Public health surveillance systems
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Public Health Surveillance Systems. Goals. Adverse events surveillance Syndromic surveillance Registries Laboratory data. Review purpose of surveillance Describe types of state and local surveillance systems: Vital records Disease reporting (morbidity data) Surveys

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Goals l.jpg
Goals

  • Adverse events surveillance

  • Syndromic surveillance

  • Registries

  • Laboratory data

  • Review purpose of surveillance

  • Describe types of state and local surveillance systems:

    • Vital records

    • Disease reporting

      (morbidity data)

    • Surveys

    • Sentinel surveillance

    • Zoonotic disease

      surveillance

  • Provide example of public health actions resulting from surveillance data


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Purpose of Surveillance

  • Collecting surveillance data has many purposes

    • Monitoring disease trends

    • Detecting outbreaks

    • Providing information to plan public health interventions

    • Stimulating research


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Purpose of Surveillance

  • Specific uses of surveillance data vary depending on organization or agency

  • National agencies

    • Monitoring disease trends over time to inform policy

  • State and local agencies

    • Assuring accurate diagnosis and treatment of infected persons

    • Managing people exposed to disease

    • Detecting outbreaks

    • Guiding public health prevention and control programs


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Types of State and Local Surveillance Systems

  • Surveillance systems used to monitor disease trends and plan public health programs

    • Vital statistics, disease reporting, surveys

  • More specialized systems

    • Sentinel surveillance, zoonotic disease surveillance, adverse events surveillance, syndromic surveillance, disease registries, laboratory surveillance

  • Some types more useful for certain diseases than others; each fills a specific need


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Vital Statistics

  • Records of births and deaths: a basic but critical cornerstone of public health surveillance

  • Mortality data over past century show decrease in rate of deaths due to infectious diseases; rate of death from non-infectious causes remain steady

  • Infant mortality rate (number of deaths among infants per 1,000 births) long used as indicator of overall population health

  • Birth data used to monitor incidence of preterm birth, risk factor for variety of adverse health outcomes


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Vital Statistics

  • In United States, vital statistics available from

    • National Center for Health Statistics

    • State vital records offices

    • CDC WONDER – online system containing data on births, deaths, many diseases from Centers for Disease Control and Prevention (CDC)


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Disease Reporting (Morbidity Data)

  • Disease reporting required internationally by World Health Organization through International Health Regulations

    • Smallpox

    • Wild-type poliomyelitis

    • Severe acute respiratory syndrome (SARS)

    • Human influenza caused by new subtypes

    • Any public health emergency of international concern

      • Broad definition used to capture any disease, condition, event that could represent international risk


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Disease Reporting (Morbidity Data)

  • In the United States, disease reporting mandated by state law

    • List of reportable diseases varies by state

  • States report nationally notifiable diseases to CDC on voluntary basis

    • List of notifiable diseases updated regularly by Council of State and Territorial Epidemiologists and CDC


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Surveys

  • Especially useful for monitoring chronic diseases and health-related behaviors

    • Youth Risk Behavior Survey (YRBS) asks high school students about substance use, sexual behavior, physical activity, nutrition

  • Results used to monitor trends in health behaviors, plan public health programs, evaluate public health policies at national and state levels


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Surveys

Percent of high school students who reported smoking in the 30 days prior to the survey, United States, 1997-2007

  • YRBS shows decline in youth smoking from 36% in 1997 to 20% in 2007


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Surveys

  • Other national surveys conducted by CDC:

    • Behavioral Risk Factor Surveillance System (BRFSS)

    • National Health Interview Survey (NHIS)

    • Pregnancy Risk Assessment Monitoring System (PRAMS)

    • National Health and Nutrition Examination Survey (NHANES)


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Sentinel Surveillance

  • Alternative to population-based surveillance,

  • Involves collecting data from sample of reporting sites (sentinel sites)

    • Example: Selected health care providers report number of cases of influenza-like illness to state health department on weekly basis

  • Allows states to monitor trends using relatively small amount of information


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Graph indicates peak of influenza activity during 2007- 2008 season in late February and early March (Weeks 7-9)

Sentinel Surveillance

Percentage of visits for influenza-like illness reported by US sentinel provider network, 2006-2007, 2007-2008


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Sentinel Surveillance 2008 season in late February and early March (Weeks 7-9)

  • Sentinel providers also used to gather more specific information

    • Example: sentinel provider network in British Columbia, Canada, used in a study of vaccine effectiveness during 2005-2006 influenza season


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Zoonotic Disease Surveillance 2008 season in late February and early March (Weeks 7-9)

  • Surveillance of zoonotic diseases (diseases found in animals that can be transmitted to humans) often involves system for detecting infected animals

  • Example: 2001 Florida surveillance for West Nile Virus (WNV):

    • Web site and telephone hotline to report dead birds, some collected and tested for WNV

    • Mosquitoes collected and tested for WNV in 10 counties

    • Blood collected from 3-12 sentinel chickens in each of 212 flocks up to 4 times per month, tested for antibodies to WNV

    • Veterinarians asked to test horses with neurologic symptoms consistent with WNV

    • Health care providers reminded of reporting and diagnostic criteria for possible human cases of WNV


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Zoonotic Disease Surveillance 2008 season in late February and early March (Weeks 7-9)

  • Surveillance systems allowed public health authorities to determine intensity of WNV by geographic area

  • Detection of WNV led to public health control measures:

    • Advising public to protect against mosquito bites

    • Intensifying mosquito abatement efforts


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Adverse Events Surveillance 2008 season in late February and early March (Weeks 7-9)

  • Surveillance system focusing on patient safety: Adverse Events Reporting System (AERS), operated by Food and Drug Administration (FDA)

    • Negative effects experienced by people who received approved drugs, therapeutic agents

    • Voluntary reports from health care providers (physicians, pharmacists, nurses) and public (patients, lawyers)

    • Health care providers/patients may report events directly to product manufacturer; manufacturer required to report event to AERS

  • FDA uses AERS to identify possible safety concerns associated with approved products


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Adverse Events Surveillance 2008 season in late February and early March (Weeks 7-9)

  • Vaccine Adverse Events Reporting System (VAERS) also focused on patient safety; operated by CDC with FDA

    • Like AERS, but for negative effects experienced by people who have received licensed vaccines

    • Used in 2003 for smallpox vaccines to health care and public health professionals in preparation for bioterrorist attack

      • >100 adverse events reported after smallpox vaccination, 16 suspect and 5 probable cases of myocarditis or pericarditis

      • Advisory Committee on Immunization Practices recommended ending vaccination after health care and public health response teams


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Adverse Events Surveillance 2008 season in late February and early March (Weeks 7-9)

  • Passive surveillance systems may be limited by underreporting or biased reporting, cannot be used to determine whether a drug or vaccine caused a specific adverse health event

    • (See FOCUS Volume 5, Issue 5 for definitions of active and passive surveillance)

  • Used as early warning signals

  • Possible associations between drugs or vaccines and adverse events examined using well designed epidemiologic study, appropriate action based on results


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Syndromic Surveillance 2008 season in late February and early March (Weeks 7-9)

  • Relatively new surveillance method, uses clinical information about disease signs and symptoms, before diagnosis is made

  • Often use electronic data from hospital emergency rooms


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Syndromic Surveillance 2008 season in late February and early March (Weeks 7-9)

  • Example: New York City operates syndromic surveillance system using emergency department chief-complaint data from approximately 44 hospitals

    • Data monitored electronically for beginning of disease outbreak

    • In 2002, system detected higher than usual number of diarrheal and vomiting symptoms

    • Health department notified hospital emergency departments of possible outbreak and collected stool specimens, several tested positive for norovirus


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Syndromic Surveillance 2008 season in late February and early March (Weeks 7-9)

  • Example: New York City (continued)

    • Similar outbreak later that year not detected by the system

    • Failure to detect attributed to incorrect coding of chief complaint by emergency departments

  • Illustrates potential benefits of syndromic surveillance, areas where changes needed to increase usefulness of system


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Registries 2008 season in late February and early March (Weeks 7-9)

  • Surveillance system used for particular conditions

  • Often established at state level to collect information about persons diagnosed with condition

    • Example: cancer registries collect information about type of cancer, anatomic location, stage of disease at diagnosis, treatment, outcomes

  • Used to improve prevention programs

    • Example: women in rural areas diagnosed with breast cancer later than women in urban areas; choose to promote mammography screening in rural areas using mobile van


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Laboratory Data 2008 season in late February and early March (Weeks 7-9)

  • Public health laboratories routinely conduct tests for viruses, bacteria, other pathogens

    • In US, labs participate in National Salmonella Surveillance System through electronic reporting of Salmonella isolates

    • 2006: >40,000 isolates reported

  • Lab serotyping provides information about cases likely to be linked to common source

  • Serotypes are useful for detecting local, state, or national outbreaks


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Laboratory Data 2008 season in late February and early March (Weeks 7-9)

  • Another lab system: PulseNet by CDC and Association of Public Health Laboratories to monitor foodborne illness outbreaks

    • Enables labs across US to compare pulsed-field gel electrophoresis (PFGE) patterns of bacteria from ill persons and determine similarity

    • Allows scientists to determine whether outbreak is occurring, even at geographically distant locations

    • Can decrease time required to identify outbreaks of foodborne illness and causes


Public health actions resulting from surveillance poliomyelitis l.jpg
Public Health Actions Resulting From Surveillance: Poliomyelitis

  • Dramatic decrease in paralytic poliomyelitis in US following licensure of inactivated polio vaccine (1955), oral polio vaccine (1961)

  • Global example: monitoring progress toward eradication of poliomyelitis

Number of cases of paralytic poliomyelitis by year, United States, 1967-1997


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Public Health Actions Resulting From Surveillance: Poliomyelitis

  • Global example: monitoring progress toward eradication of poliomyelitis (continued)

    • Using data from countries around world, World Health Organization implemented intensive vaccination programs where decline not as significant


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Public Health Actions Resulting From Surveillance: HIV/AIDS Poliomyelitis

  • Example: surveillance for HIV/AIDS ongoing since detection of disease in the US in 1981

  • Data on incidence and prevalence among population subgroups, geographic areas important to guide prevention, control efforts

    • 2003-2006: estimated number of cases increased among men who have sex with men, remained steady among heterosexuals, decreased among injection drug users

    • Suggests that prevention programs working more effectively in some groups than others   


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Mapping rates shows clear pattern of higher risk in southeastern states than in rest of nation

Suggests need for more prevention measures in southeast

Public Health Actions Resulting From Surveillance: HIV/AIDS

Rates of diagnosed HIV/AIDS, by area of residence, United States, 2006


Conclusion l.jpg
Conclusion southeastern states than in rest of nation

  • Many sources of public health surveillance data at local, state, national levels

  • Knowing where to look for different types of data can save time and resources

  • Data used for variety of purposes:

    • Guiding prevention strategies and targeting resources

    • Detecting disease outbreaks of local, national, international significance

    • Evaluating control measures


Resources l.jpg
Resources southeastern states than in rest of nation

  • National Vital Statistics System

    • Data on births, deaths, marriages, divorces, fetal deaths from all 50 states, 2 cities (Washington, DC, and New York City), 5 territories (Puerto Rico, Virgin Islands, Guam, American Samoa, Commonwealth of the Northern Mariana Islands); much of information available online

    • http://www.cdc.gov/nchs/nvss.htm

  • CDC WONDER

    • User-friendly query system providing public health information on births, deaths, cancer incidence, HIV and AIDS, tuberculosis, vaccinations, census data

    • http://wonder.cdc.gov/

  • Nationally Notifiable Infectious Diseases

    • List of diseases recommended for states to report to CDC

    • http://www.cdc.gov/ncphi/disss/nndss/phs/infdis.htm


References l.jpg
References southeastern states than in rest of nation

  • Birkhead GS, Maylahn CM. State and local public health surveillance. In: Teutsch SM, Churchill RE, eds. Principles and Practice of Public Health Surveillance. 2nd ed. New York, NY: Oxford University Press; 2000:253-286.

  • Armstrong GL, Conn LA, Pinner RW. Trends in infectious disease mortality in the United States during the 20th century. JAMA. 1999;281(1):61-66.

  • World Health Organization. International health regulations (2005). 2nd ed. http://www.who.int/csr/ihr/en/. Published 2008. Accessed October 3, 2008.

  • Centers for Disease Control and Prevention. Summary of notifiable diseases – United States, 2006. Morb Mortal Wkly Rep. 2008;55(53):1-84.

  • Centers for Disease Control and Prevention. Cigarette use among high school students – United States, 1991-2007. Morb Mortal Wkly Rep. 2008;57(25):689-691.


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References southeastern states than in rest of nation

  • FluView. Outpatient illness surveillance. Centers for Disease Control and Prevention Web site. http://www.cdc.gov/flu/weekly/. Updated October 10, 2008. Accessed October 14, 2008.

  • Skowronski DM, Masaro C, Kwindt TL, et al. Estimating vaccine effectiveness against laboratory-confirmed influenza using a sentinel physician network: results from the 2005-2006 season of dual A and B mismatch in Canada. Vaccine. 2007;25(15):2842-2851.

  • Blackmore CGM, Stark LM, Jeter WC, Oliveri RL, Brooks RG, Conti LA, Wiersma ST. Surveillance results from the first west nile virus transmission season in Florida, 2001. Am J Trop Med Hyg. 2003;69(2):141-150.

  • Food and Drug Administration, Center for Drug Evaluation and Research. Adverse Event Reporting System (AERS) Web site. http://www.fda.gov/cder/aers/default.htm. Published August 7, 2002. Updated September 5, 2008. Accessed November 21, 2008.


References35 l.jpg
References southeastern states than in rest of nation

  • Zhou W, Pool V, Iskander JK, et al. Surveillance for safety after immunization: vaccine adverse events reporting system (VAERS) – United States, 1991-2001. MMWR CDC Surveill Summ. 2003;52(SS-1):1-11.

  • Centers for Disease Control and Prevention. Update: adverse events following civilian smallpox vaccination – United States, 2003. Morb Mortal Wkly Rep. 2004;53(5):106-107.

  • Centers for Disease Control and Prevention. Advisory Committee on Immunization Practices (ACIP) statement on smallpox preparedness and vaccination. http://www.bt.cdc.gov/agent/smallpox/vaccination/acipjun2003.asp. Published June 18, 2003. Accessed October 23, 2008.

  • Steiner-Sichel L, Greenko J, Heffernan R, Layton M, Weiss D. Field investigations of emergency department syndromic surveillance signals – New York City. Morb Mortal Wkly Rep. 2004;53(suppl):190-195.


References36 l.jpg
References southeastern states than in rest of nation

  • Centers for Disease Control and Prevention. Salmonella surveillance: annual summary, 2006. http://www.cdc.gov/ncidod/dbmd/phlisdata/salmonella.htm. Published 2008. Accessed October 14, 2008.

  • Swaminathan B, Barrett TJ, Fields P. Surveillance for human salmonella infections in the United States. J AOAC Int. 2006;89(2):553-559.

  • Centers for Disease Control and Prevention. What is PulseNet? PulseNet Web site. http://www.cdc.gov/pulsenet/whatis.htm. Published July 24, 2006. Accessed December 3, 2008.

  • Centers for Disease Control and Prevention. Summary of notifiable diseases, United States, 1997. Morb Mortal Wkly Rep. 1998;46(54):1-87.

  • Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2006. Vol. 18. http://www.cdc.gov/hiv/topics/surveillance/resources/reports/. Published 2008. Accessed October 14, 2008.


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