National Immunization Conference Using Surveillance Indicators for Vaccine-Preventable Diseases: National Notifiable Diseases Surveillance System 2000-2010 Sandra W. Roush, MT, MPH National Immunization Conference March 2011 National Center for Immunization & Respiratory Diseases National Immunization Conference: Using Surveillance Indicators for VPDs

Vaccine-Preventable Diseases (VPDs) Surveillance Indicators Team National Center for Immunization and Respiratory Diseases Centers for Disease Control and Prevention Linda M. Baldy, MPH Albert Barskey, MPH Susan B. Redd Sandra W. Roush, MT, MPH

Purpose of Surveillance Indicators Assess national surveillance and data quality for measles, mumps, rubella, pertussis, and Haemophilus influenzae, in terms of: surveillance infrastructure timeliness of reporting adequacy of case investigation appropriateness of laboratory testing and diagnostic effort

National Surveillance Background Diseases/conditions under national public health surveillance determined by the Council of State and Territorial Epidemiologists (CSTE) reported by health care providers and laboratories to local/state public health officials included in the National Notifiable Diseases Surveillance System (NNDSS) National Notifiable Diseases Surveillance System passive system monitor epidemiologic trends and assess programmatic impact electronic data to CDC through the National Electronic Telecommunications System for Surveillance(NETSS) or the National Electronic Disease Surveillance System (NEDSS)

Factors Related to Reporting Variations for Vaccine-Preventable Diseases Disease/condition Jurisdiction (laws, regulations) Patient and provider awareness symptoms incidence Clinical severity Transmission setting Laboratory diagnostics availability Electronic data transmission capacity

General Methods NNDSS data MMWR surveillance data - mumps - rubella annual (provisional and final) published in CDC's MMWR MMWR surveillance data 2000-2009 final, 2010 provisional analyzed to assess disease specific surveillance indicators - mumps - measles - rubella - pertussis - Haemophilus influenzae

Measles, Mumps, and Rubella Shared Surveillance Indicators Measles, mumps, and rubella have four indicators in common: The proportion of confirmed cases reported to NNDSS with complete information The median interval between symptom onset and notification of a public health authority The proportion of confirmed cases that is laboratory-confirmed The proportion of cases that has an imported source

Measles and Rubella Disease-Specific Surveillance Indicators the proportion of cases for which at least one clinical specimen for virus isolation was collected and submitted to CDC the number of discarded measles-like illness (MLI) reports (discontinued 1/1/2006) Rubella: the proportion of confirmed cases among women of child-bearing age with known pregnancy status

Pertussis Surveillance Indicators The proportion of cases reported to NNDSS with complete information The mean interval between date of symptom onset and date of public health notification The proportion of cases meeting clinical case definition that is laboratory tested The proportion of cases with complete vaccine history

Haemophilus influenzae Surveillance Indicators The proportion of cases reported to NNDSS with complete information The proportion of cases among children < 5 years of age with complete vaccine history The proportion of cases among children < 5 years of age with isolate serotyping

Assessment of Measles, Mumps, and Rubella Surveillance Indicators Analyses included: ▲ cases reported with confirmed or unknown case status (measles, rubella) or ▲ confirmed, probable, and unknown (mumps) case status Reporting interval: median number of days from date of onset to notification Reporting completeness assessment: ▲ clinical case definition ▲ hospitalization ▲ lab testing ▲ vaccine history ▲ date reported to health department ▲ transmission setting ▲ outbreak related ▲ epidemiologic linkage ▲ date of birth ▲ onset date Missing values were considered invalid Unknown values were considered valid

Assessment of Pertussis Surveillance Indicators Analyses included cases reported with: ▲ confirmed ▲ probable or ▲ unknown case status Reporting interval: median number of days from date of onset to notification Reporting completeness assessment: ▲ clinical case definition ▲ complications ▲ antibiotic treatment ▲ lab testing ▲ vaccine history ▲ epidemiologic data (outbreak, epidemiologic linkage) Complete vaccination history: vaccine date and type for all reported doses Missing and unknown values were considered invalid

Assessment of Haemophilus influenzae Surveillance Indicators Analyses included cases reported with: ▲ confirmed ▲ probable or ▲ unknown case status Reporting completeness assessment: ▲ clinical case definition (species, specimen type) ▲ vaccine history ▲ serotype Missing values were considered invalid Unknown values were considered valid

Results: Surveillance Indicators

U. S. Pertussis Surveillance Indicators for NNDSS: Completeness U.S. Pertussis Surveillance Indicators for NNDSS: Completeness*, Lab Testing, Vaccination History, Reporting Interval,** 2000 – 2010*** percent * Clinical case definition, complications (pneumonia, seizures, hospitalized, encephalopathy, death), antibiotic treatment, laboratory testing, ever received pertussis vaccine, epidemiologic data (epi-link, outbreaks); unknown and missing=“incomplete” response ** Reporting interval (onset to report) range 24-86 days (mean) ***Annual number of cases ranged from 7,580 (2001) to 25,827 (2004); 2010 data are provisional

U.S. Haemophilus influenzae Surveillance Indicators for NNDSS: Completeness*, Vaccination History, Serotype, 2000 – 2010** percent * Clinical case definition (e.g., specimen, invasive infection, species=Hi), serotype, ever received H. influenzae vaccine: unknown and missing=“incomplete” response **Annual number of cases (all ages) ranged from 1,597 (2001) to 3,022 (2009); annual number of cases (<5 yrs) ranged from 325 (2001) to 449 (2009); 2010 data are provisional

U. S. Measles Surveillance Indicators for NNDSS: Completeness U.S. Measles Surveillance Indicators for NNDSS: Completeness*, Lab Confirmation, Importation Status, Reporting Interval**, and CDC Specimens, 2000-2010*** percent * Clinical case definition, hospitalization, any lab test done, ever received measles vaccine, date reported, transmission setting, outbreak related, epi linked, date of birth, onset date: yes, no, unknown = “valid” ** Reporting interval (median days rash onset to report) range 1-6 days ***Total cases ranged from 140 (2008) to 37 (2004); 2010 data are provisional

U. S. Rubella Surveillance Indicators for NNDSS: Completeness U.S. Rubella Surveillance Indicators for NNDSS: Completeness*, Lab Confirmation, Importation Status, Reporting Interval,** and CDC Specimens, 2000 - 2010*** percent * Clinical case definition, hospitalization, any lab test done, ever received rubella vaccine, date reported, transmission setting, outbreak related, epi linked, date of birth, onset date: yes, no, unknown = “valid” ** Reporting interval (median days rash onset to report) range 1-23 days *** Total cases ranged from 23 (2001) to 3 (2009); 2010 data are provisional

U. S. Mumps Surveillance Indicators for NNDSS: Completeness U.S. Mumps Surveillance Indicators for NNDSS: Completeness*, Lab Confirmation, Importation Status, Reporting Interval**, and CDC Specimens, 2000 - 2010*** percent * Clinical case definition, hospitalization, any lab test done, ever received mumps vaccine, date reported, transmission setting, outbreak related, epi linked, date of birth, onset date: yes, no, unknown = “valid” **Median reporting interval (symptom onset to report) range 4-11 days *** Total cases ranged from 6,584 (2006) to 231 (2003); 2010 data are provisional

State Reports and Follow Up Surveillance indicator reports distributed to Immunization Program Managers in states, NYC, DC in February/March (and also in May to epidemiology) Report review and follow up varies by year and grantee Reporting (to local/state) and notification (to CDC) influenced by Administrative procedures Jurisdiction laws/regulations Epidemiologic data availability Testing availability Capacity for electronic data transmission

State and CDC Electronic Case Notification Data 16 states (AL, AR, ID, MD, ME, MT, NE, NM, NV, RI, SC, TN, TX, VA, VT, and WY) use NEDSS Base System (NBS) to transmit data Other states (and NYC, DC) use NETSS (legacy) to transmit data Issues identified this year for data from NBS states: Outdated NBS valid value tables Mapping and translation challenges at CDC Vaccine manufacturer data considerations Data and systems reviews still in process

Observations Surveillance indicators can be monitored using passive surveillance data collected electronically. However, NBS states’ data in the national data set currently does not accurately reflect state-based data or surveillance effort. H. influenzae: Data completeness is very low in the national data set, especially the percent of cases <5 years with serotype and with complete vaccine history. Measles: Effort must be maintained to ensure data completeness in the national data set, determination of importation status, and laboratory testing at CDC. Pertussis: Strategies must be implemented to enhance documentation of (adult and child) case vaccination history in the national data set, while building laboratory testing infrastructure. Rubella: Effort must be enhanced to achieve data completeness in the national data set, focusing on female pregnancy status and importation status for all cases. Mumps: Effort must be enhanced for data completeness in the national data set, including specimen collection, laboratory testing, clinical description, vaccination history, and epi linkage.

Recommendations Resolve electronic issues for NBS state’s data in the national surveillance data set Continue assessment of VPD surveillance indicators Continue accountability for data system challenges Monitor progress in surveillance effort Note that data from NBS states does not accurately represent state data or surveillance effort Communicate assessment results and support follow up Apply results in setting surveillance goals and strategies

THANK YOU! Sandy Roush 404-639-8741 swr1@cdc.gov