The latter three efforts and "syndromic surveillance" projects undertaken by academic colleagues, and the Department of Defense represent a novel approach to early detection surveillance. Syndromic surveillance is an investigational approach to early detection of outbreaks through the monitoring of real-time, electronic data that are screened for indicators of disease as early in the course of illness as possible. Although promising, this approach to public health surveillance has not undergone rigorous evaluation and validation for its usefulness and value. There is still much to be learned about the most useful data sources, analytic strategies, and methods for presenting the information from the multiple possible data sources to State and local health department partners in coherent usable format. This is particularly critical because state and local partners have limited human resources to do follow up investigations on “alerts,” many of which may be false alarms. CDC has taken a leadership role in developing a systematic approach to evaluating syndromic systems, and believes it is critical to undertake such evaluations before these systems can be recommended for widespread use. Other related activities useful for early detection of emerging infections or other critical biological agents include CDC's Emerging Infections Programs (EIP). CDC funds EIP cooperative agreements with state and local health departments to conduct population-based surveillance and research that goes beyond the routine functions of health departments to develop "next generation" surveillance science, and often involve partnerships among public health agencies and academic medical centers. Of note, NEDSS supports many EIP information system needs. In addition, CDC has established other networks of clinicians-- whether infectious disease or travel medicine specialists, or emergency department physicians-- whose functions are to serve as "early warning systems" for public health by providing information about unusual cases CDC's Public Health Surveillance Activities May 5, 2003 encountered in the clinical practices of its members. It is important to note that these relationships, particularly between health care providers and local health departments, are the foundation on which our surveillance systems operate. The state and local health department is the front-line of defense for the public health system. Emergency Preparedness In addition to these efforts, CDC is enhancing its capacity to detect unusual clusters of illness, whether from intentional threats or naturally occurring problems such as SARS, by building upon a long history of successful surveillance collaborations with healthcare providers. Through a collaboration with our public health partners and the American Association of Health Plans (AAHP), CDC is working with epidemiologists and experts in informatics at Harvard Pilgrim Health Care to create a system of access to real-time electronic ambulatory care data through the National Bioterrorism Syndromic Surveillance Demonstration Program (NBSSDP). This program, which expands a successful project operating in Massachusetts since late 2001, targets geographically oriented information about possible clusters of specific health events to State health departments within 24 hours or less. The program makes use of information both from local health plans and from a national telephone triage system, in which nurses screen calls from health plan members. The systems currently participating in the program serve over 20 million people throughout the U.S. Expansion to local health plans in Minnesota and Colorado are first, with on-line reports to health departments and CDC from sites outside Massachusetts scheduled to begin on or about May 1. Incorporation of nurse call data from all 50 states is expected soon thereafter, to be followed by data from health plans in Texas and California. To ensure that the needs of the public health system are integrated into this program at every stage, an advisory group with active participation by State health officials guides the implementation of CDC's Public Health Surveillance Activities May 5, 2003 data collection and reporting activities. In addition to early warnings of a bioterrorist attack, this system should prove invaluable in facilitating the daily surveillance work of State and local health departments. CDC is working to make parts of this system available now to address our public health partners' needs for managing possible responses to the SARS epidemic: Global Disease Surveillance Since 1994, CDC has been engaged in a nationwide effort to revitalize national capacity to protect the public from infectious diseases. The emergence of SARS, a previously unrecognized microbial threat, has provided a strong reminder of the threat posed by emerging infectious diseases. In March 2003, the Institute of Medicine (IOM) published Microbial Threats to Health: Emergence, Detection, and Response, a report describing the spectrum of microbial threats to national and global health, factors affecting their emergence or resurgence, and measures needed to address them effectively. Although much progress has been made, especially in the areas of strengthened surveillance and laboratory capacity, the IOM recommends much remains to be done both domestically and internationally. In many countries, participation in disease surveillance outside of their borders is not a major health priority. For these countries, control of endemic diseases - major killers of children - is a far more urgent need. From a global health perspective, however, the capability of these countries to recognize and report disease outbreaks is crucial because new diseases are most likely to emerge in poor rural areas where disease rates are high. The WHO International Health Regulations that are currently being revised are expected to address countries' abilities to detect and respond to events of international health importance. CDC's Public Health Surveillance Activities May 5, 2003 CDC is intensifying its efforts to work with the World Health Organization (WHO) and other partners to create a comprehensive global network that detects and controls local outbreaks before they grow into worldwide pandemics. Currently, there are Field Epidemiology Training Programs (FETP's) in 30 countries throughout the world that support disease detection activities and provide an essential link in global surveillance. These FETP's have been developed under the auspices of CDC and with the support of WHO. They are modeled after the Epidemic Intelligence Service (EIS) training program which focuses its attention on epidemiology and surveillance and their application as a means to control an outbreak and to prevent further disease spread. Additionally, there is a concerted effort to develop and expand other fledgling regional disease surveillance networks that include less developed nations as members. These networks, which can build on the established FETP's or on their model, include the Caribbean Epidemiology Center's disease surveillance network, the Amazon and Southern Cone networks in South America, the Integrated Disease Surveillance and Epidemic Preparedness and Response Project in Africa, and the Mekong Basin Disease Surveillance system in Southeast Asia. In the years ahead, these regional disease surveillance networks are likely to grow in number and geographical scope. Over the long-run, these networks can expand, interact, and become the building blocks of a worldwide "network of networks” that monitors priority diseases of global concern, including pandemic influenza, drug-resistant diseases, and diseases cause by biological agents. They will also provide early warning of new and re-emerging threats. CDC has also created two International Emerging Infections Programs (IEIPs)--one in Thailand (established in 2001) and one in Kenya (scheduled to open in 2003)--that are modeled on the domestic EIP Programs described earlier that have been so successful in the United States. The IEIPs will serve a double purpose: fostering the next generation of international public health leaders while providing high quality disease surveillance data and rapid response capacity for new and emerging diseases. A pilot IEIP site- established in Bangkok in 2001 as a collaboration CDC's Public Health Surveillance Activities May 5, 2003 with the Thai Ministry of Public Health (MOPH) is currently serving as a regional hub for CDC's SARS control activities in Asia, coordinating the shipment of diagnostic specimens from Taiwan, Thailand, and Vietnam, and deploying staff, as requested, to Hong Kong, Laos, and Taiwan. When SARS occurred in Thailand on March 11, carried by an arriving airline passenger, the IEIP was able to respond within minutes by isolating the passenger at the airport and implementing strict infection control procedures at the hospital. These procedures remained in place over the subsequent 3 weeks and no health care workers or other community members became infected. Within hours the IEIP began assisting the Thai MOPH, and WHO to contain transmission at other hospitals, implement a nationwide SARS surveillance system, and train public health workers in appropriate control measures. Further, there is an FETP located in China (CFETP) which has taken a significant lead on the management and control of the SARS outbreak there. Teams of epidemiologists and other scientists were assembled to investigate and direct the national response to the ongoing epidemic. A CFETP trainee is included on these teams. These trainees have had a role in coordinating the surveillance efforts required to track and stem the outbreak of cases. Chinese health officials credit the ability to draw on the FETP staff and trainees and their medical expertise regarding epidemiology and surveillance with helping to prevent the uncontrollable spread of SARS in at least one of China's most densely populated provinces. Additionally, two years ago, during the anthrax investigation in the United States, the Bangkok IEIP responded to requests for advice, diagnostics, and testing of suspected materials not only from the Thai MOPH, but also from U.S. embassies in other Asian countries. Global programs like the IEIP and the FETP's builds in-country public health expertise to diagnose or rule out known diseases and to recognize and report new or unusual illnesses to the global community. CDC's Public Health Surveillance Activities May 5, 2003 |