Integrated disease surveillance and response

A. Indications for nutritional therapy

Improving client outcomes through differentiated practice: Serum albumin, pre-albumin, and transferrin should not be used as markers of nutritional status but instead should be considered surrogate markers of risk and level of inflammation Acta Odont Scand ; A general framework was presented earlier see Figure , representing a holistic model of causes of malnutrition and mortality, which was endorsed by most international organizations and nutrition planners. Monitoring these policies and programmes will therefore require three different types of evaluations , namely monitoring implementation of programmes, evaluation of programme impact, and, keeping track of general trends in the nutritional situation.

Nutrition Landscape Information System (NLiS)

Dental sealants Also called pit-and-fissure sealants, these are thin plastic coatings that are applied to pits and fissures in teeth to prevent decay.

Dentate Having one or more natural permanent tooth present in the mouth excluding third molars. Edentulous Having no natural permanent teeth in the mouth excluding third molars.

Also called complete tooth loss or edentulism. Enamel fluorosis A hypomineralization of enamel, characterized by greater surface and subsurface porosity than normal enamel caused by fluoride ingestion during periods of tooth development first 6 years of life for most permanent teeth.

FPL Federal poverty level. Federal poverty thresholds are defined by the U. Census Bureau based on family income and size of family.

A series of surveys fielded by the National Center for Health Statistics. Root caries Tooth decay in the tooth root that it is exposed to the oral environment because of gum recession this part of the tooth that is normally below the gums in a healthy mouth.

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Reliability of Examinations Dental examiners were calibrated periodically by the survey's reference dental examiner. Diagnostic Criteria A list of terms and abbreviations is included to facilitate the reading and interpretation of the diagnostic criteria and results. Discussion Dental Caries Dental caries and tooth loss were among the most common causes for rejection of young men from military service during the Civil War and the two World Wars Dental Sealants Dental sealants are highly effective in preventing dental caries that occur on the surfaces of teeth that have pits and fissures.

Tooth Retention and Edentulism The findings in this report indicate that the prevalence of tooth loss continues to decline in the United States and provides further evidence that edentulism is not inevitable with advanced age.

Enamel Fluorosis Enamel fluorosis is a hypomineralization of enamel, characterized by greater surface and subsurface porosity than normal enamel, and is related to fluoride ingestion during periods of tooth development by young children 55 first 6 years of life for most permanent teeth.

Conclusions This report documents improvements in the oral health of the civilian, U. The following is a list of seven important findings in this report: The decline in the prevalence and severity of dental caries in permanent teeth, reported in previous national surveys, continued during and It has benefited children, adolescents, and adults. A notable proportion of untreated tooth decay was observed across all age groups and sociodemographic characteristics.

No reductions were observed in the prevalence and severity of dental caries in primary teeth. The use of dental sealants among children and adolescents increased substantially. This increase was probably the result of both public and private efforts and denotes a continuing interest in using dental sealants for the prevention of tooth decay. Older adults are retaining more of their teeth and fewer are losing all their teeth.

Prevalence of enamel fluorosis has increased in cohorts born since This increase should be evaluated in the context of total fluoride exposure. Recommendations for Public Health Action Appropriate public health interventions to prevent dental caries should extend to all age groups and sociodemographic categories. Factors related to the lack of reduction of dental caries in primary teeth need to be studied.

Programs designed to promote oral health e. Timely surveillance tools are needed to monitor fluoride exposure from multiple sources. Acknowledgments The authors thank former members of the U. A coefficient of agreement for nominal scales. Educ Psychol Meas ; Percent agreement, Pearson's correlation and kappa as measures of inter-examiner reliability. J Dent Res ;5: J Dent Res in press.

Criteria for diagnosis of dental caries. American Dental Association; Studies on dental caries: Dental status and dental needs of elementary school children.

Public Health Rep ; A measurement of dental caries prevalence and treatment service for deciduous teeth. J Dent Res ; Coronal caries in the primary and permanent dentition of children and adolescents years of age: Coronal and root caries in the dentition of adults in the United States, The prevalence of dental sealants in the US population: Tooth retention and tooth loss in the permanent dentition of adults: The investigation of physiological effects by the epidemiological method.

Fluoride and dental health. American Association for the Advancement of Science; The differential diagnosis of fluoride and non-fluoride enamel opacities. Oral health of United States children. The national survey of dental caries in U. National and regional findings. US Public Health Service; National Health and Nutrition Examination Survey, Age adjustment using the projected U. National Center for Health Statistics; Healthy People Statistics Notes.

Schenker N, Gentleman JF. On judging the significance of differences by examining the overlap between confidence intervals. Prevalence and trends in enamel fluorosis in the United States from the s and s. J Am Dent Assoc ; Oral health status in the United States: J Dent Edu ; Decayed, missing, and filled teeth in adults, United States, Decayed, missing, and filled teeth among children, United States.

HSM , Series 11, No. Decayed, missing, and filled teeth among youths years, United States. HRA , Series 11, No. The prevalence of dental caries in United States children, Oral health of United States adults. The national survey of oral health in U.

The future of the caries decline. J Public Health Dent ; Trends in caries prevalence in North American children. Int Dent J ;44 4 Suppl 1: Caries prevalence in the United Kingdom. Trends in dental care among insured Americans: Estimating rates of new root caries in older adults.

Oral health in America: Relationship between smoking and dental status in , , , and year-old individuals. J Clin Periodontol ; Tobacco use and oral disease. J Dent Educ ; Ten-year cross-sectional and incidence study of coronal and root caries and some related factors in elderly Swedish individuals.

National Institutes of Health. Consensus development conference statement on dental sealants in the prevention of tooth decay. Factors influencing the effectiveness of sealantsa meta analysis. Community Dent Oral Epidemiol ; Task Force on Community Preventive Services. Recommendations on selected interventions to prevent dental caries, oral and pharyngeal cancers, and sport-related craniofacial injuries. Am J Prev Med ;23 1 Suppl: Comparing the costs of three sealant delivery strategies.

Impact of targeted, school-based dental sealant programs in reducing racial and economic disparities in sealant prevalence among schoolchildrenOhio, Measuring oral health and quality of life. Risk factors for total tooth loss in the United States; longitudinal analysis of national data.

Surveillance for use of preventive health-care services by older adults, Public health and aging: The impact of edentulousness on food and nutrient intake. The impact of oral health on stated ability of eat certain food; findings from the National Diet and Nutrition Survey of Older People in Great Britain.

Intake of non-starch polysaccharide dietary intake in edentulous and dentate persons: Br Dent J ; How dentition status and masticatory function affect nutrient intake.

The impact of dental status on diet, nutrition and nutritional status in U. University of London; The relationship among dental status, nutrient intake, and nutritional status in older people.

Association of edentulism and diet and nutrition in US adults. The relationship between oral health status and body mass index among older people: Shortened dental arches and oral function.

J Oral Rehab ;8: Agerberg G, Carlsson GE. Chewing ability in relation to dental and general health: Acta Odont Scand ; An oral health strategy for England. Department of Health; The nature and mechanisms of dental fluorosis in man.

Risk of enamel fluorosis associated with fluoride supplementation, infant formula, and fluoride dentifrice use. Am J Epidemiol ; Use of fluoride supplementation by children living in fluoridated communities. Risk factors for enamel fluorosis in a fluoridated population. Risk factors for enamel fluorosis in a nonfluoridated population.

Risk factors for enamel fluorosis in optimally fluoridated children born after the US manufacturers' decision to reduce the fluoride concentration of infant formula. Fluorosis risk from early exposure to fluoride toothpaste. The cost of non-collection may be measured, in the case of a food subsidy programme, for example, by the difference between the cost of the programme if it is carried out without particular targeting, in the absence of any indicator allowing targeting, and the cost of the programme for the target population, plus the cost of targeting, if the programme is to be directed at a high risk group only.

Nevertheless, information on the cost of collecting an indicator for each situation is seldom available.

It is difficult to measure, and estimates are generally based on the cost of different types of survey within the country, taking account of the fact that several indicators are collected at the same time. Indicators can be categorized schematically in the following way according to the level at which they are produced or made available:. They include both indicators regarding the implementation of services as well as indicators regarding the situation or the impact of actions under way.

It is generally easy to obtain them from the departments concerned, which usually have time series that are very useful in distinguishing medium- and long-term trends. Even so, it is not always possible to cross-tabulate these indicators, since they do not necessarily come from the same databases and are accessible only in a relatively aggregated form. It is also difficult to verify the quality of the original data. Lastly, even if the data are collected on a frequent basis monthly reports, for example , recovery and analysis may take too long.

Such data tend not to be immediately accessible except in summary form, although it is easy to organize new analyses with the departments in charge of them.

These data allow statistical cross-tabulation to be made between the many variables collected simultaneously on the sample. Although carried out at best at very long intervals, they can be updated with reasonable projections, especially if information on trends in the fields of interest, based on routinely collected data, are also available. These data are often kept together in national statistical offices. They consist of a regular collection of information based on a small number of selected indicators.

The system varies by country, those that perform best are based on an explicit conceptual framework and are linked to a clear decision-making mechanism. They can represent a sound basis for central monitoring. A particular category is derived from surveys conducted by international bodies for various purposes: These cross-sectional surveys are conducted directly at household level on samples which are representative at national level but of variable size; they include a wide variety of indicators in number, goals and qualities and are now frequently repeated.

Although conducted peripherally, they are generally available and used centrally. These sources, which are in principle fairly reliable, benefit from an advanced level of analysis allowing causal inference to be derived of relationships among various household indicators, and with individual indicators, such as nutritional status. They represent a precious source when establishing a baseline and when analysing causes prior to launching an intervention.

These are constructed primarily on the basis of routinely collected data from local government offices, community-based authorities. They are usually passed on as indicators or raw data to the central level, and then sent back to the decentralized levels, with varying degree of regularity, after analysis.

They are often disaggregated by district or locality, but are not always representative, since they often refer only to users of the services under consideration. They are generally grouped together at the central administrations of regions or administrative centres. The indicators relate primarily to activities that lend themselves to regular observation, either because they record activities indicators of operation or delivery of services or because they are necessary for decision-making crop forecasts, unemployment rates or for monitoring purposes market prices of staples, number of cases of diseases, etc.

They do not necessarily include indicators of the causes of the phenomena recorded and are not in principle qualitative indicators. Indicators collected at decentralized levels should meet both the needs of users on these levels and also those of users on the central level for the implementation and monitoring of programmes.

If these regularly compiled indicators do not have any real use at the local level and are intended only for the national central level, there is a danger that their quality will drop over time, for lack of sufficient motivation of those responsible for collection and transmission - and gaps are therefore often found in available data sets. Nevertheless, they are invaluable in giving a clear picture of the situation on the regional or district level, together with medium-term trends.

Generally speaking, their limitation is the low level of integration of data from different sectors. A certain number of indicators, particularly those concerning the life of communities or households and not touching on the activities of the various government departments, are not routinely collected by such departments and are in any case not handed on to the regional or central offices. They are sometimes collected at irregular intervals by local authorities, but most often by non-governmental organizations for specific purposes connected with their spheres of activity - health, hygiene, welfare, agricultural extension, etc.

Analytical capabilities are often lacking at this level, and the available raw data may not have led to the production of useful indicators. Action therefore should be taken to enhance analytical capacities or else sample surveys will have to be carried out periodically on these data in order to produce indicators.

A sound knowledge of local records and their quality is needed to avoid wasting time. New collection procedures often have to be introduced for use by local units, while being careful not to overload them or divert them from their own work. Otherwise a specific collection has to be carried out by surveying village communities targeted for analysis or intervention. These surveys are vital for a knowledge of the situation and behaviours of individuals and households and an evaluation of their relationship with the policies introduced.

In general, they offer an integrated view of the issues concerned. They may have the aim of supplying elements concerning the local situation and local analysis, in order to confirm the consensus of the population and of those in charge as to the situation and interventions to be carried out, and also to allow an evaluation of the impact of such interventions.

The participatory aspect should be emphasized rather than the precision or sophistication of data. An FAO work on participatory projects illustrates issues of evaluation, and especially the choice of indicators in the context of such projects FAO If data already collected are used or if a new survey is carried out for use on a higher level, the size and representativeness of the sample must be checked, and it must be ensured that the data can be linked to a more general set on the basis of common indicators collected under the same conditions method, period, etc.

Verification of the quality of the data is crucial. Before undertaking a specific data collection, a list of indicators and of corresponding raw data should be developed which can be used by services at all levels; it is not unusual to find that surveys could have been avoided by a better knowledge of the data available from different sources. To track down these useful sources and judge the quality of the data available and their level of aggregation, a good understanding is needed of the goals and procedures of the underlying information system.

The country had set up a monthly national information system on production estimates for 35 crops, covering information on crop intentions, areas actually planted, crop yields and quantities harvested in each state.

The information was obtained during monthly meetings of experts at various levels - local, regional and national. The information was then put together at the state level, and then at the national level, reviewed by a national committee of experts, and sent on to the central statistics office.

The different levels thus had some rich information at their disposal, coming from a range of local-level sources. Although it was certainly fairly reliable, being confirmed by a large number of stakeholders and experts, its precision could not be defined, in view of its diversity.

The usefulness of such data varies depending on information needs and thus on the quality of the data required. Data concentrated at the central level are probably useful primarily for analysing trends. On the other hand, apart from the figures, more general information on production systems exists at local level, and this can be useful for identifying relevant indicators of causes, or for simplifying monitoring of the situation.

We have seen that there is a great number of indicators which differ widely in quality; the availability of corresponding data is variable, and any active collection will be subject to constraints. Therefore the choice of indicators must be restricted to the real needs of decision makers or programme planners. This implies that a method is needed for guiding the choice. The main elements that will guide choice are: Any intervention is based on an analysis of the situation, an understanding of the factors that determine this situation, and the formulation of hypotheses regarding programmes able to improve the situation.

A general framework was presented earlier see Figure , representing a holistic model of causes of malnutrition and mortality, which was endorsed by most international organizations and nutrition planners.

However, the convenient classification that it implies, for instance into levels of immediate, underlying or basic causes needs to be operationalized through further elaboration in context. The benefit of constructing such a framework, over and above the complete review of the chain of events which determine the nutritional situation, is to allow the expression, in measurable terms, of general concepts which, because of their complexity, are not always well defined.

For example, it is not enough to refer to "food security"; one should state which of the existing definitions is to be used, on which dimensions of food security the focus is placed and the corresponding indicators. The use of conceptual frameworks when implementing programmes or planning food and nutrition is not new. Many examples have been developed, focusing on different aspects.

The concept of food security is generally perceived as that of sufficient availability of food for all. However, several dozen different definitions have been proposed over these last 15 years! This concept may, for example, comprise different aspects depending on the level being related to: In the first case, analysis will focus on agricultural production, and in the second the emphasis will be on improving the resources of those who lack access to a correct diet.

This preliminary brainstorming exercise will allow a better definition of the perceived chain of causes production shortfall, excessive market prices, defective marketing infrastructures, low minimum wage, low level of education, etc. It will then be easier to consider potential indicators of the situation and its causes, or potential indicators of programme impact.

Obviously it is not so much the final diagram which is of importance as the process through which it was developed. Insofar as the relations between all the links of the chain of events or flow data, depending on the type of representation have been discussed step by step and argued with supporting facts, the framework will be adapted to the local situation and will become operational. Methodologies have been developed for making this process effective in the context of planning, for example with the method of "planning by objectives" see ZOPP , which comprises several phases: During this planning process, all programme activities, corresponding partners, necessary inputs and resulting outputs as well as indicators for both monitoring implementation and evaluating impact of the programme will be successively identified.

The method acts as a guide for team work, encouraging intersectoral analysis and offering a simplified picture of the situation, so that the results of discussions are clear to all in the team.

Let us again take the example of a problem of food security. It can be broken down into three determining sectors: A series of structural elements can be defined for each sector: These elements affect both production levels and operation of markets. A certain number of macro-economic or specific policies will affect one or all the elements in this block. Each block can be considered in a similar way, and this will provide the groundwork for a theoretical model of how the system works see C.

The final steps in order to operationalize the model are i that of defining indicators that will, in the specific context of the country, reflect the key elements of the system, and ii , once policies and programmes have been chosen, that of identifying which of these indicators are useful for monitoring trends and evaluating programme impact.

This will be the basis for an information system reflecting the overall framework of the programme and how it should work. Another method has been proposed by researchers from the Institute of Tropical Medicine in Antwerp based on their field experience in collaboration with different partners Lefèvre et al. Basically, it stresses the participatory aspect, with the aim of obtaining a true consensus on the local situation, the rationality of interventions in view of the situation, and the choice of indicators.

It includes first a phase in which a causal framework is developed with the aim of providing an understanding of the mechanisms leading to undernutrition in the context under consideration. The framework is constructed in the form of a schematic, hierarchized diagram of causal hypotheses formulated after discussions among all stakeholders.

The way it is built tends to favour a clear, "vertical" visualization of series of causal relationships, eliminating the lateral links or loops that are often the source of confusion in other representations.

In a second phase, a framework is developed linking the human or material resources available at the onset inputs , the procedures envisaged activities , the corresponding results of implementation outputs , and the anticipated intermediate outcomes or final impact of each activity or of the programme.

This tool is very useful for defining all the necessary indicators. This represents the formalisation of a real conceptual scheme. While many representations of conceptual models comprise comparable elements, it is essential that a model should never be considered as directly transposable, since it must absolutely apply to the local context. A direct transposition would therefore be totally counter-productive. While it is obvious that the conceptual analysis must ideally be carried out before the programmes are launched, it can be done or updated at any time, leading to greater coherence and a consensus on current and anticipated actions; this applies even more in a long-term perspective of sustainability.

In operational terms, establishment of a conceptual framework allows to define in a coherent way the various types of indicators to be used at each level. After defining the activities to be undertaken, status indicators referring to the target group will be identified, as well as indicators of causes that will or will not be modified by these activities, and indicators that will reflect the level or quality of the activities performed.

Lastly, indicators will be chosen to reflect the changes obtained, whether or not these are a result of the programme. Identification of precise objectives makes it possible to monitor changes in impact indicators not only vis-à-vis the original situation but also in terms of fulfilment of the objectives adopted. During this initial phase, existing indicators are assessed, as well as those that will be taken from records or collected through specific surveys.

It should be specified who needs this information, as well as who collects the data. In fact, it is important that this choice should be demand-driven, in order to be sure that the information selected is then actually used. One might be dealing with several groups of users who do not exactly have the same needs: In this way, foundations can be laid for an information system essential for monitoring and evaluation.

A proximate, often indirect, indicator will have to be sought and limitations to its validity in the context considered will have to be verified carefully which will depend on the precise objective. For example, can a measurement of food stocks at a given moment be validly replaced in the context under consideration with a measurement of food consumption in order to assess the food insecurity situation of a target group?

Is a measurement of food diversity a good proximate indicator for micronutrient intake? Does it at least consistently classify consumers into strong and weak consumers? Does it allow defining an acceptable level of consumption vis-à-vis recommendations? Will it allow children to be classified correctly vis-à-vis a goal of improved growth?

Validity studies are sometimes available locally, otherwise specific studies can be carried out; hence the usefulness of collaborating with research groups - for example from universities - who will be able to carry out this type of validation study under good conditions. The relationship between two variables, making them interchangeable for defining an indicator, may vary over time as a result of implementation of a programme, and this must be taken into account.

For example, if there is a clear link between family size and food insecurity in a given context, the criterion of family size can simply be taken as a basis for identifying families at risk. However, if a specific programme has been successfully carried out among these families, this indicator could lose its validity. The ideal would be to use the same indicators in all places and at all times in order to have the benefit of common experience regarding collection and analysis, so that direct comparisons can be made.

In practice, however, concepts on indicators evolve steadily with the progress of knowledge, leading to the dilemma of being unable to carry out comparisons either with older series of indicators or with what is being done elsewhere. Comparability within time is obviously a priority in the case of monitoring. Preference will thus be given to indicators that, although not necessarily identical, are comparable, in other words give a similar type of information.

The issue of the comparability of data from different sources has been the subject of studies especially in the field of health indicators. The first indications of disease outbreak or bioterrorist attack may not be the definitive diagnosis of a physician or a lab. Syndromic surveillance systems monitor data from school absenteeism logs, emergency call systems, hospitals' over-the-counter drug sale records, Internet searches, and other data sources to detect unusual patterns.

When a spike in activity is seen in any of the monitored systems disease epidemiologists and public health professionals are alerted that there may be an issue. An early awareness and response to a bioterrorist attack could save many lives and potentially stop or slow the spread of the outbreak.

The most effective syndromic surveillance systems automatically monitor these systems in real-time, do not require individuals to enter separate information secondary data entry , include advanced analytical tools, aggregate data from multiple systems, across geo-political boundaries and include an automated alerting process. A syndromic surveillance system based on search queries was first proposed by Gunther Eysenbach , who began work on such a system in More flu -related searches are taken to indicate higher flu activity.

The results closely match CDC data, and lead it by 1—2 weeks. The results appeared in Nature. Influenzanet is a syndromic surveillance system based on voluntary reports of symptoms via the internet. Residents of the participant countries are invited to provide regular reports on the presence or absence of flu related symptoms.

The system has been in place and running since in the Netherlands and Belgium. The success of this first initiative led to the implementation of Gripenet in Portugal in followed by Italy in and Brasil , Mexico , and the United Kingdom in Some conditions, especially chronic diseases such as diabetes mellitus , are supposed to be routinely managed with frequent laboratory measurements.

Since many laboratory results, at least in Europe and the US, are automatically processed by computerized laboratory information systems, the results are relatively easy to inexpensively collate in special purpose databases or disease registries. Unlike most syndromic surveillance systems, in which each record is assumed to be independent of the others, laboratory data in chronic conditions can be theoretically linked together at the individual patient level. If patient identifiers can be matched, a chronological record of each patient's laboratory results can be analyzed as well as aggregated to the population level.

Laboratory registries allow for the analysis of the incidence and prevalence of the target condition as well as trends in the level of control. For instance, an NIH -funded program called the Vermedx Diabetes Information System [13] maintained a registry of laboratory values of diabetic adults in Vermont and northern New York State in the US with several years of laboratory results on thousands of patients.

Since the data contained each patient's name and address, the system was also used to communicate directly with patients when the laboratory data indicated the need for attention.

Out of control test results generated a letter to the patient suggesting they take action with their medical provider. Tests that were overdue generated reminders to have testing performed.