Implementing a Syndromic Surveillance System: Objectives, Policy and Cost

1. Implementing a Syndromic Surveillance System: Objectives, Policy and Cost Aaron Fleischauer, PhD, MPH Bioterrorism Preparedness and Response Program National Center for Infectious Diseases

2. Objectives • What is Syndromic Surveillance? • Where syndromic surveillance fits in? • How it works? • Challenges and limitations • Policy issues with implementing a system • Cost and burden

3. Definition “The collection and analysis of health-related data that precede diagnosis and signal a sufficient probability of case or an outbreak to warrant further public health response.”

4. Rationale PRODROME SEVERE ILLNESS RELEASE Number of Cases Notifiable Disease Reporting Syndromic Surveillance

5. Rationale PRODROME SEVERE ILLNESS EXPOSURE Number of Cases Notifiable Disease Reporting Syndromic Surveillance

6. Increase sensitivity & timeliness of outbreak detection Strategies • Make outbreaks of any kind & individual cases of unusual disease officially reportable 24/7 • Routine use of PFGE fingerprinting (PulseNet) and the Laboratory Response Network (LRN) with sharing of information across states to identify clusters/ cases. • Automated analysis of reportable disease/lab data • Implement syndromic surveillance • Environmental monitoring (e.g., Biowatch, BDS)

7. Syndromic Surveillance Process

8. Laboratory Tests EMS Nursing Hotlines Emergency Departments Syndromic Surveillance Data Sources Poison Control Veterinarian Clinics Prescription Drugs School Absentee Over-the-counter

9. ED collects data on each patient Step 1 Syndromic Surveillance Process

10. Send data (e.g., 24 hours) via secure server to Health Department ED collects data on each patient Step 2 Syndromic Surveillance Process

11. Electronic ED Data -- CK s. x3 -- NG ER VA Date Time Sex Age Birth date Chief Complaint ---------------------------------------------------------- 08/08/2004 00:28 Female 13 01/31/1991 MIGRAINE NAUSEA 08/08/2004 00:38 Female 29 08/23/1974 COUGH,FEVER 08/08/2004 00:50 Male 48 09/01/1955 HUMAN BITE TO CHEST 08/08/2004 01:44 Male 53 07/29/1951 ABD PAIN, GENERAL 08/08/2004 09:00 Male 6 02/16/1998 N & VOMITING X 3 08/08/2004 09:21 Male 50 07/21/1954 SPRAIN ANKLE 08/08/2004 09:29 Female 1 03/21/2004 CRYING & FUSSINESS 08/08/2004 09:42 - Hospital A, August 8, 2004

12. Syndromes 

13. Send data (e.g., 24 hours) via secure server to HD Hospital can receive reports or view data ED collects data on each patient Step 3 Syndromic Surveillance Process HD performs aberration detection and analyses

14. Early Aberration Reporting System (EARS) Washington County ALL HOSPITALS Respiratory with Fever/ ILI Signal Moving 7-day baseline

15. Send data (e.g., 24 hours) via secure server to HD Hospital can receive reports or view data ED collects data on each patient Step 4 Syndromic Surveillance Process HD performs aberration detection and analyses Signals require further analysis and interpretation

16. Total GI (Last 24 Hrs): 2 Total GI (Last 24 Hrs): 0 Total GI (Last 24 Hrs): 0 Total GI (Last 24 Hrs): 1 Total GI (Last 24 Hrs): 0 Total GI (Last 24 Hrs): 3 Total GI (Last 24 Hrs): 2 Total GI (Last 24 Hrs): 4 Total GI (Last 24 Hrs): 1 Total GI (Last 24 Hrs): 1

17. Send data (e.g., 24 hours) via secure server to HD Hospital can receive reports or view data ED collects data on each patient Step 5 Syndromic Surveillance Process HD performs aberration detection and analyses Epidemiologists investigate Signals Signals require further analysis and interpretation

18. Phased Response

19. Challenges and Limitations

20. Signal • What questions are being asked of these data? • Specific questions to non-specific data • Limitations • Signal to noise (false positives) • Signal desensitization • Cost and resources

21. Sufficient Probability • Assessed by performing validations • Validate syndrome case definitions • Validate system to detect outbreaks • Sensitivity and specificity • Improving sensitivity • Increase false positive rate

22. Response • What signals warrant further public health response? • Thresholds • Sufficient size of the event • Among Syndromes • Do all data sources have a response? • Emergency Departments • Over-the-counter Pharmaceuticals

23. Policy IssuesExample: The Boston City Health Commission

24. Background • Previous outbreak detection systems • Reportable Disease Surveillance • Volume-based ED surveillance • Both mandated by City Regulation • Democratic National Convention • Pressure to implement electronic ED-based syndromic surveillance

25. Stakeholders • All Hospitals and Urgent Care Centers operating an Emergency Department in Boston • HIPAA • Privacy rule expressly permits use of protected health information for: • Reportable disease reporting • Public health surveillance • Epidemiologic investigation • Includes patient identifiable information • Limited Data Set Rule

26. Public Health Regulation DISEASE SURVEILLANCE AND REPORTING REGULATION PREAMBLE WHEREAS, The Boston Public Health Commission is charged with protecting, preserving and promoting the health and well-being of all Boston residents, particularly those who are most vulnerable. WHEREAS, The Boston Public Health Commission is charged with…

27. Disease Surveillance Regulation • All health care facilities in the City of Boston that operate or maintain an • emergency department and/or an urgent care facility, shall report for each visit during a twenty-four (24) hour period, to such emergency department or urgent care facility, the following information about each patient: • a. Age; • b. Gender; • c. Race/Ethnicity; • d. Residential zip code; • e. Chief complaint; and • f. Diagnostic code (if available).

30. CSTE concerns • Cost implications of monitoring syndromic surveillance systems and following up aberrations • With BT funding decreasing, evaluation of cost and effectiveness relative to other strategies for early detection of diseases of concern is badly needed

31. Estimating Cost • Difficult to measure • Parameters requiring estimates • Software packages • Data transfer mechanisms • Person-time and dedicated staff • R&D and Maintenance • Investigation of aberrations

32. Estimated Costs: NYC • Start-up costs • Developed from post-9/11 drop-in system • Paper-based with deployed staff to area hospitals • Electronic system • Direct annual costs estimated at $150,000/ year • Not including cost associated with: • Research and development • Surveillance for non-infectious outcomes • Data transmission costs incurred by hospitals

33. Aberration Detection Software • EARS (Early Aberration Reporting System) • Developed by CDC (Lori Hutwagner) • Shareware, available free of cost • RODS (Real-time Outbreak Detection Software) • Shareware, with ~$350/hour support/consult fees • Other packages from private vendors • May average ~$50,000

34. Final Thoughts

35. CSTE Recommendation Need evaluation of syndromic surveillance and a critical determination made as to whether it should be used routinely for aberration detection – or only in special circumstances (public health events)? We should not be expanding it without evaluation.

36. CSTE Position on Syndromic/ Bioterrorism Surveillance Recommendations: CDC form an advisory group to review all efforts at improving BT surveillance and advise re: which are worth keeping and funding, which should be encouraged of all states, and which should be scrapped. www.cste.org - position statements

37. For more information: Websites: www.syndromic.org http://www.cdc.gov/epo/dphsi/syndromic http://www.bt.cdc.gov/surveillance/ears

38. Signal • Detection scenario • Stoto et al. Chance 2004; 17(1): 19-24 • Excess of 9 cases over two days • 3X daily average • 50% probability of alarm • Excess of 18 cases over 9 days • Not until 9th day • 50% probability of alarm