1. Infectious Disease Surveillance & National/Health Security Michael A. Stoto CNSTAT Workshop on Vital Data for National Needs April 30, 2008, Washington DC

2. Stoto CNSTAT 4/08 Outline “Biosurveillance” for national/health security –Detection of bioterrorist attacks vs. –Situational awareness for public health emergencies Relationship to the U.S. vital statistics system –Using mortality data to monitor disease outbreaks –Applying vital statistics system ideas for public health surveillance

3. Stoto CNSTAT 4/08 Syndromic surveillance Biosurveillance / Syndromic surveillance –Near real-time acquisition and use of pre- diagnostic health data for monitoring population health Builds on existing data systems Health care, ED chief complaints, medication sales, absenteeism, …NOT vital data Usually electronic/networked Statistical analyses used to detect changes  disease outbreak, especially a covert bioterrorist attack

4. Stoto CNSTAT 4/08

5. Shewhart Mild Medium Ultra CUSUM Expo

6. Stoto CNSTAT 4/08

7. Statistical issues Obtaining and integrating accurate data quickly from a variety of sources Determining when something is “unusual” –In the presence of highly variable and possibly unstable background variation –When there may be other reasons for changes in the data Tradeoffs among –Sensitivity –False positive rate (specificity) –Timeliness

8. Stoto CNSTAT 4/08 Practical issues Patient privacy concerns –HIPAA regulations, state law, etc. Proprietary concerns and turf issues Concern about secondary uses of data by others Operational costs of sharing data –including personnel and IT costs Information overload –excess flagging at health department end Ability to interpret and respond at higher levels Inability to detect small outbreaks Sense that utility of SS is not yet proven

9. Stoto CNSTAT 4/08 Goals and purpose shifting From “statistical” approaches –increase in the number of people with common symptoms to detect BT events –cannot detect small numbers of cases, even if very unusual To “situational awareness” –facilitate physician reporting –active surveillance / case finding –aid in outbreak investigations –real-time monitoring of disease outbreaks including, when to cease interventions –information sharing within public health

10. Stoto CNSTAT 4/08 Vital statistics for 21 st Century health surveillance? Given emphasis on timeliness, can vital statistics be used for biosurveillance? –Can Lemuel Shattuck’s 18 th Century approach to monitoring health with mortality rates be updated to the 21 st Century?

11. Stoto CNSTAT 4/08 Mills et al, Nature. 2004; 432:904-906

12. Stoto CNSTAT 4/08

13. Downloaded from CDC 4/26/08

14. Stoto CNSTAT 4/08 Vital statistics for health surveillance? Given emphasis on timeliness, can vital statistics be used for biosurveillance? –Excess P&I mortality key to what we know now (perhaps then) about the 1918 flu pandemic major current flu surveillance system –How can modern IT (e.g. E-Vital, EDR) make mortality data more useful for real-time monitoring? increased timeliness more geographically representative –improve accuracy of P&I coding include causes of death other than P&I

15. Stoto CNSTAT 4/08 Vital statistics system approaches for public health surveillance Notifiable disease reporting system –state & local function with limited national coordination mainly what to report –19 th century concept of operations post card  fax, phone, Internet CDC Biosense Notifiable Disease Cooperative Program –state & local ownership of case reports for local action –federal ownership (and standardization and funding) of statistical data for disease surveillance as a national security resource