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 ProblemResponse 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

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,

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,

Lyme Disease Exposures in 3 Counties in Illinois,

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, TOXIC SHOCK SYNDROME (TSS) United States, *Includes cases meeting the CDC definition for confirmed and probable cases for staphylococcal TSS National Center for Infectious Diseases (NCID) data* National Electronic Telecommunications System for Surveillance (NETSS) data Year (Quarter) Reported Cases

Reported Toxic Shock Syndrome in Illinois,

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 Oral vaccine was licensed in Year Reported Cases Source: CDC. Summary of notifiable diseases Rate/100,000 Population Year Inactivated Vaccine Oral Vaccine United States,

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,

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

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

Friday, October 17

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

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

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 hyperchlorinate d Aug

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