Laboratory tools and strategies for methicillin-resistant Staphylococcus aureus screening, surveillance and typing: state of the art and unmet needs

The public health burden caused by methicillin-resistant Staphylococcus aureus (MRSA) infections is now widely recognized, and is a cause of public alarm. Effective MRSA risk management in the healthcare system as well as in the community should rely on accurate detection of reservoirs and sources of transmission, as well as on close monitoring of the impact of interventions on disease incidence and bacterial dissemination. MRSA carrier screening and disease surveillance, coupled with molecular typing, are key information tools for integrated MRSA control and individual risk assessment. These tools should be tailored to the distinct needs of local interventions and national prevention programmes. Surveillance schemes should primarily inform local staff and serve as quality assurance about MRSA risk management. New technologies, including the use of selective culture media and real-time PCR assays, allow faster detection of MRSA carriers upon admission or during stay in healthcare institutions. More research is needed to ascertain their cost-effectiveness for MRSA control. Likewise, tremendous progress has been made concerning molecular typing methods, with optimization and standardization of sequence-based technologies offering broad applicability and high throughput. However, no single S. aureus typing method is yet providing fully reliable information within the range of discrimination needed for public health action. Further refinement of genotyping methods and international harmonization of surveillance and typing schemes must be achieved to facilitate global MRSA control.     

Past,present and future of external quality assessment of medical laboratory testing in Japan

In Japan, three major bodies have conducted external quality surveillance of medical laboratory performance: the Japan Medical Association, the Japan Association of Medical Technologists, and the Japan Society of Registered Medical Laboratories. Although these systems are working very well to elevate the quality of laboratory tests, each has adopted its own surveillance system with little communication. All of these surveillance systems have problems in the evaluation of laboratory proficiency. Thus, the 3 bodies should be unified first to establish an efficient National External Quality Assurance Scheme. New IT technology should also be introduced into the system in the future.     

Design and implementation of a national public health surveillance system in Jordan

Understanding and improving the health status of communities depend on effective public health surveillance. Adoption of new technologies, standardised case definitions and clinical guidelines for accurate diagnosis, and access to timely and reliable data, remains a challenge for public health surveillance systems however and existing public health surveillance systems are often fragmented, disease specific, inconsistent and of poor quality. We describe the application of an enterprise architecture approach to the design, planning and implementation of a national public health surveillance system in Jordan. This enabled a well planned and collaboratively supported system to be built and implemented using consistent standards for data collection, management, reporting and use. The system is case-based and integrated and employs mobile information technology to aid collection of real-time, standardised data to inform and improve decision-making at different levels of the health system.     

Postgraduate training of pathologists]

Specialization of institutions engaged in training of pathologists is a key condition of skilled specialists turn out. Medical colleges should be responsible for training hospital and junior physicians. Institutes for postgraduate medical education must ensure updating of the practicing pathologists knowledge and prepare them for getting special degrees and diplomas including "European Pathologist". The system of continuous training of pathologists should rest on fundamental legal base which should be warranted by the Russian Federation Ministry of Public Health.     

The ALPHA Project: an architecture for leveraging public health applications

OBJECTIVE: Public health surveillance applications are central to the collection, analysis and dissemination of disease and health information. As these applications evolve and mature, it is evident that many of these applications must address similar requirements, such as policies, security and flexibility. It is important a software architecture is created to meet these requirements. METHODS: We outline the requirements for a public health surveillance application, and define a set of common components to address these requirements. These components are configured to produce services used in the development of public health applications. RESULTS: A layered software architecture, the ALPHA architecture, has been developed to support the development of public health applications. The architecture has been used to build eleven surveillance applications for the Public Health Agency of Canada in the areas of disease surveillance, survey, distributed data collection and inventory management. CONCLUSIONS: We have found that a software architecture that addresses requirements on policies, security and flexibility facilitates the development of configurable public health applications. By creating this architecture, key success factors, such as reducing cost and time-to-market of applications, adapting to changing surveillance targets and increasing user efficiency are achieved.     

A case for using grid architecture for state public health informatics: the Utah perspective

This paper presents the rationale for designing and implementing the next-generation of public health information systems using grid computing concepts and tools. Our attempt is to evaluate all grid types including data grids for sharing information and computational grids for accessing computational resources on demand. Public health is a broad domain that requires coordinated uses of disparate and heterogeneous information systems. System interoperability in public health is limited. The next-generation public health information systems must overcome barriers to integration and interoperability, leverage advances in information technology, address emerging requirements, and meet the needs of all stakeholders. Grid-based architecture provides one potential technical solution that deserves serious consideration. Within this context, we describe three discrete public health information system problems and the process by which the Utah Department of Health (UDOH) and the Department of Biomedical Informatics at the University of Utah in the United States has approached the exploration for eventual deployment of a Utah Public Health Informatics Grid. These three problems are: i) integration of internal and external data sources with analytic tools and computational resources; ii) provide external stakeholders with access to public health data and services; and, iii) access, integrate, and analyze internal data for the timely monitoring of population health status and health services. After one year of experience, we have successfully implemented federated queries across disparate administrative domains, and have identified challenges and potential solutions concerning the selection of candidate analytic grid services, data sharing concerns, security models, and strategies for reducing expertise required at a public health agency to implement a public health grid.     

特大地震灾害后平武南坝镇应急卫生快速评估分析

目的了解特大地震后重灾区主要公共卫生问题和需求，确定救灾防疫工作重点和干预策略。方法采用访谈法和调查法，了解当地概况、历史疫情、卫生资源、震灾影响、群众安置、人畜尸体处理、饮用水卫生、饮食卫生、环境卫生、疾病监测体系、灾民与救援部队人员健康状况、卫生处置以及外部需求等，对灾区现场进行全面快速卫生学评估。结果评估结果表明，特大地震灾害后，平武县南坝镇生态环境被破坏；卫生资源受重创且运行困难；环境卫生条件恶化；蝇密度高；生活饮用水、食品卫生存在较大隐患；疾病监测体系亟待建立：急需外部专业防疫力量的援助。结论特大地震灾区初始阶段，生活饮用水、食品卫生与环境消杀以及完善的症状监测体系是确保大灾之后无大疫的关键环节。     

From cause to care: Triple surveillance for better outcomes in birth defects and rare diseases

Better outcomes are a priority for all those who care about birth defects and rare diseases. Public health surveillance and epidemiologic data tracking historically have provided good data on disease occurrence but at most uncertain value in promoting better outcomes, be these in terms of supporting primary prevention or better care.We propose three enhancements to improve the value of surveillance. First, merge: eliminate the largely artificial separation between birth defects and rare diseases in surveillance. Second, expand the scope of surveillance to ‘triple surveillance’: include in surveillance the three components of the causal chain from primary cause (e.g., folic acid insufficiency) to disease occurrence (e.g., spina bifida prevalence) and further to health outcomes (e.g., mortality, morbidity). Third, integrate public health with clinical surveillance: streamline data collection (avoid ‘recreational data collection’) and use the data rapidly not only for epidemiologic assessment but also for evaluation and improvement of clinical care.Many countries have one or more of the elements of this framework already in place. Typically, however, they are not integrated, and work and data get wasted. Fundamentally, these enhancements require rethinking priorities, partnerships and data sharing policies. By reducing waste (e.g., activities leading to data being collected but not used) they will add value and probably decrease costs. Importantly, such systems can help make visible the health issues of a population and the benefits (or lack thereof) of interventions, and support quality improvement in prevention and delivery of care.     

Propagation of program control: a tool for distributed disease surveillance

PURPOSE: The purpose of the study was (1) to identify the requirements for syndromic, disease surveillance and epidemiology systems arising from events such as the SARS outbreak in March 2003, and the deliberate spread of Bacillus anthracis, or anthrax, in the US in 2001; and (2) to use these specifications as input to the construction of a system intended to meet these requirements. An important goal was to provide information about the diffusion of a communicable disease without being dependent on centralised storage of information about individual patients or revealing patient-identifiable information. METHODS: The method applied is rooted in the engineering paradigm involving phases of analysis, system specification, design, implementation, and testing. The requirements were established from earlier projects' conclusions and analysis of disease outbreaks. The requirements were validated by a literature study of syndromic and disease surveillance systems. The system was tested on simulated EHR databases generated from microbiology laboratory data. RESULTS: A requirements list that a syndromic and disease surveillance system should meet, and an open source system, "The Snow Agent system", has been developed. The Snow Agent system is a distributed system for monitoring the status of a population's health by distributing processes to, and extracting epidemiological data directly from, the electronic health records (EHR) system in a geographic area. CONCLUSIONS: Syndromic and disease surveillance tools should be able to operate at all levels in the health systems and across national borders. Such systems should avoid transferring patient identifiable data, support two-way communications and be able to define and incorporate new and unknown diseases and syndrome definitions that should be reported by the system. The initial tests of the Snow Agent system shows that it will easily scale to national level in Norway.     

Web-based infectious disease reporting using XML forms

OBJECTIVE: Exploring solutions for infectious disease information sharing among hospital and public health information systems is imperative to the improvement of disease surveillance and emergent response. This paper aimed at developing a method to directly transmit real-time data of notifiable infectious diseases from hospital information systems to public health information systems on the Internet by using a standard eXtensible Markup Language (XML) format. METHODS: The mechanism and work flow by which notifiable infectious disease data are created, reported and used at health agencies in China was evaluated. The capacity of all participating providers to use electronic data interchange to submit transactions of data required for the notifiable infectious disease reporting was assessed. The minimum data set at national level that is required for reporting for national notifiable infectious disease surveillance was determined. The standards and techniques available worldwide for electronic health data interchange, such as XML, HL7 messaging, CDA and ATSM CCR, etc. were reviewed and compared, and an XML implementation format needed for this purpose was defined for hospitals that are able to access the Internet to provide a complete infectious disease reporting. RESULTS: There are 18,703 county or city hospitals in China. All of them have access to basic information infrastructures including computers, e-mail and the Internet. Nearly 10,000 hospitals possess hospital information systems used for electronically recording, retrieving and manipulating patients' information. These systems collect 23 data items required in the minimum data set for national notifiable infectious disease reporting. In order to transmit these data items to the disease surveillance system and local health information systems instantly and without duplication of data input, an XML schema and a set of standard data elements were developed to define the content, structure and semantics of the data set. These standards make it possible to view and analyse the data accurately outside the hospital information systems in many different document formats. The paper also identified other issues involved in notifiable disease reporting in the future, such as the adoption of approved vocabulary standards and implementation problems such as the route, secure transfer, parsing, and objective identifying of the XML message. CONCLUSIONS: XML is an increasingly important standard for exchange and transmission of data between disparate applications and systems. As in its early stages of developing an interoperable health information system in China, the XML document structures could be a way to exchange the notifiable case information among interest parties on the web at present.     

National public health information system

Information production and its communication being a key public health activity, developing modern information systems is a precondition for its fulfilling these assignments. A national public health information system (NPHIS) is a set of human resources combined with computing and communication technologies. It enables data linkage and data coverage as well as undertaking information production and dissemination in an effective, standardized and safe way. The Croatian Institute of Public Health LAN/WAN modules are under development. Health Safety System, Health Workers Registry, and Digital Library are among the Institute's developmental priorities. Communication between NPHIS participants would unfold over the Internet by using every relevant data protection method. Web technology-based applications would be run on special servers. Between individual applications, use would be made of the transaction module of communication through an exchange of the HL7 standard-based xml messages. In the conditions of transition, the health system must make an optimal use of the resources, which is not feasible without applying modern information and communication technologies.     

Surveillance of antimicrobial resistance—what, how and whither?

Objective   To express the views of a working party held to consider antibiotic resistance surveillance systems, their strengths and weaknesses, and their current and future applications.
Methods   The participants, all of whom were experienced in this field, discussed the development of surveillance systems in relation to the increasing prevalence of resistance to antibacterial agents and the current interest in surveillance systems shown by many official bodies, in both the human and veterinary fields. The problems inherent in surveillance systems were considered together with the applications of different systems.
Results   The properties of good antibiotic resistance surveillance systems were defined. Surveillance systems vary widely from those with a narrow base, focusing on few organisms in one disease area, to those covering many diseases, many organisms (including normal flora) and many compounds. Whatever their design, they should be able to detect significant differences and shifts in susceptibility to various antibacterial agents, and the information derived from them should reach as many interested parties as possible in a timely manner. In using this information to decide strategies, criteria for action need to be determined by pragmatic consensus. Funding remains a major problem, with few large studies being supported by official bodies in spite of their professed enthusiasm for surveillance. In consequence, many current systems are funded by the pharmaceutical industry and are of necessity restricted in their focus.
Conclusions   Antibiotic resistance surveillance studies should and can be well planned and well executed. Many current systems suffer from well-recognized but uncorrected biases. Consortium funding will be necessary for large schemes to be successful. There is no 'ideal' surveillance system.     

Understanding the information needs of public health practitioners: a literature review to inform design of an interactive digital knowledge management system

The need for rapid access to information to support critical decisions in public health cannot be disputed; however, development of such systems requires an understanding of the actual information needs of public health professionals. This paper reports the results of a literature review focused on the information needs of public health professionals. The authors reviewed the public health literature to answer the following questions: (1) What are the information needs of public health professionals? (2) In what ways are those needs being met? (3) What are the barriers to meeting those needs? (4) What is the role of the Internet in meeting information needs? The review was undertaken in order to develop system requirements to inform the design and development of an interactive digital knowledge management system. The goal of the system is to support the collection, management, and retrieval of public health documents, data, learning objects, and tools.Method:The search method extended beyond traditional information resources, such as bibliographic databases, tables of contents (TOC), and bibliographies, to include information resources public health practitioners routinely use or have need to use—for example, grey literature, government reports, Internet-based publications, and meeting abstracts.Results:Although few formal studies of information needs and information-seeking behaviors of public health professionals have been reported, the literature consistently indicated a critical need for comprehensive, coordinated, and accessible information to meet the needs of the public health workforce. Major barriers to information access include time, resource reliability, trustworthiness/credibility of information, and “information overload”.Conclusions:Utilizing a novel search method that included the diversity of information resources public health practitioners use, has produced a richer and more useful picture of the information needs of the public health workforce than other literature reviews. There is a critical need for public health digital knowledge management systems designed to reflect the diversity of public health activities, to enable human communications, and to provide multiple access points to critical information resources. Public health librarians and other information specialists can serve a significant role in helping public health professionals meet their information needs through the development of evidence-based decision support systems, human-mediated expert searching and training in the use information retrieval systems.     

Informatics in the Croatian health care system

Informatization process of the Croatian health care system started relatively early. Computer processing of data of persons not covered by health insurance started in 1968 in Zagreb. Remetinec Health Center served as a model of computer data processing (CDP) in primary health care and Sveti Duh General Hospital in inpatient CDP, whereas hospital administration and health service were first introduced to Zagreb University Hospital Center and Sestre Milosrdnice University Hospital. At Varazdin Medical Center CDP for health care services started in 1970. Several registries of chronic diseases have been established: cancer, psychosis, alcoholism, and hospital registries as well as pilot registries of lung tuberculosis patients and diabetics. Health statistics reports on healthcare services, work accidents and sick-leaves as well as on hospital mortality started to be produced by CDP in 1977. Besides alphanumeric data, the modern information technology (IT) can give digital images and signals. Communication in health care system demands a standardized format of all information, especially for telemedicine. In 2000, Technical Committee for Standardization in Medical Informatics was founded in Croatia, in order to monitor the activities of the International Standardization Organization (ISO) and Comite Européen de Normalisation (CEN), and to implement their international standards in the Croatian standardization procedure. The HL7 Croatia has also been founded to monitor developments in the communication standard HL7. So far, the Republic of Croatia has a number of acts regulating informatization in general and consequently the informatization of the health care system (Act on Personal Data Confidentiality, Act on Digital Signature, Act of Standardization) enacted. The ethical aspect of data security and data protection has been covered by the Code of Ethics for medical informaticians. It has been established by the International Medical Informatics Association (IMIA), and the Croatian Society of Medical Informatics (CSMI) has translated it into Croatian and published it on its website. Based on a survey of medical staff attitudes toward health care system informatization, the Croatian health system appears to be ready for informatization. The only requirement is that the present and future health care providers have appropriate medical informatics education, proper computer equipment at their workplace, and an opportunity to participate in the development and/or improvement of the health information system. One of the EU health strategy priorities is the improvement of health information and knowledge. It means that integrated health information systems are required, i.e. systems able to provide key information on health and health care system to the politicians, health professionals and public in general.     

The long road to semantic interoperability in support of public health: Experiences from two states

Proliferation of health information technologies creates opportunities to improve clinical and public health, including high quality, safer care and lower costs. To maximize such potential benefits, health information technologies must readily and reliably exchange information with other systems. However, evidence from public health surveillance programs in two states suggests that operational clinical information systems often fail to use available standards, a barrier to semantic interoperability. Furthermore, analysis of existing policies incentivizing semantic interoperability suggests they have limited impact and are fragmented. In this essay, we discuss three approaches for increasing semantic interoperability to support national goals for using health information technologies. A clear, comprehensive strategy requiring collaborative efforts by clinical and public health stakeholders is suggested as a guide for the long road towards better population health data and outcomes.     

Information infrastructure for inter-organizational mental health services: an actor network theory analysis of psychiatric rehabilitation

In the supply of mental health services to communities, data and information are managed not only by clinical organizations, but also by welfare state agencies and charities. The aim of this study is to use methods of analysis from actor network theory to identify organizational interventions necessary for the development of an information infrastructure for inter-organizational mental health services. Data was collected in a project aimed at developing an information system that supports inter-organizational psychiatric rehabilitation in a Swedish municipality. Three organizational interventions were identified: an integrated service policy defined by the national government, a common legal framework allowing sharing of high-level client data, and commissioned support for local inter-agency workspaces. It is concluded that organizational interventions must be regarded when configuring an information infrastructure for mental health services. Organizational interventions should also routinely be addressed in systems design methods to be used in inter-organizational settings.     

Redesigning electronic health record systems to support public health

Current electronic health record systems are primarily clinical in focus, designed to provide patient-level data and provider-level decision support. Adapting EHR systems to serve public health needs provides the possibility of enormous advances for public health practice and policy. In this review, we evaluate EHR functionality and map it to the three core functions of public health: assessment, policy development, and assurance. In doing so, we identify and discuss important design, implementation, and methodological issues with current systems. For example, in order to support public health's traditional focus on preventive health and socio-behavioral factors, EHR data models would need to be expanded to incorporate environmental, psychosocial, and other non-medical data elements, and workflow would have to be examined to determine the optimal way of collecting these data. We also argue that redesigning EHR systems to support public health offers benefits not only to the public health system but also to consumers, health-care institutions, and individual providers.     

Ethical issues in public health informatics: implications for system design when sharing geographic information

Public health programs today constitute a multi-professional inter-organizational environment, where both health service and other organizations are involved. Developing information systems, including the IT security measures needed to suit this complex context, is a challenge. To ensure that all involved organizations work together towards a common goal, i.e., promotion of health, an intuitive strategy would be to share information freely in these programs. However, in practice it is seldom possible to realize this ideal scenario. One reason may be that ethical issues are often ignored in the system development process. This investigation uses case study methods to explore ethical obstacles originating in the shared use of geographic health information in public health programs and how this affects the design of information systems. Concerns involving confidentiality caused by geographically referenced health information and influences of professional and organizational codes are discussed. The experience presented shows that disregard of ethical issues can result in a prolonged development process for public health information systems. Finally, a theoretical model of design issues based on the case study results is presented.     

Outbreak detection through automated surveillance: a review of the determinants of detection

Public health agencies and other groups have invested considerable resources in automated surveillance systems over the last decade. These systems generally follow syndromes in pre-diagnostic data drawn from sources such as emergency department visits. A main goal of syndromic surveillance systems is to detect outbreaks rapidly and the number of studies evaluating outbreak detection has increased recently. This paper reviews these studies with the goal of identifying the determinants of outbreak detection in automated syndromic surveillance systems. The review identified 35 studies with 22 studies (63%) relying on naturally occurring outbreaks and 13 studies (37%) relying on simulated outbreaks. In general, the results from these studies suggest that syndromic surveillance systems are capable of detecting some types of disease outbreaks rapidly with high sensitivity. The determinants of detection included characteristics of the system and of the outbreak. Influential system characteristics included representativeness, the outbreak detection algorithm, and the specificity of the algorithm. Important outbreak characteristics included the magnitude and shape of the signal and the timing of the outbreak. Future evaluations should aim to address inconsistencies in the evidence noted in this review and to identify the potential influence of other factors on outbreak detection.