1. Aaron Kite-Powell, MS Florida Department of Health Bureau of Epidemiology International Society of Disease Surveillance Webinar May 2009 Emergency Department- based Syndromic Surveillance: Outbreak Detection

2. Background Florida Department of Health Florida Department of Health Central offices located in Tallahassee Central offices located in Tallahassee Bureau of Epidemiology Bureau of Epidemiology 67 County Health Departments (CHDs) 67 County Health Departments (CHDs) 67 epidemiology sections/departments 67 epidemiology sections/departments Reportable disease/conditions follow-up Reportable disease/conditions follow-up Syndromic surveillance Syndromic surveillance Bureau of Epidemiology Bureau of Epidemiology Advisory role to CHDs Advisory role to CHDs Manage data systems Manage data systems Routine analysis of data Routine analysis of data

3. Background Earlier Regional Implementations Earlier Regional Implementations Miami-Dade County Region (ESSENCE) Miami-Dade County Region (ESSENCE) Hillsborough County Region (STARS) Hillsborough County Region (STARS) Duval County Region (BioDefend) Duval County Region (BioDefend) State Level Implementation State Level Implementation State syndromic surveillance workgroup State syndromic surveillance workgroup Invested resources in 2006 Invested resources in 2006 Implemented ESSENCE in summer of 2007 Implemented ESSENCE in summer of 2007 As of 5/2009: 109 hospitals sending data every day As of 5/2009: 109 hospitals sending data every day Voluntary participation Voluntary participation Represents > 50% of all ED visits in Florida Represents > 50% of all ED visits in Florida

4. Routine Monitoring Statewide monitoring Statewide monitoring 12,000-14,000 ER visits per day 12,000-14,000 ER visits per day State level - daily review by one analyst State level - daily review by one analyst CHD trainings  improve data analysis at local level CHD trainings  improve data analysis at local level County-level monitoring County-level monitoring 28 counties with reporting hospitals 28 counties with reporting hospitals No. of hospitals reporting per county ranges from 1–16 No. of hospitals reporting per county ranges from 1–16 County-level monitoring process varies widely County-level monitoring process varies widely Perceived value of the data Perceived value of the data Resources, hospital relationships, and local protocols Resources, hospital relationships, and local protocols Level of training Level of training

5. Expectations of ED-based Syndromic Surveillance What do we expect from ED-based syndromic surveillance? What do we expect from ED-based syndromic surveillance? Situational awareness Situational awareness Detect outbreaks Detect outbreaks Large seasonal outbreaks (ILI, norovirus)? Large seasonal outbreaks (ILI, norovirus)? Smaller clusters of potentially related patients? Smaller clusters of potentially related patients? How can we better use existing variables in ED data to improve outbreak detection? How can we better use existing variables in ED data to improve outbreak detection?

6. South Florida Mass Migration Exercise: Broward County South Florida Mass Migration Exercise: Broward County Example 1: Large Outbreak (exercise)

7. South Florida Mass Migration Exercise: Broward South Florida Mass Migration Exercise: Broward County County

8. Example 1: Large Outbreak (exercise) South Florida Mass Migration Exercise: Broward South Florida Mass Migration Exercise: Broward County County

9. Example 2: Small Outbreak Analysis did not produce an alert for the day, but a subset of patients was defined as an outbreak by the investigators. See line list on the next slide. Hillsborough County GI outbreak Hillsborough County GI outbreak

10. Example 2: Small Outbreak Hillsborough County GI outbreak Hillsborough County GI outbreak

11. Example 2: Small Outbreak Hillsborough County GI outbreak Hillsborough County GI outbreak

12. Example 3: Small Outbreak Duval County GI Outbreak Duval County GI Outbreak

13. Example 3: Small Outbreak Duval County GI Outbreak Duval County GI Outbreak

14. Example 3: Small Outbreak Duval County GI Outbreak Duval County GI Outbreak

15. Opportunity Develop additional analyses that: Develop additional analyses that: Look for clustering by the time the patients arrive at the ED. Look for clustering by the time the patients arrive at the ED. By hospital By hospital By patient zip code By patient zip code End result could include: End result could include: Detection of smaller outbreaks Detection of smaller outbreaks Quantification of the “epi-eyeball..” Quantification of the “epi-eyeball..”

16. Questions? Contact information: Contact information: Aaron Kite-Powell Aaron Kite-Powell Aaron_Kite-Powell@doh.state.fl.us Aaron_Kite-Powell@doh.state.fl.us Aaron_Kite-Powell@doh.state.fl.us 850-245-4444 ext. 2638 850-245-4444 ext. 2638