Application of change point analysis to daily influenza-like illness emergency department visits

Background

The utility of healthcare utilization data from US emergency departments (EDs) for rapid monitoring of changes in influenza-like illness (ILI) activity was highlighted during the recent influenza A (H1N1) pandemic. Monitoring has tended to rely on detection algorithms, such as the Early Aberration Reporting System (EARS), which are limited in their ability to detect subtle changes and identify disease trends.

Objective

To evaluate a complementary approach, change point analysis (CPA), for detecting changes in the incidence of ED visits due to ILI.

Methodology and principal findings

Data collected through the Distribute project (isdsdistribute.org), which aggregates data on ED visits for ILI from over 50 syndromic surveillance systems operated by state or local public health departments were used. The performance was compared of the cumulative sum (CUSUM) CPA method in combination with EARS and the performance of three CPA methods (CUSUM, structural change model and Bayesian) in detecting change points in daily time-series data from four contiguous US states participating in the Distribute network. Simulation data were generated to assess the impact of autocorrelation inherent in these time-series data on CPA performance. The CUSUM CPA method was robust in detecting change points with respect to autocorrelation in time-series data (coverage rates at 90% when −0.2≤ρ≤0.2 and 80% when −0.5≤ρ≤0.5). During the 2008–9 season, 21 change points were detected and ILI trends increased significantly after 12 of these change points and decreased nine times. In the 2009–10 flu season, we detected 11 change points and ILI trends increased significantly after two of these change points and decreased nine times. Using CPA combined with EARS to analyze automatically daily ED-based ILI data, a significant increase was detected of 3% in ILI on April 27, 2009, followed by multiple anomalies in the ensuing days, suggesting the onset of the H1N1 pandemic in the four contiguous states.

Conclusions and significance

As a complementary approach to EARS and other aberration detection methods, the CPA method can be used as a tool to detect subtle changes in time-series data more effectively and determine the moving direction (ie, up, down, or stable) in ILI trends between change points. The combined use of EARS and CPA might greatly improve the accuracy of outbreak detection in syndromic surveillance systems.     

基于地级市区域卫生信息平台的疾病主动监测系统设计

阐述基于地级市区域卫生信息平台的疾病主动监测系统设计思路、整体架构和主要功能,包括症候群监测、法定传染病监测、慢病监测、统计分析和报告管理等,对系统应用效果和存在的问题进行探讨,指出系统有助于降低漏报率,提高疾病监测的质量和效率。     

Electronic health record–based disease surveillance systems: A systematic literature review on challenges and solutions

ObjectiveDisease surveillance systems are expanding using electronic health records (EHRs). However, there are many challenges in this regard. In the present study, the solutions and challenges of implementing EHR-based disease surveillance systems (EHR-DS) have been reviewed.Materials and MethodsWe searched the related keywords in ProQuest, PubMed, Web of Science, Cochrane Library, Embase, and Scopus. Then, we assessed and selected articles using the inclusion and exclusion criteria and, finally, classified the identified solutions and challenges.ResultsFinally, 50 studies were included, and 52 unique solutions and 47 challenges were organized into 6 main themes (policy and regulatory, technical, management, standardization, financial, and data quality). The results indicate that due to the multifaceted nature of the challenges, the implementation of EHR-DS is not low cost and easy to implement and requires a variety of interventions. On the one hand, the most common challenges include the need to invest significant time and resources; the poor data quality in EHRs; difficulty in analyzing, cleaning, and accessing unstructured data; data privacy and security; and the lack of interoperability standards. On the other hand, the most common solutions are the use of natural language processing and machine learning algorithms for unstructured data; the use of appropriate technical solutions for data retrieval, extraction, identification, and visualization; the collaboration of health and clinical departments to access data; standardizing EHR content for public health; and using a unique health identifier for individuals.ConclusionsEHR systems have an important role in modernizing disease surveillance systems. However, there are many problems and challenges facing the development and implementation of EHR-DS that need to be appropriately addressed.     

基层医疗卫生机构设置发热哨点诊室的建议与思考

基层医疗卫生机构在突发公共卫生事件应急网络中起到“网底”的作用。在基层医疗卫生机构设置发热哨点诊室有利于实现突发公共卫生事件和发热诊室“早发现、早诊断、早隔离和及时上报”,从而控制疫情进展。目前,我国正在加紧基层医疗卫生机构发热哨点诊室的建设,对其建设标准和职能有了初步的规定。根据相关文件要求,基层医疗卫生机构发热哨点诊室的最低标准应包括建设布局、硬件和软件配置三方面的内容,针对目前基层医疗卫生机构普遍存在的问题,应加强社区卫生应急体系建设、广泛开展人员培训与工作督导、建设便捷通畅的信息网络,规范建设发热哨点诊室并实施持续性运行管理,才能有效发挥发热哨点诊室的作用,使之在公共卫生事件应急体系中发挥重要的“网底”作用。     

北京市西城区中学传染病症状监测预警系统研究

目的摸索建立西城区中学传染病症状监测预警系统的方法以及对传染病早期预警的意义。方法通过监测网络收集监测点每日学生因病缺勤、发热、腹泻情况，观察其时间和空间聚集性。结果成功构建症状监测预警系统，共监测学生因病缺勤、发热、腹泻病例分别为1152例，636例和285例；12月份是中学生出现发热症状的高峰时段；监测系统发现1起聚集性预警事件。结论该监测系统能够及时反映中学生因病缺勤、发热、腹泻等情况在时间和空间上的聚集性，对学生传染病早期预警具有一定的意义。     

大力加强我国公共卫生突发事件主动监测系统的研究

我国公共卫生突发事件的主动监测基本结构应该包括医院急诊室病例监测和症状监测、公共卫生实验室对病原体的检测、药品和医疗相关物品销售监测、大城市人群症状监测、中小学生缺课监测、动物死亡监测、120呼救电话监测和不明原因死亡病例的监测等.主动监测为及时发现公共卫生突发事件、启动成本效益合理的应急反应提供重要依据,是公共卫生危机管理的核心内容之一.因此,必须大力加强我国公共卫生突发事件主动监测系统的研究.     

Syndromic Surveillance Using Ambulatory Electronic Health Records

Objective

To assess the performance of electronic health record data for syndromic surveillance and to assess the feasibility of broadly distributed surveillance.

Design

Two systems were developed to identify influenza-like illness and gastrointestinal infectious disease in ambulatory electronic health record data from a network of community health centers. The first system used queries on structured data and was designed for this specific electronic health record. The second used natural language processing of narrative data, but its queries were developed independently from this health record. Both were compared to influenza isolates and to a verified emergency department chief complaint surveillance system.

Measurements

Lagged cross-correlation and graphs of the three time series.

Results

For influenza-like illness, both the structured and narrative data correlated well with the influenza isolates and with the emergency department data, achieving cross-correlations of 0.89 (structured) and 0.84 (narrative) for isolates and 0.93 and 0.89 for emergency department data, and having similar peaks during influenza season. For gastrointestinal infectious disease, the structured data correlated fairly well with the emergency department data (0.81) with a similar peak, but the narrative data correlated less well (0.47).

Conclusions

It is feasible to use electronic health records for syndromic surveillance. The structured data performed best but required knowledge engineering to match the health record data to the queries. The narrative data illustrated the potential performance of a broadly disseminated system and achieved mixed results.     

EARS在北京市流感大流行预警中的应用

目的：阐明累积和法用于北京市流感暴发预警的有效性。方法:应用基于累积和算法的早期异常报告系统（early aberration reporting system, EARS）对北京市流感样病例监测数据进行预警分析,以流感病原学监测结果作为判断流感高峰来临的金标准。 结果:2009年至2010年北京市共有421家医院开展了流感样病例监测,7家网络实验室开展了流感病原学监测。2009年6月至2010年4月,421家医院的平均流感样病例百分比为2.56%,共在11家医院采集流感样病例咽拭子19 262份,分离流感病毒5 045株,以新甲型H1N1流感病毒为主。使用累积和法对北京市二级以上医院流感样病例监测数据进行分析较好地预警了流感高峰的来临。结论:应用累积和法对北京市流感监测数据进行分析,可以高效准确地对流感高峰进行预警。     

Towards a global antibiotic resistance surveillance system: a primer for a roadmap

The need for global data about the scale of antibiotic resistance (ABR) in a geographical explicit and timely manner has been identified by many stakeholders, including the World Health Organization. This primer should help defining the objectives, scale, scope, and structure of possible future efforts. Stakeholders and their expected information demands were identified to generate an inventory of surveillance objectives. For simplification, an original approach was chosen to bundle sets of objectives that represent common demands and can be addressed by common subject areas, which fall into three areas. Subject area I addresses clinical demands and focuses on patients; subject area II addresses public health demands by focusing on meta-populations; subject area III addresses infection control demands and focuses on pathogens. A division into these areas leads to a separation of surveillance activities suggesting a modular approach which can provide complementary information. Moreover, the modules address the conundrum of ABR at the complementary levels of 1) patient, 2) population, and 3) pathogen, which—rather conventionally—follow the operational and professional fault-lines of the main disciplines involved, namely clinical medicine, public health, and biology. Essential features that define different surveillance systems have been listed and taken into consideration when suggesting templates for future efforts. Putting ABR on the global health map is a daunting task as it requires acceptance, agreements, and engagement but also concessions at many different levels. Given the existing gaps in the global diagnostic service landscape only a step-wise approach which defines achievable aims, objectives, and milestones will succeed to produce a sustainable system of international co-operative surveillance of ABR.     

上海市长宁区中小学及幼儿园传染病症状监测结果的初步分析

 目的 探索建立上海市长宁区中小学及幼儿园传染病症状监测预警系统的方法,实现早期预警。方法 通过监测网络收集监测点每日学生因病缺课及流感样综合征、发热呼吸道综合征、腹泻综合征、麻疹样病例综合征的发生情况。结果 成功构建中小学及幼儿园传染病症状监测预警信息系统,2007年9月至2008年6月间长宁区中小学及幼儿园监测点学生共缺课1 094人次,其中因流感样症状缺课的占39%,因发热呼吸道症状缺课的占49%,因麻疹样病例症状缺课的占2%,因腹泻症状缺课的占10%。监测数据提示,流感、发热及呼吸道疾病仍然是学生缺课的主要原因,主要高发于新学年开学之初、秋冬之交及初春。结论 学校传染病症状监测预警系统能及早发现校园突发公共卫生事件,对于控制疫情、制定有针对性的控制措施有非常重要的意义。     

我国基层医疗卫生机构发热诊室设置与利用情况调查研究

背景　新型冠状病毒肺炎（简称新冠肺炎）疫情防控期间,基层医疗卫生机构发热诊室设置是一项重要的经验总结与尝试,目前发热诊室试点工作已开展一年有余,分析其运行情况十分必要。目的　调查基层医疗卫生机构发热诊室的设置与利用情况,总结经验并提出相应建议。方法　于2021-02-22至2021-03-02,采用多阶段抽样法,选取基层医疗卫生机构（社区卫生服务中心/乡镇卫生院）全程参与新冠肺炎疫情防控工作的主要负责人员开展问卷调查,调查其所在机构是否开设了发热诊室〔包括疫情防控期间设置的发热（哨点）诊室和疫情防控前设置的发热门诊〕,以及累计使用时间、累计接诊人次、累计转诊率、累计确诊人次。结果　最终回收有效问卷718份,来自408家基层医疗卫生机构。其中,在新冠肺炎疫情防控期间开设了发热诊室的机构208家（51.0%）,在新冠肺炎疫情防控之前已开设的机构91家（22.3%）,一直未开设的机构109家（26.7%）。271例应答者参与了发热诊室工作。根据该271份问卷：截至2021年1月底,发热诊室的中位累计使用时间为12（10）个月;188例（69.4%）应答者表示累计接诊人次<300人次,45例（16.6%）应答者表示累计接诊人次>1 000人次;184例（67.9%）应答者表示累计转诊率<3%,35例（12.9%）应答者表示累计转诊率>70%;238例（87.8%）应答者表示接诊的所有患者中最终确诊为新冠肺炎的人数为0例。χ2检验结果显示：新冠肺炎疫情防控期间开设发热诊室与疫情防控之前开设发热诊室的累计接诊人次比较,差异有统计学意义（P<0.05）;但不同地区（包括按经济带划分、按本城市内地理位置划分、按所属地区疫情期间最高风险等级划分）发热诊室的累计接诊人次、累计转诊率、累计确诊人次比较,差异无统计学意义（P>0.05）。Spearman秩相关分析结果显示,发热诊室的设置时间与累计使用时间、累计接诊人次呈正相关（rs值分别为0.37、0.18,P<0.05）,按经济带划分地区（东、中、西部）与累计确诊人次呈正相关（rs=0.13,P<0.05）。结论　超2/3的基层医疗卫生机构在新冠肺炎疫情防控期间或之前设置了发热诊室/门诊。不同地区因素的发热诊室在累计接诊人次、累计转诊率、累计确诊人次方面无明显差异。新冠肺炎疫情防控之前开设发热门诊的接诊工作量高于新冠肺炎疫情防控期间设置的发热（哨点）诊室,表明基层医疗卫生机构具有一定处置发热患者的工作潜力。     

北京某区医院的突发事件监测情况调查

目的:了解医院突发事件监测机构的设置及相关监测内容,为寻找合理的监测指标、完善医院日常监测、建立突发事件监测系统提供科学依据.方法:选取北京某区医院为研究现场,对该区所有二级和三级医院(共计15所)进行问卷调查,并回顾门/急诊量的变化及药品销售量情况.结果:53.3%的医院现行监测机构设在门/急诊,其余设在其他部门.三级医院监测资料分析周期为每周,二级医院为每月.15所医院不同程度地对就诊人员的性别、年龄、职业等11项内容实施监测.2002年和2003年的1～6月门/急诊量变化趋势以3月份为分界点,3月份之前基本一致;2003年3月份后的门/急诊量开始与2002年的曲线分离.SARS流行期间对比往年同期水平销售量增幅最大的药品依次为抗病毒类药、抗生素类药、中药、免疫制剂.结论:门急诊是医院的重点监测部门,监测项目中的人群特征不可忽视.医院门/急诊量及药品销售变化对突发事件具有警示作用,是亟待挖掘的监测指标.     

学校症状监测信息系统的建立与运作情况分析

目的对佛山市学校症状监测信息系统的建立与运作情况进行分析评价。探讨在学校传染病疫情预防控制中发挥的作用。方法开发“学生健康监护信息系统”，从2007年1月1日起，学校通过信息系统网络报告因病缺勤、发热、腹泻、呕吐、咳嗽、皮疹、红眼症等7个症状指标数据以及异常情况事件。结果113间中小学校及托幼机构加入该监测信息系统，2007年1～50周，109间（占96.46％）学校及托幼机构坚持每周及时上报症状监测信息；57间（占50．4％）学校及托幼机构报告基于爆发疫情早期的异常情况事件498起，平均每起小事件报告病例2．5例。结论学校症状监测信息系统在本地区成功建立并正常运作，对中小学校及托幼机构传染病预防控制及疫情早期预警防控起到了积极的作用。     

基于健康体检的居民健康档案

介绍健康体检档案的特点,研究基于健康体检的健康档案数据组织、归集方式,阐述数据项收集标准,介绍健康档案构成,包括受检者基本信息、病史信息、临床物理检查、化验检查、影像检查信息等,最后给出体检信息采集与综合管理系统架购。     

Responsibility for health: personal, social, and environmental

Most of the discussion in bioethics and health policy concerning social responsibility for health has focused on society's obligation to provide access to healthcare. While ensuring access to healthcare is an important social responsibility, societies can promote health in many other ways, such as through sanitation, pollution control, food and drug safety, health education, disease surveillance, urban planning and occupational health. Greater attention should be paid to strategies for health promotion other than access to healthcare, such as environmental and public health and health research.     

An overview of disease surveillance and notification system in Nigeria and the roles of clinicians in disease outbreak prevention and control

While outbreaks of infectious diseases have long presented a public health challenge, especially in developing countries like Nigeria; within recent years, the frequency of such outbreaks has risen tremendously. Furthermore, with the recent outbreaks of emerging and re-emerging infectious diseases such as Ebola virus disease and other epidemic prone diseases in Nigeria demanding immediate public health action, there is a need to strengthen the existing notifiable disease surveillance and notification system with increased clinicians’ involvement in timely reporting of notifiable diseases to designated public health authorities for prompt public health action. Hence, this paper provides the opportunity to increase awareness among clinicians on the importance of immediate reporting of notifiable diseases and intensify engagement of clinicians in disease notification activities by describing various notifiable diseases in Nigeria using their surveillance case definition, outlines the reporting channel for notifying these diseases and highlights the roles of clinicians in the current disease surveillance and notification network for early disease outbreak detection and public health response in Nigeria.     

医院信息系统与突发公共卫生事件

在对目前国家卫生防疫信息网络系统进行大致分析的基础上,就医院信息系统灵活性的设计和建设基于医院信息系统的突发公共卫生事件监测、预警系统进行了论述.建议由国家出面尽快以专项课题的方式组织实施建设基于医院信息系统的突发公共卫生事件监测、预警系统,以利于在最高的层面上实现统一领导,整合优势资源,有效解决实现标准化最需要的权威性问题,避免低水平的重复.     

The Value of Patient Self-report for Disease Surveillance

Objective

To determine the accuracy of self-reported information from patients and families for use in a disease surveillance system.

Design

Patients and their parents presenting to the emergency department (ED) waiting room of an urban, tertiary care children’s hospital were asked to use a Self-Report Tool, which consisted of a questionnaire asking questions related to the subjects’ current illness.

Measurements

The sensitivity and specificity of three data sources for assigning patients to disease categories was measured: the ED chief complaint, physician diagnostic coding, and the completed Self-Report Tool. The gold standard metric for comparison was a medical record abstraction.

Results

A total of 936 subjects were enrolled. Compared to ED chief complaints, the Self-Report Tool was more than twice as sensitive in identifying respiratory illnesses (Rate ratio [RR]: 2.10, 95% confidence interval [CI] 1.81–2.44), and dermatological problems (RR: 2.23, 95% CI 1.56–3.17), as well as significantly more sensitive in detecting fever (RR: 1.90, 95% CI 1.67–2.17), gastrointestinal problems (RR: 1.10, 95% CI 1.00–1.20), and injuries (RR: 1.16, 95% CI 1.08–1.24). Sensitivities were also significantly higher when the Self-Report Tool performance was compared to diagnostic codes, with a sensitivity rate ratio of 4.42 (95% CI 3.45–5.68) for fever, 1.70 (95% CI 1.49–1.93) for respiratory problems, 1.15 (95% CI 1.04–1.27) for gastrointestinal problems, 2.02 (95% CI 1.42–2.87) for dermatologic problems, and 1.06 (95% CI 1.01–1.11) for injuries.

Conclusions

Disease category assignment based on patient-reported information was significantly more sensitive in correctly identifying a disease category than data currently used by national and regional disease surveillance systems.     

传染病监测系统症状监测模块发展策略研究

通过文献调研梳理我国传染病监测系统建设情况,以SWOT方法分析现阶段传染病监测系统症状监测模块建设发展的优势、劣势、机遇和挑战,提出相关建议,为进一步完善我国传染病监测系统提供参考。     

2001～2003年苏州市区职业性健康监护和新诊职业病例特点分析

①目的　分析近 3年苏州市职业性健康监护和新诊断职业病例的特点及原因。②方法　对 2 0 0 0年 1 1月～ 2 0 0 3年 1 0月苏州市职业健康监护和新诊断职业病例的构成、所属企业性质及监护结果和新诊职业病例间的关系进行分析。③结果　近 3年来 ,苏州市职业健康监护的企业受检率 ,国有企业 >三资企业 >个私企业。职业性疑似病例国有企业居多 ,但新增职业病例以个私企业最多。④结论　国企的职业病防治工作相对比较有效 ,健康监护的阳性率所占比例明显减少 ,三资和个私企业的健康监护率较低 ,个私企业新诊病例所占比例升高 ,应加强三资和个私企业的职业卫生工作。