Evolution of Public Health Surveillance

When considering the history of public health surveillance, this practical art has evolved from a collection of loosely associated procedures, geared toward communicable disease control, into a robust body of purposefully structured methodologies; each of which targeting one or more of the profuse challenges associated with safeguarding the health and well-being of the global community. Nearly 700 years ago, the idea of using scientifically derived evidence as a precursor for public health interventions was modeled during the European renaissance era (Declich, 1994 & Multiple). Centuries later this tactical train of thought, and its foundational precepts, have been broadly disseminated, slowly ripening into one of the most widely-recognized components of the public health research and practice. However, long before the universal diffusion and uptake of this procedural ideology, its utilization within primitive surveillance approaches was meticulously recorded throughout the archives of human history (Historical References Multiple).

Amongst the earliest verified examples of public health surveillance are found the strategies employed during one of the most vehement epidemics known to man, the pneumonic/bubonic plague (Historical References Multiple). From the accounts of Declich (1994) we learn that, during the Black Death pandemic, government officials in Italy began appointing what would now be considered public health surveillance officers to track all vessels transporting disease-ridden individuals, throughout the region (Declich, 1994). In examining the preventative measures taken during this perilous outbreak, we can extrapolate how the coarse tracking techniques of eld have contributed significantly to the doctrine of modern-day surveillance methods (Moro & McCormick, Ref #11 in Declich, 1994, Others).

Accompanying marked advancements in science, industry, and social institutions, the rudimentary investigation tactics of the fourteenth century underwent an enrichment phase in the proceeding eras, which featured the incorporation of more refined analytic process (Moro & McCormick, Ref #11 in Declich, 1994, Others). This development resulted in the formulation of more comprehensive approaches to disease control and prevention. One prime examples of this temporal progression in surveillance practices can be observed in the exertions of John Graunt, during his analysis of Bills of Mortality records in 1662 (Historical References Multiple). This investigation, which occurred during the London plague outbreak of the time, is considered one of the first documented accounts of the analysis and interpretation of Big Data, for public health purposes (Historical References Multiple).

Nearly a century later, we can trace the origins of epidemiologic surveillance in the United States to the establishment and advancement of the colonial settlements (Historical References Multiple). During this era, chronicled accounts described the process by which communicable conditions such as small pox, cholera, and yellow fever were surveilled through an organized system of observation and reporting, instituted in local taverns (Historical References Multiple). Though the public health pursuits of the early European settlers were influential in shaping future surveillance practices in the United States, without question the most renowned contributions to the contemporary surveillance methods utilized in our nation today are those of Dr. Alexander Langmuir. Known as the father of public health surveillance, Dr. Langmuir was the first chief epidemiologist at the Communicable Disease Center, now known as the Centers for Disease Control and Prevention (Buehler, 2012; Schultz, 2015). Amid joining the CDC in 1949, Langmuir's visionary conjectures within the biomedical sciences led to the manifestation of some of the most celebrated works in applied epidemiology (Buehler, 2012; Schultz, 2015). Shortly after establishing the CDC's Epidemic Intelligence Service (EIS) in 1951, Dr. Langmuir's active surveillance of the 1955 polio outbreak, which he and his colleagues effectively linked back to the mass distribution of faulty vaccines from a tainted supplier, is considered one of his greatest demonstrations of the value of efficient surveillance practices in the nation's history (Buehler, 2012; Schultz, 2015). Today in the United States, and across the globe, Dr. Alexander D. Langmuir's influence on the process by which health-related data is collected, reported, and analyzed is both timeless and immemorial.

Successive innovations in public health surveillance procedures have been shaped by an iterative process that has ushered in an era of practical monitoring techniques that have now begun to incorporate more behavioral and event-based data streams (Historical References Multiple). From measuring dynamic shifts in health status following natural disasters to the unerring tracking of time sensitive events such as drug overdose and suicide, the current landscape of applied epidemiology is now imbued with an abundance of fresh approaches revitalizing the age-old practice of surveillance (Trad/Novel References Multiple). Among these inventive designs we can find the emerging method that constitutes the primary focus of this study, syndromic surveillance.

Syndromic Surveillance in the United States

The functional underpinnings of syndromic surveillance systems have been detailed within the introductory passages of this study, and will be deliberated in the closing discussion; however, it is equally as important that we discuss the historical realities which have led to the current state of syndromic surveillance agendas in the United States. Though the real-time monitoring of health-related indicators is an operational process that has been in existence for decades, its significance, and subsequently the significance of syndromic surveillance, ascended to the forefront of national conversations, following the events of September 11th, 2001 (Historical References Multiple). After suffering such a devastating impedance of national security and public trust, the U.S. government swiftly prioritized the fortification of our defense mechanisms against potential terroristic threats (Historical References Multiple). Consequently, the paramount objectives amongst both the armed forces and public health entities emphasized the need to protect our nation against exposures to weaponized pathogens, such as bacillus anthracis (Historical References Multiple). Throughout this time of conflict and uncertainty, the socio-political climate, in the U.S. and across the globe, continued to perpetuate concerns of biowarfare. This lingering threat urshered in an era of sizable investments into preventative measures, aimed towards safeguarding the nation's wellbeing, as we spearheaded The War Against Terrorism (Historical References Multiple). In response to strong congressional support and hefty financial backing from both public and private industries, many surveillance practitioners began testing practical solutions to combat bioterrorism through the meaningful use of technological advancements (Historical References Multiple). Moreover, after scouring for the most effective means of detecting signs of biowarfare, the establishment of a nation-wide syndromic surveillance systems was recognized as a top priority for accomplishing this feat (Historical References Multiple).

One of the earliest and most renowned syndromic surveillance systems operating in the United States, The Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) was first developed by scientists from the Johns Hopkins Applied Physics Laboratory (JHU-APL) in conjunction with the United States Department of Defense (DOD) (Historical References Multiple). The ESSENCE program was sponsored through special funding from the DOD's Defense Advanced Research Projects Agency (DARPA), an intra-agency faction dedicated exclusively to pioneering advanced technical solutions (Lombardo, 2003; DARPA, 2018). The original system, known as ESSENCE I, was designed to monitor the occurance of infectious disease conditions within U.S. military bases both domestically and abroad (Historical References Multiple). As the ESSENCE I system was being implemented to surveil the health status of military personnel, the JHU-APL team in conjunction with high level public health administrators in the National Capital Region (NCR) began the development of a similar indicator-based surveillance system (Historical References Multiple). This newly contrived instrument, ESSENCE II, would be used to provide the same type of early detection and situational awareness as the EESENCE I program, with the exception that it would operate exclusively for civilian purposes (Historical References Multiple). In its infancy the ESSENCE II pilot program, incubated in the NCR, was only intended to perform a limited amount of surveillance tasks (Historical References Multiple). As local public health practitioners and other operators of the novel surveillance apparatus became acclimated to its operational capacities, the system began to undergo a series of trial runs in a more expansive set of initiatives (Historical References Multiple). Eventually after a significant amount of time was spent evaluating and calibrating the ESSENCE II platform, its utilization transcended the NCR test-bed and began being adopted by various public health and healthcare organizations across the country (Historical References Multiple). Most notably, one of the first jurisdictions outside of the NCR to utilize the newly created ESSENCE II system was the New City York Department of Health and Mental Hygiene (NYC-DOHMH), whose practitioners were also heavily involved in propelling the original NCR trial projects (Historical References Multiple).

As ESSENCE continued to expand and gain notoriety, another syndromic surveillance program that acquired even greater recognition and support throughout the nation was the CDC's Biosense initiative (Historical References Multiple). Biosense is the cloud-based surveillance network found at the core of the CDC's National Syndromic Surveillance Program (NSSP) (Historical References Multiple). In the early stages of the NSSP and the Biosense program, most of the planned efforts of the system were focused on the detection of threats of bioterrorism attacks, similar to the ESSENCE system (Historical References Multiple). Today, Biosense remains the operational core of the NSSP; however, the ESSENCE software has been incorporated into the network, and now assumes all analytic tasks (Historical References Multiple). As we have recounted the time-honored foundations of epidemiologic surveillance, the investigative premise of this dissertation solicits that we explore those eccentric surveillance capacities, which are still being revolutionized today. Hence, the following excerpts will examine a series of scholarly works detailing both mainstream and novel approaches to syndromic surveillance.

Trends in Syndromic Surveillance Publications

The preceding components of this chapter describe the import of syndromic surveillance, within both public health and national security agendas, and its correlation with the increased safety concerns linked to our nation's then impending wartime operations (Trad/Novel References Multiple). Naturally, the first major cluster of published literature regarding the utility of syndromic surveillance systems evaluated its suitability as a real-time detection mechanism, for unforeseen acts of bioterrorism (Trad/Novel References Multiple). These studies investigated the potential advantages of syndromic surveillance from both theoretical and practical perspectives (Trad/Novel References Multiple). Following the nation's war on terror, scientific literature exploring syndromic surveillance methods experienced an influx in studies substantiating its' more expanded operational capacities. (Trad/Novel References Multiple). Amongst these studies, the rapid identification and detection of weaponized influenza suffered a diminished status across a reformation of research agendas, giving way to the monitoring of more seasonal incidences of the flu (Trad/Novel References Multiple). This redirection came on the cusp of the scientific revelation that the biodefense-based detection protocols of syndromic surveillance systems were easily transferrable to the detection of more casual health-related events (Trad/Novel References Multiple). Among these studies were landmark initiatives that supported the case for further investment into syndromic surveillance systems even after the heightened security measures against terrorism began to slowly fade away, as the social and political climates surrounding the issue became more stable (Trad/Novel References Multiple).

Specific Examples of Traditional SS Initiatives

The chronological progression of public health surveillance as an enduring component of the U.S. public health system has ultimately led to an impetus of derivative surveillance applications (Trad/Novel References Multiple). These systems have harnessed a gamut of unconventional tactics, and continue to evolve (Trad/Novel References Multiple). In respect to this trend, and the potential implications of this research study, it is necessary to survey published literature exhibiting both standard and non-standard approaches to syndromic surveillance.

Enacting this style of examination should yield a robust profile of the current body of knowledge surrounding the utility of syndromic surveillance systems, while adhering to the more specific topical emphasis of this dissertation. Thus, the following appraisal of syndromic surveillance methods will stratify the associated publications into two subsets: 1.) the traditional 2.) and non-traditional applications of syndromic surveillance, which in itself is considered one of the most pristine non-traditional methods of public health surveillance. To commence this process, we begin with an overview of peer-reviewed investigations utilizing syndromic surveillance for its intended purpose, the early detection of threats of bioterrorism and infectious disease outbreaks.

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