Disease Surveillance

A Public Health Informatics Approach

Joseph S. Lombardo, David L. Buckeridge

• Publisher: Wiley-Interscience
• Year: 2012
• Print ISBN: 9780470068120
• eBook ISBN: 9781118569054
• Edition: 1
• Topic: Medicine
• Subtopic: Biostatistics

An up-to-date and comprehensive treatment of biosurveillance techniques

With the worldwide awareness of bioterrorism and drug-resistant infectious diseases, the need for surveillance systems to accurately detect emerging epidemicsis essential for maintaining global safety. Responding to these issues, Disease Surveillance brings together fifteen eminent researchers in the fields of medicine, epidemiology, biostatistics, and medical informatics to define the necessary elements of an effective disease surveillance program, including research, development, implementation, and operations. The surveillance systems and techniques presented in the text are designed to best utilize modern technology, manage emerging public health threats, and adapt to environmental changes.

Following a historical overview detailing the need for disease surveillance systems, the text is divided into the following three parts:

• Part One sets forth the informatics knowledge needed to implement a disease surveillance system, including a discussion of data sources currently used in syndromic surveillance systems.
  
  

• Part Two provides case studies of modern disease surveillance systems, including cases that highlight implementation and operational difficulties as well as the successes experienced by health departments in the United States, Canada, Europe, and Asia.
  
  

• Part Three addresses practical issues concerning the evaluation of disease surveillance systems and the education of future informatics and disease surveillance practitioners. It also assesses how future technology will shape the field of disease surveillance.
  
  

This book's multidisciplinary approach is ideal for public health professionals who need to understand all the facets within a disease surveillance program and implement the technology needed to support surveillance activities. An outline of the components needed for a successful disease surveillance system combined with extensive use of case studies makes this book well-suited as a textbook for public health informatics courses

Chapter 1

Disease Surveillance, a Public Health Priority

Joseph S. Lombardo, David Ross

Pandemic influenza, West Nile virus, severe acute respiratory syndrome (SARS), and bioterrorism are a few of the current challenges facing public health officials. The need for early notification of, and response to, an emerging health threat is gaining increasing visibility as public opinion increases the pressure to reduce the mortality and morbidity of health threats. With the greater emphasis on the early recognition and management of health threats, federal, state, and local health departments are turning to modern technology to support their disease surveillance activities. Several modern disease surveillance systems are in operational use today. This book presents the components of an effective automated disease surveillance system and is intended for use by public health informatics students, masters of public health students interested in modern disease surveillance techniques, and health departments seeking to improve their disease surveillance capacities.

This introductory chapter provides an overview of the changing requirements for disease surveillance from the perspective of past, present, and future concerns. It includes a brief history of how technology has evolved to enhance disease surveillance, as well as a cursory look at modern disease surveillance technology and activities.

1.1 INTRODUCTION

Control of infectious diseases is a cornerstone of public health. Various surveillance methods have been used over the centuries to inform health officials of the presence and spread of disease. The practice of disease surveillance began in the Middle Ages and evolved into the mandatory reporting of infectious disease cases to authorities responsible for the health of populations.

A common definition of surveillance is “the ongoing systematic collection, analysis, and interpretation of outcome-specific data for use in planning, implementation, and evaluation of public health practice” [1]. One of the more challenging aspects of public health surveillance is the early identification of infectious disease outbreaks that have the potential to cause high morbidity and mortality. In recent years, concern over potential uncontrolled outbreaks due to bioterrorism or the appearance of highly virulent viruses such as avian influenza has placed increased pressure on public health officials to monitor for abnormal diseases. Public concern was heightened when at the beginning of the twenty-first century, the dissemination of a biological warfare agent through the U.S. mail system revealed weaknesses in the ability of existing public health surveillance systems to provide early detection of a biological attack.

Containment of potential outbreaks is also confounded by advances in transportation technology. Modern transportation systems permit communicable diseases to be carried around the world in hours over many public health jurisdictions. Health authorities can no longer simply be concerned only with the health status of the populations they serve; they must also cooperate and collaborate in surveillance and containment activities at regional, national, and international levels.

The Internet is an enabling technology for collaboration across wide geographic areas. Information technology in general is also playing a vital role in the timely capture and dissemination of information needed for identification and control of outbreaks. The subject of this book is the use of modern information technology to support the public health mission for early disease recognition and containment.

1.2 THE EMERGING ROLE OF INFORMATICS IN PUBLIC HEALTH PRACTICE

For more than 50 years, public health has been undergoing a change in identity that strongly affects how the public health sector envisions the use of information technologies. Public health is best viewed as an emergent industry. It has grown from a collection of single-purpose disease prevention and intervention programs to a national network of professionals linked through professional and organizational bonds. The 1988 Institute of Medicine report titled “The Future of Public Health” recognized that public health was established around three core functions and 10 essential services.

The core functions are:

• Assessment
• Assurance
• Policy development

The 10 essential services are:

1. Monitor health status to identify and solve community health problems.

2. Diagnose and investigate health problems and health hazards in the community.

3. Inform, educate, and empower people about health issues.

4. Mobilize community partnerships to identify and solve health problems.

5. Develop policies and plans that support individual and community health efforts.

6. Enforce laws and regulations that protect health and ensure safety.

7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable.

8. Assure a competent public health and personal health care workforce.

9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services.

10. Research for new insights and innovative solutions to health problems.

Information is one of the central products produced by public health. Protecting community health; promoting health; and preventing disease, injury and disability require vigorous monitoring and surveillance of health threats and aggressive application of information and knowledge by those able to prevent and protect the public’s health. Thus, public health informatics supports the activities, programs, and needs of those entrusted with assessing and ensuring that the health status of entire populations is protected and improves over time.

Public health informatics has been defined as the systematic application of information and computer science and technology to public health practice [2]. The topic supports the programmatic needs of agencies, improves the quality of population-based information upon which public health policy is based, and expands the range of disease prevention, health promotion, and health threat assessment capability extant in every locale throughout the world [3]. In the future, public health informatics may change to be defined as informatics supporting the public’s health, a discipline that may be practiced beyond the walls of the health department.

In 1854, John Snow conducted the first comprehensive epidemiological study by linking the locations of cholera patients’ homes to a single water pump. In doing so, he established that cholera was a waterborne disease. Using visual data, Snow quickly convinced the authorities to remove the pump handle. Following that simple intervention, the number of infections and deaths fell rapidly [4].

Over the past 30–50 years, public health programs have emerged around specific diseases, behaviors, or intervention technologies (e.g., immunization for vaccine preventable diseases), each having specific data and information needs. Not surprisingly, information systems were developed to meet the specific needs of each categorical program, and a culture of program-specific information system design permeated public health thinking. By the mid-1990s, leaders in public health acknowledged the need to rethink public health information systems, conceive of systems as support tools for enterprise goals, and do so through nationally adopted standards. As noted in [3] “Public health has lagged behind health care delivery and other sectors of industry in adopting new information technologies, in part because public health is a public enterprise depending on funding action by legislative bodies (local, state, and federal). Additionally, adoption of new technologies requires significant effort to work through government procurement processes.” A 1995 Centers for Disease Control and Prevention (CDC) study reported that integrated information and surveillance systems “can join fragments of information by combining or linking the data systems that hold such information. What holds these systems together are uniform data standards, communications networks, and policy-level agreements regarding confidentiality, data access, sharing, and reduction of the burden of collecting data” [5].

In the late 1990s, it became apparent that public health should be more comprehensive in understanding disease and injury threats. Reassessing its information mission has led federal programs such as CDC and Health Resources Service Administration (HRSA), to view information system integration as the driver for future information system funding. Integration across programs and organizations requires interoperability: data from various sources being brought together, collated in a common format, analyzed, and interpreted without manual intervention. Interoperability also requires an underlying architecture for data coding, vocabularies, message formats, message transmission packets, and system security. Interoperability implies connectedness among systems, which requires agreements that cover data standards, communications protocols, and sharing or use agreements. Interconnected, interoperable information systems will allow public health to address larger aspects of the public’s health. The twenty-first century will probably be seen as the enterprise era of public health informatics. Once the domain of humans alone, the process of gathering and interpretating data should now be mediated by computers. Major advances in the quality, timeliness, and use of public health data will require a degree of machine intelligence not presently embedded in public health information systems [6].

The context in which informatics can contribute to public health progress is changing. New initiatives within public health and throughout the health care industry portend changes in how data are captured, the breadth of data recorded, the speed with which data are exchanged, the number of parties involved in the exchange of data, and how results of analyses are shared. Increasing use of electronic health record systems provides an opportunity to gather more granular, discrete data from a variety of sources, including nursing, pharmacy, laboratory, radiology, and physician notes, thereby changing the specificity and timeliness of knowledge about the distribution of risk factors, preventive measures, disease, and injury within subpopulations.

As agreements are reached on the major information architectural standards (data, transmission, and security) and appropriate approaches to governance and viable business models can be demonstrated, health information exchanges will emerge to assist and transform how health care is delivered. Public health considerations must be central to this transformation, and public health informatics will be central to how public health agencies participate in this rapidly evolving environment.

1.3 EARLY USE OF TECHNOLOGY FOR PUBLIC HEALTH PRACTICE

There are historical accounts in the bible of social distancing as a control measure to stop the spread of leprosy. During the spread of plague in Europe in the fourteenth century, public health authorities searched vessels looking for signs of disease in passengers waiting to disembark. In the United States, the practice of disease surveillance by public health inspection at immigration has been highly publicized as a result of the renovation of Ellis Island. The immigration law of 1891 required a health inspection of all immigrants coming into the United States by Public Health Service physicians. Between 1892 and 1924, over 22 million immigrants seeking to become American citizens were subject to health inspections (Fig. 1.1). The law stipulated the exclusion of “all idiots, insane persons, paupers or persons likely to become public charges, persons suffering from a loathsome or dangerous contagious diseases” [7]. Technology was limited to paper-and-pencil recordkeeping for these surveillance and control activities.

Fig. 1.1 Public health inspectors at Ellis Island looking at the eyes of immigrants for signs of trachoma.

(Photo courtesy of the National Library of Medicine)

1.3.1 Early Use of Analytics, Visualization, and Communications

One of the earliest technologies used in disease surveilla...

Table of contents

• Cover
• Half Title page
• Title page
• Copyright page
• Dedication
• Contributors
• Preface
• Acknowledgments
• Chapter 1: Disease Surveillance, a Public Health Priority
• Part I: System Design and Implementation
• Part II: Case Studies
• Part III: Evaluation, Education, and the Future
• Index