&EPA
United States
Environmental Protection
Agency
Public Health Surveillance Design Guidance
For Water Quality Surveillance and Response Systems
Office of Water (AWBERC, MS 140) EPA 817-B-16-001
July 2016
-------
Disclaimer
The Water Security Division of the Office of Ground Water and Drinking Water has reviewed and
approved this document for publication. This document does not impose legally binding requirements on
any party. The information in this document is intended solely to recommend or suggest and does not
imply any requirements. Neither the U.S. Government nor any of its employees, contractors or their
employees make any warranty, expressed or implied, or assume any legal liability or responsibility for
any third party's use of any information, product, or process discussed in this document, or represent that
its use by such party would not infringe on privately owned rights. Mention of trade names or commercial
products does not constitute endorsement or recommendation for use.
Questions concerning this document should be addressed to WQ_SRS@epa.gov or the following contact:
Steve Allgeier
U.S. EPA Water Security Division
26 West Martin Luther King Drive
Mail Code 140
Cincinnati, OH 45268
(513)569-7131
Allgeier.Steve@epa.gov
-------
Acknowledgements
The document was developed by EPA's Water Security Division, with additional support provided under
EPA contract EP-C-15-012.
Steve Allgeier, EPA, Water Security Division
Adam Haas, CSRA
Darcy Shala, CSRA
Peer review of this document was provided by the following individuals:
Jonathan Colvin, Drug and Poison Information Center, Cincinnati Children's Hospital
Kirsten Larson, Association of Public Health Laboratories
Royal Law, Centers for Disease Control and Prevention
Ami Patel, Philadelphia Department of Public Health
David Travers, EPA, Water Security Division
June Weintraub, San Francisco Department of Public Health
-------
Table of Contents
LIST OF FIGURES iv
LIST OF TABLES v
ABBREVIATIONS vi
SECTION 1: INTRODUCTION 1
SECTION 2: OVERVIEW OF PHS DESIGN 3
2.1 Generation of Public Health Datastreams 3
2.2 PHS Design Elements, Design Goals, and Performance Objectives 6
SECTION 3: PARTNERSHIP WITH PUBLIC HEALTH 8
3.1 Establishing Relationships with Public Health Partners 8
3.2 Establishing a Joint Public Health and Utility Workgroup 10
SECTION 4: PUBLIC HEALTH SURVEILLANCE SYSTEMS 12
4.1 Public Health Datastreams 12
4.2 Public Health Surveillance Techniques 19
4.3 Utility Role in Integrating Public Health Surveillance Capabilities into an SRS 25
SECTION 5: ALERT INVESTIGATION PROCEDURE 31
5.1 Developing an Effective Alert Investigation Procedure 31
5.2 Developing Investigation Tools 36
5.3 Preparing for Real-time Alert Investigations 37
SECTION 6: PRELIMINARY PHS DESIGN 40
RESOURCES 42
REFERENCES 45
GLOSSARY 48
-------
List of Figures
FIGURE 1-1. SURVEILLANCE AND RESPONSE SYSTEM COMPONENTS 1
FIGURE 2-1. EXAMPLE CHEMICAL CONTAMINATION SCENARIO (CARBAMATE PESTICIDE) 5
FIGURE 2-2. EXAMPLE PATHOGEN CONTAMINATION SCENARIO (VIBRIO CHOLERAS) 5
FIGURE 3-1. PROCESS FOR ENGAGING PUBLIC HEALTH PARTNERS WITH A POTENTIAL ROLE IN PHS 9
FIGURE 4-1. PUBLIC HEALTH DATASTREAM ATTRIBUTE SUMMARY 19
FIGURE 4-2. OVERVIEW OF PUBLIC HEALTH SURVEILLANCE TECHNIQUES 20
FIGURE 4-3. EXCERPT FROM THE PUBLIC HEALTH SURVEILLANCE ASSESSMENT (HEALTH DEPARTMENT - SYNDROMIC
SURVEILLANCE DATASTREAMS) 26
FIGURE 5-1. EXAMPLE ALERT INVESTIGATION PROCESS FLOW DIAGRAM FOR VALID PHS ALERTS 34
FIGURE 5-2. EXAMPLE ALERT INVESTIGATION RECORD 37
IV
-------
List of Tables
TABLE 2-1. CONTAMINANT CLASSES THAT CAN BE DETECTED THROUGH PUBLIC HEALTH SURVEILLANCE 3
TABLE 2-2. PUBLIC HEALTH DATASTREAMS AND THEIR LEVEL OF MEDICAL ASSESSMENT 4
TABLE 2-3. DESIGN ELEMENTS FOR PUBLIC HEALTH SURVEILLANCE 6
TABLE 2-4. COMMON SRS AND PHS DESIGN GOALS 6
TABLE 2-5. EXAMPLE PHS PERFORMANCE OBJECTIVES 7
TABLE 4-1. WATER CONTAMINATION INCIDENTS IDENTIFIED THROUGH CASE-BASED SURVEILLANCE 22
TABLE 4-2. SYNDROMES RELATED TO WATER CONTAMINATION 23
TABLE 4-3. COMMON SYNDROMIC SURVEILLANCE SYSTEMS 24
TABLE4-4. EXAMPLE ASSESSMENT OF EXISTING PUBLIC HEALTH SURVEILLANCE SYSTEMS 27
TABLE 4-5. EXAMPLE STRATEGY FOR ADDRESSING GAPS IN PUBLIC HEALTH SURVEILLANCE CAPABILITIES 30
TABLE 5-1. EXAMPLE CAUSES OF PHS VALID ALERTS 32
TABLE 5-2. EXAMPLE OF GENERIC ROLES AND RESPONSIBILITIES FOR PHS ALERT INVESTIGATIONS 35
-------
APHL
CDC
CSTE
ED
EHR
EMR
EMS
EPA
ESSENCE
NNDSS
NPDS
NRDM
OTC
PCC
PHS
RODS
SRS
Abbreviations
Association of Public Health Laboratories
Centers for Disease Control and Prevention
Council of State and Territorial Epidemiologists
Emergency Department
Electronic Health Record
Electronic Medical Record
Emergency Medical Services
U.S. Environmental Protection Agency
Electronic Surveillance System for the Early Notification of
Community-based Epidemics
National Notifiable Diseases Surveillance System
National Poison Data System
National Retail Data Monitor
Over-the-counter (medication sales)
Poison Control Center
Public Health Surveillance
Real-time Outbreak and Disease Surveillance
Water Quality Surveillance and Response System
VI
-------
Public Health Surveillance Design Guidance
Section 1: Introduction
The U.S. Environmental Protection Agency (EPA) designed a Water Quality Surveillance and Response
System (SRS) that employs multiple components to detect water quality incidents with potential public
health and economic consequences. Figure 1-1 shows the components of an SRS grouped into two
operational phases, surveillance and response. Procedures guide the systematic investigation of anomalies
detected by the surveillance components in order to identify its cause. If distribution system
contamination is detected, response plans guide actions intended to minimize consequences. An SRS can
be implemented by drinking water utilities to improve their ability to detect and respond to undesirable
water quality changes. EPA intends the design of an SRS to be flexible and adaptable based on a utility's
goals and the resources available to support implementation and operation of the system.
Surveillance
Response
Online Water
Quality Monitoring
Enhanced Security
Monitoring
Take corrective
action if necessary,
then resume routine
surveillance.
YES
Can distribution
system contamination
be ruled out?
Customer Complaint
Surveillance
T
If unusual water
quality is detected,
an alert is generated
and investigated.
Figure 1-1. Surveillance and Response System Components
Public Health Surveillance (PHS) is one of four surveillance components of an SRS. The purpose of this
document is to provide guidance for designing the PHS component of an SRS. It is written for drinking
water professionals who would be responsible for coordinating with public health partners to implement
PHS. The guidance provides information about public health partners who may be engaged to support
PHS, includes an overview of available public health datastreams, and discusses common surveillance
techniques that can be leveraged to improve capability to monitor for illness due to exposure to
contaminated drinking water. It does not address the design of new public health surveillance systems,
which would fall entirely within the domain of public health professionals.
This document is organized into the following major sections:
Section 2 provides information about the generation of public health datastreams and a
description of the PHS design elements that define the component. Guidance on developing each
design element is presented in the following sections. Section 2 also introduces the concepts of
design goals and performance objectives and explains how they inform the design of PHS.
Section 3 provides guidance on creating a partnership with public health agencies. The section
identifies and describes common public health partners and provides guidance on methods to
engage them.
-------
Public Health Surveillance Design Guidance
Section 4 describes available public health datastreams and common surveillance techniques, and
provides recommendations regarding how existing capabilities could be leveraged and potentially
enhanced to support the goals of the PHS component of an SRS.
Section 5 provides guidance on investigating PHS alerts. It describes attributes of an effective
alert investigation procedure, explains a utility's role in the investigation of a PHS alert, describes
tools to support the investigation, and provides guidance on investigating alerts in real time.
Section 6 describes the process for developing a preliminary design for the PHS component of an
SRS.
Resources presents a comprehensive list of documents, tools, and other resources useful for PHS
implementation. A summary and link to each resource is provided.
References presents a comprehensive list of published literature cited within the document.
Glossary presents definitions of terms used in this document, which are indicated by bold italic
font at first use in the body of the document.
This document is written in a modular format in which the guidance provided on a specific topic is largely
self-contained, allowing the reader to skip sections that may not be applicable to their approach to PHS,
or that include capabilities that have already been implemented. Furthermore, this document was written
to provide a set of core guidance principles that are sufficient to design the PHS component, while
pointing the reader to additional technical resources useful for a specific design task.
-------
Public Health Surveillance Design Guidance
Section 2: Overview of PHS Design
Public health surveillance is the systematic collection, analysis, and interpretation of public health data for
the purpose of detecting public health incidents, or changes in the health status of a community, in
sufficient time to mitigate the consequences of the incident. Ongoing collection of public health data can
also be used to establish the baseline health status in a community, which is a useful benchmark for any
public health initiative, including detection of drinking water contamination. Public health surveillance
operates on the principle that individuals experiencing unusual or severe symptoms will seek healthcare.
These actions create datastreams that can be monitored to detect signs of a public health incident.
2.1 Generation of Public Health Datastreams
In the context of an SRS, the purpose of PHS is to provide early detection of drinking water
contamination incidents and provide an opportunity to minimize adverse health impacts in exposed
individuals. Table 2-1 presents contaminant classes which can cause significant public health
consequences if introduced into a water distribution system, example contaminants within those classes,
and chief complaints (i.e., the primary symptom that a patient states as the reason for seeking medical
care). The contaminant classes in Table 2-1 are separated into categories of delayed and rapid symptom
onset, based on the delay between exposure to the contaminant and onset of acute symptoms.
Table 2-1. Contaminant Classes that can be Detected through Public Health Surveillance
Contaminant Classes
Delayed Symptom Onset
Rapid Symptom
Onset
Bacteria
Viruses
Protozoa
Toxins
Heavy metals
Radiochemicals
Arsenic (III)
compounds
Cyanide
Mercury
compounds
Pesticides
Example
Contaminants
Bacillus anthracis
Campylobacter spp.
Legionella pneumophila
Salmonella Typhi
Vibrio cholerae
Adenovirus
Enterovirus
Norovirus
Cryptosporidium
parvum
Giardia lamblia
Botulinum toxin
Microcystins
Ricin
Lead
Cesium-137
Sodium arsenite
Cyanide
Mercuric chloride
Aldicarb, dichlorvos
Chief Complaints1
Chills, fever, nausea, bloody vomiting
Headache, fever, abdominal pain, vomiting, bloody diarrhea
Muscle pain, cough, fever, shortness of breath, nausea,
vomiting, diarrhea
Headache, abdominal pain, fatigue, fever, diarrhea
Leg cramps, watery diarrhea, vomiting
Sore throat, sneezing, headache, cough, fever
Muscle pain, cough, sneezing, wheezing, difficulty breathing
Muscle pain, abdominal pain, nausea, vomiting, watery
diarrhea, fever
Abdominal cramps, fever, nausea, vomiting, diarrhea
Abdominal cramps, fatigue, nausea, vomiting, diarrhea
Muscle weakness, blurred vision, vomiting, difficulty breathing
Headache, abdominal pain, vomiting, diarrhea, fever
Nausea, vomiting, diarrhea
Abdominal pain, headache, fatigue, memory loss, seizures,
vomiting, constipation
Fatigue, fever, nausea, vomiting, diarrhea
Difficulty swallowing, burning sensation in throat, thirst,
dizziness, abdominal pain, vomiting, diarrhea
Headache, dizziness, confusion, nausea, vomiting
Pain in mouth and throat, abdominal pain, difficulty breathing,
vomiting, diarrhea
Sweating, blurred vision, vomiting, diarrhea, difficulty breathing
1 For a specific contaminant, the chief complaint can vary by the route of exposure to contaminated water, which can include
ingestion, dermal contact, and inhalation of aerosols or water vapor.
-------
Public Health Surveillance Design Guidance
Individuals exposed to contaminated water may seek healthcare, possibly urgently, depending on the type
of symptoms and the rapidity of symptom onset. Healthcare seeking behavior may include calling 911,
calling a. Poison Control Center (PCC), calling a health advice hotline, requesting Emergency Medical
Services (EMS) response, making an appointment with a primary care physician, visiting a hospital
emergency department (ED), or purchasing an over-the-counter (OTC) medication. These actions become
public health datastreams through the creation of call logs, patient medical records, or pharmacy
medication sales records. Often when individuals seek healthcare by visiting their primary care physician
or an ED, nurses or physicians will collect clinical samples and order a laboratory analysis. The results of
clinical laboratory analyses are another potential public health datastream.
Public health datastreams are composed of numerous individual records (i.e., call logs, medical records,
or medication sales) which contain specific case details (e.g., date, time, location, symptoms). Depending
on the specific healthcare seeking behavior that patients pursue when experiencing symptoms, they may
or may not be assessed by a medically trained professional before their information is captured and enters
a datastream. For example, if a patient purchases OTC medication to alleviate their symptoms,
information about the type of medication purchased, and the date, time, and location of the medication
sale can be captured. However, the patient would not be assessed by a medical professional when taking
this action. Conversely, if a patient schedules an appointment with their primary care physician,
information about their health status would be assessed and captured during the visit by a medical
professional. Table 2-2 below presents the level of medical assessment that occurs for each datastream
discussed in this guidance.
Table 2-2. Public Health Datastreams and their Level of Medical Assessment
Public Health Datastream
911 calls
OTC medication sales
PCC calls
Health advice hotline calls
EMS runs
ED cases
Healthcare networks
Clinical laboratory results
Assessor
911 operator
Salesperson
Physicians, nurses, and pharmacists
Nurses
Emergency medical technicians
Physicians, physicians assistants, nurses
Physicians, physicians assistants, nurses
Laboratory analysts
Level of Medical Assessment
None
Phone assessment
In-person assessment
Two example drinking water contamination scenarios are presented below showing timelines associated
with symptom onset, healthcare seeking behavior of an exposed individual, and the unique datastreams
that are created by these behaviors. Figure 2-1 shows the timeline, symptoms, and healthcare seeking
behaviors of an individual who consumes water contaminated with a carbamate pesticide. In this example,
the individual calls 911 following rapid onset of severe symptoms. An EMS unit is dispatched to the
individual's home and transports them to the ED. The attending physician at the ED recognizes symptoms
suggesting chemical poisoning and contacts the PCC to discuss treatment of the patient. The physician
also collects a blood sample from the patient and orders a clinical laboratory test of the sample. This
sequence of healthcare seeking behaviors generates signals in the 911, EMS, ED, PCC, and clinical
laboratory results datastreams.
-------
Public Health Surveillance Design Guidance
7:OOAM
8:OOAM
9:OOAM
9:1 SAM
10:OOAM
11:OOAM
Pv
==N
I J
Person consumes
contaminated water
^ ~-\
Symptom onset:
sweating,
nausea, blurred
vision
=^
^ "X
Symptoms
worsen: vomiting,
diarrhea, difficulty
breathing
V J
>
Individual calls
911, requests
EMS transport^*|v
911
data
>
/ ^
EMS delivers
patient to ED and
closes out record
EMS data
Figure 2-1. Example Chemical Contamination Scenario (Carbamate Pesticide)
Figure 2-2 shows the healthcare seeking behaviors of an individual who consumes water contaminated
with Vibrio cholerae. In this example, the individual initially purchases OTC medication to treat
relatively mild symptoms. Four days later symptoms worsen and the individual drives to the ED to seek
urgent healthcare. The patient is assessed by the attending physician at the hospital and clinical laboratory
tests are ordered on several clinical samples collected from the patient. This sequence of healthcare
seeking behaviors generates signals in the OTC, ED, and clinical laboratory results datastreams. Under a
variation of this scenario, the symptomatic individual might visit their primary care provider before going
to the ED, thus generating a signal in an additional datastream. The pathogen contamination scenario
differed from the carbamate pesticide scenario with respect to the severity and timing of symptom onset,
which resulted in a different sequence of health seeking behaviors.
7:OOAM
2 days later
4 days later
10 days later
Pe
cor
<^^
/-LK
rson consum
laminated WE
es
ter
'
Symptom onset:
nausea, stomach
cramps, fever
V }
>
Individual drives to
pharmacy to
purchase OTC
medication ^^-^
OTC data
>
Symptoms worsen:
vomiting, watery
diarrhea,
dehydration, leg
cramps
=£
Figure 2-2. Example Pathogen Contamination Scenario (Vibrio cholerae)
-------
Public Health Surveillance Design Guidance
2.2 PHS Design Elements, Design Goals, and Performance Objectives
Design elements are the functional areas which comprise each component of an SRS. PHS consists of
three design elements, which are described in Table 2-3.
Table 2-3. Design Elements for Public Health Surveillance
Design Element
Partnership with Public
Health
Public Health Surveillance
Systems
Alert Investigation Procedure
Description
Standing relationships between water utility personnel and public health
partners who have developed a mutual understanding of each other's
responsibilities and capabilities, and who are committed to supporting the
goals of PHS.
Systems that support routine monitoring of public health datastreams for
indicators of possible public health incidents. This includes medical
assessments of patients by healthcare professionals and monitoring of
public health datastreams such as: PCC calls, ED visits, EMS runs, health
advice hotline calls, healthcare networks, clinical laboratory results, 911 calls,
and OTC medication sales.
A documented procedure for the timely and systematic investigation of PHS
alerts, with clearly defined roles and responsibilities for each step of the
process.
An effective PHS component should have capability for each of the design elements listed in Table 2-3.
Sections 3 through 5 of this document define a target capability for each of these design elements, which
if achieved, will result in a fully functional PHS component. However, the specific manner in which each
design element is implemented can vary, and it is possible to substantially improve PHS capabilities
without fully achieving the target capability for each design element. Likewise, PHS capabilities can be
implemented that exceed the target capability.
The decision regarding how to implement each of these design elements and build the PHS component is
informed by design goals, which are the specific benefits a utility hopes to realize through
implementation of an SRS. Design goals for PHS are derived from overarching design goals established
for the SRS, as illustrated in Table 2-4.
Table 2-4. Common SRS and PHS Design Goals
SRS Design Goal
Detect water contamination
incidents
Strengthen interagency
relationships
Coordinate on issues of mutual
concern to a utility and its
public health partners
Demonstrate the safety of the
drinking water supply
PHS Design Goal
Provide timely detection of possible water contamination incidents involving
contaminants that produce symptoms with either rapid or delayed symptom
onset.
Work collaboratively with public health partners to increase mutual awareness
of each other's capabilities and to prepare to respond to any emergency.
Work collaboratively with public health partners to address public health
initiatives related to water quality and treatment, such as reducing the risk of
Legionella outbreaks in hospitals, and monitoring for lead exposure in children.
Demonstrate to the community and regulators that the utility is collaborating
with public health partners to investigate drinking water as the possible cause of
public health incidents, and that the majority of public health incidents are not
waterborne.
Additional factors to consider when designing PHS are performance objectives, which are metrics used to
gauge how well the SRS or its components meet the established design goals. While specific performance
objectives must be developed in the context of a utility's unique design goals, general performance
objectives for an SRS are defined in the Water Quality Surveillance and Response System Primer and are
-------
Public Health Surveillance Design Guidance
further described in Table 2-5 in the context of PHS. The table also includes a recommended benchmark
for each performance objective. The objectives described below are for the performance of the overall
PHS component.
Table 2-5. Example PHS Performance Objectives
PHS Performance
Objectives
Description
Recommended Benchmark
Contaminant
coverage
The number of contaminant classes that can be detected,
which is dependent on the types of public health data
monitored through PHS.
Detect contaminant classes
that produce rapid symptom
onset and those that produce
delayed symptom onset
Spatial coverage
The percentage of the distribution system service area
monitored by PHS, which is dependent on the public health
jurisdictions included in the monitored public health
datastreams.
100% of the distribution
system service area
Timeliness of
detection and
investigation
The time between when healthcare seeking behaviors enter
a monitored datastream and when a PHS alert is generated,
which is dependent on the delay between data generation
and data analysis as well as the frequency of data analysis.
This performance objective also considers the time to reach
a conclusion from the investigation of an alert.
24 hours or less to generate
an alert
2 hours or less to reach a
conclusion from the alert
investigation
Operational
reliability
The percentage of time that utility personnel are available to
support the investigation of water contamination as the
possible cause of a PHS alert, which depends on the
availability of trained utility personnel and the information
management systems used during an investigation.
Availability of surveillance
capabilities and coverage of
PHS alert investigation
responsibilities 24/7/365
Data quality
Availability of sufficient data to support the investigation of
water contamination as the possible cause of a PHS alert or
public health incident, including utility data and public health
case details. Also, the degree to which patients have been
assessed by a medically trained professional, as described
in Table 2-2 (i.e., none, phone assessment, in-person
assessment).
Utility data: water quality
parameter measurements,
laboratory results, customer
feedback
Public health case details:
demographics, symptoms,
date/time of contact, location
where exposure occurred
Sustainability
The ability to maintain and operate PHS using available
resources, which is dependent on the benefits derived from
the component relative to the costs to maintain it.
PHS alert investigation
procedures are incorporated
into routine utility operations
within 1 year of transitioning to
real-time operation
The design goals and performance objectives established by a utility in collaboration with its public
health partners provide the basis for designing PHS in a manner that meets the objectives and constraints
of both entities. The following sections present guidance on potential approaches to enhance capabilities
for each of the three PHS design elements described in Table 2-3. Additional background on the design
elements, design goals, and performance objectives for PHS can be found in the Public Health
Surveillance Primer.
-------
Public Health Surveillance Design Guidance
Section 3: Partnership with Public Health
This design element addresses the relationships between water utility personnel and public health partners
with a role in PHS. It is the foundation for establishing notification and investigation procedures that are
necessary for effective detection and investigation of possible water contamination incidents.
TARGET CAPABILITY
A standing relationship has been established between a water utility and its public health partners, including the city
or county health department and the regional PCC.
This section provides guidance on establishing partnerships with public health and covers the following
topics:
Subsection 3.1 provides guidance on establishing relationships with public health partners
Subsection 3.2 provides guidance on establishing a joint public health and utility workgroup
3.1 Establishing Relationships with Public Health Partners
Utilities should engage with the following two categories of public health partners to implement PHS:
Health department. Health departments are established for different jurisdictions, such as the
city, county, and state. They are generally responsible for implementing various public health
initiatives, monitoring the health of the community they serve, and enforcing public health
regulations within their jurisdiction. Health departments typically employ epidemiologists,
environmental health specialists, and laboratorians with experience in interpreting public health
data. Many health departments have established environmental health service programs with
complaint hotlines, where citizens can report concerns related to food safety, recreational or
drinking water quality, illegal trash dumping, or rodent/insect control. In the context of PHS,
health departments may monitor public health datastreams capable of detecting a broad spectrum
of potential contaminants, including chemicals, radiochemicals, biotoxins, and pathogens. They
conduct an initial investigation of PHS alerts and would contact the water utility, if necessary, to
investigate contaminated water as a potential cause of an emerging public health incident.
Poison Control Center. PCCs are regional service centers staffed by physicians, nurses, and
pharmacists with toxicological expertise. They provide expert advice to persons who have been
exposed to a substance capable of causing illness or injury (e.g., medication, consumer product,
household/industrial chemical, bite/envenomation, environmental contaminant), or to persons
who are experiencing symptoms suspected to be the result of a poisoning exposure. PCCs are
routinely consulted by healthcare professionals who are actively treating poisoned patient(s)
within various medical settings. In the context of PHS, PCCs upload call data to the National
Poison Data System (NPDS) in near real time, and are capable of monitoring for broad and/or
isolated public health incidents involving chemicals, radiochemicals, and biotoxins. During the
investigation of a PHS alert, they can assist with contaminant identification, risk analysis, and
ongoing situational awareness.
-------
Public Health Surveillance Design Guidance
Figure 3-1 provides a four-step process for identifying and engaging public health partners. Guidance on
each step of the process is provided below.
Identify the health
department(s) and
PCC with jurisdictions
that overlap the
utility's distribution
system
Establish
contact with the
health
department(s)
and PCC
Hold a kickoff
meeting
Determine the
potential extent
of the
partnership
Figure 3-1. Process for Engaging Public Health Partners with a Potential Role in PHS
The first step is to identify public health partners with jurisdictions that overlap all or a portion of a
utility's distribution system service area. There may be multiple health departments within a utility's
service area, such as a city and county health department. There may also be regional public health
entities that serve an area that extends beyond a utility's distribution system boundaries. At a minimum, a
utility should identify the health department and PCC with jurisdictional boundaries that provide the
broadest spatial coverage of the service area. Local listings or an Internet search should be sufficient to
identify the appropriate health department(s). The PCC that serves the community in the utility's service
area can be identified through the American Association of Poison Control Centers.
After the appropriate health department(s) and PCC(s) have been identified, the next step is to establish a
point of contact within each. It is important to identify an individual within the organization who has
sufficient authority to commit a modest amount of the organization's time to preliminary discussions with
the utility regarding its role in monitoring and protecting the safety of the community's drinking water. It
may be useful to contact existing city or county interagency groups, such as those involved in emergency
preparedness planning, to identify specific health department or PCC personnel who could serve a role in
the PHS component of the SRS.
After initial contact has been made with the appropriate public health partners, the utility should consider
holding a kickoff meeting with this group of potential partners. The objective of this meeting is to make
connections, share information, and gauge the interest of public health partners in participating in the PHS
component of the SRS. During the kickoff meeting, the utility should describe their system, their
organizational structure, their goal and vision for the SRS, and the potential role of PHS in an SRS. The
utility should also describe their capabilities for monitoring water quality and supporting the investigation
of a possible water contamination incident. Also during this meeting, each public health partner should be
provided with an opportunity to present information about their organization, capabilities, and potential to
support PHS. The resource Public Health Surveillance Kickoff
Meeting is a PowerPoint template which can be opened by clicking
the icon in the callout box. The template can be customized to
provide an overview of your utility and its surveillance and response
capabilities to public health partners during a kickoff meeting.
This template can be
customized to provide
an overview of your
utility and the SRS.
-------
Public Health Surveillance Design Guidance
HELPFUL HINT
Invite public health partners
to tour utility facilities and
laboratories to increase their
understanding of the utility's
capabilities.
Ideally, the kickoff meeting would allow the utility to determine
which public health partners have the resources and interest to engage
in PHS. When discussing the potential role and level of involvement
of various public health partners, the utility should keep in mind that
the resources of many public health partner organizations are spread
thin. This may temper their willingness to commit. However, if PHS
is designed and implemented in a manner that aligns with the core
mission of participating public health partners, successful
implementation and sustained operation of PHS can be achieved.
3.2 Establishing a Joint Public Health and Utility Workgroup
As noted in the previous section, the outcome of initial engagement should result in identification of
public health partners who have some level of commitment to PHS as a component of an SRS. These
partners will play an important role in the design, implementation, and operation of PHS. To maintain
partner engagement throughout this process, it is recommended that a joint public health and utility
workgroup be formed. While it will take some time and effort to establish and maintain the workgroup, it
should not require financial expenditures by the utility or public health partners.
DID You KNOW?
Public health partners in your area may
be actively participating in a Community
of Practice - established by CDC in
collaboration with public health
associations - designed to improve
communication and enhance data
sharing among partners (CDC, 2016a).
When establishing the workgroup, a charter should be
created which includes the mission, goals, and
responsibilities of members. The workgroup should
designate a leader and determine who will assume
responsibility for administrative duties. Inclusion of a clear
vision statement in the workgroup charter that establishes
the purpose of the workgroup can be useful to convey the
value of participation to utility and public health personnel.
During the design of PHS, this workgroup will identify design goals and performance objectives for the
component that consider applications of PHS beyond the SRS that are important to the public health
partners. During the design stage of the project the workgroup will likely need to meet frequently to
evaluate alternatives and make decisions about the final design of the component. This may involve a
thorough evaluation of existing public health partner capabilities that might support surveillance and alert
investigations. The ability of these existing capabilities can be assessed against design goals and
performance objectives, and potential enhancements to PHS capabilities can be identified and evaluated.
After PHS has been designed and implemented, the workgroup provides a forum for maintaining the
relationships between the utility and public health partners. The workgroup could meet routinely (e.g.,
once or twice a year) to review operation of PHS and discuss other issues related to drinking water and
public health that may not directly relate to the operation of the SRS. Examples of initiatives that may be
of mutual interest to the utility and its public health partners include:
Monitoring for long term exposure to lead or other commonly occurring environmental
contaminants
Public concerns over water quality issues such as fluoridation of drinking water
Pharmaceuticals in drinking water and public education on proper disposal of medications
Monitoring and mitigation strategies for waterborne Legionella outbreaks in hospitals
Planning for continuity of operations during severe public health incidents, such as pandemic flu
Changes in source water availability and quality due to natural disasters or short- and long-term
changes in weather or climate
Effectiveness of various water treatment processes on various chemical and biological
contaminants
10
-------
Public Health Surveillance Design Guidance
Potential impacts of changes in drinking water treatment processes on water quality and public
perception
Such initiatives can reinforce the relationship between a utility and its public health partners, which in
turn helps to sustain operation of PHS. Furthermore, these relationships can provide lasting benefits to the
community that extend beyond the scope and purpose of the SRS.
PUBLIC HEALTH ASSOCIATIONS
Utilities that actively collaborate with their public health partners may consider participating in regional- or
national-level events or conferences as a means to remain current on issues that may be of mutual interest to
utilities and public health professionals. The following list includes large public health associations which host
annual conferences:
Council of State and Territorial Epidemiologists
National Association of County and City Health Officials
Association of Public Health Laboratories
National Environmental Health Association
11
-------
Public Health Surveillance Design Guidance
Section 4: Public Health Surveillance Systems
Public health surveillance systems are designed to provide early detection of public health incidents. This
design element leverages public health surveillance systems currently used by health departments,
healthcare professionals, and the PCC that provide service to utility customers. To implement this design
element, a utility should collaborate with the health department(s) within its service area and the regional
PCC to identify existing public health surveillance systems and determine whether they can be leveraged
to support the goals of the SRS. Furthermore, some of these systems can be optimized to improve their
ability to detect possible water contamination.
TARGET CAPABILITY
Integrate public health surveillance currently performed by a utility's public health partners into an SRS to provide
timely detection of public health incidents that could be related to water contamination.
This section describes public health datastreams and surveillance techniques, providing guidance on
assessing existing public health surveillance systems with respect to their ability to detect possible water
contamination. This section consists of the following:
Subsection 4.1 provides an overview of public health datastreams and their attributes
Subsection 4.2 provides an overview of public health surveillance techniques
Subsection 4.3 describes a utility's role in integrating public health surveillance into an SRS
4.1 Public Health Datastreams
Public health datastreams are the data produced when symptomatic individuals seek healthcare, which can
be monitored for indicators of potential public health incidents, such as unusual patterns of illness or
deviations from the normal health status of a community. Public health surveillance techniques, discussed
in Section 4.2, are the methods and tools that are used to analyze these datastreams. Datastreams vary
with respect to the type of information collected, reporting mechanisms, and other attributes. Because of
these differences, monitoring multiple datastreams can improve the detection capabilities of PHS.
This section defines attributes of public health datastreams, including: contaminant coverage, spatial
coverage, timeliness, and data quality. This section also includes a brief description of the most common
public health datastreams (i.e., PCC calls, ED visits, EMS runs, health advice hotlines, healthcare
networks, clinical laboratory results, 911 calls, and OTC medication sales) and explains how well each
datastream meets these attributes.
Attributes
Attributes are characteristics of a public health datastream that should be considered when evaluating the
effectiveness of a datastream for PHS.
Contaminant coverage. Ability of a datastream to detect a wide range of potential contaminant
classes. Public health datastreams vary in their ability to detect contaminants which produce
delayed or rapid symptom onset.
Spatial coverage. The percentage of the utility distribution system service area covered by the
datastream. Spatial coverage provided by a datastream is often limited to a specific jurisdiction,
such as a city, county, state, or multi-state region.
Timeliness. The amount of time between the initial presentation of symptoms and when the call,
case record, clinical laboratory result, or OTC medication sale is captured in a datastream.
12
-------
Public Health Surveillance Design Guidance
Timeliness depends on how quickly a symptomatic individual seeks healthcare, which is
influenced by the severity of symptoms and speed with which they worsen.
Data quality. The availability of sufficient case details, such as demographics, symptoms or chief
complaint, and the date, time, and location where the exposure occurred. Also, the degree to
which case details for records entering a datastream have been assessed by a medical professional
(i.e., not at all, phone assessment, or in-person assessment [see Table 2-2]).
The overall "value to an SRS" is characterized for each datastream as high, moderate, or low based on the
collective set of attributes, experience gained from utilities that have implemented PHS, and feasibility of
integrating the datastream into the PHS component of an SRS. Information on the relevance and value of
various public health datastreams can be found in a retrospective study published following the
Milwaukee cryptosporidiosis outbreak, which evaluated the strengths and weaknesses of eight different
datastreams, including some of those discussed in this document (Proctor et al., 1998). A discussion of
the efficacy of syndromic surveillance for waterborne disease detection can be found in a review of
retrospective, prospective, and simulation studies (Berger et al., 2006).
General Assessment of Public Health Datastreams
This section will briefly explain the types of datastreams that public health partners may already be
monitoring. The potential applicability of any of these datastreams to an SRS for detection of possible
water contamination will depend on the manner in which monitoring of the datastream is implemented.
The datastreams are presented in order of their potential value to an SRS from high to low.
Poison Control Center calls. PCC data is generated when individuals contact a PCC by calling the
national Poison Help line at 1-800-222-1222 to seek information or medical advice regarding a potentially
harmful substance. Trained toxicologists at PCCs handle calls in real time, provide a preliminary medical
assessment, identify specific substances and potential routes of exposures, and enter the caller's case
information into an existing database. PCC toxicologists may follow up with the caller to assess whether
or not the condition requires further medical attention, and the results of this interaction are added to the
record. Healthcare providers treating selected patients may also contact the PCC as a resource for patient
diagnosis and treatment advice. Attributes of the PCC datastream are described below:
Contaminant coverage: PCC data is likely to capture contaminants producing rapid symptom
onset which may prompt urgent healthcare seeking behavior.
Spatial coverage: PCC coverage spans the country and every region in the U.S. has a PCC
assigned to it, thus all utilities have at least one PCC that services the population living within the
utility's distribution system area.
Timeliness: PCC calls are very timely, as they typically occur within minutes after an exposure or
onset of symptoms. The time elapsed between a call to the PCC and upload to NPDS is often less
than 30 minutes (J. Colvin, personal communication, 2016).
Data quality: PCC toxicologists capture data from callers, including: demographics, symptoms,
the date and time of the call, the location of the caller. Toxicologists provide a medical
assessment of a caller's symptoms and often obtain information about potential sources of
exposure from the individuals seeking their assistance. An additional level of medical assessment
is involved when PCCs receive toxicology consultations from ED physicians who are in the
process of assessing a patient.
Value to an SRS: High. Although contaminant coverage for the PCC datastream may be limited to
contaminants producing rapid symptom onset, the PCC is a valuable resource for identifying exposures to
a wide variety of chemicals and toxins. For this reason, most state and some local health departments
already collaborate with the PCC that serves their region (CSTE, 2013). An evaluation of current
13
-------
Public Health Surveillance Design Guidance
relationships between health departments and PCCs nationwide demonstrated that many PCCs are already
sharing data with health departments electronically through online access to PCC systems, web services,
or proprietary applications. The assessment also showed that data is often provided by PCC staff upon
informal requests from health department staff (CSTE, 2013). Integrating the PCC datastream into the
PHS component of an SRS requires a modest investment of time by the utility or health department but
should not require financial expenditures given that it is an existing resource functioning in a capacity that
is directly relevant to the design goals for PHS.
Emergency Department visits. ED data is generated when individuals visit an ED as a result of an injury
or suspected illness. Trained healthcare professionals (e.g., physicians, nurses) attempt to identify the
cause of the symptoms, provide treatment, and document the case details. ED data is typically entered
into an existing medical records system. In addition to maintaining case records in-house, cases or
suspected cases ofreportable diseases, which are established by state regulations, are reported to the
health department where they are logged. Attributes of the ED datastream are described below:
Contaminant coverage: ED data provides broad coverage of contaminants producing both rapid
and delayed symptom onset.
Spatial coverage: ED data is typically managed and consolidated by health departments. Thus,
the spatial coverage provided by the ED datastream depends on the overlap between the
catchment area of the ED, the jurisdictions covered by the health departments, and the utility's
distribution system area. For large utilities, it may be necessary to coordinate with multiple health
departments in order to maximize spatial coverage.
Timeliness: ED data can be timely if procedures are in place for direct reporting from healthcare
professionals to health departments if a higher than normal case volume is observed with unusual
symptoms not attributable to a known public health incident. However, detection through ED
surveillance can be delayed by several days if standard reporting procedures based on state
regulations for reportable diseases is relied upon.
Data quality: ED data includes patient demographics, symptoms or chief complaint, date, time,
and location. Physicians provide an in-person medical assessment of patients who arrive at the
ED which provides a high degree of data quality. In some cases, the datastream may include a
discharge diagnosis for patients that have been treated.
Value to an SRS: High. The ED datastream provides broad contaminant coverage and high data quality.
Furthermore, it is widely monitored by health departments and may require little or no effort to integrate
into the PHS component of an SRS. However, modifications to analysis methods or procedures may be
necessary to achieve timely detection.
Emergency Medical Service runs. EMS run data is generated when emergency medical technicians
respond to an emergency, providing medical assessment, support, and transport. Following an EMS run,
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 capture a broad range of situations
reported by the public, including injuries, fires, accidents, and illness. For an SRS, EMS runs are filtered
to capture only the subset of runs reporting illness that could be linked to an environmental exposure.
Attributes of the EMS datastream are described below:
Contaminant coverage: EMS runs are most likely to capture contaminants producing rapid
symptom onset which may prompt urgent healthcare seeking behavior.
Spatial coverage: EMS runs are often managed within jurisdictions such as cities, counties, or
neighborhoods. Therefore, public health partners and utilities may need to coordinate with
multiple EMS departments in order to achieve 100% spatial coverage across a utility's
distribution system.
14
-------
Public Health Surveillance Design Guidance
Timeliness: EMS data can be very timely if there is minimal delay between completion of an
EMS run and datatransmittal.
Data quality: Data from EMS runs usually include patient demographics, a chief complaint, date,
time, and location. Patients receive an in-person medical assessment by emergency medical
technicians which provides a high degree of data quality.
Value to an SRS: Moderate. EMS run data can be timely and is of high quality given that patients are
medically assessed in-person. However, if multiple EMS providers operate within the utility's distribution
system area, it may be costly to automate monitoring of EMS data from all providers. That limitation
aside, EMS data can add value to PHS due to its potential to provide early detection of exposure to
contaminants that produce rapid symptom onset.
Health Advice Hotlines. Health advice hotline data is generated when individuals contact a hotline to
seek medical advice related to an injury or suspected illness. Trained healthcare professionals, such as
registered nurses, handle calls in real time usually following a hierarchy of questions to provide
preliminary medical assessment of a patient's symptoms and recommend either self-care or direct the
patient to see a healthcare professional. Attributes of the health advice hotline datastream are described
below:
Contaminant coverage: Health advice hotline calls
provide broad coverage of contaminants producing
both rapid and delayed symptom onset.
Spatial coverage: The spatial coverage provided by
health advice hotlines can vary depending on the fhtatede Nu,^ Hetalth hAdvice N"e
J f ° through a collaboration between the
organization that manages the hotline. For example,
insurance hotlines or hospital hotlines may not
represent the entire population served by a utility, or
may cover an area served by more than one utility.
Timeliness: Health advice hotlines can be timely for
contaminants producing delayed symptom onset, as
sick individuals may call a hotline before seeking
other forms of healthcare and thus enter another
NEW MEXICO'S STATEWIDE HEALTH
ADVICE LINE
The state of New Mexico operates a
state and the larger private and public
provider systems, to provide universal
access to residents within the state.
This specific hotline has established
syndromic surveillance practices and
reports increases in specific symptoms
to public health officials (Nurse Advice
New Mexico, 2016).
datastream (e.g., ED, physician, OTC). One study that evaluated a specific healthcare network
demonstrated that hotline data captured for that network preceded outpatient visits by 8.3 to 50
hours (CDC, 2004).
Data quality: Health advice hotline calls generally include caller demographics, symptoms, and
the date and time of the call. Patients are medical assessed over the phone.
Value to an SRS: Moderate. The reports that a health department receives from a health advice hotline
may precede data that would be captured by OTC sales or from a visit to a primary care physician or ED.
Health advice data includes an over-the -phone medical assessment of a patient's symptoms. While this
datastream is a pre-established service which can provide an early signal of unusual cases, effective
integration of this datastream into PHS may require that health departments educate healthcare
professionals responsible for operating health advice hotlines on procedures for timely reporting of
unusual cases or clusters of cases to the health department.
Healthcare Networks. Patient data is generated when individuals visit a primary care physician's office
as a result of an injury or suspected illness. Trained medical professionals (e.g., doctors, physician
assistants, nurses) conduct an in-person assessment during these visits, attempt to identify the cause of the
symptoms, and provide treatment. Patient data captured during these visits is entered into an existing
15
-------
Public Health Surveillance Design Guidance
medical records system. While paper records are still in use, electronic record management is becoming
more common (see callout box), which offers numerous advantages for surveillance. Healthcare networks
provide a potential means to effectively monitor this datastream because of the large number of
physicians who are members of the network, and the fact that networks may use electronic record
management. In addition to maintaining case records in-house, cases or suspected cases of reportable
diseases, which are established by state regulations, are reported to the health department where they will
be logged. Attributes of the healthcare networks datastream are described below:
Contaminant coverage: The healthcare network datastream provides coverage of contaminants
producing delayed symptom onset.
Spatial coverage: Primary care physicians may report unusual cases to the appropriate health
jurisdiction, so spatial coverage depends on the overlap between the area served by the healthcare
network and the distribution system service area.
.^^ ^^^.
Timeliness: Data resulting from primary care
physician office visits is not timely, as ill patients
will need to schedule an appointment and see the
physician, which could delay the physician's
assessment of the patient by days. If the patient's
condition worsens while waiting for their
appointment, they make seek alternate healthcare
and enter another datastream, such as the ED
datastream.
Data quality: Healthcare network data typically
includes patient demographics, symptoms, date,
time, and location. Physicians provide an in-
person medical assessment of patients resulting in
high quality data from primary care physician
office visits.
ELECTRONIC MEDICAL RECORDS AND
ELECTRONIC HEALTH RECORDS
(EMR/EHR)
The Centers for Medicare and Medicaid
Services is facilitating the adoption of
EHRs through financial incentives to
healthcare providers in order to provide
improved data sharing between
healthcare providers, public health
stakeholders, and patients (CDC, 2012).
As of 2014, 82.8% of office-based
physicians use an EMR/EHR system
(HHS, 2016). EHR technology has the
potential to aid the development of PHS
systems through better access to
standardized healthcare data.
Value to an SRS: Moderate. While healthcare networks provide high quality data that has been assessed
by a medical professional, this datastream will likely not capture patients with rapid symptom onset as
they are more likely to seek healthcare urgently through other means (e.g., call a PCC or visit an ED).
Also, it may require a significant effort to establish processes to collect and aggregate data from multiple
healthcare networks.
Clinical Laboratory Results. Healthcare providers may order clinical laboratory testing of samples
collected from patients. The purpose of this testing is to provide definitive identification of the chemical,
toxin, or pathogen that caused illness in a patient. Clinical laboratory analysis is performed by in-house
hospital laboratories or by contracted laboratories that receive samples from hospitals and medical offices.
Attributes of clinical laboratory results are described below:
Contaminant coverage: Clinical laboratory tests are available for a wide range of contaminant
classes including chemicals, toxins, and pathogens; however, clinical test capability will vary by
laboratory. Also, there may be some contaminants for which a clinical laboratory test has not yet
been developed. Some contaminants may not be detected in clinical samples if they are collected
more than several days after exposure, as the contaminant may have been fully metabolized and
excreted from the patient's system at that time.
Spatial coverage: Hospitals and primary care physicians request clinical laboratory analyses and
report the results to the health department responsible for the jurisdiction in which they operate.
Thus, spatial coverage depends on the overlap between the area served by health departments
receiving clinical laboratory results and the distribution service area.
16
-------
Public Health Surveillance Design Guidance
Timeliness: The delay between the time of symptom onset and the availability of clinical
laboratory results, is often days to weeks, and is affected by the time required to collect and
process a clinical sample, and the reporting timeframe required by state regulations for reportable
diseases once they are confirmed by a laboratory analysis.
Data quality: Clinical laboratory results provide a definitive confirmation of the presence of a
contaminant in a clinical sample as long as the concentration of the contaminant exceeds the
detection limit of the test method. Analyses of clinical laboratory samples, ordered by healthcare
providers and performed by trained laboratory analysts, confer a high degree of data quality.
Value to an SRS: Moderate. Similar to the results from laboratory analysis of water samples, clinical
laboratory results can provide definitive identification of a contaminant. However, contaminant coverage
is limited by availability of clinical laboratory tests and the capabilities of clinical laboratories.
Furthermore, the significant delay in the availability of laboratory results limits the ability of this
datastream to provide information in sufficient time to respond to a transient water quality problem in a
manner that reduces consequences. Despite these limitations, clinical laboratory results may still prove
useful for detection of a sustained source of water contamination that is causing an ongoing public health
incident.
911 calls. 911 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 that is used by EMS, fire, and police first responders. 911 calls capture a broad range of
situations reported by the public, including injuries, fires, accidents, and illness. For an SRS, 911 calls are
filtered to capture only the subset of calls reporting illness that could be broadly linked to an
environmental exposure. Attributes of the 911 datastream are described below:
Contaminant coverage: 911 calls are most likely to capture contaminants producing rapid
symptom onset which may prompt urgent healthcare seeking behavior.
Spatial coverage: 911 dispatch centers often provide coverage within the jurisdiction of a county
or fire protection district. Therefore, public health partners and utilities may need to coordinate
with multiple dispatch centers to achieve 100% spatial coverage across a utility's distribution
system.
Timeliness: A 911 call may be the first record of an individual's healthcare seeking behavior
before entering other datastreams, such as EMS and ED, and can be the first indicator of a public
health incident.
Data quality: 911 dispatch centers follow a standardized protocol to triage calls according to
complaint type and severity. Case details that may be provided in the record include the patient's
age, sex, and location, the date and time of the call, and the incident code. 911 calls capture self-
reported illness without a medical assessment.
Value to an SRS: Low. Although 911 call data is timely, data quality is low. Furthermore, the need to
coordinate with multiple jurisdictions can make this an expensive datastream to implement and monitor.
These limitations aside, 911 call data can add value to PHS due to its potential to provide early detection
of exposure to contaminants that produce rapid symptom onset.
Over-the-Counter medication sales. Sales of medications commonly used to treat symptoms potentially
caused by exposure to contaminated water are grouped into categories such as gastrointestinal illness and
respiratory illness, and are aggregated across participating pharmacies. Attributes of the OTC medication
sales datastream are described below:
17
-------
Public Health Surveillance Design Guidance
Contaminant coverage: OTC medication sales data is most likely to capture contaminants
producing minor symptoms or those with delayed symptom onset because individuals purchase
OTC medication for self-care to alleviate symptoms which are not severe or life-threatening.
Spatial coverage: It is very difficult to achieve complete spatial coverage due to the number of
pharmacies in most communities. Additionally, the only location data available for this
datastream is the location of pharmacies, which may not represent the location of exposures.
Timeliness: While this datastream may provide an early indicator of a contaminant producing
delayed symptom onset, an increase in OTC medication sales may not be detected until days after
the initial exposure due to the delay in symptom onset that is common for many pathogenic
diseases.
Data quality: No case details associated with the individual purchasing an OTC medication are
captured during the sales transaction. Details associated with OTC medication sales that may be
available include the date, time, and location of the transaction and the type of medication that is
purchased (e.g., medication for gastrointestinal illness, respiratory illness, or fever). Additionally,
OTC medication sales may be biased by market trends or sales. There is no medical assessment
associated with this datastream.
Value to an SRS: Low. Developing and maintaining relationships and data sharing practices with
pharmacy retailers may prove difficult or expensive. Retailers may be reluctant to provide sensitive
business information and it may be difficult to coordinate data sharing with all retailers in a region.
However, for a public health incident involving a contaminant producing delayed symptom onset, OTC
medication sales data could precede a rise in healthcare network visits or ED visits.
UTILIZATION OF PUBLIC HEALTH DATASTREAMS FOR PHS
The information provided in this callout box characterizes the likelihood that public health partners are already
using, or would consider using, a particular public health datastream. References are provided that describe the
implementation of the datastream to monitor a community's health status.
PCC calls: All health departments coordinate with the PCC serving their region, although the degree to which
PCC calls are utilized as a datastream varies (CDC, 2005).
ED visits: All health departments routinely monitor ED data (Hirshon, 2000).
EMS runs: EMS runs are not widely utilized because it is often necessary to coordinate with multiple EMS
jurisdictions to achieve complete spatial coverage, which may increase the cost of implementation (Yih et al.,
2010).
Health advice hotlines: Use of health advice hotline calls for PHS varies widely and depends on their
availability. Most health advice hotlines are affiliated with a healthcare network or insurance carrier. New Mexico
is the only state thus far which operates a statewide hotline, funded through a public-private partnership. This
hotline is a model that other states could adopt to assist residents during pandemics and emergencies
(Preparedness Summit, 2015).
Healthcare networks: All states have laws, statutes, or other regulations that mandate reporting of
communicable or infectious diseases and have the authority to collect and monitor a central repository of disease
case information where patterns, clusters, and outbreaks may be detected. Although the list of reportable
diseases varies from state to state, everyone uses the same criteria to define what constitutes a case of a given
disease.
Clinical laboratory results: All states have infectious disease-reporting regulations that require laboratories to
report clinical test results to the health department.
911 calls: 911 calls are not widely utilized because they lack medical assessment and can be costly to monitor in
an automated manner (Greenko et al., 2003; Haas et al., 2011).
OTC medication sales: OTC medication sales data are not widely utilized because they lack medical
assessment, and it is often impractical to achieve complete spatial coverage (Pivette et al., 2014).
18
-------
Public Health Surveillance Design Guidance
Figure 4-1 presents a generalization of the strengths and weaknesses of each datastream described above
with respect to the timeliness, data quality, and contaminant coverage attributes. Spatial coverage is not
included as it will vary based on the jurisdiction(s) in which the datastream is monitored. The diagram
provides a visual comparison of the overall value of each datastream to an SRS. For example, the ED
visits datastream provides excellent data quality, captures contaminants which produce both rapid and
delayed symptom onset, is moderately timely, and thus has high potential value to an SRS. Because each
datastream has strengths and weaknesses, a robust PHS component should involve monitoring of multiple
datastreams to detect public health incidents.
CONTAMINANT COVERAGE
Rapid Symptom Onset Delayed Symptom Onset Rapid and Delayed Symptom Onset
Higher
Data Quality/
Less Timely
Higher
Data Quality/
More Timely
Lower
Data Quality/
Less Timely
Lower
Data Quality/
More Timely
jr
Over-
the-Counler
Medication
Sales
Figure 4-1. Public Health Datastream Attribute Summary
4.2 Public Health Surveillance Techniques
As discussed in the previous section, datastreams are the data produced when symptomatic individuals
seek healthcare. Surveillance techniques are methods, tools, and assessments used to analyze these
datastreams in order to detect possible public health incidents. A surveillance technique defines the
manner in which a datastream is collected, analyzed, and presented to investigators. Utilities should work
with their public health partners to determine which public health surveillance techniques are currently in
use and characterize these existing surveillance techniques with respect to the design goals and
performance objectives of the SRS. Leveraging existing public health surveillance techniques can be an
effective, low-cost method of developing PHS as a component of an SRS.
19
-------
Public Health Surveillance Design Guidance
As depicted in Figure 4-2, surveillance techniques can be grouped into two broad categories: case-based
and syndromic. Both case-based and syndromic surveillance can be applied to any datastream. For
example, an ED physician may call the health department to report an unusual case (case-based) while the
health department analyzes electronic ED records for a rise in gastrointestinal illness (syndromic).
However, some techniques are more useful for some datastreams. For example, 911 call and EMS run
datastreams are more amenable to analysis using syndromic surveillance.
Public Health Surveillance Techniques
Case-based
Surveillance
Individual assessment
conducted in-person by
healthcare professionals,
via calls received by PCCs
and health advice
hotlines, orth rough
receipt of individual
\ laboratory sample results J
Syndromic Surveillance
Monitoring of datastreams that
include data available earlierthan
clinical diagnosis or laboratory
confirmation
Manual
Surveillance
Automated
Surveillance
Automated analysis of
datastreams
conducted using
statistical algorithms or
software tools
Manual analysis of
datastreams
conducted by health
department, healthcare
. professionals, or PCCs i
Figure 4-2. Overview of Public Health Surveillance Techniques
Case-based Surveillance
Case-based surveillance involves the identification and reporting of unusual cases or clusters of cases to
the health department for investigation. Case-based surveillance relies on the professional judgment of
trained healthcare professionals, including physicians, nurses, pharmacists, and EMS technicians who
interact directly with patients and conduct medical assessments to consider whether cases of illness in the
population represent a threat to public health. For example, an astute clinician may observe the
presentation of unusual symptoms during in-person assessments or a rise in the number of patients with
common infections. Because the reporting party is often interacting directly with the symptomatic
individual, additional case details can be provided to the health department. This type of reporting can be
expedited if the reporting party is particularly concerned about the possibility of a public health incident,
and may occur before a diagnosis is confirmed via laboratory results. Case-based surveillance also
includes mandatory reporting of reportable diseases.
Health departments and their epidemiologists monitor information provided by healthcare professionals
who conduct case-based surveillance as described below:
EMS technicians can report any unusual observations during response, such as similarities in
symptoms of multiple individuals receiving treatment by EMS.
20
-------
Public Health Surveillance Design Guidance
Healthcare professionals in healthcare networks, urgent care facilities, or EDs, can report
individual cases or an increased case volume presenting with similar, and possibly unusual
number and types of symptoms not attributable to a known ongoing public health incident.
Clinicians or microbiologists who analyze clinical samples can report a sudden increase in orders
for specific laboratory tests for reportable diseases or conditions in advanced of confirmed results.
Healthcare professionals who answer health advice hotline calls can report a sudden increase in
the number of calls with inquiries involving similar and possibly unusual symptoms.
Pharmacists can report a sudden rise in prescription or OTC medication sales or queries related to
unusual symptoms reported by customers.
PCCs can report an increase in calls or a unique case in which the exposure is closely linked to
water.
CASE-BASED SURVEILLANCE: REPORTABLE DISEASES AND NOTIFIABLE DISEASES
Reportable Diseases
Each state has its own laws and regulations defining which diseases are reportable. The list of reportable diseases,
including infectious and noninfectious conditions, varies among states and overtime. It is mandatory that reportable
disease cases be reported to state and territorial jurisdictions when identified by a health provider, hospital, or
laboratory. Additionally, the requirements for timeliness of reporting depend on the condition. Diseases which are
rare or severe (Ebola virus, botulism) may require immediate notification, while more common diseases, such as
influenza, may be reported weekly. While an individual healthcare provider may not recognize the significance of a
small increase in cases of a specific disease, a local or state health department epidemiologist may identify a public
health incident by surveying all reports across a jurisdiction or region. Some states have disease surveillance
systems that can be used to analyze data on a regional basis.
Notifiable Diseases
CDC maintains a list of nationally notifiable diseases which is reviewed and modified annually by the Council of
State and Territorial Epidemiologists and CDC. CDC receives case notifications of notifiable diseases from 57
reporting jurisdictions (including state health departments and territories) which are voluntarily reported into the
National Notifiable Infectious Diseases Surveillance (NNDSS) system. This allows for nationwide aggregation and
monitoring of disease data. Every nationally notifiable disease is not necessarily reportable in each state (CDC,
2015).
Examples of notifiable diseases and conditions of relevance to water utilities include:
Biological: Cryptosporidiosis, Shigellosis
k» Chemical: Pesticide-related illness and injury
Toxins: Botulinum
Waterborne disease outbreak
If optimized for the goals of PHS, case-based surveillance can be a sensitive and timely method of
detecting public health incidents, including water contamination. It is importance to note that it is the
responsibility of the health department, not the utility, to establish relationships, procedures, and training
with healthcare professionals who conduct case-based surveillance. A utility would only interface with
the health department if their review of surveillance data suggested that the cases might have resulted
from exposure to contaminated water. Case-based surveillance has proven to be effective for detecting
drinking water contamination incidents, as illustrated by the examples in Table 4-1.
21
-------
Public Health Surveillance Design Guidance
Table 4-1. Water Contamination Incidents Identified Through Case-based Surveillance
Location
Contaminant(s)
Role of Case-based Surveillance in Detection of Outbreak
Alamosa, CO
Salmonella
Three cases were reported by healthcare providers from the Alamosa County
Nursing Service to the regional epidemiologist, and this information was
subsequently reported to Colorado Department of Public Health and
Environment. Epidemiologists working on the outbreak later contacted the
safe drinking water program team to discuss the outbreak and the possibility
that the outbreak was related to Alamosa's public drinking water supply (Berg,
2009).
South Bass
Island, OH
Multiple biological
contaminants and
bacterial indicators
The Ottawa County Health Department in Ohio received several telephone
calls from persons reporting gastrointestinal illness after visiting South Bass
Island. A food-borne disease outbreak investigation was initiated by the
Ottawa County Health Department and the Ohio Department of Health.
Subsequently, Ohio EPA was informed about a possible waterborne outbreak
and began an investigation of the drinking and wastewater systems (Fong,
2007).
Gideon, MO
Salmonella
Typhimurium
Seven culture-confirmed cases of Salmonella Typhimurium gastroenteritis
among Anderson Township residents were reported to the Missouri
Department of Health. Food histories revealed no common food exposures,
but all patients had consumed water in Gideon. The drinking water was tested
and found to contain fecal coliform bacteria (Angulo, 1997).
Netherlands
Multiple biological
contaminants and
bacterial indicators
Upon receiving several taste and odor complaints, the water company
initiated an investigation which discovered a cross-connection with a grey
water system incurred during maintenance work on the distribution system. A
boil water advisory was issued, which prompted a healthcare provider to notify
the public health service of an excessive number of patients with
gastrointestinal illness in recent days (Fernandes, 2007).
Bergen,
Norway
Giardia lamblia
The municipal medical officer was notified by a university hospital of an
increase in laboratory confirmed giardiasis cases, which correlated with a rise
in gastrointestinal illness visits to healthcare providers. An outbreak
investigation team of representatives from public health, food safety, and
water and sewage treatment was formed to investigate the cases (Nygard,
2006).
Syndromic Surveillance
Syndromic surveillance is the monitoring of pre-diagnosis public health data, such as chief complaints or
other proxy for illness, using categories of similar health issues (for example, gastrointestinal illness or
respiratory illness). Syndromic surveillance can be used to group related illness categories or identifiers
into one overall category that is monitored on a continual basis for anomalies. For example, a variety of
related 911 incident codes might be grouped into a general category (e.g., gastrointestinal) and can be
monitored for an incident which might involve exposures to a chemical contaminant producing rapid
symptom onset (EPA, 2014).
Syndromes can be defined according to the objective of the surveillance system, and common syndrome
definitions have emerged in practice. Table 4-2 lists syndromes that are applicable to detecting water
contamination.
22
-------
Public Health Surveillance Design Guidance
Table 4-2. Syndromes Related to Water Contamination1
Syndrome
Gastrointestinal
Respiratory
Cardiac
Dermal
Neurological
Description
Includes stomach pain, nausea, vomiting, or diarrhea resulting from exposure to
contaminants that cause acute infection or irritation of the upper or lower gastrointestinal
tract.
Includes cough, shortness of breath, difficulty breathing, or throat pain resulting from
exposure to contaminants that cause acute infection or irritation of the upper or lower
respiratory tract.
Includes slow or rapid heart rate, low or high blood pressure, tightness of chest, headache,
or sweating resulting from exposure to contaminants that cause cardiac distress or arrest.
Includes burning, itching, swelling, or rash resulting from exposure to contaminants that
cause an acute skin infection or skin irritation.
Includes confusion, dizziness, blurred vision, slurred speech, muscle weakness, or stroke
resulting from exposure to contaminants that cause acute neurological symptoms.
1 This list is not inclusive of all syndromes that may be relevant.
Typically, syndromic surveillance is conducted by epidemiologists at the local, regional, state, and
national levels to monitor trends in public health or detect a public health incident. While case-based
surveillance can trigger an investigation based on a single, unusual case, syndromic surveillance focuses
on detecting anomalous patterns of cases across a defined geographic area. Syndromic surveillance has
the advantage of being utilized continuously and across an entire region, identifying broader patterns in
the health of a community, and providing ongoing situational awareness for a known incident.
While effective integration of syndromic surveillance into PHS will likely require a greater level of effort
and financial investment by the utility's public health partners, this enhancement can significantly
improve their ability to identify early signals of public health incidents, including possible water
contamination. Health departments may already be conducting some form of syndromic surveillance on at
least one datastream. Syndromic surveillance can be conducted manually, but is increasingly performed
with automated anomaly detection systems. Data is queried by the epidemiologist or automated system,
analyzed by advanced statistical algorithms, and an alert is generated if an anomaly is detected. Table 4-3
lists some of the most common automated systems utilized by health partners for syndromic surveillance
(Uscher-Pines et al., 2009).
23
-------
Public Health Surveillance Design Guidance
Table 4-3. Common Syndromic Surveillance Systems
Tool/Application
Datastream
Description
BioSense
911 calls
ED visits
EMS runs
BioSense is a web application used to track health data at regional
and national levels and to provide public health partners with the
information necessary to monitor, identify, respond, and prevent
epidemics and public health incidents. While BioSense was
originally developed to identify bioterrorism-related illness, it has
been undergoing redesign since 2010 to provide regional and
nationwide situational awareness for all-hazard health-related
threats and to support national, state, and local responses to those
threats (CDC, 2016b).
Epicenter
ED visits
PCC calls
Reportable disease
data
Epicenter is a commercial application used by health departments
and individual healthcare facilities to conduct syndromic
surveillance of ED visits. Surveillance of PCC calls through
Epicenter is available in select areas and reportable disease data
is available for regions where this data type is collected (Health
Monitoring Systems, 2016).
ESSENCE
ED visits
The Electronic Surveillance System for the Early Notification of
Community-based Epidemics (ESSENCE) monitors health data as
it becomes available to identify epidemics, outbreaks, and other
potential public health incidents at the outset. ESSENCE is an
open source surveillance tool that is primarily used to monitor ED
visits, although it could be applied to other public health
datastreams (Johns Hopkins Applied Physics Laboratory, 2016).
EPA developed a water security module to aid detection of
drinking water contamination (EPA, 2012).
NPDS
PCC calls
The National Poison Data System (NPDS) is the repository for
PCC case data that is uniformly collected by all regional PCCs in
the U.S. NPDS is used to monitor poison exposure outbreaks in
real-time across the country. It enables case definitions to be
defined and monitored using manual or statistical search
algorithms to analyze calls. Alerts are sent to appropriate PCCs for
further investigation (American Association of Poison Control
Centers, 2016).
NRDM
OTC medication sales
The National Retail Data Monitor (NRDM) is a public health
surveillance tool that collects and analyzes daily sales data for
OTC medications. NRDM collects data in near real time from more
than 15,000 retail stores and makes them available to public
health officials (University of Pittsburgh, 2016a).
PulseNet
Clinical laboratory data
PulseNet is a network of 83 local, state, and federal public health
laboratories that can analyze DNA fingerprints of bacteria from
patients. Centers for Disease Control and Prevention (CDC)'s
PulseNet team compares fingerprint data submitted from
laboratories across the country to find clusters of disease that
might represent unrecognized outbreaks. Since its inception in
1996, this system has identified numerous foodborne outbreaks,
and has also identified outbreaks cause by bacteria from animals
and recreational water (CDC, 2016c).
RODS
ED visits
OTC medication sales
Real-time Outbreak and Disease Surveillance (RODS) is an open
source surveillance resource that enables users to perform
surveillance of ED visit records from participating hospitals. It also
serves as the user interface for national OTC medication sales
surveillance data collected through NRDM (University of
Pittsburgh, 2016b).
24
-------
Public Health Surveillance Design Guidance
4.3 Utility Role in Integrating Public Health Surveillance Capabilities
into an SRS
While public health partners own and operate public health surveillance systems, a utility has an
important role in the integration of these capabilities into PHS to provide timely detection of possible
drinking water contamination. This section provides guidance on the following steps that utilities can take
to integrate public health surveillance capabilities into an SRS:
Identify and characterize existing public health surveillance capabilities
Assess existing capabilities relative to SRS design goals and performance objectives
Develop a strategy to address gaps in public health surveillance capabilities relative to SRS
design goals and performance objectives
Identify and Characterize Existing Public Health Surveillance Capabilities
Utilities should meet with public health partners to encourage interest in supporting the design goals of
PHS and to identify public health datastreams and techniques currently used by public health partners.
The datastreams should be assessed with respect to the
attributes discussed in Section 4.1 using the resource Public
Health Surveillance Assessment: Interview with Public
Health Partners. This resource, which can be accessed by
clicking the icon in the callout box, is a fillable PDF form
that can be completed electronically or by hand. The
assessment form also includes prompt questions to record information about procedures that may be in
place for responding to alerts generated by public health surveillance systems. It is recommended that a
separate assessment be conducted with the health department and the PCC.
This fillable form can be used
to capture the attributes of
existing public health
datastreams and techniques.
25
-------
Public Health Surveillance Design Guidance
Syndromic Surveillance Assessment Questions
1. 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
2. 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
DYes
D No
EMS Runs
D Yes
DNo
911 Calls
D Yes
DNO
OTC Medication Sales
D Yes
D No
Other:
D Yes
DNo
3. Timeliness: For each datastream monitored by the health department, what is the typical delay between
health seeking behavior and alert generation?
ED Data
EH Real-time
D Hours
D Days
D Weeks
EMS Runs
D Real-time
D Hours
D Days
D Weeks
911 Calls
EH Real-time
D Hours
D Days
D Weeks
OTC Medication Sales
Cl Real-time
D Hours
D Days
D Weeks
Other:
CD Real-time
D Hours
D Days
D Weeks
Figure 4-3. Excerpt from the Public Health Surveillance Assessment (Health Department
Syndromic Surveillance Datastreams)
26
-------
Public Health Surveillance Design Guidance
Assess Existing Capabilities Relative to SRS Design Goals and Performance Objectives
After the existing public health surveillance capabilities have been characterized, the utility should assess
how well these public health surveillance capabilities support the primary design goal of PHS in the
context of an SRS: to provide timely detection of possible drinking water contamination incidents. The
degree to which this design goal is realized depends largely on the performance objectives established for
the SRS, specifically: contaminant coverage, spatial coverage, timeliness, and data quality.
Assessment criteria for existing public health surveillance systems can be described in terms of the
attributes of public health datastreams, as presented in Section 4.1. For example:
Contaminant coverage: ability of a public health surveillance system 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 the
public health surveillance system.
Timeliness: the time between health seeking behavior and the time that a PHS alert is generated.
Data quality: the completeness of underlying case details (e.g., demographics, symptoms, date,
time, and location where exposure occurred) for PHS alerts.
A utility should meet with their public health partners to complete the Public Health Surveillance
Assessment, which will provide the information necessary to populate this worksheet and conduct the
assessment. Once the attributes of existing public health surveillance systems have been assessed, the
utility and their public health partners can identify gaps between existing and target capabilities for PHS.
In conducting this gap analysis, it is important to consider how the combination of all public health
surveillance systems meets the assessment criteria. For example, while an individual surveillance system
may have a gap such as 50% spatial coverage, that deficiency may be compensated by another
surveillance system which covers 100% of the utility's service area. If the existing public health
surveillance systems meet the targets established by the assessment criteria, then integrating public health
surveillance capabilities into the SRS may be as simple as establishing an agreement with public health
partners to share information about PHS alerts that might be related to drinking water contamination.
However, in many cases, gaps will be identified. An example of a completed assessment is provided in
Table 4-4.
Table 4-4. Example Assessment of Existing Public Health Surveillance Systems
Assessment
Criteria
ED Visits
PCC Calls
Healthcare
Networks
Gap Analysis
Contaminant
Coverage
(Rapid/Delayed
Symptom Onset)
Rapid and
delayed symptom
onset
Rapid symptom
onset
Delayed symptom
onset
No gap
Spatial Coverage
(Percent of
Service Area)
70%
100%
80%
No gap
Timeliness
(Delay from
Healthcare Seeking
Behavior to Alert
Generation)
Alert notifications are
provided daily to health
department
Alert notifications are
not provided daily to
health department
No standard procedure
for reporting suspected
water contamination
Data from PCCs and
healthcare networks are
not reported same day
Data Quality
(Sufficient Case
Details)
No case details
provided in alert
notifications
Alert details and
underlying case details
captured in NPDS
Underlying case
details captured
No ED case details in
alert notifications
27
-------
Public Health Surveillance Design Guidance
Strategy for Addressing Gaps in Public Health Surveillance Capabilities Relative to SRS Design
Goals and Performance Objectives
Once the utility has characterized and assessed existing public health surveillance capabilities, a strategy
should be developed with its public health partners to determine how gaps identified during the
assessment can be addressed. The utility and public health partners should collaborate to identify and
evaluate alternatives for addressing the gaps from a benefit-cost perspective. The resource Framework for
Comparing Alternatives for Water Quality Surveillance and Response Systems can be used to compare
viable and well-defined SRS design alternatives. For PHS, this resource could be used to compare the
relative value and cost of viable enhancements, which might include modifications to existing public
health surveillance systems or implementation of new systems. While the utility should be involved in
developing this strategy, deference should be given to public health partners who will likely bear the
majority of the cost and effort to implement and operate public health surveillance systems.
Potential methods for enhancing existing case-based surveillance techniques are described below:
Optimize mechanisms for reporting unusual incidents of disease within the utility's distribution
system service area. The health department may be able to optimize existing procedures for
disease reporting from healthcare providers to improve the timeliness of reporting. For example, a
procedure may be developed for direct reporting to the health department if a healthcare network
or healthcare provider suspects that the cases they are seeing might be related to an emerging
public health incident prior to laboratory confirmation. Similarly, a mechanism could be
implemented for clinicians and microbiologists to report a significant increase in the volume of
orders for analyses of clinical samples for a specific disease in advance of laboratory
confirmation. To accomplish this enhancement, the health department could coordinate an
outreach campaign to educate healthcare providers about proactively reporting cases that may
indicate an emerging possible public health incident.
Train healthcare providers on indicators of drinking water contamination. Public health partners
can use the resource Training for Healthcare Professionals on Indicators of Drinking Water
Contamination to increase knowledge among local healthcare professionals about indicators of
water contamination. This training could be presented through established public health
workgroups or forums. Most importantly, healthcare professionals should understand who to call
and what to report if water contamination is suspected.
Potential methods for enhancing existing syndromic surveillance techniques are described below:
Add new syndromes to existing syndromic surveillance
systems. If the syndromes utilized by existing
syndromic surveillance systems do not capture the
broad range of possible symptoms related to water
contamination, then new syndromes (Table 4-2) could
be incorporated into existing systems.
Extract additional case details from a public health
datastream already being monitored through
syndromic surveillance. The utility, health department,
and PCC should consider whether the underlying case
details available in syndromic surveillance systems
would be adequate to support the investigation of water
contamination as a potential cause of a PHS alert. If the desired details are not available, the data
collection process could be modified, or the public health surveillance system could be updated to
extract the missing information.
28
DEVELOPMENT OF A
WATER SYNDROME
One public health partner supporting
PHS developed a water syndrome,
which was integrated into an existing
syndromic surveillance system. The
syndrome included a combination of
gastrointestinal and respiratory chief
complaints to capture a variety of
symptoms that may be related to
exposure to contaminated water.
-------
Public Health Surveillance Design Guidance
Build stronger relationships with data providers. To address issues with data reliability and
completeness, the health department can work to increase the participation of data providers. If
there is a gap in the timeliness of a syndromic surveillance system, business processes can be
changed in order to expedite data uploads.
Increase the frequency of analysis by automated surveillance systems. If data batches are received
more frequently than once per day, the health department may consider increasing the analysis
frequency of existing syndromic surveillance systems to increase the timeliness of detection.
Increase the number of data providers. To increase spatial coverage, additional data providers
that serve customers within the utility's service area could be identified and integrated into an
existing syndromic surveillance system (e.g., 911 dispatch, EMS providers, EDs, pharmacy
retailers).
When evaluating new systems to support PHS, it may be helpful to consider whether any systems
currently in the process of being procured by the public health partners for other initiatives may serve the
goals of PHS. Furthermore, public health partners should evaluate whether PHS capabilities could be
incorporated during regular upgrades of existing systems to avoid cost associated with procuring a new
system. A utility's public health partners will need to consider a variety of factors when evaluating
whether to implement a new public health surveillance system. While CDC has developed extensive
guidelines for evaluating public health surveillance systems (CDC, 2001), general considerations are
presented below:
Cost and level of effort required to implement and maintain the system
Specialized skills or knowledge required to implement and maintain the system
Prospect for reliable technical support over the life of the system
Ability of frontline users to understand and utilize the system
Information management requirements for the system
Additional hardware and software required to implement the system
Compatibility of the new system with existing systems
Ability to incorporate new functionality to meet future requirements
Commonly used syndromic surveillance systems are described above in Table 4-3 and should be
considered when evaluating new systems. If the health department decides to procure a new system for
PHS, they may consider including detection of possible drinking water contamination as a justification for
purchasing the new system in grant applications. Likewise, PCCs could incorporate goals related to
detection of water contamination through staff training, development of new procedures, or development
of water algorithms in NPDS in grant applications or funding request justifications.
INTEGRATING PHS DATA INTO AN SRS INFORMATION MANAGEMENT SYSTEM
Some utilities may elect to integrate one or more public health datastreams into their SRS information management
system. Given constraints imposed by the Health Insurance Portability and Accountability Act, PHS alerts may be
the only information that can be provided to the utility. While it can be useful for utility personnel to evaluate
geospatial relationships between PHS alerts and utility data, utilities should consider potential limitations in the
ability of their personnel to use and interpret public health data before deciding to implement this enhancement.
However, if a utility decides to integrate some PHS data into their information management systems, they should
clearly define requirements fordoing so. Two potentially useful resources are:
Information Management Requirements Development Tool
Dashboard Design Guidance for Water Quality Surveillance and Response Systems
29
-------
Public Health Surveillance Design Guidance
The example presented in Table 4-4 demonstrated gaps in an example public health surveillance
capabilities assessment. Table 4-5 below presents an example strategy for addressing those gaps.
Table 4-5. Example Strategy for Addressing Gaps in Public Health Surveillance Capabilities
Assessment Criteria
Contaminant Coverage
Spatial Coverage
Timeliness
Data Quality
Gap Analysis
No gap
No gap
Data from PCCs and
healthcare networks is
not reported same day
No ED case details in
alert notifications
Planned Enhancement
Not applicable
Not applicable
Health department will work with PCC to implement a
procedure for reporting suspected water contamination
within a day of symptom presentation
Health department will provide training to healthcare
professionals on indicators of possible water
contamination
Health department will evaluate which underlying case
details could be captured and included in ED alert
notifications
30
-------
Public Health Surveillance Design Guidance
Section 5: Alert Investigation Procedure
Once the public health partners who will support PHS have been identified and the specific public health
datastreams have been selected for inclusion in the SRS (as described in Sections 3 and 4), a PHS alert
investigation procedure should be developed. The objective of this procedure is to guide the systematic
investigation of a PHS alert in order to determine whether or not it may have been caused by
contaminated water.
TARGET CAPABILITY
A procedure has been developed, documented, and put into practice to facilitate the timely and efficient
investigation of a PHS alert to determine whether or not contaminated water is the likely cause of the alert. The
procedure provides a clear and comprehensive sequence of steps for the investigation of alerts and assigns
responsibilities for carrying out each of these steps. The procedure is supported by investigation tools, such as
checklists. Personnel are trained on proper implementation of the procedure and tools.
This section describes considerations for developing a PHS alert investigation procedure and covers the
following topics:
Subsection 5.1 provides guidance on developing an effective alert investigation procedure
Subsection 5.2 provides guidance on developing tools to support the investigation
Subsection 5.3 provides guidance on preparing to implement the procedure as part of real-time
monitoring
5.1 Developing an Effective Alert Investigation Procedure
This section describes a methodical process for developing a PHS alert investigation procedure. The steps
of the process, listed below, are described in the following subsections.
Define Potential Alert Causes: develop a discrete list of alert causes used to classify each alert
Establish an Alert Investigation Process: develop a detailed, sequential listing of steps for
investigating alerts
Assign Roles and Responsibilities: establish a listing of all personnel who have a role in alert
investigations and a summary of their responsibilities
This template can be
used to develop a PHS
I alert investigation
procedure.
The PHS Alert Investigation Procedure Template includes an
editable table, process flow diagram, and checklist that can be used
to document the utility's role during a PHS alert investigation. The
template can be opened in Word by clicking the icon in the callout
box.
Define Potential Alert Causes
The objective of the alert investigation process is to identify the cause of an alert. At the highest level,
alerts should be categorized as invalid or valid. While the utility will need to manage and categorize
invalid alerts for the other SRS surveillance components, PHS alerts are initially reviewed by public
health partners and invalid alerts should not be passed on to the utility SRS Manager. Thus, from the
utility's perspective, only valid PHS alerts need to be investigated.
Valid alerts for PHS are defined as alerts attributable to a public health incident that might be due to
contaminated water. Once a utility is notified of a valid PHS alert, they should work with their public
health partner to identify the potential cause of the alert. Table 5-1 lists and describes three potential
31
-------
Public Health Surveillance Design Guidance
causes of valid PHS alerts, including the possibility that the PHS alert, while valid, was not caused by
contaminated water.
Table 5-1. Example Causes of PHS Valid Alerts
Alert Cause
Unrelated to Drinking
Water Quality
Premise Plumbing Issue
Possible Contamination
Description
Even though a public health partner cannot initially rule out drinking water contamination,
the joint investigation by a utility and its public health partners may subsequently rule out
drinking water contamination as the cause of the public health incident.
Improper installation or repair of premise plumbing systems, such as an accidental
cross-connection with a non-potable source, can result in contamination of the water
supply for a building of complex. However, the contaminated water would be contained
within the premise plumbing system and would not be a distribution system problem.
Accidental or intentional introduction of a contaminant into the distribution system that is
causing illness in exposed customers.
Establish an Alert Investigation Process
With potential causes of a valid PHS alert defined, the next step is to develop an alert investigation
process to guide investigators through a detailed sequence of steps in order to determine the cause of the
alert. In general, the process begins with notification from a public
health partner of a valid PHS alert and ends with a determination
regarding whether or not water contamination is possible. The steps in
between involve a review of available information to investigate
potential causes of the alert. The alert investigation process is generally
structured to consider the most likely causes first, allowing
contamination to be quickly ruled out for the majority of alerts.
However, if the cause of the alert cannot be determined through this
review, the process concludes with the determination that
contamination is possible.
HELPFUL HINT
An alert investigation
procedure can be used to
identify the information
resources accessed during
an investigation, which can
be useful for developing
information management
requirements.
The type of information typically documented in an alert investigation process includes:
Detailed instructions for completing the step
The name and role of specific individual(s) responsible for completing the step
Information resources that should be consulted during the step
Actions that should be taken, including personnel who should be notified, upon completion of the
step
When establishing the alert investigation process, the utility should work with its public health partners to
understand the PHS alert information that will be provided to the utility SRS Manager (e.g., symptoms,
demographics, and location of cases), which may vary with different public health surveillance systems.
Some of this information may have been documented during the evaluation of existing public health
surveillance systems, as described in Section 4.3. During the development of the process, the utility
should also inform its public health partners about the information the utility would review during a PHS
alert investigation, such as data from other SRS components and results from Sampling and Analysis.
The alert investigation process can be visually depicted in a diagram that shows the progression of steps
through the entire process. This simplified representation of the alert investigation process allows
individuals with responsibilities for discrete steps to see how their activities support the overall
investigation.
32
-------
Public Health Surveillance Design Guidance
Figure 5-1 provides an example of a PHS alert investigation process flow diagram. The major steps and
decision points are shown in the flowchart on the left side of the figure, and additional detail on the
actions implemented is shown to the right. Steps taken by the public health partner are shown in green
and steps taken by the utility are shown in blue. In general, public health partners are responsible for
determining if a PHS alert is valid and indicative of a possible public health incident. As public health
partners continue the investigation, they consider whether or
not contaminated water might be the cause of the public
health incident. If drinking water contamination cannot be
ruled out, the public health partner notifies the utility and a
joint investigation follows. The utility's role in the
investigation is to conduct a targeted review of relevant utility
data to determine if there are indicators that contaminated
water may be the cause of the alert. The utility investigation
should be guided by information provided by the public
health partner, such as the location and time of suspected
exposures to the contaminant.
HELPFUL HINT
During the investigation, public health
professionals may be able to use
water utility data or public health case
details to tentatively identify a
contaminant or contaminant class,
which can inform other investigation
activities, such as selecting target
analytes for analysis of water
samples.
If the utility and public health partners jointly conclude that water contamination is not the cause of the
PHS alert, the investigation is closed. However, if contamination cannot be ruled out as the cause of the
PHS alert, Consequence Management activities would be initiated and the investigation continued to
determine if contamination is credible.
A range of estimated times for properly trained personnel to complete steps in the investigation is shown
to the left of the flowchart in Figure 5-1. These times are based on experience at utilities that have
implemented PHS (EPA, 2014). The total time for utility personnel to complete a PHS alert investigation
could range from 11 to 105 minutes, depending on the number of steps in the investigation process that
need to be completed before a conclusion can be reached regarding whether or not contamination is
possible.
33
-------
Public Health Surveillance Design Guidance
ALERT INVESTIGATION PROCESS
ACTIONS IMPLEMENTED
Public health partners
conclude that water contamination
cannot be ruled out as a possible
*"- cause of a valid PHS alert
Public health partner notifies
the utility of a PHS alert
for which water contamination
cannot be ruled out
Utility conducts targeted
review of relevant data sources
and reports findings to their
public health partner
i
o f
NT! "
Can water contamination
be ruled out?
YES
NO
Contamination is possible;
utility and public health
partner(s) conduct
collaborative investigation
Water
contamination is
unlikely and the
utility's role in
the investigation
is complete
Public health partner reviews the
following data to determine if the
alert is valid:
Similarity of reported symptoms
Similarity of case demographics
Location of cases
(i.e., case clustering or wide-
spread distribution of cases)
If the alert is valid and indicative of
a public health incident, the public
health partner investigates
possible causes of the incident.
Alert details provided to
SRS Manager:
Type of alert
Location of cases
Estimated time of exposure
Hypothesis regarding the
identity of the contaminant
(i.e., biological, chemical,
unknown)
Utility reviews the following data
sources to identify potential
spatial and temporal relationships
between potential water quality
issues and public health data:
Water quality data
Customer complaints related
to water quality
Distribution system operations
and monitoring data
Work activities and main breaks
in the distribution system
Treatment plant operations
and monitoring data
Security breaches at distribution
system facilities
Utility may conduct targeted
sampling and analysis using
information from the previous
steps of the investigation
Figure 5-1. Example Alert Investigation Process Flow Diagram for Valid PHS Alerts
34
-------
Public Health Surveillance Design Guidance
Assign Roles and Responsibilities
Table 5-2 lists public health partners and utility personnel who may have a role during the investigation
of a PHS alert and describes their potential responsibilities. Utility personnel would only be engaged in
the investigation if public health partners could not rule out contaminated water as a potential cause of a
valid alert.
Table 5-2. Example of Generic Roles and Responsibilities for PHS Alert Investigations
Role
Primary Public
Health Partner1
Public Health Data
Provider2
Utility SRS
Manager3
Utility Water Quality
Manager
Utility Customer
Service Manager
Utility Security
Manager
Utility Distribution
System Manager
Utility Operator
Alert Investigation Responsibilities
Receives initial notification of PHS alerts
Performs an initial investigation to determine if a PHS alert is valid
Evaluates contaminated drinking water as a potential cause of a PHS alert and contacts
the drinking water utility if water contamination cannot be ruled out
Collaborates with the utility during the investigation of possible water contamination
incidents
Provides detailed case information to primary public health partners during the
investigation of a PHS alert
Investigates additional information from the public health datastream managed by the data
provider, which may not have been captured in the PHS alert
Receives notification from primary public health partners in the event of a valid PHS alert
potentially related to contaminated drinking water
Coordinates utility-lead aspects of a PHS alert investigation
Communicates the results of a utility investigation to primary public health partners
Collaborates with primary public health partners to determine whether or not drinking
water contamination is possible
Activates Consequence Management
Continues the investigation of the possible water contamination incident in collaboration
with primary public health partners
Reviews data from online water quality sensors and the results from analysis of grab
samples collected in the vicinity of cases associated with a PHS alert
Reviews customer water quality complaints in the vicinity of cases associated with a
PHS alert
Reviews security records for incidents of unauthorized access to utility facilities that serve
the area in which cases associated with a PHS alert are located
Reviews distribution system work activities and equipment failures that could have
impacted water quality in the vicinity of cases associated with a PHS alert
Reviews system operating conditions that could have impacted water quality in the vicinity
of cases associated with a PHS alert
1 Includes partners with primary responsibility for monitoring public health, such as health departments (including epidemiologists,
environmental health specialists, and laboratorians) and PCCs
2 Includes entities that manage public health datastreams monitored through PHS, such as 911 call centers, EMS dispatch centers,
hospitals, healthcare professionals, and pharmacies
3 Some utilities may choose to delegate alert investigation responsibilities listed in the table for the SRS Manager to other personnel
with sufficient authority and training to perform the tasks
Arrangements should also be made to provide coverage of alert investigation responsibilities at all times,
through approaches such as:
Training personnel from all shifts on the alert investigation procedure
Assigning backup personnel for each activity in the case that the primary investigator is
unavailable
Cross-training investigators on multiple roles
35
-------
Public Health Surveillance Design Guidance
Assigning personnel to be on call for critical investigation functions, particularly those requiring a
decision about the possibility of water contamination
5.2 Developing Investigation Tools
While the detailed alert investigation procedure described in Section 5.1 is necessary, the detailed
documentation of this procedure is generally not used during real-time alert investigations. This section
describes tools that can be developed to assist investigators in efficiently carrying out their
responsibilities. The investigation tools that will be discussed in this section include:
Checklists
Record of Alert Investigations
Quick Reference Guides
Checklists
Alert investigation checklists are job aids that guide personnel
through their investigative responsibilities and document
investigation findings. Checklists can help to ensure consistency
among investigators, verify that all activities are completed, and
reduce the time required to conduct alert investigations. They
generally list the activities assigned to specific roles, and thus more
than one checklist may be developed to support the PHS alert
investigation procedure.
HELPFUL HINT
Public health partners will have
their own tools and methods for
documenting their investigation
of a PHS alert, and would
generally not need a new
checklist specific to their role in
an SRS.
A checklist should be streamlined, concise, and intuitive to use for personnel trained on the procedure. It
should guide personnel through the steps of the investigation and provide space for them to record
important information for each activity completed. In some cases, it
may be sufficient to simply check a box indicating completion of an
activity. In others, the investigator may need to record a time or provide
more details on a particular conclusion or investigative activity. An
editable PHS Alert Investigation Checklist can be opened by clicking
the icon in the callout box.
This template
I includes an editable
alert investigation
checklist.
Record of Alert Investigations
A record of alert investigations provides documentation of key information, including the actions
implemented during the investigation as well as the likely cause of the alert. This record can also serve as
a resource during investigation of future alerts.
There are a variety of ways to document alert investigations. For example, a simple solution uses a
spreadsheet maintained on a shared drive that can be accessed by all investigators as well as the SRS
Manager. Use of an electronic tool, such as a spreadsheet, can facilitate standardization of data entry
through use of defined lists and data entry masks. Figure 5-2 provides an example record that shows
useful fields to capture.
36
-------
Public Health Surveillance Design Guidance
Component
PHS
PHS
PHS
PHS
Alert Date/Time
5/10/201511:15
7/14/201513:22
8/27/20156:27
10/29/20157:13
Alert Location
Central Business
District
Washington
Heights
Morgan
West Side
Investigator
Morgan
Wisecarver
John Webber
Kim Sullivan
Dave Collins
Investigation
Start Date/Time
5/10/201511:20
7/14/201513:25
8/27/20156:35
10/29/20157:18
Investigation
End Date/Time
5/10/2015 11:48
7/14/2015 13:57
8/27/20158:43
10/29/20157:46
Conclusion
Valid alert: unrelated to
drinking water quality
Valid alert: unrelated to
drinking water quality
Cause identified:
premise plumbing
issue
Valid alert: unrelated to
drinking water quality
Notes
No abnormalities in
utility data.
No abnormalities in
utility data.
Cross-connection
during AC installation
resulted in minor
illness.
No abnormalities in
utility data.
Figure 5-2. Example Alert Investigation Record
It a. dashboard will be used to support the SRS, electronic alert investigation tracking may be
incorporated into the design. For example, electronic checklists can be developed and the information
entered can automatically be saved in a database, facilitating further analysis and use of the records. See
Dashboard Design Guidance for Water Quality Surveillance and Response System for more information
on this option.
Quick Reference Guides
While many alert investigation activities become second nature to investigators, additional tools may be
useful for guiding investigators through complex or less frequently implemented tasks. Development of
quick reference guides, in which key information is concisely summarized in an easily-accessible form
such as a factsheet, ensure investigators can quickly and easily get the information they need. Examples
of quick reference guides that can be useful for PHS include:
A list of contact information for all utility personnel and public health partners who may need to
be contacted during an alert investigation.
A list of lag times between exposure and onset of symptoms for a variety of contaminants. The
list would guide utility personnel in identifying the time period to target for their data review
based on definitive or presumptive identification of the contaminant by a public health partner.
A list of sampling locations organized by zip code. This is useful if spatial information from
public health partners is limited to zip codes.
Other SRS component alert investigation tools.
5.3 Preparing for Real-time Alert Investigations
This section describes a suggested process for putting the PHS alert investigation procedure into practice.
The benefits of PHS can be fully realized only if PHS alerts are investigated in real time and responded to
appropriately. The following topics are covered under this section:
Training
Preliminary operation
Real-time operation
Training
Proper training on the alert investigation procedure ensures that all utility personnel with a role in the
investigation of PHS alerts are aware of their responsibilities and have the knowledge and expertise
needed to implement those responsibilities. It is suggested that training on the alert investigation
procedure include the following:
An overview of the purpose and design of the PHS component, including a description of the
datastreams monitored by public health partners
A description of the public health partners and their role in PHS
37
-------
Public Health Surveillance Design Guidance
A detailed description of the alert investigation procedure and the role of each participant
A review of checklists, quick reference guides, information management systems, and other tools
available to support PHS alert investigations
Instructions for using the record of alert investigations, both for entering new records and
retrieving previous records to support new alert investigations
Section 6 of Guidance for Developing Integrated Water Quality Surveillance and Response Systems
provides guidance on implementing a training and exercise program. In general, classroom training is
used first to orient personnel to the procedure and their responsibilities during PHS alert investigations.
Once they are comfortable with the procedure, drills and exercises give them the opportunity to practice
implementing their responsibilities in a controlled environment. The SRS Exercise Development Toolbox
is an interactive software program designed to help utilities design, conduct, and evaluate exercises
specific to PHS and the other SRS components.
Preliminary Operation
A period of preliminary operation should follow initial
training, allowing utility personnel to practice their
responsibilities in test mode before the transition to real-time
operation. For example, personnel can be asked to investigate
alerts in batches as they have time, not necessarily as the
alerts are generated. During this period, investigators may or
may not receive alert notifications such as emails or text
messages.
HELPFUL HINT
Do not rush preliminary operation of
the PHS component. This period
provides an opportunity for personnel
to practice their responsibilities and
learn the resources used during
investigations, thus improving the
efficiency of alert investigations.
One approach to conducting alert investigations during preliminary operation is to hold regular meetings
with all utility personnel and public health partners with a role in the process. The group process
facilitates sharing of information and ideas about the steps taken to evaluate whether or not a PHS alert is
potentially related to contaminated water. Inclusion of both utility personnel and public health partners in
this process allows each to gain insight into the other's role in the process. Furthermore, these joint
meetings can help to maintain effective communication and coordination between the utility and its public
health partners (see Section 3). Meeting monthly during the period of preliminary operation is appropriate
and sufficient for most PHS applications.
During real-time operation, it is expected that the number of PHS alerts that require a utility investigation
will be small, possibly fewer than one per year. Thus, additional PHS alerts, including those that normally
would not be passed on to the utility, should be investigated by both the utility and its public health
partners during preliminary operations. This provides personnel with additional opportunities to practice
conducting alert investigations and strengthens the utility-public health partnership.
Real-time Operation
During real-time operation, PHS alerts are investigated as they are generated, and Consequence
Management is activated if drinking water contamination is considered possible. The transition from
preliminary operation to real-time operation should be clearly communicated to all utility personnel and
public health partners with a role in PHS alert investigations. This includes establishing a date for the
transition as well as providing expectations for how alert investigations will be performed and
documented.
To sustain real-time operation, the alert investigation procedure should be integrated into existing job
functions and responsibilities to the extent possible. Sufficient time must be allocated for personnel to
investigate PHS alerts as they are generated. Public health partners take on the primary responsibility for
38
-------
Public Health Surveillance Design Guidance
receiving PHS alerts and performing the initial investigation, and in many cases already receive and
review these alerts as part of their core job responsibilities. Utility personnel are involved in the
investigation only if contaminated water cannot be ruled out as a possible cause of the PHS alert. In most
cases, this will be a small fraction of the total number of PHS alerts generated. Furthermore, the actions
taken by a utility to investigate contaminated water as a potential cause of a PHS alert can typically be
completed in under an hour. Thus, the overall time commitment of utility personnel to support PHS alert
investigations is minimal outside of a contamination incident.
Maintenance of the alert investigation procedure during real-time operation may involve periodic review
of the procedure to verify that it is working as intended. Furthermore, the alert investigation record should
be reviewed to ensure that the procedure is being correctly implemented. Because PHS alerts requiring
utility investigation may be infrequent, refresher training may be needed to maintain proficiency. Finally,
it is important to thoroughly train new staff on their responsibilities for supporting the investigation of
PHS alerts that may be related to contaminated water.
HELPFUL HINT
Routine updates to the alert investigation procedure and tools are necessary to maintain their usefulness.
Recommendations for procedure maintenance include:
Designate one or more individuals with responsibility for maintaining alert investigation materials
Establish a review schedule (annual review should suffice in most cases)
Review the record of alert investigations, conduct tabletop exercises, and solicit feedback from
investigators to identify necessary updates
Establish a protocol for submission and tracking of change requests
39
-------
Public Health Surveillance Design Guidance
Section 6: Preliminary PHS Design
The information presented in the previous sections of this document can guide development of a
preliminary PHS design that supports a utility's design goals and performance objectives. If PHS will be a
component in a multi-component SRS, the design of the integrated system will likely be guided by a
project management team. In this case, guidelines for design of the individual components should be
provided to the component implementation teams, and should include:
Overarching design goals and performance objectives for the SRS
Existing resources that could be leveraged to implement the SRS components, including
personnel, procedures, equipment, and information management systems
Project constraints, such as budget ceilings, schedule milestones, and policy restrictions
Instructions or specific guidelines for the development of preliminary component designs
It is also useful to develop a preliminary PHS alert investigation procedure prior to developing a
preliminary PHS design. Information is this procedure can inform various aspects of the design, such as
information management requirements.
Regardless of whether PHS will be developed as a stand-alone
component or as part of a multi-component SRS, the preliminary
PHS design should be documented in sufficient detail to assess
This template can be
used to develop the
preliminary PHS design.
whether or not it can achieve the design goals established for the
component within project constraints. A Preliminary PHS Design
Template can be opened and edited in Word by clicking the icon in the callout box. This template covers
the following aspects of PHS design:
Component implementation team: Identify personnel from the utility and public health partner
organizations that will have a role in the design and implementation of PHS. Document the role,
responsibilities, and estimated time commitment of each team member.
Design goals and performance objectives: Use the overarching design goals and performance
objectives established for the SRS to develop goals and performance objectives for PHS to guide
the process of designing the PHS component.
Public health surveillance systems: Identify all case-based and syndromic surveillance systems
that will be used to monitor for customer exposure to waterborne contaminants. If existing
systems will be enhanced, describe the enhancements. If new systems will be deployed, provide
specifications, including the datastreams that will be monitored. Specifications for enhancements
should be worked out with public health partner and agreed to before a preliminary design is
developed.
Preliminary information management requirements: Identify all information management systems
that would be used during operation of PHS. This will likely include utility systems that will be
accessed during the investigation of PHS alerts as well as systems operated and maintained by
public health partners. Develop an information flow diagram depicting user-to-machine and
machine-to-machine interactions. Document requirements for any new or modified information
management systems. Note any data sharing agreements that will need to be established in order
to implement the information management solution.
Initial training requirements: Develop a training plan to educate personnel about their
responsibilities during operation of PHS.
Budget: Develop a line item budget for the PHS component noting the entity responsible for
covering the cost of each line item. Any cost sharing between the utility and public health
40
-------
Public Health Surveillance Design Guidance
partners should be noted. It is recommended that the budget include implementation as well as
operation and maintenance costs, which can be used to develop a lifecycle cost estimate. The
budget should indicate the year in which each cost is incurred. Contingencies should be included
to avoid cost overruns.
Schedule: Develop a schedule that shows the planned sequencing of activities as well as any key
dependencies. The schedule may reflect a phased implementation over multiple years, which may
be advantageous or necessary to overcome resource (financial or personnel) limitations. The
schedule should be developed in collaboration with, or at least reviewed by, any public health
partners that will have a substantial role in implementing PHS.
In some cases, multiple design alternatives may emerge. A benefit-cost analysis should be performed to
identify the preferred option. The resource Framework for Comparing Alternative Water Quality
Surveillance and Response Systems provides an objective process for comparing design alternatives with
respect to their lifecycle costs and capability.
41
-------
Public Health Surveillance Design Guidance
Resources
Overview of PHS Design
Water Quality Surveillance and Response System Primer
http://www.epa.gov/sites/production/files/2015-
06/documents/water quality sureveillance and response system_primer.pdf
This document provides an overview of SRSs for drinking water distribution systems. It defines
the components of an SRS, describes common design goals and performance objectives for an
SRS, and provides an overview of the approach for implementing an SRS. EPA 817-B-15-002,
May 2015.
Public Health Surveillance Primer
http://www.epa.gov/sites/production/files/2015-06/documents/public health surveillance.pdf
This document provides an overview of the PHS component and presents information about the
goals and objectives of PHS in the context of an SRS. EPA 817-B-15-0002D, May 2015.
Partnership with Public Health
American Association of Poison Control Centers
http://www.aapcc.org/
This website provides information about PCCs in the U.S. including the poison help line, the
latest poison news, and information about the NPDS. A search field is also provided which can be
used to locate local PCCs.
Association of Public Health Laboratories
http://www.aphl. org/Page s/default. aspx
The Association of Public Health Laboratories (APHL) is an organization that works to
strengthen laboratories serving the public's health in the U.S. and globally. APHL represents state
and local governmental health laboratories in the U.S. Its members, known as public health
laboratories, monitor and detect health threats to protect the health and safety of Americans.
Council of State and Territorial Epidemiologists
http://www.cste.org/
The Council of State and Territorial Epidemiologists is an organization of member states and
territories representing public health epidemiologists. The Council works to establish more
effective relationships among state and other health agencies. It also provides technical advice
and assistance to partner organizations and to federal public health agencies such as CDC.
National Association of County and City Health Officials
http://www.naccho.org/
The National Association of County and City Health Officials is an organization which represents
the nation's 2,800 local health departments. The Association works in many areas of public
health, including public health preparedness, environmental health, community health, and public
health infrastructure and systems.
National Environmental Health Association
http://www.neha.org/
The National Environmental Health Association is an organization composed of 5,000 members
that has established a standard, known as the Registered Environmental Health Specialist or
Registered Sanitarian credential, which signifies that an environmental health professional has
42
-------
Public Health Surveillance Design Guidance
mastered a body of knowledge, and has acquired sufficient experience, to satisfactorily perform
work responsibilities in the environmental health field.
Public Health Surveillance Kickoff Meeting Template (PowerPoint File)
Click this link to open the presentation template
This customizable presentation template allows utilities to prepare for a kickoff meeting when
designing the PHS component with public health partners, such as the health department and
PCC. July 2016.
Public Health Surveillance Systems
Public Health Surveillance Assessment: Interview with Public Health Partners
Click this link to open the assessment form
This fillable form allows utilities to conduct an assessment of public health surveillance systems.
It includes prompt questions to guide discussions with public health partners responsible for
monitoring available public health datastreams, such as epidemiologists at health departments and
toxicologists at PCCs. EPA 817-B-15-001, January 2015.
Framework for Comparing Alternatives for Water Quality Surveillance and Response Systems
http://www.epa.gov/sites/production/files/2015-
07/documents/framework_for_comparing_alternatives_for_water_quality_surveillance_and_resp
onse_sy stems .pdf
This document provides guidance for selecting the most appropriate SRS design from a set of
viable alternatives. It guides the user through an objective, stepwise analysis for ranking multiple
alternatives and describes, in general terms, the types of information necessary to compare the
alternatives. EPA 817-B-15-003, June 2015.
Training for Healthcare Professionals on Indicators of Drinking Water Contamination
https://www.epa.gov/waterqualitysurveillance/public-health-surveillance-resources
This training module describes how public health professionals can identify signs of drinking
water contamination when performing their routine job functions. It also describes the manner in
which drinking water and public health professionals can work together to investigate a possible
drinking water contamination incident. September 2016.
Information Management Requirements Development Tool
http://www.epa.gov/waterqualitysurveillance/surveillance-and-response-system-resources
This tool is intended to help users develop requirements for an SRS information management
system to inform the selection and implementation of an information management solution.
Specifically, this tool (1) assists SRS component teams with development of component
functional requirements, (2) assists IT personnel with development of technical requirements, and
(3) allows the IT design team to efficiently consolidate and review all requirements. EPA 817-B-
15-004, October 2015.
Dashboard Design Guidance for Water Quality Surveillance and Response Systems
http://www.epa.gov/sites/production/files/2015-
12/documents/srs_dashboard_guidance_ 112015.pdf
A dashboard is a visually-oriented user interface that integrates data from multiple SRS
components to provide a holistic view of distribution system water quality. This document
provides information about useful features and functions that can be incorporated into an SRS
dashboard. It also provides example interface designs. EPA 817-B-15-007, November 2015.
43
-------
Public Health Surveillance Design Guidance
Alert Investigation Procedure
Alert Investigation Procedure Template (Word File)
Click this link to open the template
The alert investigation procedure template includes an editable table, flow diagram, and checklist
that can be used to document the utility's role in a PHS alert investigation process. July 2016.
Alert Investigation Checklist (Word File)
Click this link to open the template
The alert investigation checklist can be used to document the utility's role in a PHS alert
investigation. July 2016.
Guidance for Developing Integrated Water Quality Surveillance and Response Systems
http://www.epa.gov/sites/production/files/2015-
12/documents/guidance_for_developing_integrated_wq_srss_l 10415.pdf
This document provides guidance for applying system engineering principles to the design and
implementation of an SRS to ensure that the SRS functions as an integrated whole and is
designed to effectively perform its intended function. Section 6 provides guidance on developing
atraining and exercise program to support SRS operations. EPA 817-B-15-006, October 2015.
SRS Exercise Development Toolbox
https://www.epa.gov/waterqualitysurveillance/water-quality-surveillance-and-response-system-
exercise-development-toolbox
The Exercise Development Toolbox helps utilities and response partner agencies to design,
conduct, and evaluate SRS-related exercises. These exercises can be used to develop and refine
SRS procedures, and train personnel in the proper implementation of those procedures. The
toolbox guides users through the process of learning about SRS training programs, developing
realistic scenarios, designing SRS discussion-based and operations-based exercises, and creating
exercise documents. March 2016.
Preliminary PHS Design
Preliminary PHS Design Template (Word File)
Click this link to open the template
This Word template can be used to document aspects of PHS component design, such as: the
component implementation team, design goals and performance objectives, public health
surveillance systems, preliminary information management requirements, initial training
requirements, budget, and schedule. July 2016.
44
-------
Public Health Surveillance Design Guidance
References
American Association of Poison Control Centers. (2016). National Poison Data System. Retrieved from
http://www.aapcc.org/data-system/
Angulo, F. J., Tippen, S., Sharp, D. J., Payne, B. J., Collier, C., Hill, J. E., Swerdlow, D. L. (1997). A
community waterborne outbreak of salmonellosis and the effectiveness of a boil water order.
American Journal of Public Health, 87 (4): 580-584.
Berg R. (2009). The Alamosa Salmonella Outbreak: A Gumshoe Investigation. Journal of Environmental
Health, 71 (2): 54-55.
Berger, M., Shiau, R., and Weintraub, J. (2006). Review of syndromic surveillance: implications for
waterborne disease detection. Journal ofEpidemiological Community Health, 60(6): 543-550.
CDC. (2001). Updated Guidelines for Evaluating Public Health Surveillance Systems. Retrieved from
http: //www .cdc. gov/mmwr/pre vie w/mmwrhtml/rr5 013a 1 .htm
CDC. (2004). Comparison of Office Visit and Nurse Advice Hotline Data for Syndromic Surveillance -
Baltimore-Washington, D.C., Metropolitan Area, 2002. Retrieved from
http://www.cdc.gov/mmwr/preview/mmwrhtml/su530 Ia23 .htm
CDC. (2005). Using the National Poison Data System for Public Health Surveillance. Retrieved from
http: //www .cdc. gov/nceh/hsb/chemicals/pdfs/npds .pdf
CDC. (2012). Meaningful Use. Retrieved from http://www.cdc.gov/ehrmeaningfuluse/introduction.html
CDC. (2015). National Notifiable Diseases Surveillance System (NNDSS). Retrieved from
https: //wwwn .cdc. gov/nndss/data-collection .html
CDC. (2016a). Poison Center and Public Health Collaborations Community of Practice (CoP). Retrieved
from http://www.cdc.gov/nceh/hsb/chemicals/poison_center.htm
CDC. (2016b). National Syndromic Surveillance Program: BioSense Platform. Retrieved from
http://www.cdc.gov/nssp/biosense/index.html
CDC. (2016c). PulseNet: Outbreak detection. Retrieved from http://www.cdc.gov/pulsenet/outbreak-
detection/index.html
Colvin, J. (2016, May 16). Email communication.
Council of State and Territorial Epidemiologists (CSTE), et al. (2013). Use of Poison Center Data
Assessment Report 2012. Retrieved from
http://c.vmcdn.com/sites/www. cste.org/resource/resmgr/environmentalhealth/poisonassessmentrepor
t2012.pdf
EPA. (2012). Electronic Surveillance System for the Early Notification of Community-based Epidemics
(ESSENCE) Water Security Module. 600-R-12-735. Washington, D.C.
45
-------
Public Health Surveillance Design Guidance
EPA. (2014). Water Security Initiative: Evaluation of the Public Health Surveillance Component of the
Cincinnati Contamination Warning System Pilot. Retrieved from
http://www.epa.gov/sites/production/files/2015-
06/documents/wsi_evaluation_of_thej3ublic_health_surveillance_component_of_the_cincinnati_co
ntamination_warning_system_pilot.pdf
Fernandes, T. M. A., Schout, C., De RodaHusman, A. M., Eilander, A., Vennema, H., and van
Duynhoven, Y. T. H. P. (2007). Gastroenteritis associated with accidental contamination of drinking
water with partially treated water. Epidemiology and Infection, 135(5): 818-826.
Fong, T.-T., Mansfield, L. S., Wilson, D. L., Schwab, D. J., Molloy, S. L., and Rose, J. B. (2007).
Massive Microbiological Groundwater Contamination Associated with a Waterborne Outbreak in
Lake Erie, South Bass Island, Ohio. Environmental Health Perspectives, 115(6): 856-864.
Greenko, J., Mostashari, F., Fine, A., and Layton, M. (2003). Clinical Evaluation of the Emergency
Medical Services (EMS) Ambulance Dispatch-Based Syndromic Surveillance System, New York
City. Journal of Urban Health, 80 (2): i50-i56.
Haas, A., Gibbons, D., Dangel, C., Allgeier, C. (2011). Automated surveillance of 911 data for detection
of possible water contamination. Int. Jour. Health Geographies, 10(22).
Health Monitoring Systems. (2016). EpiCenter. Retrieved from
https://www.hmsinc.com/service/epicenter.html
Hirshon, J.M. (2000). The Rationale for Developing Public Health Surveillance Systems Based on
Emergency Department Data. Academic Emergency Medicine, 7(12): 1428-32.
HHS. (2016). Office-based Physician Electronic Health Record Adoption: 2004-2014. Retrieved from
http://dashboard.healthit.gov/quickstats/pages/physician-ehr-adoption-trends.php
Johns Hopkins Applied Physics Laboratory. (2016). Electronic Surveillance System for the Early
Notification of Community based Epidemics. Retrieved from
http://www.jhuapl.edu/sages/tools.html
Nygard, K., Schimmer, B., S0bstad, 0., Walde, A., Tveit, I., Langeland, N., Hausken, T., and Aavitsland,
P. (2006). A large community outbreak of waterborne giardiasis- delayed detection in a non-endemic
urban area. BMC Public Health, 6, 141.
Nurse Advice New Mexico. (2016). Syndromic Surveillance. Retrieved from
http://www.nurseadvice.org/what-we-do/svndromic-surveillance/
Pivette, M., Mueller, J. E., Crepey, P., and Bar-Hen, A. (2014). Drug sales data analysis for outbreak
detection of infectious diseases: a systematic literature review. BMC Infectious Diseases, 14: 604.
Preparedness Summit. (2015). NurseAdvice New Mexico: A Case Study Analysis. Retrieved from
http://www.eventscribe.com/2015/NACCHOSummit/assets/pdf/175305.pdf
University of Pittsburgh. (2016a). How to Obtain Access to the NRDM. Retrieved from
https://www.rods.pitt.edu/site/content/view/22/42/
46
-------
Public Health Surveillance Design Guidance
University of Pittsburgh. (2016b). Real-Time Outbreak and Disease Surveillance. Retrieved from
https://www.rods.pitt.edu/site/content/category/8/22/36/
Uscher-Pines, L., Farrell, C. L., Cattani, J., Hsieh, Y. H. Moskal, M. D., Babin, S. M., Gaydos, C. A.,
Rothman, R.E. (2009). A survey of usage protocols of syndromic surveillance systems by state
public health departments in the United States. J Public Health Manag Pract, 15(5): 432-8.
Yih, W. K., Deshpande, S., Fuller, C., Heisey-Grove, D., Hsu, J., Kruskal, B. A., Kuldorff, M., Leach,
M., Nordin, J., Patton-Levine, J., Puga, E., Sherwood, E., Shui, I., and Platt, R. (2010). Evaluating
Real-Time Syndromic Surveillance Signals from Ambulatory Care Data in Four States. Public
Health Reports, 125(1): 111-120.
47
-------
Public Health Surveillance Design Guidance
Glossary
alert. An indication from an SRS surveillance component that an anomaly has been detected in a
datastream monitored by that component. Alerts may be visual or audible, and may initiate automatic
notifications such as pager, text, or email messages.
alert investigation. The process of investigating the validity and potential causes of an alert generated by
an SRS surveillance component.
alert investigation checklist. A form that lists a sequence of steps to follow when investigating an SRS
alert. This form ensures consistency with an alert investigation procedure and provides documentation of
each investigation.
alert investigation procedure. A documented process that guides the investigation of an SRS alert. A
typical procedure defines roles and responsibilities for alert investigations, includes an investigation
process diagram, and provides one or more checklists to guide investigators through their role in the
process.
anomaly. A deviation from an established baseline in a monitored datastream. Detection of an anomaly
by an SRS surveillance component generates an alert.
anomaly detection system. A data analysis tool designed to detect deviations from an established
baseline. An anomaly detection system may take a variety of forms, ranging from complex computer
algorithms to a simple set of heuristics that are manually implemented.
benefit. An outcome associated with the implementation and operation of an SRS that promotes the
welfare of a utility and the community it serves. Benefits can be derived from a reduction in the
consequences of a contamination incident and from improvements to routine utility operations.
benefit-cost analysis. An evaluation of the benefits and costs of a project or program, such as an SRS, to
assess whether the investment is justifiable considering both financial and qualitative factors.
case-based surveillance. A form of public health surveillance in which frontline healthcare providers
detect potential public health incidents through the cumulative assessment of case details or case volume.
clinical laboratory testing. Analysis of clinical specimens performed by laboratories to identify the agent
that caused a disease or illness.
component. One of the primary functional areas of an SRS. There are four surveillance components:
Online Water Quality Monitoring; Enhanced Security Monitoring; Customer Complaint Surveillance; and
Public Health Surveillance. There are two response components: Consequence Management and
Sampling and Analysis.
component team. A designated group of individuals responsible for design and implementation of an
SRS component.
confirmed. In the context of the threat level determination process, contamination is confirmed when the
analysis of all available information provides definitive, or nearly definitive, evidence of the presence of a
specific contaminant or contaminant class in a distribution system. While positive results from laboratory
48
-------
Public Health Surveillance Design Guidance
analysis of a sample collected from a distribution system can be a basis for confirming contamination, a
preponderance of evidence, without the benefit of laboratory results, can lead to this same determination.
consequence. An adverse public health or economic impact resulting from a contamination incident.
Consequence Management. One of the response components of an SRS. This component encompasses
actions taken to plan for and respond to possible drinking water contamination incidents in order to
minimize the response and recovery timeframe, and ultimately minimize consequences to a utility and its
customers.
constraints. Requirements or limitations that may impact the viability of an alternative. The primary
constraints for an SRS project are typically schedule, budget, and policy issues (for example, zoning
restrictions, IT restrictions, and union prohibitions).
contamination incident. The presence of a contaminant in a drinking water distribution system that has
the potential to cause harm to a utility or the community served by the utility. Contamination incidents
may have natural (e.g., toxins produced by a source water algal bloom), accidental (e.g., chemicals
introduced through an accidental cross-connection), or intentional (e.g., purposeful injection of a
contaminant at a fire hydrant) causes.
credible. In the context of the threat level determination process, a contamination incident is
characterized as credible if information collected during the investigation of possible contamination
corroborates information from a validated SRS alert.
Customer Complaint Surveillance (CCS). One of the surveillance components of an SRS. CCS
monitors water quality complaint data in call or work management systems and identifies abnormally
high volumes or spatial clustering of complaints that may be indicative of a contamination incident.
dashboard. A visually-oriented user interface that integrates data from multiple SRS components to
provide a holistic view of distribution system water quality. The integrated display of information in a
dashboard allows for more efficient and effective management of distribution system water quality and
the timely investigation of water quality anomalies.
data analysis. The process of analyzing data to support routine system operation, rapid identification of
water quality anomalies, and generation of alert notifications.
design elements. The functional areas which comprise each component of an SRS. In some cases design
elements are divided into design sub-elements. In general, the information presented in SRS guidance and
products is organized by design elements and sub-elements.
design goal. The specific benefits to be realized through deployment of an SRS and each of its
components. A fundamental design goal of an SRS is detecting and responding to drinking water
contamination incidents. Additional design goals for an SRS are established by a utility and often include
benefits to routine utility operations.
Enhanced Security Monitoring (ESM). One of the surveillance components of an SRS. ESM includes
the equipment and procedures used to detect and respond to security breaches at distribution system
facilities that are vulnerable to contamination.
functional requirement. A type of information management requirement that defines key features and
attributes of an information management system that are visible to the end user. Examples of functional
49
-------
Public Health Surveillance Design Guidance
requirements include the manner in which data is accessed, types of tables and plots that can be produced
through the user interface, the manner in which component alerts are transmitted to investigators, and the
ability to generate custom reports.
hardware. A physical IT assets such as servers or user workstations.
healthcare professional. Physicians, physicians' assistants, nurses, nurse practitioners, and EMS
technicians who conduct medical assessments of ill or injured patients seeking diagnosis and treatment.
information management. The processes involved in the collection, storage, access, and visualization of
information. In the context of an SRS, information includes the raw data generated by SRS surveillance
components, alerts generated by the components, ancillary information used to support data analysis or
alert investigations, details entered during alert investigations, and documentation of Consequence
Management activities.
information management system. The combination of hardware, software, tools, and processes that
collectively support an SRS and provides users with information needed to monitor real-time system
conditions. The system allows users to efficiently identify, investigate, and respond to water quality
incidents.
invalid alert. An alert from an SRS surveillance component that is not due to a water quality incident or
public health incident.
IT design team. Personnel responsible for selecting, designing, and implementing the SRS information
management system.
lifecycle cost. The total cost of a system, component, or asset over its useful life. Lifecycle cost includes
the cost of implementation, operation and maintenance, and renewal.
medical assessment. An evaluation of a disease or condition based on the patient's subjective report of
the symptoms and course of the illness or condition and the medical professional's objective findings,
including data obtained through physical examination, medical history, clinical laboratory tests, and
information reported by family members and other healthcare professionals.
monitoring. The process of collecting and analyzing a datastream overtime.
notifiable disease. Cases are voluntarily reported to CDC by state and territorial jurisdictions for
nationwide aggregation and monitoring of disease data. The list of nationally notifiable diseases is
reviewed and modified annually by the CSTE and CDC.
Online Water Quality Monitoring (OWQM). One of the surveillance components of an SRS. OWQM
utilizes data collected from monitoring stations that are deployed at strategic locations in a source water
or distribution system. Monitored parameters can include common water quality parameters (e.g.,
chlorine residual, pH, specific conductance and turbidity) and advanced parameters (e.g., total organic
carbon and UV-Vis spectral data). Data from remote monitoring locations is transferred to a central
location and analyzed for water quality anomalies.
performance objectives. Measurable indicators of how well an SRS or its components meet established
design goals.
50
-------
Public Health Surveillance Design Guidance
Poison Control Center (PCC). An agency employing toxicologists, medical doctors, and other
professions with pharmacological expertise for the purpose of providing guidance to persons who may
have been exposed to a toxic substance, or to healthcare providers with responsibility for treating exposed
persons.
possible. In the context of the threat level determination process, water contamination is considered
possible if the cause of an alert from one of the surveillance components cannot be identified or
determined to be benign.
Primers. A set of seven concise documents that provides overview information about the SRS or one of
its six components. The primers provide an introduction to SRS practices and useful background for the
application of technical SRS products and guidance.
public health datastreams. Data generated by individuals seeking healthcare, which may include 911
calls, emergency medical service records, and emergency department data. Public health datastreams are
monitored to detect potential public health incidents.
public health incident. An occurrence of disease, illness, or injury within a population that is a deviation
from the disease baseline in the population.
public health partner. Public health organizations that may serve a role in PHS include the health
department and Poison Control Center.
Public Health Surveillance (PHS). One of the surveillance components of an SRS. PHS involves the
analysis of public health datastreams to identify public health incidents, and the investigation of such
incidents to determine whether they may be due to drinking water contamination.
real-time. A mode of operation in which data describing the current state of a system is available in
sufficient time for analysis and subsequent use to support assessment, control, and decision functions
related to the monitored system.
reportable disease. Cases or suspected cases of disease that must be reported to state or territorial
jurisdictions by healthcare professionals, hospitals, or laboratories when they are identified. Each state has
its own laws and regulations defining what diseases are reportable.
Sampling and Analysis (S&A). One of the response components of an SRS. S&A is activated during
Consequence Management to help confirm or rule out possible water contamination through field and
laboratory analyses of water samples. In addition to laboratory analyses, S&A includes all the activities
associated with site characterization. S&A continues to be active throughout remediation and recovery if
contamination is confirmed.
software. A program that runs on a computer and performs certain functions.
solution. The design and configuration of the hardware, software, and other products that will be used to
construct an information management system.
syndrome. A group of symptoms that occur together and characterize a particular health condition.
syndromic surveillance. A form of public health surveillance in which electronic public health data, such
as 911 calls or emergency department chief complaints, is analyzed in order to detect anomalies that may
51
-------
Public Health Surveillance Design Guidance
be indicative of public health incidents. Syndromic surveillance may be automated or performed
manually.
target capability. A level of performance or an outcome for a design element that is necessary for an
effective PHS component.
technical requirement. A type of information management requirement that defines system attributes
and design features that are often not readily apparent to the end user but are essential to meeting
functional requirements or other design constraints. Examples include attributes such as system
availability, information security and privacy, back-up and recovery, data storage needs, and integration
requirements.
template. A pre-defined standard format which is developed for commonly used documents, tables, or
graphical displays. Development and use of templates can reduce the time required for data review and
reporting.
threat level determination process. A systematic process in which all relevant information available
from an SRS is evaluated to determine whether contamination is possible, credible, or confirmed. This is
an iterative process in which the threat level is revised as additional information becomes available. The
conclusions from this process are considered during Consequence Management when making response
decisions.
valid alert. Alerts due to water contamination, verified water quality incidents, intrusions at utility
facilities, or public health incidents.
water quality complaints. Complaints received by a utility from a customer indicating that water quality
is not as expected. Traits such as an unusual taste, odor, or appearance can all indicate abnormal water
quality within the distribution system.
water quality incident. An incident that results in an undesirable change in water quality (e.g., low
residual disinfectant, rusty water, taste & odor, etc.). Contamination incidents are a subset of water quality
incidents.
Water Quality Surveillance and Response System (SRS). A system that employs one or more
surveillance components to monitor and manage drinking water quality in real time. An SRS utilizes a
variety of data analysis techniques to detect water quality anomalies and generate alerts. Procedures guide
the investigation of alerts and the response to validated water quality incidents that might impact
operations, public health, or utility infrastructure.
Water Quality Surveillance and Response System Manager (SRS Manager). A role within an SRS
typically filled by a mid- to upper-level manager from a drinking water utility. Responsibilities of this
position include: receiving notification of valid alerts, coordinating the threat level determination process,
integrating information across the different surveillance components, and activating Consequence
Management.
work management system. Software used by a utility to schedule and track maintenance, repair, or other
operations in the distribution system.
52
------- |