Infectious Disease Surveillance

This fully updated edition of Infectious Disease Surveillance is for frontline public health practitioners, epidemiologists, and clinical microbiologists who are engaged in communicable disease control. It is also a foundational text for trainees in public health, applied epidemiology, postgraduate medicine and nursing programs. 

The second edition portrays both the conceptual framework and practical aspects of infectious disease surveillance. It is a comprehensive resource designed to improve the tracking of infectious diseases and to serve as a starting point in the development of new surveillance systems. Infectious Disease Surveillance includes over 45 chapters from over 100 contributors, and topics organized into six sections based on major themes.

Section One highlights the critical role surveillance plays in public health and it provides an overview of the current International Health Regulations (2005) in addition to successes and challenges in infectious disease eradication. 

Section Two describes surveillance systems based on logical program areas such as foodborne illnesses, vector-borne diseases, sexually transmitted diseases, viral hepatitis healthcare and transplantation associated infections. Attention is devoted to programs for monitoring unexplained deaths, agents of bioterrorism, mass gatherings, and disease associated with international travel.

Sections Three and Four explore the uses of the Internet and wireless technologies to advance infectious disease surveillance in various settings with emphasis on best practices based on deployed systems. They also address molecular laboratory methods, and statistical and geospatial analysis, and evaluation of systems for early epidemic detection.

Sections Five and Six discuss legal and ethical considerations, communication strategies and applied epidemiology-training programs. The rest of the chapters offer public-private partnerships, as well lessons from the 2009-2010 H1N1 influenza pandemic and future directions for infectious disease surveillance.

• Language: English
• Publisher: Wiley
• Release date: Mar 11, 2013
• ISBN: 9781118543528

Book preview

Infectious Disease Surveillance

Second Edition

Nkuchia M. M’ikanatha

Division of Infectious Disease Epidemiology

Pennsylvania Department of Health

Harrisburg, PA

USA

Ruth Lynfield

Minnesota Department of Health

St. Paul, MN

USA

Chris A. Van Beneden

Respiratory Diseases Branch

National Center for Immunization and Respiratory Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

Henriette de Valk

Infectious Disease Department

Institut de Veille Sanitaire

Saint Maurice

France

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Library of Congress Cataloging-in-Publication Data

Infectious disease surveillance / edited by Nkuchia M’ikanatha … [et al.]. - 2nd ed.

p. ; cm.

Includes bibliographical references and index.

ISBN 978-0-470-65467-5 (hardback : alk. paper)

I. M’ikanatha, Nkuchia M.

[DNLM: 1. Communicable Disease Control. 2. Disease Outbreaks-prevention & control. WA 110]

614.5-dc23

2012036992

A catalogue record for this book is available from the British Library.

Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.

Cover image: World map, Sameh Boktor; Flu chart, courtesy of Centers for Disease Control and Prevention; Electron micrograph of the influenza virus, Centers for Disease Control and Prevention; Escherichia coli microscope image, with permission from Elsevier; Pulsed-field gel electrophoresis image, with permission from Eurosurveillance Cover design by Steve Thompson

Contributors

Ibrahim Abubakar

Research Department of Infection and Population Health

University College London, and Tuberculosis Section

Health Protection Agency

London

UK

Katherine Ahrens

Boston University School of Public Health

Boston, MA

USA

Andrea Ammon

European Centre for Disease Prevention and Control

Stockholm

Sweden

Roberta Andraghetti

Pan American Health Organization

Washington, DC

USA

Delphine Antoine

Infectious Disease Department

Institut de Veille Sanitaire

Saint Maurice

France

Melissa Arvay

Division of Preparedness and Emerging Infections

National Center for Emerging and Zoonotic Infectious Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

Koye Balogun

Immunisation, Hepatitis and Blood Safety Department

Health Protection Agency

London, UK

Steven R. Becknell

Division of Public Health Systems and Workforce Development

Center for Global Health

Centers for Disease Control and Prevention

Atlanta, GA

USA

Robert A. Bednarczyk

Department of Epidemiology and Biostatistics

School of Public Health

University at Albany

Albany, NY

USA

John M. Besser

National Center for Emerging and Zoonotic Infectious Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

Madhulekha Bhattacharya

National Institute of Health and Family Welfare

N. Delhi

India

Guthrie S. Birkhead

New York State Department of Health and School of Public Health

University at Albany

Albany, NY

USA

Thierry Blanchon

Université Pierre et Marie Curie

Institut National de la Santé et de la Recherche Médicale

Paris

France

Michael Blench (deceased)

Public Health Agency of Canada

Ottawa, ON

Canada

Louise Boily

Public Health Agency of Canada

Ottawa, ON

Canada

Arnold Bosman

Public Health Training Section

European Centre for Disease Prevention and Control

Stockholm

Sweden

Lynnette Brammer

Influenza Division

Centers for Disease Control and Prevention

Atlanta, GA

USA

John S. Brownstein

Children’s Hospital Boston, Harvard Medical School

Boston, MA

USA

David L. Buckeridge

Department of Epidemiology, Biostatistics, and Occupational Health

McGill University

Montreal, QC

Canada

Alicia P. Budd

Influenza Division

Centers for Disease Control and Prevention

Atlanta, GA

USA

James W. Buehler

Public Health Surveillance and Informatics Program Office

Office of Surveillance, Epidemiology, and Laboratory Services

Centers for Disease Control and Prevention

Atlanta, GA

USA

Tom M. Chiller

Division of Foodborne, Waterborne and Environmental Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

Joan M. Chow

Sexually Transmitted Disease Control Branch

California Department of Public Health

Richmond, CA

USA

R. Elliott Churchill

Division of International Health Training (Retired)

Centers for Disease Control and Prevention

Atlanta, GA

USA

Bruno Coignard

Infectious Disease Department

Institut de Veille Sanitaire

Saint Maurice

France

Richard N. Danila

Minnesota Department of Health

St. Paul, MN

USA

Gilles Desvé

EpiConcept

Paris

France

Rebecca J. Eisen

Bacterial Diseases Branch

Division of Vector-Borne Diseases

National Center for Emerging Zoonotic

Infectious Diseases

Centers for Disease Control and Prevention

Fort Collins, CO

USA

Amy L. Fairchild

Columbia University Mailman School of Public Health

New York, NY

USA

Lyn Finelli

Influenza Division

Centers for Disease Control and Prevention

Atlanta, GA

USA

Marc Fischer

Arboviral Diseases Branch

Centers for Disease Control and Prevention

Fort Collins, CO

USA

Aaron T. Fleischauer

Office of Public Health Preparedness and Response

Centers for Disease Control and Prevention

Atlanta, GA

USA

Katherine Fleming-Dutra

Epidemic Intelligence Service

Centers for Disease Control and Prevention

Atlanta, GA

USA

Andrea M. Forde

Australian National University

Canberra

Australia

Kate Fowlie

Contra Costa Health Services

Martinez, CA

USA

Jerome E. Freier

Centers for Epidemiology and Animal Health

USDA

APHIS

Veterinary Services

Fort Collins, CO

USA

Andrew Friede

SRA International, Inc.

Atlanta, GA

USA

Renu Garg

HIV Unit

Department of Communicable Diseases

WHO/SEARO

N. Delhi

India

Petra Gastmeier

Institute of Hygiene and Environmental Medicine

Charité—University Medicine Berlin

Berlin

Germany

Kathryn Gay

Philadelphia Animal Welfare Society

Philadelphia, PA

USA

Mark Grabowsky

National Vaccine Program Office

Department of Health and Human Services

Washington, DC

USA

Samuel L. Groseclose

Office of Science and Public Health Practice

Office of Public Health Preparedness and Response

Centers for Disease Control and Prevention

Atlanta, GA

USA

Hajo Grundmann

Department of Medical Microbiology

University Medical Center Groningen

University of Groningen

The Netherlands

James L. Hadler

Connecticut Emerging Infections Program

Yale School of Public Health

New Haven, CT

USA

Douglas H. Hamilton

Scientific Education and Professional Development Program Office

Centers for Disease Control and Prevention

Atlanta, GA

USA

Maxwell C. Hardiman

Regulations and Procedures

Department of Global Capacities, Alert and Response

World Health Organization

Geneva

Switzerland

Craig Hedberg

Division of Environmental Health Sciences

School of Public Health

University of Minnesota

Minneapolis, MN

USA

Leonhard Held

Division of Biostatistics

Institute of Social and Preventive Medicine

University of Zurich

Zurich

Switzerland

D.A. Henderson

Center for Biosecurity

University of Pittsburgh

Baltimore, MD

USA

Lauri A. Hicks

Respiratory Diseases Branch

National Center for Immunization and Respiratory Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

Joseph M. Hilbe

SSA Program

Jet Propulsion Laboratory

California Institute of Technology and Arizona

State University

Tempe, AZ

USA

Susan D. Hillis

Office of Noncommunicable Diseases, Injury, and Environmental Health

Centers for Disease Control and Prevention

Atlanta, GA

USA

Richard E. Hoffman

Colorado School of Public Health

Denver, CO

USA

Jerry A. Holmberg

Department of Health and Human Services

Office of Public Health and Science

Rockville, MD

USA

John H. Holmes

Center for Clinical Epidemiology and Biostatistics

University of Pennsylvania Perelman School of Medicine

Philadelphia, PA

USA

Donald R. Hopkins

The Carter Center—Health Programs

Atlanta, GA

USA

Teresa C. Horan

Division of Healthcare Quality Promotion

National Center for Emerging and Zoonotic Infectious Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

Rubina Imtiaz

Division of Global HIV/AIDS

Center for Global Health

Centers for Disease Control and Prevention

Atlanta, GA

USA

John K. Iskander

Office of the Associate Director for Science

Centers for Disease Control and Prevention

Atlanta, GA

USA

Michael A. Jhung

Influenza Division

Centers for Disease Control and Prevention

Atlanta, GA

USA

David M. Johns

Columbia University Mailman School of Public Health

New York, NY

USA

Alexander H. Jones

The Carter Center—Health Programs

Atlanta, GA

USA

Kathleen G. Julian

Penn State College of Medicine

Hershey, PA

USA

James J. Kazmierczak

Wisconsin Division of Public Health

Madison, WI

USA

Dmitry M. Kissin

Office of Noncommunicable Diseases, Injury, and Environmental Health

Centers for Disease Control and Prevention

Atlanta, GA

USA

Jeffrey D. Klausner

Department of Medicine

University of California

Los Angeles, CA

USA

Katrin S. Kohl

Division of Global Migration and Quarantine

National Center for Emerging and Zoonotic Infectious Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

Denise Koo

Scientific Education and Professional Development Program Office

Centers for Disease Control and Prevention

Atlanta, GA

USA

Gérard Krause

Department for Infectious Disease Epidemiology

Robert Koch Institute

Berlin

Germany

Matthew J. Kuehnert

Office of Blood, Organ, and Other Tissue Safety

Division of Healthcare Quality Promotion

Centers for Disease Control and Prevention

Atlanta, GA

USA

Lisa M. Lee

Office of Surveillance, Epidemiology, and Laboratory Services

Centers for Disease Control and Prevention

Atlanta, GA

USA

Mira J. Leslie

British Columbia Ministry of Agriculture

Abbotsford, BC

Canada

Francisco J. Luquero

Epicentre

Paris

France

Ruth Lynfield

Minnesota Department of Health

St. Paul, MN

USA

J.A. Magnuson

Oregon Health Authority

Portland, OR

USA

Barbara Mahon

National Center for Emerging Zoonotic

Infectious Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

Sunny Mak

Epidemiology Services

British Columbia Centre for Disease Control

Vancouver, BC

Canada

Samuel Makoy

Southern Sudan Guinea Worm Eradication Program

Directorate of Public Health

Ministry of Health—Republic of South Sudan

Juba

Sudan

Balcha Masresha

World Health Organization Office for Africa

Brazzaville

Congo

Barbara L. Massoudi

Center for the Advancement of Health IT

RTI International

Atlanta, GA

USA

Mehran S. Massoudi

Scientific Education and Professional Development Program Office

Centers for Disease Control and Prevention

Atlanta, GA

USA

Abla Mawudeku

Public Health Agency of Canada

Ottawa, ON

Canada

Toby McAdams

Minnesota Department of Health

St. Paul, MN

USA

Louise-Anne McNutt

Department of Epidemiology and Biostatistics

School of Public Health

University at Albany

Albany, NY

USA

Stephanie D. Meyer

Foodborne, Vectorborne, and Zoonotic Diseases Unit

Minnesota Department of Health

St. Paul, MN

USA

Nkuchia M. M’ikanatha

Division of Infectious Disease Epidemiology

Pennsylvania Department of Health

Harrisburg, PA

USA

Elizabeth Miller

Health Protection Agency

London

UK

Eve D. Mokotoff

Michigan Department of Community Health

Detroit, MI

USA

Chester G. Moore

Department of Microbiology, Immunology, & Pathology

Colorado State University

Fort Collins, CO

USA

Alain Moren

EpiConcept

Paris

France

Dale L. Morse

New York State Department of Health

Albany, NY

USA

Hanna M. Nohynek

National Institute for Health and Welfare

Helsinki

Finland

Kurt B. Nolte

Office of the Medical Investigator

University of New Mexico School of Medicine

Albuquerque, NM

USA

Mac Otten

Malaria Control Program

World Health Organization

Geneva

Switzerland

Michaela Paul

Division of Biostatistics

Institute of Social and Preventive Medicine

University of Zurich

Zurich

Switzerland

Julie A. Pavlin

Armed Forces Health Surveillance Center

Silver Spring, MD

USA

Mindy J. Perilla

Johns Hopkins Bloomberg School of Public Health

Baltimore, MD

USA

Lyle R. Petersen

Division of Vector-Borne Diseases

Centers for Disease Control and Prevention

Fort Collins, CO

USA

Bruce J. Plotkin

Regulations and Procedures

Department of Global Capacities, Alert and Response

World Health Organization

Geneva

Switzerland

Catherine Quigley

North West Regional Epidemiology

Health Protection Agency

London

UK

Gita Ramjee

HIV Prevention Research Unit

Medical Research Council

Durban

South Africa

Mary E. Ramsay

Immunisation, Hepatitis and Blood Safety Department

Health Protection Agency

London, UK

Thomas M. Rehle

HIV/AIDS, Sexually Transmitted Infections and TB (HAST)

Human Sciences Research Council

Cape Town

South Africa

Barbara J. Reynolds

Office of the Associate Director for Communication

Centers for Disease Control and Prevention

Atlanta, GA

USA

Alfonso Rodriguez-Lainz

Division of Global Migration and Quarantine

National Center for Emerging and Zoonotic Infectious Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

Dale D. Rohn

Maryland Department of Health and Mental Hygiene

Baltimore, MD

USA

Martha Ruben

Martha Ruben Services

Ottawa, ON

Canada

Ernesto Ruiz-tiben

The Carter Center—Health Programs

Atlanta, GA

USA

George W. Rutherford

University of California

San Francisco, CA

USA

Ron St. John

St. John Public Health Consulting International Inc.

Manotick, ON

Canada

Michael C. Samuel

Sexually Transmitted Disease Control Branch

California Department of Public Health

Richmond, CA

USA

Elaine Scallan

Colorado School of Public Health

University of Colorado Denver

Aurora, CO

USA

Ann M. Schmitz

Infectious Diseases Pathology Branch

Centers for Disease Control and Prevention

Atlanta, GA

USA

Frederic E. Shaw

Office of Surveillance, Epidemiology, and Laboratory Services

Centers for Disease Control and Prevention

Atlanta, GA

USA

R. Luke Shouse

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Centers for Disease Control and Prevention

Atlanta, GA

USA

Kirk E. Smith

Foodborne, Vectorborne, and Zoonotic Diseases Unit

Minnesota Department of Health

St. Paul, MN

USA

Perry F. Smith

State University of New York at Albany

School of Public Health

Albany, NY

USA

Brian G. Southwell

RTI International and University of North Carolina at Chapel Hill

Research Triangle Park, NC

USA

Edward van Straten

European Centre for Disease Prevention and Control

Stockholm

Sweden

Donna F. Stroup

Data for Solutions, Inc.

Decatur, GA

USA

Heather Tate

Food and Drug Administration

Center for Veterinary Medicine

Laurel, MD

USA

Stephen B. Thacker

Office of Surveillance, Epidemiology, and Laboratory Services

Centers for Disease Control and Prevention

Atlanta, GA

USA

Somsak Thamthitiwat

International Emerging Infections Program

Thailand Ministry of Public Health–US CDC Collaboration

Nonthaburi

Thailand

Herman D. Tolentino

Scientific Education and Professional Development Program Office

Centers for Disease Control and Prevention

Atlanta, GA

USA

Marta Valenciano

EpiConcept

Paris

France

Henriette de Valk

Infectious Disease Department

Institut de Veille Sanitaire

Saint Maurice

France

Chris A. Van Beneden

Respiratory Diseases Branch

Centers for Disease Control and Prevention

Atlanta, GA

USA

Charles R. Vitek

Division of Global HIV/AIDS

Centers for Disease Control and Prevention

Atlanta, GA

USA

Evgeny Voronin

Research and Clinical Center for HIV Prevention and Treatment of Pregnant Women

St. Petersburg

Russia

Gabriel Waat

The Carter Center—Health Programs

Atlanta, GA

USA

Hillard Weinstock

Division of STD Prevention

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention

Centers for Disease Control and Prevention

Atlanta, GA

USA

David P. Welliver

Clarific Services

Columbus, OH

USA

Jean M. Whichard

Division of Foodborne, Waterborne and Environmental Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

Robert P. Wise

Center for Biologics Evaluation and Research

Food and Drug Administration

Rockville, MD

USA

Danilo Lo Fo Wong

Division of Communicable Diseases, Health Security, and Environment

World Health Organization Regional Office for Europe

Geneva

Switzerland

Chee Fu Yung

Immunisation, Hepatitis and Blood Safety Department

Health Protection Agency

London, UK

Elizabeth R. Zell

National Center for Immunization and Respiratory Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

Yenlik Zheteyeva

National Center for Emerging and Zoonotic Infectious Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

Foreword to the Second Edition

Long-standing, fundamental barriers to effective prevention and control of infectious diseases remain with us—poverty, war, politics, cultural differences, and ethics challenges. Moreover, the recent financial crisis has resulted in substantial budget cuts throughout the USA and Europe, and decreases in salaries and reductions in staff require public health authorities to re-evaluate such core activities as disease surveillance. In this context of diminished resources, surveillance continues to be the cornerstone of public health practice, the primary tool for triggering interventions to prevent and control infectious diseases. Consequently, cost-effective surveillance is needed to tackle the challenges that infectious diseases still pose. Meanwhile, opportunities exist to enhance surveillance practice through increased global collaboration, dramatic advances in information science and technology, and development of new biologic science (e.g., genomics).

In this second edition of Infectious Disease Surveillance, a new chapter on the history of infectious disease surveillance provides the reader a context of both continuity and change. Two other new chapters on disease eradication build on the lessons learned from the Smallpox Eradication Program. A fourth new chapter on monitoring antibiotic usage and infections with antibiotic-resistant pathogens demonstrates the value of surveillance in formulating strategies to promote antibiotic stewardship to reduce emergence of antibiotic-resistant pathogens.

The epidemiologic pattern of infectious diseases has evolved since the book’s first edition. New bacterial strains (e.g., the carbapenemase-producing Enterobacteriaceae) continually emerge, and previously recognized viruses are spreading outside of their original area of endemicity. Arboviruses (e.g., chikungunya and dengue) are becoming pandemic with the spread of the Aedes albopictus mosquito. The introduction of chikungunya in Italy in 2007 resulted in a proficient community transmission that caused over 200 cases. Recently, autochthonous cases of chikungunya virus infections have been documented in France. Dengue virus autochthonous transmission has been documented in both France and Croatia, as well as in Florida (USA). In addition to the updates to chapters from the first edition to reflect such changes as these, chapters have been added on surveillance for infections related to transfusion and transplantation, antibiotic resistance, and human immunodeficiency virus/acquired immunodeficiency syndrome in countries undergoing transition. Other new chapters address infection control during international travel and among border populations. As addressed in another new chapter, surveillance during mass gatherings has become critical, especially with increased concerns regarding terrorism.

Emergence in 2009 of an influenza pandemic strain highlighted multiple challenges for infectious disease surveillance. While global event-based surveillance focused on emergence of avian influenza (H5N1) in Asia, resulting in early detection of clusters and timely investigation to assess human-to-human transmission, a new pandemic strain of swine origin emerged in the Americas. It was identified only after it had resulted in widespread community transmission, had spread to neighboring countries, and probably had been exported to Europe. Surveillance for the pandemic highlighted the difficulty in monitoring its spread worldwide and, in particular, to characterize its severity. The challenge of adjusting surveillance for pandemic influenza, from the detection of imported cases to the monitoring of its spread throughout communities, was enormous. A chapter on what was learned from this experience is also included.

Re-emergence of wild poliomyelitis in 2011 resulted in hundreds of cases, indicating that surveillance efforts failed to detect its re-emergence at a stage that would have allowed timely disease prevention and control. Similarly, elimination of measles in Europe remains a challenge partly because endemic and imported cases are not recognized in a timely manner. High-quality surveillance systems can play a crucial role in monitoring and preventing spread of diseases (e.g., poliomyelitis and measles), and robust systems support other vital public health interventions.

The revised International Health Regulations now in place provide a framework for a global approach to infectious disease surveillance and control. These regulations required national health jurisdictions to assess and strengthen their capacity to conduct surveillance for infectious diseases by June 2012. However, despite a long tradition of infectious disease surveillance, the majority of advanced countries still have gaps in their ability to detect and respond to infectious diseases, especially among hard-to-reach communities.

Advances in information technology are inducing paradigm shifts in public health practice. The backbone of infectious disease surveillance remains the traditional notification of cases of diseases and analysis of trends and clustering (indicator-based surveillance). Implementation of Internet-based notification in certain areas has improved timeliness of reporting dramatically because notifications are conveyed to a central database where they can be analyzed. Health information exchanges in the USA have improved both reporting timeliness and completeness. In addition, event-based surveillance (e.g., implementation of a mobile-based disease surveillance system during the 2009 hajj in Saudi Arabia) has emerged as a complementary approach to infectious disease surveillance. Although initial efforts focused on comprehensively scanning the epidemiologic horizon, recent approaches emphasize information integration. Chapters on electronic sentinel surveillance and wireless applications highlight these modern surveillance tools.

Surveillance science continues to evolve. Chapters on statistical modeling and use of spatial analysis with geographic information systems highlight the importance of integrating statistical and epidemiologic sciences with surveillance practice. With the emergence of social networks, we are confronted with yet another challenge for surveillance science and practice. Similarly, the monitoring of search terms related to influenza in Google® (Google, Inc., Mountain View, CA) has proven to be highly correlated with influenza outbreak trends (http://www.google.org/flutrends). However, understanding the role of new technologies in surveillance for emergent situations will require additional studies to, for example, distinguish useful information from meaningless epidemiologic noise. More than ever before, communities are playing an active role in infectious disease surveillance and control. Social networks are being used to monitor specific emerging events, but in the future they might play a substantial role in disease surveillance.

Public health surveillance of infectious diseases remains a synthesis of art and science, requiring an optimal balance of ingredients. Experienced public health practitioners from around the world, by contributing to this book, provide the reader essential knowledge about infectious disease surveillance as well as practical tools that can be translated into successful public health practice.

Stephen B. Thacker

Office of Surveillance, Epidemiology,

and Laboratory Services

Centers for Disease Control and Prevention

Atlanta, GA

USA

Denis M. Coulombier

Surveillance and Response Support Unit

European Centre for Disease Prevention and Control

Stockholm

Sweden

May 2013

Foreword to the First Edition

A compendium of infectious disease surveillance must confront both the inevitable and the impossible. As long as the human host and microbial agents occupy the same environment, it is inevitable that infectious diseases will continue to occur and pose real challenges to public health programs and the populations they serve. Unlike classical surveillance for vital statistics, which tracks those constants of the human condition—birth and death—surveillance for infectious diseases tackles the impossibly diverse spectrum of illness that an evolving microbial world sets loose on the human population. In recent years, infectious disease surveillance is increasingly bridging the gap between human and animal worlds in order to track infections in the vectors that play important roles in the emergence and spread of new infectious diseases. Our surveillance systems are now tasked to extend to multiple host species in order to better monitor infectious threats to humans. Additionally, in recent years, authorities are interested in surveillance systems that can anticipate what has not yet happened: identify new infectious agents before they emerge, detect signals of exposure or prodromal symptoms before a disease has become manifest in large numbers of the population. Fortunately, the seemingly impossible scope and standards to which practitioners of surveillance for infectious disease must strive is often matched by innovation and execution equal to these challenges.

This new textbook on infectious disease surveillance features selected best practices and model surveillance programs that are being carried out on a local, state, national, or global scale, to address the infectious disease challenges of the twenty-first century. The book also contains lessons learned from surveillance of the past—in particular, the experience of surveillance targeted against the only infectious disease ever eradicated globally, smallpox. Public health practitioners and students approach infectious disease surveillance from a variety of backgrounds, and must assume a range of responsibilities in carrying out their mandates. For example, today every public health practitioner has by necessity become a leader in their own community’s efforts to prepare for future pandemics of influenza. This textbook can provide a strong grounding in infectious disease surveillance that is vital to these efforts.

Pathogens: Many infectious diseases caused by the major pathogens of the past century are now well controlled in several regions of the world and progress is being made in others—thanks to the advent of effective vaccines, sanitation, infection control, and improvements in food hygiene and nutrition. Surveillance for vaccine-preventable diseases and enteric pathogens highlights some of these success stories and guards against the complacency that can precede resurgences. However, an astounding number of new infectious diseases have emerged in the past 30 years, and some agents of the past such as tuberculosis have reemerged with more severe, multidrug-resistant forms that challenge traditional control programs. Each of these poses some unexpected challenges to surveillance approaches. The emergence of West Nile virus into new regions of the world brought surveillance in insects, birds, and horses into the mainstream of state and local public health efforts. The emergence of drug resistance among bacteria, parasites, and more recently viruses, and the recent diffusion of a new hypervirulent strain of Clostridium difficile in hospitals of North America and Europe are just a few timely examples of infectious disease surveillance needs that showcase the interdependence and synergy that occurs when laboratory characterization of strains is linked with epidemiologic analysis of disease patterns. Preparedness for pandemic influenza requires facile and flexible laboratory-based surveillance systems that can span the globe and detect new variants. The number of pathogens of interest to infectious disease surveillance programs is expanding, and the availability and usefulness of detailed pathogen information down to the genetic code has also increased.

People: In addition to the dynamic nature of the microbial world, infectious disease surveillance must address a changing human population. Globalization, increased life expectancy, major expansion of populations suffering from immune suppression (from pathogens like HIV, and from treatments for conditions such as cancer and organ transplantation) have resulted in larger numbers of susceptible people who have ample opportunities to encounter microbes that can do them harm. Add to these forces the often-surprising types of human behavior, and one finds surveillance requirements that may encompass what is personal, private, or at times political. Inclusion of sociological, ethical, and legal aspects of surveillance in a core infectious disease surveillance textbook is clear recognition of the reality that in the twenty-first century the term surveillance has taken on increasingly nuanced connotations.

Places: The evolving environment and its interaction with infectious agents, animals, and people play an increasingly recognized role in disease transmission and emerging infections. The places in which people live, travel, work, and recreate encompass very diverse conditions that influence how surveillance should be implemented at various levels. Monitoring the impact on infectious disease of climate change, extension of the range of several vectors of infectious disease such as dengue, West Nile virus, or Chickungunya virus, are among the many new environmental challenges for surveillance and public health response. The healthcare environment continues to serve as a hot bed for infectious disease transmission and requires attention in all countries, including those with limited resources. The 2003 epidemic of severe acute respiratory syndrome (SARS) was characterized by major amplification of the newly recognized SARS coronavirus in the healthcare environment. Sensitive and timely surveillance was vital to the global control of SARS, permitting the effective targeted use of traditional strategies such as infection control, quarantine, and social distancing in order to interrupt transmission.

Processing information: Confronting the need for information that is faster, more granular, and increasingly complex, a huge growth area for innovations in surveillance relates to the technologic processes required to share public health information. From pony express to the information highway, from telegraph to text messaging, technology has the potential to transform infectious disease surveillance. However, the promise is often frustratingly greater than our current realities can deliver. Much of the world’s population now lives in a 24/7 media cycle where surveillance data may become dated before they are even issued. Assuring both scientific accuracy and public health relevance in this evolving social environment has always been important to infectious disease surveillance and shall remain so, but increasingly high expectations may become more and more difficult for local, state, or national public health authorities to meet. Despite the opportunities that technological advances have provided to enhance infectious disease surveillance, there have often been political constraints to information sharing of public health data that is construed to threaten tourism, economic, or political interests. However, major changes in the legal framework that underpins communicating urgent public health information to the World Health Organization (WHO) and among nations result from the new WHO International Health Regulations (2005) endorsed by 192 countries at the World Health Assembly in 2005 and scheduled to be implemented in June 2007. These regulations emphasize the need for transparency and timeliness in communicating selected public health events around the world and offer a new global standard for sharing critical surveillance information. This new standard implies, however, that each country develops a critical level of public health surveillance and response capacity to meet the challenges of the new regulations.

Principles: Given the dynamic nature of the pathogens, people, places, and processes associated with infectious disease surveillance, assembling a textbook on this broad subject might be considered an impossible task. Fortunately, the principles underlying surveillance for infectious diseases are surprisingly stable. The common threads woven through the chapters of this book should display to the reader the key principles of why, how, when, and where to employ infectious disease surveillance programs. These principles will serve the public health practitioner well for the foreseeable future. The diverse public health workforce engaged at local, state, national, and international levels in infectious disease surveillance activities can look to this textbook to emphasize the basics for those new to the field and expand horizons for those who have spent careers engaged in one or more aspect of this work.

Anne Schuchat and Jean-Claude Desenclos

July 2007

Preface to Second Edition

High quality national surveillance is the cornerstone of infectious disease prevention and control.

—World Health Organization (2004)

Advances in biomedical sciences have enabled substantial gains in the prevention and control of infectious diseases including the ability to detect, track, treat, and immunize against some diseases. However, infectious pathogens continue to evolve and adapt. Recently, the global community has experienced a resurgence of measles in Western Europe, introduction of cholera in Haiti, and the emergence of New Delhi metallo-β-lactamase 1-producing Klebsiella pneumoniae. The World Health Organization’s International Health Regulations (2005) called for strengthening of capacity to conduct surveillance in every Member State. In 2009, the first major test of these regulations occurred during the H1N1 influenza pandemic.

In recent years, infrastructures to conduct surveillance benefited from innovations in information technology including powerful mobile devices and widespread use of the Internet. The ongoing transformation of the healthcare information systems, especially increased use of electronic medical records, offers additional opportunities for complementary surveillance systems. Implementation of Internet-based systems and large datasets, however, has resulted in a complexity that requires development of new skills among public health professionals. This requires close collaboration with information technology specialists and biostatisticians. It is also prudent to assess the legal and ethical dimensions related to the use of these technologies for core surveillance activities, which, for epidemiologic reasons, include collection of private personal information.

Advances in laboratory and epidemiologic methods, including molecular diagnostic tests for organism identification, have expanded the surveillance toolset and knowledge base of public health practitioners. Further progress in healthcare technology has enabled life-saving procedures including blood transfusion and solid organ transplantation. These positive changes pose inherent risk of transmission of pathogens from donors to recipients. Thus, an understanding of these new frontiers is a prerequisite for robust surveillance systems.

Inspired by a shared vision to support global surveillance efforts, we have collaborated with over 120 authors in writing the second edition of Infectious Disease Surveillance. Its 46 chapters primarily represent surveillance systems from North America and Europe. However, the principles and approaches can be applied in other settings.

We have organized the chapters into six sections based on major themes. Section one begins with an introductory chapter that highlights the critical role surveillance plays in public health and offers an overview of the rest of the book. Subsequent chapters offer historical perspectives including lessons learned in the 1970s from the smallpox eradication campaign. The rest of the chapters address the International Health Regulations and supranational surveillance in the European Union.

Section two describes program-specific surveillance systems, such as population-based surveillance for bacterial pathogens, vector-borne, and transplantation-related infections. Section three explores the use of information technology to advance infectious disease surveillance. Chapters in this section discuss use of the Internet to facilitate disease reporting, dissemination of findings, electronic transfer of surveillance data from laboratories, and data management. In addition, novel surveillance systems that use emerging mobile technologies are covered, as are automated algorithms to assist in detection of cases in electronic laboratory data or to detect temporal and spatial clustering. Section four presents topics in surveillance methodology, including molecular epidemiology, data analyses, geographic information systems, and evaluation of surveillance systems.

Section five addresses broad topics important in the conduct of public health surveillance for infectious diseases. Two chapters discuss ethical and legal considerations in the conduct of surveillance. Additional chapters cover communication with mass media and examples of surveillance-related training opportunities. Lastly, section six provides a rationale for and examples of public–private partnerships in surveillance programs, and lessons learned from the 2009 influenza pandemic.

It is our hope that this book will serve as a practical guide for surveillance practitioners and key partners; it provides not just conceptual theories but also practical pearls from other practitioners who have been involved in implementation of public health programs. Illustrative examples are provided and referenced for further reading. This book can also serve as a textbook for public health students and for trainees in applied epidemiology and preventive medicine. Lastly, the book may also be of interest to academic and industry researchers in infectious diseases and medical informatics.

Finally, we acknowledge with gratitude many individuals who made this book possible through their encouragement and support. In particular, we are indebted to the generosity of the contributors and external reviewers, and the patience and understanding of our families and friends. We are encouraged by the hope that this book, which grew out of the dedication and expertise of many collaborators, will strengthen current efforts to enhance infectious disease surveillance.

Nkuchia M. M’ikanatha

Ruth Lynfield

Chris A. Van Beneden

Henriette de Valk

May 2013

About the cover

The cover uses two sets of images to represent surveillance for endemic diseases (seasonal influenza) and use of DNA fingerprinting technology to investigate an emerging infectious disease (a new strain of Escherichia coli associated with a large outbreak in Germany and other European countries in 2011). Images: one set is a pulsed-field gel electrophoresis profile of the E. coli O104:H4 isolates involved in 2011 in Germany on a background of a scanning electron micrograph of E. coli. The other is a figure based on weekly surveillance for seasonal influenza in the USA on a background of an electron micrograph for influenza H1N1 virus. Cover artwork suggestions: Sameh Boktor and Carol Sandt; conceptual design Nkuchia M’ikanatha.

Preface to First Edition

High quality national surveillance is the cornerstone of infectious disease prevention and control.

—World Health Organization, 2004

Major challenges to global and national public health systems during the past 30 years arising from both emerging and established pathogens demonstrate the need for reassessment of the commitment to infectious disease surveillance. The critical need for better surveillance became more urgent during the past decade with the threat of bioterrorism and the recognition of the potential for an influenza pandemic. Concurrently, changes in public health information infrastructure, especially the widespread use of computers and Internet-based systems, resulted in ongoing improvements in the conduct of surveillance. In addition, advances in laboratory and epidemiologic methods, including molecular diagnostic tests for organism identification, have expanded the surveillance toolset and knowledge base.

Inspired to support local and national public health efforts in infectious disease surveillance, we have collaborated to create a readily accessible resource inclusive of recent developments in the field. It contains 40 chapters drawn from experiences of over 100 authors involved in implementation of surveillance systems. We acknowledge the disproportionate representation of surveillance systems from North America and Europe, but when possible, we sought to include considerations for surveillance as it may be applied around the world.

We have organized the subjects into four sections based on major themes. Section I begins with an introductory chapter that highlights the critical role surveillance plays in public health and offers an overview of the rest of the book. The second chapter introduces the International Health Regulations (IHR 2005) and its emphasis on international reporting and strengthening surveillance capacities worldwide. The other chapters in the first section describe disease-specific or program-specific surveillance systems, such as foodborne and vector-borne disease surveillance.

Section II explores the use of information technology to advance infectious disease surveillance. The chapters discuss use of the Internet to facilitate disease reporting and dissemination of findings, electronic transfer of surveillance data from laboratories, and data management. Also, novel surveillance systems that use algorithms to assist in detection of cases in electronic laboratory data or use automated analyses to detect temporal and spatial clustering are introduced. Section III presents topics in surveillance methodology, including molecular epidemiology, data analyses, communication with the media and the public, and evaluation of surveillance systems.

Section IV addresses broad topics important in the conduct of public health surveillance for infectious diseases. Chapters discuss ethical considerations, the legal basis for conducting surveillance, and the legal considerations for isolation and quarantine. In addition, examples of surveillance-related training opportunities and partnerships in the private sector are presented. Lastly, Section V concludes with a review of historical lessons learned from application of surveillance in disease control—in the 1970s, smallpox, and more recently in 2003, the severe acute respiratory syndrome or SARS.

It is our hope that this book will serve as a practical guide for surveillance practitioners and key partners; it provides not just conceptual theories, but practical pearls from other practitioners who have been involved in implementation of public health programs. Illustrative examples are provided and referenced for further reading. This book can also serve as a textbook for public health students and for trainees in applied epidemiology and preventive medicine. Lastly, the book may also be of interest to academic and industry researchers in infectious disease and medical informatics.

Finally, we acknowledge with gratitude many individuals who made this book possible through their encouragement and support. In particular, we are indebted to the generosity of the contributors and external reviewers, and the patience and understanding of our families and friends. We are encouraged by the hope that this book, which grew out of the dedication and expertise of many collaborators, will strengthen, even in a small way, current efforts to enhance infectious disease surveillance.

Nkuchia M. M’ikanatha

Ruth Lynfield

Chris Van Beneden

Henriette de Valk

July 2007

Acknowledgments

This book could not have taken shape without the shared vision and work of many people. Over 100 experts in public health put finger to keyboard at very late hours in order to share their expertise. We are truly grateful for their generosity.

In addition to the authors’ labors on their chapters, a number of people put significant effort into reviewing various components of the book. In particular, we thank Chris Carr, Lars Eisen, David Fleming, Jaclyn Fox, D.A. Henderson, Kathleen Julian, Denise Koo, Stephen Ostroff, Dale Rohn, Carol Sandt, Kay Smith, William K. Reisen, and David Welliver for reviewing chapters. We thank Hellen Shenk, Amanda Perry, and Deepa Saravana for assistance with document search and management. We are grateful to Sameh Boktor, who served as illustration consultant and finalized many of the illustrations in this book.

We recall with fondness Michael Blench, past Canada’s Global Public Health Intelligence Network (GPHIN) Technical Advisor and Project Coordinator, the position he held from 1997 until his untimely death in 2011. Michael embraced the vision for this book and he contributed to Chapter 31: The Public Health Intelligence Network, which we dedicate to his memory.

We are grateful to our colleagues at Wiley-Blackwell for their encouragement and assistance, in particular Maria Khan, Kate Newell, and Rebecca Huxley. We are grateful to Lindsey Williams for the invaluable help she provided during the production stage of this edition.

Finally, we extend our most sincere gratitude to each of our family members, co-workers, and friends who supported our commitment to this project, and enabled it to come to fruition.

Disclaimer

The findings and conclusions in chapters by authors from federal agencies (e.g., US Centers for Disease Control and Prevention, US Food and Drug Administration) are those of the authors and do not necessarily represent the views of the federal agencies.

Weighing of the Heart

Stele: Princess Nefertiabet and Her Food.

Old Kingdom, 4th Dynasty, Reign of Cheops ($c$.4500 years ago).

Painted limestone ($37.5 × 52.5$ cm).

Original image in Musée du Louvre, Paris, France/C. Décamps.

nffirsg002.jpg

To count them all, demands a thousand tongues,/a throat of brass, and adamantine lungs, Homer said of the massive Greek armies gathered against the terrified Trojans in The Iliad. As they marched, the gleam of their armor flashed up into the firmament of heaven, the bard ventured, taking the metaphorical route. But still unable to describe their immensity, he settled for a sample. He devised a list naming only the captains and the ships and left the rest to the imagination. Their names, their numbers, and their chiefs I sing. In this poetic treatment of a mathematical puzzle, Homer managed to enumerate something that eluded his capacity for control and denomination.

Lists, such as the one Homer used in The Iliad and The Odyssey, abound in the literature of all ages. Eons after Homer, in crafting another Ulysses, James Joyce iterated his own legendary lists of things, from catalogs of books and daily budgets to the contents of Leopold Bloom’s kitchen drawer, which gave clues to his character. Among a host of items, "A Vere Foster’s handwriting copybook … : 2 fading photographs of queen Alexandra of England and of Maud Branscombe, actress and professional beauty: a Yuletide card, bearing on it a pictorial representation of a parasitic plant; the legend Mizpah … : a butt of red partly liquefied sealing wax, obtained from the stores department of Messrs Hely’s, Ltd., 89, 90 and 91 Dame street … ."

The ancient Egyptians were master list-makers. Firm believers in an extension of life on earth, they devised religious texts or lists of spells for navigating the complexities of afterlife. In the land of the night the ship of the sun is drawn by the grateful dead. During the Old Kingdom, extensive funerary texts, called Pyramid Texts, were meant to protect the pharaohs from hostile elements and ensure their place among the gods. We now return our souls to the creator, as we stand on the edge of eternal darkness. Later they were also found in burial chambers of high-ranking officials and on the coffins of other non-royals. In the New Kingdom and through the Late Kingdom, the Coffin Texts became known as the Book of the Dead.

There were spells to help remember one’s name; spells against dying again; spells against putrefaction or decapitation; spells against crocodiles, snakes, and other dangerous animals; spells to protect hearts from being stolen.

In the 1842 translation of a manuscript dated to the Ptolemaic era, a spell-numbering system was introduced. One of the spells identified at that time, Spell 125, usually contained a scene showing the heart being weighed against the goddess Ma’at, often depicted as an ostrich feather, the hieroglyphic sign for her name. This same spell also contained a long text referred to as Negative Confession, in which the dead recited what they had or had not done so their actions could be weighed and survival in the afterlife could be determined.

Participation in the afterlife depended on preserving the identity of the dead person and therefore the body. Elaborate preparations saw to it that the dead would be supplied with all necessities and care. They were buried with utilitarian objects that would comfort them and, if these were not available, pictures were used of clothing, bowls, wigs, combs, and food. The wealthy had luxurious accommodations with furniture, jewelry, perfumes, and shabtis—figurines—who would carry out tasks on their behalf.

Steles, commemorative stone or wooden slabs bearing the names, titles, and future nourishment of the dead, were a central part of Egyptian funerary art. Princess Nefertiabet and Her Food, the stele included in this book on infectious disease surveillance, is one of the most ancient and best preserved. Red, yellow, black, and green colors, now faded, embellish the delicate relief. Nefertiabet lived during the reign of King Cheops, also known as Khufu. Some of the best artists of the day were invited to accumulate her possessions for the afterlife. The stele was embedded in the outer wall of her tomb at Giza, at the foot of the Great Pyramid.

The seated woman and the inscription the king’s daughter Nefertiabet above her are facing toward the right, the usual orientation for writing. All other inscriptions, expressing the offerings made to her, face the princess. Clad in panther skin, she is seated on a stool carved with bull’s feet and papyrus umbel across from a stone pedestal table arrayed with slices of golden-crusted bread.

The remainder of the stele is inscribed with pictorial lists: a double rectangle above the table with cosmetics, drinks, and various delicacies; a vertical panel on the right, divided into three sections, with lists of fabric pieces. In addition, pictographs express the essential elements of the offering: libation in front of the face; lustration before the chest; leg of beef, ribs, duck, linen, crockery, beer, meat and poultry, thousand, thousand, thousand—the words an integral part of the image.

Referred to, among other things, as the poetics of etcetera, lists have persisted in the modern and postmodern world for many reasons. Just as Homer was unable to name all the Greek warriors in The Iliad, we are stumped by galaxies, feelings, names, things, places, and facts, whose sheer abundance defies full enumeration. Scientists have certainly grasped and tamed lists. Ever since Aristotle classified the animals, we have grouped things according to what we define or view as their essence. At a loss for defining something, we make a list of its characteristics. Fueled by efforts to understand disease enough to control it, public health has made of lists a science and called it surveillance.

Surveillance, collecting and analyzing data for action, is an indispensable tool in our efforts against disease. Public health investigators count conditions and gather relevant information on populations of interest to detect changes in trend or distribution. They record age and sex, height and weight, place of residence, birth and death, though, unlike the learned Egyptians, they monitor individual data with an eye on transforming them into population statistics, indicators of population health (infant death rate, life expectancy), and using them to investigate disease and establish control measures.

The Egyptians listed earthly belongings on the walls of tombs to ensure survival of their loved ones in the afterlife. Archaeologists, by deciphering, classifying, and analyzing the lists, immortalized local life and times. Evidence contained in tombs has illuminated more than 3000 years of ancient history. Similarly, future medical history might well benefit from the lists now drawn by epidemiologists. They count not just how many cases of a certain disease are found in various populations but also the characteristics of those, alive or dead, who became ill: their food, their homes, their pets, their friends and family, their travel destinations, their medical records, their work and leisure activities, even their appearance and personal behavior.

Why a list is made determines its nature. Like a modern-day bard, public health surveillance recreates out of the chaos of infinite choices a controlled relevant sample of a population. Meticulous collection, evaluation, and grouping of data—isolation and identification of infectious agents by laboratories, patterns of current and past infections, vaccine availability and effectiveness, and levels of immunity in population segments—these are central to designing interventions for reducing the rates of disease, controlling its course, and preventing recurrence. Evaluating data to resolve a public health crisis is much like weighing of the heart. Actions done or not done are examined against the norm. Moreover, the stakes are higher because the practicability, uniformity, and frequently the expeditiousness of the list determine not just the health of a single person but also that of the population.

Polyxeni Potter

Emerging Infectious Diseases

Centers for Disease Control and Prevention

Atlanta, GA

USA

May 2013

Bibliography

Eco U. The Infinity of Lists. McEwen A, translator. New York, NY: Rizzoli, 2009.

Faulkner R, Andrews C (eds.). The Ancient Egyptian Book of the Dead. Austin, TX: University of Texas Press, 1972.

Grajetzki W. Burial Customs in Ancient Egypt: Life in Death for Rich and Poor. London, UK: Duckworth, 2003.

Taylor J. Death and Afterlife in Ancient Egypt. Chicago, IL: The University of Chicago Press, 2001.

SECTION ONE

Introduction to Infectious Disease Surveillance

1

Infectious disease surveillance: a cornerstone for prevention and control

Nkuchia M. M’ikanatha¹, Ruth Lynfield², Kathleen G. Julian³, Chris A. Van Beneden⁴ and Henriette de Valk⁵

¹Division of Infectious Disease Epidemiology, Pennsylvania Department of Health, Harrisburg, PA, USA

²Minnesota Department of Health, St. Paul, MN, USA

³Penn State College of Medicine, Hershey, PA, USA

⁴Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA

⁵Infectious Disease Department, Institut de Veille Sanitaire, Saint Maurice, France

In view of the galloping pace of globalization that is transforming the world into a global village, close international co-operation is essential in the detection, prevention, and control of communicable diseases.

—Leung Pak-yin, Centre for Health Protection, Hong Kong [1]

Introduction

Throughout human history, infectious diseases have been a major force—continually changing as new human behaviors pose new risks, old pathogens adapt, and novel pathogens emerge. During the second half of the 20th century, the widespread availability of clean water, sanitation, vaccines, and antibiotics contributed to dramatic declines in morbidity and mortality associated with infectious diseases. This resulted in a mistaken view, expressed by some leaders in the late 1960s and 1970s, that infectious diseases would be conquered [2]. In the following decades, this optimism was replaced by a realization of the enormity of infectious diseases challenges. New pathogens, including human immunodeficiency virus (HIV), have erupted while known pathogens, such as drug-resistant tuberculosis (TB) and malaria, have re-emerged. Globally, infectious diseases are a leading cause of morbidity and mortality, accounting for approximately 11 million deaths each year worldwide [3].

The economic consequences associated with infectious diseases are enormous. Direct and indirect economic costs of the 2003 severe acute respiratory syndrome (SARS) pandemic were estimated at US$80 billion [4]. More recently, the 2009 pandemic H1N1 influenza contributed to a decline in international travel, which undermined a fragile global economy. For example, the estimated cost of pandemic H1N1 influenza to the Mexican economy was over US$2 billion, largely owing to a decline in trade and tourism. Endemic diseases also account for considerable human and economic costs [5]. In the USA, direct and indirect annual costs of seasonal influenza have been estimated at US$87.1 billion (based on 2003 data), which included more than 3 million hospitalization days, 41 000 deaths, and 31.4 million outpatient visits [6].

In this chapter and throughout this book, we will demonstrate that, to confront threats from emerging and known endemic pathogens, systematic disease-tracking systems are crucial to guide prevention and control programs. Surveillance has played a critical role in controlling infectious diseases. Through careful surveillance for complete case detection and vaccination of contacts, smallpox has been eradicated (Figure 1.1). In May 2010, Margaret Chan [7], the Director General of the World Health Organization (WHO), unveiled a statue to commemorate the 30th anniversary of the eradication of smallpox and described the statue as a reminder of the power of international health cooperation to do great and lasting good. In a recent reflection on successful eradication of smallpox in Ethiopia, de Quadros [8] credited international support for surveillance combined with innovation and persistence.

c01f001

Figure 1.1 Local health department nurse immunizing a child. Vaccination against smallpox at a local health department in the USA.

Source: Centers for Disease Control and Prevention.

The idea that diseases such as plague and smallpox could be prevented by deliberate human actions became evident in 18th century Europe. Chapter 2 reviews major historical developments in the effort to track and control infectious diseases, including their application in public health practice. The evidence that surveillance results in undisputed public health benefits is made in Chapter 3, Part 1. During the final phases of the smallpox eradication efforts, timely reporting of cases was followed by swift, targeted vaccination response.

Guided by surveillance data, public health efforts have contributed to a reduction in the burden of a variety of infectious diseases. Chapter 3, Part 2, describes the use of surveillance to inform Guinea worm (Dracunculus) eradication efforts in South Sudan. The Guinea Worm Eradication Program has exceeded expectations by contributing to over 80% worldwide reduction in cases of Guinea worm disease from 20 581 cases in 2006 to 1060 cases in 2011 [9]. Commitment to a public health goal and regional cooperation coupled with sound surveillance programs also resulted in elimination of measles in the western hemisphere in 2002. Provided there is political and social commitment combined with heightened surveillance, measles elimination could be realized in Europe by 2015, despite recent setbacks [10]. The formidable nature of infectious diseases is illustrated in Chapter 3, Part 3.

We will introduce principles and methods that form the foundation of infectious disease surveillance. To portray the breadth of types of surveillance systems, we will provide a glimpse into the vast array of surveillance systems deployed around the world. The emphasis is on practical considerations including innovations that have enhanced surveillance over time.

Definition and scope of infectious disease surveillance

The general principles of public health surveillance are used in programs to prevent and control infectious diseases, chronic diseases, and injuries. In this book, we focus on surveillance for infectious diseases, primarily as communicable pathogens relate to human health but also with attention to pathogens in the interrelated veterinary realm and the environment (this is known as a one health approach). Public health authorities or infection prevention entities in healthcare institutions primarily carry out the infectious disease surveillance activities discussed; nevertheless, infectious disease surveillance requires collaboration with partners in a variety of fields, including veterinary medicine, information technology (IT), and law.

The conduct of surveillance can be conceived as a three-legged stool consisting of three main integrated activities: (1) systematic collection of significant data (e.g., case reports of a specific disease); (2) analyses of these data; and (3) timely dissemination of results to guide interventions. The three surveillance legs are contained both in the original 1969 International Health Regulations and in the most recent definition of surveillance in the current International Health Regulations (IHR 2005) [11]. The IHR 2005 define surveillance as the systematic ongoing collection, collation and analysis of data for public health purposes and the timely dissemination of public health information for assessment and public health response as necessary. These components are considered central to public health surveillance system.

Besides the WHO, local, regional, and national agencies have embraced surveillance as a means to characterize and address endemic and emerging infectious disease threats. Although many of the examples covered in this book are from North America and Western Europe, infectious disease surveillance is conducted worldwide, albeit in varying degrees and forms.

What happens in the absence of infectious disease surveillance?

In considering the values of surveillance, it is instructive to ask, What happens to public health in the absence of surveillance? Where disease tracking is compromised, as is often the case during protracted armed conflicts, progress made in disease control efforts may be reversed.

For example, Afghanistan reported 80 cases of wild poliovirus in 2011, a threefold increase since 2010. The Global Polio Eradication Initiative cites continuing insecurity as the major reason for the setback in Afghanistan [12]. Presence of polio in one country undermines eradication efforts in neighboring countries.

The lack of surveillance and control programs contributed to resurgence of diseases such as human African trypanosomiasis in the Democratic Republic of Congo (DRC) in the 1990s [13]. Gains made earlier in the century were lost during war and socioeconomic deterioration—the incidence of trypanosomiasis rose to an estimated 34 400 in 1994, with neglected areas reporting the highest rates of the century. Over the past decade, 70% of the reported cases of trypanosomiasis occurred in the DRC, including 500 cases in 2010 [14]. Impromptu surveillance and disease control measures can be expected to be much more difficult to implement in countries that have suffered long-standing waves of violence and breakdown of the public sector infrastructure. Chapter 23 offers practical considerations for conducting surveillance in complex emergencies characterized by war or civil strife affecting large civilian populations. Examples are drawn from experiences in Albania, Basrah (Iraq), the Greater Darfur region (Sudan), and Haiti.

Inadequate surveillance and consequent blindness to the health status of the population has contributed to the uncontrolled global spread of HIV/acquired immunodeficiency syndrome (AIDS), one of the worst pandemics in human history. Without accurate surveillance data to understand the true health status of their populations and to guide the use of limited public health resources, leaders can be grossly misinformed and, as in the case of HIV/AIDS, miss opportunities for early prevention and control before the virus becomes entrenched. Stigmatization, discrimination, and marginalization—all fueled by ignorance—have contributed simultaneously to the denial and, paradoxically, to the explosion of the HIV/AIDS pandemic. Three decades after recognition of HIV/AIDS, an estimated 34 million people were living with HIV worldwide and 1.8 million infected people died. There were 2.7 million new HIV infections in 2010 including approximately 390 000 among children (Figure 1.2) [15].

c01f002

Figure 1.2 Globally, human immunodeficiency virus (HIV) infections continued to increase until 1997 when new infections peaked, whereas deaths peaked in the mid-2000s. Approximately 2.7 million new HIV infections and 1.8 million deaths occurred in 2010 [15]. Used with permission from the Joint United Nations Programme on HIV/AIDS (UNAIDS).

Complacency and diversion of resources have hindered maintenance of surveillance systems that can detect and control diseases