to be duplicates at
all levels, and providing duplicate review resolution to CDC (i.e., Same as or Different than)
must be carried out on a regular basis.
Within a state, surveillance software and routine surveillance practices are used to identify and
eliminate duplicate case reports. These processes can use personally identifiable information
(PII) and other useful information maintained at a state or local level. At the national level,
CDC does not receive PII (e.g., name, Social Security Number) so duplicate case reports
cannot be identified with the same degree of accuracy. Thus, CDC requires all surveillance
areas to perform both intrastate and interstate review and de-duplication on a routine basis and
ensure that each person in the surveillance database is given one unique state-assigned case
number (stateno).

Intrastate Duplicate Review
The prerequisites (structural requirements), best practices (process standards), and outcome
standards for intrastate duplicate review are described next, followed by more in-depth
guidance on specific topics.

Structural Requirements
1. Case, laboratory, and other reports received on a person
2. HIV Surveillance System Software, eHARS

3
National HIV Surveillance System Technical Guidance – Duplicate Review, December 2018

3. eHARS Data Entry Quick Reference Guide1
4. eHARS Technical Reference Guide2
5. Data processing policies, procedures and tools for record linkage (see file Record
Linkage)
6. Procedures for evaluating accuracy of HIV surveillance systems (see file Evaluation
and Data Quality)
7. Variables to ascertain potential intrastate duplicate case reports:
 The eHARS report “Intrastate Duplicate Cases Based on CDC Matching String”
is available under Operational in the eHARS REPORT module index. The report
identifies and generates a list of potential duplicate case reports within a
jurisdiction’s eHARS using CDC matching strings. Cases are first matched using
the following Person View variables: last name soundex (last_name_sndx), date
of birth (dob), sex at birth (birth_sex) and state of residence at HIV diagnosis
(rsh_state_cd). Country of residence at HIV diagnosis (rsh_country_cd) is used if
rsh_state_cd is ‘FC – Foreign Country’. If no match is found then cases are
matched on last name soundex, date of birth, sex at birth and state or country of
residence at AIDS diagnosis (rsa_state_cd / rsa_country_cd). Cases that match on
the CDC string but have previously been confirmed by the jurisdiction as
different persons are excluded from the list.
 In addition to running the above eHARS report, jurisdictions are encouraged to
perform more in-depth duplicate reviews using information that are readily
available at the state level, e.g., first name (first_name), last name (last_name),
middle name (middle_name), first and last name soundex (first_name_sndx,
last_name_sndx), date of birth (dob), sex at birth (birth_sex), race/ethnicity
(race), full Social Security Number (ssn), death date (dod). When these values are
identical, other variables may be used to determine if the cases are duplicates.
Examples of such variables include: medical record number (medrecno); inmate
identification number (prisno); date of diagnosis of HIV infection (hiv_dx_dt);
and date of diagnosis of stage 3 HIV infection (aids_dxx_dt).

Process Standards
1. Frequency of Procedure


Monthly run eHARS canned report Intrastate Duplicate Cases Based on CDC
Matching String, merge duplicate case reports and update eHARS status.

1

All health department HIV Surveillance personnel who are United States citizens are eligible to access
the HIV Incidence and Case Surveillance Branch (HICSB) workspace on CDC SharePoint at
https://partner.cdc.gov/sites/NCHHSTP/HICSB/default.aspx. If you have questions or problems with access,
please contact your assigned CDC epidemiologist through the HIV Incidence and Case Surveillance
Branch’s main number (404) 639-2050.
2

See footnote 1, immediately above. eHARS technical documentations available at SharePoint.
4

National HIV Surveillance System Technical Guidance – Duplicate Review, December 2018



Jurisdictions should also perform more in-depth intrastate duplicate review using
exact and fuzzy (i.e., inexact) matching methods.

2 . Records that Represent the Same Person


Case reports that have been confirmed to be duplicates should be merged. When
merging, retain the STATENO belonging to the case that was first entered into
eHARS (the case with the earlier Person View enter_dt).



eHARS contains a Transfer Document feature which can be found under Document
and Case Maintenance in the ADMIN module index. Transfer Document allows the
user to merge duplicate case reports by entering the appropriate state and stateassigned case number (stateno), eHARS unique identifier (ehars_uid) or document
unique identifier (document_uid) of the source case (i.e., the case with the later
Person View enter_dt), and the appropriate state and state-assigned case number
(stateno) or eHARS unique identifier (ehars_uid) of the target case (i.e., the case
with the earlier Person View enter_dt).



The Adult Case Report Form (ACRF) and the Pediatric Case Report Form (PCRF)
documents in eHARS contain a Duplicate Review tab that allows the user to enter
duplicate status information regarding two reported cases of HIV infection.
Jurisdictions may utilize the Duplicate Review tab to maintain a log of cases (e.g.,
STATENOs) that have been merged with another case within the jurisdiction’s
eHARS. To do this, the surveillance staff needs to enter an ACRF or PCRF
document for the target case and, under the Duplicate Review tab, select duplicate
status as ‘1 – Same as’, select the jurisdiction’s name for site and enter the
STATENO of the source case as the state ID number.

3. Records that Represent Different Persons


When a pair of case reports in the “Intrastate Duplicate Cases Based on CDC
Matching String” report has been determined to represent two different persons, the
jurisdiction should notify CDC by entering an ACRF or PCRF document into
eHARS for at least one of the cases and updating the duplicate status under the
Duplicate Review tab to “2 – Different than” and entering the jurisdiction’s name
for site and the STATENO of the other case in the pair as the state ID number.

Outcome Standard


≤1% of cases for a report year have duplicate case reports, assessed 12 months after the
report year. Duplication rates should be calculated using methods shown in the file
Evaluation and Data Quality.

Interstate Duplicate Review
The same HIV-infected person may be reported multiple times to public health departments in
different states. Interstate duplicate case reports can result from persons moving or receiving
care in different states over time and being reported to multiple state health departments in
5
National HIV Surveillance System Technical Guidance – Duplicate Review, December 2018

accordance with local reporting requirements. Interstate duplicate review is designed to ensure
that a case of HIV infection is counted only once in the National HIV Surveillance System
(NHSS). The potential for duplicate reporting in the NHSS may increase as persons with HIV
infection remain healthier longer due to advances in the clinical treatment of HIV infection and
increased laboratory-driven surveillance. Therefore, routine interstate case de-duplication
activities are critical to ensure accurate case counts at the national level. In 1986 and 2001,
respectively, the Council of State and Territorial Epidemiologists (CSTE) passed resolutions
for state-to-state reciprocal notification processes for AIDS and HIV case reporting to
encourage resolution of duplicate case counting (See
http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/PS/1986-17.pdf and
http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/PS1/2001-ID-04.pdf). HIV
surveillance program staff should communicate with other states to resolve potential duplicates
using guidance outlined below in accordance with CSTE position statements and detailed
procedural guidance disseminated by CDC.
Potential interstate duplicate case reports may be identified in three ways. Before entering a
new case into eHARS, surveillance staff may contact the CDC Division of HIV/AIDS
Prevention (DHAP) Helpdesk (1-877-659-7725) to determine if the case has been reported by
another jurisdiction. (Using the Secure Online Soundex Match application, state and local
health departments are able to search for potential duplicates instead of calling the Helpdesk.)
There are three potential outcomes:
1. The case has been reported by another jurisdiction. In this situation, surveillance staff
should still enter the case into eHARS and ensure that data elements in the Duplicate
Review tab are appropriately populated (i.e., select ‘1 – Same as’ for ‘duplicate status’,
the name of the other jurisdiction for ‘site’, and the other jurisdiction’s STATENO for
the case for ‘state ID number’)
2. The case has not been reported by another jurisdiction, but the person’s last name
soundex, date of birth and sex at birth match those of a case reported by another
jurisdiction. In this situation, when entering the case into eHARS, surveillance staff
should also ensure that data elements in the Duplicate Review tab are populated (i.e.,
select ‘2 – Different than’ for ‘duplicate status’, the name of the other jurisdiction for
‘site’, and the other jurisdiction’s STATENO for the case for ‘state ID number’)
3. The case has not been reported by another jurisdiction and no match on last name
soundex, date of birth and sex at birth are found by the CDC DHAP Helpdesk, then data
elements in the Duplicate Review tab should be left blank when entering the case into
eHARS.
The second way that potential interstate duplicate case reports are identified is through
duplicate review reports that CDC distributes to local and state health departments; the semiannual Routine Interstate Duplicate Review (RIDR) reports and the Cumulative Interstate
Duplicate Review (CIDR) report that was distributed in January 2018. RIDR/CIDR reports are
generated after data transmitted to CDC by local and state health departments have been
consolidated. It is highly encouraged that jurisdictions proactively contact the CDC DHAP
Helpdesk for more timely identification of potential duplicates to help reduce the number of
potential interstate duplicate pairs in their semi-annual RIDR reports.
6
National HIV Surveillance System Technical Guidance – Duplicate Review, December 2018

The third way that potential interstate duplicate case reports can be identified is through the use
of a secure data sharing tool. Through grant PS 18-1805 Georgetown University is funded to
provide a secure data sharing tool with matching algorithm to all 59-funded state and local
health departments. The secure data sharing tool will assess case pairs using information
available at the local level that is not available at the national level (e.g., Social Security
Number, last name, etc.), and will generate a report indicating the matching level for each
potential duplicate (e.g., exact, extremely high, etc.). Therefore, it has the ability to more
efficiently identify “exact” matches compared to standard RIDR/CIDR methods and may also
find matches not detected through RIDR/CIDR. However, accuracy of the matches should be
determined before entering the information into eHARS. Accuracy can be determined by
selecting a subset of matches at various matching levels and discussing them further with the
other jurisdictions to determine if they are true matches. This will establish a threshold where
matches can be assumed to be true matches. For details on Georgetown’s secure data sharing
tool and requirements for participation, please contact Georgetown University,
[email protected].

National Data Processing and RIDR/CIDR Report Generation
To prevent overcounting of cases at the national level, on a quarterly basis, CDC de-duplicates
the national HIV surveillance database as part of National Data Processing. The de-duplication
process involves 1) identifying duplicate case reports and 2) combining duplicate case reports
and selecting one report state code (report_state_cd) and the corresponding STATENO
(stateno) for the case. Duplicate case reports are identified using the CDC match string as well
as the eHARS duplicate review data. Cases are first linked by last name soundex
(last_name_sndx), date of birth (dob), sex at birth (birth_sex), and state of residence at HIV
diagnosis (rsh_state_cd). Country of residence at HIV diagnosis (rsh_country_cd) is used if
rsh_state_cd is ‘FC – Foreign Country’. If no match is found, the process substitutes state and
country of residence at stage 3 HIV infection diagnosis (rsa_state_cd / rsa_country_cd) for state
and country of residence at HIV diagnosis. Moreover, case reports are regarded as duplicates if
they do not agree on the CDC match string but one or more jurisdiction’s duplicate review data
indicate that the cases are the “1 – Same as”; case reports are regarded as for different persons
if they match on the CDC match string but one or more jurisdiction’s duplicate review data
indicate that the cases are “2 – Different than”.
RIDR reports are generated using data from the eHARS consolidated database on a semiannual
basis. The list is generated by identifying cases that match on last name soundex
(last_name_sndx), date of birth (dob) and sex at birth (birth_sex), but have not been confirmed
as the same or different persons by the local and state health departments. These potential
interstate duplicate case reports are distributed to local and state health departments for
resolution. In RIDR reports, at least one case in the duplicate had to be reported during the six
months prior to the generation of the report. In order to resolve older duplicates in the national
dataset, in January 2018, CDC also generated the CIDR report. CIDR reports contain all
unresolved duplicates regardless of when they were reported to CDC.
The prerequisites (structural requirements), best practices (process standards), and outcome
standard for interstate duplicate review are described next.

7
National HIV Surveillance System Technical Guidance – Duplicate Review, December 2018

Structural Requirements
1. Link to CSTE 1986-17 AIDS Case Reporting: Reciprocal Notification
(http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/PS/1986-17.pdf).
2. L i n k t o CSTE 2001-ID-04 Reciprocal (Interstate) Notification of HIV Cases
(http://c.ymcdn.com/sites/www.cste.org/resource/resmgr/PS1/2001-ID-04.pdf).
3. HIV Surveillance System Software, eHARS.
4. Variables used for CDC matching string last name soundex (last_name_sndx), date of
birth (dob), sex at birth (birth_sex), and state of residence at diagnosis (rsh_state_cd or
rsa_state_cd) or, if a non-US resident at time of diagnosis, country of residence at
diagnosis (rsh_country_cd / rsa_country_cd).
5. Standard procedure for processing of CDC’s Cumulative and Routine Interstate
Duplicate Review reports (see SharePoint/Case Surveillance/RIDR/Instructions for
Processing CDC’s Duplicate Review Report_YYYYMM).
6. Case Residency Assignment Policies and Procedures (see file Date and Place of
Residence).
7. Procedures for evaluating accuracy of integrated HIV surveillance systems (see file
Evaluation and Data Quality).
8. Access to Secure Access Management Services; Current Digital Certificate.

Process Standards
1. Frequency of Procedure
Routine Interstate Duplicate Review must be performed semiannually. Cumulative
Interstate Duplicate Review must be completed over the course of the PS 18-1802
funding cycle (2018-2022).
2. Duplicate Review of Out-of-Jurisdiction Cases
States should maintain information on out-of-jurisdiction cases in eHARS. To
determine if a pair in the RIDR/CIDR report represents the same person or different
persons, contact the other state’s surveillance coordinator (or his or her designees) to
compare and collect additional information. Questions to ask to determine if pairs are the
same or different persons might include:


Do the cases share the same name, including considerations of other available name
types (e.g., alias)?



Does the Social Security Number prefix come from the other state?



Are there any comments that reference the other state?



Is there a death date match?
8

National HIV Surveillance System Technical Guidance – Duplicate Review, December 2018



Is there a current residence match?



Is there an unusual mode of exposure?

3. Records that Represent the Same Person
If, after discussion with the other state’s surveillance coordinator (or his or her
designees), the cases are deemed to represent the same person, case residency at
diagnosis must be established for the pair. Use policies and procedures for state of
residence at diagnosis to ensure that cases are counted appropriately (see file Date and
Place of Residence). Once state of residence is established, jurisdictions should inform
CDC of the duplicate review resolution by updating the data elements in the Duplicate
Review tab of the ACRF or PCRF document (i.e., select “1-same as” for duplicate
status, etc.) as well as the residency at diagnosis information (i.e., rsh_state_cd /
rsh_country_cd and rsa_state_cd / rsa_country_cd [if the person has a diagnosis of
stage 3 HIV infection]).
In addition to updating the residence at diagnosis and information on the Duplicate
Review tab, jurisdictions are encouraged to share with each other additional
information about the case in accordance with their respective reporting and data
sharing laws and regulations. Such information may include risk factors, AIDS-defining
conditions, vital status, date of death, last negative test result, if nucleotide sequences
are available, care status etc. In particular, surveillance staff should help each other to
determine in which jurisdiction does the patient currently reside and enter the address
information into the Identification tab of the ACRF or PCRF document in eHARS.
4. Records that Represent Different Persons
If, after discussion with the other state’s surveillance coordinator (or his or her
designees), the cases are deemed to represent different persons, jurisdictions should
inform CDC of the duplicate review resolution by updating the data elements in the
Duplicate Review tab of the ACRF or PCRF document (i.e., select “2 – Different than”
for duplicate status, etc.).
5. Resolution of Potential Duplicates
100% of potential interstate duplicate pairs in the RIDR/CIDR reports should be
resolved and duplicate status updated in eHARS in the following timeframes:


RIDR report released in January should be completed by June of the same year.



RIDR report released in July should be completed by December of the same year.



CIDR report released in January 2018 should be completed by December 2022,
with at least 20% of duplicates being resolved each year.

Staff approved to release information about HIV cases to other jurisdictions can be found on
the CSTE HIV/AIDS Contact Board Web site. Please contact the HIV surveillance support
staff at CSTE for information on obtaining sign-on identifications and passwords to access the
web site (http://www.cste.org/?page=HIVContact); the CSTE point of contact can be reached
at 770-458-3811.
9
National HIV Surveillance System Technical Guidance – Duplicate Review, December 2018

Contact the CDC’s designated subject matter expert (SME) for RIDR.CIDR for any questions
related to the RIDR/CIDR process. The RIDR/CIDR SME may be reached at the CDC HIV
Incidence and Case Surveillance Branch’s main number (404-639-2050) or through the CDC
epidemiologist assigned to your jurisdiction for technical assistance support.

Outcome Standard




≤2% of Routine Interstate Duplicate Review (RIDR) pairs remain unresolved at the end
of each six month RIDR cycle, assessed at the end of each cycle.
A minimum of 20% of case pairs on the CIDR list are to be resolved by the December
data transfer each year of the funding cycle (2018-2022). At the end of PS18-1802
(December 2022), 100% of case pairs on the CIDR list should be investigated and
resolved.

10
National HIV Surveillance System Technical Guidance – Duplicate Review, December 2018