Surveillance and reporting of 
communicable diseases


Responsibility for public health protection from communicable diseases exists at three government levels in the U.S. (federal, state/tribe, and local/municipal), with states having the authority to require reporting of communicable diseases along with legislation that supports this. The CDC’s National Notifiable Diseases Surveillance System (NNDSS) collects information from state, local, and territorial health departments, along with federal and international public health agencies that enables all levels of public health “to share health information to monitor, control, and prevent the occurrence and spread of state-reportable and nationally notifiable infectious and some noninfectious diseases and conditions.”31 Although the list of reportable infectious diseases may vary slightly from state to state, the NNDSS allows for consistent case definitions and the dissemination of information weekly and annually via the Morbidity and Mortality Weekly Report (MMWR).


Reportable diseases in North Carolina

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In North Carolina there are “diseases and conditions declared to be dangerous to the public health and are hereby made reportable within the time period specified after the disease or condition is reasonably suspected to exist,” mandated by legislation 10A ncac 41a .0101.32 These mandated reportable diseases and case definitions are available at: epi.publichealth.nc.gov/cd/lhds/manuals/cd/­reportable_diseases.html.

Some of the functions of the Communicable Disease branch at the NCDHHS listed on the public website (epi.public health.nc.gov/cd/report.html) include the following:

  • Educating the public, health care providers, and local health departments on communicable diseases and how to prevent them. Alerts on emerging or seasonal communicable disease events, such as flu, food-borne illness, or the occurrence of a new (novel) communicable disease.
  • Investigation of and intervention in response to disease outbreaks, as well as the ongoing development of strategies, policies, and practices to prevent the spread of diseases.
  • Outpatient care and support services related to HIV/AIDS, other sexually transmitted diseases, and tuberculosis.
  • Communication sharing between local, state, and federal public health agencies, private physicians, and hospital and occupational infection control personnel, as an essential part of disease surveillance and control efforts.

The most common cases (average yearly) of reported communicable diseases in North Carolina from 2009 to 2013 were as follows: for STDs, chlamydia (46,393), gonorrhea (14,337), nongonococcal urethritis (4,892), HIV disease (1,562 new diagnoses), and an increase of syphilis (1,231 all stages); salmonellosis (2,166); and the highest number of cases of vaccine-preventable diseases involved hepatitis B–chronic (980) and pertussis (392). This public information is available from the North Carolina Division of Public Health, Epidemiology Section, Communicable Disease Branch through a Monthly CD Report.

Outbreak investigation and preparing for Ebola. In West Africa, malaria, a parasitic protozoan disease transmitted by the female Anopheles mosquito, is considered endemic in that it occurs regularly in the population and is the leading cause of morbidity and mortality, especially in young children. In Sierra Leone, West Africa, the entire population of 5.7 million are considered at risk, and there were 2.2 million reported malaria cases last year, which involved presenting with symptoms similar to Ebola, including flu-like symptoms such as chills, fever, sweating, nausea, headache, and vomiting.34 


An epidemic is defined as an unusual occurrence of a disease in a population, such as an unusual increase of influenza cases during the 2014-15 flu season or a reoccurrence of measles. In 1976, a highly infectious, deadly viral disease was first described in a remote area known as Zaire, Africa (now called the Democratic Republic of Congo), near the Ebola River. Named after that location of the outbreak, Ebola Virus Disease (EVD) is now known to be an RNA virus of the family Filoviridae, genus Ebolavirus. Five Ebola virus strains have since been identified, with four known to cause disease in humans. Ebola is spread by direct contact of body fluids from an infected person, or through contact with objects that have been contaminated with the blood or other body fluids of an infected person or potentially eating uncooked infected animals such as primates or bats.35 


There have been other outbreaks of EVD in Africa since 1976, with a theory that bats may be the reservoir of transmission, but no outbreak has been as large as the ongoing epidemic in West Africa today. In March 2014, WHO was notified of an outbreak in Guinea, West Africa, of a communicable disease characterized by a high fever, severe diarrhea, vomiting, and a high fatality rate. The disease was Zaire ebolavirus, and during the summer it quickly spread to the surrounding countries of Liberia and Sierra Leone, with WHO declaring the epidemic to be a Public Health Emergency of International Concern on August 8, 2014.36 As of December 31, 2014, there were 20,416 total reported cases, with 12,894 laboratory-confirmed cases and 8,004 total deaths, predominately in West Africa.35 The CDC has assisted in the fight against Ebola in West Africa with a goal to eliminate new cases and has made great progress, especially in Liberia. In addition, Sierra Leone has introduced a trial vaccine against Ebola. In the U.S., there have been four confirmed cases and one death.


Katz and colleagues suggest the following series of steps for an outbreak investigation, which are currently used in public health investigations:


  • Make a tentative diagnosis (to specify the disease to be investigated)

  • Establish the case definition (to distinguish cases from noncases)

  • Determine whether an epidemic exists (is there an unusual occurrence of disease?)

  • Characterize the epidemic by time, place, and person (this allows hypotheses on source and route)

  • Develop hypotheses regarding spread (case studies, develop laboratory assays)

  • Initiate control measures and then follow up on surveillance to evaluate the control measures.1


Using Ebola as an example, clinicians are urged to take a travel history and ask about potential sick contacts from any patient presenting with symptoms of viral infection. A tentative diagnosis can be made if a patient presents with symptoms of fever, severe headache, muscle pain, weakness, fatigue, diarrhea, vomiting, abdominal pain, and/or unexplained hemorrhage and if the patient has epidemiologic risk factors such as contact with a patient who is symptomatic with Ebola (or the patient’s body fluids) or has traveled to West African countries (including Sierra Leone, Liberia, Guinea, Mali, and Nigeria) within the last 21 days. Symptoms may appear from two to 21 days after exposure to Ebola, but the average time frame is eight to 10 days.37 Health care providers who suspect a case of Ebola (or person under investigation [PUI]) should immediately take infection control measures (isolate the PUI in a private bathroom; use standard contact, droplet precautions, and personal protective equipment [PPE]); and contact his or her state or local health department.38 The public health department will then follow up with contacting local EMS, hospitals, state laboratory, and patient contacts, all based on the CDC case definition of Ebola.39 Details of the case definition and laboratory testing for Ebola can be found at: cdc.gov/vhf/ebola/hcp/case-definition.html. 


Although no confirmed cases of reported Ebola (also known as hemorrhagic fever) have been reported in North Carolina, the NCDHHS has worked with the CDC on Ebola preparedness plans since July 2014, not only for EMS and hospitals, but also educating the public, health care providers, and local health departments who may be the first to receive questions or suspected cases.40 Presently, an Ebola Planning and Response Dashboard is set up with partners and community outreach to assist with training in the use of PPE, state laboratory tests, and surveillance of travelers returning from West Africa.41 Physicians are required to contact their local health department or the state Communicable Disease Branch (919-733-3419) as soon as Ebola or any other hemorrhagic fever virus infection is reasonably suspected. 


Conclusion


The international spotlight has focused on Ebola, and rightfully so because of the West African nations that have been hit hardest by this highly virulent, often fatal virus. A focus on Ebola preparedness efforts in the U.S. is justified in terms of making sure the nation is prepared for Ebola and other emerging communicable diseases, but there is also much work to be done to meet the challenges posed by infectious and communicable diseases that are already here, and in some cases reappearing after supposedly being eradicated. That work includes the following:


  • Renewed efforts on public education on basic preventive methods such as hand-washing, staying away from others when sick with an infectious disease, and other hygiene/infection control measures. 

  • Making sure that all health care workers are up to date in recommended vaccinations, along with training in OSHA standards for infection control. 

  • Reducing the overuse or misuse of antibiotics that contribute to drug-resistant infectious diseases.

  • Improvements in public health vaccination programs, debunking vaccination myths, and better public education as to the value of vaccinations.

  • Renewed commitment to Healthy People 2020 goals and implementing USPSTF screening recommendations.

  • Greater attention and care in the surveillance and reporting of communicable diseases.


With greater attention to these aspects of communicable disease prevention, screening, and reporting, many lives could be saved, even as the nation continues to ensure that it is adequately prepared for outbreaks such as measles or Ebola.

Jean Ann Davison, DNP, FNP-BC, is a family nurse practitioner and clinical assistant professor at the University of North Carolina at Chapel Hill, School of Nursing.


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References


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  2. Armstrong GL, Conn LA, Pinner RW. Trends in infectious disease mortality in the United States during the 20th century. JAMA. 1999;281(1):61-66. 

  3. CDC. Deaths: final data for 2013. National Vital Statistics Reports. 2013;64(2). Available at cdc.gov/nchs/fastats/leading-causes-of-death.htm

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  12. Bell BG, Schellevis F, Stobberingh E, et al. A systematic review and meta-analysis of the effects of antibiotic consumption on antibiotic resistance. BMC Infect Dis. 2014;14:13.

  13. CDC. Vital signs: Preventing Clostridium difficile infections. MMWR Morb Mortal Wkly Rep. 2012;61(9):157-162. 

  14. Brown KA, Khanafer N, Daneman N, Fisman DN. Meta-analysis of antibiotics and the risk of community-associated Clostridium difficile infection. Antimicrob Agents Chemother. 2013;57(5):2326-2332. 

  15. CDC. Office-related antibiotic prescribing for persons aged ≤ 14 years—United States, 1993-1994 to 2007-2008. MMWR Morb Mortal Wkly Rep. 2011;60(34):1153-1156. 

  16. CDC. (2014). Cold or flu. Antibiotics don’t work for you. Available at cdc.gov/getsmart/campaign-materials/print-materials/Brochure-general.html

  17. CDC. (2014). What would happen if we stopped vaccinations? Available at cdc.gov/vaccines/vac-gen/whatifstop.htm.

  18. Orenstein W, Seib K. Mounting a good offense against measles. N Engl J Med. 2014;371(18):1661-1663. 

  19. CDC. Measles-United States, January 1-August 24, 2013. MMWRMorbid Mortal Wkly Rep. 2013;62(36):741-743. 

  20. CDC. (2015). Measles cases and outbreaks: 2015 Measles Cases in the US, January 1 to April 3. Retrieved from cdc.gov/measles/cases-outbreaks.html.

  21. Seither R, Masalovich S, Knighton CL, et al. Vaccination coverage among children in kindergarten-United States, 2013-14 School Year. MMWR Morb Mortal Wkly Rep. 2014;63(41):913-920. 

  22. Healy CM, Pickering LK. How to communicate with vaccine-hesitant parents. Pediatrics. 2011;127(suppl 1):S127-S133. 

  23. Kennedy A, Basket M, Sheedy K. (2011). Vaccine attitudes, concerns, and information sources reported by parents of young children: Results from the 2009 HealthStyles survey. Pediatrics. 2011;127(suppl 1):S92-S99.

  24. Jacobson Vann JC, Szilagyi P. Patient reminder and recall systems to improve immunization rates (review). Cochrane Database Syst Rev. 2005;3:CD003941.

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  27. Torrone E, Papp J, Weinstock H; Centers for Disease Control and Prevention (CDC). Prevalence of Chlamydia trachomatis genital infection among persons aged 14-39 years—United States, 2007-2012. MMWR Morb Mortal Wkly Rep. 2014;63(38):834-838.

  28. US Preventive Services Task Force (2014). About the USPSTF. Retrieved from uspreventiveservicestaskforce.org/Page/Name/about-the-uspstf

  29. US Preventive Services Task Force (2014). Grade definitions. Retrieved from uspreventiveservicestaskforce.org/uspstf/grades.htm

  30. US Preventive Services Task Force (2014). USPSTF A and B recommendations. Available at uspreventiveservicestaskforce.org/Page/Name/uspstf-a-and-b-recommendations/

  31. CDC. (2014). National Notifiable Diseases Surveillance System (NNDSS). Available at cdc.gov/nndss/default.aspx

  32. North Carolina Administrative Code (2014). Reporting of communicable diseases. Available at reports.oah.state.nc.us/ncac/title%2010a%20-%20health%20and%20human%20services/chapter%2041%20-%20epidemiology%20health/subchapter%20a/10a%20ncac%2041a%20.0101.html

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  34. Nets for Life (2011). Malara FAQs. Available at netsforlifeafrica.org/malaria/malaria-faqs

  35. CDC. (2014l). 2014 Ebola outbreak in West Africa. Available at cdc.gov/vhf/ebola/outbreaks/2014-west-africa/

  36. WHO Ebola Response Team. Ebola virus disease in West Africa—the first 9 months of the epidemic and forward projections. N Engl J Med. 2014;371(16):1481-1495. 

  37. CDC. (2014). Ebola signs and symptoms. Available at cdc.gov/vhf/ebola/symptoms/index.html

  38. CDC. (2014). Ebola information for healthcare workers and settings. Available at cdc.gov/vhf/ebola/hcp/index.html

  39. CDC. (2014). Case definition for Ebola virus disease (EVD). Available at cdc.gov/vhf/ebola/hcp/case-definition.html

  40. North Carolina Department of Health and Human Services 
(n.d.). NCDHHS Ebola information. Available at ncdhhs.gov/
ebola/

  41. North Carolina Department of Health and Human Services (2014). Ebola planning and response dashboard. Available at ncdhhs.gov/ebola/pdfs/Ebola_Planning_Response_Dashboard.pdf


All electronic documents accessed on May 4, 2015.


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From the May 01, 2015 Issue of Clinical Advisor

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CME/CE