surveillance: the public health version of csi€¦ · ♦estimate magnitude of the problem ......

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 Factor Identification: What is the

cause?

Intervention Evaluation:

What works?

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

http://www.cdc.gov/�

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


followup ♦Estimate magnitude of the problem ♦Determine geographic distribution of

disease ♦Detect sudden increases in disease-

Outbreak detection

Situations Requiring Prophylaxis of Contacts




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




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

02468

1012141618

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Year

Num

ber

of c

ases

DuPage CountyJoDaviess CountyOgle County




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



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 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998

National Center for Infectious Diseases (NCID) data*

National Electronic Telecommunications System for Surveillance (NETSS) data

0

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60

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120

140

160

Year (Quarter)

Rep

orte

d C

ases

Reported Toxic Shock Syndrome in Illinois, 1980-2004

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60

1980

1982

1984

1986

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1998

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2004

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Investigation leads to prevention

Poliomyelitis (Paralytic)

NOTE: Inactivated vaccine was licensed in 1955. Oral vaccine was licensed in 1961. Year

0

5

10

15

20

25

30

35

40

45

50

55

60

1968 1973 1978 1983 1988 1993 1998

Rep

orte

d C

ases

Source: CDC. Summary of notifiable diseases. 1998.

Rat

e/10

0,00

0 P

opul

atio

n

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

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

Hum

an C

ases

0

2000

4000

6000

8000

10000

12000

14000

16000

Cattl

e Ca

ses

HumansCattle

Trends in Pertussis in Illinois by Age Group (1998 through December 2004)

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300

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1998 1999 2000 2001 2002 2003 2004

< 6 Mo 6-11 Mo 1-4 Yrs 5-9 Yrs10-19 Yrs >20 Yrs

Examples of Changes in Health Practices

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 case

♦ 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

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/2003

Friday, October 17

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/2003

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

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/2003

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

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/04

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Purchase rat Onset of rat illness

Onset of mother’s illness

Onset of daughter’s illness Death 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

23

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

Num

ber o

f cas

es

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”

surveillance: the public health version of csi€¦ · ♦estimate magnitude of the problem ......

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