- Email: [email protected]
Measurement of surveillance signal response effectiveness
Correspondence
Measurement of surveillance signal response effectiveness Gabriel Milnovich and colleagues 1 report the limitations and benefits of the use of internet-based syndromic surveillance systems to monitor and detect infectious disease syndromes, notably influenza-like illness and dengue. They show in their Review the success of surveillance systems in improving early detection of infectious diseases. They note the crucial issue that few studies have explored how these types of surveillance systems are translated into public health responses. We contend that it is important to understand the effect, beyond timeliness, that these surveillance systems have on public health
Panel: Response components of the US Centers for Disease Control and Prevention (CDC) and WHO surveillance assessment frameworks CDC, 2004* • Timeliness at various points of the investigation, including start of public health investigation • Resources directed to follow-up of the alert • Resulting public health response (suggested examples are assessments of public health responses, including alerts to clinicians, timely dissemination of information to other health entities, and vaccination campaigns or no further responses) • Assessment of the value of the follow-up effort (suggested example is the effort was an appropriate application of public health resources) WHO, 2006† • Existence of an epidemic preparedness committee • Existence of rapid response teams • Existence of districts with rapid response teams • Capacity for outbreak response • Availability of rapid response kits • Timeliness of response to suspected outbreaks • Template that asks “were appropriate control interventions implemented to all identified populations at risk?” *No explicit guidelines are provided on measures to assess the effectiveness of the surveillance system. The framework notes that system usefulness depends on its contribution to early detection of outbreaks of public health importance that lead to effective intervention. It notes that measurement of usefulness is inexact. †The WHO guidelines recognise that response and control are core functions of a surveillance system. Indicators provided to measure response are restricted to structural components. No metrics are provided to measure appropriate control interventions.2,3
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responses. We postulate that the scarcity of published work on this subject is not a result of limited use of surveillance systems or because this literature is not useful to public health practitioners, but rather that there are few ways to measure the effectiveness of the response to the systems. Frameworks and guidelines2,3 have been developed for the assessment of syndromic surveillance; however, with the rapid advances in digital syndromic surveillance methods, these frameworks might no longer be suitable. The International Health Regulations’4 emphasis on both early outbreak detection and response has started a shift of focus from public health surveillance to situational awareness and appropriate responses to deviations from the norm, particularly in developing countries.5 Commonly used assessment frameworks do not adequately measure these characteristics. Surveillance systems are assessed on several attributes: simplicity, flexibility, acceptability, sensitivity, p r e d i c t i v e v a l u e p o s i t i v i t y, representativeness, and timeliness. The commonly used US Centers for Disease Control and Prevention (CDC ) 2 or WHO 3 assessment guidelines emphasise timeliness, descriptions of the response, and resource allocations as measures of public health response (panel). These metrics are inadequate to objectively establish effectiveness of the response, including whether the response was proportionate and the return on investment—ie, mortality, morbidity, or economic losses averted. In view of the rapid proliferation of surveillance approaches and the emphasis on response, the development of assessment frameworks that encompass these characteristics is certainly necessary. Appropriate indicators need to be developed and a new standardised assessment framework needs to be created.
Leading worldwide agencies, including the CDC, WHO, and the Food and Animal Organization of the UN, should collaborate to support the development of a new assessment framework, suitable for assessment of the effectiveness of surveillance of and response to emerging infectious diseases in both people and animals. BJP is supported by a Hunter Medical Research Institute Postdoctoral Research Fellowship. We declare no competing interests.
*Beverley J Paterson, David N Durrheim [email protected] Hunter Medical Research Institute, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia 1
2
3
4
5
Milinovich GJ, Williams GM, Clements AC, Hu W. Internet-based surveillance systems for monitoring emerging infectious diseases. Lancet Infect Dis 2014; 14: 160–68. Buehler JW, Hopkins RS, Overhage JM, Sosin DM, Tong V. Framework for evaluating public health surveillance systems for early detection of outbreaks: recommendations from the CDC Working Group. MMWR Recomm Rep 2004; 53: 1–11. WHO. Communicable disease surveillance and response systems: guide to monitoring and evaluating. Geneva: World Health Organization, 2006. WHO. International health regulations (2005), 2nd edn. Geneva: World Health Organization, 2008. Paterson BJ, Durrheim DN. The remarkable adaptability of syndromic surveillance to meet public health needs. J Epidemiol Glob Health 2013; 3: 41–47.
Empiric tuberculosis treatment in retreatment patients in high HIV/tuberculosisburden settings Grant Theron and colleagues’ Personal View 1 brings necessary attention to empiric tuberculosis treatment in high-burden settings. A bias towards overtreatment rather than undertreatment of tuberculosis is understandable in view of the high pretest probability and mortality attributable to tuberculosis in the setting of HIV co-morbidity (particularly in the preantiretroviral
www.thelancet.com/infection Vol 14 September 2014
Measurement of surveillance signal response effectiveness Gabriel Milnovich and colleagues 1 report the limitations and benefits of the use of internet-based syndromic surveillance systems to monitor and detect infectious disease syndromes, notably influenza-like illness and dengue. They show in their Review the success of surveillance systems in improving early detection of infectious diseases. They note the crucial issue that few studies have explored how these types of surveillance systems are translated into public health responses. We contend that it is important to understand the effect, beyond timeliness, that these surveillance systems have on public health
Panel: Response components of the US Centers for Disease Control and Prevention (CDC) and WHO surveillance assessment frameworks CDC, 2004* • Timeliness at various points of the investigation, including start of public health investigation • Resources directed to follow-up of the alert • Resulting public health response (suggested examples are assessments of public health responses, including alerts to clinicians, timely dissemination of information to other health entities, and vaccination campaigns or no further responses) • Assessment of the value of the follow-up effort (suggested example is the effort was an appropriate application of public health resources) WHO, 2006† • Existence of an epidemic preparedness committee • Existence of rapid response teams • Existence of districts with rapid response teams • Capacity for outbreak response • Availability of rapid response kits • Timeliness of response to suspected outbreaks • Template that asks “were appropriate control interventions implemented to all identified populations at risk?” *No explicit guidelines are provided on measures to assess the effectiveness of the surveillance system. The framework notes that system usefulness depends on its contribution to early detection of outbreaks of public health importance that lead to effective intervention. It notes that measurement of usefulness is inexact. †The WHO guidelines recognise that response and control are core functions of a surveillance system. Indicators provided to measure response are restricted to structural components. No metrics are provided to measure appropriate control interventions.2,3
794
responses. We postulate that the scarcity of published work on this subject is not a result of limited use of surveillance systems or because this literature is not useful to public health practitioners, but rather that there are few ways to measure the effectiveness of the response to the systems. Frameworks and guidelines2,3 have been developed for the assessment of syndromic surveillance; however, with the rapid advances in digital syndromic surveillance methods, these frameworks might no longer be suitable. The International Health Regulations’4 emphasis on both early outbreak detection and response has started a shift of focus from public health surveillance to situational awareness and appropriate responses to deviations from the norm, particularly in developing countries.5 Commonly used assessment frameworks do not adequately measure these characteristics. Surveillance systems are assessed on several attributes: simplicity, flexibility, acceptability, sensitivity, p r e d i c t i v e v a l u e p o s i t i v i t y, representativeness, and timeliness. The commonly used US Centers for Disease Control and Prevention (CDC ) 2 or WHO 3 assessment guidelines emphasise timeliness, descriptions of the response, and resource allocations as measures of public health response (panel). These metrics are inadequate to objectively establish effectiveness of the response, including whether the response was proportionate and the return on investment—ie, mortality, morbidity, or economic losses averted. In view of the rapid proliferation of surveillance approaches and the emphasis on response, the development of assessment frameworks that encompass these characteristics is certainly necessary. Appropriate indicators need to be developed and a new standardised assessment framework needs to be created.
Leading worldwide agencies, including the CDC, WHO, and the Food and Animal Organization of the UN, should collaborate to support the development of a new assessment framework, suitable for assessment of the effectiveness of surveillance of and response to emerging infectious diseases in both people and animals. BJP is supported by a Hunter Medical Research Institute Postdoctoral Research Fellowship. We declare no competing interests.
*Beverley J Paterson, David N Durrheim [email protected] Hunter Medical Research Institute, University of Newcastle, University Drive, Callaghan, NSW 2308, Australia 1
2
3
4
5
Milinovich GJ, Williams GM, Clements AC, Hu W. Internet-based surveillance systems for monitoring emerging infectious diseases. Lancet Infect Dis 2014; 14: 160–68. Buehler JW, Hopkins RS, Overhage JM, Sosin DM, Tong V. Framework for evaluating public health surveillance systems for early detection of outbreaks: recommendations from the CDC Working Group. MMWR Recomm Rep 2004; 53: 1–11. WHO. Communicable disease surveillance and response systems: guide to monitoring and evaluating. Geneva: World Health Organization, 2006. WHO. International health regulations (2005), 2nd edn. Geneva: World Health Organization, 2008. Paterson BJ, Durrheim DN. The remarkable adaptability of syndromic surveillance to meet public health needs. J Epidemiol Glob Health 2013; 3: 41–47.
Empiric tuberculosis treatment in retreatment patients in high HIV/tuberculosisburden settings Grant Theron and colleagues’ Personal View 1 brings necessary attention to empiric tuberculosis treatment in high-burden settings. A bias towards overtreatment rather than undertreatment of tuberculosis is understandable in view of the high pretest probability and mortality attributable to tuberculosis in the setting of HIV co-morbidity (particularly in the preantiretroviral
www.thelancet.com/infection Vol 14 September 2014