Disease Surveillance in the 21st Century

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Disease Surveillance in the 21st Century

• Anthony Lee, MPH
• Epidemiologist
• Communicable Disease Division
• Oklahoma State Department of Health

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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

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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
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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
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Surveillance Programs

• Infectious disease
• Chronic disease
• Occupational safety health
• Health effects of environmental toxic exposures
• Injuries
• Personal health practices
• Preventive health technologies

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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
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Surveillance Systems
Active System
Sentinel System
Passive System
Syndromic System
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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.

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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

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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

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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

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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

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Objectives of Surveillance

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

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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
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Surveillance And Response



_at_

_at_ PEP
Disease Reporting
Vaccination
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Detect Increases in Disease Incidence
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PFGE Analysis by the PHL
Trigger Investigation of Etiology and Control of
Disease Transmission
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Disease Reporting
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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

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National Notifiable Infections
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Case Definitions
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Meningococcal Case Definition 2005
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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

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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
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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

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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

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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

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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.

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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.

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Morbidity and Mortality Reports

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

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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

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Old System
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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

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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

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PHIDDO Demo
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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

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Non-electronic Reporting

• Faxes
• Mail
• Phone calls
• Not 21st Century, but well take them!

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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

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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

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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

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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

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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)

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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