Assessing the relative timeliness of Ontario's syndromic surveillance systems for early detection of the 2009 influenza H1N1 pandemic waves.

OBJECTIVES: Building on previous research noting variations in the operation and perceived utility of syndromic surveillance systems in Ontario, the timeliness of these different syndromic systems for detecting the onset of both 2009 H1N1 pandemic (A(H1N1)pdm09) waves relative to laboratory testing data was assessed using a standardized analytic algorithm. METHODS: Syndromic data, specifically local emergency department (ED) visit and school absenteeism data, as well as provincial Telehealth (telephone helpline) and antiviral prescription data, were analyzed retrospectively for the period April 1, 2009 to January 31, 2010. The C2-MEDIUM aberration detection method from the US Centers for Disease Control and Prevention's EARS software was used to detect increases above expected in syndromic data, and compared to laboratory alerts, defined as notice of confirmed A(H1N1)pdm09 cases over two consecutive days, to assess relative timeliness. RESULTS: In Wave 1, provincial-level alerts were detected for antiviral prescriptions and Telehealth respiratory calls before the laboratory alert. In Wave 2, Telehealth respiratory calls similarly alerted in advance of the laboratory, while local alerts from ED visit, antiviral prescription and school absenteeism data varied in timing relative to the laboratory alerts. Alerts from syndromic data were also observed to coincide with external factors such as media releases. CONCLUSIONS: Alerts from syndromic surveillance systems may be influenced by external factors and variation in system operations. Further understanding of both the impact of external factors on surveillance data and standardizing protocols for defining alerts is needed before the use of syndromic surveillance systems can be optimized.

What do Canadians think about physician-pharmaceutical industry interactions?

BACKGROUND: Many health professional and regulatory groups have guidelines for identifying, disclosing and managing potential conflicts of interest (COI). The opinions of the Canadian public regarding what constitutes COI are unknown. METHODS: Bilingual telephone survey in all provinces using a validated questionnaire on public opinions on physician-pharmaceutical industry interactions (POPPII). Adults 18 years or older were contacted using random digit dialing (RDD) with representative national sampling of households. Results were analyzed for predictors of opinions and were compared with the reference COI guideline. Two follow-up focus groups were held. RESULTS: 1041 participants (56.8% female, mean age 52.6 years (SD 16.5), 18.2% francophone, 57.7% with post-secondary education) completed the survey. 34.0% reported a prior concern about physician-pharmaceutical industry relationships. Acceptability of interactions varied from high for requesting information about a particular drug or small gifts of obvious educational value to the patient, to mixed for free meals to listen to pharmaceutical industry personnel or payment to attend a conference, to low for research recruitment fees, personal use of medication samples or for using information not yet public about a new drug to make investment decisions. Age of the participant influenced ratings of acceptability. There was reasonable agreement (>60% participants) with only half of the related reference COI guideline statements. CONCLUSIONS: Public opinions on physician-pharmaceutical industry interactions differ depending on the scenario but suggest a significant level of concern regarding interactions involving direct financial benefit to physicians.

The use of syndromic surveillance for decision-making during the H1N1 pandemic: a qualitative study.

BACKGROUND: Although an increasing number of studies are documenting uses of syndromic surveillance by front line public health, few detail the value added from linking syndromic data to public health decision-making. This study seeks to understand how syndromic data informed specific public health actions during the 2009 H1N1 pandemic. METHODS: Semi-structured telephone interviews were conducted with participants from Ontario's public health departments, the provincial ministry of health and federal public health agency to gather information about syndromic surveillance systems used and the role of syndromic data in informing specific public health actions taken during the pandemic. Responses were compared with how the same decisions were made by non-syndromic surveillance users. RESULTS: Findings from 56 interviews (82% response) show that syndromic data were most used for monitoring virus activity, measuring impact on the health care system and informing the opening of influenza assessment centres in several jurisdictions, and supporting communications and messaging, rather than its intended purpose of early outbreak detection. Syndromic data had limited impact on decisions that involved the operation of immunization clinics, school closures, sending information letters home with school children or providing recommendations to health care providers. Both syndromic surveillance users and non-users reported that guidance from the provincial ministry of health, communications with stakeholders and vaccine availability were driving factors in these public health decisions. CONCLUSIONS: Syndromic surveillance had limited use in decision-making during the 2009 H1N1 pandemic in Ontario. This study provides insights into the reasons why this occurred. Despite this, syndromic data were valued for providing situational awareness and confidence to support public communications and recommendations. Developing an understanding of how syndromic data are utilized during public health events provides valuable evidence to support future investments in public health surveillance.

Perceived usefulness of syndromic surveillance in Ontario during the H1N1 pandemic.

BACKGROUND: Despite the growing popularity of syndromic surveillance, little is known about if or how these systems are accepted, utilized and valued by end users. This study seeks to describe the use of syndromic surveillance systems in Ontario and users' perceptions of the value of these systems within the context of other surveillance systems. METHODS: Ontario's 36 public health units, the provincial ministry of health and federal public health agency completed a web survey to identify traditional and syndromic surveillance systems used routinely and during the pandemic and to describe system attributes and utility in monitoring pandemic activity and informing decision-making. RESULTS: Syndromic surveillance systems are used by 20/38 (53%) organizations. For routine surveillance, laboratory, integrated Public Health Information System and school absenteeism data are the most frequently used sources. Laboratory data received the highest ratings for reliability, timeliness and accuracy ('very acceptable' by 92, 51 and 89%). Hospital/clinic screening data were rated as the most reliable and timely syndromic data source (50 and 43%) and ED visit data the most accurate (48%). During the pandemic, laboratory data were considered the most useful for monitoring the epidemiology and informing decision-making while ED screening and visit data were considered the most useful syndromic sources. CONCLUSIONS: End user perceptions are valuable for identifying opportunities for improvement and guiding further investments in public health surveillance.

Seroprevalence of pandemic influenza H1N1 in Ontario from January 2009-May 2010.

BACKGROUND: We designed a seroprevalence study using multiple testing assays and population sources to estimate the community seroprevalence of pH1N1/09 and risk factors for infection before the outbreak was recognized and throughout the pandemic to the end of 2009/10 influenza season. METHODS: Residual serum specimens from five time points (between 01/2009 and 05/2010) and samples from two time points from a prospectively recruited cohort were included. The distribution of risk factors was explored in multivariate adjusted analyses using logistic regression among the cohort. Antibody levels were measured by hemagglutination inhibition (HAI) and microneutralization (MN) assays. RESULTS: Residual sera from 3375 patients and 1024 prospectively recruited cohort participants were analyzed. Pre-pandemic seroprevalence ranged from 2%-12% across age groups. Overall seropositivity ranged from 10%-19% post-first wave and 32%-41% by the end of the 2009/10 influenza season. Seroprevalence and risk factors differed between MN and HAI assays, particularly in older age groups and between waves. Following the H1N1 vaccination program, higher GMT were noted among vaccinated individuals. Overall, 20-30% of the population was estimated to be infected. CONCLUSIONS: Combining population sources of sera across five time points with prospectively collected epidemiological information yielded a complete description of the evolution of pH1N1 infection.

Can current electronic systems meet drug safety and effectiveness requirements?

BACKGROUND: Every health policy jurisdiction is endeavoring to enhance its ability to evaluate drug effectiveness, safety and cost in the real world (pharmacosurveillance). METHODS: A nominal group consensus conference of stakeholders finalized data items deemed necessary for pharmacosurveillance. Large administrative datasets (LADs), electronic health records (EHRs) and electronic patient registries (PRs), were investigated as sources of this information and for their vulnerability to methodologic bias. Health data privacy legislation and research guidelines were systematically reviewed for their constraint to linked data resource analyses. RESULTS: More than 129 data items were strongly recommended for routine pharmacosurveillance. LADs had very complete information, but restricted to a small number of required data items. EHRs, especially with e-pharmacy links, offer by far the most complete set of health information domains but data entry completeness is highly variable. Adjustment methods for channeling bias are inadequate to mimic randomized trials. Anonymized, linked data held within a secure academic research environment, poses the least privacy concerns. CONCLUSIONS: Notwithstanding major technical, methodologic and privacy challenges, individual-level linkage of health data resources poses the best option for pharmacosurveillance today. In future, drug regulators and reimbursement agencies should consider mandatory post-marketing randomized trials.