Current Trends in
Surveillance
Dr. David Mowat
Director General
Centre for Surveillance Coordination
University of Toronto/alPHa
14 March, 2003
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
What is surveillance?
• Health surveillance is the ongoing,
systematic use of routinely collected
health data to guide public health action
• Surveillance processes include data
collection, collation, analysis,
interpretation and dissemination
followed by action
Surveillance is not …
• research
• evaluation
Information on: "health events"
•
•
•
•
•
•
•
morbidity
mortality
risk factors
threats to health
laboratory diagnosis
adverse events
etc.
Information uses:
• identifying emerging & re-emerging
diseases
• monitoring trends
• identifying outbreaks
• identifying unusual patterns
• forecasting
• generating hypotheses
Information ultimately used for decisions
•
•
•
•
policies
programs
practice
public
local
health
events
provincial/territorial
national
actions
John Snow
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
New Challenges
• new threats
• new concerns
• new technologies
e.g. bioterrorism
e.g. biotechnology
e.g. genomics
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
Evidence-Based Decision-Making
• information on events
• information on interventions
• information on context
Surveillance & Surveillance Infostructure
The infrastructure approach provides;
• efficiency
• power of integration
• flexibility & responsiveness
Design Considerations
•
•
•
•
Start with the business
Make the business explicit
Document the purpose(s)
Choose desired characteristics
Developing Data Sources
•
•
•
•
re-use
"by-product"
"transactional"
preclinical/syndromic
Bio-Surveillance Detection Timeline
Detection Analysis Timeline
Non-clinical and behavioral
data
Pre-diagnostic clinical data
Diagnostic data
T0
T SMC
T Diag
T Death
W1
W2
W3
IDW
Time of attack (Fixed)
Time to seek medical care (Mean)
Time of typical diagnosis (Mean)
Time of death (Mean)
Window to detect (Non-Traditional)
Window to detect (Non-Trad. Medical)
Window to detect (Trad. Medical)
Improved Detection Window
Ease of Detecting Bioagent
Effects Over Timeline
IDW
T0
TONSET
W2
TSMC
W3
~~
W1
T Diagnosis.
Bio-Agent Impact Timeline
T Death
Developing Data Sources
•
•
•
•
•
re-use
"by-product"
"transactional"
preclinical/syndromic
intelligence
Data Integration
• data warehouses
• data marts
Analysis
• power
• business intelligence tools
OLAP
SOLAP
presentation tools
spatial tools
Extracting Meaning
• monitoring
• alerts
Access
•
•
•
•
•
connectivity
language
discovery
manipulation
permission
Discovery
The "virtual library"
• store
• classify
• search/navigate/browse
Inventories
Health Canada
Injury
Environmental
CHAIN
The Infospace Vision
•
•
•
•
•
•
•
•
•
databases
summary reports
daily updates/news
bulletins
systematic reviews
position papers
practice guidelines
regulatory notices
dictionaries, references
• tools: business intelligence
Geographic Information System
• automated alert function
• discovery functions:
inventories
metadata
search/navigation
• continuing education
• discussion environments
• conference, job postings, etc.
Schneider's lunchmate outbreak
Canada, 1998
Schneider’s recall 1
(March 31)
Number of Cases
40
35
30
25
Recall
(March 20)
Outbreak recognized
(March 16)
Outbreak recognized
(March 25)
20
Lunchmate (386)
( < 386 )
No Lunchmate (127)
Schneider’s recall 2
(April 9)
Cheese recall
(April 15)
15
10
5
0
Date of Onset Of Illness
NN=513
< 513
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
Supporting end-to-end surveillance
enteric disease
Childillill
Child
Child
Childillillill
Child
Hospital
Hospital
Hospital
visit
Hospital
Hospital
visit
visit
visit
visit
Family teaching,
investigation, follow up
Public Health Nurse
calls or visits homes
Outbreak plan becomes
operational
Alert report
to MOH
Benchwork
work
Bench
Bench
work
in
Provlab
lab
Bench
work
Bench
work
in
Prov
in
Prov
lab
Provlab
lab
ininProv
Food samples
to lab
Coordinate other prov
agency investigation
Alert report
to Province
Alert report
to HC
Is this a
national
outbreak or
one
involving
CFIA?
Supporting end-to-end surveillance
(vaccine-preventable disease)
Childillill
Child
Child
Childillillill
Child
Immunization
registry
Hospital
Hospital
Hospital
visit
Hospital
Hospital
visit
visit
visit
visit
Exclusion, immunization,
investigation, follow up
Public Health Nurse
calls or visits school
Outbreak plan becomes
operational
Alert report
to MOH
Benchwork
work
Bench
Bench
work
in
Provlab
lab
Bench
work
Bench
work
in
Prov
in
Prov
lab
Provlab
lab
ininProv
Identify sources of
vaccine
Alert report
to Province
Alert report
to HC
National
response;
long term
work on
vaccine
strategy
Architecture
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
CDC
G. I. S.
Geographic data
Disease
data
GIS
Denominator data
G. I. S.
•
•
•
•
access to data
tools to download
service
consultation & training
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
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
Modules Currently Available
•
•
•
•
Orientation to Online Learning
Module 1: Basic Epidemiological Concepts
Module 2: Measurement of Health Status
Module 3: Descriptive Epidemiological
Methods
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.
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.
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