Communicable Disease Epidemiology & Public Health Surveillance: An Overview

Amy D. Sullivan, PhD, MPH Epidemiologist Multnomah County Health Dept.

Unlike a forest fire, in a bioterrorism (BT) event

Seeing the fire requires capturing epidemiologic data Responding requires using that data

Topics in Presentation

Basic principles

Communicable disease epidemiology Public health surveillance

Disease and outbreak reporting (local, state, and federal roles) Adapting for Incident Command System

Basic Principles

Epidemiologic Science
Disagreement and confusion about basic ideas in epidemiology do not necessarily attest to the thick-headedness of epidemiologists; a more charitable interpretation [is] that the basic ideas fundamental to [this] new science have not yet displaced traditional thinking.
Rothman and Greenland, Modern Epidemiology

What Is Epidemiology?
Studying the distribution & determinants of health-related states in specific populations to control health problems

Usually human, but veterinary too Diseases or conditions Demand a set of actions as outcome

Sub-Specialties

Chronic Environmental Social Reproductive Infectious disease

Acute & Communicable Chronic Communicable

Doing Epi

Assess patterns of disease in populations

Identify potential risks for disease Decrease/eliminate risk of disease

Describe disease in population by Person, Place, and Time

Person

How many Clinical characteristics Medical history

Immunization status Age, sex Race/ethnicity/culture

Demographic characteristics

Place and Time

Geographic clustering Association with a point source Clustering in time Rate of development of new cases

Time

Epidemiologic Triad
Host Agent

Environment

Epidemiologic Triad
Host
Person Place & Time Agent

Environment

Epidemiologic Triad
Host

Agent

Environment

Epidemiology in Public Health Practice

Public Health Surveillance Outbreak & illness cluster investigation Special studies
Resolve issues of detection bias or small numbers Program design & evaluation

Public Health Surveillance

Passive vs. Active

Passive Surveillance

Wait for reports to arrive

Active Surveillance

Go out and collect information Example: Medical record reviews

Purposes of Surveillance

Allow assessment of health status of a given population Provide quantitative basis to

Set priorities Define strategies & objectives for action

Evaluate interventions/programs/ outcomes

How Surveillance is Used

Routine Surveillance

Detect cases of disease of public health significance Detect outbreaks and illness clusters Monitor progression of event Assess utility of intervention

Event-specific surveillance

Outbreaks and Clusters

Unusual amount of illness in a given 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 specific meal & have similar symptoms

Smallpox
1 case anywhere in the world

Conditions Under Which Epi Field Investigation Occurs

Situations where

Event unexpected Immediate response required Extent of investigation limited by need for timely intervention

Assess urgency of event

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

Preliminary Response

Symptom profile of initially reported person(s)

Confirm diagnosis Onset dates & duration of illness Demographics, recent travel Pertinent medical history Confirm diagnoses!

Characteristics of affected persons

If others similarly affected

Elements of an Epidemiologic Field 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 prevention measures Write-up & plan for further study

Essential Tasks of Investigation

Investigation

Data collection & analysis

Case interviews & contact tracing

Surveillance

Monitoring

Active surveillance with affected institution(s)

Evaluation of interventions Communications, managing personnel, etc.

Conducting Epi Field Investigations at MCHD

Routine activity for some programs

Communicable Disease Environmental Health STD TB

Large event requires surge capacity

Disease and Outbreak Reporting in Oregon

Disease & Outbreak Reporting in Oregon

Specific conditions defined by Oregon Administrative Rules,

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

Legally required reporting through physicians and labs Passive surveillance

Reported by Physicians
(Excluding STDs)
Anthrax Botulism Brucellosis Campylobacteriosis Cryptosporidiosis Cyclospora infection Diphtheria Escherichia coli (Shiga-tox.) Giardiasis Malaria

OTHER
Animal bites Any Arthropod-borne infection7 HUS Lead poisoning Marine intoxications Any Outbreak of disease Pesticide poisoning Any Uncommon illness of potential public health significance

Haemophilus influenzae
Hantavirus Hepatitis A Hepatitis B Hepatitis C (new infections) Hepatitis D (delta) Legionellosis Leptospirosis Listeriosis Lyme disease

Measles (rubeola) Meningococcal disease Plague Polio Rabies Rubella Pertussis Q fever Salmonellosis (incl. typhoid) Shigellosis Taenia solium/Cysticercosis Tetanus Trichinosis Tuberculosis Tularemia Vibrio infection Yersiniosis

TIMING OF REPORTS
Immediatelyday or night Within 24 hours Within 1 working day Within 1 week

Lab Reportable Only

Tick-borne illnesses

Ehrlichia Rickettsia

Lab reporting often more reliable than physician reporting

Response to Reports

Report or diagnosis confirmed by local Community Health Nurse State receives notification; assists as requested Follow-up locally

Investigative Guidelines

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

Overview of Local, State, and Federal Roles

LHD has public health authority in Oregon State

Track data on public health conditions & reporting federal level Support LHD Liaison with other states and federal National disease reporting data Support state and local health departments Control/release certain pharmaceuticals

Federal

State Structure
Oregon Department of Human Services
Health Services Public Health Office of Disease Prevention and Epidemiology (ODPE) Immunization Program Office of the State Public Health Officer Public Health Preparedness Program Oregon State Public Health Laboratory

Acute & Communicable Disease Program (ACD)

Role of the State in an Investigation

Receive information on reportable condition

Timeframe set out in BT/CD Assurances Notification & summary of findings/actions Counties decide on lead; state assists

Support multi-county investigations

Support/conduct investigation if county resources inadequate

Get LHD agreement

Liaise with CDC

Technical advise, obtain pharmaceuticals/ vaccines, etc

Other Aspects of Local-State Relationship

State not a regulatory agency State does control funds In a declared emergency, State Health Officer has expanded powers

Federal Structure
Secretary & Dep. Secretary of Health U.S. Department of Health and Human Services Asst. Secretary of Health U.S. Public Health Service

Centers for Disease Control And Prevention (CDC) Office of the Director Epidemiology Program Office
State Branch

National Center for Infectious Diseases

National Immunization Prog.

Bacterial and Mycotic Diseases Viral & Rickettsial Diseases

Bioterrorism Preparedness & Response Program Vector-Borne Infectious Diseases Parasitic Diseases

Role of the CDC in an Investigation

Support state and local public health

Technical experts Laboratory testing Pharmaceuticals & vaccines Lead multi-state outbreaks

Coordinate information nationally Liaise with other countries & international organizations

Epi Activities in an ICS Context

Possible BT Event ICS Structure (Epi Functions)

Epidemiology

Branch/Group Case Investigation Hospital Surveillance Contact Tracing

Epidemiology Unit
Demobilization Unit Technical Experts: Epi Training, ID/Med, Personal Protection

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

Planning Section: Epi Planning

Epidemiologic information needed to direct operations

Plan investigation Develop & provide materials & training Assure collection & entry of data from Ops epi field activities Analyze and summarize epi data
Case numbers & disease rates Populations at risk & prophylaxed

Scenario Example

Scenario: First Report

MCHD Communicable Disease Program receives these two reports:

A County jail prisoner has died; 1 staff & 4 other inmates in hospital w/ similar symptoms Local hospital ICP reports 2 ED workers hospitalized with a serious respiratory illness
Symptoms: chills, high fever, body pains, chest discomfort, and a very bad cough

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, but might involve multiple institutions

Preliminary Response: Scenario Example

Symptom profiles

Comparable symptoms among all ill & onsets within 2 days Initial inmate died within 3 days Initial inmate homeless man; arrived in town within 2 days of arrest ED workers worked same shift; recent death in ED on that shift

Characteristics of affected persons

Scenario: Day 2

Corrections:

Dead inmate diagnosed as pneumonic plague; confirmation pending Additional ill

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