what are the 5 steps of surveillance?

MMWR 2002;51:9501. Stay informed about our latest work in Privacy and Surveillance First name Last name Email ZIP code Characterization of the outbreak by person provides a description of whom the case-patients are and who is at risk. The alternative hypothesis, which will be adopted if the null hypothesis proves to be implausible, is that exposure is associated with disease. Because the Fisher Exact Test is tedious to calculate, let Epi Info or another computer program perform the calculations for you. A case definition is a standard set of criteria for deciding whether an individual should be classified as having the health condition of interest. MMWR 2003;52:5657. A systematic difference between cases and controls that results in a mistaken estimate of the association between exposure and disease is called a bias. The investigators asked case-patients and controls how much time they spent in the store and where they went in the store. In contrast to outbreak and epidemic, a cluster is an aggregation of cases in a given area over a particular period without regard to whether the number of cases is more than expected. The goal is to identify potential vulnerabilities and address them to prevent sensitive information from being lost, stolen, or compromised. When a federal agency is involved in the survey of 10 or more individuals, the data collection instrument must first be cleared by the White House Office of Management and Budget (OMB). But you'll need a plan. The hypotheses should be testable, since evaluating hypotheses is the next step in the investigation. Description: Name: Mason, M; Age: 40; Phone: 555-3756; Address: 34 Winifred Ave., Brookville, VA; County: Columbia; Sex: Female; Race: White; Disease: Lyme Disease; Date of Onset: 8/17/2006; Lab Confirmed? Some people have changed their behaviors in response to surveillance. These data would seem to indicate that persons exposed to Grocery Store A had 11.6 times the odds of developing legionellosis than persons not exposed to that store. The earliest case occurred during the week of October 28. By dividing the number of cases by the size of the population, county-specific rates of ehrlichiosis can be calculated (Figure 6.9). This is an online version of a printed textbook. If surveillance has not been ongoing, now is the time to initiate active surveillance. The conversations about possible exposures should be open-ended and wide-ranging, not necessarily confined to the known sources and vehicles. Disability Organizations with Local Chapters Nationwide All information these cookies collect is aggregated and therefore anonymous. The data showing the relationship between an exposure and disease are often displayed in a two-by-two table. J Infect Dis 1992;165:7369. A p-value this small indicates that the null hypothesis is highly improbable, and the investigators rejected the null hypothesis. The process of compiling, analyzing, and interpreting the results of primary and secondary data collection. Jacobus CH, Holick MF, Shao Q, Chen TC, Holm IA, Kolodny JM, et al. After the cause was known and diagnostic tests were developed, investigators could use the laboratory test to learn about the true spectrum of illness, and could broaden the case definition to include those with early infection or mild symptoms. A case might be temporarily classified as probable or possible while laboratory results are pending. If patient information is disclosed to unauthorized persons without the patients permission, the patient may be stigmatized or experience rejection from family and friends, lose a job, or be evicted from housing. Outcomes of treated human granulocytic ehrlichiosis cases. Thank you for taking the time to confirm your preferences. A communications plan must be established. Planning and sampling tools. How might health officials track behaviors that place citizens at increased risk of heart disease or diabetes? Outbreak of histoplasmosis among industrial plant workers Nebraska, 2004. Potentially correlated events can be noted on the graph. Summarizing data by key demographic variables provides a comprehensive characterization of the outbreak trends over time, geographic distribution (place), and the populations (persons) affected by the disease. Eosinophilia-myalgia syndrome New Mexico. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. For smaller studies, a test called the Fisher Exact Test may be more appropriate. Data collection tools. When is the likely date(s) of exposure, based on one average incubation period prior to the peak (median date) of the outbreak? Some cities have placed cameras on stop lights as a way to help prevent people from speeding or from going through a red light. The attack rate is low among those not exposed, so the difference or ratio between attack rates is high. Five Steps for Inclusive Health Promotion [FACT SHEET] June 2017. Disease surveillance involves a constellation of information systems that identify and record health related outcomes. Often, the number of case-patients that can be enrolled in a study is limited by the size of the outbreak. Surveillance identifies new cases and detects importation of wild poliovirus The four steps of surveillance are: 1. To create an effective business continuity plan, a firm should take these five steps: Step 1: Risk Assessment. The epi curve shows the magnitude of the epidemic over time as a simple, easily understood visual. Environmental inspection of the fairgrounds identified lack of chlorination of the well supplying water to that zone. Since this technique is not precise, widen the probable period of exposure by, say, 20% to 50% on either side of these dates, and then ask about exposures during this widened period in an attempt to identify the source. Investigators may conduct what is sometimes called stimulated or enhanced passive surveillance by sending a letter describing the situation and asking for reports of similar cases. The date of onset of the last known case was during the week of November 18, less than one month later. Source: Jani AA, Barrett E, Murphy J, Norton D, Novak C, Painter J, Toney D. A steamship full of trouble: an outbreak of Salmonella Typhimurium DT 104 gastroenteritis at a holiday banquetVirginia, 2003. Thus, the investigators were forced to develop new hypotheses about a source of Legionnaires disease to explain this outbreak. Which item shows the highest attack rate? Because cases can occur from 15 to 50 days after exposure, all cases from a point source exposure should occur within a span of 50 15 = 35 days. The illness was given the name eosinophilia-myalgia syndrome. Even in the era of computers, many epidemiologists still maintain a handwritten line listing of key data items, and turn to their computers for more complex manipulations and cross-tabulations. In practice, however, persons in a random sample may be difficult to contact and enroll. For airborne diseases, strategies may be directed at modifying ventilation or air pressure, and filtering or treating the air. What are the known risk factors? : Yes; Lab Results: WB IgG+; Comments: Arthritis, arthralgias, headache, fatigue, sweats, chills; Physician Reporting: Dr. Howard; Phone: 555-1950; Date of Report: 11/24/06. Section 1: Introduction Section 2: Purpose and Characteristics of Public Health Surveillance Section 3: Identifying Health Problems for Surveillance Section 4: Identifying or Collecting Data for Surveillance Section 5: Analyzing and Interpreting Data Section 6: Disseminating Data and Interpretations Section 7: Evaluating and Improving Surveillance The controls must not have the disease being studied, but should represent the population in which the cases occurred. MMWR 2004;53:10202. Using the information in the line listing below, determine whether or not each should be classified as a case, according to the initial case definition above. Vehicle borne transmission may be interrupted by elimination or decontamination of the vehicle. Both the peak of the outbreak and the median case occurred during the week of November 4. The circumstances may allow you to learn more about the disease, its modes of transmission, the characteristics of the agent, host factors, and the like. Source Ramsey AH, Belongia EA, Gale CM, Davis JP. This sounds pretty obvious but youd be surprised. If an outbreak affects a restricted population such as persons on a cruise ship, in a school, or at a work site, and if many cases are mild or asymptomatic and therefore undetected, a survey of the entire population is sometimes conducted to determine the extent of infection. Data analysis and reporting tools. Most countries use Demographic and Health Survey (DHS) data for health programs and . Table 6.2 Epidemiologic Steps of an Outbreak Investigation. Was she a friend or acquaintance of any of the Luverne cases? So the investigators rejected the null hypothesis (that beef was not associated with illness) and adopted the alternative hypothesis (that beef was indeed associated with illness). In a point-source epidemic of a known disease with a known incubation period, the epidemic curve can be used to identify a likely period of exposure. J Epidemiol Comm Health 1989;43:3114. Some 31% say they have heard a lot about the government surveillance programs and another 56% say they had heard a little. 1. Several counties are shaded to indicate the number of cases in that location. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. In a third study, investigators used radio broadcast appeals to identify healthy restaurant patrons who had eaten the implicated sandwich. A detailed description of statistical testing is beyond the scope of this lesson, but the following text presents some key features and formulas. Description: Name; Rollins, W; Age: 45; Phone: 555-4771; Address: 127 Midland St.; Portland, VA; County: Columbia; Sex: Male; Race: White; Disease: Lyme Disease; Date of Onset: Mid May 2006; Lab Confirmed? Emerg Infect Dis 2002;8:398-401. This is usually health care providers who provide clinical care, such as doctors, nurses, clinical officers, etc. If you do not have the clinical background to verify the diagnosis, bring a qualified clinician with you. Since a two-by-two table has 1 degree of freedom, a chi-square larger than 3.84 corresponds to a p-value smaller than 0.05. Indeed, the Dictionary of Epidemiology defines outbreak as an epidemic limited to localized increase in the incidence of disease, e.g., village, town, or closed institution.(23). Some simple and effective strategies protect portals of entry. Investigators of an outbreak of salmonellosis in The Dalles, Oregon, were stumped when they were able to implicate salad bars in several local restaurants, but could not identify any common ingredients or distribution system. The "contents" of a communication consists of any information . Each of the steps is described below in more detail, based on the assumption that you are the health department staff member scheduled to conduct the next field investigation. Typically, hypotheses in a field investigation are evaluated using a combination of environmental evidence, laboratory science, and epidemiology. In other words, epidemiologists cannot afford to conduct an investigation that is quick and dirty. They must conduct investigations that are quick and clean.(22) Under such circumstances, epidemiologists find it useful to have a systematic approach to follow, such as the sequence listed in Table 6.2. Step 3: Work on the plan as a team. But there are steps you can take to protect yourself, like using a #VPN at all times. However, this ideal is not always met. Statistical significance testing. Epidemic curves are a basic investigative tool because they are so informative (see Lesson 6). In the first study, investigators compared exposures of case-patients and controls from the general public to implicate a restaurant. Step 2. They help us to know which pages are the most and least popular and see how visitors move around the site. You also need to know what supplies or equipment to bring to protect yourself. In others, investigators use a generic case report form. By comparing the observed with expected patterns, epidemiologists can determine whether the observed pattern differs substantially from what should be expected and, if so, by what degree. Adapted from: Acute hemorrhagic conjunctivitis outbreak caused by Coxsackievirus A24Puerto Rico, 2003. Efforts to prevent fecal-oral transmission often focus on rearranging the environment to reduce the risk of contamination in the future and on changing behaviors, such as promoting hand washing. For example, in an outbreak of hypervitaminosis D that occurred in Massachusetts in 1991, investigators found that all of the case-patients drank milk delivered to their homes by a local dairy. In an outbreak context, hypotheses are generated in a variety of ways. If so, where are the new cases? Preparedness is a continuous cycle of activities such as emergency planning, staff training, exercising, assessment and remedial actions. (49) Thus the epidemiologic, environmental, and laboratory arms of the investigation complemented one another, and led to an inescapable conclusion that the well had been contaminated and was the source of the outbreak. These cookies may also be used for advertising purposes by these third parties. And also, relevant authorities can monitor road conditions with the live surveillance cameras. After collecting similar information from each attendee, the investigator calculates an attack rate for those exposed to (e.g., who ate) a particular item and an attack rate for those who were not exposed. In addition, investigators must consider logistical issues, such as how to contact potential controls, gain their cooperation, ensure that they are free of disease, and obtain appropriate exposure data from them. Am J Public Health 1995;85:6569. Reclassify each patient using the revised case definition. Cookies used to track the effectiveness of CDC public health campaigns through clickthrough data. In that situation, it may be useful to draw several epidemic curves with different units on the x-axis to find one that best portrays the data. This type of care refers to a multidisciplinary system that could include a range of other treatments including mild therapeutic hypothermia . The numbering scheme for this step is problematic, because preparing for field work often is not the first step. Electronic surveillance is the acquisition of information by an electronic, mechanical, or other surveillance device of the contents of any wire or electronic communication, under circumstances in which a party to the communication has a reasonable expectation of privacy. Look up the average and minimum incubation periods of the disease. If you do not allow these cookies we will not know when you have visited our site, and will not be able to monitor its performance. This isn't a complete list, and it won't make you completely safe from spying. The following 10 suggestions will help you conduct a more cost-effective and successful surveillance. 4. It's easy to say that you'll exercise every day. This is because at each step in the surveillance process, some individuals or patients are missed. You can review and change the way we collect information below. Some investigators use a more quantitative approach and calculate a population attributable risk percent for each food. Once the decision to conduct a field investigation of an acute outbreak has been made, working quickly is essential as is getting the right answer. Figure 6.3 Typical Epi Curves for Different Types of Spread. The 5, 9, and 14 Eyes agreements mean there are very few places in the world where your online data is completely safe from government surveillance. Klee AL, Maldin B, Edwin B, IPoshni I, Mostashari F, Fine A, et al. Cookies used to enable you to share pages and content that you find interesting on CDC.gov through third party social networking and other websites. Lukacs SL, Hsu V, Harper S, Handzel T, Hayslett J, Khabbaz R, et al. JAMA 1985;253:12758. Self study modules on Tuberculosis, Module 7: Confidentiality in Tuberculosis Control: Background. Return to text. Figure 6.2d shows the same data one more time, but with stacks of squares that each represent one case. To test the statistical significance of this finding, a chi-square test can be computed using the formula shown earlier. There appeared to be no clustering by either residence or worksite, and no connection with exposure to the towns cooling towers. For example, in the box on page 6-16, you can see the Pan American Health Organization (PAHO) recommended case definition for meningococcal disease. The shape of the epidemic curve may provide clues about the pattern of spread in the population, e.g., point versus intermittent source versus propagated. Video surveillance Firms are allowed to engage in video surveillance in common areas, but not private spaces such as bathrooms or locker rooms. Steps for Conducting a Lit Review - Literature Review: Conducting & Writing - LibGuides at University of West Florida Libraries Literature Review: Conducting & Writing 1. These clinical frequency distributions are considered so important in establishing the credibility of the diagnosis that they are frequently presented in the first table of an investigations report or manuscript. Source: Ramsey AH, Belongia EA, Gale CM, Davis JP. Compared to case-patients who had also eaten the sandwich, controls were more likely to have avoided the onions that came with the sandwich. Capt. Many epidemiologists use the terms outbreak and epidemic interchangeably, but the public is more likely to think that epidemic implies a crisis situation. If exposure is much more common among the case-patients than among the controls, i.e., the observed exposure among case-patients is greater than expected exposure provided by the controls, then exposure is said to be associated with illness. Description: Name: Michael, S; Age: 53; Phone: 555-4899; Address: 48 Valley Hill Dr., Brookville, VA; County: Columbia; Sex: Male; Race: Black; Disease: Lyme Disease; Date of Onset: 9/02/2006; Lab Confirmed? Baseline surveillance data is a useful resource for making this decision. (46,47) Thus, the investigations resulted not only in the development of appropriate control and prevention strategies, but also in increased knowledge about a health problem not previously seen or studied in the Western hemisphere. Infect Control Hosp Epidemiol 2003;24:84852. Part 5: STEPS Instrument. In December 2003, an outbreak of gastroenteritis occurred among tenth-grade students who had participated in a city-wide field trip. The plan should include how often and when to have conference calls with involved agencies, who will be the designated spokesperson, who will prepare health alerts and press releases, and the like. Finally, recall that one reason to investigate outbreaks is research. When designing a case-control study, one of the most important decisions is deciding who the controls should be. The curve shows where you are in the course of the epidemic still on the upswing, on the down slope, or after the epidemic has ended. Why are some groups with particular age, sex, or other person characteristics at greater risk than other groups with different person characteristics? When the attack rate for the exposed group is the same as the attack rate for the unexposed group, the relative risk is equal to 1.0, and the exposure is said not to be associated with disease. The 5 Whys and/or 8 Disciplines of Problem-Solving (8D) approaches are good root-cause analysis techniques that can help them work together on crafting a good problem statement, identifying the root cause/s, and brainstorming on appropriate solutions to address non-conformance. 1. (36) A year later, a member of a local cult admitted that the cult had intentionally contaminated the salads bars with Salmonellaorganisms. Patients from the same physician practice or hospital who do not have the disease in question. You are called to help investigate a cluster of 17 persons who developed brain cancer in an area over the past couple of years. Therefore, the epidemic curve can be used to identify the likely period of exposure. In some challenging investigations that yielded few clues, investigators have convened a meeting of several case-patients to search for common exposures. The hypothesis that the locally produced ground beef was the vehicle could easily be tested by asking case-patients and controls (persons without thyrotoxicosis or other thyroid disease) whether they ate ground beef from the same source. Return to text. Second, many investigators clinicians and non-clinicians find it useful to visit one or more patients with the disease. Snow; Phone: 555-1200; Date of Report: 11/24/06. Like its precursor of telephone wiretapping, it must be subjected to meaningful judicial process before it is authorized. An intermittent common-source epidemic (in which exposure to the causative agent is sporadic over time) usually produces an irregularly jagged epidemic curve reflecting the intermittence and duration of exposure and the number of persons exposed. Last JM. In analytic epidemiology, inclusion of false-positive cases can produce misleading results. This phase includes: Evaluation of the company's risks and exposures. Verifying the diagnosis is important: (a) to ensure that the disease has been properly identified, since control measures are often disease-specific; and (b) to rule out laboratory error as the basis for the increase in reported cases. A dictionary of epidemiology, 4th ed. Steps in carrying out surveillance (go to Outline) But surveillance involves carrying out many integrated steps by many people: Reporting Someone has to record the data. It permits the investigator to distinguish epidemic from endemic disease. Early in an investigation, investigators may restrict the descriptive epidemiology to numbers of cases. Single case of disease caused by an uncommon agent (e.g., glanders, smallpox, viral hemorrhagic fever, inhalational or cutaneous anthrax) without adequate epidemiologic explanation, Unusual, atypical, genetically engineered, or antiquated strain of an agent (or antibiotic-resistance pattern), Higher morbidity and mortality in association with a common disease or syndrome or failure of such patients to respond to usual therapy, Unusual disease presentation (e.g., inhalational anthrax or pneumonic plague), Disease with an unusual geographic or seasonal distribution (e.g., tularemia in a non-endemic area, influenza in the summer), Stable endemic disease with an unexplained increase in incidence (e.g., tularemia, plague), Atypical disease transmission through aerosols, food, or water, in a mode suggesting deliberate sabotage (i.e., no other physical explanation), No illness in persons who are not exposed to common ventilation systems (have separate closed ventilation systems) when illness is seen in persons in close proximity who have a common ventilation system, Several unusual or unexplained diseases coexisting in the same patient without any other explanation, Unusual illness that affects a large, disparate population (e.g., respiratory disease in a large population may suggest exposure to an inhalational pathogen or chemical agent), Illness that is unusual (or atypical) for a given population or age group (e.g., outbreak of measles-like rash in adults), Unusual pattern of death or illness among animals (which may be unexplained or attributed to an agent of bioterrorism) that precedes or accompanies illness or death in humans, Unusual pattern of death or illness among humans (which may be unexplained or attributed to an agent of bioterrorism) that precedes or accompanies illness or death in animals, Ill persons who seek treatment at about the same time (point source with compressed epidemic curve), Similar genetic type among agents isolated from temporally or spatially distinct sources, Simultaneous clusters of similar illness in noncontiguous areas, domestic or foreign, Large number of cases of unexplained diseases or deaths. Were most of the 57 case-patients exposed to that food item? The global goals to end the COVID-19 emergency are to reduce SARS-CoV-2 transmission and the impact of COVID-19 disease. The STEPS instrument is comprised of three different levels or "steps" of risk factor assessment: Step 1 (questionnaire), Step 2 (physical measures) and Step 3 (biochemical measures). (45) However, capitalizing on this unfortunate experiment of nature, investigators continued to follow the patients to determine the persistence of IgM and the prognosis of patients up to two years after infection. Subtract the time of onset of the median case from the time of exposure to estimate the median incubation period. This information can be found on disease fact sheets available on the Internet or in the, Identify the peak of the outbreak or the median case and count back on the. No analytic epidemiology was really necessary to evaluate the basic hypothesis in this setting or to implement appropriate control measures, although investigators did conduct additional studies to identify additional risk factors.38,39. The case definition may be restricted by time (for example, to persons with onset of illness within the past 2 months), by place (for example, to residents of the nine-county area or to employees of a particular plant) and by person (for example, to persons with no previous history of a positive tuberculin skin test, or to premenopausal women). If the map shows a cluster or other pattern (such as cases along a road), the investigator must consider possible explanations perhaps water supplies, wind currents, or proximity to a restaurant or grocery. Recover. 5. This assumption is known as the null hypothesis. Staff from different agencies have different perspectives, approaches, and priorities that must be reconciled. Salmonellosis associated with marijuana: a multistate outbreak traced by plasmid fingerprinting. The population attributable risk percent for beef was 76.7% (see Table 6.8), much higher than that for any other food. Consider the gastroenteritis and beef consumption data presented in Table 6.8. Source Castel AD, Blythe D, Edwards L, Totaro J, Shah D, Moore M. A large outbreak of Salmonella Enteritidis infections associated with crabcakes at a church fundraiserMaryland, 2003. Consider new vehicles or modes of transmission. Did this person ever go to Luverne? In studying sick-building syndrome and other disorders related to air-flow patterns in buildings, cases should be plotted by work location. Most, perhaps all, used cell phones. Interpreting an epidemic curve. Recognize, however, that the chi-square and similar tests are guides to help you make a decision about a hypothesis. Palmer SR. Adapted from: European Programme for Intervention Epidemiology Training [Internet]. But it is often more complete than passive surveillance. Epidemiol Bull 2001;22(4):146. Privacy and Surveillance The ACLU works in courts, legislatures, and communities to defend and preserve the individual rights and liberties that the Constitution and the laws of the United States guarantee everyone in this country.

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