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Cavallaro M, Coelho J, Ready D, Decraene V, Lamagni T, McCarthy ND, Todkill D, Keeling MJ. Cluster detection with random neighbourhood covering: Application to invasive Group A Streptococcal disease. PLoS Comput Biol 2022; 18:e1010726. [PMID: 36449515 PMCID: PMC9744322 DOI: 10.1371/journal.pcbi.1010726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2021] [Revised: 12/12/2022] [Accepted: 11/10/2022] [Indexed: 12/02/2022] Open
Abstract
The rapid detection of outbreaks is a key step in the effective control and containment of infectious diseases. In particular, the identification of cases which might be epidemiologically linked is crucial in directing outbreak-containment efforts and shaping the intervention of public health authorities. Often this requires the detection of clusters of cases whose numbers exceed those expected by a background of sporadic cases. Quantifying exceedances rapidly is particularly challenging when only few cases are typically reported in a precise location and time. To address such important public health concerns, we present a general method which can detect spatio-temporal deviations from a Poisson point process and estimate the odds of an isolate being part of a cluster. This method can be applied to diseases where detailed geographical information is available. In addition, we propose an approach to explicitly take account of delays in microbial typing. As a case study, we considered invasive group A Streptococcus infection events as recorded and typed by Public Health England from 2015 to 2020.
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Affiliation(s)
- Massimo Cavallaro
- The Zeeman Institute for Systems Biology & Infectious Disease Epidemiology Research, University of Warwick, Coventry, United Kingdom
- School of Life Sciences and Mathematics Institute, University of Warwick, Coventry, United Kingdom
- UK Health Security Agency, United Kingdom
| | | | - Derren Ready
- UK Health Security Agency, United Kingdom
- Health Protection Research Unit in Behavioural Science and Evaluation at the University of Bristol, Bristol, United Kingdom
| | | | | | - Noel D. McCarthy
- The Zeeman Institute for Systems Biology & Infectious Disease Epidemiology Research, University of Warwick, Coventry, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
- Institute of Population Health, School of Medicine, Trinity College Dublin, University of Dublin, 2 Dublin, Ireland
| | - Dan Todkill
- UK Health Security Agency, United Kingdom
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Matt J. Keeling
- The Zeeman Institute for Systems Biology & Infectious Disease Epidemiology Research, University of Warwick, Coventry, United Kingdom
- School of Life Sciences and Mathematics Institute, University of Warwick, Coventry, United Kingdom
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2
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Smith G, Harcourt S, Hoang U, Lemanska A, Elliot A, Morbey R, Hughes H, Lake I, Edeghere O, Oliver I, Sherlock J, Amlôt R, de Lusignan S. Observational study of mental health presentations across healthcare setting during the first 9 months of the COVID-19 pandemic in England. JMIR Public Health Surveill 2022; 8:e32347. [PMID: 35486809 PMCID: PMC9359118 DOI: 10.2196/32347] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 03/15/2022] [Accepted: 04/26/2022] [Indexed: 11/13/2022] Open
Abstract
Background The COVID-19 pandemic has resulted in an unprecedented impact on the day-to-day lives of people, with several features potentially adversely affecting mental health. There is growing evidence of the size of the impact of COVID-19 on mental health, but much of this is from ongoing population surveys using validated mental health scores. Objective This study investigated the impact of the pandemic and control measures on mental health conditions presenting to a spectrum of national health care services monitored using real-time syndromic surveillance in England. Methods We conducted a retrospective observational descriptive study of mental health presentations (those calling the national medical helpline, National Health Service [NHS] 111; consulting general practitioners [GPs] in and out-of-hours; calling ambulance services; and attending emergency departments) from January 1, 2019, to September 30, 2020. Estimates for the impact of lockdown measures were provided using an interrupted time series analysis. Results Mental health presentations showed a marked decrease during the early stages of the pandemic. Postlockdown, attendances for mental health conditions reached higher than prepandemic levels across most systems—a rise of 10% compared to that expected for NHS 111 and 21% for GP out-of-hours service—while the number of consultations to GP in-hours service was 13% lower compared to the same time previous year. Increases were observed in calls to NHS 111 for sleep problems. Conclusions These analyses showed marked changes in the health care attendances and prescribing for common mental health conditions across a spectrum of health care provision, with some of these changes persisting. The reasons for such changes are likely to be complex and multifactorial. The impact of the pandemic on mental health may not be fully understood for some time, and therefore, these syndromic indicators should continue to be monitored.
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Affiliation(s)
- Gillian Smith
- Real-time Syndromic Surveillance Team, Field Service, UK Health Security Agency, 1st Floor, 5 St Philips Place, Birmingham, GB.,NIHR Health Protection Research Unit in Emergency Preparedness and Response, King's College London, London, GB
| | - Sally Harcourt
- Real-time Syndromic Surveillance Team, Field Service, UK Health Security Agency, 1st Floor, 5 St Philips Place, Birmingham, GB
| | - Uy Hoang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, GB
| | - Agnieszka Lemanska
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, GB
| | - Alex Elliot
- Real-time Syndromic Surveillance Team, Field Service, UK Health Security Agency, 1st Floor, 5 St Philips Place, Birmingham, GB.,NIHR Health Protection Research Unit in Emergency Preparedness and Response, King's College London, London, GB
| | - Roger Morbey
- Real-time Syndromic Surveillance Team, Field Service, UK Health Security Agency, 1st Floor, 5 St Philips Place, Birmingham, GB.,NIHR Health Protection Research Unit in Emergency Preparedness and Response, King's College London, London, GB
| | - Helen Hughes
- Real-time Syndromic Surveillance Team, Field Service, UK Health Security Agency, 1st Floor, 5 St Philips Place, Birmingham, GB
| | - Iain Lake
- School of Environmental Science, University of East Anglia, Norwich, GB.,NIHR Health Protection Research Unit in Emergency Preparedness and Response, King's College London, London, GB
| | - Obaghe Edeghere
- Real-time Syndromic Surveillance Team, Field Service, UK Health Security Agency, 1st Floor, 5 St Philips Place, Birmingham, GB.,NIHR Health Protection Research Unit in Emergency Preparedness and Response, King's College London, London, GB
| | - Isabel Oliver
- NIHR Health Protection Research Unit in Behavioural Science and Evaluation, Population Health Sciences, University of Bristol, Bristol, GB.,Chief Scientist Advisor Group, UK Health Security Agency, London, GB
| | - Julian Sherlock
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, GB
| | - Richard Amlôt
- NIHR Health Protection Research Unit in Emergency Preparedness and Response, King's College London, London, GB.,NIHR Health Protection Research Unit in Behavioural Science and Evaluation, Population Health Sciences, University of Bristol, Bristol, GB.,Behavioural Science and Insights Unit, UK Health Security Agency, London, GB
| | - Simon de Lusignan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, GB.,Faculty of Health and Medical Sciences, University of Surrey, Surrey, GB.,Royal College of General Practitioners, London, GB
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3
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The Utility of Ambulance Dispatch Call Syndromic Surveillance for Detecting and Assessing the Health Impact of Extreme Weather Events in England. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19073876. [PMID: 35409559 PMCID: PMC8997786 DOI: 10.3390/ijerph19073876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 03/03/2022] [Accepted: 03/14/2022] [Indexed: 11/26/2022]
Abstract
Extreme weather events present significant global threats to health. The National Ambulance Syndromic Surveillance System collects data on 18 syndromes through chief presenting complaint (CPC) codes. We aimed to determine the utility of ambulance data to monitor extreme temperature events for action. Daily total calls were observed between 01/01/2018−30/04/2019. Median daily ’Heat/Cold’ CPC calls during “known extreme temperature” (identified a priori), “extreme temperature”; (within 5th or 95th temperature percentiles for central England) and meteorological alert periods were compared to all other days using Wilcoxon signed-rank test. During the study period, 12,585,084 calls were recorded. In 2018, median daily “Heat/Cold” calls were higher during periods of known extreme temperature: heatwave (16/day, 736 total) and extreme cold weather events (28/day, 339 total) compared to all other days in 2018 (6/day, 1672 total). Median daily “Heat/Cold” calls during extreme temperature periods (16/day) were significantly higher than non-extreme temperature periods (5/day, p < 0.001). Ambulance data can be used to identify adverse impacts during periods of extreme temperature. Ambulance data are a low resource, rapid and flexible option providing real-time data on a range of indicators. We recommend ambulance data are used for the surveillance of presentations to healthcare related to extreme temperature events.
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Todkill D, de Jesus Colon Gonzalez F, Morbey R, Charlett A, Hajat S, Kovats S, Osborne NJ, McInnes R, Vardoulakis S, Exley K, Edeghere O, Smith G, Elliot AJ. Environmental factors associated with general practitioner consultations for allergic rhinitis in London, England: a retrospective time series analysis. BMJ Open 2020; 10:e036724. [PMID: 33277274 PMCID: PMC7722376 DOI: 10.1136/bmjopen-2019-036724] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES To identify key predictors of general practitioner (GP) consultations for allergic rhinitis (AR) using meteorological and environmental data. DESIGN A retrospective, time series analysis of GP consultations for AR. SETTING A large GP surveillance network of GP practices in the London area. PARTICIPANTS The study population was all persons who presented to general practices in London that report to the Public Health England GP in-hours syndromic surveillance system during the study period (3 April 2012 to 11 August 2014). PRIMARY MEASURE Consultations for AR (numbers of consultations). RESULTS During the study period there were 186 401 GP consultations for AR. High grass and nettle pollen counts (combined) were associated with the highest increases in consultations (for the category 216-270 grains/m3, relative risk (RR) 3.33, 95% CI 2.69 to 4.12) followed by high tree (oak, birch and plane combined) pollen counts (for the category 260-325 grains/m3, RR 1.69, 95% CI 1.32 to 2.15) and average daily temperatures between 15°C and 20°C (RR 1.47, 95% CI 1.20 to 1.81). Higher levels of nitrogen dioxide (NO2) appeared to be associated with increased consultations (for the category 70-85 µg/m3, RR 1.33, 95% CI 1.03 to 1.71), but a significant effect was not found with ozone. Higher daily rainfall was associated with fewer consultations (15-20 mm/day; RR 0.812, 95% CI 0.674 to 0.980). CONCLUSIONS Changes in grass, nettle or tree pollen counts, temperatures between 15°C and 20°C, and (to a lesser extent) NO2 concentrations were found to be associated with increased consultations for AR. Rainfall has a negative effect. In the context of climate change and continued exposures to environmental air pollution, intelligent use of these data will aid targeting public health messages and plan healthcare demand.
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Affiliation(s)
- Dan Todkill
- Field Epidemiology Training Programme, National Infection Service, Public Health England, Birmingham, UK
- Health Services Division, Warwick Medical School, University of Warwick, Coventry, UK
| | - Felipe de Jesus Colon Gonzalez
- School of Environmental Sciences, University of East Anglia, Norwich, UK
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Roger Morbey
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, UK
| | - Andre Charlett
- Statistics, Modelling and Economics Unit, Public Health England, London, UK
| | - Shakoor Hajat
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Sari Kovats
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas J Osborne
- School of Public Health, Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- European Centre for Environment and Human Health, College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Sotiris Vardoulakis
- Australian National University, Canberra, Australian Capital Territory, Australia
| | - Karen Exley
- Air Quality & Public Health Group, Environmental Hazards and Emergencies Department, Centre for Radiation, Chemical and Environmental Hazards, Public Health England, Chilton, UK
| | - Obaghe Edeghere
- Field Epidemiology Training Programme, National Infection Service, Public Health England, Birmingham, UK
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, UK
| | - Gillian Smith
- Health Services Division, Warwick Medical School, University of Warwick, Coventry, UK
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, UK
| | - Alex J Elliot
- Health Services Division, Warwick Medical School, University of Warwick, Coventry, UK
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, UK
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5
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Morbey RA, Elliot AJ, Smith GE, Charlett A. Adapting Syndromic Surveillance Baselines After Public Health Interventions. Public Health Rep 2020; 135:737-745. [PMID: 33026959 DOI: 10.1177/0033354920959080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Public health surveillance requires historical baselines to identify unusual activity. However, these baselines require adjustment after public health interventions. We describe an example of such an adjustment after the introduction of rotavirus vaccine in England in July 2013. METHODS We retrospectively measured the magnitude of differences between baselines and observed counts (residuals) before and after the introduction of a public health intervention, the introduction of a rotavirus vaccine in July 2013. We considered gastroenteritis, diarrhea, and vomiting to be indicators for national syndromic surveillance, including telephone calls to a telehealth system, emergency department visits, and unscheduled consultations with general practitioners. The start of the preintervention period varied depending on the availability of surveillance data: June 2005 for telehealth, November 2009 for emergency departments, and July 2010 for general practitioner data. The postintervention period was July 2013 to the second quarter of 2016. We then determined whether baselines incorporating a step-change reduction or a change in seasonality resulted in more accurate models of activity. RESULTS Residuals in the unadjusted baseline models increased by 42%-198% from preintervention to postintervention. Increases in residuals for vomiting indicators were 19%-44% higher than for diarrhea. Both step-change and seasonality adjustments improved the surveillance models; we found the greatest reduction in residuals in seasonally adjusted models (4%-75%). CONCLUSION Our results demonstrated the importance of adjusting surveillance baselines after public health interventions, particularly accounting for changes in seasonality. Adjusted baselines produced more representative expected values than did unadjusted baselines, resulting in fewer false alarms and a greater likelihood of detecting public health threats.
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Affiliation(s)
- Roger Antony Morbey
- 371011 Real-time Syndromic Surveillance Team, Field Service, National Infection Service, Public Health England, Birmingham, UK
| | - Alex James Elliot
- 371011 Real-time Syndromic Surveillance Team, Field Service, National Infection Service, Public Health England, Birmingham, UK
| | - Gillian Elizabeth Smith
- 371011 Real-time Syndromic Surveillance Team, Field Service, National Infection Service, Public Health England, Birmingham, UK
| | - Andre Charlett
- 371011 Statistics, Modelling and Economics Department, National Infection Service, Public Health England, London, UK
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Noufaily A, Morbey RA, Colón-González FJ, Elliot AJ, Smith GE, Lake IR, McCarthy N. Comparison of statistical algorithms for daily syndromic surveillance aberration detection. Bioinformatics 2020; 35:3110-3118. [PMID: 30689731 PMCID: PMC6736430 DOI: 10.1093/bioinformatics/bty997] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 11/16/2018] [Accepted: 01/22/2019] [Indexed: 11/29/2022] Open
Abstract
Motivation Public health authorities can provide more effective and timely interventions to protect populations during health events if they have effective multi-purpose surveillance systems. These systems rely on aberration detection algorithms to identify potential threats within large datasets. Ensuring the algorithms are sensitive, specific and timely is crucial for protecting public health. Here, we evaluate the performance of three detection algorithms extensively used for syndromic surveillance: the ‘rising activity, multilevel mixed effects, indicator emphasis’ (RAMMIE) method and the improved quasi-Poisson regression-based method known as ‘Farrington Flexible’ both currently used at Public Health England, and the ‘Early Aberration Reporting System’ (EARS) method used at the US Centre for Disease Control and Prevention. We model the wide range of data structures encountered within the daily syndromic surveillance systems used by PHE. We undertake extensive simulations to identify which algorithms work best across different types of syndromes and different outbreak sizes. We evaluate RAMMIE for the first time since its introduction. Performance metrics were computed and compared in the presence of a range of simulated outbreak types that were added to baseline data. Results We conclude that amongst the algorithm variants that have a high specificity (i.e. >90%), Farrington Flexible has the highest sensitivity and specificity, whereas RAMMIE has the highest probability of outbreak detection and is the most timely, typically detecting outbreaks 2–3 days earlier. Availability and implementation R codes developed for this project are available through https://github.com/FelipeJColon/AlgorithmComparison Supplementary information Supplementary data are available at Bioinformatics online.
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Affiliation(s)
- Angela Noufaily
- Statistics and Epidemiology, Warwick Medical School, University of Warwick, Coventry, UK
| | - Roger A Morbey
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, UK
| | | | - Alex J Elliot
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, UK
| | - Gillian E Smith
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, UK
| | - Iain R Lake
- School of Environmental Sciences, University of East Anglia, Norwich, UK
| | - Noel McCarthy
- Population Evidence and Technologies, Warwick Medical School, University of Warwick, Coventry, UK
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7
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Developing influenza and respiratory syncytial virus activity thresholds for syndromic surveillance in England. Epidemiol Infect 2020; 147:e163. [PMID: 31063101 PMCID: PMC6518470 DOI: 10.1017/s0950268819000542] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Influenza and respiratory syncytial virus (RSV) are common causes of respiratory tract infections and place a burden on health services each winter. Systems to describe the timing and intensity of such activity will improve the public health response and deployment of interventions to these pressures. Here we develop early warning and activity intensity thresholds for monitoring influenza and RSV using two novel data sources: general practitioner out-of-hours consultations (GP OOH) and telehealth calls (NHS 111). Moving Epidemic Method (MEM) thresholds were developed for winter 2017-2018. The NHS 111 cold/flu threshold was breached several weeks in advance of other systems. The NHS 111 RSV epidemic threshold was breached in week 41, in advance of RSV laboratory reporting. Combining the use of MEM thresholds with daily monitoring of NHS 111 and GP OOH syndromic surveillance systems provides the potential to alert to threshold breaches in real-time. An advantage of using thresholds across different health systems is the ability to capture a range of healthcare-seeking behaviour, which may reflect differences in disease severity. This study also provides a quantifiable measure of seasonal RSV activity, which contributes to our understanding of RSV activity in advance of the potential introduction of new RSV vaccines.
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Morbey RA, Charlett A, Lake I, Mapstone J, Pebody R, Sedgwick J, Smith GE, Elliot AJ. Can syndromic surveillance help forecast winter hospital bed pressures in England? PLoS One 2020; 15:e0228804. [PMID: 32040541 PMCID: PMC7010388 DOI: 10.1371/journal.pone.0228804] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 01/23/2020] [Indexed: 11/25/2022] Open
Abstract
Background Health care planners need to predict demand for hospital beds to avoid deterioration in health care. Seasonal demand can be affected by respiratory illnesses which in England are monitored using syndromic surveillance systems. Therefore, we investigated the relationship between syndromic data and daily emergency hospital admissions. Methods We compared the timing of peaks in syndromic respiratory indicators and emergency hospital admissions, between 2013 and 2018. Furthermore, we created forecasts for daily admissions and investigated their accuracy when real-time syndromic data were included. Results We found that syndromic indicators were sensitive to changes in the timing of peaks in seasonal disease, especially influenza. However, each year, peak demand for hospital beds occurred on either 29th or 30th December, irrespective of the timing of syndromic peaks. Most forecast models using syndromic indicators explained over 70% of the seasonal variation in admissions (adjusted R square value). Forecast errors were reduced when syndromic data were included. For example, peak admissions for December 2014 and 2017 were underestimated when syndromic data were not used in models. Conclusion Due to the lack of variability in the timing of the highest seasonal peak in hospital admissions, syndromic surveillance data do not provide additional early warning of timing. However, during atypical seasons syndromic data did improve the accuracy of forecast intensity.
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Affiliation(s)
- Roger A. Morbey
- National Infection Service, Public Health England, Birmingham, England, United Kingdom
- * E-mail:
| | - Andre Charlett
- Department Head, Statistics and Modelling Economics Department, Public Health England, London, England, United Kingdom
| | - Iain Lake
- School of Environmental Sciences, University of East Anglia, Norwich, England, United Kingdom
| | | | - Richard Pebody
- National Infection Service, Public Health England, London, England, United Kingdom
| | - James Sedgwick
- National Infection Service, Public Health England, Ashford, England, United Kingdom
| | - Gillian E. Smith
- National Infection Service, Public Health England, Birmingham, England, United Kingdom
| | - Alex J. Elliot
- National Infection Service, Public Health England, Birmingham, England, United Kingdom
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9
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Lake IR, Colón-González FJ, Barker GC, Morbey RA, Smith GE, Elliot AJ. Machine learning to refine decision making within a syndromic surveillance service. BMC Public Health 2019; 19:559. [PMID: 31088446 PMCID: PMC6515660 DOI: 10.1186/s12889-019-6916-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 04/29/2019] [Indexed: 12/27/2022] Open
Abstract
Background Worldwide, syndromic surveillance is increasingly used for improved and timely situational awareness and early identification of public health threats. Syndromic data streams are fed into detection algorithms, which produce statistical alarms highlighting potential activity of public health importance. All alarms must be assessed to confirm whether they are of public health importance. In England, approximately 100 alarms are generated daily and, although their analysis is formalised through a risk assessment process, the process requires notable time, training, and maintenance of an expertise base to determine which alarms are of public health importance. The process is made more complicated by the observation that only 0.1% of statistical alarms are deemed to be of public health importance. Therefore, the aims of this study were to evaluate machine learning as a tool for computer-assisted human decision-making when assessing statistical alarms. Methods A record of the risk assessment process was obtained from Public Health England for all 67,505 statistical alarms between August 2013 and October 2015. This record contained information on the characteristics of the alarm (e.g. size, location). We used three Bayesian classifiers- naïve Bayes, tree-augmented naïve Bayes and Multinets - to examine the risk assessment record in England with respect to the final ‘Decision’ outcome made by an epidemiologist of ‘Alert’, ‘Monitor’ or ‘No-action’. Two further classifications based upon tree-augmented naïve Bayes and Multinets were implemented to account for the predominance of ‘No-action’ outcomes. Results The attributes of each individual risk assessment were linked to the final decision made by an epidemiologist, providing confidence in the current process. The naïve Bayesian classifier performed best, correctly classifying 51.5% of ‘Alert’ outcomes. If the ‘Alert’ and ‘Monitor’ actions are combined then performance increases to 82.6% correctly classified. We demonstrate how a decision support system based upon a naïve Bayes classifier could be operationalised within an operational syndromic surveillance system. Conclusions Within syndromic surveillance systems, machine learning techniques have the potential to make risk assessment following statistical alarms more automated, robust, and rigorous. However, our results also highlight the importance of specialist human input to the process.
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Affiliation(s)
- I R Lake
- School of Environmental Sciences, University of East Anglia, Norwich, NR4 7TJ, UK. .,National Institute for Health Research Health Protection Research Unit in Emergency Preparedness and Response, London, UK.
| | - F J Colón-González
- School of Environmental Sciences, University of East Anglia, Norwich, NR4 7TJ, UK.,National Institute for Health Research Health Protection Research Unit in Emergency Preparedness and Response, London, UK
| | - G C Barker
- National Institute for Health Research Health Protection Research Unit in Emergency Preparedness and Response, London, UK
| | - R A Morbey
- National Institute for Health Research Health Protection Research Unit in Emergency Preparedness and Response, London, UK.,Real-time Syndromic Surveillance Team, Field Service, National Infection Service, Public Health England, Birmingham, B3 2PW, UK
| | - G E Smith
- National Institute for Health Research Health Protection Research Unit in Emergency Preparedness and Response, London, UK.,Real-time Syndromic Surveillance Team, Field Service, National Infection Service, Public Health England, Birmingham, B3 2PW, UK
| | - A J Elliot
- National Institute for Health Research Health Protection Research Unit in Emergency Preparedness and Response, London, UK.,Real-time Syndromic Surveillance Team, Field Service, National Infection Service, Public Health England, Birmingham, B3 2PW, UK
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10
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El-Khatib Z, Taus K, Richter L, Allerberger F, Schmid D. A Syndrome-Based Surveillance System for Infectious Diseases Among Asylum Seekers in Austrian Reception Centers, 2015-2018: Analysis of Reported Data. JMIR Public Health Surveill 2019; 5:e11465. [PMID: 30810535 PMCID: PMC6414818 DOI: 10.2196/11465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 11/08/2018] [Accepted: 12/03/2018] [Indexed: 11/25/2022] Open
Abstract
Background Austria has been among the main European countries hosting incoming asylum seekers since 2015. Consequently, there was an urgent need to predict any public health threats associated with the arriving asylum seekers. The Department of Surveillance and Infectious Disease Epidemiology at the Austrian Agency for Health and Food Safety (AGES) was mandated to implement a national syndrome-based surveillance system in the 7 reception centers by the Austrian Ministry of Interior and Ministry of Health. Objective We aimed to analyze the occurrence and spread of infectious diseases among asylum seekers using data reported by reception centers through the syndrome-based surveillance system from September 2015 through February 2018. Methods We deployed a daily data collection system for 13 syndromes: rash with fever; rash without fever; acute upper respiratory tract infection; acute lower respiratory tract infection; meningitis or encephalitis; fever and bleeding; nonbloody gastroenteritis or watery diarrhea; bloody diarrhea; acute jaundice; skin, soft tissue, or bone abnormalities; acute flaccid paralysis; high fever with no other signs; and unexplained death. General practitioners, the first professionals to consult for health problems at reception centers in Austria, sent the tally sheets on identified syndromes daily to the AGES. Results We identified a total of 2914 cases, presenting 8 of the 13 syndromes. A total of 405 signals were triggered, and 6.4% (26/405) of them generated alerts. Suspected acute upper respiratory tract infection (1470/2914, 50.45% of cases), rash without fever (1174/2914, 40.29% of cases), suspected acute lower respiratory tract infection (159/2914, 5.46% of cases), watery diarrhea (73/2914, 2.51% of cases), and skin, soft tissue, or bone abnormalities (32/2914, 1.10% of cases) were the top 5 syndromes. Conclusions The cooperation of the AGES with reception center health care staff, supported by the 2 involved ministries, was shown to be useful for syndromic surveillance of infectious diseases among asylum seekers. None of the identified alerts escalated to an outbreak.
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Affiliation(s)
- Ziad El-Khatib
- Department of Surveillance and Infectious Disease Epidemiology, Institute of Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Karin Taus
- Department of Surveillance and Infectious Disease Epidemiology, Institute of Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - Lukas Richter
- Department of Surveillance and Infectious Disease Epidemiology, Institute of Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - Franz Allerberger
- Department of Surveillance and Infectious Disease Epidemiology, Institute of Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria
| | - Daniela Schmid
- Department of Surveillance and Infectious Disease Epidemiology, Institute of Medical Microbiology and Hygiene, Austrian Agency for Health and Food Safety, Vienna, Austria
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11
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Estimating the burden on general practitioner services in England from increases in respiratory disease associated with seasonal respiratory pathogen activity. Epidemiol Infect 2018; 146:1389-1396. [PMID: 29972108 DOI: 10.1017/s0950268818000262] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Understanding the burden of respiratory pathogens on health care is key to improving public health emergency response and interventions. In temperate regions, there is a large seasonal rise in influenza and other respiratory pathogens. We have examined the associations between individual pathogens and reported respiratory tract infections to estimate attributable burden. We used multiple linear regression to model the relationship between doctor consultation data and laboratory samples from week 3 2011 until week 37 2015. We fitted separate models for consultation data with in-hours and out-of-hours doctor services, stratified by different age bands. The best fitting all ages models (R2 > 80%) for consultation data resulted in the greatest burden being associated with influenza followed by respiratory syncytial virus (RSV). For models of adult age bands, there were significant associations between consultation data and invasive Streptococcus pneumoniae. There were also smaller numbers of consultations significantly associated with rhinovirus, parainfluenza, and human metapneumovirus. We estimate that a general practice with 10 000 patients would have seen an additional 18 respiratory tract infection consultations per winter week of which six had influenza and four had RSV. Our results are important for the planning of health care services to minimise the impact of winter pressures. •Respiratory pathogen incidence explains over 80% of seasonal variation in respiratory consultation data.•Influenza and RSV are associated with the biggest seasonal rises in respiratory consultation counts.•A third of consultation counts associated with respiratory pathogens were due to influenza.
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Smith GE, Elliot AJ, Ibbotson S, Morbey R, Edeghere O, Hawker J, Catchpole M, Endericks T, Fisher P, McCloskey B. Novel public health risk assessment process developed to support syndromic surveillance for the 2012 Olympic and Paralympic Games. J Public Health (Oxf) 2018; 39:e111-e117. [PMID: 27451417 DOI: 10.1093/pubmed/fdw054] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Syndromic surveillance aims to provide early warning and real time estimates of the extent of incidents; and reassurance about lack of impact of mass gatherings. We describe a novel public health risk assessment process to ensure those leading the response to the 2012 Olympic Games were alerted to unusual activity that was of potential public health importance, and not inundated with multiple statistical 'alarms'. Methods Statistical alarms were assessed to identify those which needed to result in 'alerts' as reliably as possible. There was no previously developed method for this. We identified factors that increased our concern about an alarm suggesting that an 'alert' should be made. Results Between 2 July and 12 September 2012, 350 674 signals were analysed resulting in 4118 statistical alarms. Using the risk assessment process, 122 'alerts' were communicated to Olympic incident directors. Conclusions Use of a novel risk assessment process enabled the interpretation of large number of statistical alarms in a manageable way for the period of a sustained mass gathering. This risk assessment process guided the prioritization and could be readily adapted to other surveillance systems. The process, which is novel to our knowledge, continues as a legacy of the Games.
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Affiliation(s)
- Gillian E Smith
- Real-Time Syndromic Surveillance Team, Public Health England, 5 St Philip's Place, Birmingham B3 2PW, UK
| | - Alex J Elliot
- Real-Time Syndromic Surveillance Team, Public Health England, 5 St Philip's Place, Birmingham B3 2PW, UK
| | - Sue Ibbotson
- Public Health England Centre, West Midlands, Public Health England, 5 St Philip's Place, Birmingham B3 2PW, UK
| | - Roger Morbey
- Real-Time Syndromic Surveillance Team, Public Health England, 5 St Philip's Place, Birmingham B3 2PW, UK
| | - Obaghe Edeghere
- Field Epidemiology Service, Public Health England, 5 St Philip's Place, Birmingham B3 2PW, UK
| | - Jeremy Hawker
- Field Epidemiology Service, Public Health England, 5 St Philip's Place, Birmingham B3 2PW, UK
| | - Mike Catchpole
- Public Health England Centre for Infectious Disease Surveillance and Control, 61 Colindale Avenue, London NW9 5EQ, UK
| | - Tina Endericks
- Department of Global Health, Wellington House, 133 to 155 Waterloo Road, London SE1 8UG, UK
| | - Paul Fisher
- Real-Time Syndromic Surveillance Team, Public Health England, 5 St Philip's Place, Birmingham B3 2PW, UK
| | - Brian McCloskey
- Department of Global Health, Wellington House, 133 to 155 Waterloo Road, London SE1 8UG, UK
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Colón-González FJ, Lake IR, Morbey RA, Elliot AJ, Pebody R, Smith GE. A methodological framework for the evaluation of syndromic surveillance systems: a case study of England. BMC Public Health 2018; 18:544. [PMID: 29699520 PMCID: PMC5921418 DOI: 10.1186/s12889-018-5422-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 04/09/2018] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Syndromic surveillance complements traditional public health surveillance by collecting and analysing health indicators in near real time. The rationale of syndromic surveillance is that it may detect health threats faster than traditional surveillance systems permitting more timely, and hence potentially more effective public health action. The effectiveness of syndromic surveillance largely relies on the methods used to detect aberrations. Very few studies have evaluated the performance of syndromic surveillance systems and consequently little is known about the types of events that such systems can and cannot detect. METHODS We introduce a framework for the evaluation of syndromic surveillance systems that can be used in any setting based upon the use of simulated scenarios. For a range of scenarios this allows the time and probability of detection to be determined and uncertainty is fully incorporated. In addition, we demonstrate how such a framework can model the benefits of increases in the number of centres reporting syndromic data and also determine the minimum size of outbreaks that can or cannot be detected. Here, we demonstrate its utility using simulations of national influenza outbreaks and localised outbreaks of cryptosporidiosis. RESULTS Influenza outbreaks are consistently detected with larger outbreaks being detected in a more timely manner. Small cryptosporidiosis outbreaks (<1000 symptomatic individuals) are unlikely to be detected. We also demonstrate the advantages of having multiple syndromic data streams (e.g. emergency attendance data, telephone helpline data, general practice consultation data) as different streams are able to detect different outbreak types with different efficacy (e.g. emergency attendance data are useful for the detection of pandemic influenza but not for outbreaks of cryptosporidiosis). We also highlight that for any one disease, the utility of data streams may vary geographically, and that the detection ability of syndromic surveillance varies seasonally (e.g. an influenza outbreak starting in July is detected sooner than one starting later in the year). We argue that our framework constitutes a useful tool for public health emergency preparedness in multiple settings. CONCLUSIONS The proposed framework allows the exhaustive evaluation of any syndromic surveillance system and constitutes a useful tool for emergency preparedness and response.
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Affiliation(s)
- Felipe J. Colón-González
- School of Environmental Sciences, University of East Anglia, Norwich, NR4 7TJ UK
- NIHR Health Protection Research Unit for Emergency Preparedness and Response, London, UK
| | - Iain R. Lake
- School of Environmental Sciences, University of East Anglia, Norwich, NR4 7TJ UK
- NIHR Health Protection Research Unit for Emergency Preparedness and Response, London, UK
| | - Roger A. Morbey
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, B3 2PW UK
- NIHR Health Protection Research Unit for Emergency Preparedness and Response, London, UK
| | - Alex J. Elliot
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, B3 2PW UK
- NIHR Health Protection Research Unit for Emergency Preparedness and Response, London, UK
| | - Richard Pebody
- Respiratory Diseases Department, National Infection Service, Public Health England, London, NW9 5EQ UK
| | - Gillian E. Smith
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, B3 2PW UK
- NIHR Health Protection Research Unit for Emergency Preparedness and Response, London, UK
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Fleischauer AT, Gaines J. Enhancing Surveillance for Mass Gatherings: The Role of Syndromic Surveillance. Public Health Rep 2018; 132:95S-98S. [PMID: 28692398 DOI: 10.1177/0033354917706343] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Aaron T Fleischauer
- 1 Office of Public Health Preparedness and Response, Centers for Disease Control and Prevention, Atlanta, GA, USA.,2 Division of Public Health, North Carolina Department of Health and Human Services, Raleigh, NC, USA
| | - Joanna Gaines
- 3 Division of Global Migration and Quarantine, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA, USA
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Todkill D, Loveridge P, Elliot AJ, Morbey R, de Lusignan S, Edeghere O, Smith G. Socioeconomic and geographical variation in general practitioner consultations for allergic rhinitis in England, 2003-2014: an observational study. BMJ Open 2017; 7:e017038. [PMID: 28801431 PMCID: PMC5724116 DOI: 10.1136/bmjopen-2017-017038] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Allergic rhinitis (AR) is a global health problem, potentially impacting individuals' sleep, work and social life. We aimed to use a surveillance network of general practitioners (GPs) to describe the epidemiology of AR consultations in England. SETTING A large GP surveillance network covering approximately 53% of the English population. METHODS GP consultations for AR across England between 30 December 2002 and 31 December 2014 were analysed. Using more granular data available between 2 April 2012 and 31 December 2014 rates and rate ratios (RR) of AR were further analysed in different age groups, gender, rural-urban classification and index of multiple deprivation score quintile of location of GP. RESULTS The mean weekly rate for AR consultations was 19.8 consultations per 100 000 GP registered patients (range 1.13-207), with a regular peak occurring during June (weeks 24-26), and a smaller peak during April. Between 1 April 2012 and 31 December 2014, the highest mean daily rates of consultations per 1 00 000 were: in age group 5-14 years (rate=8.02, RR 6.65, 95% CI 6.38 to 6.93); females (rate=4.57, RR 1.12 95% CI 1.12 to 1.13); persons registered at a GP in the most socioeconomically deprived quintile local authority (rate=5.69, RR 1.48, 95% CI 1.47 to 1.49) or in an urban area with major conurbation (rate=5.91, RR 1.78, 95% CI 1.69 to 1.87). CONCLUSIONS AR rates were higher in those aged 5-14 years, females and in urban and socioeconomically deprived areas. This needs to be viewed in the context of this study's limitations but should be considered in health promotion and service planning.
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Affiliation(s)
- Daniel Todkill
- Field Epidemiology Service, National Infection Service, Public Health England, Birmingham, UK
- Health Services Division, Warwick Medical School, University of Warwick, Coventry, UK
| | - Paul Loveridge
- Real-time Syndromic Surveillance, National Infection Service, Public Health England, Birmingham, UK
| | - Alex James Elliot
- Real-time Syndromic Surveillance, National Infection Service, Public Health England, Birmingham, UK
- NIHR Health Protection Research Unit, Emergency Preparedness and Response, London, UK
| | - Roger Morbey
- Real-time Syndromic Surveillance, National Infection Service, Public Health England, Birmingham, UK
| | - Simon de Lusignan
- Department of Clinical & Experimental Medicine, University of Surrey, Surrey, UK
- Research and Surveillance Centre, Royal College of General Practitioners, London, England
| | - Obaghe Edeghere
- Field Epidemiology Service, National Infection Service, Public Health England, Birmingham, UK
- Real-time Syndromic Surveillance, National Infection Service, Public Health England, Birmingham, UK
| | - Gillian Smith
- Real-time Syndromic Surveillance, National Infection Service, Public Health England, Birmingham, UK
- NIHR Health Protection Research Unit, Emergency Preparedness and Response, London, UK
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Utility of Ambulance Data for Real-Time Syndromic Surveillance: A Pilot in the West Midlands Region, United Kingdom. Prehosp Disaster Med 2017; 32:667-672. [DOI: 10.1017/s1049023x17006690] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AbstractIntroductionThe Public Health England (PHE; United Kingdom) Real-Time Syndromic Surveillance Team (ReSST) currently operates four national syndromic surveillance systems, including an emergency department system. A system based on ambulance data might provide an additional measure of the “severe” end of the clinical disease spectrum. This report describes the findings and lessons learned from the development and preliminary assessment of a pilot syndromic surveillance system using ambulance data from the West Midlands (WM) region in England.Hypothesis/ProblemIs an Ambulance Data Syndromic Surveillance System (ADSSS) feasible and of utility in enhancing the existing suite of PHE syndromic surveillance systems?MethodsAn ADSSS was designed, implemented, and a pilot conducted from September 1, 2015 through March 1, 2016. Surveillance cases were defined as calls to the West Midlands Ambulance Service (WMAS) regarding patients who were assigned any of 11 specified chief presenting complaints (CPCs) during the pilot period. The WMAS collected anonymized data on cases and transferred the dataset daily to ReSST, which contained anonymized information on patients’ demographics, partial postcode of patients’ location, and CPC. The 11 CPCs covered a broad range of syndromes. The dataset was analyzed descriptively each week to determine trends and key epidemiological characteristics of patients, and an automated statistical algorithm was employed daily to detect higher than expected number of calls. A preliminary assessment was undertaken to assess the feasibility, utility (including quality of key indicators), and timeliness of the system for syndromic surveillance purposes. Lessons learned and challenges were identified and recorded during the design and implementation of the system.ResultsThe pilot ADSSS collected 207,331 records of individual ambulance calls (daily mean=1,133; range=923-1,350). The ADSSS was found to be timely in detecting seasonal changes in patterns of respiratory infections and increases in case numbers during seasonal events.ConclusionsFurther validation is necessary; however, the findings from the assessment of the pilot ADSSS suggest that selected, but not all, ambulance indicators appear to have some utility for syndromic surveillance purposes in England. There are certain challenges that need to be addressed when designing and implementing similar systems.TodkillD, LoveridgeP, ElliotAJ, MorbeyRA, EdeghereO, Rayment-BishopT, Rayment-BishopC, ThornesJE, SmithG. Utility of ambulance data for real-time syndromic surveillance: a pilot in the West Midlands region, United Kingdom. Prehosp Disaster Med. 2017;32(6):667–672.
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Buckingham-Jeffery E, Morbey R, House T, Elliot AJ, Harcourt S, Smith GE. Correcting for day of the week and public holiday effects: improving a national daily syndromic surveillance service for detecting public health threats. BMC Public Health 2017; 17:477. [PMID: 28525991 PMCID: PMC5438549 DOI: 10.1186/s12889-017-4372-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 05/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND As service provision and patient behaviour varies by day, healthcare data used for public health surveillance can exhibit large day of the week effects. These regular effects are further complicated by the impact of public holidays. Real-time syndromic surveillance requires the daily analysis of a range of healthcare data sources, including family doctor consultations (called general practitioners, or GPs, in the UK). Failure to adjust for such reporting biases during analysis of syndromic GP surveillance data could lead to misinterpretations including false alarms or delays in the detection of outbreaks. The simplest smoothing method to remove a day of the week effect from daily time series data is a 7-day moving average. Public Health England developed the working day moving average in an attempt also to remove public holiday effects from daily GP data. However, neither of these methods adequately account for the combination of day of the week and public holiday effects. METHODS The extended working day moving average was developed. This is a further data-driven method for adding a smooth trend curve to a time series graph of daily healthcare data, that aims to take both public holiday and day of the week effects into account. It is based on the assumption that the number of people seeking healthcare services is a combination of illness levels/severity and the ability or desire of patients to seek healthcare each day. The extended working day moving average was compared to the seven-day and working day moving averages through application to data from two syndromic indicators from the GP in-hours syndromic surveillance system managed by Public Health England. RESULTS The extended working day moving average successfully smoothed the syndromic healthcare data by taking into account the combined day of the week and public holiday effects. In comparison, the seven-day and working day moving averages were unable to account for all these effects, which led to misleading smoothing curves. CONCLUSIONS The results from this study make it possible to identify trends and unusual activity in syndromic surveillance data from GP services in real-time independently of the effects caused by day of the week and public holidays, thereby improving the public health action resulting from the analysis of these data.
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Affiliation(s)
- Elizabeth Buckingham-Jeffery
- Centre for Complexity Science and Warwick Infectious Disease Epidemiology Research Centre, University of Warwick, Coventry, UK. .,School of Mathematics, University of Manchester, Manchester, UK.
| | - Roger Morbey
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, UK
| | - Thomas House
- School of Mathematics, University of Manchester, Manchester, UK
| | - Alex J Elliot
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, UK
| | - Sally Harcourt
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, UK
| | - Gillian E Smith
- Real-time Syndromic Surveillance Team, National Infection Service, Public Health England, Birmingham, UK
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18
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An Observational Study Using English Syndromic Surveillance Data Collected During the 2012 London Olympics - What did Syndromic Surveillance Show and What Can We Learn for Future Mass-gathering Events? Prehosp Disaster Med 2016; 31:628-634. [PMID: 27641930 DOI: 10.1017/s1049023x16000923] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Introduction In preparation for the London 2012 Olympic Games, existing syndromic surveillance systems operating in England were expanded to include daily general practitioner (GP) out-of-hours (OOH) contacts and emergency department (ED) attendances at sentinel sites (the GP OOH and ED syndromic surveillance systems: GPOOHS and EDSSS). Hypothesis/Problem The further development of syndromic surveillance systems in time for the London 2012 Olympic Games provided a unique opportunity to investigate the impact of a large mass-gathering event on public health and health services as monitored in near real-time by syndromic surveillance of GP OOH contacts and ED attendances. This can, in turn, aid the planning of future events. METHODS The EDSSS and GPOOHS data for London and England from July 13 to August 26, 2012, and a similar period in 2013, were divided into three distinct time periods: pre-Olympic period (July 13-26, 2012); Olympic period (July 27 to August 12); and post-Olympic period (August 13-26, 2012). Time series of selected syndromic indicators in 2012 and 2013 were plotted, compared, and risk assessed by members of the Real-time Syndromic Surveillance Team (ReSST) in Public Health England (PHE). Student's t test was used to test any identified changes in pattern of attendance. RESULTS Very few differences were found between years or between the weeks which preceded and followed the Olympics. One significant exception was noted: a statistically significant increase (P value = .0003) in attendances for "chemicals, poisons, and overdoses, including alcohol" and "acute alcohol intoxication" were observed in London EDs coinciding with the timing of the Olympic opening ceremony (9:00 pm July 27, 2012 to 01:00 am July 28, 2012). CONCLUSIONS Syndromic surveillance was able to provide near to real-time monitoring and could identify hourly changes in patterns of presentation during the London 2012 Olympic Games. Reassurance can be provided to planners of future mass-gathering events that there was no discernible impact in overall attendances to sentinel EDs or GP OOH services in the host country. The increase in attendances for alcohol-related causes during the opening ceremony, however, may provide an opportunity for future public health interventions. Todkill D , Hughes HE , Elliot AJ , Morbey RA , Edeghere O , Harcourt S , Hughes T , Endericks T , McCloskey B , Catchpole M , Ibbotson S , Smith G . An observational study using English syndromic surveillance data collected during the 2012 London Olympics - what did syndromic surveillance show and what can we learn for future mass-gathering events? Prehosp Disaster Med. 2016;31(6):628-634.
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Ye C, Li Z, Fu Y, Lan Y, Zhu W, Zhou D, Zhang H, Lai S, Buckeridge DL, Sun Q, Yang W. SCM: a practical tool to implement hospital-based syndromic surveillance. BMC Res Notes 2016; 9:315. [PMID: 27317431 PMCID: PMC4912801 DOI: 10.1186/s13104-016-2098-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 05/23/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Syndromic surveillance has been widely used for the early warning of infectious disease outbreaks, especially in mass gatherings, but the collection of electronic data on symptoms in hospitals is one of the fundamental challenges that must be overcome during operating a syndromic surveillance system. The objective of our study is to describe and evaluate the implementation of a symptom-clicking-module (SCM) as a part of the enhanced hospital-based syndromic surveillance during the 41st World Exposition in Shanghai, China, 2010. METHODS The SCM, including 25 targeted symptoms, was embedded in the sentinels' Hospital Information Systems (HIS). The clinicians used SCM to record these information of all the visiting patients, and data were collated and transmitted automatically in daily batches. The symptoms were categorized into seven targeted syndromes using pre-defined criteria, and statistical algorithms were applied to detect temporal aberrations in the data series. RESULTS SCM was deployed successfully in each sentinel hospital and was operated during the 184-day surveillance period. A total of 1,730,797 patient encounters were recorded by SCM, and 6.1 % (105,352 visits) met the criteria of the seven targeted syndromes. Acute respiratory and gastrointestinal syndromes were reported most frequently, accounted for 92.1 % of reports in all syndromes, and the aggregated time-series presented an obvious day-of-week variation over the study period. In total, 191 aberration signals were triggered, and none of them were identified as outbreaks after verification and field investigation. CONCLUSIONS SCM has acted as a practical tool for recording symptoms in the hospital-based enhanced syndromic surveillance system during the 41st World Exposition in Shanghai, in the context of without a preexisting electronic tool to collect syndromic data in the HIS of the sentinel hospitals.
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Affiliation(s)
- Chuchu Ye
- Research Base of Key Laboratory of Surveillance and Early-warning on Infectious Disease in China CDC, Shanghai Pudong New Area Center for Disease Control and Prevention, Shanghai, China
| | - Zhongjie Li
- Key Laboratory of Surveillance and Early-warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Yifei Fu
- Research Base of Key Laboratory of Surveillance and Early-warning on Infectious Disease in China CDC, Shanghai Pudong New Area Center for Disease Control and Prevention, Shanghai, China
| | - Yajia Lan
- Research Base of Key Laboratory of Surveillance and Early-warning on Infectious Disease in China CDC, West China School of Public Health, Sichuan University, Chengdu, China
| | - Weiping Zhu
- Research Base of Key Laboratory of Surveillance and Early-warning on Infectious Disease in China CDC, Shanghai Pudong New Area Center for Disease Control and Prevention, Shanghai, China
| | - Dinglun Zhou
- Research Base of Key Laboratory of Surveillance and Early-warning on Infectious Disease in China CDC, West China School of Public Health, Sichuan University, Chengdu, China
| | - Honglong Zhang
- Key Laboratory of Surveillance and Early-warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China
| | - Shengjie Lai
- Key Laboratory of Surveillance and Early-warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China.,Department of Geography and Environment, University of Southampton, Southampton, UK
| | | | - Qiao Sun
- Research Base of Key Laboratory of Surveillance and Early-warning on Infectious Disease in China CDC, Shanghai Pudong New Area Center for Disease Control and Prevention, Shanghai, China.
| | - Weizhong Yang
- Key Laboratory of Surveillance and Early-warning on Infectious Disease, Chinese Center for Disease Control and Prevention, Beijing, China.
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Morbey RA, Elliot AJ, Charlett A, Verlander NQ, Andrews N, Smith GE. The application of a novel 'rising activity, multi-level mixed effects, indicator emphasis' (RAMMIE) method for syndromic surveillance in England. Bioinformatics 2015. [PMID: 26198105 DOI: 10.1093/bioinformatics/btv418] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
MOTIVATION Syndromic surveillance is the real-time collection and interpretation of data to allow the early identification of public health threats and their impact, enabling public health action. The 'rising activity, multi-level mixed effects, indicator emphasis' method was developed to provide a single robust method enabling detection of unusual activity across a wide range of syndromes, nationally and locally. RESULTS The method is shown here to have a high sensitivity (92%) and specificity (99%) compared to previous methods, whilst halving the time taken to detect increased activity to 1.3 days. AVAILABILITY AND IMPLEMENTATION The method has been applied successfully to syndromic surveillance systems in England providing realistic models for baseline activity and utilizing prioritization rules to ensure a manageable number of 'alarms' each day. CONTACT roger.morbey@phe.gov.uk.
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Affiliation(s)
- Roger A Morbey
- Real-time Syndromic Surveillance Team, Public Health England, Birmingham B3 2PW, UK and
| | - Alex J Elliot
- Real-time Syndromic Surveillance Team, Public Health England, Birmingham B3 2PW, UK and
| | - Andre Charlett
- Statistics and Modelling Economics Department, Public Health England, London, UK
| | - Neville Q Verlander
- Statistics and Modelling Economics Department, Public Health England, London, UK
| | - Nick Andrews
- Statistics and Modelling Economics Department, Public Health England, London, UK
| | - Gillian E Smith
- Real-time Syndromic Surveillance Team, Public Health England, Birmingham B3 2PW, UK and
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Internet-based remote health self-checker symptom data as an adjuvant to a national syndromic surveillance system. Epidemiol Infect 2015; 143:3416-22. [PMID: 25858297 DOI: 10.1017/s0950268815000503] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Syndromic surveillance is an innovative surveillance tool used to support national surveillance programmes. Recent advances in the use of internet-based health data have demonstrated the potential usefulness of these health data; however, there have been limited studies comparing these innovative health data to existing established syndromic surveillance systems. We conducted a retrospective observational study to assess the usefulness of a national internet-based 'symptom checker' service for use as a syndromic surveillance system. NHS Direct online data were extracted for 1 August 2012 to 1 July 2013; a time-series analysis on the symptom categories self-reported by online users was undertaken and compared to existing telehealth syndromic data. There were 3·37 million online users of the internet-based self-checker compared to 1·43 million callers to the telephone triage health service. There was a good correlation between the online and telephone triage data for a number of syndromic indicators including cold/flu, difficulty breathing and eye problems; however, online data appeared to provide additional early warning over telephone triage health data. This assessment has illustrated some potential benefit of using internet-based symptom-checker data and provides the basis for further investigating how these data can be incorporated into national syndromic surveillance programmes.
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Smith GE, Bawa Z, Macklin Y, Morbey R, Dobney A, Vardoulakis S, Elliot AJ. Using real-time syndromic surveillance systems to help explore the acute impact of the air pollution incident of March/April 2014 in England. ENVIRONMENTAL RESEARCH 2015; 136:500-504. [PMID: 25460672 DOI: 10.1016/j.envres.2014.09.028] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Revised: 09/11/2014] [Accepted: 09/29/2014] [Indexed: 06/04/2023]
Abstract
During March and early April 2014 there was widespread poor air quality across the United Kingdom. Public Health England used existing syndromic surveillance systems to monitor community health during the period. Short lived statistically significant rises in a variety of respiratory conditions, including asthma and wheeze, were detected. This incident has demonstrated the value of real-time syndromic surveillance systems, during an air pollution episode, for helping to explore the impact of poor air quality on community health in real-time.
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Affiliation(s)
- Gillian E Smith
- Real-time Syndromic Surveillance Team, Public Health England, UK.
| | - Zharain Bawa
- Real-time Syndromic Surveillance Team, Public Health England, UK
| | - Yolande Macklin
- Centre for Radiation Chemical and Environmental Hazards, Public Health England, UK
| | - Roger Morbey
- Real-time Syndromic Surveillance Team, Public Health England, UK
| | - Alec Dobney
- Centre for Radiation Chemical and Environmental Hazards, Public Health England, UK
| | - Sotiris Vardoulakis
- Centre for Radiation Chemical and Environmental Hazards, Public Health England, UK
| | - Alex J Elliot
- Real-time Syndromic Surveillance Team, Public Health England, UK
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McCloskey B, Endericks T, Catchpole M, Zambon M, McLauchlin J, Shetty N, Manuel R, Turbitt D, Smith G, Crook P, Severi E, Jones J, Ibbotson S, Marshall R, Smallwood CAH, Isla N, Memish ZA, Al-Rabeeah AA, Barbeschi M, Heymann DL, Zumla A. London 2012 Olympic and Paralympic Games: public health surveillance and epidemiology. Lancet 2014; 383:2083-2089. [PMID: 24857700 PMCID: PMC7138022 DOI: 10.1016/s0140-6736(13)62342-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Mass gatherings are regarded as potential risks for transmission of infectious diseases, and might compromise the health system of countries in which they are hosted. The evidence for increased transmission of infectious diseases at international sporting mass gatherings that attract many visitors from all over the world is not clear, and the evidence base for public health surveillance, epidemiology, and response at events such as the Olympics is small. However, infectious diseases are a recognised risk, and public health planning is, and should remain, a crucial part of the overall planning of sporting events. In this Series paper, we set out the planning and the surveillance systems that were used to monitor public health risks during the London 2012 Olympic and Paralympic Games in the summer of 2012, and draw attention to the public health issues-infectious diseases and chemical, radiation, and environmental hazards-that arose. Although the absolute risk of health-protection problems, including infectious diseases, at sporting mass gatherings is small, the need for reassurance of the absence of problems is higher than has previously been considered; this could challenge conventional public health surveillance systems. Recognition of the limitations of health-surveillance systems needs to be part of the planning for future sporting events.
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Affiliation(s)
- Brian McCloskey
- Global Center for Mass Gathering Medicine, Riyadh, Saudi Arabia; Global Health and WHO Collaborating Centre on Mass Gatherings, London, UK.
| | - Tina Endericks
- Global Health and WHO Collaborating Centre on Mass Gatherings, London, UK
| | - Mike Catchpole
- Centre for Infectious Disease Surveillance and Control, London, UK
| | | | - Jim McLauchlin
- Food, Water, and Environmental Microbiology Services, London, UK
| | | | | | | | | | | | - Ettore Severi
- European Programme for Intervention Epidemiology Training, London, UK
| | - Jane Jones
- Travel and Migrant Health Section, London, UK
| | | | | | | | - Nicolas Isla
- Global Preparedness, Surveillance and and Response, WHO, Geneva, Switzerland
| | - Ziad A Memish
- Global Center for Mass Gathering Medicine, Riyadh, Saudi Arabia; Ministry of Health, Riyadh, Saudi Arabia; Al-Faisal University, Riyadh, Saudi Arabia
| | - Abdullah A Al-Rabeeah
- Global Center for Mass Gathering Medicine, Riyadh, Saudi Arabia; Ministry of Health, Riyadh, Saudi Arabia
| | - Maurizio Barbeschi
- Global Center for Mass Gathering Medicine, Riyadh, Saudi Arabia; Global Capacities, Alert and Response, WHO, Geneva, Switzerland
| | - David L Heymann
- Global Center for Mass Gathering Medicine, Riyadh, Saudi Arabia; Public Health England, London, UK; Royal Institute of International Affairs, Chatham House, London, UK; London School of Hygiene and Tropical Medicine, London, UK
| | - Alimuddin Zumla
- Global Center for Mass Gathering Medicine, Riyadh, Saudi Arabia; Division of Infection and Immunity, University College London, London, UK; University College London Hospitals NHS Foundation Trust, London, UK
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Report and session summary from the 18th World Congress on Disaster and Emergency Medicine. Prehosp Disaster Med 2014; 29:218-20. [PMID: 24918249 DOI: 10.1017/s1049023x14000065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Editor's Introductory NoteThis section of Prehospital and Disaster Medicine (PDM) presents a report and summary of a session at the 18th World Congress on Disaster and Emergency Medicine (WCDEM) held in Manchester, UK in May of 2013. Additional reports and summaries were published in PDM (Volume 28, No. 6). Abstracts of Congress oral and poster presentations were published in May, 2013 as a supplement to PDM (Volume 28, Supplement 1).Report and session summary from the 18th World Congress on Disaster and Emergency Medicine. Prehosp Disaster Med. 2014:29(1):1-3.
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Williams K, Sinclair C, McEwan R, Fleet K, Balasegaram S, Manuel R. Impact of the London 2012 Olympic and Paralympic Games on demand for microbiology gastrointestinal diagnostic services at the Public Health Laboratory London. J Med Microbiol 2014; 63:968-974. [PMID: 24809387 DOI: 10.1099/jmm.0.070821-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Planning for the London 2012 Olympic and Paralympic Games at the Public Health Laboratory London was based on the requirement to meet potential increased demand with scalable capacity. The aim of this study was to determine the impact on demand for microbiology gastrointestinal diagnostic services during the Games period. Retrospective cross-sectional time-series data analysis was used to assess the number of gastrointestinal specimens received in the laboratory and the number of positive results. There was no increase in the number of gastrointestinal specimens received during the Games period, thus the Games had no impact on demand for microbiology gastrointestinal diagnostic services at the laboratory. There was a decrease in the number of public health specimens received for culture [incidence rate ratio = 0.34, 95% confidence interval (CI) = 0.13-0.86, P = 0.02] and a decrease in the number of culture positive community specimens (odds ratio = 0.59, 95 % CI = 0.40-0.85, P = 0.005), suggesting a decrease in gastrointestinal illness during the Games period. As previous planning assumptions were not based on actual specimen activity, the results of this study may modify the extent of additional planning for microbiological services required for mass gatherings.
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Affiliation(s)
- K Williams
- Public Health Laboratory London, Public Health England, London, UK
| | - C Sinclair
- Field Epidemiology Services Victoria, Public Health England, London, UK
| | - R McEwan
- Public Health Laboratory London, Public Health England, London, UK
| | - K Fleet
- North East and North Central London Health Protection Team, Public Health England, London, UK
| | - S Balasegaram
- Field Epidemiology Services Victoria, Public Health England, London, UK
| | - R Manuel
- Public Health Laboratory London, Public Health England, London, UK
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MORBEY RA, ELLIOT AJ, CHARLETT A, IBBOTSON S, VERLANDER NQ, LEACH S, HALL I, BARRASS I, CATCHPOLE M, McCLOSKEY B, SAID B, WALSH A, PEBODY R, SMITH GE. Using public health scenarios to predict the utility of a national syndromic surveillance programme during the 2012 London Olympic and Paralympic Games. Epidemiol Infect 2014; 142:984-93. [PMID: 23902949 PMCID: PMC9151140 DOI: 10.1017/s095026881300188x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2013] [Revised: 06/07/2013] [Accepted: 07/09/2013] [Indexed: 11/06/2022] Open
Abstract
During 2012 real-time syndromic surveillance formed a key part of the daily public health surveillance for the London Olympic and Paralympic Games. It was vital that these systems were evaluated prior to the Games; in particular what types and scales of incidents could and could not be detected. Different public health scenarios were created covering a range of potential incidents that the Health Protection Agency would require syndromic surveillance to rapidly detect and monitor. For the scenarios considered it is now possible to determine what is likely to be detectable and how incidents are likely to present using the different syndromic systems. Small localized incidents involving food poisoning are most likely to be detected the next day via emergency department surveillance, while a new strain of influenza is more likely to be detected via GP or telephone helpline surveillance, several weeks after the first seed case is introduced.
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Affiliation(s)
- R. A. MORBEY
- Health Protection Agency (HPA), Real-time Syndromic Surveillance Team, Health Protection Services, Birmingham, UK
| | - A. J. ELLIOT
- Health Protection Agency (HPA), Real-time Syndromic Surveillance Team, Health Protection Services, Birmingham, UK
| | - A. CHARLETT
- HPA, Statistics, Modelling and Economics Department, London, UK
| | - S. IBBOTSON
- HPA, West Midlands Regional Director's Office, Birmingham, UK
| | - N. Q. VERLANDER
- HPA, Statistics, Modelling and Economics Department, London, UK
| | - S. LEACH
- HPA, Emergency Response Department, Porton Down, UK
| | - I. HALL
- HPA, Emergency Response Department, Porton Down, UK
| | - I. BARRASS
- HPA, Emergency Response Department, Porton Down, UK
| | | | - B. McCLOSKEY
- HPA, London Regional Director's Office, Head, WHO Collaborating Centre on Mass Gatherings and High Consequence, High Visibility Events, London, UK
| | - B. SAID
- HPA, Gastrointestinal, Emerging and Zoonotic Infections Department, HPS Colindale, London, UK
| | - A. WALSH
- HPA, Gastrointestinal, Emerging and Zoonotic Infections Department, HPS Colindale, London, UK
| | - R. PEBODY
- HPA, Respiratory Diseases Department, HPS Colindale, London, UK
| | - G. E. SMITH
- Health Protection Agency (HPA), Real-time Syndromic Surveillance Team, Health Protection Services, Birmingham, UK
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Morbey RA, Elliot AJ, Charlett A, Andrews N, Verlander NQ, Ibbotson S, Smith GE. Development and refinement of new statistical methods for enhanced syndromic surveillance during the 2012 Olympic and Paralympic Games. Health Informatics J 2014; 21:159-69. [PMID: 24442480 DOI: 10.1177/1460458213517577] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
UNLABELLED Prior to the 2012 London Olympic and Paralympic Games, new statistical methods had to be developed for the enhanced syndromic surveillance during the Games. Different methods were developed depending on whether or not historical data were available. Practical solutions were needed to cope with the required daily reporting and data quality issues. During the Games, nearly 4800 signals were tested on average each day, generating statistical alarms that were assessed to provide information on areas of potential public health concern and reassurance that no major adverse incident had occurred. GRAPHICAL ABSTRACT spjhi;21/2/159/FIG41460458213517577 F1 fig4-1460458213517577.
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Elliot AJ, Morbey RA, Hughes HE, Harcourt SE, Smith S, Loveridge P, Edeghere O, Ibbotson S, McCloskey B, Catchpole M, Smith GE. Syndromic surveillance - a public health legacy of the London 2012 Olympic and Paralympic Games. Public Health 2013; 127:777-81. [PMID: 23870845 DOI: 10.1016/j.puhe.2013.05.007] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Revised: 05/14/2013] [Accepted: 05/16/2013] [Indexed: 11/17/2022]
Affiliation(s)
- A J Elliot
- Real-time Syndromic Surveillance Team, Public Health England, London, UK.
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Microbiological aspects of public health planning and preparedness for the 2012 Olympic Games. Epidemiol Infect 2012; 140:2142-51. [PMID: 22892344 DOI: 10.1017/s0950268812001835] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Although communicable diseases have hitherto played a small part in illness associated with Olympic Games, an outbreak of infection in a national team, Games venue or visiting spectators has the potential to disrupt a global sporting event and distract from the international celebration of athletic excellence. Preparation for hosting the Olympic Games includes implementation of early warning systems for detecting emerging infection problems. Ensuring capability for rapid microbiological diagnoses to inform situational risk assessments underpins the ability to dispel rumours. These are a prelude to control measures to minimize impact of any outbreak of infectious disease at a time of intense public scrutiny. Complex multidisciplinary teamwork combined with laboratory technical innovation and efficient information flows underlie the Health Protection Agency's preparation for the London 2012 Olympic and Paralympic Games. These will deliver durable legacies for clinical and public health microbiology, outbreak investigation and control in the coming years.
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