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Question: Discuss about the Australian Public health Surveillance System. Answer: Notification and Surveillance Hemolytic uraemic syndrome (HUS) is a rare but serious disease, distinguished by acute renal damage in young children and grownups (1). Mostly, this clinical syndrome, being a systemic thrombotic microangiopathy can affect the life expectancy of the patients, due to the diverse etiologies (2). In Australia, HUS is a notifiable infectious disease, as per the Public Health Act 1997 (3), making it obligatory for the health professionals to comply with the prevailing enforceable Code of Practice 2006 (4). This essay is an attempt to investigate why the HUS is notifiable, and how this is achieved through the Australian surveillance system. An overview of the Australian Public health surveillance system The Australian public health surveillance is a continuous, systematic compilation and analysis, as well as interpretation and dissemination of crucial data, relating to a specific health oriented event for reducing its morbidity and mortality. It is presumed that the availability of such data will enhance the health of the Australians through public health initiatives and program planning, as well as their assessment. It can steer a sudden action for incidents that have public health importance, and measure the amount of disease burden and health concerns. The surveillance data could be used for monitoring disease status, program evaluation, public policy development, and many more, while perceiving systemic changes in implementing health practices. They will also become helpful in prioritizing the health resource allocation and the epidemiologic research-promotion (5). Process and methods of the surveillance system Australia is a federation of six states and two territories, namely, Queensland, New South Wales, Tasmania, South Australia, Victoria, Western Australia, the Australian Capital and the Northern province. The State and the territorial health departments collect notifications of communicable diseases, according to their corresponding public health legislations. The National Health Security Act 2007 provides them the authority for exchanging health information between them and the Government. It is under the purview of this Act that the National Notifiable Diseases List has been established, to look after the operational arrangements, such as the formation and development of the existing surveillance and reporting systems. In 2014, in lieu of this Agreement, the states and territories renewed notification data, relating to 65 communicable diseases for listing under the national communicable disease surveillance (3). In the Australian surveillance system, the legislators and the public health officials are entitled to implement the health surveillance activities throughout the country, for meeting the public needs. The surveillance systems adopted for these actions range from the collection of data belonging to a single case, to multiple data formats and surveys, through the electronic systems. These systems will have the likelihood of expansion, keeping the patient safety, confidentiality, and the system security at optimum level (5). The health surveillance is not limited to a biological monitoring, as it is a prolonged process, consisting of gathering information about an individuals occupational history, physical examination and testing for biological monitoring (6). Methods The National Notifiable Diseases Surveillance System (NNDSS) requires (i) unique record-reference number (ii) name of the notifying state or territory (iii) the disease-code (iv) status of confirmation, and (v) the date of notification by the concerned health department. Other types of data needed are: (i) personal details, like birth date, age, sex, indigenous status, and many more, including disease commencement date, specimen collection date, reference number of the outbreak, etc. The quality of the data and surveillance will be monitored and updated periodically by the Health Protection and the National Surveillance Committee (NSC). All information about the communicable disease surveillance is exchanged through different channels, like the tele-conferences of the Communicable Diseases Network Australia (CDNA). In addition, the journal of Communicable Diseases Intelligence (CDI) publishes current surveillance data, annual reports, and articles about the communicable diseases in A ustralia (3). Components and attributes of an effective Surveillance system The surveillance system components: The Australian system of public health surveillance focuses on the communicable diseases and other health conditions, such as injuries, environmental hazards, occupational health and safety, birth defects, drug addictions, severe diseases, mental health, and other health behaviors. The players in the system are public health agencies, voluntary health care organizations, and hospitals, and also the non-government organizations. All surveillance systems collect, review, and evaluate, as well as transform the data collected for public health accomplishment (15). The public health system attributes: A public health surveillance scheme monitors the acute health-related events, by identifying and reducing the risks due to them. It is constructive, if it helps in alleviating the problems associated with the health-related event, from its first insignificant condition to its ongoing significance. The surveillance system data supply several performance measures for the needs assessments and system accountability. Therefore, a representative surveillance system needs to be identified as uncomplicated, flexible, tolerable, and steady, for promoting a public health action. Such a surveillance system has the following attributes: Simplicity- provides the structure and ease of operation in meeting the objectives. Flexibility- displays adaptive nature to changing information requirements with minimal time, personnel, and funds. It is viable for new health events and any other system variation. Data quality- reflects the reliability and the fullness of the system data. Acceptability ensures the participation of persons and institutions in the surveillance through their consents Sensitivity- denotes the level of the reported health related event and the systems capability to detect the outbreaks. Predictive Value Positive- provides the reported proportion of the cases placed under surveillance. Representativeness- describes the rate of recurrence of a health related event and its distribution, according to population, place, and individual. Timeliness suggest the speed in fulfilling the procedural steps in the surveillance system. tability- assures the reliability and availability of the system for surveillance Australian surveillance system and HUS Australian cases of Haemolytic uraemic syndrome are characterized by severe renal impairment, associated with STEC infection. In 2014, there were 20 notified cases of HUS, whereas in 2013, the number of HUS cases reported was only 15. Out of this, about 55% of notifications belonged to the states of New South Wales and Victoria. It was found that in 2014, 45% of the 04 years age group has been the most frequently notified, while half of the cases were in males (3). Summary Protocol The HUS is a microangiopathic haemolytic anaemia, with fragmented red blood cells, leading to thrombocytopenia and severe renal impairment. Out of the two separate clinical sub-groups, the first group shows a prodrome of diarrhea in the summer, whereas the second group lacks diarrheal prodrome, without any seasonal variation. The patients of the latter group may have a family history of HUS, caused by infection, like Streptococcus pneumonia, which can become worse. The studies conducted by the Australian Paediatric Surveillance Unit (APSU) prove that O157:H7 is rare in Australia and that the common one is O111:H. There were no previous national HUS outbreak figures and the incidence of HUS (7). According to the APSU, there were a minimum of 0.58/100,000 incidences of children below 15 years and 1.27 incidences of children below 5 years (7). Considering the etiologic and pathogenic variations in the classifications of hemolytic uremic syndrome, clinical studies have established that the gene mutation that encodes the complement-regulatory proteins are responsible for all types of thrombotic microangiopathy (9). It is also found that the Shiga-toxin-producingEscherichia coli(STEC) O157:H7 is a newly emerged zoonotic pathogen, having severe morbidity (10). In this connection, Vally et al., 2012, reports that the Shiga toxin-producing Escherichia coli (STEC) are an important cause of gastroenteritis in Australia and worldwide and can also result in serious sequelae, such as haemolytic uraemic syndrome (HUS) (8). Majowicz et al., 2014 also hold the same view. They argue that the Shiga toxinproducingEscherichia coli(STEC) are the main reason for the foodborne diseases, resulting in the frequent incidences of HUS and end-stage renal disease (11). The surveillance statistics overview On examining the data available from the national and state notifications, serotypes, mortality, hospitalizations, and the outbreaks, the annual rate of notified STEC illness found in Australia was 0.4 cases per 100,000 each year for the period from 2000 to 2010 (8). During this period, out of the total 822 STEC infection cases notified in Australia, there was only a single notification in the Australian Capital Territory, while South Australia had 413 notifications, where the surveillance for STEC infection was intense. The notification rate in the whole Australia was 0.12 cases per 100,000 each year, for STEC O157 infections, in the 9 year period, with 11 outbreaks, due to STEC. The surveillance statistics show that the STEC infections and HUS cases displayed a seasonal distribution, with most cases occurred between December and February. When compared to other developed countries, the disease incidence and its burden, due to STEC and HUS, were low in Australia (8). Merits of the public health surveillance on HUS The above facts unequivocally confirm that the HUS surveillance is a way to monitor the trends in STEC O157 infections. The surveillance is necessary to assess the strains of STEC leading to severe illness, and is helpful in evaluating the medical care improvements to control the frequency of HUS in children, having STEC. With the introduction of a consistent marker of STEC incidence, the HUS surveillance could become effective in determining the disease prevention measures. However, the HUS surveillance lacks singular diagnostic test and therefore needs more data to validate every reported incidence of HUS. This improvement is essential to reduce the post-diarrheal HUS incidences among the children, belonging to the age group below 5 years. That was why the HUS was accorded a place in the Healthy People 2010 goal (10). Evaluation As per Elliott et al., 2001, the evaluation of the Australian Paediatric Surveillance Unit, which is a functional part part of the Public Health Surveillance System of Australia, has proved that the clinicians perceived surveillance methods as simple and useful. The case sensitivity assessment was acceptable and the predictive value of notification was above 70%. The professional support of the pediatric system and the streamlined reporting scheme, the clinician workload, and the clinical practice paved the way for a higher level of compliance. The educational impact was evolved through the dissemination of information, such as newsletters, periodical reports, presentations, publication, etc. The monitoring of the association between hemolytic uremic syndrome and Shiga toxin-producingEscherichia coli, were effectively conducted by the other units (12). Though the APSU is capable of monitoring the disease incidence trend management, there is considerable delay in case identification. By giving proper background information on haemolytic uraemic syndrome cases nationally, the surveillance system could investigate an outbreak in South Australia, immediately after the condition was listed on the monthly card. The HUS data have enhanced the disease control and prevention strategies, such as changing the code for the fermented meat production, forwarding haemolytic uraemic syndrome notifications to the state public health departments, and educating the public about food storage and preparation. Since a surveillance systems success is solely based on its capability to meet specific requirements, the CDC has changed its approach, by adopting stringent measures in evaluating the surveillance systems. Despite these changes, the appropriateness in evaluating the surveillance unit was not at all effective (13). The reason for the above situation was the presence of two fundamental problems in the system. The first one was the inconsistency in the reported rates of incidence of infections and the rate of actual incidents. The second issue was the inability to detect the trends in the non-O157 STEC infections, as they cannot be detected through routine plating stool specimens. It is because, the passive surveillance for HUS will not have the microbial diagnostic element, which is salient to an active surveillance system. Apart from these distinct problems, the authentic surveillance data are essential for preventing HSU infections, and therefore the national HUS surveillance system will need to gather and disseminate information for assessing the emerging new vehicles of STEC transmission (14). Significance of public health surveillance In order to put an epidemic under surveillance, it is essential to monitor the less frequent incidence of outbreaks that affect a very small portion of the population, when such events occur for a specific period and place. Sometimes, the diseases that are unimportant, due to the effective control measures, may require re-assessment because of their capability to emerge again. That means the public health importance of a health oriented incidence is determined by the method adopted for its prevention. Their components include: Indices of frequency and severity Health-related event disparities Expenditure for controlling the outbreak Methods of prevention Clinical action procedures Public apprehension The system could work only if there is a clear and authentic explanation for the health-related event that is placed under surveillance. Such details include symptoms, laboratory results, epidemiology, and other specific information. The evaluation must relate how the public health surveillance system is integrated with all other systems of surveillance and health information. It addresses comorbidity and risk factors, and possible outcomes from the health related event. The components of the surveillance system include all matters that relate to public health information, concerns, hardware, software, interface, and ethical standards (5). Reasons for notification of HUS Public Health Surveillance of communicable disease is a public health priority at the global level for preventing the spread of infectious diseases (18). The criteria for determining a disease as notifiable in Australia are: collection viability, priority, immediate intervention facility, outbreak potential, fatality rate, societal and international concerns, program evaluation, and importance to indigenous health. HUS is a notifiable condition regardless of cause and the infectious aetiology, due to Shiga toxin-producingEscherichia coli or other infectious agents can result in HUS (16), while Streptococcus pneumoniae can become more severe with a higher mortality and morbidity. Around 40to 60% of children, having HUS needed dialysis, and 3to 5% of them die eventually (17). Conclusion The public health surveillance in Australia collects, analyses, interprets, and disseminates data relating to several infectious diseases that are harmful to public health. The availability of such data enhances the health of the Australians and helps prevent and eradicate communicable diseases, like Hemolytic uraemic syndrome (HUS). The HUS is an acute disease, causing renal damage in children and grownups, and is a notifiable infectious disease, as per the Public Health Act 1997. The need for placing such diseases under surveillance is essential to monitor the incidence of outbreaks and their eradication. However, the surveillance of a contagious disease will become successful only if it meets the system requirements. Though the Australian public health surveillance system is efficient enough to control any disease outbreaks, it still has some weaknesses, despite the unvarying efforts of the Centers for Disease Control and Prevention (CDC). Reference List Parmar, MS. 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