BioWatch and Public Health Surveillance Evaluating Systems for the Early Detection of Biological Threats: Abbreviated Version (2011) / Chapter Skim
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5 Enhancing Surveillance to Detect and Characterize Infectious Disease Threats
5 Enhancing Surveillance to Detect and Characterize Infectious Disease Threats
Pages 119-154
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From page 119... ...
.1 These analyses share some broad themes. • The nation is facing an increased threat from infectious disease outbreaks, both intentional from terrorists and natural from emerging and re-emerging pathogens.
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With its focus on the BioWatch system and a short timeframe in which to conduct its work, this committee acknowledges the large number of completed and ongoing efforts over the past decade, especially since 2001, to improve infectious disease surveillance and detection of disease outbreaks. In this chapter, the committee describes opportunities it has identified for further enhancing the detection of public health threats, especially threats from biological hazards, including bioterrorism.
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From page 121... ...
LEGALLY MANDATED REPORTING As discussed in Chapter 4, each state has laws requiring health care providers, laboratories, and other entities to report certain diseases and other conditions to local or state public health authorities. Typically, state laws also mandate reporting of unusual clusters of disease or outbreaks, even if the disease in question is not on the list of reportable conditions.
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From page 122... ...
Electronic Laboratory Reporting Systems Electronic reporting of laboratory results to public health officials can improve the timeliness and completeness of information regarding notifiable diseases and other agents of potential concern (Effler et al., 1999; Panackal et al., 2002; Babin et al., 2007)
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From page 123... ...
For this to translate into better public health response, sufficient numbers of skilled public health professionals and high-quality information management systems are needed to quickly assess if reports meet disease case criteria and to implement appropriate case and contact investigations. Notifiable Disease Reporting by Health Care Providers As discussed in Chapter 4, all states mandate that physicians, veterinarians, laboratories, and other health care providers report certain health conditions -- mainly infectious diseases -- to their local or state department of public health, or both.
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While common in hospitals, they are less often present in ambulatory care settings. Strengthening the system of infection control professionals across the health care system could provide an important tool to improve capacity for surveillance and response to bioterrorism or emerging infectious diseases, while simultaneously reducing health care-associated infections.
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From page 125... ...
Ironically, the data systems in place to track mortality in most states use the same technology employed in these earlier centuries -- i.e., paper -- and are therefore slow. Electronic death reporting could improve timeliness of detection of clusters of deaths, identification of cases of infectious disease that should have been reported to public health by the treating physician, and identification of seasonal trends in infectious causes of death (Fallon and Boone, 2004)
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Yet it is vital that these same clinicians promptly recognize index cases that might signify a bioterrorist attack or an emerging outbreak of a dangerous infectious disease. Traditionally, health departments and professional societies have relied on continuing education, posters, and pocket cards to educate health care professionals about the signs and symptoms of an illness caused by bioterrorism agents and other dangerous diseases.
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Unfortunately, the care settings in which this information exchange must occur (hospital EDs, intensive care units, and acute care adult and pediatric wards in hospitals and clinics) often have weak links with health departments, which tend to have more established ties with infectious disease departments.
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Regional Health Information Exchanges In a growing number of communities, information from EMRs, electronic laboratory reporting, hospital and other clinical registration systems, and other electronic health data are securely shared across organizational boundaries in regional health information exchanges (eHealth Initiative, 2008)
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Such use would promote early and effective management of infectious disease outbreaks, improved tracking of chronic disease management, the ability to gather data for research purposes, and the evaluation of health care based on value, by way of comparable price and quality information" (ONC, 2008, pp.
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In theory, the availability and use of validated multiplex point-of-care bioassays at frontline acute and primary care clinical settings would allow clinicians to test patients in response to public health alerts for persistent and seasonal pathogens, as well as bioterrorism agents and other pathogens of potentially great public health significance (e.g., avian influenza, SARS)
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. Collection and Testing of Clinical Specimens The ability and capacity to collect and test clinical specimens as part of public health surveillance systems, either as an ongoing process or in response to possible alerts, needs to be expanded or enhanced.
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As with other tools discussed here, its best use should be an area of cautious implementation and active evaluation. Public health information originates from a variety of sources external to public health agencies, and even within a public health agency surveillance information is often compartmentalized by program (e.g., communicable disease, maternal and child health, environmental health)
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From page 133... ...
It distributes a daily situational awareness report to the CDC director, division directors, and branch chiefs, and to selected external partners regarding infectious disease outbreaks, toxic spills and other accidental exposures, and natural disasters such as earthquakes and hurricanes. BioPHusion receives information about BioSense anomalies and the BioSense news digest.
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From page 134... ...
The original impetus for fusion centers was the threat of terrorism, but most of them also collect, analyze, and disseminate criminal information. State health departments are partners in a number of fusion centers, but these centers are not generally viewed as the locus of situational awareness for public health agencies.
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From page 135... ...
. HSPD-21 also calls for the Secretary of Health and Human Services to establish an Epidemiologic Surveillance Federal Advisory Committee, including representatives of state and local public health and privatesector health care, "to ensure that the federal government is meeting the BOX 5-1 Biosurveillance: A Critical Component of Public Health and Medical Preparedness Homeland Security Presidential Directive 21 Public Health and Medical Preparedness says, in part: The United States must develop a nationwide, robust, and inte grated biosurveillance capability, with connections to international disease surveillance systems, in order to provide early warning and ongoing characterization of disease outbreaks in near real time.
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. Electronic laboratory Information Exchange: strengthening information exchanges between and among clinical and public health laboratories and between laboratories and public health programs for use in investigations.
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. COSTS OF INFECTIOUS DISEASE SURVEILLANCE AND ENHANCEMENTS Part of the charge to the committee was to "assess the costs and benefits of an enhanced national surveillance system that relies on U.S.
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Surveillance and detection of infectious disease threats is part of the second of these services: "Diagnose and investigate health problems and health hazards in the community." While these studies concluded that public health expenditures can be measured reliably and consistently using the essential services framework, they noted a number of serious limitations in this approach, including differences in state and local public health agency organizational structures, variability in the interpretation of terminology, lack
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. of information on public health expenditures by non-public health agencies, and variability in the quality of local health department data.
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This includes ready access to laboratories for routine diagnostic and surveillance needs; ready access to laboratories able to support investigation of public health threats, hazards, and emergencies; licensed and/or credentialed laboratories; and maintenance of guidelines or protocols for handling laboratory samples. To date, the NPSPHP has been used by public health agencies in more than 35 states for self-assessment.
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From page 141... ...
IEc was least successful in obtaining cost estimates for marginal expansion of laboratory testing and diagnostic capabilities; clinical decision support tools and point-of-care diagnostic tools; health alert networks; and fusion centers. In some instances, anticipated costs varied greatly between two different localities' planned implementation of enhancements (e.g., regional health information exchanges in Tarrant County, Texas, and planned by Pennsylvania and Ohio)
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BIOWATCH ANd PuBlIC HEAlTH SuRVEIllANCE BOX 5-3 Pandemic Influenza A (H1N1) : Implications for Enhanced Surveillance On April 21, 2009, the Centers for Disease Control and Prevention (CDC, 2009c)
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3 ENHANCINg SuRVEIllANCE FOR INFECTIOuS dISEASES �aboratory of Hygiene, and virtually all probable cases were later confirmed by additional analysis. The number of probable cases increased daily, includ ing many among Milwaukee school children.
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Enhancing Methods for Surveillance Infectious disease surveillance is a key public health practice, and it is the responsibility of state and local government. One federal role -- aggregation and analysis of surveillance data -- is achieved primarily through mutual agreement and cooperation with the state and local public health agencies and through federal funding incentives.
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Program planning should identify the need for additional evidence regarding effectiveness, identify gaps in the geographic deployment and quality of public health surveillance, identify and evaluate promising methods and technologies, and integrate and harmonize approaches across the many surveillance programs used by CDC and others in the public health community. The focus of this effort should be to improve • notifiable condition reporting by clinicians and laboratories, including automated, electronic reporting methods; • syndromic and other automated health information monitoring; • environmental surveillance; • public health reference laboratory services; • situational awareness based on integration of multiple surveillance and other information streams, including intelligence on terrorism threats; • efficiency, effectiveness, and agility of information management at the state and local levels; • horizontal and vertical information sharing across jurisdictions; • surveillance support for rapid decision making and response; and • methods to compare the utility and cost-effectiveness of surveillance methods.
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A decentralized cooperative infrastructure should also enhance data sharing because the data providers would find it to be useful in carrying out their missions. Accordingly, CDC and the states should focus their efforts on developing and deploying methods for intra- and interstate, cross-jurisdictional integration, sharing, analysis, and display of public health surveillance information.
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The systems should be easily modifiable so they can be updated to reflect evolving knowledge of a bioterrorist attack or infectious disease outbreak
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. At that time, there were plans under the Public Health Improvements Act of 2000 to provide grants to improve basic state and local public health infrastructure and under the Public Health Threats and Emergency Act of 2000 to provide grants for state and local bioterrorism preparedness.
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Key state and local capacities should include the following: • Adequate amounts and types of staff expertise, including infec tious diseases, veterinary health, laboratory science, environmental health, applied epidemiology and biostatistics, and health informatics; • Adequate public health reference laboratory capacity; • Electronic laboratory reporting systems to ensure timely and complete transmission of notifiable disease reports from commercial and hospital-based laboratories to public health; • Universal access to public health reference laboratory services for detecting and confirming biothreats and other emerging infectious diseases and performing molecular typing to link cases in outbreaks; • Robust surveillance and outbreak management information systems; • Electronic death registration systems; • Health alert networks that connect public health departments with all health care facilities and providers in their jurisdictions; and • Integration of public health needs and systems into emerging health information exchanges. For maximum benefit this investment should be directed at developing and maintaining staff expertise, informed decision making, and response capabilities that would serve in both natural and bioterrorism-related disease outbreaks.
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2008b. Potential effects of electronic laboratory reporting on improving timeliness of infectious disease notification -- Florida, 2002–2006.
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Clinical Infectious diseases 32(2)
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2004. Evaluation of reporting timeliness of public health surveillance systems for infectious diseases.
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2002. Automatic electronic laboratory-based reporting of notifiable infectious diseases at a large health system.
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Homeland Security Presidential Directive (HSPD)
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