Current Trends in Surveillance Dr David Mowat Director

Current Trends in Surveillance Dr. David Mowat Director General Centre for Surveillance Coordination University of Toronto/al. PHa 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 T 0 T SMC T Diag T Death W 1 W 2 W 3 IDW Ease of Detecting Bioagent Effects Over Timeline T 0 TONSET W 2 TSMC ~ ~ IDW W 1 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. Medi Window to detect (Trad. Medical) Improved Detection Window W 3 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 Recall (March 20) Outbreak recognized (March 16) Outbreak recognized (March 25) 35 30 25 Lunchmate (386) 386 ) (< No Lunchmate (127) 20 Schneider’s recall 2 (April 9) Cheese recall (April 15) 15 10 5 Date of Onset Of Illness pr 19 -A pr -A 12 pr -A 05 ar -M 29 ar -M 22 ar -M 15 ar -M 08 01 -M ar 0 N < 513 N=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 Child ill Child ill Hospital Hospitalvisit visit Bench work Bench. Prov lab work Bench. Prov Bench in worklab in work in Prov lab inin Prov lab Family teaching, investigation, follow up Public Health Nurse calls or visits homes Outbreak plan becomes operational Alert report to MOH 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) Child ill Child ill Immunization registry Hospital Hospitalvisit visit Bench work Bench. Prov lab work Bench. Prov Bench in worklab in work in Prov lab inin Prov lab Exclusion, immunization, investigation, follow up Public Health Nurse calls or visits school Outbreak plan becomes operational Alert report to MOH 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, 19 th Century CD C

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 Ø 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. Ø 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