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Queen’s University Emergency Syndromic Surveillance Team
(QUESST)Dr Kieran MooreSSM Innovation CentreGIS in Health Care DayMay 17 2007Algoma University College
Queen’s University Emergency Syndromic Surveillance Team
Objectives
What is Syndromic Surveillance?
Emergency Department Syndromic Surveillance Project
Ontario’s Telehealth Surveillance Project
GIS-mapping the data
Queen’s University Emergency Syndromic Surveillance Team
Who we are-QUESST
ITSoftwareGISEpidemiologistsPublic HealthAcute Care SectorGrants/MOH LTC
Queen’s University Emergency Syndromic Surveillance Team
Syndromes SARS
Queen’s University Emergency Syndromic Surveillance Team
Water…food…
Queen’s University Emergency Syndromic Surveillance Team
Food…
6
©2002 Siemens Medical Solutions Health Services Corporation.Siemens Confidential:
02000400060008000
100001200014000160001800020000
-2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Num
ber o
f Peo
ple
Onset of SymptomsSpecific SyndromeDeaths
Intel
Demographics, Chief Complaint, Visit Data
Lab results, X-Rays, etc.
Courtesy: Michael Wagner, MD, University of Pittsburgh
Biosensors
Potential Strategies for Early Detection
Queen’s University Emergency Syndromic Surveillance Team
Innovative electronic surveillance systems
Action oriented-integrated-change from passive to active
Capture existing health data automatically in Real Time including demographics
What is Syndromic Surveillance?
Queen’s University Emergency Syndromic Surveillance Team
Syndromic Surveillance Systems
IT linking data sources
Natural language processing-text mining
Syndromes of interest
Anomaly detection
Temporal Spatial analysis-Mapping
Queen’s University Emergency Syndromic Surveillance Team
Work-school
Primary CareClinic
Emergency Dept
Lab test
Pharmacy
Telehealth
Surveillance Options
Queen’s University Emergency Syndromic Surveillance Team
Emergency Department Visits – Respiratory SyndromeKingston Hospitals, August 2001 to August 2005
70
60
50
40
30
20
10
# of
Vis
its
Queen’s University Emergency Syndromic Surveillance Team
Goal of Syndromic Surveillance
Enhanced communication, collaborationImproved response times – data available 24/7/365 in real-timeSituational awarenessImproved epidemiological analysis and outbreak detection– FOCUS: GI and Respiratory
Queen’s University Emergency Syndromic Surveillance Team
What should be collected?
Collect real time anonymous data from…– Emergency Department visits
Date and Time of VisitHospitalAgeSexPostal Code (5 digits)Chief ComplaintCTAS Triage ScoreFebrile Respiratory Illness (FRI) Screening results
– Admissions to hospital
Queen’s University Emergency Syndromic Surveillance Team
Canadian Triage and Acuity Scale(CTAS)
NON URGENTV
LESS URGENTIV
URGENTIII
EMERGENTII
RESUSCITATIONI
TRIAGE LEVELS Formal method of prioritizing patients- Based on ‘Usual
Presentation’ of patients discharged with a sentinel (ICD9CM) diagnoses
Queen’s University Emergency Syndromic Surveillance Team
Febrile Respiratory Illness (FRI)Screening Tool – Non-outbreak
CBA
3 SECTIONS
CONTACT/TRAVEL HISTORY
TEMPERATURESYMPTOMS
If ‘YES’ to A (new or worse cough or shortness of breath)
B (fever, shakes or chills in last 24 hrs) – temperature taken
If ‘YES’ to A and B
Contact precautions implemented.
If ‘YES’ to A, B and C – notify Infection Control immediately.
Queen’s University Emergency Syndromic Surveillance Team
DEMO - Using the RODS TOOL
Log InMain PageEpiPlot‘Get Cases’ line listingMapPlot
Queen’s University Emergency Syndromic Surveillance Team
RODS log in
Cryptocard access, etc.
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Scenarios – RODS Main Page Date accessed:
Queen’s University Emergency Syndromic Surveillance Team
Scenarios – RODS EpiPlot
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Real-time ED data Applications
Using real-time data for syndromic surveillance – GI
syndrome
Salmonella enteritidis outbreak Nov/05-Jan/06
Syndrome Surveillance (GI): Salmonella outbreak Province-wide: source unknown
Epi curve of S . Enteriditis in Ontario, June 1 - November 26, 2005 (n=589)
0
50
100
150
200
250
June
1-4Ju
ne 5-11
June
12-18Ju
ne 19-25
June
26-July2
July 3
-9Ju
ly10-16
July1
7-23Ju
ly 24-30
July 3
1-Aug 6Aug 7
-13Aug 1
4-20Aug 2
1-27Aug 2
8-Sep 3Sep 4
-10Sep 1
1-17Sep 1
8-24Sep 2
5-Oct
1Oct
2-Oct8
Oct 9-15
Oct 16-2
2Oct
23-29
Oct 30-N
ov 5Nov
6-12
Nov 13
-19Nov.
20-26
Week received at Ontario Central Public Health Lab
Num
ber o
f cas
es
Other SEs
PT pending
PT13
Courtesy of Public Health Agency of Canada, Guelph, ON.
Epidemic curve of S . Enteritidis cases in Ontario, by day received at CPHL, October 1 - December 6, 2005 (n=612)
0
10
20
30
40
50
60
70
Oct. 3
Oct. 5
Oct. 7
Oct. 12
Oct. 14
Oct. 17
Oct. 19
Oct. 23
Oct. 25
Oct. 27
Oct. 31
Nov. 2
Nov. 4
Nov. 8
Nov. 1
0Nov
. 14
Nov. 1
6Nov
. 18
Nov. 2
1Nov
. 23
Nov. 2
5Nov
. 28
Nov. 3
0Dec
. 2Dec
. 5
Day received at Ontario Central Public Health Lab
Num
ber o
f cas
es
Other SEs
PT pending
PT13
Courtesy of Public Health Agency of Canada, Guelph, ON.
Salmonella outbreak Province-wide: source unknown
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Figure 4 - KFL&A Salmonella Enteritidis outbreak – ED visits for GI syndrome mapped to 5-digit Postal Code areas Nov 16-25/05
Queen’s University and KGH
Queen’s University Emergency Syndromic Surveillance TeamRetrospective Analysis - EARS graph of revised GI syndrome (diarrhea +/- other Sx) for patients visiting KGH and HDH ED - Nov/05
Initial cluster of patients presents to ED with diarrhea +/-other symptoms –
cultures taken
Using Real-time data to support Public Health decision-making
and monitor the effectiveness of Public Health interventions
Queen’s University Emergency Syndromic Surveillance TeamQueen’s University Emergency Syndromic Surveillance Team
Secondary Uses – Heat Alerts
For immediate releaseTuesday, July 12, 2005 Level 1 Heat Alert issued for KFL&A areaKingston�KFL&A Public Health is issuing a Level 1 Heat Alert to residents of the KFL&A area with hot, humid weather forecast for the next few days. A Level 1 Heat Alert is issued when temperatures or humidex are forecast to be 36°C for two or more consecutive days.
Sentinel Surveillance
The ‘Homecoming’Effect
Queen’s University Emergency Syndromic Surveillance Team
2005 Homecoming Sept 23-25
0
50
100
150
200
250
9/9/05
9/10/0
59/1
1/05
9/12/0
59/1
3/05
9/14/0
59/1
5/05
9/16/0
59/1
7/05
9/18/0
59/1
9/05
9/20/0
59/2
1/05
9/22/0
59/2
3/05
9/24/0
59/2
5/05
9/26/0
59/2
7/05
9/28/0
59/2
9/05
9/30/0
510
/1/05
10/2/
0510
/3/05
10/4/
0510
/5/05
10/6/
0510
/7/05
10/8/
0510
/9/05
Date
# of
ED
vis
its (K
GH
and
HD
H
all 17+ 17-25yrs 26-64yrs 65+ yrs
Sentinel surveillance
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
NO alerts homecoming weekend
Example of retrospective review of syndromic surveillance:
Anomaly Detection
Seasonal Influenza
Queen’s University Emergency Syndromic Surveillance Team
Characterizing the Flu Seasons
2001-02 sporadic cases beginning in mid-January
2002-03 good match with Vaccine, very few positive influenza tests, beginning in mid-January
2003-04 large numbers of casesbeginning in mid-November (artifact of SARS?)
2004-05 similar to 2001-02; beginning New Years
Queen’s University Emergency Syndromic Surveillance Team
Influenza in KFL&A – 2001/02
0
20
40
60
80
9/1/2001 10/1/2001 11/1/2001 12/1/2001 1/1/2002 2/1/2002 3/1/2002 4/1/2002
Const - all agesResp - all ages
0
1
2
3
4
5
9/1/2001 10/1/2001 11/1/2001 12/1/2001 1/1/2002 2/1/2002 3/1/2002 4/1/2002
Resp - CuSUMResp - RLSConst - CuSUMConst - RLS
0
1
2
3
9/1/2001 10/1/2001 11/1/2001 12/1/2001 1/1/2002 2/1/2002 3/1/2002 4/1/2002
Positive Influenza
Queen’s University Emergency Syndromic Surveillance Team
Influenza in KFL&A – 2002/03
0102030405060
9/1/2002 10/1/2002 11/1/2002 12/1/2002 1/1/2003 2/1/2003 3/1/2003 4/1/2003
Const - all agesResp - all ages
0
1
2
3
4
5
9/1/2002 10/1/2002 11/1/2002 12/1/2002 1/1/2003 2/1/2003 3/1/2003 4/1/2003
Resp - CuSUMResp - RLSConst - CuSUMConst - RLS
0
1
2
3
9/1/2002 10/1/2002 11/1/2002 12/1/2002 1/1/2003 2/1/2003 3/1/2003 4/1/2003
Positive Influenza
Queen’s University Emergency Syndromic Surveillance Team
Influenza in KFL&A – 2003/04
0
20
40
60
80
100
9/1/2003 10/1/2003 11/1/2003 12/1/2003 1/1/2004 2/1/2004 3/1/2004 4/1/2004
Const - all agesResp - all ages
0
1
2
3
4
5
9/1/2003 10/1/2003 11/1/2003 12/1/2003 1/1/2004 2/1/2004 3/1/2004 4/1/2004
Resp - CuSUMResp - RLSConst - CuSUMConst - RLS
0
2
4
6
8
9/1/2003 10/1/2003 11/1/2003 12/1/2003 1/1/2004 2/1/2004 3/1/2004 4/1/2004
Positive Influenza
Queen’s University Emergency Syndromic Surveillance Team
Influenza in KFL&A – 2004/05
0
20
40
60
80
12/1/2004 12/16/2004 12/31/2004 1/15/2005 1/30/2005 2/14/2005 3/1/2005 3/16/2005 3/31/2005
Const - all agesResp - all ages
0
1
2
3
4
5
12/1/2004 12/16/2004 12/31/2004 1/15/2005 1/30/2005 2/14/2005 3/1/2005 3/16/2005 3/31/2005
Resp - CuSUMResp - RLSConst - CuSUMConst - RLS
01234567
12/1/2004 12/16/2004 12/31/2004 1/15/2005 1/30/2005 2/14/2005 3/1/2005 3/16/2005 3/31/2005
Positive Influenza
Queen’s University Emergency Syndromic Surveillance Team
Telehealth Ontario
Nurse help line
Computerized decision tree
Guidelines recommended
Electronic data base
Queen’s University Emergency Syndromic Surveillance Team
Guidelines to Syndromes
Upper Respiratory• Colds (Adult After Hours)• Colds (Pediatric After Hours)• Congestion - Guideline Selection
(Pediatric After Hours)• Croup (Pediatric After Hours)• Ear - Congestion (Adult After Hours)• Ear - Congestion (Pediatric After
Hours)• Ear - Discharge (Adult After Hours)• Ear - Discharge (Pediatric After Hours)• Earache (Adult After Hours)• Earache (Pediatric After Hours)
• Hoarseness (Adult After Hours)• Hoarseness (Pediatric After Hours)• Respiratory Multiple Symptoms - Guideline
Selection (Adult After Hours)• Respiratory Multiple Symptoms - Guideline
Selection (Pediatric After Hours)• Sinus Infection Follow-Up Call (Adult After Hours)• Sinus Infection Follow-up Call (Pediatric After
Hours)• Sinus Pain and Congestion (Adult After Hours)• Sinus Pain Or Congestion (Pediatric After Hours)• Sore Throat (Adult After Hours)• Sore Throat (Pediatric After Hours)
Queen’s University Emergency Syndromic Surveillance Team
Guidelines to Syndromes
Lower Respiratory• Guideline• Cough - Acute Non-productive (Adult After Hours)• Cough - Acute Productive (Adult After Hours)• Cough - Chronic (Adult After Hours)• Cough (Pediatric After Hours)• Coughing Up Blood (Adult After Hours)• Wheezing - Other Than Asthma (Pediatric After Hours)
Queen’s University Emergency Syndromic Surveillance Team
Guidelines to Syndromes
Fever/ILI• Fever (Adult After Hours)• Fever (Pediatric After Hours)• Influenza (Adult After Hours)• Influenza (Pediatric After Hours)
Gastroenteritis• Diarrhea (Adult After Hours)• Diarrhea (Pediatric After Hours)• Stools - Blood In (Pediatric After Hours)• Stools - Unusual Color (Pediatric After
Hours)• Stools - Unusual Color Of (Adult After
Hours)• Vomiting (Adult After Hours)• Vomiting (Pediatric After Hours)
Queen’s University Emergency Syndromic Surveillance Team
Telehealth –All Respiratory Calls (3 day MA)
0
100
200
300
400
500
600
700
800
6/1/2004 8/1/2004 10/1/2004 12/1/2004 2/1/2005 4/1/2005 6/1/2005 8/1/2005 10/1/2005 12/1/2005 2/1/2006 4/1/2006 6/1/2006
Queen’s University Emergency Syndromic Surveillance Team
0
500
1000
1500
2000
2500
3000
3500
6/1/20
04
8/1/20
04
10/1/
2004
12/1/
2004
2/1/20
05
4/1/20
05
6/1/20
05
8/1/20
05
10/1/
2005
12/1/
2005
2/1/20
06
4/1/20
06
6/1/20
06Telehealth Respiratory Calls (3 day MA)and Respiratory Virus isolates (x3)
All RespFlu A
Flu B
Flu A or B
RSV
PIV
Adeno
Queen’s University Emergency Syndromic Surveillance Team
0
100
200
300
400
500
600
700
800
6/1/2004 8/1/2004 10/1/2004 12/1/2004 2/1/2005 4/1/2005 6/1/2005 8/1/2005 10/1/2005 12/1/2005 2/1/2006 4/1/2006 6/1/2006
Telehealth Respiratory Calls (3 day MA)and RSV isolates
All Resp
RSV isolates
Queen’s University Emergency Syndromic Surveillance Team
0
100
200
300
400
500
600
700
800
6/1/2004 8/1/2004 10/1/2004 12/1/2004 2/1/2005 4/1/2005 6/1/2005 8/1/2005 10/1/2005 12/1/2005 2/1/2006 4/1/2006 6/1/2006
Telehealth Respiratory Calls (3 day MA)and PIV isolates
All Resp
PIV isolates
Queen’s University Emergency Syndromic Surveillance Team
0
100
200
300
400
500
600
700
800
6/1/2004 8/1/2004 10/1/2004 12/1/2004 2/1/2005 4/1/2005 6/1/2005 8/1/2005 10/1/2005 12/1/2005 2/1/2006 4/1/2006 6/1/2006
Telehealth Respiratory Calls (3 day MA)and Flu A isolates
All Resp
Flu A isolates
Queen’s University Emergency Syndromic Surveillance Team
0
100
200
300
400
500
600
700
800
6/1/2004 8/1/2004 10/1/2004 12/1/2004 2/1/2005 4/1/2005 6/1/2005 8/1/2005 10/1/2005 12/1/2005 2/1/2006 4/1/2006 6/1/2006
Telehealth Respiratory Calls (3 day MA)and Flu B isolates
All Resp
Flu B isolates
Queen’s University Emergency Syndromic Surveillance Team
0
100
200
300
400
500
600
700
800
6/1/2004 8/1/2004 10/1/2004 12/1/2004 2/1/2005 4/1/2005 6/1/2005 8/1/2005 10/1/2005 12/1/2005 2/1/2006 4/1/2006 6/1/2006
Telehealth Respiratory Calls (3 day MA)and Flu A and B isolates
All Resp
Flu B isolates
Flu A isolates
Queen’s University Emergency Syndromic Surveillance Team
0
100
200
300
400
500
600
700
800
6/1/2004 8/1/2004 10/1/2004 12/1/2004 2/1/2005 4/1/2005 6/1/2005 8/1/2005 10/1/2005 12/1/2005 2/1/2006 4/1/2006 6/1/2006
Telehealth Respiratory Calls (3 day MA)and Flu isolates (A and B)
All Resp
Flu isolates(A and B)
Queen’s University Emergency Syndromic Surveillance Team
Emergency Department Visits –National Ambulatory Care Reporting System (NACRS)
Timelines– April 1, 2004 until March 31, 2006
Data Elements– Date and Time– Patient’s Age and Sex– Patient’s Postal Code– Most Responsible Diagnosis (ICD-10)
Coded by Hospital Health records post-discharge
Syndromes based on Selected ICD-10 codes
Queen’s University Emergency Syndromic Surveillance Team
NACRS RESP Classification
UNSPECIFIED ACUTE LOWER RESPIRATORY INFECTIONJ22
ACUTE BRONCHIOLITISJ21
ACUTE BRONCHITISJ20
PNEUMONIA, ORGANISM UNSPECIFIEDJ18
PNEUMONIA IN DISEASES CLASSIFIED ELSEWHEREJ17
PNEUMONIA DUE TO OTHER INFECTIOUS ORGANISMS, NOT ELSEWHERE CLASSIFIEDJ16
BACTERIAL PNEUMONIA, NOT ELSEWHERE CLASSIFIEDJ15
PNEUMONIA DUE TO HAEMOPHILUS INFLUENZAEJ14
PNEUMONIA DUE TO STREPTOCOCCUS PNEUMONIAEJ13
VIRAL PNEUMONIA, NOT ELSEWHERE CLASSIFIEDJ12
INFLUENZA, VIRUS NOT IDENTIFIEDJ11
INFLUENZA DUE TO IDENTIFIED INFLUENZA VIRUSJ10
ACUTE UPPER RESPIRATORY INFECTIONS OF MULTIPLE AND UNSPECIFIED SITESJ06
ACUTE OBSTRUCTIVE LARYNGITIS [CROUP] AND EPIGLOTTITISJ05
ACUTE LARYNGITIS AND TRACHEITISJ04
ACUTE TONSILLITISJ03
ACUTE PHARYNGITISJ02
ACUTE SINUSITISJ01
ACUTE NASOPHARYNGITIS [COMMON COLD]J00
Queen’s University Emergency Syndromic Surveillance Team
0
500
1000
1500
2000
2500
3000
6/1/2004 8/1/2004 10/1/2004 12/1/2004 2/1/2005 4/1/2005 6/1/2005 8/1/2005 10/1/2005 12/1/2005 2/1/2006 4/1/2006 6/1/2006
Telehealth Respiratory Callsand ED Visits - Ontario
ED Resp Visits
TelehealthResp Calls
Queen’s University Emergency Syndromic Surveillance Team
0
500
1000
1500
2000
2500
3000
3500
6/1/2004 8/1/2004 10/1/2004 12/1/2004 2/1/2005 4/1/2005 6/1/2005 8/1/2005 10/1/2005 12/1/2005 2/1/2006 4/1/2006 6/1/2006
Telehealth Respiratory Calls (x 5)ED Visits (x1) and Influenza Pos - Ontario
ED Resp Visits
TelehealthResp Calls
Flu A
Flu B
Flu A or B
Queen’s University Emergency Syndromic Surveillance Team
0
500
1000
1500
2000
2500
3000
3500
6/1/2004 8/1/2004 10/1/2004 12/1/2004 2/1/2005 4/1/2005 6/1/2005 8/1/2005 10/1/2005 12/1/2005 2/1/2006 4/1/2006 6/1/2006
Telehealth Respiratory Calls (x 5)ED Visits (x1) and Influenza Pos (x3)- Ontario
ED Resp Visits
TelehealthResp Calls
Flu A
Flu B
Flu A or B
Queen’s University Emergency Syndromic Surveillance Team
0
100
200
300
400
500
600
700
6/1/2004 8/1/2004 10/1/2004 12/1/2004 2/1/2005 4/1/2005 6/1/2005 8/1/2005 10/1/2005 12/1/2005 2/1/2006 4/1/2006 6/1/2006
Telehealth GI Callsand ED GI Visits (x5) - Ontario
ED GI Visits
TelehealthGI Calls
Queen’s University Emergency Syndromic Surveillance Team
Telehealth Fever/ILI Calls (x5)and Positive Influenza isolates- Ontario
0
100
200
300
400
500
600
700
800
6/1/2004 8/1/2004 10/1/2004 12/1/2004 2/1/2005 4/1/2005 6/1/2005 8/1/2005 10/1/2005 12/1/2005 2/1/2006 4/1/2006 6/1/2006
Flu A
Flu B
Flu A or B
Queen’s University Emergency Syndromic Surveillance Team
Influenza Is Seasonal-FluWatch 2006
Influenza activity September 18–24, 2005
Influenza activity March 5–11, 2006
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Queen’s University Emergency Syndromic Surveillance Team
Conclusion: Objectives
What is Syndromic Surveillance?
Emergency Department Syndromic Surveillance Project
Ontario’s Telehealth
GIS-mapping the data