Climate & Health Syndromic Surveillance Webinar

1. Climate & Health Syndromic Surveillance Webinar Facilitators: Matthew Roach Arizona Department of Health Services & Kristin Raab Minnesota Department of Health Tuesday, April 9, 2013 2:00-3:30 PM (EST)

2. Participants Signed Up: • 33 People • 13 States • 1 City & 1 County Health Department • 4 Canadian Public Health Agencies Representatives from various levels of government and programs: • Climate Ready States & Cities Initiative • Environmental Public Health Tracking • New BRACE States • State Health Agency Syndromic Surveillance Programs • CDC • Health Canada • Health Agencies from Several Canadian Provinces

3. Brief Introductory Remarks • Steven Davis, Centers for Disease Control & Prevention (CDC) • -Public Health Advisor, Climate and Health Program • AbderrahmaneYagouti, Health Canada • -Senior Analyst, Climate Change & Health Office

4. Webinar Agenda

5. Before We Begin… • Please put your phone on mute (not on hold) • Remember to un-mute your phone when you’d like to ask a question

6. Presentation 1 • Name: Melissa Jordan & Philip Cavicchia • Agency: Florida Department of Health

7. Use of Syndromic Surveillance to Monitor Heat Related Illness in Florida Melissa Jordan & Philip Cavicchia Environmental Epidemiology Surveillance & Response Bureau of Epidemiology Florida Department of Health

8. Syndromic Surveillance in Florida • Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE) • Technical assistance and development of the ESSENCE system is provided by the Johns Hopkins University Applied Physics Laboratory • State specific options/data feed • Analytic tools used to identify outbreaks or unusual trends more rapidly, leading to a more timely public health response

9. Reporting Sources • Emergency departments & urgent care centers • Chief complaint data from participating hospitals and urgent care centers • Florida Poison Information Center Network (FPICN) • Information from calls to the Poison Control Center hotline (1-800-222-1222) • Reportable disease database (Merlin) • Office of Vital Statistics, mortality data • Assistant Secretary for Preparedness and Response (ASPR) - mission data with data transmission occurring only when teams are deployed in the state

10. Completeness • Emergency departments & urgent care centers • 157 emergency departments • 21 urgent care centers • 85% coverage statewide • FPICN • 3 Poison Centers in Florida • Reportable disease database (Merlin) • All counties • Office of Vital Statistics, mortality data • All counties

11. Reporting Sources • Emergency departments & urgent care centers • Updated between once every two hours to once a day • Florida Poison Information Center Network (FPICN) • Near real time data transfer (updated every 10 minutes) • Reportable disease database (Merlin) • Updated once an hour • Office of Vital Statistics, mortality data • Updated once a day

12. Initiation of Surveillance • Monitor National Oceanic and Atmospheric Administration (NOAA) graphical depiction of high temperatures for excessive heat • Trigger for surveillance when Heat Index exceeds 110

13. Query Development • Heat-related illness queries are based on an ESSENCE emergency department syndrome category • Includes chief complaint search for: -Heat cramping -Heat exhaustion -Heat illness -Heat rash -Heat stroke -Heat trauma -Over heating -Sun poisoning -Heat casualty -Heat emergency -Heat exposure -Heat injury -Heat related -Heat syncope -Over heat -Sun exposure -Sun rash -Heat cramp -Heat exacerbation -Heat fatigue -Heat prostration -Heat stress -Heat syndrome -Over heated -Sun poison -Sun stroke

14. Chief complaint free text search

15. Queries • Query all state data • Weekly percentage of all ED visits compared to previous two years

16. Queries • Query all state data • Daily number of visits

17. Queries • Query all state data • Weekly number of visits

18. Queries • Query all state data • Weekly number of visits by age group

19. Region

20. Queries • County level data

21. Distribution • During times of excessive heat, reports on heat-related illness are distributed to partners for situational awareness using a listserv • Also post to EpiCom – system used to distribute public health information to partners statewide

22. Limitations/Weaknesses • Data are available from 178 hospitals and urgent care clinics in 38 counties (57% of counties have at least one hospital reporting into ESSENCE) in Florida which represents ~85% of all ED visits. • Data analyzed based on free text query. Patients presenting with other chief complaints due to physical activity or other underlying chronic conditions that heat exposure may have exacerbated will be missed in this analysis. Similarly, final physician diagnosis might differ for some of the heat- related illness cases. • There are limited details about the mode and duration of exposure to heat. • No occupational data are available.

23. Future Improvements • Develop text queries of mortality data and evaluate usefulness/reporting lag • Expand text queries of chief complaint data beyond traditional heat-related illness • Explore the use of ESSENCE for other extreme weather conditions

24. Related Projects & Opportunities • CSTE Roundtable – Monday, 6/10 - 5:45-6:30PM • Use of Syndromic Surveillance to Provide Situational Awareness During Wildfire and Heat Related Illness: Monitoring of Health and Climate Data for Environmental Exposure and Illness Surveillance • Environmental Public Health Tracking – special projects

25. Contact Information • Melissa Jordan • 850-245-4577 • Melissa_Jordan@doh.state.fl.us • Philip Cavicchia • 850-245-4444, Ext 3873 • Philip_Cavicchia@doh.state.fl.us

26. Presentation 2 • Name: David Swenson & Ken Dufault • Agency: New Hampshire Department of Health & Human Services

27. NH Heat-Related Illness Reporting Climate & Health Effects Syndromic Surveillance Workshop April 9, 2013 David Swenson, PMP & Kenneth Dufault State of NH, DHHS Division of Public Health Services

28. Agenda • Overview of Heat-related illness and NH’s statewide syndromic surveillance system (Automated Hospital Emergency Department Data or AHEDD) • CDC’s Heat-related illness case definition • System coverage • How and what Information is collected, timeliness • How the system works • Heat-related illness detection • System benefits & weaknesses • Quality of data

29. HEAT-Related Illness CDC Case Definition: • Heat stroke (high body temperature; rapid pulse; red, hot, dry skin; headache; dizziness; nausea; confusion; unconsciousness) • Heat exhaustion (heavy sweating, paleness, muscle cramps, tiredness, weakness, headache, dizziness, nausea, fainting) • Heat cramps (muscle pains or spasms in abdomen, arms, or legs) • Sunburn (red, painful skin, followed by blistering) Vulnerable Population: • Elderly (people 65 years or older), infants and children, and people with chronic medical conditions Suggested Remedies: • Air-conditioning is the number one protective factor against heat-related illness and death • Drinking plenty of fluids • Replacing salts and minerals in the body

30. AHEDD System Overview Includes: • Secured electronic data exchange • Real-time health data collection • Automatic surveillance and alerting • Allows for rapid investigation • Participation mandated under He-P 301 Currently includes: • 26 hospitals • 100 % of NH’s hospital volume Purposes: • Syndrome & health risk detection • NH situational awareness and investigation

31. AHEDD System Data Flow NH DPHS SecuredFirewall Syndromic Surveillance Application Disease Surveillance: Planning for Syndromic surveillance charting and data error feedback • Reviews alerts • Queries syndromes & symptoms • Investigates & monitors health activity • Follows up with hospitals Hospitals Encounter chief complaints assigned to 8 syndromes and alerts set Transmit/update Real-time Electronic ED data Via HL7 and VPN ED data repository

32. How AHEDD Works • Syndrome Detection • Real-time Outbreak and Disease Surveillance (RODS) system CoCo classifier used to assign encounter chief complaint to 1 of 8 syndromes • Alerts detected (compared to historical data) and distributed to state surveillance staff • Charting and line-level reporting capabilities • Data Mining for Health Risks • Various disease and health risk queries are run to identify specific conditions • Custom query tool used to build/tweak queries on the fly (used for Heat-Related Illness) • Line-level reporting capability • Proactive Disease Reporting • Reportable disease alerting from diagnosis code updates • Line-level reporting capability

33. Heat-Related Illness Query Process • Create query from CDC case definition • Start with CDC symptoms • Tweak with actual values from hospital data • Build & run real-time Chief Complaint query • +heat+excessive:+heat+exhaust:+heat+exposure:+heat+fatigue:+heat+stroke:+heat+syncope:+heatstroke:+hyper+thermia:+heat+dehydra (includes and/or/exclusionary logic) • Values are pasted from Word document into AHEDD custom query tool (MS Access with Oracle database) and run • Build & run ICD-9-CM code confirmatory query • 708.2, 992.0 - 992.6, 992.8, 992.9, E900.0, E900.9 • Values are selected from AHEDD ICD9 Look-up query tool and run • Yearly review and modification (for greater accuracy)

34. Custom Query Tool

35. Heat-Related Illness Detections • July 2010 Heat-Related Illness • Highest totals in southeast counties - Hillsborough (51 encounters), Rockingham (28), Merrimack (24), and Strafford (21) • Highest percentage in 18-64 age group (54%), followed by 65+ group (33%) • July 2011 Heat-Related Illness • Highest totals in southeast counties - Hillsborough (26 encounters), Rockingham (8), Strafford (8) and Merrimack (7) • Highest percentage in 5-24 age group (35%), followed by 25-49 group (32%) • July 2012 Heat-Related Illness • Highest totals in southeast counties - Hillsborough (26 encounters), Rockingham (22), Carroll (20) and Strafford (18) • Highest percentage in 18-64 age group (57%) of which 25-49 represented 56%, followed by 65+ group (29%)

36. Other Custom Query Detections • December 2009-1010 GI Anthrax investigation (retrospective/prospective analysis performed) • Retrospective and prospective analysis of both relevant chief complain and diagnosis codes, with DHMC MD review of relevant cases • 183,973 encounters reviewed, 7,111 met GI Anthrax query criteria, 62 warranted further investigation, 0 additional cases • Other investigations • August 2011 Hurricane Irene injury & GI investigation • October 2010 – June 2012 Hep C investigation • October 2012 Snow storm injury investigation • October - December 2012 Fungal Meningitis

37. System Benefits • Earlier disease detection, quicker response & control by public health & hospital staff • Prompt, flexible investigation capability using queries & data mining • Greater opportunities to share data electronically (between hospitals, state, and federal public health partners) • Collaboration with Incident Command Center (ICC) during emergencies • Regarding Heat-Related Illness , the Surveillance Section provides town line data and GIS maps that inform or validate placement of cooling stations • With custom query tool can tweak to get queries that work

38. Activated Incident Command Center • Team leader activates the ICC and notifies ICC team via HAN • ICC team meets to identify emergency response needs • Data analysis, reporting, dissemination as needed

39. Heat-Related Illness Reporting

40. Heat-Related Illness Mapping

41. System Weaknesses • Morbidity is only 1 part of the picture, which is why NH analyzes heat-related illness mortalities too • Minimal fields included (chief complain, diagnosis codes, and demographic data (gender, DOB, resident town/state/zip code, etc.) • Only able to do breakdowns by state, county, and town levels • One hospital won’t provide patient number (have to use probabilistic linkage techniques to create a patient number) • Diagnosis reporting needs improvement • Two hospitals aren’t sending diagnosis code updates • Chief complaint reporting could be improved • Some hospitals submit values of little significance (“Not feeling well”, “ILL”, “Not supplied”, etc.) • GIS mapping is manually done, unable to do electronically

42. Data Quality • Issues with Data Quality • Minimal issues with missing (town, gender, etc.) • Some visit number and Admit Date/time duplicates • Some encounters don’t receive final diagnoses • Issues with regard to Heat-Related Illness • Because of the volume, we do not routinely confirm each heat-related illness encounter • Some hospitals only provide a menu-driven chief complaint (not enough detail provided to relate to query values) • Dehydration although included could be associated with some other condition

43. Contact Information David Swenson AHEDD Project Manager Infectious Disease Surveillance Section Phone: (603) 271-7366 Email: dswenson@dhhs.state.nh.us Ken Dufault Surveillance Specialist Infectious Disease Surveillance Section Phone: (603) 271-5165 Email: kadufault@dhhs.state.nh.us Questions?

44. Questions?

45. Goals for Syndromic Surveillance System Workgroup • Learn about climate and health syndromic surveillance systems in the US and Canada (how they are set up, time commitment, range of coverage, benefits, drawbacks, usefulness, who has access to the data/how is data shared) • Learn about how agencies started and then maintained their syndromic surveillance system (including legislative action, partnerships, funding) • Share information on best practices for improving and using data from syndromic surveillance systems for climate change

46. Next Steps • Workgroup meets quarterly or more often? • AZ will send out a Meeting Wizard for the next workgroup meeting. Tentative date: May/June? • THANK YOU!!!!