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1.  Syndromic Surveillance from a Local Perspective – A Review of the Literature 
Objective
Review of the origins and evolution of the field of syndromic surveillance. Compare the goals and objectives of public health surveillance and syndromic surveillance in particular. Assess the science and practice of syndromic surveillance in the context of public health and national security priorities. Evaluate syndromic surveillance in practice, using case studies from the perspective of a local public health department.
Introduction
Public health disease surveillance is defined as the ongoing systematic collection, analysis and interpretation of health data for use in the planning, implementation and evaluation of public health, with the overarching goal of providing information to government and the public to improve public health actions and guidance [1,2]. Since the 1950s, the goals and objectives of disease surveillance have remained consistent [1]. However, the systems and processes have changed dramatically due to advances in information and communication technology, and the availability of electronic health data [2,3]. At the intersection of public health, national security and health information technology emerged the practice of syndromic surveillance [3].
Methods
To better understand the current state of the field, a review of the literature on syndromic surveillance was conducted: topics and keywords searched through PubMed and Google Scholar included biosurveillance, bioterrorism detection, computerized surveillance, electronic disease surveillance, situational awareness and syndromic surveillance, covering the areas of practice, research, preparedness and policy. This literature was compared with literature on traditional epidemiologic and public health surveillance. Definitions, objectives, methods and evaluation findings presented in the literature were assessed with a focus on their relevance from a local perspective, particularly as related to syndromic surveillance systems and methods used by the New York City Department of Health and Mental Hygiene in the areas of development, implementation, evaluation, public health practice and epidemiological research.
Results
A decade ago, the objective of syndromic surveillance was focused on outbreak and bioterrorism early-event detection (EED). While there have been clear recommendations for evaluation of syndromic surveillance systems and methods, the original detection paradigm for syndromic surveillance has not been adequately evaluated in practice, nor tested by real world events (ie, the systems have largely not ‘detected’ events of public health concern). In the absence of rigorous evaluation, the rationale and objectives for syndromic surveillance have broadened from outbreak and bioterrorism EED, to include all causes and hazards, and to encompass all data and analyses needed to achieve “situational awareness”, not simply detection. To evaluate current practices and provide meaningful guidance for local syndromic surveillance efforts, it is important to understand the emergence of the field in the broader context of public health disease surveillance. And it is important to recognize how the original stated objectives of EED have shifted in relation to actual evaluation, recommendation, standardization and implementation of syndromic systems at the local level.
Conclusions
Since 2001, the field of syndromic surveillance has rapidly expanded, following the dual requirements of national security and public health practice. The original objective of early outbreak or bioterrorism event detection remains a core objective of syndromic surveillance, and systems need to be rigorously evaluated through comparison of consistent methods and metrics, and public health outcomes. The broadened mandate for all-cause situation awareness needs to be focused into measureable public health surveillance outcomes and objectives that are consistent with established public health surveillance objectives and relevant to the local practice of public health [2].
PMCID: PMC3692931
evaluation; biosurveillance; situational awareness; syndromic surveillance; local public health
2.  Microcomputers and the future of epidemiology. 
Public Health Reports  1994;109(3):439-441.
The Workshop on Microcomputers and the Future of Epidemiology was held March 8-9, 1993, at the Turner Conference Center, Atlanta, GA, with 130 public health professionals participating. The purpose of the workshop was to define microcomputer needs in epidemiology and to propose future initiatives. Thirteen groups representing public health disciplines defined their needs for better and more useful data, development of computer technology appropriate to epidemiology, user support and human infrastructure development, and global communication and planning. Initiatives proposed were demonstration of health surveillance systems, new software and hardware, computer-based training, projects to establish or improve data bases and community access to data bases, improved international communication, conferences on microcomputer use in particular disciplines, a suggestion to encourage competition in the production of public-domain software, and longrange global planning for epidemiologic computing and data management. Other interested groups are urged to study, modify, and implement those ideas.
PMCID: PMC1403510  PMID: 7910692
3.  Steps to a Sustainable Public Health Surveillance Enterprise
A Commentary from the International Society for Disease Surveillance 
More than a decade into the 21st century, the ability to effectively monitor community health status, as well as forecast, detect, and respond to disease outbreaks and other events of public health significance, remains a major challenge. As an issue that affects population health, economic stability, and global security, the public health surveillance enterprise warrants the attention of decision makers at all levels.
Public health practitioners responsible for surveillance functions are best positioned to identify the key elements needed for creating and maintaining effective and sustainable surveillance systems. This paper presents the recommendations of the Sustainable Surveillance Workgroup convened by the International Society for Disease Surveillance (ISDS) to identify strategies for building, strengthening, and maintaining surveillance systems that are equipped to provide data continuity and to handle both established and new data sources and public health surveillance practices.
doi:10.5210/ojphi.v5i2.4703
PMCID: PMC3733763  PMID: 23923095
disease surveillance; enterprise; sustainable; policy; information technology; epidemiology
4.  Update from CDC’s Public Health Surveillance & Informatics Program Office (PHSIPO) 
Objective
To provide updates on current activities and future directions for the National Notifiable Diseases Surveillance System (NNDSS), BioSense 2.0, and the Behavioral Risk Factor Surveillance System (BRFSS) and on the role of PHSIPO as the “home” at CDC for addressing cross-cutting issues in surveillance and informatics practice.
Introduction
The practice of public health surveillance is evolving as electronic health records (EHRs) and automated laboratory information systems are increasing adopted, as new approaches for health information exchange are employed, and as new health information standards affect the entire cascade of surveillance information flow. These trends have been accelerated by the Federal program to promote the Meaningful Use of electronic health records, which includes explicit population health objectives. The growing use of Internet “cloud” technology provides new opportunities for improving information sharing and for reducing surveillance costs. Potential benefits include not only faster and more complete surveillance but also new opportunities for providing population health information back to clinicians.
For public health surveys, new Internet-based sampling and survey methods hold the promise of complementing existing telephone-based surveys, which have been plagued by declining response rates despite the addition of cell-phone sampling. While new technologies hold promise for improving surveillance practice, there are multiple challenges, including constraints on public health budgets and the workforce. This panel will explore how PHSIPO is addressing these opportunities and challenges.
Methods
Panelists will provide updates on 1) PHSIPO’s role in engaging health departments, the organizations that represent them, and CDC programs in shaping national policies for implementing the Meaningful Use program, 2) how the BioSense 2.0 program is supporting growth in syndromic surveillance capacity, including its partnership with ISDS in developing standards for syndromic surveillance as part of Meaningful Use, 3) improvements that are underway in strengthening the NNDSS, including efforts to improve CDC’s support for health department disease reporting systems and to develop a “shared services” approach that could provide a platform for streamlining the exchange of information between health departments and CDC, 4) pilot development of Internet-based panels of survey volunteers to supplement existing telephone-based sampling in the BRFSS and of approaches to extend BRFSS survey information through consent-based linkage of survey responses to selected measures recorded in respondents’ EHRs.
Results
Potential questions or discussion points that might arise include: What can or should be done to assure that the population health objectives of Meaningful Use are fulfilled? What are the lessons learned to date in leveraging investments in the Meaningful Use of EHRs to improve disease reporting and syndromic surveillance systems? What are the next steps in developing BioSense 2.0 to assure that it leads to strengthened surveillance capacity at both state/local and regional/national levels? How can insights from the BioSense redesign be applied to improve case reporting and other surveillance capacities? What is CDC doing to address states’ concerns about the growing number of CDC surveillance systems? How will national discussions about the future of public health affect the future surveillance practice? What can be done to assure the ongoing representativeness of population health surveys? Is it feasible to link BRFSS responses to information obtained from EHRs? How can data from surveillance become part of the real-time evidence base for clinical decision making?
Conclusions
The intended outcome of the panel is to foster a conversation between the panelists and the audience, to inform the audience about recent developments in PHSIPO, to obtain insights from the audience about innovations and ideas arising from their experience, and to generate new ideas for approaches to meeting the needs of public health for surveillance information.
PMCID: PMC3692948
Surveillance; BioSense 2.0; Notifiable Diseases; BRFSS—Behavioral Risk Factor Surveillance System
5.  Comprehensive effective and efficient global public health surveillance 
BMC Public Health  2010;10(Suppl 1):S3.
At a crossroads, global public health surveillance exists in a fragmented state. Slow to detect, register, confirm, and analyze cases of public health significance, provide feedback, and communicate timely and useful information to stakeholders, global surveillance is neither maximally effective nor optimally efficient. Stakeholders lack a globa surveillance consensus policy and strategy; officials face inadequate training and scarce resources.
Three movements now set the stage for transformation of surveillance: 1) adoption by Member States of the World Health Organization (WHO) of the revised International Health Regulations (IHR[2005]); 2) maturation of information sciences and the penetration of information technologies to distal parts of the globe; and 3) consensus that the security and public health communities have overlapping interests and a mutual benefit in supporting public health functions. For these to enhance surveillance competencies, eight prerequisites should be in place: politics, policies, priorities, perspectives, procedures, practices, preparation, and payers.
To achieve comprehensive, global surveillance, disparities in technical, logistic, governance, and financial capacities must be addressed. Challenges to closing these gaps include the lack of trust and transparency; perceived benefit at various levels; global governance to address data power and control; and specified financial support from globa partners.
We propose an end-state perspective for comprehensive, effective and efficient global, multiple-hazard public health surveillance and describe a way forward to achieve it. This end-state is universal, global access to interoperable public health information when it’s needed, where it’s needed. This vision mitigates the tension between two fundamental human rights: first, the right to privacy, confidentiality, and security of personal health information combined with the right of sovereign, national entities to the ownership and stewardship of public health information; and second, the right of individuals to access real-time public health information that might impact their lives.
The vision can be accomplished through an interoperable, global public health grid. Adopting guiding principles, the global community should circumscribe the overlapping interest, shared vision, and mutual benefit between the security and public health communities and define the boundaries. A global forum needs to be established to guide the consensus governance required for public health information sharing in the 21st century.
doi:10.1186/1471-2458-10-S1-S3
PMCID: PMC3005575  PMID: 21143825
6.  Incorporation of School Absenteeism Data into the Maryland Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) 
Objective
The state of Maryland has incorporated 100% of its public school systems into a statewide disease surveillance system. This session will discuss the process, challenges, and best practices for expanding the ESSENCE system to include school absenteeism data as part of disease surveillance. It will also discuss the plans that Maryland has for using this new data source, as well as the potential for further expansion.
Introduction
Syndromic surveillance offers the potential for earlier detection of bioterrorism, outbreaks, and other public health emergencies than traditional disease surveillance. The Maryland Department of Health and Mental Hygiene (DHMH) Office of Preparedness and Response (OP&R) conducts syndromic surveillance using the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE). Since its inception, ESSENCE has been a vital tool for DHMH, providing continuous situational awareness for public health policy decision makers. It has been established in the public health community that syndromic surveillance data, including school absenteeism data, has efficacy in monitoring disease, and specifically, influenza activity. Schools have the potential to play a major role in the spread of disease during an epidemic. Therefore, having school absenteeism data in ESSENCE would provide the opportunity to monitor schools throughout the school year and take appropriate actions to mitigate infections and the spread of disease.
Methods
DHMH partnered with the Maryland State Department of Education (MSDE), local health departments, and local school systems to incorporate school absenteeism data into the syndromic surveillance program. There are 24 local public school systems and 24 local health departments in the state of Maryland. OP&R contacted each local school superintendent and each local health officer to arrange a joint meeting to discuss the expansion of the ESSENCE program to include school absenteeism data. Once the meetings were arranged, OP&R epidemiologists traveled to each local jurisdiction and presented their plan for the ESSENCE expansion. At each meeting were representatives from the local health department, as well as school health, school attendance, and school IT staff. This allowed all questions and concerns to be addressed from both sides. In addition to the targeted meetings and presentations, the Secretary of Health issued an executive order which required all local school systems to sign a memorandum of understanding (MOU) with DHMH. This MOU detailed the data elements to be shared with the ESSENCE program and the process by which this would be shared. While this order made data contribution mandatory, the site visits by the OP&R staff created a working relationship and partnership with the local jurisdictions. Data was collected from all public schools in the state including elementary, middle, and high schools.
Results
As of June 30, 2012, Maryland became the first state in the United States to incorporate 100% of its public school systems (1,424 schools) into ESSENCE. Each school system reports absenteeism data daily via an automated secure FTP (sFTP) transfer to DHMH. Due to its unique properties, Johns Hopkins Applied Physics Laboratory (JHUAPL) designed a new detection algorithm in ESSENCE specifically for this data source. OP&R epidemiologist review and analyze this data for disease surveillance purposes in conjunction with other data sources in ESSENCE (emergency department chief complaints, poison control center data, thermometer sales data, and over-the-counter medication sales data). Integrating school absenteeism data will provide a more complete analysis of potential public health threats. The process by which Maryland incorporated their public school systems’ data could potentially be used as a best practice for other jurisdictions. Not only was DHMH able to obtain data from all public schools in the state, but the process also enhanced collaboration between local health departments and public school systems.
PMCID: PMC3692827
ESSENCE; Surveillance; Absenteeism
7.  Effective State-Based Surveillance for Multidrug-Resistant Organisms Related to Health Care-Associated Infections 
Public Health Reports  2011;126(2):176-185.
SYNOPSIS
In September 2008, the Council of State and Territorial Epidemiologists and the Centers for Disease Control and Prevention sponsored a meeting of public health and infection-control professionals to address the implementation of surveillance for multidrug-resistant organisms (MDROs)—particularly those related to health care-associated infections. The group discussed the role of health departments and defined goals for future surveillance activities. Participants identified the following main points: (1) surveillance should guide prevention and infection-control activities, (2) an MDRO surveillance system should be adaptable and not organism specific, (3) new systems should utilize and link existing systems, and (4) automated electronic laboratory reporting will be an important component of surveillance but will take time to develop. Current MDRO reporting mandates and surveillance methods vary across states and localities. Health departments that have not already done so should be proactive in determining what type of system, if any, will fit their needs.
PMCID: PMC3056030  PMID: 21387947
8.  Identification and Assessment of Public Health Surveillance Gaps under the IHR (2005) 
Objective
To conceive and develop a model to identify gaps in public health surveillance performance and provide a toolset to assess interventions, cost, and return on investment (ROI).
Introduction
Under the revised International Health Regulations (IHR [2005]) one of the eight core capacities is public health surveillance. In May 2012, despite a concerted effort by the global community, the World Health Organization (WHO) reported out that a significant number of member states would not achieve targeted capacity in the IHR (2005) surveillance core capacity.
Currently, there is no model to identify and measure these gaps in surveillance performance. Likewise, there is no toolset to assess interventions by cost and estimate the ROI.
We developed a new conceptual framework that: (1) described the work practices to achieve effective and efficient public health surveillance; (2) could identify impediments or gaps in performance; and (3) will assist program managers in decision making.
Methods
Published articles and grey-literature reports, manuals and logic model examples were gathered through a literature review of PubMed, Web of Science, Google Scholar, and other databases. Logic models were conceived by categorizing discrete surveillance inputs, activities, outputs, and outcomes. Indicators were selected from authoritative sources or developed and then mapped to the logic model elements. These indicators will be weighted using the principle component analysis (PCA), a method for enhanced precision of statistical analysis. Finally, on the front end of the tool, indicators will graphically measure the surveillance gap expressed through the tool’s architecture and provide information using an integrated cost-impact analysis.
Results
We developed five public health surveillance logic models: for IHR (2005) compliance; event-based; indicator-based; syndromic; and predictive surveillance domains. The IHR (2005) domain focused on national-level functionality, and the others described the complexities of their specific surveillance work practices. Indicators were then mapped and linked to all logic model elements.
Conclusions
This new framework, intended for self-administration at the national and subnational levels, measured public health surveillance gaps in performance and provided cost and ROI information by intervention. The logic model framework and PCA methodology are tools that both describe work processes and define appropriate variables used for evaluation. However, both require real-world data. We recommend pilot testing and validation of this new framework. Once piloted, the framework could be adapted for the other IHR (2005) core capacities.
PMCID: PMC3692929
Public health surveillance; Evaluation; IHR (2005); Gaps assessment; Cost-impact analysis
9.  The epidemiology and surveillance response to pandemic influenza A (H1N1) among local health departments in the San Francisco Bay Area 
BMC Public Health  2013;13:276.
Background
Public health surveillance and epidemiologic investigations are critical public health functions for identifying threats to the health of a community. Very little is known about how these functions are conducted at the local level. The purpose of the Epidemiology Networks in Action (EpiNet) Study was to describe the epidemiology and surveillance response to the 2009 pandemic influenza A (H1N1) by city and county health departments in the San Francisco Bay Area in California. The study also documented lessons learned from the response in order to strengthen future public health preparedness and response planning efforts in the region.
Methods
In order to characterize the epidemiology and surveillance response, we conducted key informant interviews with public health professionals from twelve local health departments in the San Francisco Bay Area. In order to contextualize aspects of organizational response and performance, we recruited two types of key informants: public health professionals who were involved with the epidemiology and surveillance response for each jurisdiction, as well as the health officer or his/her designee responsible for H1N1 response activities. Information about the organization, data sources for situation awareness, decision-making, and issues related to surge capacity, continuity of operations, and sustainability were collected during the key informant interviews. Content and interpretive analyses were conducted using ATLAS.ti software.
Results
The study found that disease investigations were important in the first months of the pandemic, often requiring additional staff support and sometimes forcing other public health activities to be put on hold. We also found that while the Incident Command System (ICS) was used by all participating agencies to manage the response, the manner in which it was implemented and utilized varied. Each local health department (LHD) in the study collected epidemiologic data from a variety of sources, but only case reports (including hospitalized and fatal cases) and laboratory testing data were used by all organizations. While almost every LHD attempted to collect school absenteeism data, many respondents reported problems in collecting and analyzing these data. Laboratory capacity to test influenza specimens often aided an LHD’s ability to conduct disease investigations and implement control measures, but the ability to test specimens varied across the region and even well-equipped laboratories exceeded their capacity. As a whole, the health jurisdictions in the region communicated regularly about key decision-making (continued on next page) (continued from previous page) related to the response, and prior regional collaboration on pandemic influenza planning helped to prepare the region for the novel H1N1 influenza pandemic. The study did find, however, that many respondents (including the majority of epidemiologists interviewed) desired an increase in regional communication about epidemiology and surveillance issues.
Conclusion
The study collected information about the epidemiology and surveillance response among LHDs in the San Francisco Bay Area that has implications for public health preparedness and emergency response training, public health best practices, regional public health collaboration, and a perceived need for information sharing.
doi:10.1186/1471-2458-13-276
PMCID: PMC3681650  PMID: 23530722
Influenza A (H1N1); Epidemiology; Surveillance; Public health preparedness; Public health emergency response
10.  SAGES Update: Electronic Disease Surveillance in Resource-Limited Settings 
Objective
The Suite for Automated Global Electronic bioSurveillance (SAGES) is a collection of modular, flexible, open-source software tools for electronic disease surveillance in resource-limited settings. This demonstration will illustrate several new innovations and update attendees on new users in Africa and Asia.
Introduction
The new 2005 International Health Regulations (IHR), a legally binding instrument for all 194 WHO member countries, significantly expanded the scope of reportable conditions and are intended to help prevent and respond to global public health threats. SAGES aims to improve local public health surveillance and IHR compliance with particular emphasis on resource-limited settings. More than a decade ago, in collaboration with the US Department of Defense (DoD), the Johns Hopkins University Applied Physics Laboratory (JHU/APL) developed the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE). ESSENCE collects, processes, and analyzes non-traditional data sources (i.e. chief complaints from hospital emergency departments, school absentee data, poison control center calls, over-the-counter pharmaceutical sales, etc.) to identify anomalous disease activity in a community. The data can be queried, analyzed, and visualized both temporally and spatially by the end user. The current SAGES initiative leverages the experience gained in the development of ESSENCE, and the analysis and visualization components of SAGES are built with the same features in mind.
Methods
SAGES tools are organized into four categories: 1) data collection, 2) analysis & visualization, 3) communications, and 4) modeling/simulation/evaluation. Within each category, SAGES offers a variety of tools compatible with surveillance needs and different types or levels of information technology infrastructure. SAGES tools are built in a modular nature, which allows for the user to select one or more tools to enhance an existing surveillance system or use the tools en masse for an end-to-end electronic disease surveillance capability. Thus, each locality can select tools from SAGES based upon their needs, capabilities, and existing systems to create a customized electronic disease surveillance system. New OpenESSENCE developments include improved data query ability, improved mapping functionality, and enhanced training materials. New cellular phone developments include the ability to concatenate single SMS messages sent by simple or Smart Android cell phones. This ‘multiple-SMS’ message ability allows use of SMS technology to send and receive health information exceeding normal SMS message length in a manner transparent to the users.
Conclusions
The SAGES project is intended to enhance electronic disease surveillance capacity in resource-limited settings around the world. We have combined electronic disease surveillance tools developed at JHU/APL with other freely-available, interoperable software tools to create SAGES. We believe this suite of tools will facilitate local and regional electronic disease surveillance, regional public health collaborations, and international disease reporting. SAGES development, funded by the US Armed Forces Health Surveillance Center, continues as we add new international collaborators. SAGES tools are currently deployed in locations in Africa, Asia and South America, and are offered to other interested countries around the world.
PMCID: PMC3692858
software; surveillance; electronic; open-source
11.  Surveillance for pneumonic plague in the United States during an international emergency: a model for control of imported emerging diseases. 
Emerging Infectious Diseases  1996;2(1):30-36.
In September 1994, in response to a reported epidemic of plague in India, the Centers for Disease Control and Prevention (CDC) enhanced surveillance in the United States for imported pneumonic plague. Plague information materials were rapidly developed and distributed to U.S. public health officials by electronic mail, facsimile, and expedited publication. Information was also provided to medical practitioners and the public by recorded telephone messages and facsimile transmission. Existing quarantine protocols were modified to effect active surveillance for imported plague cases at U.S. airports. Private physicians and state and local health departments were relied on in a passive surveillance system to identify travelers with suspected plague not detected at airports. From September 27 to October 27, the surveillance system identified 13 persons with suspected plague; no case was confirmed. This coordinated response to an international health emergency may serve as a model for detecting other emerging diseases and preventing their importation.
PMCID: PMC2639812  PMID: 8964057
12.  Establishing a nationwide emergency department-based syndromic surveillance system for better public health responses in Taiwan 
BMC Public Health  2008;8:18.
Background
With international concern over emerging infectious diseases (EID) and bioterrorist attacks, public health is being required to have early outbreak detection systems. A disease surveillance team was organized to establish a hospital emergency department-based syndromic surveillance system (ED-SSS) capable of automatically transmitting patient data electronically from the hospitals responsible for emergency care throughout the country to the Centers for Disease Control in Taiwan (Taiwan-CDC) starting March, 2004. This report describes the challenges and steps involved in developing ED-SSS and the timely information it provides to improve in public health decision-making.
Methods
Between June 2003 and March 2004, after comparing various surveillance systems used around the world and consulting with ED physicians, pediatricians and internal medicine physicians involved in infectious disease control, the Syndromic Surveillance Research Team in Taiwan worked with the Real-time Outbreak and Disease Surveillance (RODS) Laboratory at the University of Pittsburgh to create Taiwan's ED-SSS. The system was evaluated by analyzing daily electronic ED data received in real-time from the 189 hospitals participating in this system between April 1, 2004 and March 31, 2005.
Results
Taiwan's ED-SSS identified winter and summer spikes in two syndrome groups: influenza-like illnesses and respiratory syndrome illnesses, while total numbers of ED visits were significantly higher on weekends, national holidays and the days of Chinese lunar new year than weekdays (p < 0.001). It also identified increases in the upper, lower, and total gastrointestinal (GI) syndrome groups starting in November 2004 and two clear spikes in enterovirus-like infections coinciding with the two school semesters. Using ED-SSS for surveillance of influenza-like illnesses and enteroviruses-related infections has improved Taiwan's pandemic flu preparedness and disease control capabilities.
Conclusion
Taiwan's ED-SSS represents the first nationwide real-time syndromic surveillance system ever established in Asia. The experiences reported herein can encourage other countries to develop their own surveillance systems. The system can be adapted to other cultural and language environments for better global surveillance of infectious diseases and international collaboration.
doi:10.1186/1471-2458-8-18
PMCID: PMC2249581  PMID: 18201388
13.  Electronic public health surveillance in developing settings: meeting summary 
BMC Proceedings  2008;2(Suppl 3):S1.
In some high-income countries, public health surveillance includes systems that use computer and information technology to monitor health data in near-real time, facilitating timely outbreak detection and situational awareness. In September 2007, a meeting convened in Bangkok, Thailand to consider the adaptation of near-real time surveillance methods to developing settings. Thirty-five participants represented Ministries of Health, universities, and militaries in 13 countries, and the World Health Organization (WHO). The keynote presentation by a WHO official underscored the importance of improved national capacity for epidemic surveillance and response under the new International Health Regulations, which entered into force in June 2007. Other speakers presented innovative electronic surveillance systems for outbreak detection and disease reporting in developing countries, and methodologies employed in near-real time surveillance systems in the United States. During facilitated small- and large-group discussion, participants identified key considerations in four areas for adapting near-real time surveillance to developing settings: software, professional networking, training, and data acquisition and processing. This meeting was a first step in extending the benefits of near-real time surveillance to developing settings. Subsequent steps should include identifying funding and partnerships to pilot-test near-real time surveillance methods in developing areas.
PMCID: PMC2587694  PMID: 19025678
14.  Implications of ICD-9/10 CM Transition for Public Health Surveillance: Challenges, Opportunities, and Lessons Learned from Multiple Sectors of Public Health 
Objective
To provide a forum for local, state, federal, and international public health/health care sectors to share promising practices and lessons learned in transitioning their organizations in the use of ICD-9 to ICD-10 codes for their respective surveillance activities.
Introduction
This roundtable will provide forum for a diverse set of representatives from the local, state, federal and international public health care sectors to share tools, resources, experiences, and promising practices regarding the potential impact of the transition on their surveillance activities. This forum will promote the sharing of lessons learned, foster collaborations, and facilitate the reuse of existing resources without having to “reinvent the wheel”. It is hope that this roundtable will lay the ground-work for a more formal, collaborative, and sustainable venue within ISDS to aid in preparing the public health surveillance community for the coming ICD-9/10 CM transition.
Methods
The moderators will engage the participants in the discussion through dialogue in how their programs are currently using ICD-9 CM codes for surveillance and how the transition will impact their respective programs.
PMCID: PMC3692847
ICD-9; ICD-10; Transition
15.  Enhanced Surveillance during the Democratic National Convention, Charlotte, NC 
Objective
To describe how the existing state syndromic surveillance system (NC DETECT) was enhanced to facilitate surveillance conducted at the Democratic National Convention in Charlotte, North Carolina from August 31, 2012 to September 10, 2012.
Introduction
North Carolina hosted the 2012 Democratic National Convention, September 3–6, 2012. The NC Epidemiology and Surveillance Team was created to facilitate enhanced surveillance for injuries and illnesses, early detection of outbreaks during the DNC, assist local public health with epidemiologic investigations and response, and produce daily surveillance reports for internal and external stakeholders. Surveillane data were collected from several data sources, including North Carolina Electronic Disease Surveillance System (NC EDSS), triage stations, and the North Carolina Disease Event Tracking and Epidemiologic Collection Tool (NC DETECT).
NC DETECT was created by the North Carolina Division of Public Health (NC DPH) in 2004 in collaboration with the Carolina Center for Health Informatics (CCHI) in the UNC Department of Emergency Medicine to address the need for early event detection and timely public health surveillance in North Carolina using a variety of secondary data sources. The data from emergency departments, the Carolinas Poison Center, the Pre-hospital Medical Information System (PreMIS) and selected Urgent Care Centers were available for monitoring by authorized users during the DNC.
Methods
Within NC DETECT, new dashboards were created that allowed epidemiologists to monitor ED visits and calls to the poison center in the Charlotte area, the greater Cities Readiness Initiative region and the entire state for infectious disease signs and symptoms, injuries and any mention of bioterrorism agents. The dashboards also included a section to view user comments on the information presented in NC DETECT. Data processing changes were also made to improve the timeliness of the EMS data received from PreMIS.
Results
The DNC dashboards added to NC DETECT streamlined the workflow by placing all syndromes and annotations of interest in one place, with the date ranges and locations already pre-selected. Graphs in the dashboards could be easily copied and pasted into situation reports. The prompt development of these user-friendly tools provided effective surveillance for this mass gathering and ensured timely control measures, if necessary.
Conclusions
Syndromic surveillance systems can be enhanced to provide detailed, specific surveillance during mass gathering events. Elements that facilitate this enhancement include strong communication between skilled users and the informatics team, in order to minimize the burden placed on the surveillance team system users, data sources and system developers during the event. The visualizations developed as part of these new dashboards will be leveraged to provide additional tools to other NC DETECT user groups, including hospital-based public health epidemiologists and local health department users.
PMCID: PMC3692843
dashboards; enhanced surveillance; Democratic National Convention
16.  International Health Regulations (2005) and the U.S. Department of Defense: building core capacities on a foundation of partnership and trust 
BMC Public Health  2010;10(Suppl 1):S4.
A cornerstone of effective global health surveillance programs is the ability to build systems that identify, track and respond to public health threats in a timely manner. These functions are often difficult and require international cooperation given the rapidity with which diseases cross national borders and spread throughout the global community as a result of travel and migration by both humans and animals. As part of the U.S. Armed Forces Health Surveillance Center (AFHSC), the Department of Defense’s (DoD) Globa Emerging Infections Surveillance and Response System (AFHSC-GEIS) has developed a global network of surveillance sites over the past decade that engages in a wide spectrum of support activities in collaboration with host country partners. Many of these activities are in direct support of International Health Regulations (IHR[2005]). The network also supports host country military forces around the world, which are equally affected by these threats and are often in a unique position to respond in areas of conflict or during complex emergencies. With IHR(2005) as the guiding framework for action, the AFHSC-GEIS network of international partners and overseas research laboratories continues to develop into a far-reaching system for identifying, analyzing and responding to emerging disease threats.
doi:10.1186/1471-2458-10-S1-S4
PMCID: PMC3005576  PMID: 21143826
17.  Evaluation of Vocabularies for Electronic Laboratory Reporting to Public Health Agencies 
Clinical laboratories and clinicians transmit certain laboratory test results to public health agencies as required by state or local law. Most of these surveillance data are currently received by conventional mail or facsimile transmission. The Centers for Disease Control and Prevention (CDC), Council of State and Territorial Epidemiologists, and Association of Public Health Laboratories are preparing to implement surveillance systems that will use existing laboratory information systems to transmit electronic laboratory results to appropriate public health agencies. The authors anticipate that this will improve the reporting efficiency for these laboratories, reduce manual data entry, and greatly increase the timeliness and utility of the data. The vocabulary and messaging standards used should encourage participation in these new electronic reporting systems by minimizing the cost and inconvenience to laboratories while providing for accurate and complete communication of needed data. This article describes public health data requirements and the influence of vocabulary and messaging standards on implementation.
PMCID: PMC61359  PMID: 10332652
18.  Global Public Health Surveillance under New International Health Regulations 
Emerging Infectious Diseases  2006;12(7):1058-1065.
IHR 2005 establishes a global surveillance system for public health emergencies of international concern.
The new International Health Regulations adopted by the World Health Assembly in May 2005 (IHR 2005) represents a major development in the use of international law for public health purposes. One of the most important aspects of IHR 2005 is the establishment of a global surveillance system for public health emergencies of international concern. This article assesses the surveillance system in IHR 2005 by applying well-established frameworks for evaluating public health surveillance. The assessment shows that IHR 2005 constitutes a major advance in global surveillance from what has prevailed in the past. Effectively implementing the IHR 2005 surveillance objectives requires surmounting technical, resource, governance, legal, and political obstacles. Although IHR 2005 contains some provisions that directly address these obstacles, active support by the World Health Organization and its member states is required to strengthen national and global surveillance capabilities.
doi:10.3201/eid1207.051497
PMCID: PMC3291053  PMID: 16836821
Disease surveillance; International law; Infectious disease; Emergence; Health law; International Health Regulations; Outbreaks; World Health Organization
19.  A Focused Ethnographic Study of Sri Lankan Government Field Veterinarians’ Decision Making about Diagnostic Laboratory Submissions and Perceptions of Surveillance 
PLoS ONE  2012;7(10):e48035.
The global public health community is facing the challenge of emerging infectious diseases. Historically, the majority of these diseases have arisen from animal populations at lower latitudes where many nations experience marked resource constraints. In order to minimize the impact of future events, surveillance of animal populations will need to enable prompt event detection and response. Many surveillance systems targeting animals rely on veterinarians to submit cases to a diagnostic laboratory or input clinical case data. Therefore understanding veterinarians’ decision-making process that guides laboratory case submission and their perceptions of infectious disease surveillance is foundational to interpreting disease patterns reported by laboratories and engaging veterinarians in surveillance initiatives. A focused ethnographic study was conducted with twelve field veterinary surgeons that participated in a mobile phone-based surveillance pilot project in Sri Lanka. Each participant agreed to an individual in-depth interview that was recorded and later transcribed to enable thematic analysis of the interview content. Results found that field veterinarians in Sri Lanka infrequently submit cases to laboratories – so infrequently that common case selection principles could not be described. Field veterinarians in Sri Lanka have a diagnostic process that operates independently of laboratories. Participants indicated a willingness to take part in surveillance initiatives, though they highlighted a need for incentives that satisfy a range of motivations that vary among field veterinarians. This study has implications for the future of animal health surveillance, including interpretation of disease patterns reported, system design and implementation, and engagement of data providers.
doi:10.1371/journal.pone.0048035
PMCID: PMC3485039  PMID: 23133542
20.  A Focused Ethnographic Study of Alberta Cattle Veterinarians’ Decision Making about Diagnostic Laboratory Submissions and Perceptions of Surveillance Programs 
PLoS ONE  2013;8(5):e64811.
The animal and public health communities need to address the challenge posed by zoonotic emerging infectious diseases. To minimize the impacts of future events, animal disease surveillance will need to enable prompt event detection and response. Diagnostic laboratory-based surveillance systems targeting domestic animals depend in large part on private veterinarians to submit samples from cases to a laboratory. In contexts where pre-diagnostic laboratory surveillance systems have been implemented, this group of veterinarians is often asked to input data. This scenario holds true in Alberta where private cattle veterinarians have been asked to participate in the Alberta Veterinary Surveillance Network-Veterinary Practice Surveillance, a platform to which pre-diagnostic disease and non-disease case data are submitted. Consequently, understanding the factors that influence these veterinarians to submit cases to a laboratory and the complex of factors that affect their participation in surveillance programs is foundational to interpreting disease patterns reported by laboratories and engaging veterinarians in surveillance. A focused ethnographic study was conducted with ten cattle veterinarians in Alberta. Individual in-depth interviews with participants were recorded and transcribed to enable thematic analysis. Laboratory submissions were biased toward outbreaks of unknown cause, cases with unusual mortality rates, and issues with potential herd-level implications. Decreasing cattle value and government support for laboratory testing have contributed to fewer submissions over time. Participants were willing participants in surveillance, though government support and collaboration were necessary. Changes in the beef industry and veterinary profession, as well as cattle producers themselves, present both challenges and opportunities in surveillance.
doi:10.1371/journal.pone.0064811
PMCID: PMC3669388  PMID: 23741397
21.  Wisconsin’s Environmental Public Health Tracking Network: Information Systems Design for Childhood Cancer Surveillance 
Environmental Health Perspectives  2004;112(14):1434-1439.
In this article we describe the development of an information system for environmental childhood cancer surveillance. The Wisconsin Cancer Registry annually receives more than 25,000 incident case reports. Approximately 269 cases per year involve children. Over time, there has been considerable community interest in understanding the role the environment plays as a cause of these cancer cases. Wisconsin’s Public Health Information Network (WI-PHIN) is a robust web portal integrating both Health Alert Network and National Electronic Disease Surveillance System components. WI-PHIN is the information technology platform for all public health surveillance programs. Functions include the secure, automated exchange of cancer case data between public health–based and hospital-based cancer registrars; web-based supplemental data entry for environmental exposure confirmation and hypothesis testing; automated data analysis, visualization, and exposure–outcome record linkage; directories of public health and clinical personnel for role-based access control of sensitive surveillance information; public health information dissemination and alerting; and information technology security and critical infrastructure protection. For hypothesis generation, cancer case data are sent electronically to WI-PHIN and populate the integrated data repository. Environmental data are linked and the exposure–disease relationships are explored using statistical tools for ecologic exposure risk assessment. For hypothesis testing, case–control interviews collect exposure histories, including parental employment and residential histories. This information technology approach can thus serve as the basis for building a comprehensive system to assess environmental cancer etiology.
doi:10.1289/ehp.7150
PMCID: PMC1247574  PMID: 15471739
childhood cancer; environment; exposures; informatics; information systems; public health; surveillance; tracking
22.  Improving the Evidence Base for Decision Making During a Pandemic: The Example of 2009 Influenza A/H1N1 
This article synthesizes and extends discussions held during an international meeting on “Surveillance for Decision Making: The Example of 2009 Pandemic Influenza A/H1N1,” held at the Center for Communicable Disease Dynamics (CCDD), Harvard School of Public Health, on June 14 and 15, 2010. The meeting involved local, national, and global health authorities and academics representing 7 countries on 4 continents. We define the needs for surveillance in terms of the key decisions that must be made in response to a pandemic: how large a response to mount and which control measures to implement, for whom, and when. In doing so, we specify the quantitative evidence required to make informed decisions. We then describe the sources of surveillance and other population-based data that can presently—or in the future—form the basis for such evidence, and the interpretive tools needed to process raw surveillance data. We describe other inputs to decision making besides epidemiologic and surveillance data, and we conclude with key lessons of the 2009 pandemic for designing and planning surveillance in the future.
This article synthesizes discussions held during an international meeting, “Surveillance for Decision Making: The Example of 2009 Pandemic Influenza A/H1N1,” held at Harvard School of Public Health in June 2010. It defines the needs for surveillance in terms of the key decisions that must be made in response to a pandemic: how large a response to mount and which control measures to implement, for whom, and when. The article describes the sources of surveillance and other population-based data that can form the basis for such evidence, and the interpretive tools needed to process raw surveillance data. It concludes with key lessons of the 2009 pandemic for designing and planning surveillance in the future.
doi:10.1089/bsp.2011.0007
PMCID: PMC3102310  PMID: 21612363
23.  Communicating the threat of emerging infections to the public. 
Emerging Infectious Diseases  2000;6(4):337-347.
Communication theory and techniques, aided by the electronic revolution, provide new opportunities and challenges for the effective transfer of laboratory, epidemiologic, surveillance, and other public health data to the public who funds them. We review the applicability of communication theory, particularly the audience-source-message-channel meta-model, to emerging infectious disease issues. Emergence of new infectious organisms, microbial resistance to therapeutic drugs, and increased emphasis on prevention have expanded the role of communication as a vital component of public health practice. In the absence of cure, as in AIDS and many other public health problems, an effectively crafted and disseminated prevention message is the key control measure. Applying communication theory to disease prevention messages can increase the effectiveness of the messages and improve public health.
PMCID: PMC2640909  PMID: 10905966
24.  Utility of the ESSENCE Surveillance System in Monitoring the H1N1 Outbreak 
Online Journal of Public Health Informatics  2010;2(3):ojphi.v2i3.3028.
The Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE) enables health care practitioners to detect and monitor health indicators of public health importance. ESSENCE is used by public health departments in the National Capital Region (NCR); a cross-jurisdictional data sharing agreement has allowed cooperative health information sharing in the region since 2004. Emergency department visits for influenza-like illness (ILI) in the NCR from 2008 are compared to those of 2009. Important differences in the rates, timing, and demographic composition of ILI visits were found. By monitoring a regional surveillance system, public health practitioners had an increased ability to understand the magnitude and character of different ILI outbreaks. This increased ability provided crucial community-level information on which to base response and control measures for the novel 2009 H1N1 influenza outbreak. This report underscores the utility of automated surveillance systems in monitoring community-based outbreaks. There are several limitations in this study that are inherent with syndrome-based surveillance, including utilizing chief complaints versus confirmed laboratory data, discerning real disease versus those healthcare-seeking behaviors driven by panic, and reliance on visit counts versus visit rates.
doi:10.5210/ojphi.v2i3.3028
PMCID: PMC3615770  PMID: 23569593
H1N1; swine flu; surveillance
25.  Public health and disability: emerging opportunities. 
Public Health Reports  2002;117(2):131-136.
The public health community has traditionally paid little attention to the health needs of people with disabilities. Recent activities, however, on the part of federal and international organizations mark a shift toward engaging the health concerns of this large and growing population. First, the World Health Organization published the International Classification of Functioning, Disability, and Health (ICF), a companion to the International Classification of Diseases. The ICF describes both a conceptual framework and a classification system, providing the foundation for public health science and policy. Second, a vision for the future of public health and disability is outlined in Healthy People 2010 that, for the first time, includes people with disabilities as a targeted population. The article briefly describes activities and emerging opportunities for a public health focus on people with disabilities with the ICF as a foundation and Healthy People 2010 as a vision. Public health has traditionally responded to emerging needs; people with disabilities are a group whose health needs should be targeted.
PMCID: PMC1497417  PMID: 12356997

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