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PubMed2005

Syndromic surveillance on the epidemiologist's desktop: making sense of much data.

INTRODUCTION: Syndromic surveillance systems are becoming increasingly common in health departments. These systems represent a substantial improvement in the timeliness of ascertainment of community health status. For the value of such systems to be realized, protocols are needed for review and analysis of the findings that these systems produce. METHODS: A workgroup of experienced syndromic surveillance users and developers was convened to discuss approaches to data review and analyses. The discussion was structured to include general principles of the use of syndromic surveillance; how and why specific data are reviewed; integration of multiple data sources; daily versus research uses of systems; how data anomalies are identified by users and surveillance systems; the relative merits of anomalies; how a data anomaly is investigated to determine if it warrants a public health response; and how such a public health response should be framed. RESULTS: From this discussion, a generalized and more detailed process was documented that describes the common elements of analysis used by the workgroup participants. CONCLUSION: Establishment of a framework for evaluation and response to syndromic surveillance data will facilitate the implementation of these systems and standardization of procedures for validation of system findings. Careful development of an evaluation and response framework should be undertaken to assess whether use of syndromic surveillance systems requires excess work to distinguish between statistical anomalies and important public health events.

Data Interpretation, Statistical↗
PubMed2005

Comparison of syndromic surveillance and a sentinel provider system in detecting an influenza outbreak--Denver, Colorado, 2003.

INTRODUCTION: Syndromic surveillance systems can be useful in detecting naturally occurring illness. OBJECTIVES: Syndromic surveillance performance was assessed to identify an early and severe influenza A outbreak in Denver in 2003. METHODS: During October 1, 2003-January 31, 2004, syndromic surveillance signals generated for detecting clusters of influenza-like illness (ILI) were compared with ILI activity identified through a sentinel provider system and with reports of laboratory-confirmed influenza. The syndromic surveillance and sentinel provider systems identified ILI activity based on ambulatory-care visits to Kaiser Permanente Colorado. The syndromic surveillance system counted a visit as ILI if the provider recorded any in a list of 30 respiratory diagnoses plus fever. The sentinel provider system required the provider to select "influenza" or "ILI." RESULTS: Laboratory-confirmed influenza cases, syndromic surveillance ILI episodes, and sentinel provider reports of patient visits for ILI all increased substantially during the week ending November 8, 2003. A greater absolute increase in syndromic surveillance episodes was observed than in sentinel provider reports, suggesting that sentinel clinicians failed to code certain cases of influenza. During the week ending December 6, when reports of laboratory-confirmed cases peaked, the number of sentinel provider reports exceeded the number of syndromic surveillance episodes, possibly because clinicians diagnosed influenza without documenting fever. CONCLUSION: Syndromic surveillance performed as well as the sentinel provider system, particularly when clinicians were advised to be alert to influenza, suggesting that syndromic surveillance can be useful for detecting clusters of respiratory illness in various settings.

Algorithms↗
PubMed2005

Ambulatory-care diagnoses as potential indicators of outbreaks of gastrointestinal illness--Minnesota.

INTRODUCTION: Syndromic surveillance's capability to augment existing surveillance for community-acquired gastrointestinal disease is unknown. OBJECTIVE: The objective of this study was to evaluate the capability of a syndromic surveillance system to detect outbreaks of gastrointestinal disease. METHODS: A retrospective analysis was conducted comparing ambulatory care data from a health plan with a set of 110 gastrointestinal-disease outbreaks identified by the Minnesota Department of Health during 2001-02. Unusual clusters of illness (i.e., signals) in the health-plan data were identified by analyzing daily counts of gastrointestinal illness using an adjusted space-time scan statistic. Concordance was defined as < or =5 km between outbreak and signal and the signal occurring within 1 week of the outbreak. RESULTS: During 104 weeks, the number of signals was roughly what would have been expected by chance, suggesting that the modeling did a good job of estimating the expected counts of illness and that false alarms would not have occurred much more often than the number predicted at the various thresholds. During the same period, the health department identified 110 eligible gastrointestinal outbreaks. Apparent associations of the three statistically most unusual concordant signals with outbreaks of viral or bacterial gastrointestinal illness were ruled out by the health department on the basis of detailed knowledge of the circumstances and low numbers of affected persons seeking medical care. CONCLUSION: No previously known gastrointestinal outbreaks were identified by this surveillance system. However, relatively few recognized outbreaks resulted in patients seeking medical care, and the sensitivity of this system to detect outbreaks of real significance to public health remains to be determined. Prospective evaluation probably will be required to understand the usefulness of syndromic surveillance systems to enhance existing disease surveillance.

Ambulatory Care↗
PubMed2005

Emergency department visits for concern regarding anthrax--New Jersey, 2001.

INTRODUCTION: In October of 2001, after letters processed in Trenton, New Jersey, resulted in multiple cases of anthrax, emergency departments (EDs) in New Jersey experienced an increase in visits from patients concerned about possible exposure to agents of biologic terrorism. Information about the effect of an actual biologic terrorism attack on the emergency department population might be useful in the design of biosurveillance systems, particularly with regard to their performance during the mitigation phase that occurs after an attack. In addition, such information might help identify issues that arise regarding the public health response in the ED setting. OBJECTIVES: The objectives of this report were to identify and characterize ED visits, by patients concerned with exposure to biologic terrorism agents, in selected New Jersey hospitals after the anthrax attack in fall 2001. METHODS: A retrospective cohort design was used in this study. The setting was 15 New Jersey EDs within a 55-mile radius of Trenton. Participants were consecutive patients evaluated by ED physicians for the following four periods in 2001: 1 month before September 11; 1 month after September 11; 1 month after October 11; and for the second month after October 11. Percentages of visits were calculated with a concern for exposure (CE) visits by using International Classification of Diseases, Ninth Revision (ICD-9) descriptors: Feared Complaint-No Diagnosis (ICD-9 code v65.6) and Screening for Infectious Disease (ICD-9 code v75.9) for all hospitals and for Trenton versus non-Trenton hospitals as a percentage of ED visits. Charts were reviewed by using a structured data form. RESULTS: A total of 225,403 ED visits occurred during the 4 months, of which 698 were CE visits. The percentages of CE visits for the four periods were 0.06%, 0.06%, 0.92%, and 0.10%, respectively. For the peak third period, the percentage was increased for the two Trenton hospitals, 1.81%, versus 0.82% for the 13 non-Trenton hospitals. This report is a summary of the 508 visits associated with concern for anthrax exposure during the peak third period: 47% reported exposure to powder, 13% were postal workers, 4% received chest radiographs, 65% had a nasal swab for anthrax, 13% had ED decontamination, and 32% received antibiotics. CONCLUSION: An increase in CE visits occurred during the 1-month period after October 11, 2001. During the peak month, a higher increase occurred in Trenton EDs. Considering the substantial variation in diagnostic evaluation and treatment, readily available guidelines are needed.

Anthrax↗
PubMed2005

Hospital admissions syndromic surveillance--Connecticut, October 2001-June 2004.

INTRODUCTION: The Connecticut Department of Public Health (CDPH) has continuously monitored daily nonelective hospital admissions through a syndromic surveillance reporting system (HASS) since September 2001. Admission diagnoses are categorized into 11 syndromes including one possible indicator of smallpox, fever with rash, and one possible indicator of influenza and pneumonia. OBJECTIVES: The objectives are to describe findings from systematic investigation of individual admissions attributed to fever and rash and to determine the utility of monitoring pneumonia admissions as an indicator of severe influenza activity during the 2003-04 influenza season. METHODS: The incidence of admissions for fever and rash illness was determined for a 12-month period, and results of clinical discharge diagnoses were tabulated. Excess admissions for pneumonia by week during the influenza seasons beginning 2001-03 were determined and compared. Trends in admissions from the 2003-04 season were compared with trends from laboratory and sentinel physician surveillance. RESULTS: A total of 57 admissions for fever and rash illness were reported from 32 acute-care hospitals and verified for an incidence of 1.7 per 100,000 population. Specific clinical diagnoses were made for 29. Many were compatible with the initial clinical presentation of smallpox. Excess admissions for pneumonia during the 2003-04 season occurred concurrently with sharp increases in positive laboratory reports and percentages of visits to physician's offices attributed to influenza-like illness. The 2003-04 influenza season had many more excess admissions than the 2001-02 and 2002-03 seasons. CONCLUSION: HASS is a useful surveillance tool for rapid detection of sentinel cases of smallpox. Monitoring excess pneumonia admissions during the influenza season appears to be an effective and specific method for determining levels of influenza activity and for quantification of influenza-related morbidity and impact on the hospital system.

Connecticut↗
PubMed2005

Three years of emergency department gastrointestinal syndromic surveillance in New York City: what have we found?

BACKGROUND: Use of syndromic surveillance as a tool to detect outbreaks and potential biologic or chemical terrorist attacks is increasing. Evaluating health departments' use of syndromic surveillance is necessary to determine the value of this methodology. METHODS: Syndromic surveillance signals detected by the New York City Department of Health and Mental Hygiene (DOHMH) during November 2001-August 2004 were reviewed for diarrhea and vomiting syndromes, the methods used to investigate such signals, and results of these investigations to determine if any unreported outbreaks were detected. Gastrointestinal (GI) outbreaks reported to DOHMH also were reviewed to understand why they were not detected by DOHMH's Emergency Department (ED) syndromic surveillance system. RESULTS: During the study period, ED surveillance generated 98 citywide and 138 spatial GI signals. Multiple outbreaks suspected to be caused by norovirus and rotavirus were identified, as well as a citywide increase in diarrheal illness. Of 98 citywide signals detected, 73 (75%) occurred during seasonal outbreaks. During the same period, 49 GI outbreaks were reported to DOHMH; none was detected simultaneously by ED surveillance. CONCLUSION: Only substantial, citywide syndromic signals were identified as outbreaks and routinely reported. GI outbreaks did not generate syndromic signals. Syndromic surveillance signals occur frequently, are difficult to investigate satisfactorily, and should be viewed as a supplement to, rather than a replacement for, well-maintained traditional surveillance systems that rely on strong ties between clinicians and public health authorities.

Disease Outbreaks↗
PubMed2005

[Syndromic surveillance for the detection of outbreaks of unusual infectious diseases].

Syndromic surveillance has been developed in order to detect outbreaks of unusual infectious diseases such as severe acute respiratory syndrome (SARS) or anthrax at an early stage. Whereas the usual surveillance systems are based on established diagnoses and emergency department discharge data, syndromic surveillance uses preliminary outcomes and derived data such as absenteeism, prescription medication and requests for laboratory tests. Investigations abroad have indicated the potential ofsyndromic surveillance. In the Netherlands, the National Institute of Public Health and Environment (RIVM) is examining the feasibility of implementing syndromic surveillance.

Communicable Disease Control↗
PubMed2004

Epidemiology of cancer in the Republic of Kiribati.

Little is known about cancer epidemiology in Kiribati. Between November 1998 and December 1999, trained medical record abstractors visited 8 Micronesian jurisdictions including the Republic of Kiribati to review all available medical records in order to describe the epidemiology of cancer in Micronesia and to better understand the cancer data and control systems in each entity. The Republic of Kiribati has identified many prevalent preventable cancers. The lack of a robust cancer data tracking and surveillance system, as well as the lack of resources to institute a technologically and medically sustainable cancer control system was apparent. The implementation or existence of a national comprehensive cancer control strategic plan would facilitate greater identification, prevention, and treatment of cancer patients. The health sector and Government of Kiribati are working towards this end.

Adolescent↗
PubMed2004

Cancer in Pacific people in New Zealand: a descriptive study.

Non-Maori Pacific people constitute a significant and rapidly growing population in New Zealand. An accompanying change in lifestyle associated with changing socio-economic environments results in a change in disease patterns including cancer. The paucity of reliable data on cancer necessitates our effort to contribute to the control of cancer by reviewing the available information. Our study indicates a high incidence among non-Maori Pacific people of some cancers of public health importance as well as a disproportionately high mortality rate compared to non-Maori, non-Pacific people in New Zealand. In addition, we challenge previous documentation of a significant and high incidence of cervical cancer among Pacific women compared to non-Pacific people in New Zealand. We also identified the need to remedy the inadequacy in data quality as part of any strategy to prevent and control the rising incidence and mortality attributed to cancer among non-Maori Pacific people. In addition we have commenced regional training on cancer epidemiology and propose further cancer studies in both New Zealand and the Pacific Islands.

Epidemiologic Studies↗
PubMed2004

Epidemiology of cancer in the Republic of Nauru.

Between November 1998 and December 1999, the Republic of Nauru was one of 8 Micronesian jurisdictions visited by trained medical record abstractors to review all available medical records in order to describe the epidemiology of cancer in Micronesia and to better understand the cancer data and control systems in each entity. There is likely incomplete ascertainment of cancer cases in the Republic of Nauru because of historical events, and the lack of a robust cancer registry and a systematic cancer surveillance system. A national comprehensive cancer control strategic plan and the implementation of that plan would facilitate greater prevention, treatment and control of cancer. The government of Nauru is working towards this end.

Adolescent↗
PubMed2005

[Standardized incidence ratio: a risk index for catheter-related infection surveillance in intensive care units (REACAT network) in Northern France].

BACKGROUND: Nosocomial infection surveillance is one of the major indicators used to compare health care quality in hospital settings. Wards participating in a network with standardized methods can be compared. We propose a risk index adjusted for catheter-related infection (CRI) specific risk factors in the setting of a CRI surveillance network in intensive care units (ICU): the standardized incidence ratio (SIR). METHODS: All central venous catheters (CVC) inserted for more than 48h were prospectively followed until CVC removal or patient discharge in a yearly 4-month surveillance. Standard clinical and microbiological criteria were used to define colonization and CRI. A logistic regression model, developed on a 3-year pooled database, was used as a predictive model of CRI. Expected number of CRI was calculated and compared with the observed number of CRI to estimate SIR for each year and for each ICU per year. RESULTS: From 2000 to 2003, 108 ICU participated in at least one of the 3 surveillance periods, including 6414 CVC. Overall, 239 CRI were identified (incidence density (ID): 3.6 CRI/1000 CVC-days). At multivariate analysis, duration of CVC placement (1.1 [1.0-1.1]), rank (1.7 [1.1-2.2]) and site of CVC insertion (1.6 [1.2-2.1]), use of CVC for antibiotic therapy (0.5 [0.3-0.7]), organ failure at CVC removal (2.2 [1.5-3.2]), infection at another site at CVC removal ([1.9 [1.4-2.6]) were significantly associated with CRI. During the last period of surveillance, 14 ICU had a DI higher than 5.5 CRI/1000 CVC-days. More CRI than expected were significantly observed in two wards including one which followed less than 20 CVC. CONCLUSION: The REACAT surveillance system assesses a novel and reliable risk index which enables identification of ICU with a higher CRI risk and to focus on prevention.

Aged↗
PubMed2005

Ahead of the pack.

Wisconsin is emerging as a national model for private-sector initiatives to meet demands for information on health care costs and quality.

Benchmarking↗
PubMedDate not supplied

Methodological issues in setting up a surveillance system for birth defects in India.

India is undergoing an epidemiological transition--communicable diseases are on the decline due to better living conditions and healthcare delivery. On the other hand, the relative increase in the prevalence of non-communicable, chronic and genetic diseases threatens to be a public health problem in India. One such group of disorders is congenital malformations. Though several studies have been done on congenital malformations in India since the early 1960s, coinciding with the thalidomide tragedy in the West, no uniform methods are available for the surveillance of birth defects. Each study has come out with varying results, not only because of the geographic variation in birth defects but also due to the varying standards adopted by each study in data collection, case definition and other methodological issues. Setting up a mechanism to understand the extent and nature of birth defects would involve the creation of a birth defects registry. The goals and objectives of such a registry should be formulated before it is set up. There are three types of registries-descriptive, analytical and preventive. These can also be classified as population- or hospital-based. Whether a registry is population- or hospital-based depends largely on the movement of mothers for delivery, registration of vital events in an area defined by the programme, as well as the resources available to the registry. Data can be collected in a passive or active manner, which also depends on the resources available to the registry. Every registry should have its own working definition of eligible cases to be reported, depending on the diagnostic services available in that area, and multiple sources of information should be used to improve the ascertainment rate. All the diagnostic terms should be coded and the information collected should be stored in a well-constructed database, preferably a relational type. Registries must evaluate their methods of data collection periodically to estimate the number of false-positive and false-negative reports. Ethical issues, cost and funding for the employment of various specialized professionals should be considered before setting up a registry.

Congenital Abnormalities↗
PubMedDate not supplied

The Global Public Health Intelligence Network and early warning outbreak detection: a Canadian contribution to global public health.

The recent SARS epidemic has renewed widespread concerns about the global transmission of infectious diseases. In this commentary, we explore novel approaches to global infectious disease surveillance through a focus on an important Canadian contribution to the area--the Global Public Health Intelligence Network (GPHIN). GPHIN is a cutting-edge initiative that draws on the capacity of the Internet and newly available 24/7 global news coverage of health events to create a unique form of early warning outbreak detection. This commentary outlines the operation and development of GPHIN and compares it to ProMED-mail, another Internet-based approach to global health surveillance. We argue that GPHIN has created an important shift in the relationship of public health and news information. By exiting the pyramid of official reporting, GPHIN has created a new monitoring technique that has disrupted national boundaries of outbreak notification, while creating new possibilities for global outbreak response. By incorporating news within the emerging apparatus of global infectious disease surveillance, GPHIN has effectively responded to the global media's challenge to official country reporting of outbreak and enhanced the effectiveness and credibility of international public health.

Canada↗