Nov 9 Surveillance PHTIN

2004 Public Health Training and Information Network (PHTIN) Series: 

2004 Public Health Training and Information Network (PHTIN) Series

Site Sign-in Sheet: 

Site Sign-in Sheet Please mail or fax your site’s sign-in sheet to: Linda White NC Office of Public Health Preparedness and Response Cooper Building 1902 Mail Service Center Raleigh, NC 27699 FAX: (919) 715 – 2246

Techniques for Review of Surveillance Data: 

Techniques for Review of Surveillance Data

2004 PHTIN Training Development Team: 

2004 PHTIN Training Development Team Pia MacDonald, PhD, MPH - Director, NCCPHP Jennifer Horney, MPH - Director, Training and Education, NCCPHP Anjum Hajat, MPH – Epidemiologist, NCCPHP Penny Padgett, PhD, MPH – Epidemiologist Amy Nelson, PhD - Consultant Sarah Pfau, MPH - Consultant Amy Sayle, PhD, MPH - Consultant Michelle Torok, MPH - Doctoral student Drew Voetsch, MPH - Doctoral Candidate Aaron Wendelboe, MSPH - Doctoral student

Next PHTIN Session: 

Next PHTIN Session December 14th. . . “Risk Communication” 10:00 am - 12:00 pm (with time for discussion)

Downloading Session Slides: 

Downloading Session Slides After the airing of this session, NCCPHP will post the complete set of slides and lecture notes on the following two web sites: NCCPHP Training web site: http://www.sph.unc.edu/nccphp/phtin/index.htm North Carolina Division of Public Health, Office of Public Health Preparedness and Response http://www.epi.state.nc.us/epi/phpr/

Today’s Presenters: 

Today’s Presenters Aaron Kipp Graduate Research Assistant and Doctoral Student, NCCPHP Michelle Torok, MPH Graduate Research Assistant and Doctoral Student, NCCPHP Jennifer MacFarquhar, RN, BSN, CIC, CCPDM Public Health Epidemiologist, Coordinator, UNC Statewide Program for Infection Control and Epidemiology Sarah Pfau, MPH Consultant, NCCPHP

Session Learning Objectives: 

Session 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

Session Learning Objectives: 

Session Learning Objectives Understand the reciprocal pathway of data exchange through county, state, and federal surveillance efforts Be familiar with the North Carolina paper-based surveillance system for reportable diseases Know how to import surveillance database files into Epi Info software Know how to graph surveillance rates in Epi Info software

Techniques for Review ofSurveillance Data: 

Techniques for Review of Surveillance Data Overview

Session Overview: 

Session Overview Introduction to Public Health Surveillance Passive, active, and syndromic surveillance NC communicable disease law Paper-based surveillance of reportable diseases Applications and limitations Federal Public Health Surveillance CDC’s role Data sources Surveillance reporting examples (ArboNet, Influenza Sentinel Surveillance)

Session Overview (cont’d.): 

Session Overview (cont’d.) 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

What is Surveillance?: 

What is Surveillance?

What is Surveillance?: 

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.

Slide16: 

-Physicians -Laboratories -STD clinics -Community health clinics County and state health departments and CDC who analyze data using statistical methods Standardized data collection

Slide17: 

-Physicians -Laboratories -STD clinics -Community health clinics County and state health departments and CDC who analyze data using statistical methods -Public health officials -Health directors -Health policy officials Standardized data collection Dissemination to those who need to know Dissemination to those who need to know

Slide18: 

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

Slide19: 

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

NNDSS & NETSS: 

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)

Elements of Surveillance: 

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

Types of Surveillance: 

Types of Surveillance Passive Active Syndromic

Passive Surveillance: 

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.

Communicable Disease Reporting:Passive Surveillance: 

Communicable Disease Reporting: Passive Surveillance Hospital Physician Lab LHD State CDC Public

NC Communicable Disease Law: 

NC Communicable Disease Law Communicable disease statutes are in Article 6 of Chapter 130A of the NC General Statutes (GS 130A) http://www.ncleg.net/Statutes/GeneralStatutes/PDF/ByArticle/Chapter_130A/Article_6.pdf Communicable diseases rules are in Title 10A, Chapter 41, Subchapter 41A of the NC Administrative Code (10A NCAC 41A). http://www.epi.state.nc.us/epi/gcdc/pdf/10ANCAC41A.pdf

NC Reportable Diseases: 

NC Reportable Diseases

NC Communicable Disease Law: 

NC Communicable Disease Law Case records are not public records and are to be treated confidentially. Exceptions: Release of data for use in aggregate statistics When disclosure is necessary for control of a disease representing a significant public health hazard* When information is collected by a person other than a physician or nurse, it may not be protected * Details in 10A NCAC 41A.0211

Slide28: 

North Carolina Communicable Disease Report Card

Active Surveillance: 

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

Communicable Disease Reporting:Active Surveillance: 

Communicable Disease Reporting: Active Surveillance Hospital Physician Lab LHD State CDC

Active Surveillance: 

Time consuming Phone calls Medical records Outbreak investigation Other times when complete case ascertainment is desired Complete and timely data Active Surveillance

Question & Answer Opportunity: 

Question & Answer Opportunity

Syndromic Surveillance: 

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.

What are indicators of disease?: 

What are indicators of disease? “Indicators” are clinical signs that we can categorize into syndromes, but NOT a specific diagnosis! Example: Cough + Runny nose + Sore throat + Fatigue + Fever = Influenza-Like Illness

Common Syndromesunder Surveillance: 

Common Syndromes under Surveillance Gastroenteritis Influenza like illness (ILI) Meningitis / Encephalitis Rash / Fever Botulinic Hemorrhagic

Why do Syndromic Surveillance?: 

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

Syndromic vs. Traditional Surveillance: 

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

Limitations of Syndromic Surveillance: 

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

Limitations of Syndromic Surveillance: 

Limitations of Syndromic Surveillance Costly Staff expertise required Formal evaluation of syndromic surveillance systems are incomplete

North Carolina’s System: 

North Carolina’s System NC syndromic surveillance system is called NC BEIPS Component of the Public Health Information Network (PHIN) A system that will be composed of several data streams important to BT surveillance

Mecklenburg County  MOST Surveillance System: 

Mecklenburg County MOST Surveillance System Medical Online Surveillance Tool 7 Hospital Emergency Departments 8 Urgent Care Centers 188 Public Schools Carolinas Poison Center – 100 counties statewide 14 Child Day Care Centers http://www.ncmost.org Lorraine Houser (704) 336 - 6438

Surveillance Applications: 

Surveillance Applications

Applications: 

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

Establish Public Health Priorities:: 

Establish Public Health Priorities: Frequency (incidence / prevalence, mortality, years of life lost) Severity (case fatality rate, hospitalization, disability) Cost (direct, indirect)

Resource Allocation: 

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

Assessing Public HealthPrograms: 

Assessing Public Health Programs Data Graphed by Race and Ethnicity Gonorrhea: reported cases per 100,000 population, United States, 1987 - 2002 Source: http://www.cdc.gov/dphsi/annsum/index.htm Data Graphed by Gender

Slide48: 

*For 120 cases, origin of patients was unknown. TUBERCULOSIS among U.S.-born and foreign-born persons, by year, United States, 1990-2002 Determine Baseline Rates

Early Detection of Epidemics: 

Early Detection of Epidemics Boston, MA

Surveillance Limitations: 

Surveillance Limitations

Limitations: 

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

Slide52: 

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

National Electronic Disease Surveillance System (NEDSS): 

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

Guest Lecturer:Michelle Torok, MPH: 

Guest Lecturer: Michelle Torok, MPH Surveys of Diagnosis,Testing and Reporting Practices among Health Care Practitioners, Infection Control Practitioners and Laboratorians

Slide55: 

Surveys of Diagnosis,Testing and Reporting Practices among Health Care Practitioners, Infection Control Practitioners and Laboratorians NC Center for Public Health Preparedness

3 Populations Surveyed: 

3 Populations Surveyed Infection control practitioners in western NC 52.4% response rate Physicians, nurse practitioners, and physician assistants in western NC 18.3% response rate Clinical microbiology labs in ALL of NC 44% response rate

Understanding Reporting Practices: 

Understanding Reporting Practices All 3 surveys asked the following question: “Please indicate who is legally responsible (if anyone) for reporting the following diseases to the NC Division of Public Health”: Campylobacter infection E. Coli infection Listeriosis Salmonellosis Shigellosis Vibrio infection Yersinia infection Response options: Clinician Laboratorian Don’t Know Not Reportable

Legal Reporting Responsibility: Health Care Practitioners (n=370): 

Legal Reporting Responsibility: Health Care Practitioners (n=370)

Percent of Health Care Practitioners Indicating Disease “Not Reportable”: 

Percent of Health Care Practitioners Indicating Disease “Not Reportable” *Shiga toxin-producing infection

Actual Reporting Practices: 

Actual Reporting Practices All 3 surveys asked the following question: “Who completes the Communicable Disease (CD) report card in your office or hospital?” Response options: Physicians Laboratorians Infection Control Practitioner

Slide61: 

Who Completes the CD Report Card? Health Care Practitioners (N = 368)

Slide62: 

Who Completes the CD Report Card? Infection Control Practitioners (n=11)

Slide63: 

Who Completes the CD Report Card? Laboratorians (n=42)

Study Conclusions: 

Study Conclusions Improving providers’ understanding of and compliance with the surveillance system will improve quality and completeness of our data. Burden of reporting is one well-known barrier NEDSS may improve provider reporting

Guest Lecturer:Hospital Based Surveillance in North Carolina: 

Guest Lecturer: Hospital Based Surveillance in North Carolina Jennifer MacFarquhar, RN, BSN, CIC, CCPDM Public Health Epidemiologist, Coordinator, UNC Statewide Program for Infection Control and Epidemiology

Overview: 

Overview Describe nosocomial surveillance Discuss uses of hospital surveillance data Review the process of hospital-based surveillance

Hospital Surveillance: 

Hospital Surveillance Active surveillance ‘Nosocomial Infection’ (NI): hospital-acquired infection One in ten acquire NI (2 million persons/yr)

Hospital Surveillance Data Applications: 

Hospital Surveillance Data Applications Monitor trends Population Procedures Infections Antibiotic utilization Pathogens Determine high risk population / procedure Target potential risks of infection Improve adherence to infection control policies

Hospital Surveillance Data Applications: 

Hospital Surveillance Data Applications System detects clusters Practices changed based upon surveillance Data used to decrease the endemic rate Data used to assess the efficacy of interventions Staff aware of surveillance findings

History of Hospital Surveillance: 

History of Hospital Surveillance 1950’s: Hospital-based programs developed 1960’s: Infection control programs established Conduct surveillance Develop control measures Develop & implement infection control policies Early 1970’s: Study on the Efficacy of Nosocomial Infection Control Project (SENIC) 1976: Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

Hospital Surveillance Process: 

Hospital Surveillance Process I. Assess the population II. Select the outcome or process for surveillance III. Use surveillance definitions IV. Collect surveillance data V. Calculate and analyze infection rates VI. Apply risk stratification methodology VII. Report and use surveillance information

I. Assess the Population: 

I. Assess the Population Each organization serves different types of ‘at risk’ patients Base surveillance systems on evaluation of population Target populations at risk for the outcomes of greatest importance

II. Select Outcome or Process: 

II. Select Outcome or Process Outcome: a result of care or performance Process: series of steps taken to achieve an outcome

III. Surveillance Definitions: 

III. Surveillance Definitions Clearly define all data elements outcome or process “at risk” population risk factors Use standardized, written case definition If definition (e.g., CDC-NNIS) changes, highlight in reports

IV. Collect Data: 

IV. Collect Data Train personnel Determine appropriate approach concurrent (prospective) and / or retrospective Incorporate post-discharge surveillance Data sources

Surveillance Methods: 

Surveillance Methods Total facility / Hospital-wide Targeted surveillance Unit Population Site Antibiotic Periodic surveillance Laboratory based Post-discharge

Surveillance Methods: 

Surveillance Methods Source: Freeman & McGowan, 1991

Calculate and Analyze Surveillance Rates: 

Calculate and Analyze Surveillance Rates Express information in terms of rates Use appropriate calculations Be consistent with methodology surveillance intensity accuracy of case and population of definitions all aspects of surveillance remains the same

Data Analysis: 

Data Analysis Numerator Data: Essential Infection Laboratory Numerator Data: Risk Factors Only when used for analysis SSI: type of surgery, date of surgery, etc Denominator Data Total # of admitted or discharged patients Total # of patients & patient days in unit # of days of exposure

Outcome Measures: 

Outcome Measures Surgical site infection (SSI): # SSI  # of specific surgeries x 100 Ventilator-associated pneumonia (VAP): Rate per 1000 ventilator days # VAPS (unit)  # of ventilator days (unit) x 1000

Process Measures: 

Process Measures Immunization rate Total Immunized ÷ total eligible x 100 Surgical antibiotic prophylaxis timing # pts prophylaxed ÷ Surgical procedure x 100

Databases: 

Databases Microsoft Excel (not a relational database) Microsoft Access Epi Info http://www.cdc.gov/epiinfo/ Statistical Analysis System (SAS) http://www.sas.com

Example: Analysis: 

Example: Analysis UCL=Upper Confidence Level; LCL=Lower Confidence Level (These data are not real)

VI. Risk Stratification: 

VI. Risk Stratification Allows comparisons to be made Facilitates validity of interventions For some rates, risk stratification may not be possible Be sure populations are large enough to yield statistically meaningful data

Example: National Nosocomial Infections Surveillance (NNIS): 

Example: National Nosocomial Infections Surveillance (NNIS) *Infection Rate = (No of BSI/No of Line Days) (1000) (These data are not real)

Risk Stratification ExampleNNIS Surgical Site Risk Index: 

Risk Stratification Example NNIS Surgical Site Risk Index Each surgical site given risk score (0-3) Risk factor is present, add ‘1’ to risk class Risk factors Wound class III or IV ASA score 3, 4, or 5 Time  T (hours) (procedure specific from NNIS table) Compare SSI rates across similar risk strata

VII. Disseminate Surveillance Data: 

VII. Disseminate Surveillance Data Maintain confidentiality Regular time intervals Disseminate to those most able to impact & improve patient care

Question & AnswerOpportunity: 

Question & Answer Opportunity

5 minute break: 

5 minute break

Federal Public Health Surveillance: 

Federal Public Health Surveillance

CDC’s Role in Surveillance: 

CDC’s 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

Slide92: 

TABLE II. Provisional cases of selected notifiable diseases, United States, weeks ending June 5, 2004, and May 31, 2003 (22nd week) CDC Surveillance Data Reporting

Federal Data Sources: 

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

Federal Surveillance Resources: 

Federal Surveillance Resources CDC Morbidity and Mortality Weekly Report (MMWR) http://www.cdc.gov/mmwr CDC Office of Surveillance http://www.cdc.gov/ncidod/osr/index.htm

Council of State and Territorial Epidemiologists (CSTE): 

Council of State and Territorial Epidemiologists (CSTE) Collaborates with CDC to recommend changes in surveillance, including what should be reported / published in MMWR Develops case definitions Develops reporting procedures http://www.cste.org

Example: ArboNet: 

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.

ArboNet - Diseases: 

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

ArboNet - Data: 

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

Slide100: 

http://westnilemaps.usgs.gov/

Slide101: 

http://westnilemaps.usgs.gov/

ArboNet – Surveillance Issues: 

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

North Carolina Arboviruses: 

North Carolina Arboviruses NC Division of Public Health http://www.ncpublichealth.com State Laboratory of Public Health http://slph.state.nc.us NC Department of Agriculture and Consumer Services http://www.ncagr.com/ NC Public Health Pest Management http://www.deh.enr.state.nc.us/phpm/index.html

North Carolina Arboviruses: 

North Carolina Arboviruses West Nile Virus Human, equine, mosquito, sentinel chicken Eastern Equine Encephalitis Human, equine, mosquito, sentinel chicken LaCrosse Encephalitis Human only

Slide105: 

http://www.deh.enr.state.nc.us/phpm/html/data-maps.html

Slide106: 

http://www.deh.enr.state.nc.us/phpm/html/data-maps.html

Example: Influenza: 

Example: Influenza

U.S. Influenza Surveillance : 

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

U.S. Influenza Surveillance: 

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

North Carolina Sentinel Surveillance: 

North Carolina Sentinel Surveillance Joint effort of the State Laboratory of Public Health and the General Communicable Disease Control Branch, Division of Public Health Six consecutive years of participation Winter surveillance September – May 2003 - 2004: 55 health providers in 38 counties reported surveillance data to CDC. 2004 - 2005 to date: 59 health providers in 38 counties

NC Influenza Sentinel Surveillance Participants: 2003-2004 and 2004-2005: 

NC Influenza Sentinel Surveillance Participants: 2003-2004 and 2004-2005 2003-2004: N=55 2004-2005: N=59

Visits for Influenza-Like Illness 2002-03 & 2003-04: North Carolina: 

Visits for Influenza-Like Illness 2002-03 & 2003-04: North Carolina Source: http://www.epi.state.nc.us/epi/gcdc/flu.html

Visits for Influenza-Like Illness 2003-04: North Carolina & U.S.: 

Visits for Influenza-Like Illness 2003-04: North Carolina & U.S. Sources: http://www.epi.state.nc.us/epi/gcdc/flu.html and http://www.cdc.gov/ncidod/diseases/flu/weekly.htm

Access NC and CDC Reports:: 

Access NC and CDC Reports: www.epi.state.nc.us/epi/gcdc/flu.html Click on the “NC Flu Surveillance Update” link Questions? Please contact Torrey McLean, General Communicable Disease Control Branch, Epidemiology Section, NC Division of Public Health (919) 733 – 1193 / Torrey.McLean@ncmail.net To review CDC reports and charts containing national and regional data, please go to: www.cdc.gov/ncidod/diseases/flu/weekly.htm

Guest Lecturer: Techniques for Analysis ofSurveillance Data: 

Guest Lecturer: Techniques for Analysis of Surveillance Data Sarah Pfau, MPH Consultant, NCCPHP

Overview: 

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

Considerations: 

Considerations Surveillance data primarily yields descriptive statistics Know the inherent strengths and weaknesses of the data set Examine data from the broadest to narrowest

Rely on Computers to: : 

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

Rely on Public Health Professionals to:: 

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.

Surveillance Data: 

Surveillance Data Descriptive Epidemiology

Person, Place, and Time: 

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) ?

Tuberculosis Cases: United States 1992 - 2002: 

Tuberculosis Cases: United States 1992 - 2002 Source: http://www.cdc.gov/epo/dphsi/annsum/2002/02graphs.htm

Rates : 

Rates

Ratio: 

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.

What Do Rates Do? : 

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)

Why Use Rates?: 

Why Use Rates? Rates provide frequency measures within the context of the population.

Crude versus Specific Rates: 

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)

Rate Numerator:State Surveillance Data: 

Rate Numerator: State Surveillance Data General Communicable Disease Control Branch, Epidemiology Section, Division of Public Health, NC Department of Health and Human Services. Reportable Communicable Diseases – North Carolina. http://www.epi.state.nc.us/epi/gcdc.html To request data tables, call: (919) 733 – 3419.

Rate Denominator:Census Data: 

Rate Denominator: Census Data http://www.census.gov Click on the “State & County Quick Facts” hyperlink Choose NC in the ‘Get a Statistical Profile’ dropdown menu Click on GO Click on the “More North Carolina Data Sets” hyperlink at the top of the Quick Facts page Click on the “North Carolina 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 cells in the Excel spreadsheet Name / save the file in the Epi2000 folder

Import Data from Microsoft Excel or Access: 

Import Data from Microsoft Excel or Access

“Read / Import” Command: 

“Read / Import” Command

“Read / Import” Dialogue Window: 

“Read / Import” Dialogue Window Import files from alternative Software programs

Import Restrictions forMicrosoft Excel Files: 

Import Restrictions for Microsoft 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., #, @, !)   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.

Import Restrictions forMicrosoft Access Files: 

Import Restrictions for Microsoft 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., #, @, !) The Access file must be saved in the path: c:\Epi2000 OR c:\Epi_Info folder.

Epi Info Demonstration: 

Epi Info Demonstration Import an Excel data table for Analysis

Online Epi Info Training: 

Online Epi Info Training “Session II: Importing and Exporting Data Tables” http://www.sph.unc.edu/nccphp/training/all_trainings/at_epi_info.htm

Analyze Surveillance Data: 

Analyze Surveillance Data

Sample Analyses: 

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

Graph Surveillance Data: 

Graph Surveillance Data

Line Graph: Raw Data: 

Line Graph: Raw Data

Line Graph: Rate Data: 

Line Graph: Rate Data

Archived U.S. Census Population Estimates: 

Archived U.S. Census Population Estimates http://www.census.gov/popest/archives/1990s/ National State County Estimates: present and past Projections: future

Line Graph: 

Line Graph Raw Data Rates

Generating a Line Graph: 

Generating a Line Graph 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

Epi Info Demonstration: 

Epi Info Demonstration Generate a Line Graph

Map Surveillance Data: 

Map Surveillance Data

Raw Data Map: 

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

Choropleth Map: 

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

Choropleth Map: 

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

Data Interpretation:Considerations: 

Data Interpretation: Considerations 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?

Online Surveillance Trainings: 

Online Surveillance Trainings NC Center for Public Health Preparedness Trainings: http://www.sph.unc.edu/nccphp/training/training_list/t_surv.htm Direct link to 13 surveillance trainings

Question & AnswerOpportunity: 

Question & Answer Opportunity

Session Summary: 

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.

Session Summary: 

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.

Session Summary: 

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.

Next Session December 14th10:00 a.m. - Noon: 

Next Session December 14th 10:00 a.m. - Noon Topic: “Risk Communication”

Downloading Session Slides: 

Downloading Session Slides After the airing of this session, NCCPHP will post the complete set of slides and lecture notes on the following two web sites : NCCPHP Training web site: http://www.sph.unc.edu/nccphp/phtin/index.htm North Carolina Division of Public Health, Office of Public Health Preparedness and Response http://www.epi.state.nc.us/epi/phpr/

Site Sign-in Sheet: 

Site Sign-in Sheet Please mail or fax your site’s sign-in sheet to: Linda White NC Office of Public Health Preparedness and Response Cooper Building 1902 Mail Service Center Raleigh, NC 27699 FAX: (919) 715 - 2246

References and Resources: 

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_definitions.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

References and Resources: 

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/mm5321md.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. To request data, call: (919) 733 – 3419.

References and Resources: 

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. McLean, T. (May 2004). Influenza Sentinel Surveillance Program Update #24. General Communicable Disease Control Branch, Epidemiology Section, North Carolina Division of Public Health, Department of Health and Human Services. McLean, T. (November 2004). Influenza Sentinel Surveillance Program Update #2. General Communicable Disease Control Branch, Epidemiology Section, North Carolina Division of Public Health, Department of Health and Human Services.

References and Resources: 

References and Resources Teutsch, S. and Churchill, R. (1994). Principles and Practice of Public Health Surveillance. New York: Oxford University Press. Torok, M. (2004). Summary of Results from the Health Care Practitioner and Infection Control Practitioner Surveys of Foodborne Illness Testing and Diagnosis Practices. NC Center for Public Health Preparedness, Institute for Public Health, UNC Chapel Hill. NC Center for Public Health Preparedness Surveillance Trainings: http://www.sph.unc.edu/nccphp/training/training_list/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”