Climate & Health Syndromic Surveillance Webinar

CLIMATE & HEALTH SYNDROMIC

SURVEILLANCE WEBINAR

Facilitators:Matthew Roach

Arizona Department of Health Services&

Kristin RaabMinnesota Department of Health

Tuesday, April 9, 2013 2:00-3:30 PM (EST)

PARTICIPANTS

Signed Up: 33 People 13 States 1 City & 1 County Health Department 4 Canadian Public Health Agencies

Representatives from various levels of government and programs:

Climate Ready States & Cities Initiative Environmental Public Health Tracking New BRACE States State Health Agency Syndromic Surveillance

Programs CDC Health Canada Health Agencies from Several Canadian Provinces

BRIEF INTRODUCTORY REMARKS

Steven Davis, Centers for Disease Control & Prevention (CDC) -Public Health Advisor, Climate and Health

Program

Abderrahmane Yagouti, Health Canada -Senior Analyst, Climate Change & Health Office

WEBINAR AGENDATime Topics

00-10 Introduction of hosts: MN & AZIntroduce workgroup members: (MN) Kristin RaabBrief Remarks:

(CDC) Steven Davis (Health Canada) Abderrahmane Yagouti

10-15 Background/Purpose of the Meeting: (AZ) Matthew Roach

15-35 Presentation 1: (FL) Melissa Jordan & Philip Cavicchia

35-55 Presentation 2: (NH) David Swenson & Ken Dufault

55-65 Questions: (MN) Kristin Raab

65-80 Discussion of workgroup’s purpose and goals: (MN) Kristin Raab

80-90 Next steps: (MN) Kristin Raab

BEFORE WE BEGIN…

Please put your phone on mute (not on hold)

Remember to un-mute your phone when you’d like to ask a question

PRESENTATION 1

Name: Melissa Jordan & Philip Cavicchia Agency: Florida Department of Health

Use of Syndromic Surveillance to Monitor Heat Related Illness in FloridaMelissa Jordan & Philip Cavicchia

Environmental Epidemiology Surveillance & Response

Bureau of Epidemiology

Florida Department of Health

Syndromic Surveillance in Florida

Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE)

Technical assistance and development of the ESSENCE system is provided by the Johns Hopkins University Applied Physics Laboratory

State specific options/data feed

Analytic tools used to identify outbreaks or unusual trends more rapidly, leading to a more timely public health response

Reporting Sources Emergency departments & urgent care centers

Chief complaint data from participating hospitals and urgent care centers

Florida Poison Information Center Network (FPICN)

Information from calls to the Poison Control Center hotline (1-800-222-1222)

Reportable disease database (Merlin) Office of Vital Statistics, mortality data Assistant Secretary for Preparedness and Response

(ASPR) - mission data with data transmission occurring only when teams are deployed in the state

Completeness Emergency departments & urgent care centers

157 emergency departments

21 urgent care centers 85% coverage statewide

FPICN

3 Poison Centers in Florida

Reportable disease database (Merlin)

All counties

Office of Vital Statistics, mortality data

All counties

Reporting Sources Emergency departments & urgent care centers

Updated between once every two hours to once a day

Florida Poison Information Center Network (FPICN)

Near real time data transfer (updated every 10 minutes)

Reportable disease database (Merlin)

Updated once an hour

Office of Vital Statistics, mortality data

Updated once a day

Initiation of Surveillance Monitor National Oceanic and Atmospheric

Administration (NOAA) graphical depiction of high temperatures for excessive heat

Trigger for surveillance when Heat Index exceeds 110

Query Development Heat-related illness queries are based on an ESSENCE

emergency department syndrome category Includes chief complaint search for:

-Heat casualty-Heat emergency-Heat exposure-Heat injury-Heat related-Heat syncope-Over heat-Sun exposure-Sun rash

-Heat cramp-Heat exacerbation-Heat fatigue-Heat prostration-Heat stress-Heat syndrome-Over heated-Sun poison-Sun stroke

-Heat cramping-Heat exhaustion-Heat illness-Heat rash-Heat stroke-Heat trauma-Over heating-Sun poisoning

Chief complaint free text search

Queries Query all state data

Weekly percentage of all ED visits compared to previous two years

Queries Query all state data

Daily number of visits

Queries Query all state data

Weekly number of visits

Queries Query all state data

Weekly number of visits by age group

Region

Queries County level data

Distribution During times of excessive heat, reports on heat-

related illness are distributed to partners for situational awareness using a listserv

Also post to EpiCom – system used to distribute public health information to partners statewide

Limitations/Weaknesses Data are available from 178 hospitals and urgent care

clinics in 38 counties (57% of counties have at least one hospital reporting into ESSENCE) in Florida which represents ~85% of all ED visits.

Data analyzed based on free text query. Patients presenting with other chief complaints due to physical activity or other underlying chronic conditions that heat exposure may have exacerbated will be missed in this analysis. Similarly, final physician diagnosis might differ for some of the heat- related illness cases.

There are limited details about the mode and duration of exposure to heat.

No occupational data are available.

Future Improvements Develop text queries of mortality data and

evaluate usefulness/reporting lag

Expand text queries of chief complaint data beyond traditional heat-related illness

Explore the use of ESSENCE for other extreme weather conditions

Related Projects & Opportunities

CSTE Roundtable – Monday, 6/10 - 5:45-6:30PM Use of Syndromic Surveillance to Provide

Situational Awareness During Wildfire and Heat Related Illness: Monitoring of Health and Climate Data for Environmental Exposure and Illness Surveillance

Environmental Public Health Tracking – special projects

Contact Information Melissa Jordan

850-245-4577 [email protected]

Philip Cavicchia 850-245-4444, Ext 3873 [email protected]

PRESENTATION 2

Name: David Swenson & Ken Dufault Agency: New Hampshire Department of

Health & Human Services

NH Heat-Related Illness Reporting

David Swenson, PMP & Kenneth DufaultState of NH, DHHS

Division of Public Health Services

Climate & Health Effects Syndromic Surveillance Workshop

April 9, 2013

Overview of Heat-related illness and NH’s statewide syndromic surveillance system (Automated Hospital Emergency Department Data or AHEDD)

CDC’s Heat-related illness case definition

System coverage

How and what Information is collected, timeliness

How the system works

Heat-related illness detection

System benefits & weaknessesQuality of data

Agenda

HEAT-Related IllnessHeat stroke (high body temperature; rapid pulse; red, hot, dry skin; headache; dizziness; nausea; confusion; unconsciousness)Heat exhaustion (heavy sweating, paleness, muscle cramps, tiredness, weakness, headache, dizziness, nausea, fainting)Heat cramps (muscle pains or spasms in abdomen, arms, or legs) Sunburn (red, painful skin, followed by blistering)

CDC Case Definition:

Elderly (people 65 years or older), infants and children, and people with chronic medical conditions

Vulnerable Population:

Air-conditioning is the number one protective factor against heat-related illness and deathDrinking plenty of fluidsReplacing salts and minerals in the body

Suggested Remedies:

AHEDD System Overview

Secured electronic data exchangeReal-time health data collectionAutomatic surveillance and alertingAllows for rapid investigationParticipation mandated under He-P 301

Includes:

26 hospitals100 % of NH’s hospital volume

Currently includes:

Syndrome & health risk detectionNH situational awareness and investigation

Purposes:

AHEDD System Data FlowNH DPHS

1. Reviews alerts2. Queries syndromes &

symptoms3. Investigates & monitors

health activity

4. Follows up with hospitals

Disease Surveillance:

How AHEDD WorksSyndrome Detection

Real-time Outbreak and Disease Surveillance (RODS) system CoCo classifier used to assign encounter chief complaint to 1 of 8 syndromesAlerts detected (compared to historical data) and distributed to state surveillance staffCharting and line-level reporting capabilities

Data Mining for Health RisksVarious disease and health risk queries are run to identify specific conditionsCustom query tool used to build/tweak queries on the fly (used for Heat-Related Illness)

Line-level reporting capability

Proactive Disease ReportingReportable disease alerting from diagnosis code updatesLine-level reporting capability

Heat-Related Illness Query ProcessCreate query from CDC case definition

Start with CDC symptomsTweak with actual values from hospital data

Build & run real-time Chief Complaint query +heat+excessive:+heat+exhaust:+heat+exposure:+heat+fatigue:+heat+stroke:+heat+syncope:+heatstroke:+hyper+thermia:+heat+dehydra (includes and/or/exclusionary logic)Values are pasted from Word document into AHEDD custom query tool (MS Access with Oracle database) and run

Build & run ICD-9-CM code confirmatory query 708.2, 992.0 - 992.6, 992.8, 992.9, E900.0, E900.9Values are selected from AHEDD ICD9 Look-up query tool and run

Yearly review and modification (for greater accuracy)

Custom Query Tool

Heat-Related Illness DetectionsJuly 2010 Heat-Related Illness

Highest totals in southeast counties - Hillsborough (51 encounters), Rockingham (28), Merrimack (24), and Strafford (21)Highest percentage in 18-64 age group (54%), followed by 65+ group (33%)

July 2011 Heat-Related IllnessHighest totals in southeast counties - Hillsborough (26 encounters), Rockingham (8), Strafford (8) and Merrimack (7)Highest percentage in 5-24 age group (35%), followed by 25-49 group (32%)

July 2012 Heat-Related IllnessHighest totals in southeast counties - Hillsborough (26 encounters), Rockingham (22), Carroll (20) and Strafford (18)Highest percentage in 18-64 age group (57%) of which 25-49 represented 56%, followed by 65+ group (29%)

Other Custom Query DetectionsDecember 2009-1010 GI Anthrax investigation (retrospective/prospective analysis performed)

Retrospective and prospective analysis of both relevant chief complain and diagnosis codes, with DHMC MD review of relevant cases183,973 encounters reviewed, 7,111 met GI Anthrax query criteria, 62 warranted further investigation, 0 additional cases

Other investigations August 2011 Hurricane Irene injury & GI investigationOctober 2010 – June 2012 Hep C investigationOctober 2012 Snow storm injury investigationOctober - December 2012 Fungal Meningitis

System BenefitsEarlier disease detection, quicker response & control by public health & hospital staff

Prompt, flexible investigation capability using queries & data mining

Greater opportunities to share data electronically (between hospitals, state, and federal public health partners)

Collaboration with Incident Command Center (ICC) during emergenciesRegarding Heat-Related Illness , the Surveillance Section provides town line data and GIS maps that inform or validate placement of cooling stations

With custom query tool can tweak to get queries that work

Activated Incident Command Center

Team leader activates the ICC and notifies ICC team via HANICC team meets to identify emergency response needsData analysis, reporting, dissemination as needed

Heat-Related Illness Reporting

Heat-Related Illness Mapping

System WeaknessesMorbidity is only 1 part of the picture, which is why NH analyzes heat-related illness mortalities too

Minimal fields included (chief complain, diagnosis codes, and demographic data (gender, DOB, resident town/state/zip code, etc.)

Only able to do breakdowns by state, county, and town levelsOne hospital won’t provide patient number (have to use probabilistic linkage techniques to create a patient number)

Diagnosis reporting needs improvementTwo hospitals aren’t sending diagnosis code updates

Chief complaint reporting could be improvedSome hospitals submit values of little significance (“Not feeling well”, “ILL”, “Not supplied”, etc.)

GIS mapping is manually done, unable to do electronically

Data Quality

Issues with Data QualityMinimal issues with missing (town, gender, etc.)Some visit number and Admit Date/time duplicates

Some encounters don’t receive final diagnoses

Issues with regard to Heat-Related IllnessBecause of the volume, we do not routinely confirm each heat-related illness encounterSome hospitals only provide a menu-driven chief complaint (not enough detail provided to relate to query values)Dehydration although included could be associated with some other condition

Contact InformationDavid Swenson

AHEDD Project ManagerInfectious Disease Surveillance Section

Phone: (603) 271-7366Email: [email protected]

Ken DufaultSurveillance Specialist

Infectious Disease Surveillance SectionPhone: (603) 271-5165

Email: [email protected]

Questions?

QUESTIONS?

GOALS FOR SYNDROMIC SURVEILLANCE SYSTEM WORKGROUP

Learn about climate and health syndromic surveillance systems in the US and Canada (how they are set up, time commitment, range of coverage, benefits, drawbacks, usefulness, who has access to the data/how is data shared)

Learn about how agencies started and then maintained their syndromic surveillance system (including legislative action, partnerships, funding)

Share information on best practices for improving and using data from syndromic surveillance systems for climate change

NEXT STEPS

Workgroup meets quarterly or more often? AZ will send out a Meeting Wizard for the

next workgroup meeting. Tentative date: May/June?

THANK YOU!!!!