Syndromic Surveillance

Syndromic surveillance data is typically used for the monitoring of symptom combinations in patient chief complaints (i.e. syndromes) or health indicators within a population to inform public health actions. The Tennessee Department of Health collects emergency department (ED) data from more than 80 hospitals across Tennessee to support statewide situational awareness. Most hospitals in Tennessee provide data within 48 hours of the patient being seen in the emergency department. The timeliness of syndromic surveillance data allow for rapid estimates of impact in emergency department populations. Tennessee has successfully used these data to monitor influenza, heat related illnesses, and emergency department impacts from disaster evacuations. In addition to assessing impact and trends, syndromic surveillance can also provide early warnings for conditions of public health concern and increase the lead time public health has to initiate a response. In Tennessee, routine syndromic surveillance for mumps, hepatitis A, and other conditions has been successfully conducted statewide. Three successes from these surveillance efforts include detecting a clinically diagnosed but unreported case of mumps, early identification of hepatitis A cases during Tennessee's ongoing 2018 hepatitis A outbreak, and the detection of an epidemiologically unlikely clinical diagnosis of mumps associated with an exposure at a recreational center.

Objective: To demonstrate the utility of syndromic surveillance data in aiding public health actions and response across multiple investigations in Tennessee.

Hand, foot, and mouth disease is a highly infectious disease common among early childhood populations caused by human enteroviruses (Enterovirus genus).1 The enteroviruses responsible for HFMD generally cause mild illness among children in the United States with symptoms of fever and rash/blisters, but have also been linked to small outbreaks of severe neurological disease such as meningitis, encephalitis, and acute flaccid myelitis.2 Enteroviruses circulate year-round but increase in the summer-fall months across much of the United States.3 The drivers of this seasonality are not fully understood, but research indicates climatic factors, rather than demographic ones, are most likely to drive the amplitude and timing of the seasonal peaks.3 A recent CDC study on nonpolio enteroviruses identified dew point temperature as a strong predictor of local enterovirus seasonality, explaining around 30% of the variation in intensity of transmission across the United States.3

Objective: To assess the relationship between seasonal increases in emergency department (ED) and urgent care center (UCC) visits for hand, foot, and mouth disease (HFMD) among children 0-4 years old and average dew point temperatures in Virginia. To determine if this relationship can be used to develop an early warning tool for high intensity seasons of HFMD, allowing for earlier targeted public health action and communication to the community and local childcare centers during these high intensity seasons.

The opioid drug overdose crisis presents serious challenges to state-based public health surveillance programs, not the least of which is uncertainty in the detection of cases in existing data systems. New Jersey historically had slightly higher unintentional drug overdose death rates than the national average, but by 2001 dramatic increases in drug overdose deaths in states like West Virginia began to drive up the national rate (Figure 1). Although the rise in New Jersey's fatal overdose rates has mirrored the national rate since 1999, the rate has dramatically increased since 2011- from 9.7 per 100,000 (868 deaths) to 21.9 per 100,000 in 2016 (1,931 deaths), an increase of 125% in five years.1 The New Jersey Department of Health has been funded by the Centers for Disease Control and Prevention (CDC) to conduct surveillance of opioid-involved overdoses through the Enhanced Surveillance of Opioid-Involved Overdose in States (ESOOS) program, and to conduct syndromic surveillance through the National Syndromic Surveillance Program (NSSP); this has presented a collaboration opportunity for the Department's surveillance grantee programs to use existing resources to evaluate and refine New Jersey’s drug overdose case definitions and develop new indicators to measure the burden of overdose throughout the state and to facilitate effective responses.

Objective: Link syndromic surveillance data for potential opioid-involved overdoses with hospital discharge data to assess positive predictive value of CDC Opioid Classifiers for conducting surveillance on acute drug overdoses.

Mental health is a common and costly concern; it is estimated that nearly 20 percent of adults in the United States live with a mental illness [1] and that more money is spent on mental illness than any other medical condition [2]. One spillover effect of unmet mental health needs may be increasing emergency department utilization. National analysis by Healthcare Cost and Utilization Project (H-CUP) found a 55% increase in emergency department visits for depression, anxiety, and stress reactions between 2006- 2013 [3]. Local public health agencies (LPHAs) can play an important role in reducing costs and burden associated with mental illness. There is opportunity to use emergency department data at a local level to monitor trends and evaluate the effectiveness of local strategies. ESSENCE, available in 31 states, provides near-real time observation-level emergency department data, which can be analyzed and disseminated according to local needs. Using ESSENCE data from 6 local counties in Colorado, we developed methods to estimate the overall burden of mental health and specific mental health disorders seen in the emergency department.

Objective: In order to meet local mental health surveillance needs, we created multiple mental health-related indicators using emergency department data from the Colorado North Central Region (CO-NCR) Early Notification of Community Based Epidemics (ESSENCE), a Syndromic Surveillance (SyS) platform.

LBP is one of the leading contributors to disease burden worldwide [1]. In France, LBP is a frequent reason of general practice consultations. According to a study published in 2017 and based on 2014 data issued of the National Health Insurance Cross-Schemes Information System (Sniiram) [2], this pathology stands for 30% of thickness leave and 4 of 5 people will suffer of low back pain during their own life. Most often, LBP is a chronic pathology with acute episodes which most often require emergency care. In order to prevent chronicity, French health care insurance launched into a mainstream national prevention campaign during spring 2018. This campaign was also targeted for health professional to inform them of the best recommendations to provide to their patients. Then the French society of emergency medicine (SFMU) has been asked to relay this campaign to emergency departments (ED) where LBP is a frequent reason of attendance. Since 2004, the French syndromic surveillance system SurSaUD® [3] coordinated by the French Public Health Agency (Santé publique France) daily collects morbidity data from the emergency departments (ED) network Oscour®. Almost 92% of the French ED attendances were recorded by the system in 2017. The availability of this large ED dataset on the whole territory since several years gives the opportunity to describe LBP attendances before the potential fallout of the national prevention campaign.

Objective: The study describes the characteristics of attendances for low back pain (LBP) in the French emergency departments (ED) network Oscour®, in order to give an overview of this disease before launching a prevention campaign.

In 2011, the Centers for Disease Control and Prevention (CDC) released the PHIN Messaging Guide for Syndromic Surveillance v. 1. In the intervening years, new technological advancements including Electronic Health Record capabilities, as well as new epidemiological and Meaningful Use requirements have led to the periodic updating and revision of the Message Guide. These updates occurred through informal and semi-structured solicitation and in response to comments from across public health, governmental, academic, and EHR vendor stakeholders. Following the Message Guide v.2.0 release in 2015, CDC initiated a multi-year endeavor to update the Message Guide in a more systematic manner and released further updates via an Erratum and a technical document developed with the National Institute of Standards and Technology (NIST) to clarify validation policies and certification parameters. This trio of documents were consolidated into the Message Guide v.2.1 release and used to inform the development of the NIST Syndromic Surveillance Test Suite (http://hl7v2-ss-r2-testing.nist.gov/ss-r2/#/home), validate test cases, and develop a new rules-based IG built using NIST's Implementation Guide Authoring and Management Tool (IGAMT). As part of a Cooperative Agreement (CoAg) initiated in 2017, CDC partnered with ISDS to build upon prior activities and renew efforts in engaging the Syndromic Surveillance Community of Practice for comment on the Message Guide. The goal of this CoAg is have the final product become an HL7 Standard for Trial Use following the second phase of formal HL7 balloting in Fall 2018.

Objective: To describe the latest revisions and modifications to the œHL7 2.5.1 Implementation Guide for Syndromic Surveillance (formerly the PHIN Message Guide for Syndromic Surveillance) that were made based on community commentary and resolution of feedback from the HL7 balloting process. In addition, the next steps and future activities as the IG becomes an HL7 Standard for Trial Use will be highlighted.

When the opioid epidemic began in the early 1990s, pills such as oxycodone were the primary means of abuse. Beginning in 2010, injection use of, first, heroin and then synthetic opioids dramatically increased, which led the number of overdose deaths involving opioids to increase fivefold between 1999 and 2016.1 It would be expected that BBP rates would rise with this increase in injection use, and, nationally, there has been a rise in acute hepatitis C (HCV) rates, although the other two main BBPs, acute hepatitis B (HBV) and acute human immunodeficiency virus (HIV) have been flat and declining, respectively.2,3 In this study, we compared New Jersey's reported incidence of these three BBPs (acute HBV, acute HCV, and HIV) over five years (2013-2017) with syndromic surveillance data for opioid use over the same time period in order to test the hypothesis that emergency department (ED) visits for opioid use could be used as a predictor of BBP infection.

Objective: To utilize New Jersey's syndromic surveillance data in the study and comparison of trends in injection opioid use and infection with selected bloodborne pathogens (BBPs) over the years 2013-2017.

In Massachusetts, syndromic surveillance (SyS) data have been used to monitor injection drug use and acute opioid overdoses within EDs. Currently, Massachusetts Department of Public Health (MDPH) SyS captures over 90% of ED visits statewide. These real-time data contain rich free-text and coded clinical and demographic information used to categorize visits for population level public health surveillance. Other surveillance data have shown elevated rates of opioid overdose related ED visits, Emergency Medical Service incidents, and fatalities in Massachusetts from 2014-20171,2,3. Injection of illicitly consumed opioids is associated with an increased risk of infectious diseases, including HIV infection. An investigation of an HIV outbreak among persons reporting IDU identified homelessness as a social determinant for increased risk for HIV infection.

Objective: We sought to measure the burden of emergency department (ED) visits associated with injection drug use (IDU), HIV infection, and homelessness; and the intersection of homelessness with IDU and HIV infection in Massachusetts via syndromic surveillance data.

In Saint-Martin (31 949 inhabitants) and Saint-Barthelemy (9 625 inhabitants) islands in the French West Indies, the surveillance system is based on several data sources: (1) a syndromic surveillance system based on two emergency departments (ED) of Saint-Barthellemy (HL de Bruyn) and Saint-Martin (CH Fleming) and on mortality (SurSaUD® network [1])); (2) a network of sentinel general practitioners (GP'™s) based on the voluntary participation of 10 GPs in Saint-Martin and 5 in Saint-Barthelemy; (3) the notifiable diseases surveillance system (31 notifiable diseases to individual case-specific form); (4) the regional surveillance systems of leptospirosis and arboviruses based on the biological cases reported by physicians and laboratories of two islands. On September 6, 2017, Hurricane Irma struck Saint-Martin and Saint-Barthelemy islands. Both islands were massively destroyed. This storm led to major material damages, such as power outages, disturbance of drinking water systems, road closures, destruction of medical structures and evacuation or relocation of residents. In this context, the usual monitoring system did not work and life conditions were difficult. The regional unit of French National Public Health Agency set up an epidemiological surveillance by sending epidemiologists in the field in order to collect data directly from ED physicians, GP's and in dispensaries. Those data allowed to describe short-term health effects and to detect potential disease outbreaks in the aftermath of Hurricane Irma. This paper presents results of the specific syndromic surveillance.

Objective: Describe short-term health effects of the Hurricane using the syndromic surveillance system based on emergency departments, general practitioners and dispensaries in Saint-Martin and Saint-Barthelemy islands from September 11, 2017 to October 29, 2017.

Since 1 January 2016, the Auvergne and Rhone-Alpes regions have merged as part of the territorial reform. The new region is composed of 12 departments and accounts for more than 8 million inhabitants. Its territory is heterogeneous in population density with very urban areas (Clermont-Ferrand, Grenoble, Lyon and Saint-Etienne) and important mountainous areas (Arc Alpin, Massif Central). In France since 2004, the syndromic surveillance system SurSaUD® [1] coordinated by the French Public Health Agency (Sant© publique France) collects morbidity data on a daily basis from two data sources: the emergency departments (ED) network Oscour® and the emergency general practitioners SOS Medecins associations. In Auvergne-Rhone-Alpes, the number of structures participating in the scheme has gradually increased from 2006 to today; as of 1 September 2018, all emergency services (N = 84) and all SOS ©decins associations (N = 7) transmit their data on a daily basis. Both data sources collect medical diagnoses, using ICD10 codes in the ED network and specific medical thesaurus in SOS Medecins Associations. These data are routinely analyzed to detect and follow-up various expected or unusual public health events all over the territory [2]. A reflection on the analysis of monitoring data at the sub-regional level was conducted in the region in order to refine the analyses carried out and better meet the expectations of local partners.

Objective: Define analytic areas at a sub-regional level to better meet the needs of local decision-makers.