ADVANCEMENT OF THE SCIENCE
2020). Even setting aside conspiracy theories, disagreements abound regarding COVID-19 death rates. Physician Dr. Leana Wen, for example, suggested that death certificates might be exaggerating COVID deaths (Wen, 2023). Whereas epidemiologist Dr. Michael Osterholm (2023) commented: The idea that someone is already going to die due to an underlying condition is flawed. We are all human and we’re all going to die someday. With that line of reasoning, one could argue that the only valid underlying cause of death to list on a death certificate would be birth. If COVID-19 truly played no role, that would not have been included in the death certificate. In other words, as William Shakespeare put it in Sonnet 60 : Like as the waves make towards the pebbled shore, So do our minutes hasten to their end; Each changing place with that which goes before, In sequent toil all forwards do contend. Surveillance Public health surveillance systems can be passive or active. Passive surveillance refers to data generated without solicitation, inter- vention, or contact, whereas active surveil- lance requires some sort of regular outreach by the agency (Mausner & Kramer, 1985).
but the highest absolute number of deaths and hospitalizations are caused by norovirus because it causes more outbreaks. Active Surveillance The CDC, Food and Drug Administration (FDA), U.S. Department of Agriculture’s Food Safety and Inspection Service (USDA FSIS), and 10 state health departments established in July 1995 the Foodborne Diseases Active Surveillance Network (FoodNet), an active, population-based sentinel surveillance sys- tem to track trends for infections commonly transmitted through food (Centers for Disease Control and Prevention [CDC], 2024). Its sur- veillance area eventually included 50 million people, which is 15% of the U.S. population. Features of FoodNet include: • Contacting clinical laboratories regularly to report out findings and to ascertain what percentage of laboratories are testing for each enteric pathogen. • Contacting physicians to understand prac- tices regarding the diagnosis of acute diar- rheal diseases. • Conducting population surveys, includ- ing random digit dialing and address- based sampling. FoodNet also publishes an online toolbox to let users search and download data and see results displayed on interactive graphs, maps, and charts (www.cdc.gov/FoodNetFast). Surveillance for COVID-19 and Other Viral Respiratory Diseases Currently, surveillance for COVID-19 is all or almost all passive. Individual at-home test results are rarely reported to authorities or governing agencies. Recommended Consolidation Six former advisers to former President Joe Biden provided an opinion on a National Public Radio (NPR) program (Mosley & McMahon, 2022) about what it would take to make the pandemic manageable and to “cre- ate a new normal.” NPR cited three articles the former advisers published in JAMA (Borio et al., 2022; Emanuel et al., 2022; Michaels et al., 2022). Emanuel et al. (2022) stated: The “new normal” requires recognizing that SARS-CoV-2 is but one of several cir- culating respiratory viruses that include
influenza, respiratory syncytial virus (RSV), and more. COVID-19 must now be considered among the risks posed by all respiratory viral illnesses com- bined. Many of the measures to reduce transmission of SARS-CoV-2 (e.g., ven- tilation) will also reduce transmission of other respiratory viruses. Thus, policy makers should retire previous public health categorizations, including deaths from pneumonia and influenza or pneu- monia, influenza, and COVID-19, and focus on a new category: the aggregate risk of all respiratory virus infections. Flu Estimates With a “Multiplier” The Influenza Hospitalization Surveillance Network (FluSurv-NET) is a population- based surveillance system that collects data on laboratory-confirmed influenza-associ- ated hospitalizations among children and adults through a network of acute care hos- pitals in 14 states (CDC, 2023). According to CDC (2021): First, national rates of flu-related hos- pitalizations and in-hospital death were adjusted for the frequency of flu testing and the sensitivity of flu diagnostic assays, using a multiplier approach. However, flu testing practices at sites that contribute to our FluSurv-NET surveillance system may not be representative of flu testing practices for the entire United States. This methodology means CDC tracks posi- tive tests for influenza, then multiplies that out to estimate flu-like hospitalizations. This meth- odology would never capture rising numbers of COVID-19. Similar methods were in use for the 2022–2023 U.S. flu season (as of November 26, 2024, this information is at https://www. cdc.gov/flu-burden/php/data-vis/). Other Strategies in Use Much of the surveillance for influenza and COVID-19 is done separately, but it looks as if many of the recommendations from Eman- uel et al. (2022) are in progress. The National Center for Immunization and Respiratory Diseases (NCIRD) conducts virologic and outpatient illness surveillance, tracks posi- tive COVID-19 and influenza test results at long-term care facilities as well as hospital- izations for laboratory-confirmed influenza, and conducts mortality surveillance (CDC, 2023). Of note:
Foodborne Illness Surveillance
Passive Surveillance CDC has been conducting population-based surveillance for foodborne and waterborne diseases since the 1970s; more specifically, CDC uses NORS to captures data on food- borne, waterborne, and enteric illness out- breaks in the U.S. (Wikswo et al., 2022). State, local, and territorial public health agencies report outbreaks voluntarily. In stark contrast to the estimates by Mead et al. (1999) and Archer and Kvenberg (1985), NORS received a median of 100,563 illness reports per year between 2009 and 2019. NORS was expanded in 2009 to include person-to-person spread and other modes of transmission. Now 62% of reported outbreaks have been attributed to person-to-person spread and 24% to food- borne transmission. E. coli outbreaks have the highest case fatality and hospitalization rates,
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Volume 88 • Number 2
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