united states Public Health Surveillance Assessment:
Environmental Protection
Agency Interview with Public Health Partners
Introduction
Conducting an assessment of current public health capabilities within your utility's service area is an
important part of planning for the implementation of a Public Health Surveillance (PHS) component of a
Water Quality Surveillance and Response System (SRS). There are a variety of attributes to consider when
assessing public health datastreams including:
• Contaminant coverage: The ability of a public health datastream to detect a variety of contaminant
classes that produce rapid symptom onset or delayed symptom onset in exposed individuals.
• Spatial coverage: The percentage of the utility distribution system service area covered by a public
health datastream.
• Timeliness: The time between when healthcare seeking behaviors of symptomatic individuals enter a
monitored datastream and the time that a possible public health incident is detected.
• Data quality: The completeness of underlying case details (e.g., demographics, chief complaint or
symptoms, date, time, and location where exposure occurred) for cases that are related to a possible
public health incident.
The majority of information pertaining to public health data and procedures likely resides outside of the
immediate domain of your utility. To conduct an assessment of PHS capabilities, someone from your utility
should interview personnel responsible for monitoring available public health data such as epidemiologists at
the local, city, or county health department and toxicologists at the Poison Control Center (PCC) serving
your utility's service area. The following assessment forms are designed to assist your utility in capturing
information about the manner in which common public health datastreams are currently monitored by public
health partners in your utility's service area.
The assessment questions are organized into two parts:
• Part I: Health department's surveillance capabilities
• Part II: Poison Control Center's surveillance capabilities
Note that your utility may need to replicate Part I or Part II of the assessment if there are multiple health
departments or PCCs in your utility's service area.
Your utility should first establish which health department(s) and
PCC(s) operate within your utility's service area. An appropriate
contact at each of these organizations should be identified. An
interview should be scheduled, preferably in-person, to conduct the
PHS assessment. The assessment can be completed electronically
using this tillable PDF form, or by hand using a printed version of
this form.
The responses to these assessment questions can be used as a
starting point for subsequent discussions between your utility and public health partners who express a
commitment to supporting the goals of the SRS. Your utility should work collaboratively with these partners
to identify existing PHS capabilities that can be leveraged or opportunities to implement new capabilities that
can support the goals of the SRS and the mission of public health partners. Once the PHS assessment has been
completed, information captured in the assessment forms can be used to begin documenting the design of the
PHS component (http://www.epa.gov/waterqualitvsurveillance/public-health-surveillance-resources).
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'art I: Health Department's Surveillance Capabilities
Health Department Name:
Contact Name and Title:
Contact Phone:
Contact Email:
Interview Date:
Conversation Starter
Have public health surveillance techniques previously provided the health department with an early warning
of an environmental exposure (e.g., foodborne illness, lead exposures, tainted medications, etc.)? If so,
discuss how public health data was used to identify the cause of the exposure.
Case-based Surveillance
Case-based surveillance relies on the professional judgment of trained healthcare providers to identify and
report unusual cases or patterns of illness to the health department. This type of surveillance is conducted on a
daily basis by healthcare networks staffed by healthcare providers (e.g., physicians and nurses) who are
responsible for examining patients and making diagnoses, as well as those who staff health advice hotlines. In
the context of PHS as a component of an SRS, case-based surveillance can be used to identify unusual cases
that may be due to exposure to contaminated water.
Two potential case-based surveillance datastreams include:
• Healthcare Networks: Primary care physicians' offices are often members of a healthcare network with
trained healthcare providers (e.g., doctors, physician assistants, and nurses) who conduct in-person
medical assessments of patients to identify the cause of their symptoms and provide treatment. The
healthcare network notifies the health department of increased case volume presenting with similar, and
possibly unusual, symptoms not attributable to a known, ongoing public health incident. The network
may also provide notification of increased orders for clinical laboratory tests and the results of that
testing, when available.
• Health Advice Hotlines: Health advice hotlines serve as a frontline resource for individuals seeking
advice on choosing appropriate medical care, managing a chronic condition, or understanding treatment
options. They may be operated by an insurance company, hospital, or municipality. Healthcare providers
staffing hotlines notify the health department of an unusual number of calls that are geographically co-
located with similar, and possibly unusual, symptoms not attributable to a known, ongoing public health
incident.
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Case-based Surveillance Assessment Questions
Healthcare Networks
1. Are there healthcare networks within the jurisdiction served by the health department that
are currently conducting active surveillance of patient records for unusual symptoms or
an increased volume of cases?
If yes, record the name(s) of the healthcare network(s) below.
2. Do the healthcare networks listed above report information about unusual cases, a rise in
the number of cases, or an increase in clinical laboratory orders to the health department?
If yes:
a.
Spatial coverage: Do the geographic areas served by the healthcare networks
cover the entire utility service area?
Timeliness: Do healthcare networks report information about unusual cases as
soon as they are recognized (i.e., in advance of confirmed laboratory results)?
Data quality: Select the underlying case details that are reported.
Check the "Other" box if reports include additional underlying case
details and describe in the box below.
Demographics
Chief complaint
Symptoms
Date/time of contact
Location where
exposure occurred
Other
Record any additional notes related to surveillance conducted by healthcare networks below (e.g., if any
regular surveillance practices are automated):
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Health Advice Hotlines
1. Are there health advice hotlines operating within the jurisdiction served by the health
department that are currently conducting active surveillance of call records for unusual
symptoms or an increased volume of cases?
If yes, record the name of the system owner or operator for the health advice hotline(s) below.
2. Do the health advice hotline(s) listed above report information about unusual cases or a
rise in the number of cases to the health department?
If yes:
a.
Spatial coverage: Does the geographic area served by the health advice
hotline(s) cover the entire utility service area?
Timeliness: What is the typical delay between identification of unusual cases
or volumes of cases and reporting to the health department?
Immediately
Same day
Days later
c. Data quality: Select the underlying case details that are reported.
Check the "Other" box if reports include additional underlying case
details and describe in the box below.
CD Demographics
D Chief complaint
CD Symptoms
D Date/time of contact
D Location where
exposure occurred
D Other
Record any additional notes related to surveillance conducted by health advice hotlines below (e.g., if
hotline is in operation 24/7):
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Syndromic Surveillance
Syndromic surveillance involves monitoring of public health data, such as that listed below, to detect
incidence of illness or poisoning. While Syndromic surveillance can be manual or automated, it is increasingly
performed by automated systems that generate an alert notification whenever anomalous conditions are
detected relative to an established baseline. Investigation of syndromic surveillance alerts and underlying case
details is typically conducted by the health department or PCCs.
Four different types of syndromic surveillance datastreams include:
• Emergency Department (ED) Data: ED data is generated when individuals visit an ED
as a result of an injury or suspected illness. Trained healthcare providers (e.g., doctors,
physician assistants, nurses) document symptoms, identify the cause of the symptoms,
and provide treatment. ED data is typically entered into an existing medical records
system. Pertinent information from these records, such as the chief complaint, is filtered
for analysis.
• Emergency Medical Service (EMS) Runs: EMS run data is generated when
emergency medical technicians respond to an emergency, providing medical
assessment, support, and transport. Trained professionals enter the details of the run
into an information management system owned and operated by the jurisdiction served
by the EMS unit. EMS runs are filtered to capture the subset of runs that could be due
to a possible public health incident.
• 911 Calls: 911 call data is generated when individuals call a 911 dispatch center to
report an emergency or to seek medical assistance. Trained 911 dispatchers code each
call and enter it into a computer-aided dispatch system. 911 calls are filtered by incident
code to identify the subset of calls that could be due to a possible public health incident.
• Over-the-counter (OTC) Medication Sales: Sales of medications commonly used to
alleviate symptoms of gastrointestinal illness, respiratory illness, or any other symptoms
of interest are aggregated across participating pharmacies and monitored.
HMS
EpiCenter User Interface (Health Monitoring Systems)
1
BioSense User Interface (Centers for Disease Control and Prevention)
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Syr
1.
2.
3.
idromic Surveillance Assessment Questions
For each datastream currently monitored by the health department, record the name of the PHS system, a
brief description, and the system owner/operator. If a datastream other than the four listed is monitored,
enter information for that datastream in the "Other" row.
Datastream
ED Data
EMS Runs
911 Calls
OTC
Medication
Sales
Other:
Contaminant Class
Coverage
Rapid symptom
onset and
Delayed symptom
onset
Rapid symptom
onset
Rapid symptom
onset
Delayed symptom
onset
Name of
PHS System
Description
System
Owner/Operator
Spatial coverage: For each datastream monitored by the health department, does the geographic area
monitored by the datastream cover the entire utility service area?
ED Data EMS Runs
D Yes D Yes
D No D No
911 Calls OTC Medication Sales Other:
D Yes D Yes D Yes
n NO n NO n NO
Timeliness: For each datastream monitored by the health department, what is the typical delay between
health seeking behavior and alert generation?
ED Data EMS Runs
D Real-time D Real-time
D Hours D Hours
D Days D Days
D Weeks D Weeks
911 Calls OTC Medication Sales Other:
CD Real-time d Real-time d Real-time
D Hours D Hours D Hours
CD Days EH Days d Days
D Weeks Q Weeks Q Weeks
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4. Data quality: For each datastream monitored by the health department, select the underlying case details
that are collected and available for review. The OTC medication sales datastream is not included in this
table because underlying case details are not applicable. Check the "Other" box if additional underlying
case details are collected and describe in the "Other Case Details" box below.
ED Data
D Demographics
CD Chief complaint
D Symptoms
CH Date/time of contact
D Location where
exposure occurred
D Other
EMS Runs
D Demographics
CD Chief complaint
D Symptoms
CH Date/time of contact
D Location where
exposure occurred
D Other
911 Calls
D Demographics
CD Chief complaint
D Symptoms
CH Date/time of contact
D Location where
exposure occurred
D Other
Other:
D Demographics
CD Chief complaint
D Symptoms
CH Date/time of contact
D Location where
exposure occurred
D Other
Other Case Details:
5. For each datastream monitored by the health department, select the water-related syndromes that are
included. Check the "Other" box if additional syndromes are included and describe in the "Other
Syndromes" box below.
ED Data
D Gastrointestinal
CD Respiratory
D Cardiac
CH Dermal
D Neurological
D Other
EMS Runs
D Gastrointestinal
EH Respiratory
D Cardiac
HH Dermal
D Neurological
D Other
911 Calls
D Gastrointestinal
CD Respiratory
D Cardiac
CH Dermal
D Neurological
D Other
OTC Medication
Sales
D Gastrointestinal
CD Respiratory
D Fever
CH Dermal
D Other
Other:
D Gastrointestinal
CD Respiratory
D Cardiac
CH Dermal
D Neurological
D Other
Other Syndromes:
Summary
1. Reflecting on surveillance methods currently used by the health department, discuss PHS capabilities that
could be implemented or enhanced to provide improved surveillance for water contamination and note
them in the box below. Specific enhancements could include:
• Optimizing mechanisms for reporting unusual incidents of disease
• Adding new syndromes to an existing PHS system
• Extracting additional underlying case details through an existing PHS system
• Increasing the frequency of automated analyses performed by an existing PHS system
• Strengthening relationships with existing data providers
• Capturing data from additional data providers
2. Please discuss availability for routine meetings. The next meeting with the health department will be on
/ / at (time) at (location).
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'art II: Poison Control Center's Surveillance Capabilities
Poison Control Center Name:
Contact Name and Title:
Contact Phone:
Contact Email:
Interview Date:
Conversation Starter
Has the PCC previously provided the health department with an early warning of an environmental exposure
(e.g., contaminated food, lead exposures, tainted medications, etc.)? If so, discuss how PCC data was used to
identify the cause of the exposure.
PCC Surveillance
Case-based surveillance is conducted by the PCC by analyzing data collected from specialists when they are
advising callers and healthcare providers on suspected poisoning incidents. Phone calls are handled by
physicians, nurses, and pharmacists with toxicological expertise, and call details are uploaded to the National
Poison Data System (NPDS) in real time.
The PCC may also conduct syndromic surveillance by analyzing call details stored in the NPDS. Incoming
NPDS data is monitored continuously and anomalous signals generate an automated email alert, which is sent
to the designated regional PCC or health department. The system allows PCCs to develop customized
statistical analysis parameters for defined syndrome categories.
PCC Assessment Questions
1. Do poison control specialists handling PCC calls consider water as a source of exposure
when evaluating a patient, particularly when foodborne exposure is suspected?
2. Spatial coverage: Does the geographic area covered by the PCC cover the entire utility
service area/
3. Timeliness: What is the typical delay between calls to the PCC and alert generation for
NPDS?
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4.
Data quality: Select the underlying case details that are collected. Check the
"Other" box if additional underlying case details are collected and describe in the
"Other Case Details" box below.
Demographics
Symptoms
Date/time of
contact
Location where
exposure occurred
Other
Other Case Details:
5. Has NPDS been configured to include algorithms or key word matches used to identify
cases which suggest exposure to contaminated water in your region?
Summary
1. Reflecting on current surveillance methods implemented by the PCC, discuss enhancements that could
improve monitoring for exposures to contaminated water and note them in the box below. Specific
enhancements could include:
• Adding new syndromes
• Extracting additional underlying case details
• Increased frequency of automated analyses
2. Please discuss availability for routine meetings. The next meeting with the PCC will be on
/ / at (time) at (location).
Office of Water (MC140) | EPA 817-B-15-001 | January 2015
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