Building Biosurveillance Systems
for
Early Detection of Public Health Events
Central Asia Regional Health Security Conference
17-19 April 2012, Garmisch-Partenkirchen, Germany
COL Robert J. Lipnick, MS, MSS, ScD
Chief, Division of Communications, Standards and Training
Robert.Lipnick@us.army.mil
UNCLASSIFIED
Outline
• Define “biosurveillance”
• Describe the major elements of an effective biosurveillance
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system
Explain how biosurveillance systems improve compliance with
International Health Regulations (2005)
List major challenges to implementing an effective
biosurveillance system
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The Cost of Epidemics
• Many diseases preventable or controllable by modifying:
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Behaviors and activities
Vaccination
Public water/sewer systems
Food quality and quantity
Disease detection and early treatment
• Early detection and control reduces burden of disease
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Deaths
Disability
Lost productivity and income
Political and social instability
Increased demand on healthcare services
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Early Detection Benefit
WHO World Health Report 2007
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Biological Surveillance
• “Biosurveillance”
– Ongoing, consistent collection of data relevant to human and
animal health
– Using well-designed systems that increase the speed of data
collection, analysis and reporting
– To detect abnormal events or trends (epidemics)
– Quickly enough to prevent significant impact on health or social
stability
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Disease or Syndrome
• Disease report specifies a pathogen:
Influenza
– Clinical diagnosis (astute medical provider)
– Laboratory test result
– Can result in biological sample
• Confirmation of diagnosis
• Molecular data
• Repository for future studies
– Delayed acquisition of data but high degree of certainty
– Used for threats with high epidemic potential
– Key challenge: laboratory capabilities
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Disease or Syndrome
• Syndrome report covers a less specific category of disease:
Influenza-like illness
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Signs and symptoms of disease
Non-specific laboratory data
Defined by expert consensus
Data quickly available but lower degree of certainty
Routine health surveillance or detection of emerging “unknown”
threat
– Key challenge: data system
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Major Elements of Biosurveillance System
• Data collection
– Many different sources
– Determined by local epidemiology
– Limited by technology, training and human resources
• Analysis
– Looking for “more than expected” numbers of cases or change in
disease pattern
– Mathematical, automated systems available
– Combination of information from many sources usually needed
for full response
• Reporting
• Outbreak response
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Collection of Surveillance Data
• Medical care
– Notifiable disease reports
– Periodic case counts
– Medical record abstraction
• Use of commercial products and services
• Population-based survey
• Social media
• Targeted surveillance programs
• Syndromic surveillance
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“Syndromic” Data
• Automated collection and analysis of electronic records
• Uses diagnostic coding or other information to automatically
assign syndrome category
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International Classification of Diseases
Procedure codes
Laboratory codes
Interpretation of text
• Typically very fast analysis but non-specific disease categories
• Relies on mathematical formulas
• Typically generates many “false alerts”
• Still need traditional sources of health surveillance
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Systematic Representativeness
• Multiple surveillance
Population
Survey
types needed to cover
all potential threats
• Understand source of
data for proper
interpretation
• Different surveillance
for different problems
• Make decisions with
less than complete
information
Social Media
Products and
Services
Medical
Care
Targeted
Programs
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Timeliness Versus Certainty
• Timeliness critical for rapid detection and response
• Certainty needed to ensure proper response
• Drawbacks from favoring timeliness
– Less specific
– Less representative
– Potentially many false positive alerts
• Drawbacks from favoring certainty
– Delayed by confirmation methods
– Requires complex laboratory systems
– Requires many highly trained workers
• Combine data sources and surveillance methods to balance
timeliness and certainty
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Detecting Abnormal Events
• Requires knowledge about normal disease patterns –
“baseline”
• Special epidemiologic, environmental or ecologic
studies may be necessary
• Enough information to make a quick decision
• Define a threshold for investigation
• False positive signals can cause “surveillance
fatigue”
• Design or modify system to reduce false negatives
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What is Abnormal?
• Higher than expected numbers of cases
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Overall increases
Increases in specific populations
Increase in severe cases
Cases that should be very rare
• Events with epidemic potential
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Focus of International Health Regulations (2005)
Represent potential to cause large numbers of cases (deaths)
Can result in social instability and economic strain
Cross regional boundaries
• Biosurveillance system detects cases/events prior to impact on
population
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Electronic Data Systems
• Move information from the “ground level” to the epidemiologist
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Medical visit documentation
Financial transactions and supply distributions
Personal observations
Standardized field reports
• Faster is better
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Automated data transfer
Text messaging and Smartphone applications
Web-based data entry
Email, fax or phone
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Analysis and Reporting
• Determine when a public health response is needed
• Team of epidemiologists, medical personnel, computer
specialists and public policy staff needed
– Routine and systematic databases
– Cyclical analysis and graphical reports
– Standard operating procedures
• Communicate results to stakeholders and decision-makers
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Address major concerns
Provide interpretation along with information
Provide appropriate level of detail
Create forum for discussion
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International Health Regulations (2005)
• Public health threats cross political boundaries
• IHR 2005 requires identification and reporting of
public health emergencies of international concern
(PHEIC)
• Biosurveillance systems designed to:
– Identify reportable cases or events
– Improve health of the population through control of nonreportable epidemics
• Regional analysis of surveillance information allows
coordination of response
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Planning and Exercising
• Evaluate (measure)
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Timeliness
Certainty
Representativeness
Effectiveness of response
• Exercises and “experiments” critical
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Discover gaps in diseases, syndromes, populations
Identify training and human resource gaps
Practice coordination of response actions
Plan for purchase of equipment and supplies
Develop new methods and technologies
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Substantial Challenges
• Information and communications technology
• Training and human resources
• Coordination among many different parts of
government and civil society
• Rapid and effective communication
• Decision-making with imperfect information
• Protection of personal privacy
• Communication of information to the public
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Conclusions
• Using various data collection and surveillance
methods balance timeliness, certainty and
representativeness
• Regional and global coordination improves ability to
respond quickly and effectively
• No system is perfect, but many can be good enough
• Every system must be evaluated, exercised and
modified over time to meet new challenges
• IHR 2005 provides the basic requirements for all
nations
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Questions?
COL Robert J. Lipnick, MS, MSS, ScD
Chief, Division of Communications, Standards & Training
Robert.Lipnick@us.army.mil
UNCLASSIFIED