cdepiandphsurv2epifornonepi1

7/28/2019 CDEpiAndPHSurv2EpiForNonEpi1

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Communicable DiseaseEpidemiology & Public Health

Surveillance: An Overview

Amy D. Sullivan, PhD, MPH

Epidemiologist

Multnomah County Health Dept.


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Unlike a forest fire, in a

bioterrorism (BT) event

Seeing the fire requires capturingepidemiologic data

Responding requires using that data

Population at risk!


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Topics in Presentation

Basic principles Communicable disease epidemiology

Public health surveillance Disease and outbreak reporting

(local, state, and federal roles)

Adapting for Incident CommandSystem


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Basic Principles


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Epidemiologic Science

Disagreement and confusion about basic ideas

in epidemiology do not necessarily attest to the

thick-headedness of epidemiologists; a morecharitable interpretation [is] that the basic ideasfundamental to [this] new science have not yetdisplaced traditional thinking.

Rothman and Greenland, Modern Epidemiology


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What Is Epidemiology?

Studying the distribution &determinants of health-related

states in specific populations tocontrol health problems Usually human, but veterinary too

Diseases or conditions Demand a set of actions as outcome


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Sub-Specialties

Chronic

Environmental

Social

Reproductive

Infectious disease Acute & Communicable

Chronic Communicable


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Doing Epi

Assess patterns of disease inpopulations

Identify potential risks for disease Decrease/eliminate risk of disease

Describe disease in population by

Person, Place, and Time


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Person

How many

Clinical characteristics

Medical history Immunization status

Demographic characteristics Age, sex

Race/ethnicity/culture


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Place and Time

Place

Geographic clustering

Association with a point source

Time

Clustering in time Rate of development of new cases


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Epidemiologic Triad

Host Agent

Environment


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Epidemiologic Triad

Host Agent

Environment

PersonPlace &Time


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Epidemiologic Triad

Host Agent

Environment


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Epidemiology in PublicHealth Practice

Public Health Surveillance

Outbreak & illness clusterinvestigation

Special studies

Resolve issues of detection biasor small numbers

Program design & evaluation


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Public Health Surveillance

ongoing & systematiccollection, analysis, interpretation,

and dissemination of data onhealth-related events to reducemorbidity and mortality and to

improve health


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Passive vs. Active

Passive Surveillance Wait for reports to arrive

Active Surveillance Go out and collect information

Example: Medical record reviews


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Purposes of Surveillance

Allow assessment of health statusof a given population

Provide quantitative basis to Set priorities

Define strategies & objectives for

action Evaluate interventions/programs/

outcomes


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How Surveillance is Used

Routine Surveillance Detect cases of disease of public

health significance Detect outbreaks and illness clusters

Event-specific surveillance

Monitor progression of event Assess utility of intervention


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Outbreaks and Clusters

Unusual amount of illness in agiven population at a given time

Influenza In 1 week, % deaths due to pneumonia &

influenza (122 U.S. cities) exceeds 8.1%

Foodborne Illness

Persons from 2+ households share a specificmeal & have similar symptoms

Smallpox 1 case anywhere in the world


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Conditions Under Which EpiField Investigation Occurs

Situations where Event unexpected Immediate response required Extent of investigation limited by

need for timely intervention

Assess urgency of event


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Factors Affecting Urgency

Severity of illness

Unusualness of occurrence

Extent of outbreak Numbers of persons/households/sites

Timely intervention possible

Institutional support E.g., hospital with infectious disease

professionals involved


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Preliminary Response

Symptom profile of initiallyreported person(s)

Confirm diagnosis Onset dates & duration of illness

Characteristics of affected persons

Demographics, recent travel Pertinent medical history

If others similarly affected Confirm diagnoses!


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Elements of an EpidemiologicField Investigation

Determine existence of epidemic(including confirming diagnoses)

Orient info by person/place/time

Develop case definition & count cases Develop and test hypotheses on

specific exposures causing illness

Identify persons at risk

Execute control and preventionmeasures

Write-up & plan for further study


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Essential Tasks ofInvestigation

Investigation Data collection & analysis

Case interviews & contact tracing

Surveillance Monitoring

Active surveillance with affected institution(s)

Evaluation of interventions Communications, managing

personnel, etc.


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Conducting Epi FieldInvestigations at MCHD

Routine activity for some programs Communicable Disease

Environmental Health STD

TB

Large event requires surge capacity


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Disease and OutbreakReporting in Oregon


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Disease & OutbreakReporting in Oregon

Specific conditions defined byOregon Administrative Rules,

Chapter 333 Divisions 12, 17, 18, 19, 24, 56

Legally required reporting through

physicians and labs Passive surveillance


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Reported by Physicians(Excluding STDs)

Anthrax

Botulism

Brucellosis

Campylobacteriosis

Cryptosporidiosis

Cyclosporainfection

Diphtheria

Escherichia coli(Shiga-tox.)

Giardiasis

Haemophilus influenzae

Hantavirus

Hepatitis A

Hepatitis B

Hepatitis C (new infections)

Hepatitis D (delta)

LegionellosisLeptospirosis

Listeriosis

Lyme disease

OTHER

Animal bites

Any Arthropod-borne infection7

HUS

Lead poisoning

Marine intoxications

Any Outbreak of disease

Pesticide poisoningAny Uncommon illness of

potential public health

significance

TIMING OF REPORTS

Immediatelyday or nightWithin 24 hours

Within 1 working day

Within 1 week

Malaria

Measles (rubeola)

Meningococcal disease

Plague

Polio

Rabies

RubellaPertussis

Q fever

Salmonellosis (incl. typhoid)

Shigellosis

Taenia solium/Cysticercosis

Tetanus

Trichinosis

Tuberculosis

Tularemia

Vibrioinfection

Yersiniosis


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Lab Reportable Only

Tick-borne illnesses Ehrlichia

Rickettsia Lab reporting often more reliable

than physician reporting


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Response to Reports

Report or diagnosis confirmed bylocal Community Health Nurse

State receives notification; assistsas requested

Follow-up locally Investigative Guidelines


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Investigative Guidelines

For most reportable conditions Disease Reporting

The Disease and Its Epidemiology Case Definitions, Diagnosis, and

Laboratory Services

Routine Case Investigation

Controlling Further Spread

Managing Special Situations


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Overview of Local, State, andFederal Roles

LHD has public health authority inOregon

State Track data on public health conditions &

reporting federal level Support LHD Liaison with other states and federal

Federal National disease reporting data Support state and local health departments Control/release certain pharmaceuticals


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State Structure

Oregon Department of Human Services

Health Services Public Health

Office of Disease Preventionand Epidemiology (ODPE)

Acute & CommunicableDisease Program (ACD)

ImmunizationProgram

BioterrorismPreparedness

Office of the StatePublic Health Officer

Public HealthPreparedness Program

Oregon StatePublic Health

Laboratory


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Role of the State in anInvestigation

Receive information on reportablecondition Timeframe set out in BT/CD Assurances

Notification & summary of findings/actions Support multi-county investigations

Counties decide on lead; state assists

Support/conduct investigation ifcounty resources inadequate Get LHD agreement

Liaise with CDC Technical advise, obtain pharmaceuticals/

vaccines, etc


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Other Aspects ofLocal-State Relationship

State not a regulatory agency

State does control funds

In a declared emergency, StateHealth Officer has expandedpowers


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Federal StructureSecretary & Dep. Secretary of Health

U.S. Department of Health and Human Services

Centers for Disease ControlAnd Prevention (CDC)

National Center forInfectious Diseases

NationalImmunization Prog.

Asst. Secretary of HealthU.S. Public Health Service

Office of theDirector

EpidemiologyProgram Office

State Branch Bacterial andMycotic Diseases

Parasitic Diseases

Vector-BorneInfectious Diseases

Viral & RickettsialDiseases

Bioterrorism Preparedness& Response Program


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Role of the CDC in anInvestigation

Support state and local publichealth Technical experts Laboratory testing Pharmaceuticals & vaccines Lead multi-state outbreaks

Coordinate information nationally Liaise with other countries &

international organizations


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Epi Activities in an ICSContext


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Possible BT Event ICSStructure (Epi Functions)

Incident Commander

Operations Planning Logistics Finance/Admin

EpidemiologyBranch/Group

CaseInvestigation

HospitalSurveillance

ContactTracing

Documentation Unit

Resources Unit

Situation Unit

Epidemiology Unit

Demobilization Unit

Technical Experts:Epi Training, ID/Med,Personal Protection

MedicalBranch/Group

LaboratoryBranch/Group

Command Staff


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Operations Section:Epi Field Activities

Hospital-Based Surveillance Active surveillance & case finding Info on medical management

Case Investigation Confirm cases & assure appropriate

specimens collected Detailed interviews

Medical & social history and possible contacts Contact Tracing

Follow-up with contacts & case finding Education, symptoms, prophylaxis, additional contacts


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Planning Section:Epi Planning

Epidemiologic information neededto direct operations

Plan investigation Develop & provide materials & training

Assure collection & entry of data fromOps epi field activities

Analyze and summarize epi data Case numbers & disease rates

Populations at risk & prophylaxed


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Scenario Example


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Scenario: First Report

MCHD Communicable DiseaseProgram receives these two reports: A County jail prisoner has died; 1 staff &

4 other inmates in hospital w/ similarsymptoms Symptoms: chills, high fever, body pains, chest

discomfort, and a very bad cough

Local hospital ICP reports 2 ED workershospitalized with a serious respiratoryillness


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Factors Affecting Urgency:Scenario Example

Severity 1 death; 5-7 hospitalized

Unusualness Age / time of year /

possible number Extent >1 institution

Timely intervention possible ?

Institutional support Good, butmight involve multiple institutions


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Preliminary Response:Scenario Example

Symptom profiles Comparable symptoms among all ill &

onsets within 2 days

Initial inmate died within 3 days

Characteristics of affected persons Initial inmate homeless man; arrived

in town within 2 days of arrest

ED workers worked same shift; recentdeath in ED on that shift


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Scenario: Day 2

Corrections: Dead inmate diagnosed as pneumonic

plague; confirmation pending Additional ill

2 corrections officers; 1 nurse; 8 inmates

Hospital Pneumonic plague diagnosed in both HCWs 1 HCW died; Other seriously ill; child of dead

HCW symptomatic 20 total cases (17 from Corrections, 3

from hospital) with 2 deaths

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