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CenterforSurveillance,Epidemiology,andLaboratoryServices

PublicHealthSurveillanceActivitiesattheDivisionofHealthInformaticsandSurveillance

MiguelH.Torres-Urquidy,DDS,MS,PhD(Candidate)SeniorServiceFellowConference:DentalPublicHealthInformatics:OpportunitiesinaChangingEnvironment

January19-20,2017

OUTLINE§ InformaticsActivitieswithintheNationalPublicHealthSurveillanceSystems

– NationalNotifiableDiseaseSurveillanceSystem

– NationalSyndromicSurveillanceProgram

Disclaimer:ThefindingsandconclusionsinthisreportarethoseoftheauthoranddonotnecessarilyrepresenttheofficialpositionoftheCentersforDiseaseControlandPrevention.

NationalNotifiableDiseasesSurveillanceSystem(NNDSS)

§ TheNationalNotifiableDiseasesSurveillanceSystem(NNDSS)isanationwidecollaborationthatenablesalllevelsofpublichealth—local,state,territorial,federal,andinternational—tosharenotifiabledisease-relatedhealthinformation.

NNDSS:Overview

§ Publichealthusesthisinformationtomonitor,control,andpreventtheoccurrenceandspreadofstate-reportableandnationallynotifiableinfectiousandnoninfectiousdiseasesandconditionsandoutbreaks.

NNDSS:Overview

§ NNDSSisamultifacetedprogramthatincludesthesurveillancesystemforcollection,analysis,andsharingofhealthdata.Italsoincludespolicies,laws,electronicmessagingstandards,people,partners,informationsystems,processes,andresourcesatthelocal,state,territorial,andnationallevels.

NNDSS:SupportingPublicHealthSurveillanceinJurisdictionsandatCDC

§ Notifiablediseasesurveillancebeginsattheleveloflocal,state,andterritorialpublichealthdepartments(alsoknownasjurisdictions).Jurisdictionallawsandregulationsmandatereportingofcasesofspecifiedinfectiousandnoninfectiousconditionstohealthdepartments.

NNDSS:SupportingPublicHealthSurveillanceinJurisdictionsandatCDC

§ Thehealthdepartmentsworkwithhealthcareproviders,laboratories,hospitals,andotherpartnerstoobtaintheinformationneededtomonitor,control,andpreventtheoccurrenceandspreadofthesehealthconditions.Inaddition,healthdepartmentsnotifyCDCabouttheoccurrenceofcertainconditions.

NNDSS:SupportingPublicHealthSurveillanceinJurisdictionsandatCDC

§ TheCDCDivisionofHealthInformaticsandSurveillance(DHIS)supportsNNDSSbyreceiving,securing,processing,andprovidingnationallynotifiableinfectious

§ diseasesdatatodisease-specificCDCprograms.DHISalsosupportslocal,state,andterritorialpublichealthdepartmentsinhelpingthemcollect,manage,andsubmitcasenotificationdatatoCDCforNNDSS.

NNDSS:SupportingPublicHealthSurveillanceinJurisdictionsandatCDC

§ DHISprovidesthissupportthroughfunding,healthinformationexchangestandardsandframeworks,electronichealth informationsystems,andtechnicalsupport

§ throughtheNNDSSwebsite,tools,andtraining.Together,DHISandtheCDCprogramsprepareannualsummariesofinfectiousandnoninfectiousdiseasesandconditions,whicharepublishedintheCDCMorbidityandMortalityWeeklyReport.

NNDSS:SupportingPublicHealthSurveillanceinJurisdictionsandatCDC

§ TheseprogramscollaboratewiththeCouncilofStateandTerritorialEpidemiologists(CSTE)todeterminewhichconditionsreportedtolocal,state,andterritorialpublichealthdepartmentsarenationallynotifiable.

§ TheCDCprograms,incollaborationwithsubjectmatterexpertsinCSTEandinhealthdepartments,determinewhatdataelementsareincludedinnationalnotifications.

NNDSS:DataCollectionandReporting

§ InorderforCDCtocollectandusepublichealthsurveillancedata,theNNDSSstaffworkscloselywithstateandlocalhealthdepartments;expertsfromotherCDCprograms;

§ andpartners,suchastheCouncilofStateandTerritorialEpidemiologists(CSTE).Together,theydevelopandimplementconsistentstandards,tools,training,andtechnologytohelpensurethatdiseasereportingsystemsareintegratedwithineachstate.

NNDSS:DataCollectionandReporting

§ TheyalsohelpmakesurethatpublichealthsurveillancesystemsareinteroperablewithpublichealthsurveillancesystemsatCDCandotherstateandlocalhealth

§ departments,aswellaswithhealthITsystemsusedbyhospitals,laboratories,andprivateproviders.

NNDSS:DataCollectionandReporting

§ NNDSSprovidesNationalElectronicDiseaseSurveillanceSystem(NEDSS)standards,tools,andresourcestosupportreportingjurisdictions–state,local,territorial,andtribal

§ healthdepartments– tohelpthemimplementintegratedandinteroperablepublichealthsurveillancesystems.

NNDSS:NotifiableDiseaseSurveillanceStartsatStateandLocalLevels

§ CDCreceivescasenotificationsfrom57reportingjurisdictions.Eachstatehaslawsrequiringcertaindiseasesbereportedatthestatelevel,butitisvoluntaryforstatestoprovide

§ informationornotificationstoCDCatthefederallevel.

NNDSS:NotifiableDiseaseSurveillanceStartsatStateandLocalLevels

§ Thenotifiablediseasesdatavoluntarilysharedbythese57jurisdictionsrepresentsasmallportionofthepublichealthsurveillancedatathatjurisdictions

§ collectandusetomakedecisionsandconductpublichealthactivitiesintheircommunities(e.g.,outbreakdetectionandcontrol).Thereareseveralimportantdistinctionsbetweenareportablediseaseandanotifiabledisease.

NNDSS:NotifiableDiseaseSurveillanceStartsatStateandLocalLevels

§ Itismandatorythatreportablediseasecasesbereportedtostateandterritorialjurisdictionswhenidentifiedbyahealthprovider,hospital,orlaboratory.Thistypeof

§ requiredreportingusespersonalidentifiersandenablesthestatestoidentifycaseswhereimmediatediseasecontrolandpreventionisneeded.Eachstatehasitsownlawsandregulationsdefiningwhatdiseasesarereportable.Thelistofreportablediseasesvariesamongstatesandovertime.

NNDSS:NotifiableDiseaseSurveillanceStartsatStateandLocalLevels

§ Itisvoluntarythatnotifiable diseasecasesbereportedtoCDCbystateandterritorialjurisdictions(withoutdirectpersonalidentifiers)fornationwideaggregationandmonitoringof§ diseasedata.Regular,frequent,timelyinformationonindividualcasesisconsiderednecessarytomonitordiseasetrends,identifypopulationsorgeographicareasathighrisk,formulateandassesspreventionandcontrolstrategies,andformulatepublichealthpolicies.

NNDSS:NotifiableDiseaseSurveillanceStartsatStateandLocalLevels

§ Thelistofnotifiablediseasesvariesovertimeandbystate.ThelistofnationallynotifiablediseasesisreviewedandmodifiedannuallybytheCSTEandCDC.Everynationally

§ notifiablediseaseisnotnecessarilyreportableineachstate.

NNDSS:CaseDefinitions

§ Acasedefinitionissetofuniformcriteriausedtodefineadiseaseforpublichealthsurveillance.Casedefinitionsenablepublichealthtoclassifyandcountcasesconsistently

§ acrossreportingjurisdictions,andshouldnotbeusedbyhealthcareproviderstodeterminehowtomeetanindividualpatient’shealthneeds.

NNDSS:CaseDefinitions

§ Whilethelistofreportableconditionsvariesbystate,theCouncilofStateandTerritorialEpidemiologists(CSTE)hasrecommendedthatstatehealthdepartmentsreportcasesofselected

§ diseasestoCDC’sNationalNotifiableDiseasesSurveillanceSystem(NNDSS).Everyyear,casedefinitionsareupdatedusingCSTE’sPositionStatements.Theyprovideuniformcriteriaofnationallynotifiableinfectiousandnon-infectiousconditionsforreportingpurposes.

NNDSS:ProvisionalData

§ Provisionaldata areinitiallycollectedlocallyasaresultofstate,territorial,andlocallegislationandregulationsthatrequirehealthcare

§ providers,medicallaboratories,andotherentitiestosubmitdataonreportableconditionstostateandlocalpublichealthdepartments.Thereportableconditionsvarydependinguponeachjurisdiction’shealthpriorities.

NNDSS:ProvisionalData

§ ThereportingjurisdictionsvoluntarilysubmitcasenotificationsforthenationallynotifiableconditionstoCDC.NNDSSdataare

§ consideredprovisionalandsubjecttochangeeachweekuntilthedataarereconciledandverifiedwiththestateandterritorialdataproviderstobethefinalofficialincidencecountsforagivennotifiableconditionandyear.

NNDSS:ProvisionalData

§ Cumulativecountsofcasespresentedeachweekcanincreaseordecreaseasadditionalinformationbecomesavailableand

§ countsareupdated.Inanygivenyear,formostconditions,cumulativeprovisionalcasecountsandratesdonotmatchfinalizedcasecountsandrates.

NNDSS:FinalizedData

§ Finalizeddata arecreatedwithinapproximatelysixmonthsaftertheendofthecalendaryear.CDCfinalizesNNDSSdataincollaboration

§ withthestateandterritorialhealthdepartmentdataprovidersandCDCprogramleadersforeachnotifiablecondition.

NNDSS:FinalizedData

§ FinalizedcountsbyconditionandreportingjurisdictionarepublishedintheMMWR EarlyReleaseTableapproximatelytwomonthsafterthe

§ stateandterritorialhealthdepartmentsfinalizethedata.Inaddition,finalizeddataarepublishedintheMMWRSummaryofNotifiableInfectionsDiseasesandConditions—UnitedStates (alsoreferredtoastheSummary)approximatelyoneyearafterthedataarepublishedintheEarlyReleaseTables.

NNDSS:FinalizedData

§ TheNNDSSsurveillancedatalikelyrepresentanunderestimateofthetruenumberofcasesofagivenconditionbecauseofunder-

§ recognitionandunder-reportingofdisease.

NNDSS:ProvisionalData

Accessibleat:§ Data.cdc.gov§ CDCWONDER§ MMWRWeekly:referto"Notifiable

DiseasesandMortalityTables"

NNDSS:FinalizedData

§ SummaryofNotifiableInfectiousDiseasesandConditions*MMWR:https://www.cdc.gov/mmwr/mmwr_nd/index.html

§ SummaryofNotifiableNon-InfectiousDiseaseandConditionsMMWR:https://www.cdc.gov/mmwr/mmwr_nnc/index.html

*Onlydatafromreportingstates,territories,andjurisdictionsthatdesignatedtheinfectiousdiseaseorconditionasreportableareincludedinthesummarytables.

NationalSyndromicSurveillanceProgram(NSSP)

§ NSSPOverview§ TheNationalSyndromic

SurveillanceProgram(NSSP)promotesandadvancesdevelopmentofasyndromicsurveillancesystemforthetimelyexchangeofsyndromicdata.

NationalSyndromicSurveillanceProgram(NSSP)

§ NSSPOverview§ Thesedataareusedtoimprove

nationwidesituationalawarenessandenhanceresponsivenesstohazardouseventsanddiseaseoutbreakstoprotectAmerica’shealth,safety,andsecurity.

NationalSyndromicSurveillanceProgram(NSSP)

§ NSSPOverview§ NSSPfunctionsthroughcollaboration

amongindividualsandorganizationsatlocal,state,andfederallevelsofpublichealth;federalagenciesincludingtheU.S.DepartmentofDefenseandtheU.S.DepartmentofVeteransAffairs;publichealthpartnerorganizations;andhospitalsandhealthprofessionals.

NationalSyndromicSurveillanceProgram(NSSP)

§ NSSPFeatures§ TheBioSense Platform§ CommunityofPractice

NSSP:TheBioSense Platform

§ Tosupportnationalemergencypreparedness,theU.S.CongresspassedlegislationandappropriatedfundingtotheCentersforDiseaseControlandPrevention(CDC)toestablishanintegratednationalpublichealthsurveillancesystemforearlydetectionandrapidassessmentofbioterrorism-relatedevents.

NSSP:TheBioSense Platform

§ Tomeetthisneed,CDClaunchedBioSense in2003.Since2011,thefocushasexpandedtosituationalawarenessforall-hazardspreparednessandresponse.TheNSSPprovidessyndromicsurveillancepractitionersaccess

§ toanduseofthecloud-basedBioSense Platform,asecureintegratedelectronichealthinformationsystemwithstandardizedanalytictoolsandprocesses.

NSSP:CommunityofPracticeandCollaborationwithPartners§ NSSPpromotesaCommunityof

Practiceinwhichparticipantscollaboratetoadvancethescienceandpracticeofsyndromicsurveillance.TheNSSPCommunityofPracticeincludesCDC-fundedgrantees,nonfunded states

§ andjurisdictionsthatcontributedatatotheBioSense Platform,publichealthpractitionerswhouselocalsyndromicsurveillancesystems,CDCprograms,otherfederalagencies,partnerorganizations,hospitals,healthcareprofessionals,andacademicinstitutions.

NSSP:CommunityofPracticeandCollaborationwithPartners§ CDCworkswithpartnerstoimprovethe

timelinessandrepresentativenessofthedatathatdrivedecisionmakingandaction.CDCfundstheAssociationofStateandTerritorialHealthOfficials(ASTHO)tohosttheBioSense Platform.

§ ThroughcoordinationwithpartnerssuchasASTHO,theCouncilofStateandTerritorialEpidemiologists,theNationalAssociationofCountyandCityHealthOfficials,andtheInternationalSocietyforDiseaseSurveillance,BioSense PlatformusersprovidefeedbackondevelopmentanduseoftheBioSense Platform.

NSSP:SyndromicSurveillance

§ Syndromicsurveillanceusessyndromicdataandstatisticaltoolstodetect,monitor,andcharacterizeunusualactivityforfurtherpublichealthinvestigationorresponse.

§ Syndromicdataincludepatientencounterdatafromemergencydepartments,urgentcare,ambulatorycare,andinpatienthealthcaresettings,aswellaspharmacyandlaboratorydata.

NSSP:SyndromicSurveillance

§ Thoughthesedataarebeingcapturedfordifferentpurposes,theyaremonitoredinnearreal-timeaspotentialindicatorsofanevent,adisease,oranoutbreakofpublichealthsignificance.Publichealth

§ practitionersusevarioussurveillancesystemsanddatasourcesincombinationwithsyndromicdatatoenhancetheirunderstandingofevents.

NSSP:SyndromicSurveillance

§ Otherdatasourcesthatprovidecontextmayincludeschoolandbusinessabsenteedata,poisoncontrolreports,andevensocialmediadatathatmaypresentanemergentpictureofpublichealthevents.

NSSP:PublicHealthSyndromicSurveillanceDataFlow

NSSP:SyndromicDatainAction

§ Syndromicsurveillancecanimprovepublichealthsituationalawarenessbymonitoringdifferentconditions

§ Infectiousdiseaseoutbreaksandpandemics(EnterovirusD68,influenza,H1N1fluvirus,Norovirus,Zika)

§ Identificationofreportableconditionsnotfoundbyothersystems(Ciguaterafishpoisoning)

NSSP:SyndromicDatainAction

§ Syndromicsurveillancecanimprovepublichealthsituationalawarenessbymonitoringdifferentconditions

§ Massgatherings(SuperBowl,conventions)

§ Naturalandman-madedisasters§ Injury(falls,bicycle-relatedinjuries,

drownings,drugoverdoses)§ Chronicconditions(asthma)

NSSP:SyndromicDatainAction

§ Syndromicsurveillancecanimprovepublichealthsituationalawarenessbymonitoringdifferentconditions

§ Healthcareuse(oralhealth,medicationrefills)• Burkom H,Burrer S,BarkerL,RobisonV,HicksP,Ising A.Useof

SyndromicDatatoDetermineOralHealthVisitBurdenonEmergencyDepartments.OnlineJournalofPublicHealthInformatics.2013;5(1):e57.

• Torres-UrquidyMH,Wallstrom G,Schleyer TKL.DetectionofDiseaseOutbreaksbytheUseofOralManifestations.JournalofDentalResearch.2009;88(1):89-94.

Questions!

Contact:MiguelTorres-UrquidyDDS,MS,PhD(Candidate)mtorresurquidy@cdc.gov

SeniorServiceFellowDivisionofHealthInformaticsandSurveillanceInformaticsServicesBranchDivisionofHealthInformaticsandSurveillanceCenterforSurveillance,Epidemiology,andLaboratoryServicesOfficeofPublicHealthScientificServicesCentersforDiseaseControlandPrevention(CDC)

Formoreinformation,contactCDC1-800-CDC-INFO(232-4636)TTY:1-888-232-6348www.cdc.gov

ThefindingsandconclusionsinthisreportarethoseoftheauthorsanddonotnecessarilyrepresenttheofficialpositionoftheCentersforDiseaseControlandPrevention.