surveillance: the public health version of csi
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Surveillance: The Public Health Version of CSI. March 2006 Connie Austin and Judy Conway Illinois Department of Public Health. Outline of Surveillance Talk. Basics of Surveillance Uses of Surveillance Limitations of Surveillance Future of Surveillance - PowerPoint PPT PresentationTRANSCRIPT
Surveillance: The Public Health Version of CSI
March 2006
Connie Austin and Judy Conway
Illinois Department of Public Health
Outline of Surveillance Talk
Basics of Surveillance Uses of Surveillance Limitations of Surveillance Future of Surveillance Examples of Surveillance in Action in
Illinois Infectious Disease Quiz
Public Health Surveillance
Systematic, ongoing Collection
“get data” Analysis & Interpretation
turn data into information” Dissemination
“route to those who need it” Link to public health practice
“do something about it”
Building Block of Surveillance
All surveillance starts with the single case who is brought to the attention of public health by a laboratory, HCP or other party and who’s risk factors are investigated by the LHD CD investigator
Three Main Features of Surveillance Systematic Collection
Consolidation and Evaluation of Data
Prompt Dissemination of Results to Those Who Can Take Action
Public Health Approach
Problem Response
Surveillance:What is the
problem?
Risk FactorIdentification:What is the
cause?
InterventionEvaluation:
Whatworks?
Implementation:How do you
do it?
Legal Authority For Conducting Surveillance Diseases and conditions to be reported Who is responsible for reporting What information is required for each
case How, to whom and how quickly must
cases be reported Control measures to be taken for
specific diseases
IDPH
LHD
Reportable Infectious Diseases, 2006 67 reportable infectious diseases in
Illinois 56 diseases/conditions are nationally
notifiable to CDC 3 are reportable to WHO
Primary Data Sources for Surveillance Lab reports Health care providers Death certificates Animals/insects
Modes of Surveillance
Passive Surveillance: Wait for reports Enhanced Passive surveillance: Health
alerts to encourage rapid reporting Communication and relationship building with hospitals and clinicians
Active surveillance: Actively querying or auditing clinical sites for cases; expensive and more often part of “ramping up”
The Public Health Team
Health care providers Other Experts Epidemiologists Communicable Disease Investigators IT persons Support staff
Allied Surveillance Useful to Infectious Disease Surveillance Biowatch-environmental monitoring for
BioT agents in big cities Biosense
Uses of Surveillance
Identify cases for investigation and followup
Estimate magnitude of the problem Determine trends in incidence and
distribution Detect sudden increases in disease-
Outbreak detection
Uses of Surveillance (cont)
Generate hypotheses, stimulate research
Evaluate prevention and control measures
Monitor long-term changes/trends in infectious agents
Detect changes in health practices Facilitate planning
Uses of Surveillance
Identify cases for investigation and followup
Estimate magnitude of the problem Determine geographic distribution of
disease Detect sudden increases in disease-
Outbreak detection
Situations Requiring Prophylaxis of Contacts
Uses of Surveillance
Identify cases for investigation and followup
Estimate magnitude of the problem Determine trends in incidence and
distribution Detect sudden increases in disease-
Outbreak detection
Enterics in Illinois, 2001-2003
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2001 2002 2003
E coli O157:H7CryptosporidiaGiardiaShigellaSalmonellaCampylobacter
Uses of Surveillance
Identify cases for investigation and followup
Estimate magnitude of the problem Determine trends in incidence and
distribution Detect sudden increases in disease-
Outbreak detection
Lyme Disease Cases Reported in Illinois, 1995-2005
0
20
40
60
80
100
120
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005
Year
Num
ber
of r
epor
ted
case
s
Lyme Disease Exposures in 3 Counties in Illinois, 1995-2005
0
24
6
810
12
1416
18
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Year
Num
ber
of c
ases
DuPage CountyJoDaviess CountyOgle County
Uses of Surveillance
Identify cases for investigation and followup
Estimate magnitude of the problem Determine trends in incidence and
distribution Detect sudden increases in disease-
Outbreak detection
Surveillance-Outbreak Identification S. enteritidis, Kankakee, 2002
Histoplasmosis, Iroquois County, 2003
Rabies, 2004&2005
Uses of Surveillance
Generate hypotheses, stimulate research
Evaluate control and prevention measures
Monitor long-term changes/trends in infectious agents
Detect changes in health practices Facilitate planning
TOXIC SHOCK SYNDROME (TSS)United States, 1983-1998
TOXIC SHOCK SYNDROME (TSS)United States, 1983-1998
*Includes cases meeting the CDC definition for confirmed and probable cases for staphylococcal TSS.
1983 1984 1985 1986 1987 1988 19891990 1991 1992 1993 1994 1995 1996 1997 1998
National Center for Infectious Diseases (NCID) data*
National Electronic Telecommunications System for Surveillance (NETSS) data
0
20
40
60
80
100
120
140
160
Year (Quarter)
Rep
ort
ed
Cases
Reported Toxic Shock Syndrome in Illinois, 1980-2004
0
10
20
30
40
50
60
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
Year
Num
ber
of r
epor
ted
cas
es
Investigation leads to prevention
Uses of Surveillance
Generate hypotheses, stimulate research
Evaluate control and prevention measures
Monitor long-term changes/trends in infectious agents
Detect changes in health practices Facilitate planning
Poliomyelitis (Paralytic)
NOTE: Inactivated vaccine was licensed in 1955. Oral vaccine was licensed in 1961.NOTE: Inactivated vaccine was licensed in 1955. Oral vaccine was licensed in 1961.YearYear
00
55
1010
1515
2020
2525
3030
3535
4040
4545
5050
5555
6060
19681968 19731973 19781978 19831983 19881988 19931993 19981998
Rep
ort
ed
C
ases
Source: CDC. Summary of notifiable diseases. 1998.
Rate
/10
0,0
00
Pop
ula
tion
Year
Inactivated Vaccine
Oral Vaccine
0.001
0.01
0.1
1
10
100
1000
1951 1956 1961 1966 1971 1976 1981 1986 1991 1996
United States, 1968-1998
Rabies, potential human exposure 15% of rabies PEP unnecessary Improper timing of rabies PEP in 1/3 of
cases Improper location for injections in 1/3 of
cases Given properly in 43% of cases
Uses of Surveillance
Generate hypotheses, stimulate research
Evaluate control and prevention measures
Monitor long-term changes/trends in infectious agents
Detect changes in health practices Facilitate planning
Brucellosis in Humans and Cattle in Illinois, 1951-2004
0
50
100
150
200
250
300
350
400
450
500
51 54 57 60 63 66 69 72 75 78 81 84 87 90 93 96 99 2
Year
Hu
man
Cas
es
0
2000
4000
6000
8000
10000
12000
14000
16000
Cat
tle
Cas
es
Humans
Cattle
Trends in Pertussis in Illinois by Age Group (1998 through December 2004)
0
50
100
150
200
250
300
350
400
450
500
1998 1999 2000 2001 2002 2003 2004
< 6 Mo 6-11 Mo 1-4 Yrs 5-9 Yrs10-19 Yrs >20 Yrs
Uses of Surveillance
Generate hypotheses, stimulate research
Evaluate control and prevention measures
Monitor long-term changes/trends in infectious agents
Detect changes in health practices Facilitate planning
Examples of Changes in Health Practices
Uses of Surveillance
Generate hypotheses, stimulate research
Evaluate control and prevention measures
Monitor long-term changes/trends in infectious agents
Detect changes in health practices Facilitate planning
What Diseases Should be Under Surveillance? Cause serious morbidity and/or
mortality Have the potential to affect additional
people beyond the initial case Can be controlled or prevented with an
intervention Any outbreak or unusual increase in a
disease Any unusual case/cluster
Competing Interests
CDC State Health Department Local Health Departments Citizens and action groups Health Care providers Politicians
Types of Infectious Diseases Under Surveillance Diseases transmitted from food/drinking
water Diseases requiring contact tracing for
prophylaxis Vaccine preventables Diseases requiring environmental
control measures New/emerging/unusual infections
Diseases transmitted from food/drinking water Enterics-Salmonella, E. coli O157:H7 Other-botulism, Listeria etc PH responses
– Restrict foodhandlers– Remove contaminated foods from
commerce– Find problem in manufacturing process
Examples of diseases requiring contact prophylaxis Hepatitis A N. meningitidis Rabies Exposures
Vaccine Preventables
Examples: H. influenzae, Hepatitis A and B, pertussis, chickenpox, influenza
PH Response– Increasing vaccination rates in risk groups
Diseases Requiring Environmental Control Measures
Examples: outbreaks of legionellosis, leptospirosis, histoplasmosis, cryptosporidiosis, arboviruses
PH Response– Recommendations on how to decrease
exposure to organism and prevent further cases
New/Emerging/Unusual
Examples: monkeypox, bioterrorism agents
Limitations of Surveillance System Underreporting
Limitations (continued)
Representativeness Timeliness Inconsistency of case definitions
Characteristics of Good Public Health Surveillance Qualified and dedicated personnel Teamwork approach to investigations Strong relationships with reporters Strong relationships with partners-other
LHDs, state and federal partners
Characteristics of Good Public Health Surveillance (cont) Templates and database resources
available on hand 24/7/365 availability Always stay alert/open minded
Ways to Improve Surveillance
Improve awareness of reporters Simplify reporting Frequent feedback Active surveillance
What’s Up in the Future for Infectious Disease Surveillance in Illinois???
INEDSS– Faster reporting– LHDs have access to their own data
Electronic Reporting from labs Electronic death certificate data? IDPH-Intranet resources for each
reportable disease, A-Z
Surveillance/Epi Response overview
“Signal”– Call from clinician/hospital– Syndrome threshold/trigger– Environmental trigger
Early Epi Investigation– Targeted questions for MD, Patient– Laboratory work up– Environmental investigation– Cross-Evaluation data from all systems– Enhance surveillance/ Actively look for more cases
Outbreak investigation
Examples of Surveillance in Action in Illinois
PIAPO-Assessing Surveillance Data Problem? Investigation needed? Assessment of the situation Plan of Action Over?
Example 1
CDC’s BioSense Crimean hemorrhagic fever
Biosense Reports
On the following dates there were reports of Crimean Hemorrhagic Fever cases from Illinois VA or DOD facilities: 10/5, 10/6, 10/28, 11/1, 11/1, 11/2,12/2,12/13
Example 2
Meningococcal disease
Wednesday, October 14
0
1
2
3
4
5
Friday, October 17
0
1
2
3
4
5
Investigation?
Information to be gathered?
Meningococcal Disease Clusters
Vaccine available for serogroup A/C/Y/W-135. No vaccine for serogroup B.
Cluster requiring vaccination– 3 or more probable or confirmed cases of
serogroup C in < 3 months– Attack rate of >=10 per 100,000 population
Saturday, October 18
0
1
2
3
4
5
Information gathered
All six cases are male Ages range from 27 to 42 years of age Residents of the north side of City A All 4 confirmed cases are SG C 3 of 6 cases were fatal
Assessment
What is your assessment?
Action Plan
Health care providers were notified Public has been notified Vaccination clinics
Vaccination Campaign
Began Oct 19 with 5 vaccination sites Recommendations for vaccination Flow of persons Time frame
Example 3
Single Case?
Positive Rabies Test
You receive a call from a physician who reports a patient has tested positive for rabies
What do you do?
Additional Information Gathered
Test was an ELISA test for rabies, not approved for diagnosis of human rabies; test was equivocal
Person visited Mexico, returned and has been hospitalized for a month and is on a ventilator but can watch TV and is alert.
Assessment?
Plan of Action
Example 4. Is this a problem?
Further Information from Investigation Bitten by a sheep 3 weeks prior while
preparing sheep for a county fair
Assessment and Plan?
Example 5
Campylobacter cluster
3 cases of Campylobacter come thru from a provider into your in-box in INEDSS on the same day
Assessment and Plan?
Example 6
Problem?
Investigation?
Information Obtained
2 persons were from same household Family had purchased a hooded rat
from a chain pet store Rat became ill
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
7/29
/04
7/31
/04
8/2/
04
8/4/
04
8/6/
04
8/8/
04
8/10
/04
8/12
/04
8/14
/04
8/16
/04
8/18
/04
Purchase rat
Onset of rat illness
Onset of mother’s illness
Onset of daughter’s illnessDeath of rat
Traceback of rat
Rats purchased by pet store from Distributor A in Arkansas
This distributor was also implicated in other states
November 3, 2004 Report
Pet Store Chain in Illinois calls to report they had a hamster that died suddenly and was culture positive for S. ser. Typhimurium
Findings
Hamster purchases IDPH laboratory testing U.S. summary Rodents-antimicrobials
Plan of Action
Example 7
Background On August 12, a LHD was alerted to 5
lab-confirmed Cryptosporidium cases
Problem?
Problem?
Crypto cases reported per year in this jurisdiction: 4
Investigation?
Investigation
Upon investigation, all confirmed cases reported swimming in the municipal facility prior to illness
Investigation?
Is this enough information to take action?
Action Steps
Laboratory Investigation
12 persons had laboratory-confirmed cryptosporidiosis
The pools had been hyper-chlorinated; no water samples were available for testing
Epidemiological curve of clinical cases and date of symptom onset, July/August 2004 (N=37)
Pool hyperchlorinated Aug. 23-
24
0
1
2
3
4
5
6
7/25/20047/26/20047/27/20047/28/20047/29/20047/30/20047/31/20048/1/20048/2/20048/3/20048/4/20048/5/20048/6/20048/7/20048/8/20048/9/20048/10/20048/11/20048/12/20048/13/20048/14/20048/15/20048/16/20048/17/20048/18/20048/19/20048/20/20048/21/20048/22/20048/23/20048/24/20048/25/20048/26/20048/27/20048/28/20048/29/20048/30/2004
Date of Onset
Nu
mb
er
of
ca
se
s
Probable Lab Confirmed
Pool hyperchlorinated
Aug. 23-24
Conclusions
A visit to the pool facility was linked to becoming ill with cryptosporidiosis
The wading pool was a likely source of infection though other explanations are possible
Improved fecal accident response may reduce risk of disease transmission
Cryptosporidium remained in the pool water even though chlorine levels were generally adequately maintained
Example 8
Background
IDPH notified by the LHD on March 25 about an outbreak of GI illness in two groups eating food from a single caterer on February 25
Investigation
Do you cancel your catered luncheon from this facility?
Caterer inspection
No major problems Obtained invoice information Employees were ill
– Problem?
Epi Findings
Cases included 14, 17, 19 and 2 from the four groups, respectively
Group 1-13 of 14 ills ate pasta salad and/or tuna salad
Group 2-pasta salad Group 3-multiple including tuna
sandwich and pasta salad Group 4-tuna salad sandwiches and
mixed green salad
Epi continued
1970 Surgeon General Statement
“it was time to close the book on infectious diseases, declare the war against pestilence won, and shift national resources to such chronic problems as cancer and
heart disease”
Pets