Introduction to the Summary of Notifiable Noninfectious Conditions and Disease Outbreaks — United States

Ralph J. Coates, PhD1

Ruth Ann Jajosky, DMD1

Martha Stanbury, MSPH2

Steven C. Macdonald, PhD3

1Division of Health Informatics and Surveillance, Center for Surveillance, Epidemiology and Laboratory Services, CDC, Atlanta, Georgia

2Division of Environmental Health, Michigan Department of Community Health, Lansing, Michigan

3Environmental Public Health Division, Washington State Department of Health, Olympia, Washington

Corresponding author: Ralph Coates, Division of Health Informatics and Surveillance, Center for Surveillance, Epidemiology and Laboratory Services, CDC. Telephone: 404-498-0080; e-mail rjc5@cdc.gov.

Preface

With this 2015 Summary of Notifiable Noninfectious Conditions and Disease Outbreaks — United States, CDC is publishing official statistics for the occurrence of nationally notifiable noninfectious conditions and disease outbreaks for the first time in the same volume of MMWR as the annual Summary of Notifiable Infectious Diseases (1).

This two-part publication provides the opportunity for readers to review information on all of the nationally notifiable conditions identified by the Council of State and Territorial Epidemiologists (CSTE) in collaboration with CDC. This combined publication is the result of a February 2013 request by CSTE for CDC to present surveillance data on all nationally notifiable conditions and disease outbreaks in the same publication. In recent years, CSTE formalized and expanded the list of nationally notifiable conditions to include foodborne and waterborne disease outbreaks and four noninfectious conditions: acute pesticide-related illness and injury, cancer, silicosis, and elevated blood lead levels.* After discussion within the organization and with subject matter experts at CDC, CSTE concluded that inclusion of information on all nationally notifiable conditions in the same MMWR annual surveillance summary of nationally notifiable conditions would be useful and important for the public and public health professionals.

This Summary of Notifiable Noninfectious Conditions and Disease Outbreaks includes six chapters treating the following subjects: acute pesticide-related illness and injury arising from occupational exposure (2), cancer (3), elevated blood lead levels among employed adults (4), elevated blood lead levels among children (5), silicosis (6), and foodborne and waterborne disease outbreaks (7). Information about nonoccupational acute pesticide-related illness could not be included this year because the data were not ready for publication. However, the CDC programs involved in pesticide-related illness surveillance activities plan to include these data in the 2016 MMWR publication of the annual Summary of Notifiable Noninfectious Conditions and Disease Outbreaks.

Information on elevated lead exposure is provided in two separate chapters because the sources of lead exposure differ between children and adults. Lead exposure among children is caused principally by deteriorated lead paint found in homes whereas lead exposure among adults occurs principally in the workplace. CDC's National Center for Environmental Health (NCEH) has primary responsibility for preventing disease from environmental (principally nonoccupational) hazards, and CDC's National Institute of Occupational Safety and Health (NIOSH) is responsible for preventing disease from workplace hazards. Because of the separate delegation of responsibilities and differences in sources of lead exposure, CDC has a linked surveillance system for lead exposure with NCEH responsible for the Childhood Blood Lead Surveillance (CBLS) system (5) and with NIOSH responsible for the Adult Blood Lead Epidemiology and Surveillance system (ABLES) (4).

Each of the six chapters in this Summary (Noninfectious) presents the most recent statistics available to the CDC program. Local, state, and territorial public health departments and other agencies within those jurisdictions (e.g., departments of labor, environmental protection agencies, cancer registries, and their agents) submit data on these conditions and outbreaks to CDC programs at the National Center for Chronic Disease Prevention and Health Promotion, the National Center for Emerging and Zoonotic Infectious Diseases, NCEH, and NIOSH. Previously, the programs compiled and published surveillance data on these noninfectious conditions and disease outbreaks periodically in multiple venues with variable timeframes and formats.

The Center for Surveillance, Epidemiology, and Laboratory Services (CSELS) coordinated the development and publication of this summary. Comments and suggestions from readers on this new combined publication are encouraged, including ones about whether the information presented could be made more useful. Comments should be sent to NNDSSweb@cdc.gov.

Background

As with nationally notifiable infectious diseases, nationally notifiable noninfectious conditions and disease outbreaks require regular, frequent, and timely information for prevention and control. A brief history of the reporting of nationally notifiable conditions in the United States is available at http://wwwn.cdc.gov/nndss/case-definitions-history.html. In 1961, responsibility for the collection of data on nationally notifiable diseases and deaths in 122 U.S. cities was transferred from the National Office of Vital Statistics to CDC.

CDC's collection of data on nationally notifiable noninfectious conditions and disease outbreaks is based on surveillance conducted at the local, state, and territorial levels by health departments and other agencies on reportable conditions in each jurisdiction. Legislation, regulation, or other rules in those jurisdictions require health-care providers, hospitals, laboratories, and others to provide information on reportable conditions to public health authorities or their agents. The list of reportable conditions in each jurisdiction varies over time and across jurisdictions; more information is available at http://www.cste.org/?SRCA. Public health surveillance of noninfectious conditions and disease outbreaks at the local, state, and territorial levels protects the public's health by ensuring the proper identification of diseases and health hazards. Public health officials use these data to monitor trends in these conditions, identify populations or geographic areas at high risk, plan prevention and control policies and other interventions, allocate resources effectively, coordinate activities, and assess the effectiveness of their efforts.

A selected set of reportable conditions is designated as nationally notifiable, and case notifications for those conditions are submitted to CDC by state, local, and territorial health departments. Public health officials at state, local, and territorial health departments and CDC collaborate in identifying conditions to consider for national notification. During annual meetings, CSTE, in consultation with CDC, recommends revisions to the list of nationally notifiable conditions. Conditions are added as new pathogens, environmental hazards, or conditions emerge as public health concerns, and conditions are deleted when surveillance is found not to be useful. CDC uses these data to monitor trends at the national level, develops and implements programs, allocates resources, and assesses the effectiveness of national efforts at prevention and control. Current and historic national public health surveillance case definitions used for classifying and counting cases consistently at the national level across jurisdictions are available at http://wwwn.cdc.gov/nndss/case-definitions.html. National surveillance case definitions for noninfectious nationally notifiable conditions and disease outbreaks were added to this website in 2010.

Although reporting of conditions at the local, state, and territorial levels is mandated by legislation or regulations at those levels, submission of case notifications to CDC is voluntary. Under-reporting of noninfectious conditions and disease outbreaks to local and state health departments occurs, and completeness of reporting, and therefore of notifications to CDC, varies by condition (2–13,). A 2002 publication reported similar findings for reporting and notifications of infectious conditions (14).

Although the sources of data for nationally notifiable infectious diseases and for nationally notifiable noninfectious conditions and disease outbreaks are the same (i.e., local, state, and territorial jurisdictions' data on reportable conditions), and the purpose is the same (i.e., monitoring and responding to the condition to improve population health), there are a number of variations and differences among the conditions in this summary (1–7). Case-based surveillance of such nationally notifiable conditions as acute pesticide-related illness or injury, silicosis, and cancer is focused on detecting persons who have a condition that meets the criteria specified in national disease-specific case definitions and on collecting information about those persons' conditions. In contrast, surveillance of outbreaks of foodborne and waterborne illness seeks to identify clusters of sick persons with a common exposure (as opposed to specific diseases). Foodborne disease outbreaks are defined as two or more cases of similar illness resulting from common ingestion of a food, and waterborne disease outbreaks are defined as two or more cases of a similar illness resulting from common exposure to water or water-associated chemicals volatized into the air (http://wwwn.cdc.gov/nndss/conditions/notifiable/2014/outbreaks). Information is collected about the characteristics of the disease outbreaks, including data from epidemiologic and environmental investigations. Even among conditions for which case-based surveillance methods are used, there is substantial variation in what a condition means. For example, for a condition such as elevated blood lead levels, surveillance identifies persons who have been exposed to a hazard on the basis of a laboratory test, but does not necessarily identify persons with a diagnosis of lead poisoning. In contrast, for many other conditions, a diagnosis is needed to meet the case definition for case notification to CDC (http://wwwn.cdc.gov/nndss/conditions/notifiable/2014/noninfectious).

Among the topics treated in this summary, the definitions of the characteristics of the conditions and populations covered also differ. This variability makes it challenging for readers to compare statistics easily across conditions and geographic locations and for public health and medical professionals to develop automated electronic health information systems based on common national standards to improve sharing of information on state-reportable conditions and nationally notifiable conditions.

The meaning of the date of the occurrence of the condition varies among the conditions. For infectious diseases, the meaning of the date varies across jurisdictions as well as by condition, and might be a date of symptom or disease onset, diagnosis, or laboratory result; the date the case was reported to a jurisdiction; the date CDC was notified of a case; the date the criteria in the national surveillance case definition were met; or the date of death (http://wwwn.cdc.gov/nndss/document/MMWR_Week_overview.pdf). For cancer, as for some infectious diseases, including the arboviral diseases, tuberculosis, and human immunodeficiency virus infection diagnosis, it is the date the condition is diagnosed. For silicosis, it is the date of the initial report (e.g., the date of a hospital discharge report, clinician report, or a workers' compensation claim). For lead screening test results, it is the date of a test. For acute pesticide-related illness and injury, it is the date of the pesticide exposure that led to acute illness/injury. For disease outbreaks, it is the date of the illness onset of the first case in the outbreak.

The source and definitions of race and ethnicity vary over time and among conditions. For example, information about race and ethnicity for lead exposure is based on self-report whereas for cancer incidence, it is based on medical records, which might not be based on self-report, or from matching the names of persons with cancer with lists of surnames for different ethnic groups or with tribal registries. For silicosis, race and ethnicity are based on self-report, report from next-of-kin, or from medical records. Race- and ethnicity-specific information among the conditions also might vary depending on differences in the jurisdictions' systems for submitting notifications to CDC and the need to protect confidentiality of private health information.

The chapters in this summary use U.S. Census Bureau data sets for the denominators in the rate estimates. However, there is variation across the chapters in which specific U.S. Census Bureau data sets are used.

There are additional notable differences among the chapters in this annual summary concerning the criteria used by CDC programs to determine which case notifications are summarized and published annually in MMWR (i.e., publication criteria). For data on both infectious or noninfectious conditions to be submitted to CDC from states, territories, or cities, the condition or disease must have been designated as a reportable condition in that jurisdiction for the year of notification to CDC. However, CDC publishes information on foodborne and waterborne disease outbreaks in this annual summary even if the outbreak was not on the jurisdiction's reportable conditions list. Additional criteria, based on characteristics that define the conditions and disease outbreaks (http://wwwn.cdc.gov/nndss/case-definitions.html), are used in making a final determination on publication in this annual summary (Box).

Data Sources

Final data for nationally notifiable noninfectious conditions and disease outbreaks are derived from the surveillance systems of the CDC Centers listed below. Requests for further information regarding these data should be directed to the appropriate Center or program.

• National Center for Chronic Disease Prevention and Health Promotion
  • National Program of Cancer Registries (cancer)
• National Center for Emerging and Zoonotic Infectious Diseases
  • Foodborne Disease Outbreak Surveillance System (foodborne disease outbreaks)
  • Waterborne Disease and Outbreak Surveillance System (waterborne disease outbreaks)
• National Center for Environmental Health
  • Childhood Blood Lead Surveillance (lead exposure test results in children)
• National Institute for Occupational Safety and Health
  • Sentinel Event Notification System for Occupational Risks (SENSOR)-Pesticides Program (acute pesticide related illness)
  • Adult Blood Lead Epidemiology and Surveillance (ABLES) Program (lead exposure test results in adults)
  • State-Based Silicosis Surveillance (silicosis)

References

1. CDC. Summary of notifiable infectious diseases—United States, 2013. MMWR Morb Mortal Wkly Rep 2013;62(53).
2. Calvert GM, Beckman J, Prado JB, et al. Acute occupational pesticide-related illness and injury—United States, 2007–2010. In: CDC. Summary of notifiable noninfectious conditions and disease outbreaks—United States. MMWR Morb Mortal Wkly Rep 2013;62(54):5–9.
3. Singh SD, Henley SJ, Ryerson AB. Surveillance for cancer incidence and mortality—United States, 2011. In: CDC. Summary of notifiable noninfectious conditions and disease outbreaks—United States. MMWR Morb Mortal Wkly Rep 2013;62(54):10–50.
4. Alarcon W, State Adult Blood Lead Epidemiology and Surveillance (ABLES) Program investigators. Elevated blood lead levels among employed adults—United States, 1994–2012. In: CDC. Summary of notifiable noninfectious conditions and disease outbreaks—United States. MMWR Morb Mortal Wkly Rep 2013;62(54):51–74.
5. Raymond J, Brown MJ. Childhood lead exposure—United States, 2007–2012. In: CDC. Summary of notifiable noninfectious conditions and disease outbreaks—United States. MMWR Morb Mortal Wkly Rep 2013;62(54):75–9.
6. Filios MS, Mazurek J, Schleiff P, et al. Surveillance for silicosis—Michigan and New Jersey, 2003–2010. In: CDC. Summary of notifiable noninfectious conditions and disease outbreaks—United States. MMWR Morb Mortal Wkly Rep 2013;62(54):80–4.
7. Dewey-Mattia D, Roberts V, Yoder J, Gould LH. Foodborne and waterborne disease outbreaks—United States, 1971–2012. In: CDC. Summary of notifiable noninfectious conditions and disease outbreaks—United States. MMWR Morb Mortal Wkly Rep 2013;62(54):85–8.
8. Calvert GM, Karnik J, Mehler L, et al. Acute pesticide poisoning among agricultural workers in the United States, 1998–2005. Am J Ind Med 2008; 51:883–98.
9. US Cancer Statistics Working Group. United States cancer statistics: 1999–2011 incidence and mortality web-based report. Atlanta, GA: US Department of Health and Human Services, CDC, National Cancer Institute; 2014.
10. CDC. Very high blood lead levels among adults—United States, 2002–2011. MMWR Morb Mortal Wkly Rep 2013;62:967–71.
11. CDC. Surveillance for elevated blood lead levels among children—United States, 1997–2001. MMWR Surveill Summ 2003;52(No. SS-10).
12. Rosenman KD, Reilly MJ, Henneberger, PK, Estimating the total number of newly-recognized silicosis cases in the United States. Am J Industrial Med. 2003;44:141–7.
13. CDC. Surveillance for foodborne disease outbreaks—United States, 1998–2008. MMWR Surveill Summ 2013;62(No. SS-2).
14. Doyle TJ, Glynn MK, Groseclose SL. Completeness of notifiable infectious disease reporting in the United States: an analytical literature review. Am J Epidemiol 2002;155:866–74.