1. Developed through the APTR Initiative to Enhance Prevention and Population Health Education in collaboration with the Brody School of Medicine at East Carolina University with funding from the Centers for Disease Control and Prevention Public Health Surveillance

2. APTR wishes to acknowledge the following individuals that developed this module:  Kristina Simeonsson, MD, MSPH Department of Public Health Brody School of Medicine at East Carolina University  Julie Daugherty, MPH Department of Public Health Brody School of Medicine at East Carolina University This education module is made possible through the Centers for Disease Control and Prevention (CDC) and the Association for Prevention Teaching and Research (APTR) Cooperative Agreement, No. 5U50CD300860. The module represents the opinions of the author(s) and does not necessarily represent the views of the Centers for Disease Control and Prevention or the Association for Prevention Teaching and Research.

3. 1. Define surveillance 2. Discuss the uses of surveillance 3. Review notifiable disease surveillance 4. Describe surveillance limitations

4. Source: http://www.health.gov/phfunctions/public.htm

5.  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. www.cdc.gov

6.  Notifiable diseases  Vital records  Environmental monitoring systems  Animal health data  Individuals  Laboratories  Medical records  Over the counter medication sales  Registries  Surveys  population-based  provider-based

7.  Passive  Active  Syndromic

8.  Laboratories, physicians, or others regularly report cases of disease / death to the local or state health department  Case reports based on a standard case definition of that particular disease  Deaths reported on standard certificate

9.  Local or state health departments initiate the collection of information from laboratories, physicians, health care providers or the general population.  Achieves more complete and accurate reporting  More resource intensive for the public health agency ▪ money ▪ personnel ▪ time

10.  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.  Common surveillance syndromes  Gastrointestinal  Influenza-like illness  Rash and Fever

11.  Simple  Timely  Representative  Flexible  Sensitive  Strong predictive value  Acceptable  public  health care providers  Cost-effective

12.  Simple  Timely  Representative  Flexible  Sensitive  Strong predictive value  Acceptable  public  health care providers  Cost effective

13.  Sensitivity  Few if any missed cases  Increase by having broad case definitions  Positive predictive value  Almost all case reports received for illnesses meet the surveillance case definition  Increase by adopting a more restrictive case definition Hopkins, R. 2005

14.  Estimate magnitude of the problem  Determine geographic distribution of illness  Portray the natural history of a disease  Detect epidemics / define a problem  Generate hypotheses, stimulate research  Evaluate control measures  Monitor changes in infectious agents  Detect changes in health practices  Facilitate planning http://www.cdc.gov/osels/ph_surveillance/nndss/phs/overview.htm

15.  Estimate magnitude of the problem  Determine geographic distribution of illness  Portray the natural history of a disease  Detect epidemics / define a problem  Generate hypotheses, stimulate research  Evaluate control measures  Monitor changes in infectious agents  Detect changes in health practices  Facilitate planning

16. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5853a1.htm

17.  Estimate magnitude of the problem  Determine geographic distribution of illness  Portray the natural history of a disease  Detect epidemics / define a problem  Generate hypotheses, stimulate research  Evaluate control measures  Monitor changes in infectious agents  Detect changes in health practices  Facilitate planning

18. BOTULISM, Foodborne Outbreak Reported cases, by year, United States, 1982-2002 Source: CDC. Summary of notifiable diseases. 2002. Data from the annual survey of State Epidemiologist and Directors of State Public Health Laboratories..

19.  Estimate magnitude of the problem  Determine geographic distribution of illness  Portray the natural history of a disease  Detect epidemics / define a problem  Generate hypotheses, stimulate research  Evaluate control measures  Monitor changes in infectious agents  Detect changes in health practices  Facilitate planning

20. Varicella (ChickenPox). Number of reported cases --- Illinois, Michigan, Texas, and West Virginia*, 1993--2009 www.cdc.gov/mmwr/preview/mmwrhtml/mm5853a1.htm

21.  Foundation is state and local application of the reportable disease surveillance system known as National Notifiable Disease Surveillance System (NNDSS)  Infectious reportable diseases  Noninfectious reportable diseases ▪ Cancer ▪ Elevated blood lead levels ▪ Pesticide-related illness

22.  System for passing reports from the local to state health departments, and then on to CDC  Role of the Council of State and Territorial Epidemiologists (CSTE)  List of disease and laboratory findings of public health interest  Case definitions for their surveillance  Dissemination of surveillance data  Morbidity and Mortality Weekly Report (MMWR)  MMWR Annual Summary of Notifiable Diseases

23.  Uniform criteria for reporting cases  Clinical, Laboratory, Epidemiologic http://www.cdc.gov/osels/ph_surveillance/nndss/casedef/hepatiti sacurrent.htm

24. MMWR Annual Summary of Notifiable Diseases http://www.cdc.gov/mmwr/PDF/wk/mm5754.pdf

25.  Reporting by states to the CDC is voluntary  Reporting mandated at state level  state legislation or regulation  Variation in the lists of reportable diseases exists between states

26.  Resident of long-term care facility hospitalized with acute hepatitis B  Physician reports case to local health department (LHD) ▪ LHD nurse remembers several other cases of acute hepatitis B at same facility in past year ▪ Unsuspected outbreak of acute hepatitis B was discovered in the facility

27. MMWR, March 11, 2005 / 54(09);220-223

28.  Stillborn infant delivered at hospital diagnosed with listeriosis  Physician reports case to LHD ▪ Outbreak of listeriosis was identified among Hispanic females with 12 cases identified over 4 month period  5 stillbirths  3 premature births  2 infected newborns ▪ Case-control study identified common source of exposure

29. MMWR, July 06, 2001 / 50(26);560-2

30. Used with permission from Robert E. Whitwam

31.  Incomplete data  Overwhelming volumes of data from a variety of sources make management complex  Uneven application of information technology  Paper versus electronic reporting  Timeliness  Reporting time requirement  Reporting burden  Completeness  Unreported cases  Incomplete reports

32. CDC’s Burden of Illness Pyramid: Underascertainment of Foodborne Illness in Notifiable Diseases Surveillance Source: Adapted from Centers for Disease Control and Prevention, “FoodNet Surveillance - Burden of Illness Pyramid.” http://www.cdc.gov/foodnet/surveillance_pages/burden_pyramid.htm. Accessed October 3, 2011.http://www.cdc.gov/foodnet/surveillance_pages/burden_pyramid.htm.

33.  100 persons infected with shigella  76 symptomatic  28 consulted a healthcare provider  9 submitted stool cultures  7 had positive results  6 reported to the local health department  5 reported nationally to CDC Rosenberg et al, 1977

34. 1. Lack of awareness of legal requirement 2. Lack if knowledge of which conditions are reportable 3. Lack of knowledge of how or to whom to report 4. Assumption that someone else will report the case 5. Intentional failure to report to protect patient privacy 6. Insufficient reward for reporting 7. Insufficient penalty for not reporting Doyle et al, 2002

35.  Costly  Staff expertise required  Formal evaluations of syndromic surveillance systems are incomplete

36.  Inadequate specificity = false alarms  Software recognizes key words  Uses resources in investigation  Inadequate sensitivity = failure to detect outbreaks or bioterrorism events  Outbreak is too small  Population disperses after exposure, cluster not evident

37.  Surveillance data has many practical uses  Notifiable disease surveillance is fundamental to prevention and control efforts  List of notifiable diseases varies by state  Significant improvements are being made in advancing surveillance and reporting

38.  Center for Public Health Continuing Education University at Albany School of Public Health  Department of Community & Family Medicine Duke University School of Medicine

39. Mike Barry, CAE Lorrie Basnight, MD Nancy Bennett, MD, MS Ruth Gaare Bernheim, JD, MPH Amber Berrian, MPH James Cawley, MPH, PA-C Jack Dillenberg, DDS, MPH Kristine Gebbie, RN, DrPH Asim Jani, MD, MPH, FACP Denise Koo, MD, MPH Suzanne Lazorick, MD, MPH Rika Maeshiro, MD, MPH Dan Mareck, MD Steve McCurdy, MD, MPH Susan M. Meyer, PhD Sallie Rixey, MD, MEd Nawraz Shawir, MBBS

40.  Sharon Hull, MD, MPH President  Allison L. Lewis Executive Director  O. Kent Nordvig, MEd Project Representative