Public Health Information Network (PHIN) Series I

1. is for Epi Epidemiology basics for non-epidemiologists Public Health Information Network (PHIN) Series I

3. Series Overview Introduction to: • The history of Epidemiology • Specialties in the field • Key terminology, measures, and resources • Application of Epidemiological methods

4. Series I Sessions

5. Session I – V Slides VDH will post PHIN series slides on the following Web site: http://www.vdh.virginia.gov/EPR/Training.asp NCCPHP Training Web site: http://www.sph.unc.edu/nccphp/training

6. Site Sign-in Sheet Please submit your site sign-in sheet and session evaluation forms to: Suzi Silverstein Director, Education and Training Emergency Preparedness & Response Programs FAX: (804) 225 - 3888

7. Series ISession IV “Surveillance”

8. What to Expect. . . Today Introduction to the applications, limitations, and interpretation of public health surveillance data

9. Session Overview • Introduction to Public Health Surveillance • Passive, active, and syndromic surveillance • VA communicable disease law • Paper-based surveillance of reportable diseases • Applications and limitations • Federal Public Health Surveillance • CDC’s role • Data sources • Surveillance reporting examples

10. Session Overview (cont’d.) • Techniques for Review of Surveillance Data • Considerations when working with surveillance data • Access data sources for rate numerators and denominators • Descriptive epidemiology • Graph and map surveillance rates

11. Today’s Learning Objectives Upon completion of this session, you will: • Recognize the applications and limitations of current public health surveillance practices • Understand the function of three different types of surveillance: active, passive, and syndromic • Be familiar with federal public health surveillance systems relevant to epidemiology programs

12. Today’s Learning Objectives • Understand the reciprocal pathway of data exchange through county, state, and federal surveillance efforts • Be familiar with the Virginia paper-based surveillance system for reportable diseases • Recognize the potential benefits of National Electronic Disease Surveillance System (NEDSS) implementation in Virginia • Recognize the utility of Epi Info software for surveillance data analysis

13. Today’s Presenters Amy Nelson, PhD, MPH Consultant NCCPHP Lesliann Helmus, MS Surveillance Chief Division of Surveillance and Investigation Office of Epidemiology, Virginia Department of Health Sarah Pfau, MPH Consultant NCCPHP

14. What is Surveillance?

15. What is Surveillance? CDC: 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 dissemination to those who need to know.

16. Standardized data collection County and state health departments and CDC who analyze data using statistical methods -Physicians -Laboratories -STD clinics -Community health clinics

17. Standardized data collection County and state health departments and CDC who analyze data using statistical methods -Physicians -Laboratories -STD clinics -Community health clinics Dissemination to those who need to know Dissemination to those who need to know -Public health officials -Health directors -Health policy officials

18. Standardized data collection County and state health departments and CDC who analyze data using statistical methods -Physicians -Laboratories -STD clinics -Community health clinics Dissemination to those who need to know Dissemination to those who need to know Change in public health practice (vaccination, reduction of risk factors, medical intervention, etc.) -Public health officials -Health directors -Health policy officials Public health planning and intervention

19. Standardized data collection County and state health departments and CDC who analyze data using statistical methods -Physicians -Laboratories -STD clinics -Community health clinics Dissemination to those who need to know Public health evaluation Dissemination to those who need to know Change in public health practice (vaccination, reduction of risk factors, medical intervention, etc.) -Public health officials -Health directors -Health policy officials Public health planning and intervention

20. NNDSS & NETSS • The National Notifiable Disease Surveillance System (NNDSS) • Disease-specific epidemiologic information • 60 nationally notifiable infectious diseases • 10 non-notifiable infectious diseases • The National Electronic Telecommunications System for Surveillance (NETSS)

21. Elements of Surveillance • Mortality reporting – legally required • Morbidity reporting – legally required • Epidemic reporting • Timely reporting • Laboratory investigations • Individual case investigations • Epidemic field investigations • Analysis of data

22. Types of Surveillance • Passive • Active • Syndromic

23. Passive Surveillance Laboratories, physicians, or other health care providers regularly report cases of disease to the local or state health department based on a standard case definition of that particular disease.

24. Communicable Disease Reporting:Passive Surveillance Lab Physician Hospital Public CDC LHD State

25. VA Reportable Diseases http://www.vdh.state.va.us/epi/list.asp

26. VA Epi-1 Reporting Form for Paper-based Surveillance

27. VA Communicable Disease Law Communicable disease statutes are in Chapter 2 of Title 32.1 of the Code of Virginia. http://www.vdh.state.va.us/epi/appendxb.pdf These articles are incorporated into and referenced throughout the State Board of Health’s Regulations for Disease Reporting and Control http://www.vdh.state.va.us/epi/regs.pdf

28. Active Surveillance Local or state health departments initiate the collection of specific cases of disease from laboratories, physicians, or other health care providers.

29. Communicable Disease Reporting:Active Surveillance Lab Physician Hospital CDC LHD State

30. Active Surveillance Applications • Outbreak investigations • Other times when complete case ascertainment is desired (e.g., research study)

31. Question & Answer Opportunity

32. Syndromic Surveillance The ongoing, systematic collection, analysis, interpretation, and application of real-time indicators for disease that allow for detection before public health authorities would otherwise identify them.

33. What are “indicators of disease?” “Indicators” are clinical signs that we can categorize into syndromes, but NOT a specific diagnosis! Example: Cough + Sore throat + Fatigue + Fever = Influenza-Like Illness

34. Common Syndromesunder Surveillance • Gastroenteritis • Influenza like illness (ILI) • Meningitis / Encephalitis • Rash / Fever • Botulinic • Hemorrhagic

35. Why Do Syndromic Surveillance? • Early detection of clusters in naturally occurring outbreaks or a BT event • Minimizes mortality & morbidity • Characterize outbreak • Magnitude, rate of spread, effectiveness of control measures • Quick investigation • Detection of unexplained deaths

36. Syndromic vs. Traditional Surveillance Phase II Acute Illness Phase I Initial Symptoms Traditional Disease Detection Early Detection Gain of 2 days Effective Treatment Period Source: Johns Hopkins University / DoD Global Emerging Infections System

37. Limitations of Syndromic Surveillance • Inadequate specificity: false alarms • Uses resources in investigation • Inadequate sensitivity: failure to detect outbreaks/BT events • Outbreak is too small • Population disperses after exposure, cluster not evident

38. Limitations of Syndromic Surveillance • Costly • Staff expertise required • Formal evaluation of syndromic surveillance systems are incomplete

39. Surveillance Applications

40. Applications • Establish Public Health Priorities • Aid in determining resource allocation • Assess public health programs • Facilitate research • Determine baseline for detection of epidemics • Early detection of epidemics • Estimate magnitude of the problem • Determine geographical distribution

41. Establish Public Health Priorities: • Frequency (incidence / prevalence, mortality, years of life lost) • Severity (case fatality rate, hospitalization, disability) • Cost (direct, indirect)

42. Resource Allocation TUBERCULOSIS: Reported cases per 100,000 population, United States and U.S. territories, 2002 Source:http://www.cdc.gov/dphsi/annsum/index.htm

43. Assess Public HealthPrograms Gonorrhea: reported cases per 100,000 population, United States, 1987 - 2002 Data Graphed by Race and Ethnicity Data Graphed by Gender Source:http://www.cdc.gov/dphsi/annsum/index.htm

44. Determine Baseline Rates TUBERCULOSIS among U.S.-born and foreign-born persons, by year, United States, 1990-2002 *For 120 cases, origin of patients was unknown.

45. Early Detection of Epidemics Boston, MA

46. Surveillance Limitations

47. Limitations • Uneven application of information technology • Paper-based versus Electronic • Timeliness • Reporting time requirement • Reporting burden • Completeness • Unreported cases • Incomplete reports

48. Limitations: Multiple Categorical Systems Current Situation Program Specific Reports and Summaries MMWR Annual Summaries MMWR Weekly Tables Statistical Surveys for Chronic Diseases, Injuries and Other Public Health Problems STD*MIS TIMS NNDSS EIP Systems PHLIS HARS CDC Varied communications methods and security - specific to each system - including diskettes, e-mail, direct modem lines, etc. Reporting by Paper Form, Telephone & Fax Data Sources State Health Dept EIP Systems HARS STD*MIS TIMS NETSS PHLIS Physicians Varied communications methods and security - specific to each system- including paper forms, diskettes, e-mail, direct modem lines, etc. Chart Review Lab Reports HARS STD*MIS TIMS NETSS EIP Systems* PHLIS * EIP Systems (ABC, UD, Foodnet) City/County Health Department STD*MIS (Optional at the Clinic) TIMS (Optional at the Clinic)

49. National Electronic Disease Surveillance System (NEDSS) • NEDSS is not a surveillance system • Electronically integrate existing surveillance systems for easy data collection, storage and access • Security to meet confidentiality needs

50. Guest Lecturer:Virginia’s Surveillance Practices and Challenges Lesliann Helmus, MS Surveillance Chief Division of Surveillance and Investigation Office of Epidemiology, VDH