Mission Statement
Syndromic surveillance is a relatively inexpensive public health tool useful in both developed and resource poor settings. The Global Outreach committee aims to build a strong global network of people working in syndromic and advanced disease surveillance. The committee’s members will provide advice, education and resources about syndromic surveillance to interested parties outside of the US. This committee will aim initially to establish an international list of experts in advanced disease surveillance and increase awareness of its activities though a newsletter. In the longer term it aims to host meetings and pursue collaboration with international projects. The Global Outreach committee will also strengthen the engagement of the international syndromic surveillance community and the ISDS. An important objective will be to increase international participation at the ISDS annual conference.
Continental Perspectives
**The committee would welcome ideas and contributions for the newsletter from ISDS members or other interested individuals. We would especially encourage submissions about syndromic and electronic surveillance activities from Africa, South and Central Asia and Australia.
The following article is courtesy of Jean-Baptiste Meynard (Pasteur Institute, France)
South America: Current Syndromic Surveillance Working and Perspectives
Countries from South America (cf. map) have to deal with a lot of Public Health problems, in the area of infectious and tropical diseases (malaria, dengue fever, yellow fever, leishmaniosis, Chagas disease and others) but also in the area of non-infectious diseases (cancers, diabetes, cardiac diseases and others).
Economic development is contrasted within the countries, some having the level of developed countries (example of French Guiana), others having the level of countries in development (example of Suriname). Health Services of those countries have at their disposal different financial means, even if a lot of them have to deal with the same sanitary problems. The poorest countries receive the help of international organizations or funds, like the Global Fund. The Pan American Health Organization (PAHO) coordinates the health programs of the South American continent, but also takes part in the development of health services for each country.
Syndromic surveillance is used within several countries of South America, with different objectives and technical means. The following examples illustrate this:
The first example is a sophisticated system that has been operational since 2004 in French Guiana : the “système de surveillance spatiale des épidémies au sein des forces armées en Guyane“ (2SE FAG), developed by scientists in France (Institut de Médecine Tropicale du Service de santé des armées and Université de la Méditerranée in Marseilles) and in French Guiana (Institut Pasteur de la Guyane in Cayenne). The objectives of this system are to permit an early warning within the military forces in French Guiana, with tools interoperable with civilian local health services and military systems from allied countries of the North Atlantic Treaty Organization (NATO). This system uses technological means which permits access, in real-time, to the sanitary situation within armed forces. Its value has already been demonstrated by giving an early warning during an important outbreak of dengue fever that occurred in French Guiana during the first semester of 2006 (1).
The second example is a civilian system functioning also in French Guiana. It is a syndromic surveillance system that was set up in 2006 within the 25 health centres. Those centres exist for every remote or isolated place where no liberal general practitioner is installed. This system works with a weekly periodicity, but permits to collect and analyze some sanitary information within population for which no sanitary data were available until that date. It has detected clusters of several diseases and provided some operational elements for adapted Public Health response.
Another example is given by a system set up in a border country of French Guiana: Suriname. A syndromic surveillance system works within the network of health centres existing in all the towns of Suriname. All the collected sanitary information is centralized in the national Public Health laboratory of Paramaribo, working in collaboration with the Ministry of Health. This system has demonstrated its value during a gastrointestinal disease outbreak in 2006 along the Maroni River, permitting to size the Public health response with the best time.
The last example is the syndromic surveillance system of dengue fever in Paraguay. There is only one virological laboratory in this country, in the city of Asunción. It is impossible for this laboratory to analyze all the blood samples from febrile patients in the whole country. In collaboration with partners from Argentina, Brazil and French Guiana, the health authorities have set up a syndromic surveillance system, which permits surveillance of dengue fever, with a periodicity adapted to the epidemic context. This system was particularly useful during the dengue fever outbreak that occurred in 2007 because it used daily data to target the vector control actions on the field and the sanitary education means for the local population.
Other examples could be given for other countries of this continent, especially in Brazil or Uruguay. Except for the 2SE FAG system set up in French Guiana, the main part of those systems are functioning with rudimentary means, but are permitting health services to take into account sanitary data from different sources with a standardized periodicity. Some of those systems could take benefit from technical improvements permitting a reduction of periodicity of acquisition and analysis of data. On the analytical point of view, some collaboration could be created to permit those countries to share technical and analytical enhancements from ISDS international teams. Very few of those systems have been rigorously evaluated. Some validated evaluation methods like those proposed by the Centers for Disease Control and Prevention (CDC) of Atlanta (2) could highlight the weaknesses of these systems and find the solutions adapted to the local context to improve their functioning. It seems that syndromic surveillance could permit some useful tools to help decision-making in a lot of South American countries, devoid of biological specialized laboratories.
Map: Countries of South America, with a focus on French Guiana, Suriname and Paraguay (examples discussed in the text).
- Meynard J, Dussart P, Lamy M, Matheus S, Dupuy B, Daudens E, Texier G, Chaudet H, Pellegrin L, Tournebize O et al: Interest of syndromic surveillance within the Armed Forces in French Guiana for early warning. Advances in Disease Surveillance 2007, 2:111.
- Buehler J, Hopkins R, Overhage J, Sosin D, Tong V: Framework for evaluating public health surveillance systems for early detection of outbreaks: recommendations from the CDC Working Group. MMWR 2004, 53(RR-5):1-11.
The following article is courtesy of Duncan Cooper (Bradford and Airedale Primary Care Trust, UK) and Liselotte van Aston (Centre for Infectious Disease Control, Netherlands)
Europe: Syndromic Surveillance - A European Perspective
Emerging and common infections such as influenza and norovirus retain a high public health priority in Europe. The threat of bio-terrorism also remains, whilst the incidence of climatic events such as heatwaves and flooding is expected to increase. In response to these threats national Governments, the public and media expect rapid, accurate and geographically focussed public health surveillance.
Within Europe there are a growing number of syndromic surveillance systems providing local and national real-time intelligence about threats to health. For example, in the UK, data from a national telehealth system (NHS Direct) are being used to provide early warning of rises in influenza and norovirus syndromes, and a rapid surveillance response to major incidents (e.g. floods, heat waves, major fires). In France emergency department data have been used for the surveillance of influenza whilst crude mortality measure the impact of the health effects of heat waves. A broad syndromic surveillance evaluation project in the Netherlands has, based on preliminary results, concluded that syndromic data offers potential as a research tool for a more in-depth analysis to reveal blind spots of traditional surveillance data and improve estimates of the health impact of specific agents and agent groups.
Another example of syndromic surveillance exists in Denmark where ambulance dispatch records are used prospectively to provide early warning of influenza both locally and nationally. Within Germany enhanced surveillance of notifiable diseases, ‘relevant events’, and media sources was conducted during the 2006 football World Cup in 12 cities. Similarly, epidemiological surveillance systems using multiple data sources were set up for the Winter Olympics in Italy during and 2006 and the G8 summit in Scotland in 2005. In these examples, the benefit of new and improved communications and networking has extended beyond the events themselves. Much of this work and further discussion has been has been published in an ‘Early Warning and Response’ edition of Eurosurveillance (http://www.eurosurveillance.org/eq/2006/04-06/0406.asp).
Two events during 2007 highlighted European interest in syndromic surveillance. Firstly, the symposium ‘Advances in Disease Surveillance’ hosted by the National Institute for Public Health and the Environment (RIVM) in the Netherlands was attended by delegates from 12 countries (http://www.rivm.nl/cib/actueel/agenda/inschrijven/Programma_ADS.jsp). Secondly, the European Scientific Conference on Applied Infectious Disease Epidemiology (ESCAIDE) (Stockholm, October 2007) included a well attended plenary session entitled ‘What is the potential of Syndromic Surveillance for detecting emerging infectious disease events?’ An informal network of Europeans working in public health intend to build on the critical mass of interest generated by these two events and organise a further European Syndromic Surveillance meeting. The aims of this meeting will be to encourage Europe wide networking and sharing of syndromic surveillance practice. It is hoped that these developments will inform the ECDC epidemic intelligence policy (http://www.eurosurveillance.org/em/v11n12/1112-223.asp) and support the revised International Health Regulations call for a global surveillance system.
The following article is courtesy of Julie Pavlin (USAMC-AFRIMS, Thailand)
ASIA: Syndromic Surveillance in Asia – Opportunities and Challenges
The increased usage of and access to electronic health data is occurring internationally. In Asia, as in other parts of the world, computerized medical data are increasingly available in the number of locations and populations covered and in the amount of information received. Secondary to the increase in data access, several syndromic surveillance programs have been developed in Asia and are actively using emergency department chief complaints and diagnostic codes (1-3), inpatient diagnoses (4) sales of over-the-counter medications (5-8), ambulance runs (8) and surveillance in schools and child care centers (9-10). Most of the information published on these efforts has been from countries or locations with many resources available, such as Japan, Hong Kong, China and Taiwan.
Several new and emerging infectious disease outbreaks had their start in Asia. Severe acute respiratory syndrome (SARS) and avian influenza are two that have created devastating health and economic burdens. Syndromic surveillance efforts could serve as needed early warning and outbreak monitoring systems to allow rapid response and tailoring of preventive measures. With advanced computerization and analytic methods usually in place with syndromic systems, it may seem difficult, if not impossible, to start a program in areas with few resources and no electronic medical records. However, syndromic surveillance, while it can be, and often is, a very sophisticated and technically complex automated system, it can also be very basic, using few resources and complementing programs already in place.
The first challenge in implementing an automated surveillance system is access to data in a reliable and relatively rapid manner. Many countries in Asia have electronic medical records, at least at the hospital level, and sometimes at more remote clinics. As in other parts of the world, most of these systems were designed for patient management and not surveillance, but often have data useful for surveillance. For example, in Thailand there are electronic data management systems that record patient visits at the village health centers and government hospitals and include ICD10 diagnostic codes. The Ministry of Public Health is already using these data to capture reportable diseases.
If no electronic data exist, there is the option to create surveillance data through entry of patient illness information into an electronic database. The Early Warning Outbreak Recognition System (EWORS) developed by the Naval Medical Research Unit #2 did this in multiple clinics throughout Indonesia and other locations in SE Asia. While there are obvious drawbacks to this, the most obvious being the need for additional work by the clinic staff and an increased potential for a lack of reporting, there can be positive aspects. First, the information queried can be tailored to answer priority questions for the surveillance system that is usually not available from administrative databases, such as travel history and contact with sick animals or people. Second, the system can be created to provide a needed service for the medical system – not just syndromic infectious disease detection, but a general patient tracking system, or an administrative database for billing and cost monitoring. In this way, it can become a necessary integrated medical system that quickly stops being an added data entry burden.
Many groups in Asia who are developing new surveillance systems have expressed concerns similar to those heard in other parts of the world. In particular, the issues of data privacy and ownership, how to deal with missing data and determine data quality, and how to decrease time lags are among those that surface repeatedly. In addition, in countries with fewer resources, obtaining information technology equipment and regular access to the internet are paramount and cause significant concern. Some ways to overcome this obstacle include using widely available technology such as mobile telephones and SMS or to use existing structures, such as internet cafes to transmit data. Other significant concerns include frequent staff turnover and the need for continuous training and sustaining a system once original start-up and development funds dry up.
Many Asian countries are small in land area and share multiple borders with countries that not only have a different government and public health plan, but also have a different language and even a different alphabet, making sharing of data across borders difficult. Even within many countries, there are obstacles in implementing a system nationwide secondary to different regional health plans, similar to that seen in the US with state systems vs. federal systems. There is growing optimism that some of these national and regional disparities may decrease with the implementation of the WHO International Health Regulations. As systems are developed throughout the region, maximal use of shared data standards will assist in creating a comprehensive regional system.
Recommendations that are commonly heard throughout Asia in system development include keeping it simple. Whether the system has existing data or will be gathering new data for surveillance, ask for only that which will be used. Determine goals early and figure out what is needed to reach those goals and limit data gathering to that which is needed. Overburdening IT personnel with data requests and clinic staff with collection requirements will only decrease the ability to acquire relevant data. In addition, limiting data gathering will assist the epidemiologic staff who will be developing and analyzing the surveillance system. Other recommendations voiced include building on work that has previously been done by others, especially international organizations such as the WHO. These systems are usually open source and not only readily available but often provide assistance with implementation and troubleshooting. Finally, when building a system, plan for continuous training to not only ensure that new staff have the necessary skills for using the system, but also as a reminder of the importance of dedicated data entry and analysis.
1. Wu TJ, Shih FF, Yen M, et al. Establishing a nationwide emergency department-based syndromic surveillance system for better public health responses in Taiwan. BMC Public Health 2008;8:18-30.
2. Qiaolei M, Xiaodan P, Zhang X, Zhenlong L, Wang Q. Syndromic surveillance pilot project in Dongcheng district of Beijing, China. Advances in Disease Surveillance 2007;2:117.
3. Zhang X, Ding Y, Chen Z, Schable C. Development of an integrated surveillance system for Beijing. Advances in Disease Surveillance 2007;2:127.
4. Kikuchi K, Ohkusa Y, Sugawara T, Taniguchi K, Okabe N. Preliminary trial of syndromic surveillance to early detection of nosocomial infection outbreak. Kansenshogaku Zasshi 2007;81:162-72.
5. Ohkusa Y, Shigematsu M, Taniguchi K, Okabe N. Experimental surveillance using data on sales of over-the-counter medications – Japan, November 2003-April 2004. MMWR 2005; 54(Suppl):47-52.
6. Ohkusa Y, Shigematsu M, Taniguchi K. Second year of the surveillance on over-the counter medication sales data in Japan. Advances in Disease Surveillance 2006;1:58.
7. Sugawara T, Ohkusa Y, Shigematsu M, Taniguchi K, Murata A. Okabe N. An experimental study for syndromic surveillance using OTC sales. Kansenshogaku Zasshi 2007; 81:235-41.
8. Ohkusa Y, Sugawara T, Sugiura H, Kawaguchi Y, Taniguchi K, Okabe N. Experimental syndromic surveillances in Japan using three aspects: OTC, outpatient visits and ambulance transfer. Advances in Disease Surveillance 2006;1:57.
9. Ho F, Fang A, Li T, Choi T. Enhancing community connectivity for infectious disease surveillance in child care centres in Hong Kong. Advances in Disease Surveillance 2006;1:33.
10. Chow V, Lam T, Choi T. Use of informatics for understanding disease activity in community. Advances in Disease Surveillance 2007;2:97.
Member Profiles
Committee Board Representative:
Duncan Cooper - Location: United Kingdom, Europe; Skills/Area of Expertise: influenza surveillance, telehealth data, epidemiology; Email
Committee Chair:
Jacqueline Coberly - Location: United States, North America; Email
For more information about members with particular expertise, or to contact committee members in a location near you, please contact Don Olson.
Membership
Join the 'Network': The ISDS Global Outreach committee will welcome expressions of interest to join the committee or make a contribution to the newsletter. Please contact Don Olson for further information. Currently, the committee is working on the development of our international database of surveillance contacts as a resource for ISDS members and others. In addition, we are particularly interested in having interested people from Africa and Central Asia join the committee to provide a representation of these areas of the globe.
Events
Events list courtesy of Louise Wilson
The American Thoracic Society is committed to “disseminating the latest advances, nationally and internationally, in the fields of lung disease, sleep disorders and critical care medicine”. Last year’s conference in San Francisco was attended by over 16,000 people from 90 countries. The 2008 International Conference will be held May 16-21 in Toronto, Ontario, Canada.
The European Respiratory Society (ERS) aims “to alleviate suffering from respiratory disease and to promote lung health through research, knowledge sharing, medical and public education”. It is holding its annual congress in Berlin from October 4-8 2008.
The International Union Against Tuberculosis and Lung Disease has as its mission “the prevention and control of tuberculosis and lung disease, as well as related health problems, on a world wide basis, with a particular emphasis on low income countries”. It is holding the 39th Union World Conference on Lung Health at the Palais des Congrès de Paris, Paris, France from 16/10/2008 to 20/10/2008.
Links
The International Society for Infectious Diseases (ISID) -
ISID is committed to improving the care of patients with infectious diseases, the training of clinicians and researchers in infectious diseases and microbiology, and the control of infectious diseases around the world. The Society recognizes that infectious diseases cross all national and regional boundaries and that effective long-term solutions require international scientific exchange and cooperation. The Society and its members are dedicated to developing partnerships and to finding solutions to the problem of infectious diseases across the globe.
The United Nations is central to global efforts to solve problems that challenge humanity. Cooperating in this effort are more than 30 affiliated organizations, known together as the UN system. Day in and day out, the UN and its family of organizations work to promote respect for human rights, protect the environment, fight disease and reduce poverty. UN agencies define the standards for safe and efficient air travel and help improve telecommunications and enhance consumer protection. The United Nations leads the international campaigns against drug trafficking and terrorism. Throughout the world, the UN and its agencies assist refugees, set up programmes to clear landmines, help expand food production and lead the fight against AIDS.
The Centers for Disease Control and Prevention (CDC) -
CDC′s Mission is to promote health and quality of life by preventing and controlling disease, injury, and disability. CDC′s Vision for the 21st Century is "Healthy People in a Healthy World - Through Prevention."
World Organization for Animal Health (OIE) -
The need to fight animal diseases at global level led to the creation of the Office International des Epizooties through the international Agreement signed on January 25th 1924. In May 2003 the Office became the World Organisation for Animal Health but kept its historical acronym OIE. The OIE is the intergovernmental organisation responsible for improving animal health worldwide. It is recognised as a reference organisation by the World Trade Organization (WTO) and as of January 2008, had a total of 172 Member Countries and Territories. The OIE maintains permanent relations with 36 other international and regional organisations and has Regional and sub-regional Offices on every continent.
World Health Organization (WHO) -
WHO is the directing and coordinating authority for health within the United Nations system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries and monitoring and assessing health trends.
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