1. Disease Surveillance in NYS Jim Miller, MD, MPH Director, Bioterrorism Epidemiology New York State Department of Health jrm17@health.state.ny.us

2. Traditional and Syndromic Surveillance Traditional notifiable disease surveillance –Relies on patient seeking medical care, laboratory test being ordered and laboratory/clinician reporting –Reporting lag is typically days to weeks “Syndromic” surveillance –Tracking non-specific symptoms or health “events” (sale of diarrhea medication) –“Real time” (within hours)

3. Reportable Diseases in NYS

4. Syndromic Surveillance Goals Recognize an outbreak due to a natural cause or a terrorist agent earlier than physician, laboratory or citizen reporting. Monitor general community health – track level of disease. Provide objective evidence that an outbreak is not occurring. Help sustain a strong ongoing relationship between public health and clinical medicine.

5. Background Syndromic surveillance can detect outbreaks. Syndromic surveillance is a supplement to traditional disease reporting. Statistically significant signals must be verified clinically to determine public health significance. Inter-system comparisons may help in the interpretation of a positive signal. Although a promising approach, there is insufficient experience to evaluate if syndromic surveillance improves public health response.

6. Syndromic Surveillance Systems Operated by NYSDOH (Emergency Department Data) System Name Data Source/ Participants (No./Type) Collection Method/ Start Date/ Frequency Data Content AnalysisCurrent Output/ Frequency ED Phone Calls Hospital ED & LHD staff 52 counties 157 hospitals Phone calls w/ HIN data entry Nov 2001 Daily Voluntary except during times of heightened concern Unusual events or clusters of illnesses Counts of unusual cases/ clusters with descriptive narrative Internal NYSDOH report Mon-Fri only, Sat-Sun compiled on Mon, Daily during times of heightened concern ED Syndromic Surveillance System Hospital ED 25 hospitals 11 counties Electronic batch files via ECLRS* Dec 2003 Daily ED chief complaints categorized into 6 syndromes Resp, GI, Fever, Asthma, Rash, Neuro Counts by syndrome/ hospital, CuSum analysis Counts and pt. lists by syndrome/hospital, statistical analysis & trends - on Commerce for participating counties & hospitals–Daily * Electronic Clinical Laboratory Reporting System

7. Syndromic Surveillance Systems Operated by NYSDOH (Pharmacy Data) System Name Data Source/ Participants (No./Type) Collection Method/ Start Date/ Frequency Data ContentAnalysisCurrent Output/ Frequency NRDM/RODS* (National Retail Data Monitor/Real- time Outbreak and Disease Surveillance) OTC drug sales from 12 major retailers, 20,000 stores Nationwide as of 8/04 Electronic Batch file July 2003 Daily 6,500-8,000 OTC drug sales in NY 15 Categories Counts by category, CuSum analysis Internal NYSDOH report Mon-Fri Signals shared with LHD/RO as necessary Medicaid Over the Counter (OTC) and Prescriptions Office of Medicaid Management (OMM) Data Warehouse: 22,000-26,000 medications Electronic Batch file March 2003 Daily Medicaid scripts filled in NYS 18 Categories Counts by category, CuSum analysis County and Regional counts by drug category on Commerce Daily Short and long term graphs for signals in past 3 days only *Data available to counties registered at National site: http://rods.health.pitt.edu/NRDM.htm

8. Medicaid System Long Term Trend Report County ABC

9. Source: F Mostashari, NYCDOHMH.

10. Biosurviellance BioWatch Biohazard Detection System (BDS)

11. BioWatch 500 sensors in 31 cities Outdoor air samples every 12-24 hours Laboratory testing for biological agents Confirmed sample will initiate mass clinics Source: Miami Herald, 14 Nov 2003

12. Biohazard Detection System (BDS) Free-standing PCR-based technology Samples air continuously above mail-sorting machines at large USPS facilities Test initiated every 60 minutes Testing takes ~30 minutes Limited to Bacillus anthracis Positive “signal” leads to automatic alarm, work area evacuation, worker “decontamination” If BDS verified by LRN PCR testing, antibiotic distribution within 15 hours of presumed exposure, vaccination following culture confirmation No positive signals (yet)

13. Biohazard Detection System Source: http://www.lunewsviews.com/usps/pcr.htm

14. BDS Signal Sample to LRN Positive LRN PCRNegative LRN PCR Confirmed LRN CultureNegative LRN Culture Collect employee data Pre-positioned Meds Antibiotic distribution plan in “watch” mode Distribute 3-10-day course of antibiotics for all exposed persons 60-day antimicrobial prophylaxis and vaccination for selected employees Collect epi data Collect epi data (upstream analysis) 0-8 hours 9-15 hours 16-120 hours Initiate environmental sampling to find source of contamination 2 cartridges, liquid reserve Notify USPS Isolate sent to CDC for antibiotic sensitivity Employee shower/wash; change clothes Alert employees and public now off-site Source: CDC, with modifications by NYSDOH Responding to a BDS Signal