5/4/2018. Describe the public health surveillance system for communicable diseases.

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1 John Bos, MPH Assistant Bureau Chief Bureau of Communicable Disease Control and Prevention Missouri Department of Health and Senior Services Describe the public health surveillance system for communicable diseases. Discuss the process for communicable disease case and outbreak investigations. Describe and highlight the critically important role of hospitals and healthcare providers in conducting communicable disease surveillance and investigating outbreaks. Disease Surveillance - Definitions Systematic ongoing collection, collation, and analysis of data and the timely dissemination of information to those who need to know so that action can be taken. - Last, JM. A Dictionary of Epidemiology. 4 th Edition The continuous, systematic collection, analysis and interpretation of health-related data needed for the planning, implementation, and evaluation of public health practice. - World Health Organization 1

2 Objectives of Surveillance Monitor for disease trends. Detect increases in disease incidence. Trigger investigation of etiology and control of disease transmission. Types of Surveillance Systems Active - reports are solicited from reporting sources at established intervals. Passive - reporting sources send in reports of disease at will. Sentinel - key report sources are selected to participate in an enhanced disease surveillance system. Syndromic - focuses on various symptoms or syndromes. Disease Reporting National National Notifiable Disease Surveillance System (NNDSS) - Council of State & Territorial Epidemiologists (CSTE) meets yearly to establish the national list of notifiable diseases. - The CSTE also establishes specific case definitions for each notifiable disease. - CDC adopts and publishes the notifiable disease list and the case definitions. 2

3 Disease Reporting State and Local A list of diseases and conditions that are required to be reported to the local health authority or the Department of Health and Senior Services (19 CSR ).* Reporters include physicians, physician s assistants, nurses, hospitals, clinics, laboratories, schools, summer camps, and others. Laboratories also submit isolates or specimens associated with certain conditions to the Missouri State Public Health Laboratory. * Missouri Code of State Regulations (CSR): 19 CSR Examples of Reportable Diseases in Missouri* Salmonella E. coli O157:H7 Shigella Botulism Hepatitis A N. meningitidis Tularemia Rocky Mountain Spotted Fever Zika BT agents Anthrax Plague Smallpox Outbreaks (including nosocomial) or epidemics of any illness, disease, or condition that may be of public health concern, including * Missouri 19 CSR

4 Immediately Reportable (19 CSR B and 1C) (B) Instances, clusters, or outbreaks of unusual diseases or manifestations of illness and clusters or instances of unexplained deaths which appear to be a result of a terrorist act or the intentional or deliberate release of biological, chemical, radiological, or physical agents, including exposures through food, water, or air. (C) Instances, clusters, or outbreaks of unusual, novel, and/or emerging diseases or findings not otherwise named in this rule, appearing to be naturally occurring, but posing a substantial risk to public health and/or social and economic stability due to their ease of dissemination or transmittal, associated mortality rates, or the need for special public health actions to control. Missouri Reportable Disease Rules* A physician, physician s assistant, nurse, hospital, clinic, or other private or public institution providing diagnostic testing, screening or care to any person with any disease, condition or finding listed in sections (1) (4) of this rule or who is suspected of having any of these diseases, conditions or findings, shall make a case report to the local health authority or the Department of Health and Senior Services, or cause a case report to be made by their designee, within the specified time. * Missouri 19 CSR (6) Missouri Reportable Disease Rules* A case report shall include the patient s name, home address with zip code, date of birth, age, sex, race, home phone number, name of disease, condition or finding diagnosed or suspected, the date of onset of the illness, name and address of the treating facility (if any) and the attending physician, any appropriate laboratory results, name and address of the reporter, treatment information for sexually transmitted diseases, and the date of report. * Missouri 19 CSR (7) 4

5 The Health Insurance Portability and Accountability Act (HIPPA) of 1996 (effective April 14, 2003) Section 262: Nothing in this part shall be construed to invalidate or limit the authority, power, or procedures established under any law providing for the reporting of disease or injury, child abuse, birth, or death, public health surveillance, or public health investigation or intervention. Processing of Disease Reports Investigations are typically conducted by the local public health agencies. Cases of communicable diseases meeting case definition are entered into a disease registry. Case information is de-identified and transmitted to CDC for national compilation. Select morbidity is published weekly in the Morbidity and Mortality Weekly Report (MMWR). Clinical Description: An acute illness characterized by: Generalized, maculopapular rash lasting 3 days; and Temperature 101 F or 38.3 C; and Cough, coryza, or conjunctivitis. Probable: In the absence of a more likely diagnosis, an illness that meets the clinical description with: No epidemiologic linkage to a laboratory-confirmed measles case; and Noncontributory or no measles laboratory testing. Confirmed: An acute febrile rash illness with: Isolation of measles virus from a clinical specimen; or Detection of measles-virus specific nucleic acid from a clinical specimen using polymerase chain reaction; or IgG seroconversion or a significant rise in measles immunoglobulin G antibody using any evaluated and validated method; or A positive serologic test for measles immunoglobulin M antibody ; or Direct epidemiologic linkage to a case confirmed by one of the methods above. Temperature does not need to reach 101 F/38.3 C and rash does not need to last 3 days. Not explained by MMR vaccination during the previous 6-45 days. Not otherwise ruled out by other confirmatory testing or more specific measles testing in a public health laboratory. 5

6 The Surveillance Pyramid Tip of the Iceberg Outbreak - an epidemic limited to localized increase in the incidence of a disease or healthrelated event, e.g. in a town, village, or closed institution.* What is considered an outbreak? Two or more cases from different households of potentially infectious disease of unknown etiology Cases could have similar clinical syndrome with pending/inconclusive/no lab testing * Last, John M. A Dictionary of Epidemiology, 3 rd edition. Public complaints Healthcare professionals Public health surveillance Case investigations 6

7 (PFGE) DNA fingerprinting Epidemiological purposes Cluster detection Outbreak investigation Prevention effectiveness Procedure that determines the order of bases in genome of an organism in one process More detailed and precise that PFGE Compare millions of bases instead of bands Like comparing all the words in a book instead of just the number of chapters. -CDC 1. Determine the existence of the outbreak 2. Confirm the diagnosis 3. Define a case and count cases 4. Orient data to time, place, and person 5. Determine who is at risk of becoming ill 6. Develop a hypothesis about the exposure and test hypothesis with appropriate statistical methods 7. Compare hypothesis with established scientific knowledge 8. Plan a more systematic study 9. Prepare a written report 10. Execute control and prevention measures 7

8 Outbreak investigations may not go in this exact order Several steps may be occurring at once Control and prevention measures may be recommended soon after beginning the investigation Sometimes the cause of the outbreak is thought to be known when the investigation begins Three Legged Stool Irregular and dynamic data sources that vary dramatically in completeness/accuracy Small sample sizes Retrospective - arrive after the fact Hampered collection of specimens Bias created by publicity Reluctance of parties to participate Conflicting pressures: investigation versus intervention 8

9 An observation: anything that can go wrong will go wrong - Merriam-Webster Dictionary outbreaks reported 70 (50%) - Influenza/Influenza-like Illness 34 (24%) - Norovirus/Acute Gastrointestinal Illness 14 (10%) - Enteric pathogens (Escherichia coli, Salmonella, Campylobacter, Shigella, and others) outbreaks reported through April 16, 2018 Predominantly Influenza/Influenza-like Illnesses Image courtesy CDC/ Peggy S. Hayes *To date, April 13,

10 * n=35 for whom information was reported as of April 12, *To date, April 5, 2018 * n=132 for whom information was reported as of April 5,

11 Diagnosis and case finding Reporting Isolate/specimen submission Three Legged Stool Patient Care and Treatment Post-exposure Prophylaxis Meningococcal Disease Hepatitis A Measles Rabies Prevention Messaging Local Public Health Agencies Missouri Department of Health and Senior Services o Bureau of Communicable Disease Control and Surveillance o Bureau of Environmental Health Services o Bureau of Reportable Disease Informatics o State Public Health Laboratory Federal Partners o Centers for Disease Control and Prevention o Food and Drug Administration 11

12 John Bos, MPH Assistant Bureau Chief Bureau of Communicable Disease Control and Prevention Missouri Department of Health and Senior Services 12

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