เฝ้าระวังโรคตามกลุ่มอาการ   Kriangsak_v@yahoo.com

What 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

ธรรมชาติของการเกิดโรค No Disease Asymptomatic Symptom Disease Test Dx W D Behavior Bio-marker Syndrome Diseases Exposed S/S Death

What 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

Why do Syndromic Surveillance ? Early detection of clusters in naturally occurring outbreaks or a BT event – Minimizes mortality & morbidity Characterize outbreak – Magnitude, rate of spread, effectiveness of control measures Quick investigation Detection of unexplained deaths

สำนักงานระบาดวิทยา Hemorrhagic Fever Syndrome Respiratory Syndrome Gastrointestinal Syndrome Neurological Syndrome Skin Syndrome Undefined Reportable Syndrome

Hemorrhagic Fever Syndrome มีไข้สูง นอนซึม มีผื่นหรือ จุดแดงที่ผิวหน้ง มีไข้สูง มีเลือดออก อาเจียน ถ่ายอุจจาระเป็นสีดำ มีไข้สูง มีจุดแดงที่ผิวหนัง ถ่ายปัสสาวะไม่ออก มีไข้สูงเฉียบพลัน อาเจียน ถ่ายอุจจาระเป็นเลือด มี อาการเลือดออกอย่างรุนแรง ความดันต่ำรุนแรง มีไข้สูง มีเลือดออก ซึม ตัว เหลือง ตาเหลือง ตามองไม่ เห็น DHF DSS Hantavirus Ebola Rift Valley Fever

มีไข้ ปวดศีรษะ ปวดเมื่อย ตามตัว มีไข้ ไอเจ็บหน้าอก หายใจหอบเหนื่อย Respiratory Syndrome มีไข้ ปวดศีรษะ ปวดเมื่อย ตามตัว มีไข้ ไอเจ็บหน้าอก หายใจหอบเหนื่อย มีไข้ ไอเป็นเลือด มีไข้ เจ็บคอ มีแผ่นฝ้าขาว ในลำคอ มีไข้ ไอติดต่อกันอย่าง รุนแรง มีไข้ ต่อมน้ำเหลืองโต ไอ หอบรุนแรง Flu Pneumonia Legionnaire, Melioidosis Hanta virus TB Diphtheria Pertussis Plague

Gastrointestinal Syndrome อุจจาระร่วง และมี อาเจียนร่วมด้วย อุจจาระร่วง(คล้ายน้ำ ซาวข้าว) อาเจียน อุจจาระร่วง มีไข้ อุจจาระร่วง มีมูก มี เลือด อุจจาระร่วง มีไข้ ตา เหลือง ตัวเหลือง Food poisoning Cholera Salmonellosis, Enteric fever E.Coli O157, Shigellosis Hepatitis Leptospirorsis Yellow fever

Neurological Syndrome มีไข้ คอแข็ง หลังแข็ง มีไข้ ชัก อัมพาดแข็งเกร็ง หมดสติ มีไข้ อัมพาต กล้ามเนื้ออ่อนแรง เฉียบพลัน อัมพาต มีรอยแผลจากแมลงหรือสัตว์กัด มีไข้ ชัก กระตุก ขากรรไกรแข็ง กล้ามเนื้อแข็งเกร็ง Meningococcal meningitis CJD Poliomyelitis AFP Lyme disease Ehrlichiosis Tick paralysis Snake bite Tetanus

Skin Syndrome มีไข้ ออกผื่น ตาแดง ไอมาก มีไข้ ออกผื่น ปวดเมื่อยตามตัว มีไข้ ตุ่มใส ปวดเมื่อยตามตัว มีไข้ ต่อมน้ำลายใต้หูบวม มีไข้ ออกผื่น ปวดข้อ มีแผลบวมแข็ง บุ๋มมีสะเก็ดดำคล้ายบุหรี่จี้ มีผื่น ผิวหนังเป็นดวงราบสีขาว หรือเป็นรอย นูนแดงมีขอบชัด มีอาการชา มีไข้ แผนที่คอหอย ผื่นหรือตุ่มใสที่ฝ่ามือ และฝ่าเท้า มีแผนที่ผิวหนังนอกร่มผ้า มีขอบนูนแข็ง มีแผนขอบนูนเด่นชัด ตรงกลางมีลักษณะแดง Measles Rubella Chicken pox Mump Chikungunya Scrub typhus Leprosy HFMD Cutaneous leishmaniasis Yaws

Undefined Reportable Syndrome มีไข้ไม่น้อยกว่า ๗ วัน ตาแดงชนิดระบาด มีไข้ หนาวสั่น ปวดศีรษะ มีไข้ ปวดกล้ามเนื้อรุนแรง มีไข้เรื้อรังเกิน ๓ สัปดาห์ ผอมแห้ง ตับโต ม้ามโต อวัยวะเพศมีแผล หนอง มีไข้ ปวดเมื่อยกล้ามเนื้อ หนังตาบวม อื่น ๆ อาการระบุ........................ PUO, FUO Hemorrhagic conjunctivitis Malaria Leptospirosis Kala azar STDs Trichinosis

เครือข่ายและการไหลเวียนรายงาน สอ. SR, SRE0, SRE1, SRDR, SRE2, SRE3 ส่ง SR ภายใน 3 วัน สสอ. ส่ง SR ภายใน 3 วัน SRE0, SRE1, SRDR, SRE2, SRE3 รพช. คปสอ. ส่ง SR ภายใน 3 วัน ส่ง SR ภายใน 4 วัน SRE0, SRE1, SRDR, SRE2, SRE3 รพท./รพศ. สสจ. SRE0, SRE1, SRE2, SRE3 ของจังหวัด ส่ง SR ภายใน 5 วัน ส่ง SRE2, SRE3 ภายใน 5 วัน ระบาดภาค SRE2, SRE3 ระดับภาร/เขต ส่ง SRE2, SRE3 ภายใน 14 วัน คปสข. สคต. กองระบาดฯ

World Health Organization Acute hemorrhagic fever syndrome Acute lower respiratory tract infections Acute (watery) diarrhea Acute (bloody) diarrhea Antimicrobial resistance Anti-tuberculosis drug resistance Food borne diseases Sexually transmitted diseases/syndrome

Acute 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 following Hemorrhagic or purpuric rash Epistaxis Hematemesis Hemoptysis Blood in stools Other hemorrhagic syndrome and no known predisposing host factors for hemorrhagic manifestation

Acute hemorrhagic fever syndrome Dengue hemorrhagic fever Ebola-Marburg viral diseases Lassa fever Yellow fever Rift Valley Hatavirus infection Crimean-Congo hemorrhagic fever Other viral, bacterial or rickettsial diseases

Acute 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.

Acute lower respiratory tract infections and pneumonia Clinical case definition and classification: Pneumonia Symptoms: Cough or difficult breathing and Signs: Breathing > 50/minute for infant aged 2 month to <1 year Breathing > 40/minute for child aged 1 to 5 years and no chest indrawing, stridor or danger signs. Severe pneumonia Symptom: Cough or difficult breathing + any general danger sign or 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.

Acute 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.

Acute (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 dehydration Laboratory 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.

Acute (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).

Acute (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.

Acute (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).

Antimicrobial 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 sites Routine 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

Anti-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 laboratory Representatively sampling survey (3-5 years)

Foodborne 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 applicable Confirmed: A suspected case in whom laboratory investigation confirms the presence of one or more foodborne pathogens in a clinical specimen.

Information Flow MOPH Peripheral Intermediate Central WHO Peripheral Intermediate National Epidemiological bulletin; Electronic media Central Regional / International Weekly Epidemiological Record; Regional Bulletin; Electronic media

WHO Sample Format ICD code Disease name Rationale for surveillance Recommended case definition Recommended type of surveillance Recommended minimal data elements Recommended data analysis, presentation, reports Principal uses of data for decision-making Special aspects Contact information

CDC Botulism like Hemorrhagic illness Lymphadenitis illness Syndrome Definitions for Diseases Associated with Critical Bioterrorism-associated Agents Botulism like Hemorrhagic illness Lymphadenitis illness Localized cutaneous lesion Gastrointestinal Respiratory Neurological Rash Specific infection Fever Severe Illness or Death potentially due to infectious disease

Botulism like Syndrome Syndrome Definitions for Diseases Associated with Critical Bioterrorism-associated Agents Definition: ACUTE condition that may represent exposure to botulinum toxin ACUTE 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.

Rash Syndrome Definition: Syndrome Definitions for Diseases Associated with Critical Bioterrorism-associated Agents Definition: 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 smallpox ACUTE non-specific diagnosis of rash compatible with infectious disease, such as viral exanthem EXCLUDES allergic or inflammatory skin conditions such as contact or seborrheaic dermatitis, rosacea EXCLUDES rash NOS, rash due to poison ivy, sunburn, and eczema

Severe Illness or Death potentially due to infectious disease Definition: ACUTE onset of shock or coma from potentially infectious causes EXCLUDES shock from trauma INCLUDES SUDDEN death, death in emergency room, intrauterine deaths, fetal death, spontaneous abortion, and still births EXCLUDES induced fetal abortions, deaths of unknown cause, and unattended deaths

Severe Illness-Death due to ID ICD-9-CM Code List ICD9DESCR 780.01 COMA 785.50 SHOCK (UNSPECIFIED) 785.59 SHOCK, OTHER, W/O TRAUMA 798.1 DEATH INSTANTANEOUS 798.2 DEATH IN E.R. 798.9 DEATH UNATTENDED 799.9 MORTALITY, CAUSE UNKNOWN 656.40 INTRAUTERINE DEATH, UNSPE 656.41 INTRAUTERINE DEATH DEL.AN 656.43 FETAL DEATH, ANTEPARTUM 761.8 ABORTION OF FETUS, SPONTA 768.0 FETAL DEATH 779.9 STILLBIRTH 798.0 SUDDEN INFANT DEATH SYND

Process mode for early outbreak detection Process stage Output Data collection and processing Real time data for early outbreak detection Automate statistical Analysis Signal: Something unusual noted Epidemiological analysis and interpretation High probability outbreak Low probability of outbreak Error True increase in disease Natural variation in disease no outbreak Reporting anomaly Data Processing error Investigation Epidemiologic Forensic Natural outbreak Deliberate outbreak

Surveillance Data Flow Chart Human view of automated decisions-verification and response Automate data capturing analysis and alerting system Patient encounter data Multiple sources Historical data Action Syndrome Classification Create model Syndrome >expected Monitoring closely Signal Syndrome <expected Periodic sum Analysis algorithm No action No action False negative

Syndromic Surveillance for EnvOcc. ICD code, Disease name ? Rationale for surveillance ? Case definition ? Minimal data elements ? Principal uses of data for decision-making ?