Current Trends in Current Trends in SurveillanceSurveillance

University of Toronto/alPHa

14 March, 2003

Dr. David Mowat Dr. David Mowat Director GeneralDirector GeneralCentre for Surveillance CoordinationCentre for Surveillance Coordination

OverviewOverview

The nature of surveillance

History

Surveillance and decision-making

Surveillance and surveillance infostructure

The Network for Health Surveillance in Canada

ICTs and surveillance possibilities & progress

What is surveillance?What is surveillance?

• Health surveillance is the ongoing, systematic use of routinely collected health data to guide public health

• Surveillance processes include data collection, collation, analysis, interpretation and dissemination followed by action

action

Surveillance is not …Surveillance is not …

• research

• evaluation

Information on: "health events"Information on: "health events"

• morbidity

• mortality

• risk factors

• threats to health

• laboratory diagnosis

• adverse events

• etc.

Information uses:Information uses:

• identifying emerging & re-emerging diseases

• monitoring trends

• identifying outbreaks

• identifying unusual patterns

• forecasting

• generating hypotheses

Information ultimately used for Information ultimately used for decisionsdecisions

• policies

• programs

• practice

• public

local

provincial/territorial

national

health events

actions

John SnowJohn Snow

Natural and PoliticalNatural and PoliticalOBSERVATIONSOBSERVATIONS

Mentioned in a following Index, Mentioned in a following Index, and made upon theand made upon theBills of MortalityBills of Mortality..

By John GrauntBy John Graunt

with reference to the Government, Religion, Trade, Growth, Ayre, Diseases, and the several Changes of the said CITY.

-- Non, me ut miretur Turba, laboro. Contentus paucis Lectoribus

New ChallengesNew Challenges

• new threats e.g. bioterrorism

• new concerns e.g. biotechnology

• new technologies e.g. genomics

ICTs in Health SectorICTs in Health Sector

Banks, insurance companies typically investing 10% -12% of budget in ICT’s

Health is an intensive information-based business However:

Invested only 1% - 2% in ICT’s during 1990’s

Investments uncoordinated

Health needs larger ICT investments, and an integrated approach

Evidence-Based Decision-MakingEvidence-Based Decision-Making

• information on events

• information on interventions

• information on context

Surveillance & Surveillance InfostructureSurveillance & Surveillance Infostructure

The infrastructure approach provides;

• efficiency

• power of integration

• flexibility & responsiveness

Design ConsiderationsDesign Considerations

• Start with the business

• Make the business explicit

• Document the purpose(s)

• Choose desired characteristics

Developing Data SourcesDeveloping Data Sources

• re-use

• "by-product"

• "transactional"

• preclinical/syndromic

T 0 Time of attack (Fixed)T SMC Time to seek medical care (Mean)T Diag Time of typical diagnosis (Mean)T Death Time of death (Mean)W 1 Window to detect (Non-Traditional)W 2 Window to detect (Non-Trad. Medical)W 3 Window to detect (Trad. Medical)IDW Improved Detection Window

~ ~

T0 TSMC T DeathTONSET T Diagnosis.

W3

IDW

W2

Ease of Detecting Bioagent Effects Over Timeline

Bio-Agent Impact Timeline

Bio-Surveillance Detection TimelineBio-Surveillance Detection Timeline

Detection Analysis TimelineNon-clinical and behavioral

data

Pre-diagnostic clinical data

Diagnostic data

W1

Developing Data SourcesDeveloping Data Sources

• re-use

• "by-product"

• "transactional"

• preclinical/syndromic

• intelligence

Data IntegrationData Integration

• data warehouses

• data marts

AnalysisAnalysis

• power

• business intelligence toolsOLAP

SOLAP

presentation tools

spatial tools

Extracting MeaningExtracting Meaning

• monitoring

• alerts

AccessAccess

• connectivity

• language

• discovery

• manipulation

• permission

DiscoveryDiscovery

The "virtual library"

• store

• classify

• search/navigate/browse

InventoriesInventories

Health Canada

Injury

Environmental

CHAIN

The Infospace VisionThe Infospace Vision

• databases• summary reports• daily updates/news• bulletins• systematic reviews• position papers• practice guidelines• regulatory notices• dictionaries, references

• tools: business intelligenceGeographic Information

System• automated alert function• discovery functions:

inventoriesmetadatasearch/navigation

• continuing education• discussion environments• conference, job postings, etc.

Schneider's lunchmate outbreakSchneider's lunchmate outbreakCanada, 1998

0

5

10

15

20

25

30

35

40

01-M

ar

08-M

ar

15-M

ar

22-M

ar

29-M

ar

05-A

pr

12-A

pr

19-A

pr

Schneider’s recall 1(March 31)

Schneider’s recall 2(April 9)

Cheese recall (April 15)

Number of Cases

Lunchmate (386)

Outbreak recognized

(March 25)

Date of Onset Of Illness N=513

No Lunchmate (127)

Recall(March 20)

Outbreak recognized(March 16)

( < 386 )

N < 513

CIPHSCIPHS

• National Reportable Disease Database• Communicable diseases, immunization, VAAE• Data as a by-product of doing regular work• Provides tools to local public health (PHIS) & to

microbiology labs (LDMS)• Connects in near-real-time• Part of end-to-end strategy of HSWG

Supporting end-to-end surveillanceSupporting end-to-end surveillanceenteric diseaseenteric disease

Child ill

Hospitalvisit

Bench workin Prov lab

Child ill

Hospitalvisit

Bench workin Prov lab

Child ill

Hospitalvisit

Bench workin Prov lab

Child ill

Hospitalvisit

Bench workin Prov lab

Child ill

Hospitalvisit

Bench workin Prov lab

Public Health Nursecalls or visits homes

Family teaching, investigation, follow up

Alert reportto MOH

Alert reportto Province

Alert reportto HC

Outbreak plan becomes operational

Coordinate other prov agency investigation

Is this a national

outbreak or one involving

CFIA?

Food samplesto lab

Supporting end-to-end surveillanceSupporting end-to-end surveillance(vaccine-preventable disease)(vaccine-preventable disease)

Child ill

Hospitalvisit

Bench workin Prov lab

Child ill

Hospitalvisit

Bench workin Prov lab

Child ill

Hospitalvisit

Bench workin Prov lab

Child ill

Hospitalvisit

Bench workin Prov lab

Child ill

Hospitalvisit

Bench workin Prov lab

Public Health Nursecalls or visits school

Exclusion, immunization, investigation, follow up

Alert reportto MOH

Alert reportto Province

Alert reportto HC

Outbreak plan becomes operational

Identify sources of vaccine

National response; long term work on vaccine strategy

Immunizationregistry

ArchitectureArchitecture

StandardsStandards

“The advantages of a uniform statistical nomenclature, however imperfect, are so obvious that it is surprising that no attention has been paid to its enforcement in bills of mortality…The nomenclature is of as much importance in this department of inquiry as weights and measures in the physical sciences, and should be settled without delay.” - William Farr, 19th Century

CDCDCC

GISGIS

Geographic dataGeographic data

DiseaseDiseasedatadata

Denominator dataDenominator data

G. I. S.G. I. S.

• access to data

• tools to download

• service

• consultation & training

G. I. S.G. I. S.

Skills Enhancement for Health SurveillanceSkills Enhancement for Health Surveillance

• Develop an Internet-based training program in both official languages.

• For front-line public health professionals across Canada

• To increase skills in the following areas:–Epidemiology–Surveillance–Information management

Skills Enhancement's RoleSkills Enhancement's Role

• A continuing education training program

• NOT to replace existing training programs

• Support other educational programs

• To help fill the gap for accessible, flexible applied continuing education training for front-line public health practitioners

Modules Currently AvailableModules Currently Available

• Orientation to Online Learning

• Module 1: Basic Epidemiological Concepts

• Module 2: Measurement of Health Status

• Module 3: Descriptive Epidemiological Methods

Key InformationKey Information

• Each module ranges from 10-20 hours in length.

• Students must complete a module within 6-8 weeks.

• Registrants can take a module at no charge, but are responsible for Internet costs & for hardware/software.

Formats OfferedFormats Offered

Facilitated

Students have access to an online facilitator whose

role is to: answer content-related questions; encourage

discussion; provide feedback on exercises; and guide

students through the material.

Unfacilitated

Students progress through the course independently.

Examples of Future ModulesExamples of Future Modules• Introduction to Surveillance

• Introduction to Information Management

• Basic Biostatistics

• Survey Methods

• Communicating Data Effectively

• Moving Data to Action: Evidence-based planning

• Applied Epidemiology 1: eg: Outbreak Management and Control

• Applied Epidemiology 2: eg: Injury

• Applied Epidemiology 3: eg: Chronic Diseases