2. APC Surveillance Tools
Building a Public Health Community of Practice for Biosurveillance
&
Syndromic Surveillance for Epidemiological Investigation
APC Road Show
Covington, KY
April 26-27, 2010

3. Learning objectives:
At the end of this session, participants will be able to:
Identify the primary purposes of syndromic surveillance and how it can benefit public health and other stakeholders in a public health community of practice.
Understand why syndromic surveillance is needed and how it fits into the broader surveillance picture.
Describe and understand some key concepts for integrating syndromic surveillance in LHD operations
Explore key APC resources for building syndromic surveillance into LHD practice.

4. Building a Public Health Community of Practice A Biosurveillance Resource Compendium

5. Why should public health get involved in automated surveillance?
Primarily, it is now a key element tying public health to healthcare reform.
Secondarily, it is also a required public health component for healthcare providers to achieve “meaningful use” of electronic medical record systems. (along with immunization registries and health alert integration)

6. The context for syndromic surveillance in public health…
Healthcare reform is focused on improving:
Poor quality of care, errors resulting in more deaths annually than highway accidents, breast cancer or AIDS
Consumer empowerment
Presence of disparities in insurance, access to care and in health outcomes
Rapidly increasing costs of healthcare
Surveillance is the law-of-the-land as well as presidential directives for preparedness and broader healthcare.
Electronic health information is a key element of priority HHS program already underway!

7. More context for syndromic surveillance…
12-06: Pandemic and All-Hazards Preparedness Act (PAHPA)
Broad implications for HHS’s preparedness and response activities
Establish quadrennial National Health Security Strategy and support new programs (e.g., includes advanced development of medical countermeasures and surveillance)
11-07: Homeland Security Presidential Directive 21 (HSPD-21)
Establishes biosurveillance capability for early warning of a biological attack or disease outbreak w/ ongoing “near real-time” updates
Plus 3 other core components

8. Syndromic surveillance purpose:
Syndromic surveillance is defined as "the timely collection, analysis, and investigation of health-related data that precede diagnosis."
Syndromic surveillance is used to:
Detect changes in community health status, especially for the early detection of outbreaks
Trace disease patterns over time
Describe patterns of disease in geographic locations and demographics at any time

9. Syndromic surveillance
The system groups acquired data into sets of symptoms that define syndromes and sub-syndromes such as :
Respiratory
Influenza-like illness
Gastrointestinal
Neurological
Based on traditional sources:
Outpatient ICD-9 codes
Emergency room chief complaints
Based on non-traditional sources:
School absenteeism
Over the counter (OTC) sales
Syndromic surveillance software takes data on a set of symptoms and groups them under syndromes and sub-syndromes. A syndrome is an early presentation of illness consisting of a number of symptoms. For example, coughing would be defined under respiratory, while stomach ache and nausea would be lumped under gastrointestinal. Surveillance data has broken from traditional sources such as outpatient ICD 9 codes and ER chief complaints to non-traditional sources such as school absenteeism and OTC medication sales. These data sources allow the system to identify symptoms and group them into syndromes that are further investigated through descriptive and statistical analysis.

10. Partner participation benefits:
Early awareness is preparedness
Consider potential for pandemic, bioterrorism, etc.
Supports infection prevention goals
Shows community patterns (MRSA and HAI’s)
Provides situational awareness when outbreaks are in process – H1N1
Enhances public image of provider
Fosters collaboration with others and public health on health problem solving

11. Key steps to a Successful Syndromic Surveillance Program
Establish common ground – build program around users/providers and other stakeholders within community, not just public health
Define objectives and benefits to all stakeholders – avoids confusion, delays and disappointment
Clearly define what syndromic surveillance is
Also define what syndromic surveillance isn’t
Determine requirements and system strategy
Traditional (clinician-based) –SYRIS, EMSystems, others
Automated ( “data-mining”) – EARS, ESSENCE, RODS, other
Make sure to also capture organizational and operational requirements, not just epi-surveillance and technical

12. More Keys to a Successful Program
Assess readiness
Human resource – project management critical!
Funding – scale steps with available funding but show progress
System support/training
Agency/stakeholder support
Infrastructure and system options – in-house or service provider?
HIPAA/security
Pace the progress
Define technical and program requirements
“Sail the right ship”; realistically match milestones to resources with continuous improvement
Manage the project
Lead the team by continuously assessing and
revisiting expectations

13. Other Important Considerations for LHD leading the program
How large, complex and diverse is your community?
The greater your community’s size, complexity and diversity, the more vulnerable you may be to various covert threats and the more important it then becomes to consider and establish a syndromic surveillance capability.
Where does your community stand today in terms of emergency preparedness and healthcare reporting/surveillance?
Have public health or other community leaders completed comprehensive threat and readiness assessments?
If so, what findings seem applicable to the consideration of a syndromic surveillance system?
Is it an appropriate focus for your agency to provide a syndromic surveillance system?

14. What is biosurveillance?
Consists of two major surveillance methodologies:
Well-established public health surveillance methods and sources used for the tracking, monitoring, and reporting of health-related information, such as epidemiologic investigations of infectious disease outbreaks as well as environmental conditions and other data sources, to use as baselines comparisons, and to support the accuracy and reliability of the biosurveillance findings.
Early event detection, case detection and situational awareness - the use of an automated system to evaluate case and suspected case reporting along with statistical surveillance and data visualization of pre-diagnostic and diagnostic data to support the earliest possible detection of events that may signal an imminent public health incident of significance.

15. What is a public health community of practice?
People, organizations, resources and practices working together to share information in an effective, efficient way – working towards separate but related solutions.
Partners:
Hospitals and physicians
Schools, school-based clinics and daycares
EMS providers, law enforcement and other first responders
Long-term care facilities and mental health care providers
Public information officers and the media
Academics, vendors, subject-matter experts,
insurance providers
WELL, FOR THOSE WHO DON’T KNOW….APC’S SERVE TWO MAIN PRIMARY PURPOSES
THEY SERVE AS FORMAL DEMONSTRATION AND TRAINING SITES FOR THE CDC AND OTHER LOCAL PUBLIC HEALTH DEPTS TO PILOT, DESIGN, DEVELOP, IMPLEMENT AND DISSEMINATE TOOLS, TECHNOLOGIES, TRAINING AND OTHER PRODUCTS THAT ENHANCE PUBLIC HEALTH READINESS AND RESPONSE TO ALL HAZARDS INCLUDING BIOTERRORISM
ADDITIONALLY, THE APC’S ARE LEARNING LABORATORIES FOR DEVELOPING PUBLIC HEALTH ‘BEST PRACTICES’
WHERE DID THE APC’S COME FROM??
Next Slide……………..

16. Also including… Resources and practices: Surveillance data and systems
And their accompanying response protocols
Networks, IT assets and solutions, including:
Applications
Databases
Forums
Medical facilities and laboratories
Governance models – RHIOs, HIEs
WELL, FOR THOSE WHO DON’T KNOW….APC’S SERVE TWO MAIN PRIMARY PURPOSES
THEY SERVE AS FORMAL DEMONSTRATION AND TRAINING SITES FOR THE CDC AND OTHER LOCAL PUBLIC HEALTH DEPTS TO PILOT, DESIGN, DEVELOP, IMPLEMENT AND DISSEMINATE TOOLS, TECHNOLOGIES, TRAINING AND OTHER PRODUCTS THAT ENHANCE PUBLIC HEALTH READINESS AND RESPONSE TO ALL HAZARDS INCLUDING BIOTERRORISM
ADDITIONALLY, THE APC’S ARE LEARNING LABORATORIES FOR DEVELOPING PUBLIC HEALTH ‘BEST PRACTICES’
WHERE DID THE APC’S COME FROM??
Next Slide……………..

17. Syndromic Surveillance for Epidemiological Investigation Response Protocols for Disease Detection

18. What is a response protocol?
Clear guidelines to review and summarize large amounts of data daily
Approaches or steps to review data and analyze the anomalies in data
A methodology to prompt inquiries or interventions that need to be completed in a time frame depending on degree of urgency

19. Why response protocols are needed:
A standard framework can help distinguish statistical anomalies from more important public health events
Can translate to time and cost savings for LHD in:
Investigating alerts
Reduce time to initiate intervention
Systems development

20. Response protocols framework:
Anomaly identification & detection
Anomaly characterization
Validation of anomaly
Assessing public health significance of findings
Other factors of importance

21. Anomaly detection – use of algorithms:
Systems use statistical algorithm to determine if actual case counts exceed expected counts for syndromes
Healthcare providers send information on unusual disease clusters and incidence that system can evaluate
Syndromic surveillance systems use statistical algorithms to determine if actual case counts exceeds the norm for that community and syndrome type. These systems allow epidemiologists to monitor disease trends and identify clusters. Local health care clinicians send epidemiologists information on unusual disease clusters and incidence, which they evaluate using the system. The system cannot do this alone and neither can the epidemiologists, instead it requires system, epidemiologists and clinician generated alerts for accurate and efficient detection of community health status.

22. Anomaly detection – across jurisdictions
Helps epidemiologists spot suspicious disease clusters
Detection should occur at multiple levels to discover anomalies that may be missed in a single jurisdiction
By utilizing these algorithms, systems can help epidemiologists detect disease clusters that may be in occurring in certain areas. The problem is when data crosses jurisdictional lines. Most investigators work within certain geographic boundaries, however persons with disease do not. People move and travel, they are not stationary, so that means disease is mobile as well. Anomaly detection should be a process that occurs across multiple jurisdictions to discover any anomalies that may not be detected in any single jurisdiction.

23. Anomaly characterization – descriptive epidemiology
Anomaly should be described fully w/ respect to person, place, and time (descriptive epidemiology)
Use geographic and demographic information
Clinical data should be evaluated and summarized
More information may be needed to fully characterize
In anomaly characterization, you are attempting to describes the data according to person, place, and time. It looks at both demographic and geographic information to describe the data. It is important that the data is not only summarized quickly, but efficiently. We may need additional information to fully characterize the data, so you may need to gather information from outside sources such as physicians, labs, and other jurisdictions.

24. Anomaly validation – expected?
Anomalies: expected or unusual?
Seasonal or temporal (e.g. ILI)
Environmental causes
Disease trends
Corroborate data sources
Holiday, day-of-week effects
Same pattern prior year?
In anomaly validation, you are trying to determine if an anomaly is expected or unusual. To do this you need to address some issues:
First, can the anomaly be dismissed as seasonal? For example, you normally expect influenza like illness over the winter, but not the summer. So if you did see it over the summer, it would be considered unusual.
Second, you may want to determine if the anomaly is a result of environmental causes, such as allergies. You normally see high counts of respiratory cases in the spring due to pollen activity. But if pollen activity was not high and there were no other typical explanations, then the anomaly should be investigated.
There are some diseases that have tendency to occur at certain times of the year. Flu is one that is typical of fall and winter, but so is an increase in viral gastroenteritis. Knowing disease trends is important in making your decision to investigate an anomaly or not.

25. Assessing public health significance of findings
Extent of variance from usual frequency distribution
Atypical from known patterns
Magnitude, continuity of increase given syndrome group
Sustained for multiple days?
To determine whether a public health event is significant, it is important to check if counts vary from known frequency. Is it higher than what you typically see or not? Is the pattern typical for that syndrome group? Does an increase in syndrome counts vary from the known historical pattern?

26. Other factors of importance
Unique attributes of the data stream to assess:
Lag time between occurrence of an event and time it is available to the system for detection of anomaly
Clinical value of the data; prompt evaluation following alerts is critical
One data stream or source may be chosen as primary indicator of change and other data sources as secondary
Compare anomaly w/ other surveillance systems
Majority of surveillance systems collect multiple streams of data to assess health status of community. Each stream has unique characteristics that need to be understood to evaluate the results that they produce. One attribute that is important is lag time. This is the time it takes between when the event occurs and the time it is available to the system for detection. Some systems have a lag time of 24 hours, others have a lag time of 48 hours, so it is important to check the lag time on the system you use and keep in mind the timeline of disease agents .
Another attribute to assess is the clinical value of the data. Emergency Room data provides systems with important chief complaints data which can be grouped into syndromes providing investigators with good clinical data to evaluate, but what may be even more valuable is data with patient discharge diagnosis. In general, there is a trade-off between specificity and timeliness – diagnostic data is very specific but may be hours or days old after the onset of disease, so for early detection, combining early alerts with prompt clinical investigation is essential to successful response protocols. Another example would be data on over the counter medication sales. This data is quick to come by, but provides less specificity for the investigator, requiring more rigorous hypothesis and validation to rule-out or rule-in the significance of an alert.

27. Key considerations in drafting response protocols:
Agency size
Experience
Training
Degree of risk
Time pressures
Data quality (lag time)
Jurisdiction
Department level
1) Resources – manpower 2) Experienced epidemiologists are the best 3) is the threat something we should fear – anthrax or smallpox 4) Time of investigators and others involved in the investigation – lab 5) Lag time can result in delays of information 6) Different roles and pathways depending on where the investigator is: Public health roles: ICP at a hospital, epidemiologist from a local health department, public health authority at a state health department; Non-public health roles: EMS, law enforcement, fire, emergency preparedness

28. Final thoughts on applying APC surveillance tools
Syndromic surveillance systems have broad, major benefits
A community of public health practice engages many to be successful
LHD should assess community-level health problems
General guidelines are helpful, but may not be sufficient
Response protocols require effective communication
Staff experience key factor in protocol development
Findings and response should be shared broadly and promptly
One plan does not fit all
2) that vary according to needed information 3) with in RP can be applied to investigation of alerts 4) can facilitate quick and efficient investigation

29. Now Let’s Explore the Tools!
Building a Public Health Community of Practice A Biosurveillance Resource Compendium
Syndromic Surveillance for Epidemiological Investigation Response Protocols for Disease Detection

30. QUESTIONS
-Bill Stephens, MS, APC Manager, Tarrant County Public Health
(817)
-Kay Sanyal-Mukherji, MPH, Workforce Development Specialist
(817)

31. References and resources to learn more:
Book: “Handbook of Biosurveillance,” M. Wagner et al., Elsevier, May, Details:
Useful Websites and pages:
American Health Information Community:
CDC Biosense: and CDC PHIN:
CDC syndromic surveillance resources:
Johns Hopkins Applied Physics Lab (ESSENCE developer):
HIMSS HIT Dashboard:
HIPAA and decision tool: and
Health Level 7:
Homeland Security Presidential Directive 21:
Mirth project (open source HL7 interface engine):
Office of the National Coordinator:
PAHPA:
Regenstrief Institute:
University of Pittsburgh’s RODS Lab (RODS developer):
Southwest Center for Advanced Public Health Practice (APC):
Tarrant County Public Health: