Whats New in Surveillance

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Whats New in Surveillance

• Dona Schneider, PhD, MPH

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• Surveillance is 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
  feedback of these data to those who need to
  know. Centers for Disease Control
• Examples
• Morbidity and Mortality Weekly Report (MMWR)
• Disease Registries

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Surveillance for communicable diseases remains
important

• The world population is highly mobile
• International travel and troop movements increase
  the risk of communicable disease transmission
• Migration for war and famine, and voluntary
  immigration increase communicable disease risk
• Naturally occurring disease is not our only
  threat

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Types of Surveillance

• Passive
• Inexpensive, provider-initiated
• Good for monitoring large numbers of typical
  health events
• Under-reporting is a problem
• Active
• More expensive, Health Department-initiated
• Good for detecting small numbers of unusual
  health events
• Enhanced
• Rapid reporting and communication between
  surveillance agencies and stakeholders
• Best for detecting outbreaks and potentially
  severe public health problems

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New and complex disease entities must also be
monitored

• New syndromes may emerge that present in an
  atypical manner
• Syndromic surveillance uses health-related data
  that precede diagnosis and signal a sufficient
  probability of a case or an outbreak to warrant
  further public health response

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Example of Passive Surveillance

• Day 1- feels fine
• Day 2- headaches, fever - buys Tylenol
• Day 3- develops cough - calls nurse hotline
• Day 4- Sees private doctor dx with flu
• Day 5- Worsens - calls ambulance seen in ED
• Day 6- Admitted - pneumonia
• Day 7- Critically ill - ICU
• Day 8- Expires - respiratory failure
• Case enters surveillance system through an EDC

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Example of Syndromic Surveillance

• Day 1- feels fine
• Day 2- headaches, fever - buys Tylenol
• Day 3- develops cough - calls nurse hotline
• Day 4- Sees private doctor - dx flu
• Day 5- Worsens - calls ambulance - seen in ED
• Day 6- Admitted - pneumonia
• Day 7- Critically ill - ICU
• Day 8- Expires - respiratory failure
• Case is under immediate investigation by the LHD
  because of the pre-diagnostic information gathered

Pharmaceutical Sales
Nurses Hotline
Managed Care Org
Absenteeism records
Ambulance Dispatch (EMS)
ED Logs
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We also watch for sentinel events

• Sentinel surveillance identifies preventable
  disease, disability, or deaths that warn that
  known methods of prevention, treatment or safety
  need to be improved
• Sentinel events may have catastrophic outcomes
  they may indicate the tip of the iceberg

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Sentinel Surveillance

• Monitors
• Sites
• Events
• Providers
• Vectors/animals

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SENTINEL EVENT Nov 12, 2001 - 917 am Flight AA
587 Crashes in Rockaways 7-Zip Surveillance
showed 27 Obs / 10 Exp Resp Emergencies
plt0.001 31 Obs / 16 Exp Hospital Events
plt0.05
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Investigation

• Key Questions
• True increase or natural variability?
• Bioterrorism or self-limited illness?
• Available Methods
• Response team assigned
• Response team Drills down
• Query clinicians / laboratories
• Chart reviews
• Patient follow-up
• Increased diagnostic testing

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Investigation

• Chart review in one hospital (9 cases)
• Smoke Inhalation (1 case)
• Atypical Chest Pain / Anxious (2 cases)
• Shortness of Breath - Psychiatric (1 case)
• Asthma Exacerbation (3 cases)
• URI/LRI (2 cases)
• Checked same-day logs at 2 hospitals
• Increase not sustained

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Surveillance can

• Estimate the magnitude of a problem
• Determine geographic distribution of illness
• Detect epidemics/outbreaks
• Generate hypotheses, stimulate research
• Evaluate control measures
• Monitor changes in infectious agents
• Detect changes in health practices

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Data Sources

• Notifiable diseases
• Laboratory specimens
• Vital records
• Sentinel surveillance
• Registries and surveys
• Administrative data systems
• Other data sources

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Reported Cases of Food borne Botulism, United
States, 1981-2001
Data from annual survey of State Epidemiologists
and Directors of State Public Health Laboratories.
Source CDC. Summary of notifiable diseases.
2001.
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Cases of Measles United States, 1966-2001
Source CDC. Summary of notifiable diseases.
2001.
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Blood Lead Measurements 1975-1981
110
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Predicted blood lead
100
Lead used in gasoline (thousands of tons)
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90
Mean blood lead levels ? g/dl
80
Gasoline lead
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70
Observed blood lead
12
60
50
10
40
30
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1975
1976
1977
1978
1979
1980
1981
Year
Source Pirkle et al JAMA 272284-91, 1994
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Reported Salmonella Isolates, United States,
1976-2001
Data from Public Health Laboratory Information
System (PHLIS).
Source CDC. Summary of notifiable diseases.
2001.
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National Notifiable Diseases Surveillance System
(NNDSS) produces the data in the MMWR

• The reportable diseases list is revised
  periodically by the CSTE/CDC
• States report diseases to the CDC voluntarily
• Reporting is mandated at the state level
• All states report the internationally
  quarantinable diseases (i.e., cholera, plague,
  SARS, smallpox and yellow fever) in compliance
  with WHO International Health Regulations and a
  varied list of other diseases

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In New Jersey

• Reporting mandated by state law/regulation
• Health care providers, laboratories report to the
  LHD (county)
• LHD submits reports to the State
• Reports transmitted by State to CDC primarily
  through National Electronic Telecommunications
  System for Surveillance (NETSS)

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Other NCHS Data Systems for Surveillance

• Vital Statistics
• National Infant Mortality Surveillance (NIMS)
• Linked
• birth records
• death records

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SENSOR

• Sentinel
• Event
• Notification
• System for
• Occupational
• Risks

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Recent Occupational Monitoring Efforts for
Sentinel Events Include

• Biodetection Systems (BDS) in NJ post offices to
  detect anthrax and soon, ricin
• Biowatch, an air monitoring system in New York
  City and 30 other cities

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Weekly Communicable Disease Reporting System
(CDRS) Alerts

• Comparison of current 4-week reporting period to
  previous reporting periods generated at NJDHSS
  every Monday
• by disease
• by county
• Increase over baseline (3 SD) triggers an alert
  for further investigation
• Limitation timeliness of reporting into CDRS

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New Jersey Real Time Outbreak and Disease
Surveillance (RODS) OTC SurveillanceReports
Through March 15, 2003
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Cipro and Doxycycline Prescriptions
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National Electronic Disease Surveillance System
(NEDSS)

• Will replace NETSS, HIV/AIDS, TB, STD,
  vaccine-preventable and infectious disease
  reporting systems
• Goal is to standardize health reporting and link
  laboratory, hospital and managed care data

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Enhanced and Syndromic Surveillance

• Costs
• Implementation costs are modest
• Operational costs time of public health staff,
  investigations
• Benefits
• Possibily huge if early detection results
• Strengthens traditional surveillance
• Sets high standards for all data collection
  agencies

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• Good surveillance does not necessarily ensure the
  making of right decisions, but it reduces the
  chances of wrong ones.
• Alexander D. Langmuir
• NEJM 1963268182-191

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Free Resources

• World Health Organization
• DISMOD Software
• Centers for Disease Control
• Epi Info