Issue 19 - Let’s Not Forget the Importance of Human Surveillance

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Let’s Not Forget the Importance of Human Surveillance
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In addition to a computerized syndromic surveillance system, let’s not forget humans perform the most important surveillance of all, says Dr Ed Sherwood, Health Authority of Williamson County Texas. Dr Sherwood shared what three central Texas counties are preparing to do to enhance human surveillance at a January meeting of the Texas Public Health Association. (1)

Dr Sherwood began by reminding everyone that the CIA and the military have long taken the position that human surveillance can be the most important. The first case of anthrax in 2001 was identified by an astute clinician, not by a syndromic surveillance system.

Health departments probably need to develop several surveillance systems to adequately respond to the threat of bioterrorism, and these systems can include passive, reactive and active surveillance.

First, improve your passive surveillance process by applying the tools of performance improvement. Make a list of all the doctors, clinics, and emergency care centers that are reporting infectious diseases to the health department and those who are not. Are there locations that have never reported a case? Talk with the clinicians in an effort to improve traditional reporting.

Second, develop a “reactive” system by soliciting an agreement from Infection Control Practitioners, Infectious Disease doctors and other key healthcare providers to participate in 2-3 drills a year. Ask them to treat each drill as if it were the real thing. For example, stage a drill in which the health department will be “informed” by the FBI or an environmental monitor of a possible biological attack with ‘X’ organism. Ask participants to inform the health department immediately by email, fax, or phone if they have seen patients with symptoms of the bioterror agent (e.g., tularemia, plague). Provide clues of the disease symptoms if needed. Even those who don’t see any cases should send a negative response daily, (for X number of days appropriate to the agent of concern).

Third, begin an “Active” surveillance system. As most health officials realize, the list of legally reportable diseases would not detect many bioterrorism agents quickly enough to prevent mass casualties. Therefore, in addition to the mandated reporting, health departments need to be notified about patients seen with symptoms of radiation, chemical intoxication, bioterrorist agent, infectious disease outbreaks, and “cryptic severe illness” in a normally healthy individual aged 5-50, (such as a pneumonia death in a healthy 32 year old) (see the CELSIUS program in Scotland for help in defining “cryptic severe illness”) (2). Dr. Sherwood recommends asking key providers to send the health department an email once a week on Tuesday, stating something like “We’re here, and we haven’t seen anything to report”. Weekly emails assure you that the designated practitioners are on the lookout. If you haven’t heard something by Wednesday, call to check in and remind them to make contact.

Dr Sherwood also urged everyone to begin making preparations for electronic syndromic surveillance by taking an inventory of the computerized data available in your jurisdiction. For example, do the local hospitals and large primary care organizations capture ICD-9 or chief complaint which could be used for syndromic surveillance? Is anything beyond presenting complaints available? Collecting this information now could be invaluable when an opportunity for electronic syndromic surveillance comes your way. Finally, continue to monitor the literature and “best practices” as the science of syndromic surveillance evolves.

(1) Sherwood, Ed, MD FACP. “Early Detection of Unusual Disease Clusters.” Texas Public Health Association – Austin Regional Conference. January 8, 2004

(2) McMenamin, Jim, et al., for the Celsius Programme implementation team. The Scottish Centre for Infection & Environmental Health, Glasgow, Scotland – Poster Presentation – 2003 National Syndromic Surveillance Conference October 23-24, 2003

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