Syndromic surveillance: two decades experience of sustainable systems - its people not just data!

Syndromic surveillance is a form of surveillance that generates information for public health action by collecting, analysing and interpreting routine health-related data on symptoms and clinical signs reported by patients and clinicians rather than being based on microbiologically or clinically confirmed cases. In England, a suite of national real-time syndromic surveillance systems (SSS) have been developed over the last 20 years, utilising data from a variety of health care settings (a telehealth triage system, general practice and emergency departments). The real-time systems in England have been used for early detection (e.g. seasonal influenza), for situational awareness (e.g. describing the size and demographics of the impact of a heatwave) and for reassurance of lack of impact on population health of mass gatherings (e.g. the London 2012 Olympic and Paralympic Games).We highlight the lessons learnt from running SSS, for nearly two decades, and propose questions and issues still to be addressed. We feel that syndromic surveillance is an example of the use of 'big data', but contend that the focus for sustainable and useful systems should be on the added value of such systems and the importance of people working together to maximise the value for the public health of syndromic surveillance services.

Novel public health risk assessment process developed to support syndromic surveillance for the 2012 Olympic and Paralympic Games.

Background: Syndromic surveillance aims to provide early warning and real time estimates of the extent of incidents; and reassurance about lack of impact of mass gatherings. We describe a novel public health risk assessment process to ensure those leading the response to the 2012 Olympic Games were alerted to unusual activity that was of potential public health importance, and not inundated with multiple statistical 'alarms'. Methods: Statistical alarms were assessed to identify those which needed to result in 'alerts' as reliably as possible. There was no previously developed method for this. We identified factors that increased our concern about an alarm suggesting that an 'alert' should be made. Results: Between 2 July and 12 September 2012, 350 674 signals were analysed resulting in 4118 statistical alarms. Using the risk assessment process, 122 'alerts' were communicated to Olympic incident directors. Conclusions: Use of a novel risk assessment process enabled the interpretation of large number of statistical alarms in a manageable way for the period of a sustained mass gathering. This risk assessment process guided the prioritization and could be readily adapted to other surveillance systems. The process, which is novel to our knowledge, continues as a legacy of the Games.

London 2012 Olympic and Paralympic Games: public health surveillance and epidemiology.

Mass gatherings are regarded as potential risks for transmission of infectious diseases, and might compromise the health system of countries in which they are hosted. The evidence for increased transmission of infectious diseases at international sporting mass gatherings that attract many visitors from all over the world is not clear, and the evidence base for public health surveillance, epidemiology, and response at events such as the Olympics is small. However, infectious diseases are a recognised risk, and public health planning is, and should remain, a crucial part of the overall planning of sporting events. In this Series paper, we set out the planning and the surveillance systems that were used to monitor public health risks during the London 2012 Olympic and Paralympic Games in the summer of 2012, and draw attention to the public health issues-infectious diseases and chemical, radiation, and environmental hazards-that arose. Although the absolute risk of health-protection problems, including infectious diseases, at sporting mass gatherings is small, the need for reassurance of the absence of problems is higher than has previously been considered; this could challenge conventional public health surveillance systems. Recognition of the limitations of health-surveillance systems needs to be part of the planning for future sporting events.

Assessing the use of hospital staff influenza-like absence (ILA) for enhancing hospital preparedness and national surveillance.

BACKGROUND: Early warning and robust estimation of influenza burden are critical to inform hospital preparedness and operational, treatment, and vaccination policies. Methods to enhance influenza-like illness (ILI) surveillance are regularly reviewed. We investigated the use of hospital staff 'influenza-like absences' (hospital staff-ILA), i.e. absence attributed to colds and influenza, to improve capture of influenza dynamics and provide resilience for hospitals. METHODS: Numbers and rates of hospital staff-ILA were compared to regional surveillance data on ILI primary-care presentations (15-64 years) and to counts of laboratory confirmed cases among hospitalised patients from April 2008 to April 2013 inclusive. Analyses were used to determine comparability of the ILI and hospital-ILA and how systems compared in early warning and estimating the burden of disease. RESULTS: Among 20,021 reported hospital-ILA and 4661 community ILI cases, correlations in counts were high and consistency in illness measurements was observed. In time series analyses, both hospital-ILA and ILI showed similar timing of the seasonal component. Hospital-ILA data often commenced and peaked earlier than ILI according to a Bayesian prospective alarm algorithm. Hospital-ILA rates were more comparable to model-based estimates of 'true' influenza burden than ILI. CONCLUSIONS: Hospital-ILA appears to have the potential to be a robust, yet simple syndromic surveillance method that could be used to enhance estimates of disease burden and early warning, and assist with local hospital preparedness.

Using real-time syndromic surveillance to assess the health impact of the 2013 heatwave in England.

Heatwaves are a seasonal threat to public health. During July 2013 England experienced a heatwave; we used a suite of syndromic surveillance systems to monitor the impact of the heatwave. Significant increases in heatstroke and sunstroke were observed during 7-10 July 2013. Syndromic surveillance provided an innovative and effective service, supporting heatwave planning and providing early warning of the impact of extreme heat thereby improving the public health response to heatwaves.

Universal HIV testing in London tuberculosis clinics: a cluster randomised controlled trial.

We assessed whether implementation of a combination of interventions in London tuberculosis clinics raised the levels of HIV test offers, acceptance and coverage. A stepped-wedge cluster randomised controlled trial was conducted across 24 clinics. Interventions were training of clinical staff and provision of tailor-made information resources with or without a change in clinic policy from selective to universal HIV testing. The primary outcome was HIV test acceptance amongst those offered a test, before and after the intervention; the secondary outcome was an offer of HIV testing. Additionally, the number and proportion of HIV tests among all clinic attendees (coverage) was assessed. 1,315 patients were seen in 24 clinics. The offer and coverage of testing rose significantly in clinics without (p = 0.002 and p = 0.004, respectively) and with an existing policy of universal testing (p = 0.02 and p = 0.04, respectively). However, the level of HIV test acceptance did not increase in 18 clinics without routine universal testing (p = 0.76) or the six clinics with existing universal testing (p = 0.40). The intervention significantly increased the number of HIV tests offered and proportion of participants tested, although acceptance did not change significantly. However, the magnitude of increase is modest due to the high baseline coverage.

Establishing an emergency department syndromic surveillance system to support the London 2012 Olympic and Paralympic Games.

BACKGROUND: The London 2012 Olympic and Paralympic Games is a mass gathering event that will present a major public health challenge. The Health Protection Agency, in collaboration with the College of Emergency Medicine, has established the Emergency Department Sentinel Syndromic Surveillance System (EDSSS) to support the public health surveillance requirements of the Games. METHODS: This feasibility study assesses the usefulness of EDSSS in monitoring indicators of disease in the community. Daily counts of anonymised attendance data from six emergency departments across England were analysed by patient demographics (age, gender, partial postcode), triage coding and diagnosis codes. Generic and specific syndromic indicators were developed using aggregations of diagnosis codes recorded during each attendance. RESULTS: Over 339,000 attendances were recorded (26 July 2010 to 25 July 2011). The highest attendances recorded on weekdays between 10:00 and 11:00 and on weekends between 12:00 and 13:00. The mean daily attendance per emergency department was 257 (range 38-435). Syndromic indicators were developed including: respiratory, gastrointestinal, cardiac, acute respiratory infection, gastroenteritis and myocardial ischaemia. Respiratory and acute respiratory infection indicators peaked during December 2010, concomitant with national influenza activity, as monitored through other influenza surveillance systems. CONCLUSIONS: The EDSSS has been established to provide an enhanced surveillance system for the London 2012 Olympics. Further validation of the data will be required; however, the results from this initial descriptive study demonstrate the potential for identifying unusual and/or severe outbreaks of infectious disease, or other incidents with public health impact, within the community.

Development of a decision framework for establishing a health register following a major incident.

INTRODUCTION: Health registers have been established in the United Kingdom (UK) and elsewhere following mass exposure to novel agents or known agents, but there is no consensus on the criteria for establishing such registers. OBJECTIVE: This study aimed to develop a decision framework to assess the need for establishing a health register for major chemical, biological, radiological, and nuclear (CBRN) incidents. METHODS: The study comprised three stages. In the first stage, the study team prepared a list of potential criteria that may be used to assess the need for setting up a health register based on literature review and personal experiences in previous incidents. In the second stage, the potential criteria were evaluated in two Delphi rounds involving experts and key decision makers from the UK Health Protection Agency (HPA) and academic organizations. In the final stage, the criteria were converted into a decision framework, and its utility was tested using four fictional scenarios. RESULTS: A total of 11 statements were proposed by the study group. These criteria were revised following feedback from 16 experts in the first Delphi round. All 11 statements achieved consensus at the end of the second Delphi round. Pilot testing of the agreed criteria on four fictional scenarios confirmed validity and reliability for use in the decision process. CONCLUSIONS: A decision framework to assess the need for setting up a health register after a major incident was agreed upon and tested using fictional scenarios. Further areas of work for practical implementation of the criteria and related planning for systems and protocols have been identified.

One Health collaboration with and among EU Agencies - Bridging research and policy.

In the coming decade, Europe will dedicate billions of euros to the necessary research and innovation (R&I) to support a transition to safe and sustainable food systems. EU Agencies, individually and even more so collectively, can make a difference in supporting the European research agenda. EU Agencies are knowledge centres, bringing together know-how to inform policy makers. EU Agencies that have traditionally dealt with aspects of human health, animal health, plant health and ecosystem health in silos, now need to take a broader perspective and move towards a One Health (OH) approach. In this paper, the authors highlight the need for more transdisciplinary cooperation in support of the One Health approach, identify challenges in strengthening interagency cooperation and provide recommendations to address them. EU Agencies are natural bridges between the scientific community and policy-makers and need to dedicate time and effort in fostering this dialogue, e.g. by engaging with relevant initiatives, research projects and European Partnerships. Research generates evidence that can be used also for regulatory science, in support of policy-making. It is urgent to define transdisciplinary research needs and formulate a One Health research agenda. This would be facilitated by establishing transdisciplinary One Health Research & Innovation governance, both at national and EU levels. Ongoing large initiatives, such as the One Health European Joint Programme, have demonstrated that active dialogue with national ministries and EU agencies is beneficial for all parties. Involvement of EU Agencies in the programming of the EU Research Framework programmes is beneficial, because of their regulatory science perspective, their expertise and current or future tasks on research topics. It is timely for EU Agencies to demonstrate leadership in moving the One Health agenda forward and it is encouraging that EU Agencies have committed to establish a cross-agency task force on One Health.

Preventing the next 'SARS' - European healthcare workers' attitudes towards monitoring their health for the surveillance of newly emerging infections: qualitative study.

BACKGROUND: Hospitals are often the epicentres of newly circulating infections. Healthcare workers (HCWs) are at high risk of acquiring infectious diseases and may be among the first to contract emerging infections. This study aims to explore European HCWs' perceptions and attitudes towards monitoring their absence and symptom reports for surveillance of newly circulating infections. METHODS: A qualitative study with thematic analysis was conducted using focus group methodology. Forty-nine hospital-based HCWs from 12 hospitals were recruited to six focus groups; two each in England and Hungary and one each in Germany and Greece. RESULTS: HCWs perceived risk factors for occupationally acquired infectious diseases to be 1.) exposure to patients with undiagnosed infections 2.) break-down in infection control procedures 3.) immuno-naïvety and 4.) symptomatic colleagues. They were concerned that a lack of monitoring and guidelines for infectious HCWs posed a risk to staff and patients and felt employers failed to take a positive interest in their health. Staffing demands and loss of income were noted as pressures to attend work when unwell. In the UK, Hungary and Greece participants felt monitoring staff absence and the routine disclosure of symptoms could be appropriate provided the effectiveness and efficiency of such a system were demonstrable. In Germany, legislation, privacy and confidentiality were identified as barriers. All HCWs highlighted the need for knowledge and structural improvements for timelier recognition of emerging infections. These included increased suspicion and awareness among staff and standardised, homogenous absence reporting systems. CONCLUSIONS: Monitoring absence and infectious disease symptom reports among HCWs may be a feasible means of surveillance for emerging infections in some settings. A pre-requisite will be tackling the drivers for symptomatic HCWs to attend work.

Advancing biological hazards risk assessment.

This paper focusses on biological hazards at the global level and considers the challenges to risk assessment (RA) from a One Health perspective. Two topics - vector-borne diseases (VBD) and antimicrobial resistance (AMR) - are used to illustrate the challenges ahead and to explore the opportunities that new methodologies such as next-generation sequencing can offer. Globalisation brings complexity and introduces drivers for infectious diseases. Cooperation and the application of an integrated RA approach - one that takes into consideration food farming and production systems including social and environmental factors - are recommended. Also needed are methodologies to identify emerging risks at a global level and propose prevention strategies. AMR is one of the biggest threats to human health in the infectious disease environment. Whereas new genomic typing techniques such as whole genome sequencing (WGS) provide further insights into the mechanisms of spread of resistance, the role of the environment is not fully elucidated, nor is the role of plants as potential vehicles for spread of resistance. Historical trends and recent experience indicate that (re)-emergence and/or further spread of VBD within the EU is a matter of when rather than if. Standardised and validated vector monitoring programs are required to be implemented at an international level for continuous surveillance and assessment of potential threats. There are benefits to using WGS - such as a quicker and better response to outbreaks and additional evidence for source attribution. However, significant challenges need to be addressed, including method standardisation and validation to fully realise these benefits; barriers to data sharing; and establishing epidemiological capacity for cluster triage and response.

Evaluating knowledge gain from TB leaflets for prison and homeless sector staff: the National Knowledge Service TB pilot.

BACKGROUND: The National Knowledge Service (NKS) is a National Health Service initiative to make patient and public information available to patients and healthcare professionals. The current study was carried out with a view to determine whether the resources developed by the NKS Tuberculosis Pilot have improved knowledge about tuberculosis among the target group in the short term. METHODS: Information resources specifically targeted and developed for homeless sector staff, managers and prison officials were used for this study. Questionnaires were designed to assess a change in the level of knowledge by completing a 'before' and 'after 'questionnaire. A total of 51 participants took part in the evaluation. McNemar's test for matched pairs was used to determine observed change in knowledge. RESULTS: Staff knowledge on symptoms of tuberculosis (TB) increased significantly after reading the targeted information resources. Knowledge gain for symptoms ranged from 17% (P = 0.007) for weight loss to 45% (P = 0.00001) for persistent fever. Knowledge about general guidelines that are available to this target group also improved, as did knowledge about the potential role of staff in supporting directly observed treatment (by 68% P = 0.00001) and the usual length of TB treatment (by 32% P = 0.0001). Pre-existing knowledge about the infectiousness of TB, risks for transmission and the likely period of hospitalization of patients with TB was high. CONCLUSIONS: This study demonstrates that purposefully designed and targeted information leaflets can be used successfully to translate complex information into a simple understandable format and impart knowledge of TB.

An Observational Study Using English Syndromic Surveillance Data Collected During the 2012 London Olympics - What did Syndromic Surveillance Show and What Can We Learn for Future Mass-gathering Events?

Introduction In preparation for the London 2012 Olympic Games, existing syndromic surveillance systems operating in England were expanded to include daily general practitioner (GP) out-of-hours (OOH) contacts and emergency department (ED) attendances at sentinel sites (the GP OOH and ED syndromic surveillance systems: GPOOHS and EDSSS). Hypothesis/Problem The further development of syndromic surveillance systems in time for the London 2012 Olympic Games provided a unique opportunity to investigate the impact of a large mass-gathering event on public health and health services as monitored in near real-time by syndromic surveillance of GP OOH contacts and ED attendances. This can, in turn, aid the planning of future events. METHODS: The EDSSS and GPOOHS data for London and England from July 13 to August 26, 2012, and a similar period in 2013, were divided into three distinct time periods: pre-Olympic period (July 13-26, 2012); Olympic period (July 27 to August 12); and post-Olympic period (August 13-26, 2012). Time series of selected syndromic indicators in 2012 and 2013 were plotted, compared, and risk assessed by members of the Real-time Syndromic Surveillance Team (ReSST) in Public Health England (PHE). Student's t test was used to test any identified changes in pattern of attendance. RESULTS: Very few differences were found between years or between the weeks which preceded and followed the Olympics. One significant exception was noted: a statistically significant increase (P value = .0003) in attendances for "chemicals, poisons, and overdoses, including alcohol" and "acute alcohol intoxication" were observed in London EDs coinciding with the timing of the Olympic opening ceremony (9:00 pm July 27, 2012 to 01:00 am July 28, 2012). CONCLUSIONS: Syndromic surveillance was able to provide near to real-time monitoring and could identify hourly changes in patterns of presentation during the London 2012 Olympic Games. Reassurance can be provided to planners of future mass-gathering events that there was no discernible impact in overall attendances to sentinel EDs or GP OOH services in the host country. The increase in attendances for alcohol-related causes during the opening ceremony, however, may provide an opportunity for future public health interventions. Todkill D , Hughes HE , Elliot AJ , Morbey RA , Edeghere O , Harcourt S , Hughes T , Endericks T , McCloskey B , Catchpole M , Ibbotson S , Smith G . An observational study using English syndromic surveillance data collected during the 2012 London Olympics - what did syndromic surveillance show and what can we learn for future mass-gathering events? Prehosp Disaster Med. 2016;31(6):628-634.

Drivers for emerging issues in animal and plant health.

The history of agriculture includes many animal and plant disease events that have had major consequences for the sector, as well as for humans. At the same time, human activities beyond agriculture have often driven the emergence of diseases. The more that humans expand the footprint of the global population, encroach into natural habitats, alter these habitats to extract resources and intensify food production, as well as move animals, people and commodities along with the pathogens they carry, the greater the potential for pathogens and pests to spread and for infection to emerge or re-emerge. While essential to human well-being, producing food also plays a major role in disease dynamics. The risk of emergence of pests and pathogens has increased as a consequence of global changes in the way food is produced, moved and consumed. Climate change is likely to increase pressure on the availability of food and provide newly suitable conditions for invasive pests and pathogens. Human population displacements due to economic, political and humanitarian crises represent another set of potential drivers for emerging issues. The overlapping drivers of plant, animal and human disease emergence and environmental changes point towards the concept of 'One Health'. This paradigm underlines the urgent need to understand the influence of human behaviour and incorporate this understanding into our approach to emerging risks. For this, we face two major challenges. One is cultural; the second is methodological. We have to look at systems not under the narrow view of specific hazards but with a wider approach to system dynamics, and consider a broad spectrum of potential outcomes in terms of risk. In addition, we have to make sense of the vast amounts of data that are available in the modern age. This paper aims to help in preparing for the cultural and methodological shifts needed in our approach to emerging risks.

A controlled trial of the knowledge impact of tuberculosis information leaflets among staff supporting substance misusers: pilot study.

BACKGROUND: Information leaflets are widely used to increase awareness and knowledge of disease. Limited research has, to date, been undertaken to evaluate the efficacy of these information resources. This pilot study sought to determine whether information leaflets developed specifically for staff working with substance mis-users improved knowledge of tuberculosis (TB). METHOD: Staffs working with individuals affected by substance mis-use were recruited between January and May 2008. All participants were subjectively allocated by their line manager either to receive the TB-specific leaflet or a control leaflet providing information on mental health. Level of knowledge of TB was assessed using questionnaires before and after the intervention and data analysed using McNemar's exact test for matched pairs. RESULTS: The control group showed no evidence of a change in knowledge of TB, whereas the TB questionnaire group demonstrated a significant increase in knowledge including TB being curable (81% correct before to 100% correct after), length of treatment required (42% before to 73% after), need to support direct observation (18% to 62%) and persistent fever being a symptom (56% to 87%). Among key workers, who have a central role in implementing a care plan, 88% reported never receiving any TB awareness-raising intervention prior to this study, despite 11% of all respondents having TB diagnosed among their clients. CONCLUSION: Further randomized controlled trials are required to confirm the observed increase in short-term gain in knowledge and to investigate whether knowledge gain leads to change in health status.