SURVEILLANCE

and
the CDC
Public Health Surveillance
Public health surveillance is the
mechanism that public health agencies
use to monitor the health of their
communities. Its purpose is to provide
a factual basis from which agencies can
appropriately set priorities, plan
programs, and take actions to promote
and protect the public health.

USDHHS, Principles of Epidemiology,

1992
 Why do we have public health
surveillance?

To detect big changes in disease patterns

To follow trends in disease over time
To help identify the particular agents and
host factors involved
To detect and follow changes in health
care practices
 The
Disseminatio
n Public Setting up
surveillanc
e

Health Care
Providers

Collecting
Summaries,
and
Interpretations, Health organizing
the data
Recommendation
s Agencies
United States Department of Health and
Human Services (HSS) - Donna Shalala

Administration for Children and Families

Administration for Aging
Agency for Health Care Policy and Research
Agency for Toxic Substances and Disease Registry
Center for Disease Control
United States Department of Health and
Human Services (HSS) - Cont

Food and Drug Administration

Health Care Financing Administration
Indian Health
National Institute of Health
Substance Abuse and Mental Health Services
Administration
A history of terms:
In the 1940s, the Communicable
Disease Center developed the first
programs to systematically survey the
publics health (Dr. Alexander Langmuirs
idea)
Before that surveillance meant close
observation of persons who had been
exposed to a communicable disease
We now use public health surveillance
to describe monitoring health events in
populations and medical surveillance to
describe the surveillance of individuals
An effective public surveillance
program requires three main tasks:

1) Setting up and monitoring the capacity to

collect
and analyze data

2) Disseminating that data in a timely fashion

to public health officials and programs

3) Regularly evaluating the effectiveness of

the use of that information.
Elements in establishing a surveillance system
Establish Goals

Develop Case Definitions

Select Appropriate Personnel

Acquire tools and clearances for collection,

analysis, and dissemination

Implement Surveillance

Evaluate Surveillance Activities

Three main categories of
surveillance data:
Surveys of Disease
Surveys of Health
Surveys of Disease Indicators

Two main categories of

surveillance:
Active
Passive
Types of Public Health Surveillance Dat

Mortality
reports Demographic
Morbidity reports Environmental
Infectious disease Animal reservoirs
reports or vectors
Lab reports
Case studies
Epidemic investigations
Special surveys
(hospital admissions,
 What kind of Mortality Data is
typically available?
Vital Statistics
Birth
Death
Marriage
Divorce
Medical Examiner Data
Information on sudden or unexpected
deaths
Who surveys the vital statistics in
this country?
The CDC
The CDCs National Center for Health
Statistics collects a national monthly
sample and reports on it in the
MMWR every three months.
The NCHS provides a complete national
mortality report and dataset
about every 2- 3 years.
These reports are published in the MMWR.
 What kind of Morbidity Data is
typically available?
Notifiable Disease Reports
Laboratory Data
Hospital Data
Most hospitals have computerized
discharge records
Several states routinely compile these
reports
On a national level, the National Hospital
Discharge Survey takes a random sample of
hospitals each year (conducted by NCHS)
 Summary of Notifiable
Diseases(CDC)
Acquired immunodeficiency Haemophilus influenzae Rabies, animal

syndrome (Invasive Disease) Rabies, human

Anthrax Hansen disease (leprosy) Rocky Mountain

spotted fever

Botulism* Hantavirus pulmonary syndrome Rubella

Brucellosis Hemolytic uremic syndrome, Salmonellosis*

Chancroid* post-diarrheal Shigellosis*

Chlamydia trachomatis, Hepatitis A Streptococcal disease,

genital infection Hepatitis B invasive, group A

Cholera Hepatitis, C/non-A, non-B Streptococcus

pneumoniae,

Coccidioidomycosis* HIV infection, pediatric drug-resistant*

MMWR report Influenza Activity -- United States,
1999-2000 Season (November 19, 1999 /
48(45);1039-1042)

1) Sentinel physicians surveillance network.

Each week from October through May,
volunteer physicians in 47 states and the District of
Columbia report the number of patient visits and the
number of those visits for influenza-like illness (ILI).

2) State and territorial epidemiologists' reports.

Each week during October-May, state and
territorial epidemiologists report statewide estimates
of influenza activity to CDC. Activity levels are
defined as: 1) no activity, 2) sporadic 3) regional and
4) widespread
3) 122 Cities Mortality Reporting System.
Each week throughout the year, the vital
statistics offices for 122 U.S. cities report the total
number
of death certificates received and the number of
death certificates on which influenza or pneumonia
is listed

4) World Health Organization (WHO) and

National Respiratory and Enteric Virus
Surveillance System (NREVSS) collaborating
laboratories.
Each week from October through May,
approximately 115 WHO and NREVSS collaborating
laboratories in the United States report the total
number of specimens received for respiratory virus
testing and the number testing positive for influenza
 Limitations of Notifiable
Disease Reporting
Underreporting
Lack of knowledge that it should be reported
Negative attitude towards the process

Lack of representativeness
Underreporting is not uniformly distributed it
is disease specific

Its hard to get the material in a timely

fashion
Inconsistency in case definitions
Other kinds of morbidity data
include:
Outpatient Health Care Data
National Ambulatory Medical Care Survey
(NCHS)
National Drug and Therapeutic Index
(commerical)
Cancer registries
SEER (Surveillance, Epidemiology, and End
Result) supported by NCI
Adverse Drug Reactions
What about surveys of health?
A couple of very big programs have been
doing this for the past 30-40 years.

For example, the National Health and

Nutrition Survey (NHANES) is a national
random sample that has been conducted
periodically by NCHS since the 1960s or
the Behavioral Risk Factor Surveillance
Survey (BRFSS) which is a national random
sample conducted by the CDC.
 What about surveillance of
disease indicators?
Animal populations
Environmental Data
Drug utilization
Public School Absentee Data
Some time Employee records
 Surveying Animal
Populations
Tracking rat
proofing in textile
industries in 1907
Modern carriers of
disease include :
raccoons, ticks,
mosquitoes,
National library of
medicine Images in
oysters, grouper,
Public Health History ducks, etc.
 Surveying the
Environment
Inspection of public
water, milk, and
food supplies (here
a 1907 inspection
of a creamery)

Hazard surveillance
(chemical,
radiation, physical)
National library of medicine
Images in Public Health
History
 Agency for Toxic Substances
and Disease Registry
It is an agency of the U.S. Public Health
Service
It researches and provides data on the
release of hazardous substances
This HazDat Database includes:
Geographical information on the site
Site Characteristics (activities and events)
Contaminants found (media and
concentrations)
Results from Michigan Query:

Query Results: 178 Records Found

Site ID Site Name to_docs to_chems City

County
MID985584549 ABC DRUM  1  82 DETROIT
WAYNE

MID985598978 ABC DRUM  1  135

DETROIT WAYNE
& BARREL
- LANTZ STREET

MID079278115 ABLE FINISHING  1  80 GRAND RAPIDS

KENT
COMPANY
Site ID
abs_doc_title proj_text
Final Date Public Health Threat Category
MID017075136
BROWN H CO INC Public Health Assessment
Apr 18, 1989 Indeterminate Public Health
Hazard
MID017075136
BROWN H CO INC Health Consultation
Jul 15, 1989
MID017075136
BROWN H CO INC Health Consultation
Jan 23, 1990
MID017075136
BROWN H CO INC Public Health Assessment
Oct 28, 1993 Poses Public Health Hazard
MID017075136
H BROWN CO INC Site Review and Update
Poses Public Health Hazard
Query Results: 309 Records Found

Site ID Case ID
Contaminant
Media s_loc_txt
max_conc
conc_unit_txt

MID017075136 000095-50-1
1,2-DICHLOROBENZENE
Sediment, Unspecified Not Reported
NULL NULL

MID017075136 000540-59-0
1,2-DICHLOROETHYLENE
Groundwater, Monitor Onsite
52 ppb
 Surveying Drug Utilization

State health depts and the CDC are the only

sources of some drugs and anti-toxins
including:
Botulism antitoxin
Diptheria antitoxin
Pentamidine
By monitoring requests for the drugs, we can
effectively tally up who and how many people
What weve covered so far is
just the tip of the CDC
iceberg of surveillance
activities. . .
The CDC contains 11 main
institutes:
1. Office of Director

2. Epidemiology Program Office

3. National Center for Chronic Disease
Prevention and Health
Promotion
4. National Center for Environmental
Health
5. National Center for Health Statistics
 6. National Center for HIV, STD, and TB
Prevention
7. National Center for Infectious Diseases
8. National Center for Injury Prevention
and Control
9. National Immunization Program
10. National Institute for Occupational
Safety and Health
11. Public Health Practice Program
Current Surveillance
Programs:
Assisted Reproductive Technology Success
Rates
Behavioral Risk Factor Surveillance System
Birth Defects Surveillance
Cancer Registries Program
HIV/AIDS Surveillance
Pregnancy Risk Assessment Monitoring
System
 National Program in Cancer
Registries
In 1992, Congress established this registry
(Public Law 102-515)
The CDC supports cancer registries in 45
states, 3 territories, and Washington D.C.
CDCs goal of a national standard:
They want 95% of reportable cancer
diagnoses to be reported in these areas.
Less than 3% death certificate only
cases
CDCs National Cancer Registries
 USES OF SURVEILLANCE

The uses of surveillance information can be organized

on the basis of three categories of timeliness:

Immediate, Annual, and Archival

(Thacker and Stroup, 1994)
Immediate Detection is important fo
Epidemics

Newly emerging health problems

Changes in health practices

Changes in antibiotic resistance

Annual Dissemination for:

Estimating the magnitude of the health

problem and its cost

Assessing effectiveness of control

activities

Setting research priorities

Facilitating planning

Monitoring risk factors

Archival information for:

Describing natural history of diseases

Facilitating epidemiological and laboratory

research

Validating use of preliminary data

Setting research priorities

Documenting distribution and spread

 Selected Uses and Illustrative Sources of Public Health Surveillance Data (Slid
Use Selected Data Source Strengths Limitations
Portrait of trends in Vital statistics Essentially Complete Inaccuracies for selected
disease and health Length of history causes; Variation in
reporting across regions
Underreporting for
chronic conditions

Evaluate control Immunization Population-based Confidentially concerns

measures registries Links immunization New data collection
surveillance and system
intervention

Monitor changes in Reporting from Provides lab Incomplete

infectious agents laboratories information Lack of epidemiological
information

Estimate magnitude ofNotifiable diseases Detailed information Incomplete reporting

health problems Low sensitivity for
some diseases
 Selected Uses and Illustrative Sources of Public Health Surveillance Data (Slid
Use Selected Data Source Strengths Limitations

Monitor health practice Hospital discharge data National coverageSample, not enumeratio
Timely; Length of Measures discharges,
history not people; Cannot
detect infrequent event

Plan public health Risk factor surveillance National estimate Sample; Limited
practice epidemiological info.
Self-reported data

Test hypothesis Cancer registries Timely No national coverage

No uniform standards
 Expressing Measures of Disease
Frequency I

Any epidemiological measure can be

expressed as
m per 100 or
m per 1,000 or
m per 10, 000 or
m per 100,000 or etc.
The choice of the multiplier is arbitrary
 Expressing Measures of Disease
Frequency I

For example:
Most people feel comfortable with saying
5% but tend to feel
uncomfortable with 0.005% so
we would tend to express it as 5 per
100,000
 Expressing Measures of Disease
Frequency II

When a statistic is being described or

interpreted, we need to reference
Who -- what population or
subgroup
When -- what time point or
time period
Where -- the geographical location