Public Health Information Network PHIN Series I

1
Public Health Information Network (PHIN) Series
I
2
(No Transcript)
3
Series Overview

• Introduction to
• The history of Epidemiology
• Specialties in the field
• Key terminology, measures, and resources
• Application of Epidemiological methods

4
Series I Sessions
5
Session I V Slides

• VDH will post PHIN series slides on the
  following Web site
• http//www.vdh.virginia.gov/EPR/Training.asp
• NCCPHP Training Web site
• http//www.sph.unc.edu/nccphp/training

6
Site Sign-in Sheet

• Please submit your site sign-in sheet and
• session evaluation forms to
• Suzi Silverstein
• Director, Education and Training
• Emergency Preparedness Response Programs
• FAX (804) 225 - 3888

7
Series ISession IV

• Surveillance

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What to Expect. . .

• Today
• Introduction to the applications, limitations,
  and interpretation of public health surveillance
  data

9
Session Overview

• Introduction to Public Health Surveillance
• Passive, active, and syndromic surveillance
• VA communicable disease law
• Paper-based surveillance of reportable diseases
• Applications and limitations
• Federal Public Health Surveillance
• CDCs role
• Data sources
• Surveillance reporting examples

10
Session Overview (contd.)

• Techniques for Review of Surveillance Data
• Considerations when working with surveillance
  data
• Access data sources for rate numerators and
  denominators
• Descriptive epidemiology
• Graph and map surveillance rates

11
Todays Learning Objectives

• Upon completion of this session, you will
• Recognize the applications and limitations of
  current public health surveillance practices
• Understand the function of three different types
  of surveillance active, passive, and syndromic
• Be familiar with federal public health
  surveillance systems relevant to epidemiology
  programs

12
Todays Learning Objectives

• Understand the reciprocal pathway of data
  exchange through county, state, and federal
  surveillance efforts
• Be familiar with the Virginia paper-based
  surveillance system for reportable diseases
• Recognize the potential benefits of National
  Electronic Disease Surveillance System (NEDSS)
  implementation in Virginia
• Recognize the utility of Epi Info software for
  surveillance data analysis

13
Todays Presenters

• Amy Nelson, PhD, MPH
• Consultant
• NCCPHP
• Lesliann Helmus, MS
• Surveillance Chief
• Division of Surveillance and Investigation
• Office of Epidemiology, Virginia Department of
  Health
• Sarah Pfau, MPH
• Consultant
• NCCPHP

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What is Surveillance?
15
What is Surveillance?

• CDC 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.

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Standardized data collection
County and state health departments and CDC who
analyze data using statistical methods
-Physicians -Laboratories -STD clinics -Community
health clinics
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Standardized data collection
County and state health departments and CDC who
analyze data using statistical methods
-Physicians -Laboratories -STD clinics -Community
health clinics
Dissemination to those who need to know
Dissemination to those who need to know
-Public health officials -Health
directors -Health policy officials
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Standardized data collection
County and state health departments and CDC who
analyze data using statistical methods
-Physicians -Laboratories -STD clinics -Community
health clinics
Dissemination to those who need to know
Dissemination to those who need to know
Change in public health practice (vaccination,
reduction of risk factors, medical intervention,
etc.)
-Public health officials -Health
directors -Health policy officials
Public health planning and intervention
19
Standardized data collection
County and state health departments and CDC who
analyze data using statistical methods
-Physicians -Laboratories -STD clinics -Community
health clinics
Dissemination to those who need to know
Public health evaluation
Dissemination to those who need to know
Change in public health practice (vaccination,
reduction of risk factors, medical intervention,
etc.)
-Public health officials -Health
directors -Health policy officials
Public health planning and intervention
20
NNDSS NETSS

• The National Notifiable Disease Surveillance
  System (NNDSS)
• Disease-specific epidemiologic information
• 60 nationally notifiable infectious diseases
• 10 non-notifiable infectious diseases
• The National Electronic Telecommunications System
  for Surveillance (NETSS)

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Elements of Surveillance

• Mortality reporting legally required
• Morbidity reporting legally required
• Epidemic reporting
• Timely reporting
• Laboratory investigations
• Individual case investigations
• Epidemic field investigations
• Analysis of data

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Types of Surveillance

• Passive
• Active
• Syndromic

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Passive Surveillance

• Laboratories, physicians, or other health care
  providers regularly report cases of disease to
  the local or state health department based on a
  standard case definition of that particular
  disease.

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Communicable Disease ReportingPassive
Surveillance
Physician
Lab
Hospital
Public
CDC
LHD
State
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VA Reportable Diseases
http//www.vdh.state.va.us/epi/list.asp
26
VA Epi-1 Reporting Form for Paper-based
Surveillance
27
VA Communicable Disease Law

• Communicable disease statutes are in Chapter 2
  of Title 32.1 of the Code of Virginia.
• http//www.vdh.state.va.us/epi/appendxb.pdf
• These articles are incorporated into and
  referenced throughout the State Board of Healths
  Regulations for Disease Reporting and Control
• http//www.vdh.state.va.us/epi/regs.pdf

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Active Surveillance

• Local or state health departments initiate the
  collection of specific cases of disease from
  laboratories, physicians, or other health care
  providers.

29
Communicable Disease ReportingActive
Surveillance
Physician
Lab
Hospital
CDC
LHD
State
30
Active Surveillance Applications

• Outbreak investigations
• Other times when complete case ascertainment is
  desired (e.g., research study)

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Question Answer Opportunity
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Syndromic Surveillance

• 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.

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What are indicators of disease?

• Indicators are clinical signs that we can
  categorize into syndromes, but NOT a specific
  diagnosis!
• Example
• Cough Sore throat Fatigue Fever
  Influenza-Like Illness

34
Common Syndromesunder Surveillance

• Gastroenteritis
• Influenza like illness (ILI)
• Meningitis / Encephalitis
• Rash / Fever
• Botulinic
• Hemorrhagic

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Why Do Syndromic Surveillance?

• Early detection of clusters in naturally
  occurring outbreaks or a BT event
• Minimizes mortality morbidity
• Characterize outbreak
• Magnitude, rate of spread, effectiveness of
  control measures
• Quick investigation
• Detection of unexplained deaths

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Syndromic vs. Traditional Surveillance
Phase II Acute Illness
Phase I Initial Symptoms
Traditional Disease Detection
Early Detection
Gain of 2 days
Effective Treatment Period
Source Johns Hopkins University / DoD Global
Emerging Infections System
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Limitations of Syndromic Surveillance

• Inadequate specificity false alarms
• Uses resources in investigation
• Inadequate sensitivity failure to detect
  outbreaks/BT events
• Outbreak is too small
• Population disperses after exposure, cluster not
  evident

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Limitations of Syndromic Surveillance

• Costly
• Staff expertise required
• Formal evaluation of syndromic surveillance
  systems are incomplete

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Surveillance Applications
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Applications

• Establish Public Health Priorities
• Aid in determining resource allocation
• Assess public health programs
• Facilitate research
• Determine baseline for detection of epidemics
• Early detection of epidemics
• Estimate magnitude of the problem
• Determine geographical distribution

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Establish Public Health Priorities

• Frequency (incidence / prevalence, mortality,
  years of life lost)
• Severity (case fatality rate, hospitalization,
  disability)
• Cost (direct, indirect)

42
Resource Allocation
TUBERCULOSIS Reported cases per 100,000
population, United States and U.S. territories,
2002
Source http//www.cdc.gov/dphsi/annsum/index.htm

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Assess Public HealthPrograms
Gonorrhea reported cases per 100,000
population, United States, 1987 - 2002
Data Graphed by Race and Ethnicity
Data Graphed by Gender
Source http//www.cdc.gov/dphsi/annsum/index.htm
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Determine Baseline Rates
TUBERCULOSIS among U.S.-born and foreign-born
persons, by year, United States, 1990-2002
For 120 cases, origin of patients was unknown.
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Early Detection of Epidemics
Boston, MA
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Surveillance Limitations
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Limitations

• Uneven application of information technology
• Paper-based versus Electronic
• Timeliness
• Reporting time requirement
• Reporting burden
• Completeness
• Unreported cases
• Incomplete reports

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Limitations Multiple Categorical Systems
Current Situation
MMWR Annual Summaries
Program Specific Reports and Summaries
MMWR Weekly Tables
Statistical Surveys for Chronic Diseases,
Injuries and Other Public Health Problems
HARS
STDMIS
TIMS
NNDSS
EIP Systems
PHLIS
CDC
Varied communications methods and security -
specific to each system - including diskettes,
e-mail, direct modem lines, etc.
Reporting by Paper Form, Telephone Fax
Data Sources
State Health Dept
EIP Systems
HARS
STDMIS
TIMS
NETSS
PHLIS
Physicians
Varied communications methods and security -
specific to each system- including paper forms,
diskettes, e-mail, direct modem lines, etc.
Chart Review
Lab Reports
TIMS
STDMIS
HARS
NETSS
PHLIS
EIP Systems
EIP Systems (ABC, UD, Foodnet)
City/County Health Department
STDMIS (Optional at the Clinic)
TIMS (Optional at the Clinic)
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National Electronic Disease Surveillance System
(NEDSS)

• NEDSS is not a surveillance system
• Electronically integrate existing surveillance
  systems for easy data collection, storage and
  access
• Security to meet confidentiality needs

50
Guest LecturerVirginias Surveillance
Practices and Challenges

• Lesliann Helmus, MS
• Surveillance Chief
• Division of Surveillance and Investigation
• Office of Epidemiology, VDH

51
Overview

• Challenges in conducting surveillance
• NEDSS tool to improve surveillance
• Application Hepatitis A example

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Surveillance Challengesin Virginia

• Quality of the data
• Balancing priorities
• Discrepancies and perspectives
• Translating data into information

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Quality of the data

• The Government is very keen on amassing
  statistics. They collect them, add them, raise
  them to the nth power take the cube root and
  prepare wonderful diagrams. But you must never
  forget that everyone of these figures comes in
  the first instance from the village watchman who
  puts down what he damn well pleases.
• Sir Josiah Stamp (1896-1919) - Head of the
  Inland Revenue Department of the UK

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Quality of the Data

• Completeness of case ascertainment
• Completeness and accuracy of case information
• Timeliness of reports
• Sentinel indicators

Tip of the iceberg
55
Flow of Reports in Virginia
Reporter
Central Office
District
Regional Office
District
Central Office
CDC
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Quality of the Data

• Completeness of case ascertainment
• Completeness and accuracy of case information
• Timeliness of reports
• Sentinel indicators

Tip of the iceberg
57
Balancing Priorities
Numbers may be inflated due to duplicates
58
Discrepancies and Perspectives

• Clinical vs surveillance case definitions
• Cases worked vs cases counted
• Place of exposure, residence, diagnosis
• Re-infection or duplicate report
• Stats by date of onset, diagnosis, report

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Translating Data into Information

• Provides the basis for public health action
• Requires sound analysis and interpretation
• Extracts meaningful, actionable findings
• Requires clear presentation of complex issues

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NEDSS

• A Tool to Improve Surveillance

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National Electronic Disease Surveillance System

• Centralized data system for disease surveillance
  in Virginia
• Person based system links health events
• Accessed through the VDH network
• Ensures data confidentiality and integrity
• Supports electronic data submissions
• Will modify processes for managing reports

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Benefits from NEDSS

• Faster recognition of health problems
• Electronic transmission from large facilities
  (provides better data, faster)
• Simultaneous district/region/central office
  access to the data

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Benefits from NEDSS

• Greater consistency in data interpretation
• Shared case status (cases definitions)
• Shared dates
• As needed guidance and coaching
• Shared updates
• Shared reports

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Benefits from NEDSS

• Shift in effort
• Cases entered once
• Trail for chronic cases
• Processing of electronic transmissions
• Ability to monitor reporters activity

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Benefits from NEDSS

• Bigger picture
• Earlier look at data across jurisdictions
• Identification of people with co-infections
• More effective analysis across diseases

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Benefits from NEDSS

• Shared tools
• High level tools with low level maintenance for
  users
• Shared expertise

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Surveillance Application Example

• Hepatitis A

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Example Hepatitis A
Source Virginia Disease Control Manual
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Reporting

• Initial report
• Phone call 24/7 availability of Health Dept
• Would trigger follow-up with case
• Follow-up documentation
• Clinical (morbidity) report
• Laboratory report

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Enter Information into NEDSS
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Key Information from Provider
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Laboratory Report Information
73
Patient InterviewRisk Information
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Look for Bigger Picture

• Sporadic case ?
• Part of ongoing outbreak ?
• Beginning of new outbreak ?
• Day care age?
• Subgroup?
• General community?

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Surveillance Data AnalysisLine Lists
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Surveillance Data AnalysisCross-tabs
Hepatitis A Cases Reported in the Past Week
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Surveillance Data AnalysisTime Trends
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Confirm Case Submit Notification
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Statewide Review and Analysis

• Monthly data
• http//www.vdh.state.va.us/epi/Data/month04.as
  p
• Annual Data
• http//www.vdh.state.va.us/epi/Data/annual02.a
  sp
• Virginia Epidemiology Bulletin
• http//www.vdh.state.va.us/epi/bulletin.asp
• See Your District Epidemiologist

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Question AnswerOpportunity
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5 minute break
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Federal Public Health Surveillance
83
CDCs Role in Surveillance

• Support the states
• Provide training and consultation in public
  health surveillance
• Distribute and oversee funding
• Receive, collate, analyze, and report data
• Suggest changes to be considered in public health
  surveillance activities
• Report to the World Health Organization as
  required and appropriate

84
CDC Surveillance Data Reporting
TABLE II. Provisional cases of selected
notifiable diseases, United States, weeks ending
June 5, 2004, and May 31, 2003 (22nd week)
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(No Transcript)
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Federal Data Sources

• Over 100 federal surveillance systems
• Collect data on over 200 infectious and
  non-infectious conditions such as
• Active Bacterial Core Surveillance (ABCs)
• Foodborne Diseases Active Surveillance Network
  (FoodNet)
• National West Nile Virus Surveillance System
  (ArboNet)
• Viral Hepatitis Surveillance Program (VHSP)
• Waterborne-Disease Outbreak Surveillance System
• Influenza Sentinel Physicians Surveillance
  Network

87
Federal Surveillance Resources

• CDC Morbidity and Mortality Weekly Report (MMWR)
• http//www.cdc.gov/mmwr
• CDC Office of Surveillance http//www.cdc.gov/ncid
  od/osr/index.htm

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Council of State and Territorial Epidemiologists
(CSTE)http//www.cste.org

• Collaborates with CDC to recommend changes in
  surveillance, including what should be reported /
  published in MMWR
• Develops case definitions
• Develops reporting procedures

89
Example ArboNet

• ArboNet is a cooperative surveillance system
  maintained by CDC and 57 state and local health
  departments for detecting and reporting the
  occurrence of domestic arboviruses.

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ArboNet - Data

• Human
• Encephalitis, meningitis, fever, viremic blood
  donors, other
• Dead bird
• Equine
• Mosquito
• Sentinel animals (chicken, pigeon, horse)
• Other non-human mammals

91
ArboNet Surveillance Issues

• Real-time reporting
• Novel occurrence of West Nile virus
• Web-based reporting (states)
• Still relies on paper-based reporting (local)
• Incorporates ecologic data
• NEDSS compatible
• Duplicity of human case reporting

92
ArboNet - Diseases

• West Nile virus
• St. Louis Encephalitis virus
• Eastern Equine Encephalitis virus
• Western Equine Encephalitis virus
• California serogroup viruses (i.e., La Crosse)
• Powassan Encephalitis virus
• Japanese Encephalitis virus
• Dengue virus

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What is West Nile Virus?

• Transmitted to humans via bites from infected
  mosquitoes
• Infection usually asymptomatic some people have
  fever, headache, rash, swollen lymph glands.
• No infections documented in the Western
  Hemisphere until 1999 then 46 U.S. states
  reported WNV activity in 2003!

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Virginia Arboviruses

• VA Department of Health
• http//www.vdh.virginia.gov/whc/external_whc/westn
  ilevirus.asp
• VA Arbovirus Surveillance and Response Plan
• http//www.vdh.virginia.gov/whc/external_whc/Avian
  plan2004.asp
• State Laboratory of Public Health (VA Department
  of General Services)
• VA Department of Agriculture and Consumer
  Services
• Local Department of Agriculture Veterinary
  Laboratories
• VA Department of Game and Inland Fisheries
• U.S. Army Center for Health Promotion and
  Preventive Medicine

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Cumulative Dead Bird West Nile Virus Infections
2004
http//westnilemaps.usgs.gov/
96
Cumulative Human West Nile Virus Cases 2004
http//westnilemaps.usgs.gov/
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Cumulative Human West Nile Virus Cases 2004
http//westnilemaps.usgs.gov
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Video ClipPublic Health Grand Rounds

• Preparing for West Nile Virus Will Your
  Community be Next? (May 2001).
  GrandRounds_at_sph.unc.edu
• Notice
• Surveillance lessons learned by public health
  officials
• How the manifestation of the virus makes it easy
  to involve the general public in surveillance
  efforts
• How quickly West Nile Virus has spread across the
  U.S. in only a few years

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Example Influenza
100
U.S. Influenza Surveillance

• World Health Organization (WHO) and National
  Respiratory and Enteric Virus Surveillance System
  (NREVSS) collaborating laboratories
• State and Territorial Epidemiologists Reports
• 122 Cities Mortality Reporting System
• U.S. Influenza Sentinel Providers Surveillance
  Network (voluntary)

101
U.S. Influenza Surveillance

• Does. . .
• Find out when and where influenza is circulating
• Determine what type of influenza viruses are
  circulating
• Detect changes in the influenza viruses
• Track influenza-related illness
• Measure the impact influenza is having on deaths
  in the United States

• Does Not. . .
• Ascertain how many people have become ill with
  influenza during the influenza season

102
Influenza-like IllnessCase Definition

• The Influenza-Like Illness case definition for
  CDCs surveillance system is
• Fever of 100 degrees Fahrenheit or higher
• 2. AND cough OR sore throat.

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CDC Sentinel Influenza Surveillance
http//www.cdc.gov/flu/weekly/
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CDC Sentinel Influenza Surveillance
http//www.cdc.gov/flu/weekly/
105
VA Influenza Surveillance

• Goal . . .to detect outbreaks of influenza as
  early and quickly as possible in order to
  facilitate early public health intervention and
  to specify the organisms involved.
• Passive surveillance
• Laboratory surveillance
• Active sentinel component

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Virginia Active Sentinel Surveillance

• Virginia Department of Health conducts active
  surveillance with physicians around the state
• Season is October - April
• 60 70 physicians represent medical practices in
  each of the states five health planning regions
• Primarily family practice or internal medicine

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VA Influenza-like Illness Surveillance Activity
http//www.vdh.state.va.us/epi/flu.htm
108
Access VA and CDC Reports

• Reports of Influenza Activity in the
• Virginia Surveillance Program
• http//www.vdh.state.va.us/epi/flu.htm
• CDC reports and charts containing national and
  regional data
• www.cdc.gov/ncidod/diseases/flu/weekly.htm

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Question AnswerOpportunity
110
5 minute break
111
Guest Lecturer Techniques for Analysis
ofSurveillance Data

• Sarah Pfau, MPH
• Consultant, NCCPHP

112
Overview

• Considerations when working with surveillance
  data
• Descriptive Epidemiology
• Access surveillance data in Microsoft Excel or
  Access formats
• Access online census data
• Analyze surveillance data

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Considerations

• Surveillance data primarily yield descriptive
  statistics
• Know the inherent strengths and weaknesses of a
  data set
• Examine data from the broadest to narrowest

114
Rely on Computers to

• Generate Simple, Descriptive Statistics
• Tables frequencies, proportions, rates
• Graphs bar, line, pie
• Maps census tracts counties districts
• Aggregate or Stratify Rates
• State versus county
• Multiple weeks or months or years
• Entire population versus age, gender, or race
  specific

115
Rely on Public Health Professionals to

• Contact health care providers and laboratories to
  obtain missing data
• Interpret laboratory tests
• Make judgments about epidemiological linkages
• Identify or correct mistakes in data entry and
• Determine if epidemics are in progress.

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Surveillance Data

• Descriptive Epidemiology

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Person, Place, and Time

• Person What are the patterns of a disease among
  different populations?
• Place What are the patterns of a disease in
  different geographic locations?
• Time What are the patterns of a disease when
  compared at different times (e.g., by month,
  year, decade) ?

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Tuberculosis Cases United States 1992 - 2002
Source http//www.cdc.gov/epo/dphsi/annsum/2002/
02graphs.htm
119
Raw Numbers versus Rates
120
Ratio

• A ratio is any fraction obtained by dividing
  one quantity by another the numerator and
  denominator are distinct quantities, and neither
  is a subset of the other.
• - Teutsch and Churchill (1994).
• Rates, Proportions, and Percentages are all some
  form of a Ratio.

121
What Do Rates Do?

• Measures the frequency of an event over a period
  of time
• Includes a numerator (e.g., disease frequency for
  a period of time) and a denominator (e.g.,
  population)

122
Why Use Rates?
Rates provide frequency measures within the
context of the population.
123
Crude versus Specific Rates

• Crude Rate Rate calculated for the total
  population
• Specific Rate Rate calculated for a sub-set of
  the population (e.g., race, gender, age)

124
Rate NumeratorVA Reportable Disease
Surveillance Data

• Office of Epidemiology,
• Virginia Department of Health
• http//www.vdh.state.va.us/epi/survdata.asp
• Call (804) 864 8141
• Email epi-comments_at_vdh.state.va.us

125
Rate DenominatorU.S. Census Data

• http//www.census.gov
• Click on the State County Quick Facts
  hyperlink
• Choose VA in the dropdown menu and click on GO
• Click on the Browse Data Sets for Virginia
  hyperlink at the top of the Quick Facts data
  table
• Click on the Virginia Counties hyperlink for
  Population by Race and Hispanic or Latino
  Origin
• Open a new, blank file in Microsoft Excel
• Highlight table cells on the Census web page,
  click CTRL C to copy data, then paste into the
  same number of cells in the Excel spreadsheet
• Name / save the Excel file in the Epi2000 folder
  on your c\ drive

126
Import Data from Microsoft Excel or Access into
Epi Info
127
Read / Import Command

128
Read / Import Dialogue Window
Import files from alternative Software programs
129
Import Restrictions forMicrosoft Excel Files

• There can be no spaces in either the Excel file
  name or the column and row header cells, or sheet
  names within an Excel file. You can, however,
  have spaces in other file names in the directory
  path.
•  
• These three components of an Excel file cannot
  contain characters (e.g., , _at_, !)
•  
• The Excel file cannot contain any duplicate
  field names.
• The Excel file must be saved in the path
  c\Epi2000 folder NOT the c\Epi_Info folder
  that tends to operate as the default folder for
  Epi Info files.

130
Import Restrictions forMicrosoft Access Files

• There can be no spaces in either the file name
  or the table or form names within an Access file.
  You can, however, have spaces in other file
  names in the directory path.
•  
• These file components cannot contain characters
  (e.g., , _at_, !)
• The Access file must be saved in the path
  c\Epi2000 OR c\Epi_Info folder.

131
Online Epi Info Training

• Importing and Exporting Data Tables
• http//www.sph.unc.edu/nccphp/training/all_trainin
  gs/at_epi_info.htm

132
Analyze Surveillance Data
133
Sample Analyses

• Time trend graph of NC data over ten years, by
  year for Salmonella cases
• Raw data
• Rates
• Maps of Salmonella rates by county 2000
• Raw Data versus Rates
• Choropleth

134
Graph Surveillance Data
135
Line Graph Raw Data
136
Line Graph Rate Data
137
Archived U.S. Census Population Estimates

• http//www.census.gov/popest/archives/1990s/
• National
• State
• County
• Estimates present and past
• Projections future

138
Line Graph
Rates
Raw Data
139
Generating a Line GraphConsiderations

• Use an x-axis scale to show a trend over time
• Select an interval size that contains enough
  detail for the purpose of the graph
• Label x- and y-axes

140
Map Surveillance Data
141
Epi Map Instruction

• Generating Maps
• http//www.sph.unc.edu/nccphp/training/all_trainin
  gs/at_epi_info.htm

142
Raw Data Map
North Carolina Salmonella Cases by County 2002
Data source NC Communicable Disease Data by
county for 2000, General Communicable Disease
Control Branch, Epidemiology Section, Division
of Public Health
143
Choropleth Map
North Carolina Salmonella Cases by County 2002
Data source NC Communicable Disease Data by
county for 2000, General Communicable Disease
Control Branch, Epidemiology Section, Division
of Public Health
144
Choropleth Map
North Carolina Salmonella Rates by County 2002
Rate numerators NC Communicable Disease Data
for 2000
Rate denominators U.S. Census population data,
by county, for 2000
145
Raw Data
Rates
146
Data InterpretationConsiderations

• Underreporting
• Inconsistent Case Definitions
• Has reporting protocol changed?
• Has the case definition changed?
• Have new providers or geographic regions entered
  the surveillance system?
• Has a new intervention (e.g., screening or
  vaccine) been introduced?

147
Online Surveillance Trainings

• NC Center for Public Health Preparedness
• http//www.sph.unc.edu/nccphp/training/training_l
  ist/t_surv.htm
• Direct link to 13 surveillance trainings

148
Question AnswerOpportunity
149
Session Summary

• Surveillance is 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.
• There are three broad forms of surveillance
  passive, active, and syndromic. Passive and
  active differ primarily in the way in which data
  are reported to local health departments from
  health care providers, but both document
  confirmed cases. Syndromic surveillance involves
  collecting and analyzing real-time indicators for
  disease in an effort to identify an outbreak
  earlier than a traditional surveillance system
  will however, cases are not confirmed via one
  standardized, case definition.

150
Session Summary

• Surveillance data have many applications,
  including establishing public health priorities
  aiding in determining resource allocation
  assessing public health programs determining
  baseline rates for detection of epidemics and
  early detection of epidemics.
• The uneven application or availability of
  technologies, combined with the reporting burden
  and decentralized system of paper-based
  reporting, are inherent limitations of
  surveillance. Furthermore, electronic and
  paper-based reporting are only reliable when
  reporting practices are standardized and public
  health professionals and practitioners are
  trained in surveillance protocol and public
  health laws.

151
Session Summary

• Federal and state or local surveillance go
  hand-in-hand they are the result of a
  collaborative, reciprocal pathway for data
  collection and reporting.
• When analyzing and interpreting surveillance
  data, it is advisable to graph rates versus raw
  data. It is also advisable to investigate broad,
  total population rates prior to evaluating
  specific rates for population strata such as race
  or gender.

152
Session IV Slides

• Following this program, please visit the Web
  site below to access and download a copy of
  todays slides if you have not already done so
• http//www.vdh.virginia.gov/EPR/Training.asp

153
Dont Forget!

• Please submit your site sign-in sheet and session
  evaluation forms to
• Suzi Silverstein
• Director, Education and Training
• Emergency Preparedness Response Programs
• FAX (804) 225 - 3888

154
Next Session May 5th

• Final Session in this 5-part Series
• Epidemiology Specialties Applied
• Disaster
• Environmental
• Forensic

155
References and Resources

• Bonetti, M. et al (August 2003). Syndromic
  Surveillance PowerPoint Presentation. Harvard
  Center for Public Health Preparedness.
• CDC case definitions
• http//www.cdc.gov/epo/dphsi/casedef/case_definiti
  ons.htm
• CDC infectious disease surveillance systems
• http//www.cdc.gov/ncidod/osr/site/surv_resources/
  surv_sys.htm
• CDC Integrated project National electronic
  diseases surveillance system
• http//www.cdc.gov/od/hissb/act_int.htm

156
References and Resources

• CDC nationally notifiable infectious diseases
  http//www.cdc.gov/epo/dphsi/phs/infdis2004.htm
• CDC Notifiable diseases/deaths in selected cities
  weekly information. MMWR. June 4, 2004/53(21)
  460-468 http//www.cdc.gov/mmwr/preview/mmwrhtml/m
  m5321md.htm.
• CDC Division of Public Health Surveillance and
  Informatics, Epidemiology Program Office
• http//www.cdc.gov/epo/dphsi
• General Communicable Disease Control Branch,
  Epidemiology Section, Division of Public Health,
  NC Department of Health and Human Services.
  Reportable Communicable Diseases North
  Carolina.

157
References and Resources

• Klein, R. and Schoenborn, C. (January 2001). Age
  Adjustment Using the 2000 Projected U.S.
  Population. Healthy People 2010 Statistical
  Notes No. 20. National Center for Health
  Statistics, Centers for Disease Control and
  Prevention.
• Last, J.M. (1988). A Dictionary of Epidemiology,
  Second Edition. New York Oxford University
  Press.
• Teutsch, S. and Churchill, R. (1994). Principles
  and Practice of Public Health Surveillance. New
  York Oxford University Press.
• U.S. Department of the Interior, U.S. Geological
  Survey (January 19, 2005). http//westnilemaps.us
  gs.gov/background.html
• Virginia Department of Health Web site
  http//www.vdh.state.va.us

158
References and Resources

• NC Center for Public Health Preparedness
  Surveillance Trainings
• http//www.sph.unc.edu/nccphp/training/training_l
  ist/t_surv.htm
• Surveillance
• Utilizing Infectious Disease Surveillance
  Data
• Acute Disease Surveillance and Outbreak
  Investigation
• Syndromic Surveillance in North Carolina,
  2003
• North Carolina Communicable Disease Law
• Introduction to Surveillance
• Communicable Disease Surveillance in North
  Carolina