Module 6: Syndromic Surveillance

Syndromic Surveillance in the Developed World

The CDC defines Syndromic Surveillance (SS) as a type of surveillance that “uses individual and population health indicators that are available before confirmed diagnoses or laboratory confirmation to identify outbreaks or health events and monitor the health status of a community”.(1) SS can use readily available information such as increased drug purchases or school absences to identify potential disease outbreaks before the victims seek medical attention.(2) Speed of detection is crucial when a timely intervention can improve patient outcomes and decrease the rate of transmission. Out of fear of potential bioterrorism attacks, increased research and investment have been poured into SS in the developed world.

In the United States, the CDC developed a syndromic surveillance program called BioSense. The program was mandated by the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, and it aims to guard the health of U.S. citizens by improving data collection and analysis to give public health officials a better picture of community health.(3) BioSense 2.0 is now being redesigned to focus on various health indicators, instead of focusing primarily on pathogens that could be bioterrorism agents.(4) Syndromic surveillance is expected to improve in the U.S. now that the American Reinvestment and Recovery Act (2009) gives clinicians incentives to switch to electronic health records (EHR). EHRs make it easier to send health data (e.g. symptoms) to public health agencies for SS.(5)

SS data can come from clinical sites (such as emergency rooms and urgent care centers) and non-clinical sites (such as EMS, 911 and poison control, and schools).(6) According to the International Society for Disease Surveillance, the following are characteristics of SS that separate it from other types of surveillance:(7)

Application of Syndromic Surveillance in Developing Countries

Many experts in the field of Syndromic Surveillance believe that there is great potential for surveillance in developing countries. SS costs less than other forms of surveillance, can help with the detection of outbreaks where there are shortages of doctor, and can be done with relatively minimal technology.(8) SS may have potential where lab diagnosis is not readily available or cost effective.(9) Some countries are using health indicators like changes in weather patterns to predict disease epidemics.(10) Syndromic Surveillance could also be highly useful in cases of novel and emerging infections where the technology or expertise is not available to identify new pathogens.(11) In the developing world, there has recently been a large increase in access to the internet and to mobile phones, facilitating the feasibility of Syndromic Surveillance in low-income countries.(12) Syndromic Surveillance should be used as an enhancement of existing surveillance infrastructure in developing countries, rather than as a replacement.(13)

Case Study: Early Warning Outbreak Recognition System in Jakarta

The Early Warning Outbreak Recognition System (EWORS), developed by the Indonesian Ministry of Health and the U.S. Naval Medical Research Unit, became the national health surveillance system of Indonesia.(14) EWORS is a computer software-based Syndromic Surveillance system. Participating health care providers fill out a standard questionnaire about each of their patients that includes the patient’s clinical and demographic information. This information is emailed to the Ministry of Health, where the data across many geographic areas is collected and analyzed in the hopes of quickly identifying potential outbreaks. While there have been some challenges to the system, (including issues with standardization across the platform and mobilizing appropriate agencies to act upon data when necessary,) the program has been successful, and has expanded to include other Southeast Asian countries. Peru is also trying to develop a similar system to facilitate early detection of dengue epidemics. In the case of Jakarta, Syndromic Surveillance systems have proven to be functional and effective in controlling disease outbreaks in a developing region. More studies must be done to make ensure that SS is helpful and cost effective in developing countries.

Information in the above case study was adapted from the following article:(15)http://w09.biomedcentral.com/1471-2458/9/242

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Footnotes

(1)Syndromic Surveillance. (2012, April 3). Retrieved May 29, 2012, from Centers for Disease Control and Prevention.

(2) Lemon, S. M., Hamburg, M. A., Sparling, P. F., Choffnes, E. R., & Mack, A. (2007). Syndromic Surveillance. In Global Infectious Disease Surveillance and Detection: Assessing the Challenges—Finding Solutions (page 7) [Workshop Summary]. Retrieved May 29, 2012, from The National Academies Press.

(3)BioSense. (2012, February 8). Retrieved May 29, 2012, from Centers for Disease Control and Prevention.

(4) Ibid.

(5)Final Recommendation: Core Processes and EHR Requirements for Public Health Syndromic Surveillance. (2011, January 31). Retrieved May 29, 2012, from International Society for Disease Surveillance.

(6) Ibid.

(7) Ibid.

(8) Chretien J-P, Burkom HS, Sedyaningsih ER, Larasati RP, Lescano AG, et al. (2008) Syndromic Surveillance: Adapting Innovations to Developing Settings. PLoS Med 5(3): e72. doi:10.1371/journal.pmed.0050072.

(9) Lemon, S. M., Hamburg, M. A., Sparling, P. F., Choffnes, E. R., & Mack, A. (2007). Syndromic Surveillance. In Global Infectious Disease Surveillance and Detection: Assessing the Challenges—Finding Solutions (page 7) [Workshop Summary]. Retrieved May 29, 2012, from The National Academies Press.

(10) Chretien J-P, Burkom HS, Sedyaningsih ER, Larasati RP, Lescano AG, et al. (2008) Syndromic Surveillance: Adapting Innovations to Developing Settings. PLoS Med 5(3): e72. doi:10.1371/journal.pmed.0050072.

(11) Ibid.

(12) Ibid.

(13) May, L., Chretien, J.-P., & Pavlin, J. A. (2009, July 16). Beyond traditional surveillance: applying syndromic surveillance to developing settings – opportunities and challenges. Retrieved May 29, 2012, from BMC Public Health.

(14) Lemon, S. M., Hamburg, M. A., Sparling, P. F., Choffnes, E. R., & Mack, A. (2007). Syndromic Surveillance. In Global Infectious Disease Surveillance and Detection: Assessing the Challenges—Finding Solutions (page 7) [Workshop Summary]. Retrieved May 29, 2012, from The National Academies Press.

(15) May, L., Chretien, J.-P., & Pavlin, J. A. (2009, July 16). Beyond traditional surveillance: applying syndromic surveillance to developing settings – opportunities and challenges. Retrieved May 29, 2012, from BMC Public Health.