Global Infectious Disease Surveillance and Detection Assessing the Challenges–Finding Solutions: Workshop Summary (2007) / Chapter Skim
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1 Surveillance Strategies
1 Surveillance Strategies
Pages 45-106
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From page 45... ...
Today, traditional surveillance practices of disease reporting (by physicians, veterinarians, infection control practitioners, laboratorians, and medical examiners) , followed by epidemiological and laboratory investigation, constitute the mainstay of local infectious disease surveillance where such expensive methods are feasible (mainly in developed countries)
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From page 46... ...
In the event of an apparent or actual public health emergency, New York City's health alert system quickly disseminates information to providers on the nature of the emergency and instructions on preparing and delivering diagnostic specimens. Because New York City is at high risk for receiving imported disease, DOHMH stays attuned to global infectious disease issues via surveillance networks such as ProMED-mail (see Morse in Chapter 2)
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From page 47... ...
He defines and applies a framework for gauging the usefulness of syndromic surveillance in public health practice, then uses it to identify a number of statistical and practical challenges to using such surveillance for detecting bioterrorist events. By contrast, he finds promise in using syndromic surveillance to detect natural disease outbreaks (including seasonal and pandemic influenza)
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From page 48... ...
Infectious diseases of people and animals are drivers of poverty and associated civil unrest, disrupt ‘free' ecosystem services such as drinking water and plant pollination, and can ruin otherwise well-planned and sustainable economic development efforts." In two papers that conclude the chapter, plant pathologists Jacqueline Fletcher of Oklahoma State University and James Stack of Kansas State University define threats (both natural and intentional)
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From page 49... ...
The elaboration of more sophisticated approaches to surveillance has been stimulated by the recognition over the past 30 years of at least 30 "new" emerging infectious diseases. These encompass infections of plants, animals, and human beings.
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From page 50... ...
epidemic. For some of these emerging infections, it was months before an agent was isolated, and thus timely and sensitive public health surveillance and response was syndromic to a great degree.
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From page 51... ...
Although in the United States there is a tendency to associate syndromic surveillance with the specter of bioterrorism, WHO has come to recognize that the protection of global health against emerging infections was poorly served by the last version of the International Health Regulations (IHRs) , which mandated reporting to WHO only three specific diseases: yellow fever, plague, and cholera.
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From page 52... ...
In U.S. military basic training camps, where respiratory syndromes are particularly devastating, for decades there has been well-developed, centrally monitored syndromic surveillance for acute respiratory syndromes (Gray, 2005; Gunzenhauser, 2003)
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From page 53... ...
Reflecting all the elements to be integrated, one might define a surveillance system, as distinct from surveillance, as follows: A system for public health surveillance is a group of integrated and quality assured, cost-effective, and legally and professionally acceptable processes, designed for the purpose of identifying in an ongoing, flexible, standardized, timely, simple, sensitive, and predictive manner the emergence of meaning ful epidemiologic phenomena and their specific associations. These processes include human, laboratory, and informatics activities to skillfully manage infor mation derived from an entire defined community (or a subgroup thereof that is sufficiently representative and large)
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From page 54... ...
As became evident in a geographic analysis, the bulk of military health-care beneficiaries tracked through ESSENCE did not live where many exposures would most likely occur, in the District of Columbia, but rather had homes scattered over a hundred ZIP codes throughout the region. This residence-based misclassification, stemming from the use of "opportunistic data" easily at hand, would have greatly diluted syndromic signals arising from exposures at the workplace.
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From page 55... ...
With the DoD ESSENCE, some of the most impressive syndromic signals have come from basic training outbreaks, where the exposed population lived and worked in the same location. This meant there was no problem with the migration phenomena causing people exposed in one place to be classified geographically in another.
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From page 56... ...
In considering rare but important low-frequency emergences of a new infectious disease, the example of West Nile further illustrates the fact that the questions asked of a surveillance system differ based on the agent and the scenario to be detected. For West Nile encephalitis, tracking infrequent and not highly unique human syndromes across a large general human population may not be the most effective way to achieve the rapid recognition envisioned in the new IHRs.
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From page 57... ...
Another important outbreak scenario to detect is the contaminated water supply. The infamous Milwaukee cryptosporidiosis outbreak caused hundreds of thousands of cases of diarrhea, but its nature was such that recognition of
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From page 58... ...
GLOBAL INFECTIOUS DISEASE SURVEILLANCE AND DETECTION Cases 1-4 199 Persons 5-9 3 Deaths 10-14 26 States 15> FIGURE 1-5 E coli O157:H7 spinach-associated outbreak, 2006.
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From page 59... ...
Perhaps rigorous surveillance of intensive care units (ICUs) for epidemiologically unexpected admissions may be a critical underdeveloped element of syndromic surveillance for problems such as this anthrax episode and outbreaks of problems such as West Nile or SARS.
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From page 60... ...
A comprehensive surveillance system should set its sights on detecting a wide range of scenarios to include trial runs or largely botched low-yield events that may indicate that more effective efforts are in the offing. A recent review of abstracts accepted for presentation at the October 2006 International Disease Surveillance Conference in Baltimore, Maryland, showed that more states than not have started to explore syndromic approaches to disease detection and management.
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From page 61... ...
A system for public health surveillance, which is what needs to be built in the move from academic theory to practice, is built on that data foundation, but it also needs a set of powerful analytic tools and skillful people to use them and interpret the findings. The skill sets of local public health staff to interpret data of this type need expansion.
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From page 62... ...
• Prescriptions • Emergency medical systems (911) • Hospital and intensive care unit surveillance for syndromes • Unexplained deaths • Wild and domesticated animal health SOURCE: Kelley (2006)
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From page 63... ...
Stoto, Ph.D. Georgetown University Heightened awareness of the risks of bioterrorism since 9/11, coupled with a growing concern about naturally emerging and reemerging diseases such as West Nile, severe acute respiratory syndrome (SARS) , and pandemic influenza, have led public health policy makers to realize the need for early warning systems and, more generally, improved surveillance.
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From page 64... ...
Application of this framework to existing systems identifies a number of statistical and practical concerns when syndromic surveillance is used to detect bioterrorist events. The analysis suggests, however, that these systems may be more useful in detecting natural disease outbreaks (including seasonal and pandemic influenza)
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From page 65... ...
Concerns About Syndromic Surveillance in Public Health Practice Despite the generally recognized promise of syndromic surveillance systems, there are many practical concerns about the use of these systems in state and local public health practice. The possibility of earlier detection and more rapid response to a bioterrorist event has tremendous intuitive appeal, but its success depends on local health departments' ability to respond effectively.
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From page 66... ...
Like all alarm systems, syndromic surveillance detection algorithms have intrinsic statistical tradeoffs. The most well known is between sensitivity, the ability to detect an attack when it occurs, and the false-positive rate, the probability of sounding an alarm when in fact there is no attack.
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SURVEILLANCE STRATEGIES A 100% 80% 60% of detection Probability 40% 20% 0% 1 2 3 Day of attack B 60% 40% of detection Probability 20% 0% 1 2 3 4 5 6 7 8 9 Day of attack FIGURE 1-9 Sensitivity of syndromic surveillance (probability of detection by day) for influenza-like illness at a typical urban hospital emergency room using four detection algorithms, as indicated by shading pattern (see text)
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From page 68... ...
The most value, however, may ultimately come from its use in the detection of natural disease outbreaks. More generally, if 21st century syndromic surveillance means effective use of health information technology in identifying cases before they are formally diagnosed, it can supplement traditional public health approaches and improve their effectiveness.
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From page 69... ...
A pandemic, or worldwide outbreak of a new influenza virus, perhaps evolving from the H5N1 avian flu virus circulating in Asia, could dwarf this impact by overwhelming our health and medical capabilities, potentially resulting in hundreds of thousands of deaths, millions of hospitalizations, and hundreds of billions of dollars in direct and indirect costs. Syndromic surveillance systems feature prominently in federal, state, and local plans to prepare the United States for pandemic flu (Homeland Security Council, 2005)
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From page 70... ...
Real-time access to prediagnostic data can also help health authorities respond to public health threats. If person-to-person transmission of avian flu virus is documented in Asia, for example, health departments in Europe and the United States might want to identify and follow up on local cases of people hos
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From page 71... ...
Using syndromic surveillance -- essentially, prediagnostic health information in existing electronic databases -- as these examples suggest requires flexible and easily accessible IT systems, as well as a relationship between data providers and health departments that enables the systems to be used when needed. A benefit of developing these relationships may be improved communications between health-care providers and public health, which is essential to responding to any health emergency.
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From page 72... ...
IMPLICATIONS OF "REAL TIME" VERSUS "BATCH REPORTING" FOR SURVEILLANCE Joseph Lombardo, M.S. The Johns Hopkins University Introduction In the context of disease surveillance, there has been confusion promulgated by vendors of systems on the requirement for "real-time" data feeds. The Institute of Medicine requested the author to present material addressing the subject, "Real Time" Versus "Batched" Reporting for Surveillance.
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From page 73... ...
. Definition The terms "real time" and "batched" for disease surveillance can be used to mean different things by different authors.
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From page 74... ...
Surveillance Context Data Acquisition and Archiving Figure 1-10 presents an example of a generic disease surveillance system. Data acquisition occurs on the left of the figure.
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Messaging System. Most state and local health departments have varying requirements for the timeliness in which data are provided for surveillance.
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From page 76... ...
Typically, a user/analyst views a website once a day, but in the event of an emergent health threat, more frequent or ongoing analysis is possible if data are available. Most modern disease surveillance systems provide outputs to users as soon as the signal processing phase is complete.
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ONE WORLD -- ONE HEALTH: WILDLIFE AND EMERGING DISEASE SURVEILLANCE William B Karesh, D.V.M. Wildlife Conservation Society Outbreaks of avian influenza, severe acute respiratory syndrome (SARS)
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From page 78... ...
Their competitive advantage in this regard demands that we revisit basic strategies for disease control, including the assumptions from the 1950s declaring the chapter on the threat of infectious diseases closed. Not only was this narrow, urban human health point of view premature, but it diverted resources away from preparedness for dealing with the modern-day world of rapid travel and transportation of both goods and people, higher human population densities, and a growing dependence on intensified livestock production.
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From page 79... ...
This has changed since 2005, and a small program was begun in collaboration with the WCS to coordinate responses and investigations of highly pathogenic avian influenza virus in wild birds. The World Organization for Animal Health (OIE)
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From page 80... ...
Infectious diseases of people and animals are drivers of poverty and associated civil unrest, disrupt "free" ecosystem services such as drinking water and plant pollination, and can ruin otherwise well-planned and sustainable economic development efforts. Analyses indicate that more than 60 percent of the over 1,400 infectious diseases currently known to modern medicine are shared between humans and animals (Taylor et al., 2001)
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Surveillance of these wild populations is now needed not only to assess risk for humans and livestock, but for the wild animals themselves. In one swift
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From page 82... ...
In addition to the direct health effects of the pathogens on people and animals, animal-related disease outbreaks have caused hundreds of billions of dollars of economic damage globally, destabilizing trade, and resulting in devastating effects on human livelihoods. According to studies performed by BioEconomic Research Associates, the rash of emerging or reemerging livestock disease outbreaks around the world since the mid-1990s -- including mad cow disease, foot-and-mouth disease, avian influenza, swine fever, and other diseases -- has been estimated to have cost the world's economies more than $100 billion.
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From page 83... ...
The projected growth of industrial livestock production in developing countries to meet rising global protein demand will increase both the economic and the food security impacts of future disease outbreaks, and the global economic impacts do not adequately reflect the local, direct effects. Preventing and controlling infectious diseases in the modern world requires a far broader range of expertise than needed for previously isolated systems in highly developed countries.
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From page 84... ...
government's fight against avian influenza, because wild birds around the world can serve as sentinels for the early detection of the virus's presence. Awareness of and interest in the GAINS program continues to grow.
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From page 85... ...
Named the Wildlife Global Animal Information Network for Surveillance (Wildlife GAINS) , the effort is designed to establish a comprehensive, worldwide wildlife health surveillance system to enhance preparedness for and awareness of emerging infectious diseases.
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From page 86... ...
Finally, global health will not be achieved without a philosophical shift from the "expert dictates" paradigm inherent to both science and medicine, to a broader, multistakeholder approach, based on the understanding that there is only "one world and one health." AGRICULTURAL BIOSECURITY: THREATS AND IMPACTS FOR PLANT PATHOGENS Jacqueline Fletcher, Ph.D.0 Oklahoma State University James P Stack, Ph.D. Kansas State University Plant Vulnerability to Disease Plant resources in the United States, including crops, rangelands, and forests, are vulnerable to endemic, introduced, and emerging pathogens (American Phytopathological Society Public Policy Board, 2002; Casagrande, 2000; Madden and Wheelis, 2003; Wheelis et al., 2002; Whitby, 2002)
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From page 87... ...
combined caused preharvest losses of 42 percent and an additional 10 percent loss after harvest. Of these, 13 percent were due to plant pathogens, 15 percent to arthropods, and 13 percent to weeds.
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From page 88... ...
Rapid action is critical if we are to have these capabilities in place before they are needed for a devastating incident. Impacts of Plant Diseases Past incidences of the impacts of crop diseases on human health and society may be helpful in illustrating the potential damage of plant pathogens.
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From page 89... ...
Deliberate introductions of plant pathogens to crops and other plant resources in the United States could have serious non-nutritional impacts (Budowle et al., 2005a, b; Murch et al., 2003; Fletcher et al., 2006)
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From page 90... ...
The fact that, by definition, plant Select Agents are not indigenous within the United States necessitates the imposition of strict regulations, registrations, restrictions, and security13 on any research or possession of these microbes. Originally consisting of 10 plant pathogens, the recent removal of 2 pathogens (Plum pox virus and Phakopsora pachyrhi�i, the causal agent of soybean rust)
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From page 91... ...
In 2006, USDA APHIS revised its approach to focus on managing the disease. Arrival of Two Plant Pathogen Select Agents Two plant pathogens on the Select Agent list have arrived in the United States in the past two years.
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From page 92... ...
asiaticus will or should be removed from the Select Agent list is complicated by the fact that, although the bacterium may be established in Florida, it is not yet known to occur in citrus-growing regions of Texas, California, and other southern states. Components of a Strong Plant Biosecurity Strategy A robust system of preparedness for threatening exotic or emerging plant diseases will require the following elements:
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From page 93... ...
. The USDA Office of Pest Management Policy, assigned by the Secretary of Agriculture to develop the NPDRS, has worked to develop specific Recovery Plans for each of the Select Agents as well as for several other plant diseases of high consequence.
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From page 94... ...
Recent initiatives in various branches of government, academia, and industry have enhanced the security of our plant resources, but gaps and needs remain. Fortunately, the actions needed to sustain and protect our plant resources from intentional pathogen introduction, and to recover from deliberate plant disease outbreaks, will also enhance the effectiveness and productivity of normal U.S.
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From page 95... ...
A Biosecurity Framework A national strategy for plant biosecurity must be comprehensive with respect to science and policy and must address issues of infrastructure, technology, and 14 Biosecurity Research Institute. 15 National Institute for Microbial Forensics & Food and Agricultural Biosecurity, and Department of Entomology and Plant Pathology.
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From page 96... ...
and Homeland Security (DHS) share responsibility for preventing the introduction of new plant pathogens and insect pests that threaten our plant systems.
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From page 97... ...
Its registry of trained first detectors may serve as a resource for outbreak management. Diagnosis NPDN was established to provide a triage system for the rapid and accurate diagnosis of introduced plant pathogens and insect pests.
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From page 98... ...
Response Response to plant disease outbreaks resulting from new pathogen introductions is a responsibility of USDA APHIS. For most introductions, APHIS provides the leadership for a coordinated response that often includes APHIS-led rapid deployment teams, state departments of agriculture, industry, and in some cases, land grant university diagnostic labs.
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From page 99... ...
The original Select Agent list for plant pathogens included 10 pathogens (see Fletcher and Stack earlier in this chapter)
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From page 100... ...
Animal and Plant Health Inspection Service The authority for regulating high-consequence plant pathogens and insect pests resides within APHIS. Responsibilities include providing emergency response to outbreaks; issuing permits for interstate transport and international importation of pathogens and pests; coordinating national and regional pest surveys; providing training programs; and developing and validating diagnostic protocols.
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From page 101... ...
As has been identified for zoonotic disease surveillance (Dudley, 2004) , a central body with responsibility for plant disease health that would develop a national strategy does not exist.
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From page 102... ...
Emerging Infectious Diseases 12(12)
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From page 103... ...
2006. Plant disease surveillance and detection.
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From page 104... ...
Emerging Infectious Diseases 11(7) :1000-1002, http://www.cdc.gov/ncidod/EID/ vol11no07/pdfs/05-0194.pdf (accessed May 25, 2007)
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From page 105... ...
. Emerging Infectious Diseases 10(12)
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From page 106... ...
Emerging Infectious Diseases 10(1) :117-120, http://www.cdc.gov/ncidod/EID/vol10no1/pdfs/03-0238.pdf (accessed April 26, 2007)
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