PH Lecture 6: Morbidity and Morality

At what three levels are conditions reported?

County, state, and nationally

Who in Florida is required to notify the Florida Department of Health of diseases of public health significance?

All practitioners, hospitals, and laboratories

Under what Florida laws are practitioners required to report diseases of public health significance?

Section 381.0031, Florida Statutes, and Chapter 64D-3, Florida Administrative Code

What are the 4 reporting timeframes in Florida?

1. Suspect immediately 2. Report immediately 3. Next (business) day 4. Other

To whom should notification of a reportable disease be made?

Directly to the county health department in the county where the patient RESIDES

Which Florida Administrative Code rule lists the Table of Reportable Diseases or Conditions to Be Reported?

Rule 64D-3.029

Who is required to notify the Department of a case in the Table of Reportable Diseases?

Each licensed practitioner, medical facility, and medical examiner who diagnoses, treats, or suspects a case

Are laboratories also required to report reportable diseases?

Yes - duplicate reporting may occur, though labs and practitioners have different reporting requirements

⭐ If the lab has already submitted test results to the Department of Health, does the practitioner still need to report the disease?

YES - laboratory submission of results does NOT nullify the practitioner's obligation to also report the disease or condition

Which Florida rule specifies the content a disease report must include?

Rule 64D-3.030, Florida Administrative Code

What patient information must a Florida disease report include? (select all that apply)

1. First/last name and middle initial 2. Address 3. Telephone number 4. Date of birth 5. Sex 6. Race 7. Ethnicity 8. Pregnancy status 9. Social security number 10. Date of symptom onset 11. Diagnosis

When must 'Suspect Immediately' diseases be reported?

Immediately, 24/7, by phone upon initial clinical SUSPICION or laboratory test order - do not wait for a definitive diagnosis

Why are 'Suspect Immediately' diseases reported on suspicion alone?

They are of immediate public health concern due to their highly infectious nature or need for immediate intervention

What are examples of 'Suspect Immediately' reportable diseases? (select all that apply)

1. Anthrax 2. Cholera 3. Measles 4. Meningococcal disease 5. Plague 6. Poliomyelitis

Should a PA wait for confirmation before reporting suspected measles?

No - measles is 'Suspect Immediately'; report by phone on clinical suspicion

When must 'Report Immediately' diseases be reported?

Immediately, 24/7, by phone FOLLOWING an indicative or confirmatory test result, finding, or diagnosis

What is the key difference between 'Suspect Immediately' and 'Report Immediately'?

Suspect Immediately = report on suspicion (don't need confirmation); Report Immediately = report after an indicative/confirmatory result

What are examples of 'Report Immediately' diseases? (select all that apply)

1. Amebic encephalitis 2. Hepatitis A 3. Syphilis in pregnant women and neonates 4. VISA/VRSA (S. aureus with vancomycin resistance) 5. Typhoid fever

When must 'Next Business Day' diseases be reported?

No later than the close of the next business day following confirmatory testing or diagnosis

What are examples of 'Next Business Day' reportable conditions? (select all that apply)

1. Arsenic poisoning 2. Carbon monoxide poisoning 3. Lead poisoning 4. Varicella death 5. West Nile virus 6. Infant botulism 7. Campylobacteriosis

What is the reporting timeframe for AIDS?

2 weeks

What is the reporting timeframe for cancer?

6 months

What is the reporting timeframe for congenital anomalies?

6 months

Through what system do health departments notify the CDC about nationally tracked conditions?

The National Notifiable Disease Surveillance System (NNDSS)

About how many notifiable diseases and conditions does the CDC monitor at the national level?

About 120

What do CDC programs use NNDSS data to do? (select all that apply)

1. Recognize outbreaks 2. Track spread at state, regional, and national levels 3. Identify geographic areas of concern 4. Help health departments identify groups most at risk 5. Evaluate and fund disease control activities

What are examples of nationally notifiable diseases named in lecture? (select all that apply)

1. Ebola 2. Syphilis 3. Toxic shock syndrome (streptococcal) 4. Rabies

Is reporting of REPORTABLE diseases mandatory or voluntary?

Mandatory (state/territory laws require providers to report)

Is reporting of NOTIFIABLE diseases to the CDC mandatory or voluntary?

Voluntary - states voluntarily inform the CDC when a person meets case criteria

Who sets the list of REPORTABLE diseases?

Each state or territory sets its own laws and rules

Who sets the list of NOTIFIABLE diseases?

The Council of State and Territorial Epidemiologists (CSTE) and the CDC

Do notifiable disease case records sent to the CDC contain personally identifiable information?

No - case records are de-identified

Do reportable disease reports to health departments contain personal information?

Yes - public health departments collect information about the person and how they became ill (used to locate the outbreak source)

What are the steps of the case reporting process (local)?

1. A person feels ill and sees a provider 2. Provider diagnoses and/or lab confirms a reportable disease 3. Hospital/provider/lab sends case info to the public health department 4. Health department uses the data to control outbreaks, ensure treatment, and provide testing/preventive care to those exposed

What are the steps of the case notification process (national)?

1. Public health department sends de-identified data on notifiable diseases to CDC 2. NNDSS processes and provides data to CDC programs 3. CDC programs use data to recognize outbreaks, monitor patterns, and evaluate/fund control activities

What is a PHEIC?

Public Health Emergency of International Concern - an extraordinary event that is a public health risk to other countries through international spread and potentially requires a coordinated international response

Who is required to notify WHO of a potential PHEIC?

All WHO member countries

Who makes the final determination about whether a PHEIC exists?

The WHO

What are examples of conditions that fit PHEIC criteria?

COVID-19, Ebola

What does ELR stand for?

Electronic Laboratory Reporting

What problems did ELR solve?

Historically labs mailed or faxed reports - time- and labor-intensive with follow-ups, errors, and inconsistent formatting causing delays

What are benefits of ELR? (select all that apply)

1. Improves ease, speed, and accuracy of data transmission 2. Required fields mean fewer follow-up requests 3. No manual data entry = fewer errors

What percentage of laboratories were sending reports electronically in 2018?

About 80% (up from 54% in 2012)

What does eCR stand for?

Electronic Case Reporting

What is electronic case reporting (eCR)?

The automated, real-time exchange of case report information between EHRs and public health agencies

How does eCR work?

It runs behind the scenes in the EHR; if entered information matches codes of interest, a report is sent to the platform and, if it meets jurisdictional requirements, to the appropriate public health agency

What are the benefits of eCR? (select all that apply)

1. Reduces provider burden without disrupting clinical workflow 2. Saves time by eliminating manual data entry 3. Can fulfill legal reporting requirements

What is the difference between ELR and eCR?

ELR = labs electronically transmit reportable results; eCR = automated real-time case reports from the EHR to public health agencies

What is epidemiologic surveillance (per CDC)?

The ongoing systematic collection, analysis, and interpretation of health data essential to planning, implementing, and evaluating public health practice, integrated with timely dissemination to those who need to know

What does surveillance provide decision-makers with?

Guidance for developing and implementing the best strategies for disease prevention and control programs

What does surveillance monitor?

Changes in disease frequency and changes in level of risk factors

Where does much of our information on morbidity and mortality come from?

Surveillance

What is surveillance most frequently conducted for?

Infectious disease (but also important for congenital malformations, cancer, asthma, chemical poisoning)

What are the two main subdivisions of surveillance?

Passive and active

What is passive surveillance?

Available data on reportable diseases are used, or reporting is mandated/requested, with responsibility often falling on the health care provider

What are the pros of passive surveillance? (select all that apply)

1. Inexpensive 2. Easy to develop 3. Allows for international comparisons

What are the cons of passive surveillance? (select all that apply)

1. Variable quality and completeness 2. Underreporting is a common pitfall 3. Local outbreaks may be missed

What is active surveillance?

Project staff are recruited to make periodic field visits to health care facilities to identify new cases or deaths (interviewing physicians/patients, reviewing records)

What is the main pro of active surveillance?

Generally more accurate

What are the cons of active surveillance? (select all that apply)

1. More expensive 2. More difficult to develop initially 3. Time consuming

⭐ What is syndromic surveillance?

Active or passive data gathered from SYMPTOMS rather than diagnosis

⭐ Which type of surveillance is easiest to collect and often the first type collected in a developing country?

Syndromic surveillance

⭐ What is the main weakness of syndromic surveillance?

Lack of specificity (e.g., rash)

⭐ How can syndromic surveillance mask an epidemic? Give the lecture example.

An increase in one disease causing a syndrome may mask another - e.g., diarrhea from rotavirus decreases at the same time cholera is increasing

⭐ A health department tracks the number of patients with 'cough or flu-like symptoms in the past 7-14 days.' What type of surveillance is this?

Syndromic surveillance

What are other types of surveillance? (select all that apply)

1. Environmental public health 2. Biological terrorism 3. Complex emergency 4. Refugee populations 5. Chronic disease

In complex emergency surveillance, how do needs differ?

Surveillance needs differ in the preimpact, impact, and postimpact phases

What are attributes of a good surveillance system? (select all that apply)

1. Sound, practical, usable data framework 2. Timely, simple, complete data collection 3. Expert analysis and interpretation 4. Timely communication to users 5. Assists with controlling disease 6. Periodically evaluated

What are challenges in disease surveillance in developing countries? (select all that apply)

1. Difficult to reach 2. Difficult to maintain communication 3. Inappropriate disease definitions 4. Underreporting of clinical cases

What organism caused the Plague of Justinian and the Black Death?

Yersinia pestis

What is the origin of the term 'quarantine'?

During the Black Death, sailors were held on ships for 30 days, later increased to 40 days (quarantine)

What caused the 1918 Spanish Influenza, and how many did it kill?

H1N1 virus - killed 20 million people

When were the SARS-CoV-2 sequence released and the first COVID-19 vaccines released?

Sequence released 1/10/2020; first vaccines December 2020

What methods were used to slow the spread of COVID-19? (select all that apply)

1. Hand hygiene/face masks 2. Social distancing 3. Quarantine

When and where was the SARS epidemic first detected?

November 2002 in China (epidemic of severe pneumonia)

How did the SARS pandemic end, and what was its toll?

Ended July 2003 - more than 8,000 patients infected on 5 continents and 774 deaths

⭐ Who spearheaded the global effort to control the SARS pandemic?

The WHO

⭐ How did China contribute to the SARS response?

Mobilized all 20 Field Epidemiology Training Program (FETP) trainees for surveillance, investigation, and control

⭐ How did Canada contribute to the SARS response?

Canada (most cases outside Asia) mobilized 8 of its 10 FETP trainees for surveillance, investigations, prevention/control guidelines, and epidemiologic studies

⭐ What key factors made the SARS surveillance response successful? (select all that apply)

1. WHO-led global effort 2. Mobilization of FETP trainees (China and Canada) 3. Open collaboration among scientists and politicians of many countries 4. Rapid and accurate communication of surveillance data within and among countries

⭐ What does FETP stand for?

Field Epidemiology Training Program

Where did the electronic health record begin federally?

The VA Healthcare System in the late 1990s

How much could private practices obtain per year through the EHR incentive program?

Up to $50,000 per year for reporting quality data to Medicare or Medicaid

When did the EHR incentive program end, and what happens now?

2021 - programs serving Medicare/Medicaid patients now lose funding if they fail to submit quality data

What are the 3 stages of EHR use and incentives (Meaningful Use)?

Stage 1 = data capturing and sharing; Stage 2 = advanced clinical processes; Stage 3 = improved outcomes

What is a disease outbreak?

The occurrence of more cases than expected

What are 'contributing factors' of outbreaks?

Preventable causes of outbreaks - vary by pathogen, environmental conditions, and social practices

What are the 3 contributing factors for foodborne illness?

1. Contamination 2. Proliferation 3. Survival

In foodborne illness, what is 'contamination'?

Pathogens getting into the food supply (unsanitary)

In foodborne illness, what is 'proliferation'?

The pathogen is given an environment to grow (e.g., warm temperature food)

In foodborne illness, what is 'survival'?

The pathogen does not die during preparation (food not brought up to temperature)

Who uncovers outbreaks through surveillance data analysis? (select all that apply)

1. Health departments 2. Hospital infection control practitioners 3. CDC staff

What DISEASE factors determine whether to investigate an outbreak? (select all that apply)

1. Illness severity 2. Number of cases 3. Source 4. Mode or ease of transmission 5. Availability of prevention or control measures

What HEALTH DEPARTMENT factors determine whether to investigate an outbreak?

Availability of staff and resources, and experience in investigating

What does outbreak control and prevention depend on? (select all that apply)

1. Knowledge of the agent 2. Natural course of the outbreak 3. Usual mechanism of transmission 4. Available control measures

What are the PA's roles in outbreak and pandemic response? (select all that apply)

1. Recognition 2. Reporting 3. Clinical management 4. Prevention 5. Collaboration 6. Advocacy

In outbreak response, what does the PA's 'recognition' role involve?

Identifying unusual illness patterns, clusters, and concerning exposures

In outbreak response, what does the PA's 'prevention' role involve?

Vaccination, prophylaxis, isolation guidance, and patient/community education

In outbreak response, what does the PA's 'advocacy' role involve?

Identifying populations facing barriers to prevention, testing, or treatment

What is the infection rate?

A measurement of how often new infections occur in a specific population over a defined period (expressed as a probability or frequency)