Increasing the return-on-investment from syndromic surveillance: using the systems for routine activities

1. Increasing the return-on-investment from syndromic surveillance: using the systems for routine activities Shandy Dearth, MPH Joseph Gibson, PhD Marion County Health Department

2. Is the output worth the input? Syndromic surveillance Frequent monitoring Many alerts Few significant events Maximizing return-on-investment Minimize investment: rapidly cull unimportant alerts Maximize return: find other uses

3. Indianapolis syndromic surveillance Marion County�s population: ~865,000 October 2004: Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) goes live 14 hospitals Marion County supply ED data 8 syndromes are monitored In 3 years, 1 syndrome alert resulting in on-site public health action Only one emergency room dataset is not received. ISDH is currently working on receiving this data.Only one emergency room dataset is not received. ISDH is currently working on receiving this data.

4. Additional queries yield return� Indiana State Department of Health created a query based on key terms from the Communicable Disease Reporting Rule for the Indiana Public Health Emergency Surveillance System (PHESS) MCHD can access results via a portal MCHD can access patient information to follow up on possible public health events

5. Some everyday public health uses� Rabies prophylaxis (PHESS) Carbon monoxide exposure (PHESS) Community notification (PHESS) Possible bioterrorism (PHESS) Weather related visits (query in ESSENCE)

6. Rabies prophylaxis ~2 times each month Rabies vaccine often administered in emergency rooms The free text chief complaint captures key terms seen by nurse epidemiologists at LHD Public Health Nurses call hospital if an expected vaccination does not occur Nurses are able to see patient returns for all 5 shots ~3-4 patients each month Indiana had a death in 2006. LHD could see out of county residents who came to Indianapolis for prophylaxis. HOW MANY TIMES PER MONTH DO WE USE THIS?Indiana had a death in 2006. LHD could see out of county residents who came to Indianapolis for prophylaxis. HOW MANY TIMES PER MONTH DO WE USE THIS?

7. Carbon monoxide exposure When MCHD epidemiologists see CO exposures, the MCHD indoor air specialist is contacted to inquire about source of exposure Residential exposure risks are identified and corrected ~5 residences each winter HOW MANY TIMES PER MONTH DO WE USE THIS?HOW MANY TIMES PER MONTH DO WE USE THIS?

8. Community notification Letters sent home to parents via school often trigger precautionary ED visits Examples include scabies, head lice, shigella, etc. Not the best use of an ED, but indicates that parents received the notices sent by the health department ~5 events each year

9. Possible bioterrorism� Around 3 p.m. on a Friday before a large car race� �BEING TREATED FOR POSSIBLE EXPOSURE TO MUSTARD GAS� seen in chief complaint Dry cleaner employee had mixed a cleaner with bleach and was affected by the mixture Nurse in ED did not understand why �mustard gas� would raise concern Good reminder - not everyone has Bioterrorism on their mind 24/7

10. Weather related visits during warm temperatures� Data is queried for key terms such as ^heat^,or,^dehyd^,or,^hot^ Memo to EDs requested the use of �heat� when case was related to environmental factors Daily counts are shared with Emergency Management Agency when deciding to open community cooling centers, extend library hours, extend public swimming pool hours, etc. Human eye needed to filter out �gunshots� since hot is part of the word. Friday and Saturdays have more gunshot victims. Must make sure not to confuse this with an increase in heat related illnesses. HOW MANY TIMES PER MONTH DO WE USE THIS?Human eye needed to filter out �gunshots� since hot is part of the word. Friday and Saturdays have more gunshot victims. Must make sure not to confuse this with an increase in heat related illnesses. HOW MANY TIMES PER MONTH DO WE USE THIS?

11. Weather related visits during cold temperatures� Data is queried for key terms such as ^cold^, or, ^frost^, or,^expos^,or,^hypothermia^ Daily counts are shared with Emergency Management Agency when deciding to open additional shelters Human eye still needed to filter our �exposures� to other agents� HOW MANY TIMES PER MONTH DO WE USE THIS?Human eye still needed to filter our �exposures� to other agents� HOW MANY TIMES PER MONTH DO WE USE THIS?

12. Conclusion� Although hard to quantify time/money saved, syndromic surveillance has increased skill and capacity for investigation events of possible public health importance

13. The output is worth the input. Investment: Initial set-up 15 minutes per day monitoring & follow-up Maintenance by ISDH & Regenstrief Return: Triggers public health investigation ~1/month (excluding post exposure prophylaxis for rabies) Population information (asthma, flu curve) Possible early detection of bioterrorism We will continue to find new uses

14. Thank you to ISDH� Mike Wade, syndromic surveillance epidemiologist Dave Trepanier, technical support

15. Questions? Shandy Dearth 317.221.3158 Sdearth@hhcorp.org