Surveillance: The Public Health Version of CSI March 2006 Connie Austin and Judy Conway Illinois...

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 FactorIdentification:What is the

cause?

InterventionEvaluation:

Whatworks?

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



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

0

24

6

810

12

1416

18

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



Evaluate control and prevention measures



TOXIC SHOCK SYNDROME (TSS)United States, 1983-1998

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 19891990 1991 1992 1993 1994 1995 1996 1997 1998

National Center for Infectious Diseases (NCID) data*

National Electronic Telecommunications System for Surveillance (NETSS) data

0

20

40

60

80

100

120

140

160

Year (Quarter)

Rep

ort

ed

Cases

Reported Toxic Shock Syndrome in Illinois, 1980-2004

0

10

20

30

40

50

60

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

Year

Num

ber

of r

epor

ted

cas

es

Investigation leads to prevention

Poliomyelitis (Paralytic)

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

00

55

1010

1515

2020

2525

3030

3535

4040

4545

5050

5555

6060

19681968 19731973 19781978 19831983 19881988 19931993 19981998

Rep

ort

ed

C

ases

Source: CDC. Summary of notifiable diseases. 1998.

Rate

/10

0,0

00

Pop

ula

tion

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

Hu

man

Cas

es

0

2000

4000

6000

8000

10000

12000

14000

16000

Cat

tle

Cas

es

Humans

Cattle

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

0

50

100

150

200

250

300

350

400

450

500

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 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

0

1

2

3

4

5

Friday, October 17

0

1

2

3

4

5

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

0

1

2

3

4

5

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

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1

7/29

/04

7/31

/04

8/2/

04

8/4/

04

8/6/

04

8/8/

04

8/10

/04

8/12

/04

8/14

/04

8/16

/04

8/18

/04

Purchase rat

Onset of rat illness

Onset of mother’s illness

Onset of daughter’s illnessDeath 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

2

3

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

Nu

mb

er

of

ca

se

s

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 March 2006 Connie Austin and Judy Conway Illinois...

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