2What is Syndromic Surveillance ? The ongoing, systematic collection,analysis, interpretation, and application of real-time indicators for disease that allow for detection before public health authorities would otherwise identify them.Source: Dan Wartenberg PhD. Robert Wood Johnson Medical School, USA
3ธรรมชาติของการเกิดโรค No DiseaseAsymptomaticSymptomDiseaseTestDxWDBehaviorBio-markerSyndromeDiseasesExposedS/SDeath
4What are indicators of Diseases ? “ Indicators” are clinical symptoms & signs that we can categorize into syndromes, but “ NOT a specific diagnosis ! ”Example:Fever+ Cough+ Runny nose + Sore throat+ Fatigue= Influenza-like illness
5Why do Syndromic Surveillance ? Early detection of clusters in naturallyoccurring outbreaks or a BT event– Minimizes mortality & morbidityCharacterize outbreak– Magnitude, rate of spread, effectiveness ofcontrol measuresQuick investigationDetection of unexplained deaths
15Acute hemorrhagic fever syndrome Recommended Case Definition:Clinical case description: Acute onset of fever of less than 3 weeks duration in a severely ill patient and any 2 of the followingHemorrhagic or purpuric rashEpistaxisHematemesisHemoptysisBlood in stoolsOther hemorrhagic syndrome and no known predisposing host factors for hemorrhagic manifestation
17Acute hemorrhagic fever syndrome Recommended Type of Surveillance :Immediate case-based reporting of acute hemorrhagic fever syndrome whether occurring singly or in cluster, from peripheral to intermediate and central level, in order to ensure rapid investigation and laboratory confirmation.All cases must be investigated, with contact tracing. Blood samples and appropriate clinical specimens must be collected to confirm a diagnosis as rapidly as possible.
18Acute lower respiratory tract infections and pneumonia Clinical case definition and classification: PneumoniaSymptoms: Cough or difficult breathing andSigns: Breathing > 50/minute for infant aged 2 month to <1 yearBreathing > 40/minute for child aged 1 to 5 years andno chest indrawing, stridor or danger signs.Severe pneumoniaSymptom: Cough or difficult breathing + any general danger signor chest indrawing, stridor in a calm child.General danger signs: For children aged 2 months to 5 years.Unable to drink or breast feed, vomits everything, convulsion, lethargic or unconscious.
19Acute lower respiratory tract infections and pneumonia Recommended Type of Surveillance:Routine monthly aggregated reporting from peripheral to intermediate and central level.Community surveys/sentinel surveillance to complement routine data and for the evaluation of control program activities.Sentinel surveillance reporting monthly to intermediate and central level. Quarterly reporting of community/ household surveys from peripheral to central level.
20Acute (watery) diarrhea Clinical case definition:Acute watery diarrhea (passage of 3 or more loose or watery stools in the past 24 hours) with or without dehydrationLaboratory criteria for diagnosis:Laboratory culture of stools may be used to confirm possible outbreak of specific agents, but is not necessary for case definition.Case classification:Not applicable.
21Acute (watery) diarrhea Recommended Type of Surveillance:Routine monthly/ weekly reporting of aggregated data from peripheral level to intermediate and central level.Community surveys/sentinel surveillance to complement routine data and for the evaluation of control program activities.Note: If laboratory examination are undertaken at the start of an outbreak in order to identify the causative agent, this need not be continued once the causative agent has been identified (unnecessary burden on laboratory facilities).
22Acute (bloody) diarrhea Clinical case definition:Acute diarrhea with visible blood in stool.Laboratory criteria for diagnosis:Laboratory culture of stools may be used to confirm possible outbreak of specific diarrhea, such as S. dysenteriae Type 1, but is not necessary for case definition.Case classification:Not applicable.
23Acute (bloody) diarrhea Recommended Type of Surveillance:Routine monthly/ weekly reporting of aggregated data from peripheral level to intermediate and central level.Community surveys/sentinel surveillance to complement routine data and for the evaluation of control program activities.Note 1: Laboratory involved in diagnosis of Shigella dysenteriae Type 1 should report confirmed cases.Note 2: Central recording of antibiotic susceptibility is recommended.Note 3: After an epidemic caused by S. dysenteriae type 1 has been confirmed, it is not necessary to examine specimen from all cases (unnecessary burden on laboratory facilities).
24Antimicrobial resistance Recommended definition:Microbial isolation that is resistent to one or more antimicrobial agents on standard susceptibility test .Recommended type of surveillance:Peripheral level: Every hospital should have a surveillance system for antimicrobial resistance (e.g. routine weekly laboratory-based reporting). This must involve collaboration between microbiologists, clinicians, pharmacists, and infection control personnel.Intermediate /Central level:At minimum, reporting from sentinel sitesRoutine laboratory-based reporting (this may include comprehensive reporting of aggregate statistics as well as case-based reporting from sentinel site)Report should be at least once a year
25Anti-tuberculosis drug resistance Case definitions:Primary drug resistance: is defined as the presence of resistance strains of M. tuberculosis in a patient who, in response to direct questioning, denies having had any prior anti-tuberculous treatment or for whom, in countries were adequate documentation exist, documented evidence of such a history is found.Acquired drug resistance: is defined as the presence of resistant strains of M. tuberculosis in a patient who, in resoonse to direct questioning, admits having had prior anti-tuberculous treatment or for whom, in countries were adequate documentation exists, documented evidence of such a history is found.Recommended type of surveillance:Data collection system (One National Central registry)Reference laboratoryRepresentatively sampling survey (3-5 years)
26Foodborne diseases Recommended definition: The clinical case definition varies with the specific disease .Laboratory criteria for confirmation:Isolation of pathogen.Case classification:Suspected: A case that meet the clinical case definition of a specific foodborne disease.Probable: Not applicableConfirmed: A suspected case in whom laboratory investigation confirms the presence of one or more foodborne pathogens in a clinical specimen.
27Information Flow MOPH Peripheral Intermediate Central WHOPeripheralIntermediateNational Epidemiologicalbulletin; Electronic mediaCentralRegional / InternationalWeekly Epidemiological Record;Regional Bulletin; Electronic media
28WHO Sample Format ICD code Disease name Rationale for surveillance Recommended case definitionRecommended type of surveillanceRecommended minimal data elementsRecommended data analysis, presentation, reportsPrincipal uses of data for decision-makingSpecial aspectsContact information
29CDC Botulism like Hemorrhagic illness Lymphadenitis illness Syndrome Definitions for Diseases Associated with Critical Bioterrorism-associated AgentsBotulism likeHemorrhagic illnessLymphadenitis illnessLocalized cutaneous lesionGastrointestinalRespiratoryNeurologicalRashSpecific infectionFeverSevere Illness or Death potentially due to infectious disease
30Botulism like Syndrome Syndrome Definitions for Diseases Associated with Critical Bioterrorism-associatedAgentsDefinition:ACUTE condition that may represent exposure to botulinum toxinACUTE paralytic conditions consistent with botulism: cranial nerve VI (lateral rectus) palsy, ptosis, dilated pupils, decreased gag reflex, media rectus palsy.ACUTE descending motor paralysis (including muscles of respiration)ACUTE symptoms consistent with botulism: diplopia, dry mouth, dysphagia, difficulty focusing to a near point.
31Rash Syndrome Definition: Syndrome Definitions for Diseases Associated with Critical Bioterrorism-associated AgentsDefinition:ACUTE condition that may present as consistent with smallpox (macules, papules, vesicles predominantly of face/arms/legs)SPECIFIC diagnosis of acute rash such as chicken pox in person > XX years of age (base age cut-off on data interpretation) or smallpoxACUTE non-specific diagnosis of rash compatible with infectious disease, such as viral exanthemEXCLUDES allergic or inflammatory skin conditions such as contact or seborrheaic dermatitis, rosaceaEXCLUDES rash NOS, rash due to poison ivy, sunburn, and eczema
32Severe Illness or Death potentially due to infectious disease Definition:ACUTE onset of shock or coma from potentially infectious causesEXCLUDES shock from traumaINCLUDES SUDDEN death, death in emergency room, intrauterine deaths, fetal death, spontaneous abortion, and still birthsEXCLUDES induced fetal abortions, deaths of unknown cause, and unattended deaths
33Severe Illness-Death due to ID ICD-9-CM Code List ICD9DESCR780.01COMA785.50SHOCK (UNSPECIFIED)785.59SHOCK, OTHER, W/O TRAUMA798.1DEATH INSTANTANEOUS798.2DEATH IN E.R.798.9DEATH UNATTENDED799.9MORTALITY, CAUSE UNKNOWN656.40INTRAUTERINE DEATH, UNSPE656.41INTRAUTERINE DEATH DEL.AN656.43FETAL DEATH, ANTEPARTUM761.8ABORTION OF FETUS, SPONTA768.0FETAL DEATH779.9STILLBIRTH798.0SUDDEN INFANT DEATH SYND
34Process mode for early outbreak detection Process stageOutputData collection and processingReal time data for early outbreak detectionAutomate statistical AnalysisSignal: Something unusual notedEpidemiological analysis and interpretationHigh probability outbreakLow probability of outbreakErrorTrue increase in diseaseNatural variation in disease no outbreakReporting anomalyData Processing errorInvestigationEpidemiologicForensicNatural outbreakDeliberate outbreak
35Surveillance Data Flow Chart Human view of automated decisions-verification and responseAutomate data capturing analysis and alerting systemPatient encounter data Multiple sourcesHistorical dataActionSyndrome ClassificationCreate modelSyndrome >expectedMonitoring closelySignalSyndrome <expectedPeriodic sumAnalysis algorithmNo actionNo actionFalse negative
36Syndromic Surveillance for EnvOcc. ICD code, Disease name ?Rationale for surveillance ?Case definition ?Minimal data elements ?Principal uses of data for decision-making ?