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Public Health Surveillance After Disasters

Disaster Epidemiology Workshop
Wayne Enanoria, PhD, MPH
Center for Infectious Disease Preparedness School of Public Health, UC Berkeley 15 March 2007
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Objectives
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By the end of this lecture, participants will be able:
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define the steps for setting up a surveillance system for emergency situations; " To develop a case definition; " To describe the operational issues in setting up a surveillance system post-disaster.
Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.idready.org

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Outline
Background ! Case Examples
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Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.idready.org

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Steps in Surveillance ! Setting up a surveillance system post-disaster " Establish objectives " Developing case definitions " Determining data sources " Field test methods (if possible) " Data collection " Analysis " Dissemination of results Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.idready.org 4 .

idready. relief efforts rely on timely and accurate information. and " evaluate the effectiveness of relief efforts. ! Public health surveillance can: ! " identify health problems.org 5 . Center for Infectious Disease Preparedness UC Berkeley School of Public Health www. " establish priorities for decision-makers.Surveillance after Disasters To respond appropriately and effectively to the threats of disasters.

Objectives of a Surveillance System Wetterhall SF and Noji EK. In: Noji E. Identify groups at increased risk for adverse health outcomes. 1997. Surveillance and Epidemiology. Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.org 6 .idready. ! ! ! ! ! ! ! ! Estimate the magnitude of a health problem. Public Health Consequences of Disasters. Detect epidemics or other outbreaks Generate and test hypotheses regarding etiology Monitor changes in infectious agents/environmental agents Detect changes in health practices Identify research needs Evaluate control strategies.

idready. " Identify groups in the population at risk for adverse health events.org 7 . " Monitor the effectiveness of the relief effort. UC Berkeley School of Public Health www.The Role of the Epidemiologist ! Epidemiologists can: " Define rapidly the nature and extent of health problems. and " Recommend ways of decreasing the Center for Infectious Disease Preparedness consequences of future disasters. " Optimize relief response.

! ! ! ! ! ! ! ! ! Simplicity (structure and ease of operation) Flexibility (adapt to changing information needs) Data quality (completeness and validity) Acceptability (willingness of reporting entities) Sensitivity and specificity (case definition or OB detection) Predictive value positive (PV+) or negative (PV-) Representativeness (of target population over time) Timeliness Center for Infectious Disease Preparedness Berkeley School of Public Health Stability (reliability and UC availability) www.50(RR-13).org 8 .Elements of a good surveillance system MMWR 2001.idready.

The surveillance cycle Adapted from: Wetterhall SF and Noji EK. Public Health Consequences of Disasters. Events Response Collection of data Analysis of data Center for Infectious Disease Preparedness UC Berkeley School of Public Health www. In: Noji E.idready. Surveillance and Epidemiology.org 9 . 1997.

! Multiple sources of information must be integrated quickly and cohesively. Data must be collected rapidly under adverse conditions. ! Cycle from information to action must be rapid. Surveillance and Epidemiology. Center for Infectious Disease Preparedness ! UC Berkeley School of Public Health www. 1997. Public Health Consequences of Disasters. ! Circumstances may impede information “flow”. In: Noji E.idready.org 10 .Challenges Post-Disaster Wetterhall SF and Noji EK. accurate and repeated.

idready.Developing Case Definitions ! Case definitions enable the “case” (adverse health event) to be characterized by different data: " Clinical " Epidemiologic " Laboratory Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.org 11 .

Developing Case Definitions ! The elements of a case definition can include the degree of certainty in the diagnosis: " “suspected” " “probable” " “confirmed” Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.org 12 .idready.

Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.org 13 .idready.

org 14 .Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.idready.

www.460).org 15 . Emerg Infect Dis 2004 Center for Infectious Disease Preparedness UC Berkeley School of Public Health Feb.idready.S.SARS Example Displayed in Figure B is the number of unexplained respiratory illness reports received by CDC by week of illness report (N = 1. However. SARS case definition and is displayed by week of illness onset in Figure A.10(2):185-194. only 398 met the U.

idready. religious officials. Center for Infectious Disease Preparedness UC Berkeley School of Public Health www. pharmacies.Determine Data Sources Objectives drive data sources ! Consider nontraditional sources of information post-disaster ! " eg.org 16 . civil defense organizations. humanitarian aid agencies. etc. police.

Orleans. September 8-25. Bernard) Active surveillance was initiated in: Center for Infectious Disease Preparedness hospitals UC Berkeley School of Public Health www. CDC. and St. MMWR 2005 Oct. of Health and Hospitals. ! ! ! On September 9.org " Ten nonhospital facilities " Four 17 . and functioning emergency treatment resources established active surveillance. 2005.54(40):1018-1021. 2005. Louisiana. Louisiana Dept. Plaquermines.New Orleans.idready. The target population was persons living or working in four parishes in and around New Orleans (Jefferson.Active Surveillance Using Existing Medical Facilities Surveillance for illness and injury after hurricane Katrina -.

Active Surveillance Using Existing Medical Facilities Surveillance for illness and injury after hurricane Katrina -. 2005. September 8-25. MMWR 2005 Oct.idready. ARI. dehydration.org 18 . ! The facilities used a standardized reporting form " Demographics " Symptoms " Clinical impressions (eg.New Orleans. Louisiana. diarrhea) " Mechanism of injury ! Different modes of data collection " Healthcare members provider or surveillance team Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.54(40):1018-1021.

September 8-25. ! Illness and injury trends or individual cases of selected illness were communicated to health authorities.New Orleans. Louisiana.54(40):1018-1021.idready.Active Surveillance Using Existing Medical Facilities Surveillance for illness and injury after hurricane Katrina -. ! " Investigated by health teams as appropriate Center for Infectious Disease Preparedness UC Berkeley School of Public Health www. 2005. ! Analyses were completed daily. All data were gathered and entered into a computer database manually.org 19 . MMWR 2005 Oct.

idready. Louisiana. As of September 25. the system monitored 7.54(40):1018-1021.508 reports of health-related events. ! Center for Infectious Disease Preparedness UC Berkeley School of Public Health www. MMWR 2005 Oct. ! These data were used to identify posthurricane injury patterns and to guide prevention messages.org 20 . September 8-25.New Orleans. ! This system prompted investigations of respiratory and rash illnesses.Active Surveillance Using Existing Medical Facilities Surveillance for illness and injury after hurricane Katrina -. 2005. but no major outbreaks were detected.

org 21 .idready.Source: Surveillance for illness and injury after hurricane Katrina -. Louisiana. 2005. UC Berkeley School of Public Health www.54(40):1018Center for Infectious Disease Preparedness 1021.New Orleans. September 8-25. MMWR 2005 Oct.

Louisiana. MMWR 2005 Oct.Source: Surveillance for illness and injury after hurricane Katrina -. 2005.org 22 . Center for Infectious Disease Preparedness UC Berkeley School of Public Health www. September 8-25.54(40):10181021.New Orleans.idready.

Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.Source: Surveillance for illness and injury after hurricane Katrina -.org 23 .54(40):10181021.idready. Louisiana. September 8-25.New Orleans. MMWR 2005 Oct. 2005.

Louisiana. MMWR 2006 Jan.idready.org 24 .55(02):35-38.New Orleans Area.Updated Results Source: Injury and illness surveillance in hospitals and acute-care facilities after hurricanes Katrina and Rita -. September 25 October15. Center for Infectious Disease Preparedness UC Berkeley School of Public Health www. 2005.

MMWR 2006 Jan. Center for Infectious Disease Preparedness UC Berkeley School of Public Health www. 2005.New Orleans Area.org 25 .Updated Results Source: Injury and illness surveillance in hospitals and acute-care facilities after hurricanes Katrina and Rita -. September 25 October15.idready. Louisiana.55(02):35-38.

" One facility that identified multiple ARI cases among members of a National Guard battalion. MMWR 2005 Oct. 2005. Louisiana. ! The increase in ARI cases over time was only observed in nonhospital facilities.org 26 . ! Rash illnesses were deemed noninfectious. arthropod bites. and the abrasive effects of wet clothing on moist Center for Infectious Disease Preparedness UC Berkeley School of Public Health skin.54(40):1018-1021. www.New Orleans. September 8-25.Results of Field Investigations Surveillance for illness and injury after hurricane Katrina -.idready. they were classified as prickly heat.

! Prehurricane baseline data were not available to assess the magnitude of any increase in illnesses or injuries.New Orleans.54(40):1018-1021.org 27 . The enumeration of illnesses and injuries is incomplete. MMWR 2005 Oct. September 8-25.Limitations Surveillance for illness and injury after hurricane Katrina -. 2005.idready. Louisiana. ! Center for Infectious Disease Preparedness UC Berkeley School of Public Health www. ! Misclassification of illnesses or injuries on the standardized form was possible.

org 28 . ! ! ! ! Any facility that housed displaced persons overnight was considered an evacuation center (EC).55(02):32-35.idready.Active Surveillance Using Evacuation Centers MMWR 2006 Jan. A one-page surveillance form was designed to record the number of patient encounters at an EC for selected communicable disease signs and syndromes. Center for Infectious Disease Preparedness UC Berkeley School of Public Health www. The form was designed to record the number of patient encounters during a 24-hour period. Instructions for recording and returning the completed forms were distributed along with the forms to all identified ECs.

! ECs were called if they did not report by 11am each day. Completed forms were reported by fax.idready. or telephone to the American Red Cross disaster headquarters. email. ! Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.55(02):32-35. ! Individual forms were reviewed by medical epidemiologists for further investigation.org 29 .Active Surveillance Using Evacuation Centers MMWR 2006 Jan.

55(02):32-35. ! Syndromic data were analyzed using the Early Aberration Reporting System (EARS).idready. Data were entered into a database.Data Analysis MMWR 2006 Jan. ! Elevated cumulative sum scores and suspicious cases and clusters were investigated by telephone.org 30 . ! Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.

MMWR 2004. 2003. Syndromic Surveillance: Reports from a National Conference.idready.Syndromic Surveillance *t = time between detection by syndromic (prediagnostic) surveillance and detection by traditional (diagnosis-based) surveillance. Centers for Disease Control and Prevention. Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.org 31 .53(Suppl).

Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.Results MMWR 2006 Jan.55(02):32-35.org 32 .idready.

Center for UC Berkeley School of Public Health www.Results MMWR 2006 Jan. Influenza-like illness and rash were the most commonly reported communicable disease syndromes.org 33 .55(02):32-35.idready. ! "A skin infestation of 60 cases was determined to be four confirmed cases of scabies with the remainder being EC residents treated Infectious Disease Preparedness prophylactically. ! The majority of large clusters were attributed to overreporting.

and/or telephone were functional. email. ! Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.org 34 .Limitations The syndromic surveillance system assumed that fax.idready. ! EARS technology is quite sophisticated to apply.

org 35 . ! Center for Infectious Disease Preparedness UC Berkeley School of Public Health www.idready.Investigation of Rumors Rumors should be investigated fully and rapidly. ! By investigating significant rumors. health officials can assess accurately an evolving situation.

1997.Effective Rumor Control Wetterhall SF and Noji EK.org 36 . Public Health Consequences of Disasters. ! Use surveillance and epidemiologic methods to investigate each rumor. Surveillance and Epidemiology. ! " Same stepwise approach for investigating an outbreak Center for Infectious Disease Preparedness UC Berkeley School of Public Health www. In: Noji E. Establish a clear chain of command for disaster-relief efforts.idready. ! Designate a spokesperson for responding to inquiries and providing updates.

UC Berkeley School of Public Health ! www.org 37 . collect baseline Center for Infectious Disease Preparedness information. " Simple and understandable Reporting procedures and easily modifiable standardized forms that can be used in a variety of settings should be developed. ! When available.In Summary ! Case definitions of disaster-related illnesses and injuries should be developed.idready.

idready. 1997.Methodological Problems Wetterhall SF and Noji EK.org 38 . ! ! ! ! ! ! ! ! ! Compromise between timeliness and accuracy Competing priorities for information Logistical constraints Absence of baseline information Denominator data unavailable Underreporting of health events Lack of representativeness Resource costs of collecting and analyzing data Lack of standardized reporting mechanism Center for Infectious Disease Preparedness UC Berkeley School of Public Health www. Public Health Consequences of Disasters. In: Noji E. Surveillance and Epidemiology.