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Disease Surveillance in the 21st Century

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Title: Disease Surveillance in the 21st Century


1
Disease Surveillance in the 21st Century
  • Anthony Lee, MPH
  • Epidemiologist
  • Communicable Disease Division
  • Oklahoma State Department of Health

2
Surveillance
The continuing scrutiny of all aspects of
occurrence and spread of a disease that are
pertinent to effective control. Included are the
systematic collection and evaluation of
  • Morbidity and mortality reports
  • Reports of individual cases and field
    investigations of epidemics
  • Isolation and identification of infectious agents
    by laboratories
  • Data on exposures and risk factors

3
Surveillance
  • Ongoing systematic collection, analysis, and
    interpretation of health essential to the
    planning, implementation, and evaluation of
    public health practice
  • Timely dissemination of those data to those who
    need to know
  • Application of these data to prevention and
    control
  • Functional capacity linked to health programs

Centers for Disease Control, 1968
4
Uses of Surveillance
  • Detect new health problems
  • Detect epidemics
  • Document spread of disease
  • Provide quantitative estimates of the magnitude
    of morbidity and mortality
  • Describing the clinical course of a disease
  • Identify potential factors involved in disease
    occurrence (prevention and control)
  • Facilitating epidemiologic and lab research
  • Assessing control activities

Thacker and Berkelman, Epi Reviews
5
Surveillance Programs
  • Infectious disease
  • Chronic disease
  • Occupational safety health
  • Health effects of environmental toxic exposures
  • Injuries
  • Personal health practices
  • Preventive health technologies

6
Evaluation of Surveillance Programs
  • Regular review
  • Modifications based on
  • Usefulness
  • Cost
  • Quality
  • Sensitivity
  • Specificity
  • Predictive Value Positive
  • Representativeness
  • Timeliness
  • Simplicity
  • Flexibility
  • Acceptability

MMWR, July 27, 2001, 50(RR13)1-35
7
Surveillance Systems
Active System
Sentinel System
Passive System
Syndromic System
8
Active Surveillance
  • Reports are solicited from reporting sources at
    established intervals
  • Calling laboratories every Monday for disease
    reports
  • Limitations
  • Resource intensive
  • Difficult to maintain for extended periods of
    time.

9
Passive Surveillance
  • Sources send in reports of disease when they
    choose
  • Current system for Communicable Disease Division
    (CDD)
  • PHIDDO Electronic Disease Reporting
    Electronic Laboratory Reports
  • Paper Morbidity and Laboratory Reports
  • Limitations
  • Completeness of reporting

10
Augmenting Passive Surveillance Systems
  • Stimulate passive systems through interaction
  • Periodic Laboratory Audits
  • Periodic Review of Medical Record data ICD-9 /
    ICD-10 codes for reportable diseases
  • Death certificate review

11
Sentinel Surveillance
  • Key report sources are selected to participate in
    an enhanced disease surveillance system
  • Can include laboratory testing
  • Influenza
  • Drug-resistant Streptococcus pneumoniae
  • Medical Examiner

12
Syndromic Surveillance Systems
  • Syndromic surveillance systems
  • Electronic transfer of data fields describing
    symptoms or presenting complaints (e.g. ED visit)
  • Periodic analysis to detect temporal or spatial
    clusters
  • If pre-determined threshold exceeded, triggers
    active surveillance and medical record review.
  • Limitations
  • Numerous software packages
  • Requires compatible electronic formats
  • May be difficult to define sensitivity to
    individual or combined measures being used
  • Require more resources to operate as compared to
    other systems false alarms
  • Costly to maintain

13
Objectives of Surveillance
  • Monitor Disease Trends
  • Detect Increases in Disease Incidence
  • Trigger Investigation of Etiology and Control of
    Disease Transmission

14
Disease Progression and Reporting
  • Mild Likely not to be reported
  • Moderate Possible Likely to be reported
  • Severe Fatal Likely to be reported

Mausner and Kramer, 1985
15
Surveillance And Response



_at_

_at_ PEP
Disease Reporting
Vaccination
16
Detect Increases in Disease Incidence
17
PFGE Analysis by the PHL
Trigger Investigation of Etiology and Control of
Disease Transmission
18
Disease Reporting
19
National Disease Reporting
  • National Notifiable Disease Surveillance System
    (NNDSS)
  • CSTE creates the National Notifiable Disease List
  • States have similar statutes and rules for
    disease reporting.
  • These are modified within each state.
  • States apply the standard CSTE/CDC case
    definitions to reported cases and classify the
    cases
  • http//www.cdc.gov/epo/dphsi/casedef/
  • Changes over time
  • Testing methods
  • Incidence of disease
  • Increasing degree of specificity suspect,
    probable, confirmed

20
National Notifiable Infections
21
Case Definitions
22
Meningococcal Case Definition 2005
23
Transmission of Disease Reports
  • States report cases voluntarily to CDC through
    National Electronic Telecommunication
    Surveillance System (NETSS)
  • Created in 1983 as an electronic mail system
  • Transfer a binary file
  • Limited data on each case of disease which is a
    Nationally Notifiable Disease are transmitted
    each Tuesday to CDC via the NETSS system
  • All data are transmitted without personal
    identifiers
  • These reports are published weekly in the MMWR

24
National Disease Reporting
  • Limitations or biases
  • Assessment Bias
  • Access to healthcare
  • Severity of illness
  • Public awareness
  • Media attention
  • Changes in testing methods
  • Screening of asymptomatics
  • Delays in reporting
  • Sx onset date of collection finalize date
    of report
  • Especially for disease with long incubation
    periods

Modern Infectious Disease Epidemiology, 2nd Ed.,
J. Giesecke
25
National Disease Reporting
  • Limitations or biases
  • Not all diseases are reportable in every state
  • Not real time reporting States delay entering
    reports into the system until investigation is
    completed
  • Some states do not classify cases
  • Changes in case definitions over
    time/classification of cases can be subjective
  • Serotype/serogroup/PFGE data not transmitted on
    all diseases
  • Potential for duplicate reporting of individuals
  • Manual data entry
  • Digital certificate required for transmission

26
National Disease Reporting
  • Development of silo systems
  • Collection and transmission of more specific data
  • Some systems are one-way reporting to CDC
  • Emerging Infectious Diseases, Review of State and
    Federal Surveillance Systems, GAO-04-877
  • Laboratory PHLIS, PulseNet
  • Foodborne EFORS
  • Outbreak RODS
  • Tuberculosis TIMS
  • HIV/AIDS EHARS
  • STD STD-MIS
  • VPD PVS
  • Injury NEISS
  • Occupational FACE
  • Cancer SEER
  • Birth Defects BDMP
  • Lead STELLAR

27
Public Health Informatics Network
  • Next generation of reporting health information
  • Set of national standards for the development of
    electronic systems and messaging between them
  • National Electronic Disease Surveillance System
    (NEDSS)
  • National Notifiable Disease Message (NNDM)
  • Early Event Detection (EED)
  • Outbreak Management System (OMS)
  • Countermeasure Response Administration (CRA)
  • Partner Communications Administration (PCA)
  • Connecting Laboratory Systems

28
Disease Reporting in Oklahoma
  • OAC 310515-1-2. Disease reporting
  • OAC 310515-1-3. Immediate Disease Reporting
  • OAC 310515-1-4. Reporting of Additional
    Diseases, Conditions, and Injuries
  • OAC 310515-1-8. Organisms/specimens to be sent
    to the Public Health Laboratory.

29
HIPPA
  • The Health Insurance Portability and
    Accountability Act of 1996
  • Into effect on April 14, 2003
  • Section 262
  • Nothing in this part shall be construed to
    invalidate or limit the authority, power, or
    procedures established under any law providing
    for the reporting of disease or injury, child
    abuse, birth, or death, public health
    surveillance, or public health investigation or
    intervention.

30
Morbidity and Mortality Reports
  • Disease Reports (Morbidity)
  • Case Report Forms
  • Laboratory Reports
  • Death Certificates (Mortality)
  • Discharge Data
  • Calls from the general public

31
Communicable Disease Surveillance
  • Communicable Disease Division receives disease
    reports daily from Oklahoma-based and national
    physicians, hospitals, and laboratories.
  • Disease reports are reviewed by the Surveillance
    Officer (SO), triaged, and distributed to various
    service areas
  • Communicable Disease
  • STD/HIV/Hep B C
  • Tuberculosis

32
Old System
33
Electronic Reporting Welcome to the 21st
Century
  • Public Health Investigation and Disease Detection
    of Oklahoma (PHIDDO) system
  • Oklahoma developed the PHIDDO system by
    contracting with Titan.
  • Secure web-based disease reporting and
    investigation system
  • Real-time reporting
  • Centralized reporting
  • Data is secure and only accessible to those with
    specific permissions

34
PHIDDO
  • Users - Infection Control Practitioners, Labs,
    Physician/Clinic Users, County Health Nurses
  • Immediately notifiable report submissions PHIDDO
    to send a page, e-mail and text message to the
    Epi-On-Call 24/7/365
  • Received over 400 immediately notifiable reports
  • Regional hands-on computer lab sessions
  • PHIDDO Bytes E-Newsletter sent periodically to
    update users of changes to the system

35
PHIDDO Demo
36
Electronic Lab Reporting
  • Receive daily electronic file from 2 reference
    laboratories
  • Diagnostic Laboratory of Oklahoma
  • Laboratory Corporation of America
  • Testing daily file from the Public Health
    Laboratory
  • Requests for Proposal to have additional
    laboratories send electronic file
  • Generate PHIDDO cases from ELR

37
Non-electronic Reporting
  • Faxes
  • Mail
  • Phone calls
  • Not 21st Century, but well take them!

38
Investigators Communicable Disease Nurses
  • Each county health department has a designated
    Communicable Disease Nurse.
  • Investigate cases characterized by a risk or
    threat to other persons or the community.
  • Assess possible exposures and risk factors.
  • Make PEP and control recommendations in
    consultation with state-level epidemiologists
  • Educate on prevention and transmission

39
CDD Data Analysis
  • CDD Epis regularly analyze the reportable disease
    database to detect unusual clusters of disease.
  • Clusters of the same disease may be grouped by
  • Geographic area
  • Age
  • Gender
  • Serotype/serogroup
  • Time
  • Identified clusters warrant further investigation
    by Epis CDNs

40
Outbreak Investigations
  • Communicable Disease Division Epidemiologists
  • Establish the existence of an outbreak
  • Conduct surveys along with CDNs
  • Case Control, Cohort, or Cross-sectional
  • Recommend PEP and control measures
  • Work with County Sanitarians - enforcement
  • Analysis of the data
  • Publish results
  • Internal Reports
  • CDD Epidemiological Bulletin, Annual Summary
  • MMWR
  • Peer-Reviewed Journals

41
Disease Surveillance in the 21st Century
  • Surveillance is evolving
  • New technologies/systems
  • Collaborative Public Health Community
  • Moving to electronic data
  • Real-time/near real-time reporting
  • Limitations
  • New technologies/systems
  • Growing pains from volume received
  • Security
  • Acceptance by users

42
Student Opportunities
  • Outbreak Investigation Team
  • Dr. Hélène Carabin
  • (Helene-Carabin_at_ouhsc.edu)
  • Shadowing a CDD Epidemiologist and/or Field
    Work
  • Laurence Burnsed (Laurence_at_health.ok.gov)
  • Mentoring Program
  • Jaimie Watt (EmmaJW_at_health.ok.gov)

43
Thank You!
  • Anthony Lee, MPH
  • AnthonyL_at_health.ok.gov
  • Oklahoma State Department of Health
  • Communicable Disease Division
  • 405 - 271 4060
  • www.health.ok.gov
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