Current Trends in Surveillance

1. Current Trends in Surveillance Dr. David Mowat Director General Centre for Surveillance Coordination University of Toronto/alPHa 14 March, 2003

2. Overview • 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

3. 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

4. Surveillance is not … • research • evaluation

5. Information on: "health events" • morbidity • mortality • risk factors • threats to health • laboratory diagnosis • adverse events • etc.

6. Information uses: • identifying emerging & re-emerging diseases • monitoring trends • identifying outbreaks • identifying unusual patterns • forecasting • generating hypotheses

7. Information ultimately used for decisions • policies • programs • practice • public

8. actions health events local provincial/territorial national

9. John Snow

10. Natural and Political OBSERVATIONS Mentioned in a following Index, and made upon the Bills of Mortality. By 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

11. New Challenges • new threats e.g. bioterrorism • new concerns e.g. biotechnology • new technologies e.g. genomics

12. ICTs 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

13. Evidence-Based Decision-Making • information on events • information on interventions • information on context

14. Surveillance & Surveillance Infostructure • The infrastructure approach provides; • efficiency • power of integration • flexibility & responsiveness

15. Design Considerations • Start with the business • Make the business explicit • Document the purpose(s) • Choose desired characteristics

16. Developing Data Sources • re-use • "by-product" • "transactional" • preclinical/syndromic

17. ~ ~ IDW W1 W2 Bio-Surveillance Detection Timeline 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 • Detection Analysis Timeline • Non-clinical and behavioral data • Pre-diagnostic clinical data • Diagnostic data Ease of Detecting Bioagent Effects Over Timeline W3 TONSET T0 TSMC T Diagnosis. T Death Bio-Agent Impact Timeline

18. Developing Data Sources • re-use • "by-product" • "transactional" • preclinical/syndromic • intelligence

19. Data Integration • data warehouses • data marts

20. Analysis • power • business intelligence tools OLAP SOLAP presentation tools spatial tools

21. Extracting Meaning • monitoring • alerts

22. Access • connectivity • language • discovery • manipulation • permission

23. Discovery • The "virtual library" • store • classify • search/navigate/browse

24. Inventories • Health Canada • Injury • Environmental • CHAIN

25. databases summary reports daily updates/news bulletins systematic reviews position papers practice guidelines regulatory notices dictionaries, references The Infospace Vision • tools: businessintelligence • Geographic Information System • automated alert function • discovery functions: • inventories • metadata • search/navigation • continuing education • discussion environments • conference, job postings, etc.

26. Recall (March 20) Outbreak recognized (March 16) Schneider's lunchmate outbreak Canada, 1998 Schneider’s recall 1 Number of Cases (March 31) 40 Lunchmate (386) ( < 386 ) 35 No Lunchmate (127) 30 Outbreak recognized (March 25) 25 20 Schneider’s recall 2 (April 9) 15 Cheese recall (April 15) 10 5 0 05-Apr 12-Apr 19-Apr 01-Mar 08-Mar 15-Mar 22-Mar 29-Mar Date of Onset Of Illness N < 513 N=513

27. CIPHS • 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

28. Family teaching, investigation, follow up Child ill Child ill Child ill Child ill Child ill Public Health Nursecalls or visits homes Hospitalvisit Hospitalvisit Hospitalvisit Hospitalvisit Hospitalvisit Outbreak plan becomes operational Alert reportto MOH Coordinate other prov agency investigation Alert reportto Province Is this a national outbreak or one involving CFIA? Food samplesto lab Bench workin Prov lab Bench workin Prov lab Bench workin Prov lab Bench workin Prov lab Bench workin Prov lab Alert reportto HC Supporting end-to-end surveillanceenteric disease

29. Exclusion, immunization, investigation, follow up Child ill Child ill Child ill Child ill Child ill Public Health Nursecalls or visits school Hospitalvisit Hospitalvisit Hospitalvisit Hospitalvisit Hospitalvisit Outbreak plan becomes operational Alert reportto MOH Identify sources of vaccine Alert reportto Province National response; long term work on vaccine strategy Bench workin Prov lab Bench workin Prov lab Bench workin Prov lab Bench workin Prov lab Bench workin Prov lab Alert reportto HC Supporting end-to-end surveillance(vaccine-preventable disease) Immunizationregistry

30. Architecture

31. CD C Standards • “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

32. G. I. S. Geographic data GIS Disease data Denominator data

33. G. I. S. • access to data • tools to download • service • consultation & training

34. Skills 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

35. Skills 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

36. Modules Currently Available • Orientation to Online Learning • Module 1: Basic Epidemiological Concepts • Module 2: Measurement of Health Status • Module 3: Descriptive Epidemiological Methods

37. Key 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.

38. Formats 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.

39. Examples 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