# Presentation: 884721

## Syndromic Surveillance in New York State

- Loretta A. Santilli, MPH
- James R. Miller, MPH, MD
- Hwa-Gan Chang, PhD
- New York State Department of Health
- Division of Epidemiology
- las09@health.state.ny.us	(518) 486-2151
- Presented February 24, 2005 at the
- CDC Public Health Preparedness Conference - Atlanta, GA

**Notes:**
The presentation provides a brief overview of Syndromic Surveillance, followed by a description of  NYSDOH’s Electronic Syndromic Surveillance System.

## Objectives

- Familiarize participants with the goals and specific components of the NYS Syndromic Surveillance System.
- Describe unique aspects of the system.
- Discuss current limitations and future enhancements.

## Definitions

- 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)

**Notes:**
Traditional public health surveillance usually relies on a sequence of events occurring prior to the actual reporting of a disease or condition:  
 A patient seeks medical care 
 A laboratory test is ordered for clinical confirmation 
 The disease or condition is checked against a list of reportable diseases or conditions 
 Subsequent reporting of the disease/condition by the laboratory and or clinician via paper, telephone, fax or electronic means  

This sequence of events takes time, with a typical reporting lag-time of days to weeks.

Syndromic surveillance is a form of public health surveillance that monitors real-time health-related data that precede diagnosis. Examples of data types that are monitored within a syndromic surveillance system as potential indicators of a disease or outbreak include absenteeism data from large employers or schools, purchases of health products, prescription medications data, laboratory test orders, Emergency Department chief complaint data, and data from Nurses’ Hotline and Ambulance Dispatch (EMS) systems. 

These data are continually assessed for indicators of diseases and outbreaks, enabling detection before public health authorities would identify them utilizing traditional disease surveillance methods.  The advantage of syndromic surveillance is the lead-time it provides public health authorities to take more effective public health actions. What syndromic surveillance allows is not necessarily earlier diagnosis, but the ability to mobilize public health investigation and response capabilities prior to disease and outbreak confirmation.

## Early Syndromic Surveillance, 1665

## 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.

**Notes:**
The overlying goals of syndromic surveillance are to:

Recognize an outbreak due to a natural cause or a terrorist agent earlier than physician, laboratory or citizen reporting.
	Characterize the size, spread, and tempo of outbreaks after initial detection
Monitor general community health trends and track level of disease in the community, like flu. 
Provide objective evidence that an outbreak is not occurring.  (Example – RNC resulted in increased daily surveillance.  We were able to report to Executive staff that ‘nothing big was happening today’)
Help sustain a strong ongoing relationship between public health and clinical medicine.  Increased communication.

## 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.

**Notes:**
A little background information regarding syndromic surveillance....

We KNOW that syndromic surveillance can detect outbreaks.  For example, the data tells us every year when flu season has arrived.

Syndromic surveillance will never replace traditional disease reporting, it is a supplement to it - another piece of the puzzle.
	Other, more traditional avenues of public health surveillance are still very important.  If you utilize syndromic surveillance, you will still do what you normally do, only you will be able to react more quickly and with better awareness

Syndromic surveillance generates mathematical signals – statistically significant signals – but they MUST still be verified clinically to determine their public health significance.

Inter-system comparisons may help in the interpretation of a positive signal.  Different system components cover different populations.
	Syndromic surveillance systems have multiple components that may cover different populations within the same community.  If a signal is observed within multiple components, it is more likely to be a significant outbreak.

Although a promising approach, we just don’t know yet exactly how effective the data are in improving outcomes – the actual public health response.  More evaluation is underway.

## Syndromic Surveillance Systems Operated by NYSDOH(Emergency Department Data)

| System 
Name | Data Source/Participants
(No./Type) | Collection Method/Start Date/
Frequency | Data Content | Analysis | Current 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 
20 hospitals
9 counties

Westchester County w/ 12 hospitals is on cusp | 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

**Notes:**
NYSDOH’s Syndromic Surveillance system currently has 4 components; two Emergency Department-based components and two pharmacy data-based  components.

This slide describes the two Emergency Department-based components:  The ED Phone Call System and the Electronic ED Syndromic Surveillance System

The ED phone Call System monitors unusual events or clusters of illnesses in the EDs of participating hospitals.  This effort involves Hospital ED staff from 157 hospitals and LHD staff from 52 counties.  Counts of unusual cases/clusters along with descriptive narratives are communicated on a daily basis to NYSDOH by LHDs via phone calls, e-mail or data entry on the HIN.  Participation in the ED Phone Call system is voluntary except during times of heightened concern.

The Electronic ED Syndromic Surveillance System includes summary statistics generated from Emergency Department Chief Complaint data that are electronically submitted to NYSDOH from participating hospitals. Currently 20 facilities located in 9 counties are submitting data to this system, including 6 counties that have all of their hospitals onboard. Data from the previous day are submitted daily via ECLRS, the Department's Electronic Clinical Laboratory Reporting System.  Once received by NYSDOH, the Emergency Department Chief Complaint data are categorized into 6 syndromes: Respiratory, GI, Fever, Asthma, Neurological and Rash.  Summary and case level counts, signals (CuSum analysis results), long and short-term trend graphs as well as patient listings are available for viewing on the NYSDOH Commerce System by syndrome, hospital, county and region. Participating  hospitals may view data for their hospital only, and LHDs may view data for all participating hospitals in their county, as well as aggregated data for their county and region. Future plans include working with regional offices and LHDs to recruit as many additional hospitals as possible.

## Syndromic Surveillance Systems Operated by NYSDOH(Pharmacy Data)

| System 
Name | Data Source/Participants
(No./Type) | Collection Method/Start Date/
Frequency | Data Content | Analysis | Current 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  Prescription Medications | 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 |

**Notes:**
This slide describes the two pharmacy data-based  components of the NYSDOH’s Syndromic Surveillance system: the NRDM/RODS Over the Counter pharmacy data system, and the Medicaid Over the Counter (OTC) and Prescription Medications data system.

The National Retail Data Monitor/Real-time Outbreak and Disease Surveillance system, or NRDM/RODS is basically the system for over the counter drugs.  If you walk into your local pharmacy and buy Immodium, we get that.  We don’t know who you are, just what you bought. We get info on things like cough medicine, fever reducers, and rash creams.  There are 15 categories in all.  Like the ED surveillance, we can look at the data by count and signals are generated.  Although you are not able to view this data through Commerce, we’ll let you know if we see something.  If you would like direct access to the National system, let me know and I can point you in the right direction.

The Medicaid system is unique to New York.  It gives us data on the prescriptions written for those on Medicaid but also – and I never knew this – also covers over the counter drugs.  A mom could bring in her sick child and walk away with a ‘prescription’ for children’s Tylenol.  We get that.  Along with the traditional antibiotics, etc.  There are 18 categories in all.  Analysis is the same as the ED surveillance with individual drug category counts, signals and long and short-term trend graphs.   This data is available to all of you on the Commerce system.  So even if you do not have an ED reporter, you can get this now.

Another point to keep in mind is that Medicaid only covers a portion of your county population.  For upstate this ranges from 4 to 20%.  

## Additional Syndromic Surveillance SystemsOperated by LHDs (examples)

- NYCDOHMH ED syndromic system, 9-1-1, absenteeism, OTC medications
- Westchester County ED & outpatient depts.
- Suffolk County 9-1-1
- HVRHON 9-1-1 (Orange & Dutchess Co.), school absenteeism
- Erie County EMT transport monitoring
- Monroe County ED Census, ILI, 9-1-1
- Albany County ED Census

**Notes:**
This slide lists examples of local Syndromic Surveillance systems operated by LHDs. 

This is not all-inclusive, if you know of other systems, please let me know - we like to keep tabs on these sorts of things.

## National Syndromic Surveillance System:  BioSense

- Data Sources
- Department of Defense Military Treatment Facilities
- Veteran’s Administration facilities
- National clinical testing labs and nurse hotline data (under development)
- Data elements include health syndromes, diagnosis codes, facility name, patient zip code
- Part of the multi-department Federal BioSurveillance initiative
- BioSense = health surveillance data
- BioWatch = air monitoring
- BioShield = treatments (vaccines, new drugs, etc.)

## NYSDOH Operating Principles - 1

- LHD participation is _essential_
- Hospital inclusion limited to counties where LHD is an active participant.
- LHD has the lead in investigating syndromic signals from hospitals or medication sales within their county.
- As appropriate, LHDs will provide additional data/reports regarding syndromic signals from their county to other LHDs or hospitals.

**Notes:**
Next I’d like to go over a few basic operating principles 

First and foremost Participation of LHDs is ESSENTIAL

We will not bring a hospital on board if the LHD is not yet willing to be an active participant.  

We cannot have signals generated if the LHD is unable to investigate them.

The LHD has the lead in investigating syndromic signals and will be the one to share data with others as necessary.

## NYSDOH Operating Principles - 2

- Hospitals submit data in standard format to NYS.
- Existing LHD systems will be encouraged to submit data to NYS consistent with NYS standard format.
- Daily reports sent back to LHDs and hospitals via Commerce.
- Includes reports at county and region levels.

**Notes:**
Operating principles continued....

Hospitals submit data in standard format to NYS.  There are actually only a few variables we need to collect at this point.

We also work with existing LHD systems (such as Westchester’s) to get the data to us in a standard format.

We know how important it is for folks who submit data to get something back so we make sure daily reports are available to users.
LHDs must log onto the Commerce system to retrieve reports and view data.

## Slide 13

**Notes:**
This slide shows a screenshot of NYSDOH’s Electronic Syndromic Surveillance System’s Homepage.  The URL is listed in the red box.

As you can see, there are areas for the two components of NYSDOH's Electronic Syndromic Surveillance System that are available on the HIN and HPN for viewing and monitoring:  

ED Daily Reports – data and reports from the Electronic ED Syndromic Surveillance System 
Medicaid Prescription Daily Reports – data and reports from the Medicaid system 

I want to make you aware of the FAQ link at the bottom of the page.  This is a link to a helpful Frequently Asked Questions document, and addresses some of the basic questions you may have regarding the available data and reports. 

## Slide 14

**Notes:**
Next, I would like to show you a few examples of reports available from NYSDOH’s Syndromic Surveillance System.

This slide is an example screenshot of the short term (30 days) trend graph available for viewing from the Electronic ED Syndromic Surveillance System. This particular graph is for the Respiratory syndrome for the entire Hudson Valley Region.  These are also available at the county and individual hospital level.

There are three types of “signals” generated to alert the user to different levels of elevated counts, C1, C2 and C3 signals.  Signals are denoted by red stars, and the average is depicted by the dotted line.  Daily syndrome counts are show below the graph, with text indicators of signals in red. 

## Slide 15

**Notes:**
This slide is an example screenshot of individual daily counts by the 18 drug categories available for viewing from the Medicaid system.  Again, there are three types of “signals”  - shaded white.

This particular table is for an individual county but there are regional tables as well.

## County = County Name

**Notes:**
This slide is an example screenshot of the short term (30 days) trend graph available for viewing from the Medicaid system.  This should look familiar, it is the same type of short term graph as the ED system, same stars, counts, just different data source.

This particular graph is for the Influenza Agents drug category for an individual county.  

## County = County Name

**Notes:**
This slide is an example screenshot of the LONG term trend graph.  It will include data from the time we began to receive data to the present day.

Note that signals and daily counts are not shown on the long term graphs. This gives you your big picture.  

This particular graph is for the Influenza Agents drug category for an individual county - note the distinctive annual pattern. 

Again, there is consistency in the graphs across systems - this graph has the same exact format as the long term trend graph available within the Electronic ED Syndromic Surveillance System. 

## Slide 18

## Practical Uses of Data: Examples

- Pertussis
- RNC surveillance
- Influenza
- Public reassurance

## NYSDOH Next Steps

- Invite additional LHDs and hospitals to participate in syndromic surveillance data submission
- Active recruitment at local level by ss coordinator
- Promote user access to Syndromic Surveillance Commerce website
- Develop step-by-step user’s guide for system
- Enhance communication
- Ensure user access to all data sets via Commerce website.
- Investigate opportunities to interface multiple systems
- Develop recommendations for response protocol
- Features to consider when determining significance of a signal
- Possible actions when investigating a signal

## NYSDOH Next Steps

- Explore disease models associated with various medications
- Consider availability of data analyses by zip code, gender, age groups
- Conduct validation studies with filters
- Compare NYSDOH filters to other systems
- Fund expanded/enhanced syndromic surveillance activities

## Questions