1. is for Epi Epidemiology basics for non-epidemiologists

2. Session IV Part I Surveillance

3. Session Overview Introduction to Public Health Surveillance –Passive, active, and syndromic surveillance –Communicable disease law –Paper-based surveillance of reportable diseases –Applications and limitations Federal Public Health Surveillance –CDC’s role –Data sources –Surveillance reporting examples

4. Session Overview (cont’d.) Techniques for Review of Surveillance Data –Considerations when working with surveillance data –Access to data sources for rate numerators and denominators –Descriptive epidemiology –Graph and map surveillance rates

5. Today’s Learning Objectives Recognize the applications and limitations of current public health surveillance practices Understand the function of three different types of surveillance: active, passive, and syndromic Be familiar with federal public health surveillance systems relevant to epidemiology programs Understand the reciprocal pathway of data exchange through county, state, and federal surveillance efforts Recognize the major components of surveillance data analysis

6. What is Surveillance?

7. CDC: The ongoing systematic collection, analysis, and interpretation of health data, essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination to those who need to know.

8. -Physicians -Laboratories -STD clinics -Community health clinics County and state health departments and CDC who analyze data using statistical methods Standardized data collection

9. -Physicians -Laboratories -STD clinics -Community health clinics County and state health departments and CDC who analyze data using statistical methods -Public health officials -Health directors -Health policy officials Standardized data collection Dissemination to those who need to know

10. -Physicians -Laboratories -STD clinics -Community health clinics County and state health departments and CDC who analyze data using statistical methods -Public health officials -Health directors -Health policy officials Change in public health practice (vaccination, reduction of risk factors, medical intervention, etc.) Standardized data collection Dissemination to those who need to know Public health planning and intervention

11. -Physicians -Laboratories -STD clinics -Community health clinics County and state health departments and CDC who analyze data using statistical methods -Public health officials -Health directors -Health policy officials Change in public health practice (vaccination, reduction of risk factors, medical intervention, etc.) Standardized data collection Dissemination to those who need to know Public health planning and intervention Public health evaluation

12. NNDSS & NETSS The National Notifiable Disease Surveillance System (NNDSS) Disease-specific epidemiologic information 60 nationally notifiable infectious diseases 10 non-notifiable infectious diseases The National Electronic Telecommunications System for Surveillance (NETSS)

13. Elements of Surveillance Mortality reporting – legally required Morbidity reporting – legally required Epidemic reporting Timely reporting Laboratory investigations Individual case investigations Epidemic field investigations Analysis of data

14. Types of Surveillance Passive Active Syndromic

15. Passive Surveillance Laboratories, physicians, or other health care providers regularly report cases of disease to the local or state health department based on a standard case definition of that particular disease.

16. Communicable Disease Reporting: Passive Surveillance Hospital PhysicianLab Local Health Department State CDC Public

17. Recommended Reportable Diseases Acquired Immunodeficiency Syndrome (AIDS) Anthrax Arboviral neuroinvasive and non-neuroinvasive diseases Botulism Brucellosis Chancroid Chlamydia trachomatis, genital infections Cholera Coccidioidomycosis Cryptosporidiosis Cyclosporiasis Diphtheria Ehrlichiosis Enterohemorrhagic Escherichia coli Giardiasis Gonorrhea Haemophilus influenzae, invasive disease Hansen disease (leprosy) Specific reportable diseases and conditions are mandated by state law, and may be different for every state.

18. Active Surveillance Local or state health departments initiate the collection of specific cases of disease from laboratories, physicians, or other health care providers.

19. Communicable Disease Reporting: Active Surveillance Hospital PhysicianLab Local Heath Department State CDC

20. Outbreak investigations Other times when complete case ascertainment is desired (e.g., research study) Active Surveillance Applications

21. Syndromic Surveillance The ongoing, systematic collection, analysis, interpretation, and application of real-time indicators for disease that allow for detection before public health authorities would otherwise identify them.

22. What are “indicators of disease?” “Indicators” –Clinical signs that we can categorize into syndromes –NOT a specific diagnosis! Example: Cough + Sore throat + Fatigue + Fever = Influenza-Like Illness

23. Common Syndromes under Surveillance Gastroenteritis Influenza-like illness (ILI) Meningitis / Encephalitis Rash / Fever Botulinic Hemorrhagic

24. Why Do Syndromic Surveillance? Early detection of clusters in naturally occurring outbreaks or a BT event –Minimizes mortality & morbidity Characterize outbreak –Magnitude, rate of spread, effectiveness of control measures Quick investigation Detection of unexplained deaths

25. Limitations of Syndromic Surveillance Inadequate specificity: false alarms –Uses resources in investigation Inadequate sensitivity: failure to detect outbreaks/BT events –Outbreak is too small –Population disperses after exposure, cluster not evident

26. Limitations of Syndromic Surveillance Costly Staff expertise required Formal evaluation of syndromic surveillance systems are incomplete

27. Surveillance Applications

28. Applications Establish public health priorities Aid in determining resource allocation Assess public health programs –Facilitate research Determine baseline level of disease Early detection of epidemics –Estimate magnitude of the problem –Determine geographical distribution

29. Establish Public Health Priorities Frequency –Incidence, prevalence, mortality, years of life lost Severity –Case fatality rate, hospitalization, disability Cost –Direct, indirect

30. Resource Allocation TUBERCULOSIS: Reported cases per 100,000 population, United States and U.S. territories, 2002 Source: http://www.cdc.gov/dphsi/annsum/index.htm

31. Assess Public Health Programs Data Graphed by Race and Ethnicity Gonorrhea: reported cases per 100,000 population, United States, 1987 - 2002 Source: http://www.cdc.gov/dphsi/annsum/index.htm Data Graphed by Gender

32. *For 120 cases, origin of patients was unknown. TUBERCULOSIS among U.S.-born and foreign-born persons, by year, United States, 1990-2002 Determine Baseline Rates

33. Early Detection of Epidemics Boston, MA

34. Surveillance Limitations

35. Limitations Uneven application of information technology –Paper-based versus Electronic Timeliness –Reporting time requirement –Reporting burden Completeness –Unreported cases –Incomplete reports

36. CDC Varied communications methods and security - specific to each system- including paper forms, diskettes, e-mail, direct modem lines, etc. Current Situation MMWR Weekly Tables MMWR Annual Summaries Program Specific Reports and Summaries State Health Dept TIMSSTD*MI S HARS STD*MISTIMSNETSS EIP Systems NETSS STD*MIS (Optional at the Clinic) TIMS (Optional at the Clinic) PHLISEIP Systems * PHLIS HARS STD* MIS TIMSNNDSSEIP Systems PHLIS * EIP Systems (ABC, UD, Foodnet) Data Sources Physicia ns Varied communications methods and security - specific to each system - including diskettes, e-mail, direct modem lines, etc. Chart Review Lab Report s Reporting by Paper Form, Telephone & Fax Statistical Surveys for Chronic Diseases, Injuries and Other Public Health Problems City/County Health Department Limitations: Multiple Categorical Systems

37. National Electronic Disease Surveillance System (NEDSS) NEDSS is not a surveillance system Electronically integrates existing surveillance systems for easy data collection, storage and access Security to meet confidentiality needs

38. Surveillance Challenges at the State Level Quality of the data Balancing priorities Discrepancies and perspectives Translating data into information

39. Quality of the Data Completeness of case ascertainment Completeness and accuracy of case information Timeliness of reports Sentinel indicators ‘Tip of the iceberg’

40. Discrepancies and Perspectives Clinical vs surveillance case definitions Cases ‘worked’ vs cases ‘counted’ Place of exposure, residence, diagnosis Re-infection or duplicate report Stats by date of onset, diagnosis, report

41. Translating Data into Information Provides the basis for public health action Requires sound analysis and interpretation Extracts meaningful, actionable findings Requires clear presentation of complex issues