Mapping for Surveillance

and Outbreak
Investigation

Mapping for Surveillance

and Outbreak
Investigation
This issue of FOCUS was adapted from the
following online training on the NCCPHP Training
Web Site (http://nccphp.sph.unc.edu/training/):
Infectious disease surveillance and
outbreak investigation using GIS (2004)
Dionne Law, PhD, Spatial Epidemiology Research
Associate
Department of Epidemiology, University of North
Carolina at Chapel Hill

Goals

Describe ways maps can be used in field

epidemiology
Describe how geographic information
systems (GIS) can display and analyze
spatial data
Provide examples of surveillance and
outbreak investigation activities that
relied on GIS
Describe the use of global positioning
systems (GPS) to increase GIS
capabilities

Mapping for Surveillance

and Outbreak
Investigation
Maps are commonly used in

epidemiology to present complicated

information succinctly and clearly
This issue discusses:

How maps can be used in field epidemiology

Commonly used computer software
programs that can capture and analyze data
and integrate them into a spatial display

Maps

Earliest documented
epidemiologic study
relied on mapping

Dr. John Snows

investigation of cholera
outbreak, London,
1854
Used maps and
statistical data to trace
source of outbreak to
public water pump on
Broad Street

Maps

Most noted example of maps to

convey complicated statistical
information comes from outside
public health (1)

1869 map of French armys march to

and retreat from Moscow
Displays multivariate data (army size,
direction, geographic location,
temperature, and time)

Maps

Line widths show size of French army on

advance to Moscow (tan) and retreat (black)
Chart below lines plots temperature

Maps

Map created during disease

surveillance and response activities
around avian influenza, rural
Indonesia, 2005 (2)

Created using participatory mapping

Shows the sequence of events during
outbreak of highly pathogenic H5N1
avian influenza in poultry in a small
village

Maps

Initially spread from House 1 to House 5;

also in second village (6) and broiler farm
(top right)

Photo credit: Dr Gavin Macgregor-Skinner/USAID

Maps

Subsequent investigation revealed

that residents of House 1 and
households in second village worked
at broiler farm
Probably introduced H5N1 virus into
communities by carrying it home on
shoes and clothing

Geographic Information
Systems

Geographic information system

(GIS): a computer program designed
to store, manipulate, analyze, and
display data in a geographic context
GIS capabilities are ideal for use in
infectious disease surveillance and
control, outbreak investigation and
response

Geographic Information
Systems

GIS can help:

Optimize data collection and management

Strengthen data analysis
Strengthen outbreak infrastructure and support
Map epidemic dynamics in near real-time
Quickly plan and target response
Rapidly communicate information
Monitor changes in disease over time
Plan, monitor intervention/eradication programs
Aid emergency preparedness

GIS Example: West Nile

Virus

GIS displays information in map layers

Example: West Nile virus

Street network
Buildings: enclosures for
sentinel species (chicken
coops, horse stalls),
offices, dwellings
Population at risk
Maps of land cover, digital
elevation, precipitation,
temperature, water features,
veterinarians/physicians

GIS Example: West Nile

Virus

After data is entered into GIS tool, you can

Maintain surveillance of case-patient locations

and progression of disease for early outbreak
detection
Identify areas ideal for mosquito breeding and
apply preventive measures
Predict which populations are vulnerable to
infection based on proximity to breeding grounds
Simulate how an epidemic could evolve given
introduction of infected mosquitoes/birds at
various locations
Determine where to target interventions,
strengthen healthcare resources

Surveillance and GIS

Example:
Public Health Mapping
Developed in 1993 by WHO and UNICEF
Programme
to eradicate Guinea worm disease

GIS used to:

Visualize disease foci

Monitor newly infected or re-infected
villages,
Identify populations at risk
Target cost-effective interventions
Monitor eradication efforts

Surveillance and GIS

Example:
Public
Health
Mapping
Technology developed to control one
Programme
disease can enhance control of others

Since Guinea worm project, GIS and

mapping expanded to meet data needs for:

Onchocerciasis (river blindness)

Blinding trachoma
African trypanosomiasis (sleeping sickness)
Lymphatic filariasis (elephantiasis)
Poliomyelitis
Malaria

Surveillance and GIS

Example:
HealthMapper

Elimination of lymphatic filariasis possible

through

Mass drug administration to those at risk

Promotion of intensive hygiene on affected body
parts

Populations at risk, size, location not identified

HealthMapper enabled countries to estimate
prevalence of disease at district level, identify
precise areas to target for mass drug
administration
Also tool for standardizing surveillance,
monitoring indicators in different countries and
regions (3)

Surveillance and GIS

Example:
Roll Back Malaria Partnership

Global partnership to enable effective,

sustainable action against malaria

WHO strategy includes prompt treatment with

effective drugs, vector-control methods, preventive
treatment in pregnancy, emergency and epidemic
preparedness and response

Developed GIS to:

Strengthen surveillance at local level for early

detection, response to epidemics
Complement existing national/international health
monitoring systems
Integrate information on community interventions,
control interventions, private and public health
providers,
partner intervention areas, resources
Be accessible at different levels

Surveillance and GIS

Example: US West Nile Virus
Surveillance

CDC developed national surveillance

plan for WNV to monitor spread of
infection, provide national/regional
information, identify regional
distribution and incidence of other
arbovirus diseases
GIS used to enhance federal
surveillance system, communicate
results to the public

Surveillance and GIS

Example: US West Nile Virus
Surveillance
CDC, US

Geological
Survey
mapped
mosquito,
wild bird,
horse,
human
populations
Tracked in
sentinel
species
(chickens)

2007 U.S. Geologic Survey

Surveillance and GIS

Example: US West Nile Virus
Surveillance

Pennsylvania developed network to combat WNV

Covers all 67 counties

Includes trapping mosquitoes, collecting dead birds,
monitoring horses, people, chickens

WNV Tracking System: spatially-driven

surveillance program for following, responding to
spread of WNV

Collects information on presence of virus, identifies

mosquito-breeding areas, helps target control efforts
Alerts decision makers of new data via e-mail
Generates, posts detailed maps on secure Web site
Data for public release published on WNV Surveillance
Program Web site (www.westnile.state.pa.us/)

Outbreak Investigation
and GIS

GIS used to:

Strengthen data collection,

management, and analysis
Develop early warning systems
Plan and monitor response programs
Communicate large volumes of complex
information in simple, effective way to
decision makers and public

Outbreak Investigation
and GIS Example:
Shigellosis

Fort Bragg, North Carolina, 1997 (4)

59 cases of Shigella sonnei reported

among military health beneficiaries
Significant number of cases were
children
Preliminary investigation did not reveal
associations with daycare or common
location
Outbreak persisted despite education
about hand washing and hygiene

Outbreak Investigation
and GIS Example:
Shigellosis

Imported addresses
of all confirmed
cases into GIS and
mapped onto Fort
Bragg housing
areas

Revealed cluster of
infections on several
streets in one
particular
neighborhood

Outbreak Investigation
and GIS Example:
Shigellosis

Interviews with case families, neighbors

revealed presence of small communal
wading pools in several yards that were
frequented by affected children
Once pools were removed and homebased information campaigns were
initiated, spread of illness was halted

Outbreak Investigation
and GIS Example: STIs

GIS also used to map sexually

transmitted infections
Used in Baltimore to map distribution of
syphilis before, during, after outbreak
(5)

Data suggested that disease spread outward

from 2 central cores of infection

Outbreak Investigation
and GIS Example: STIs

Used to map
distribution of 4
sexually transmitted
infections
(chlamydia,
gonorrhea, syphilis,
and HIV infection) in
Wake County, NC (6)

Found clearly defined

spatially
heterogeneous areas
of infection for
different diseases

Global Positioning Systems

Global positioning systems (GPS) add

function to GIS, increase capabilities
A critical tool for precise
identification of research subjects,
locations, distances to related
geographic features
Allow users to locate positions on
electronic map using satellite
technology

Global Positioning Systems

Example: Atrazine Exposure

RTI International employed GPS-enabled

handheld technology in a National Cancer
Institute study to determine relationship
between exposure to atrazine and distance
from fields where used (7)

Required field trips to verify locations of

households in study area near corn fields in
Illinois
Used HP iPAQ Pocket PC with GPS receiver and
ESRI's ArcPad software (GIS software for
mapping that allows capture, display, analysis
of geographic information on handheld devices)

Global Positioning Systems

Example: Atrazine Exposure

Candidate household
addresses geocoded to
street database, loaded
onto ArcPad with aerial
photographs, street
centerline database

Staff used GPS, street names to find

approximate location of households

Modified original address-matched location (green dots)

to actual location (red dots) based on GPS and rooftops
on aerial map
If households not seen on map, GPS coordinate on
street captured

Global Positioning Systems

Example: Atrazine Exposure

Measured household's distance from corn field

where atrazine used
Concentrations of atrazine in household, in
biological samples from occupants correlated
with distance from atrazine source
Using ArcPad/GPS instead of paper maps

Allowed quick navigation from household to household

Made repositioning of household locations more
accurate
Would have been almost impossible to do under studys
time constraints without this technology
Precisely measured household locations and precise
distances from households to corn fields provided
higher precision during data analysis

Global Positioning Systems

Approach could be applied to infectious

disease surveillance and outbreak
investigation and response

To measure distance to exposure (e.g.,

water source with cryptosporidium or farm
with hoof and mouth disease)

Outbreak investigation and response

are time-limited activities: must be done
quickly to have greatest effect

GIS and GPS can greatly speed field work

Summary

Spread of disease especially infectious

disease is unavoidably spatial

Infection moves from individual to individual

following network of contacts within
population through local or global transmission

GIS capacity to capture geospatial

information ideally suited for infectious
disease surveillance and control; highly
relevant to meet demands of outbreak
investigation and response
Next issue will show how GIS used to
conduct rapid needs assessments

Additional Resources for

GIS Mapping

World Health Organization Public Health

Mapping Programme
http://www.who.int/health_mapping/en/
WHO HealthMapper
http://www.who.int/health_mapping/tool
s/ healthmapper/en/index.html
Roll Back Malaria Partnership
http://www.rbm.who.int/

Further Readings

Melnick, Alan L. Introduction to geographic

information systems in public health.
Gaithersburg, Md: Aspen Publishers; 2002.
Cromley, Ellen K. GIS and public health.
New York: Guilford Press; 2002.
Moore DA, Carpenter TE. Spatial Analytical
Methods and Geographic Information
Systems: Use in Health Research and
Epidemiology. Epidemiologic Reviews.
1999;21(2):143-160.

References
1.
2.

3.

4.

Tufte ER, The Visual Display of Quantative Information.

2nd ed. Cheshire, CT: Graphics Press, LLC; 1983:176.
Macgregor-Skinner G. Avian influenza H5N1: Getting our
ducks in a row. Presentation at: 5th Annual One
Medicine Symposium; December 12-13, 2007; Durham,
NC.
Brooker S, Beasley M, Ndinaromtan M, et al. Use of
remote sensing and a geographical information system
in a national helminth control programme in Chad.
Bulletin of the World Health Organization. 2002;80:783789.
McKee KT, Shields TM, Jenkins PR, Zenilman JM, Glass
GE. Application of a geographic information system to
the tracking and control of an outbreak of shigellosis.
Clin Infect Dis. 2000;31:728-733.

References
4.

5.

6.

7.

Gesink Law DC, Bernstein KT, Serre ML, et al. Modeling a

syphilis outbreak through space and time using the
Bayesian maximum entropy approach. Ann Epidemiol.
2006;16:797-804.
Law DCG, Serre ML, Christakos G, Leone PA, Miller WC.
Spatial analysis and mapping of sexually transmitted
diseases to optimise intervention and prevention
strategies. Sex Transm Infect. 2004;80:294-299.
ArcPadMobile GIS software for field mapping applications.
ESRI Web site. http://www.esri.com/software/arcgis/arcpad/.
Accessed April 23, 2008.
Holmes EE. Basic epidemiological concepts in a spatial
context. In: Tilman D, Kareiva P, eds. Spatial Ecology : The
Role of Space in Population Dynamics and Interspecific
Interactions. Princeton, NJ: Princeton University Press;
1997:111-136.