Alan J. Siniscalchi, MPH, MS Influenza & Bioterrorism Surveillance CoordinatorState of Connecticut Department of Public Health& the International Society for Disease Surveillance(ISDS) Public Health Practice CommitteeWednesday, December 4, 2013

BioSense 2.0 Webinar: Panel on ILI Surveillance ILI Surveillance in Connecticut

Presentation Objectives To outline the types of surveillance systems designed for detecting influenza, bioterrorism agents, and emerging infections in ConnecticutTo describehow these systems have been used to track ILI and flu-associated morbidity and mortality throughout the stateTo discuss which surveillance systems provide the best value for use in the identification and tracking of influenza outbreaks To emphasize the value of providing real-time data in assessing risk, reducing exposure, and preventing disease

Surveillance Objectives: Why should health departments conduct ongoing surveillance for seasonal influenza & emerging diseases? Situational Awareness (to detect and track emerging agents and disease activity)Health Professional Awareness and Asset Management (to provide necessary information for optimal use of vaccine supplies, etc.)Public Education & Risk Communication (to provide sufficient information to members of the public to enable them to make informed choices)

Surveillance Systems in Connecticut by Category (arranged by group and speed of detection): How soon do you want to know? Group 7. Mortality Surveillance: 122 Cities, Pediatric mortality Group 6. Traditional Laboratory Surveillance: Flu subtypes Group 5. Reportable Disease Surveillance: State & federalGroup 4. Special Hospitalization & Laboratory Surveillance: Flu-associated hospitalizations, GPR testing for anthraxGroup 3. Other Surveillance: Institutional outbreaksValue: These provide important, but slow (many days after exposure) information on the etiological agent & characterization of the disease and risk factors.

.

Surveillance Systems in Connecticut, cont. Group 2. Syndromic Surveillance (early symptoms, hours days after exposure): These systems measure ILI before diagnosis and laboratory confirmation, including ILINet outpatient providers; the CT Hospital Admissions Syndromic Surveillance (HASS) System, established in all 32 CT acute care hospital campuses following September 11, 2001; the CT Hospital Emergency Department Syndromic Surveillance (HEDSS) System, in operation since 2004; BioSense & othersValue: For situational awareness & rapid identification and tracking of severe outbreaks & epidemics.

Surveillance Systems in Connecticut, cont.Group 1. Remote Collection & Sensing Surveillance (dispersal, before widespread exposure): A variety of state and federal systems are available for real-time detection of bioterrorist agents. Remote thermal imagining systems can be used in airports and other transportation centers to detect travelers with influenza and other febrile illness. Value: Development and implementation of an expanded network of thermal imaging and other automated remote sensing systems would provide early detection and management of imported cases.

Chart3

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1213493100378

1101573000293

752503200241

220193000102

519600051

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302400012

10120004

0180005

201200017

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32700012

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12190007

1113900015

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561273000256

2302549000627

2602698110858

2243529010740

1465297000440

410141001213

19178000115

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Type Unknown

Type B Seasonal

Type A (Unspecified)

Type A (H3N2) Seasonal

Type A (H1N1) Seasonal

Type A (Unsubtypeable)

Type A (H1N1) Novel 2009

MMWR Week (April 2009 - May 2010)

No. Tests Reported

Figure 1. Laboratory Confirmed Tests by Influenza Type and Subtype During the 2009 Influenza A (H1N1) Pandemic in Connecticut

Sheet2

Fig. 1 Lab Confirmed Tests By Type/Subtype: Weeks 15 (2009) thru Week 23 (2010) (05/21/2010 Update)

MMWR WeekReported TestsCalc.ActualMMWR Week

2009-10 DatesType A (H1N1) Novel 2009Type A (Unsubtypeable)Type A (H1N1) SeasonalType A (H3N2) SeasonalType A (Unspecified)Type B SeasonalType UnknownTotalTotals

04/12/2009-04/18/20091500103509915

04/19/2009-04/25/20091601013106616

04/26/2009-05/02/20091719014353416111911917

05/03/2009-05/09/2009182605172324777718

05/10/2009-05/16/200919440229260210310319

05/17/2009-05/23/2009201690114621224924920

05/24/2009-05/30/200921220006980633033021

05/31/2009-06/06/2009229800141305356556522

06/07/2009-06/13/200923378001493312199699623

06/14/2009-06/20/200924293000573111097797724

06/21/2009-06/27/20092524100250327582382325

06/28/2009-07/04/20092610200019302231731726

07/05/2009-07/11/20092751000961515315327

07/12/2009-07/18/200928440003914888828

07/19/2009-07/25/200929140003812555529

07/26/2009-08/01/200930120002403393930

08/02/2009-08/08/20093140001201171731

08/09/2009-08/15/2009325000810141432

08/16/2009-08/22/200933170001202313133

08/23/2009-08/29/2009349000201121234

08/30/2009-09/05/2009358000700151535

09/04/2009-09/12/20093650001403222236

09/13/2209-09/19/20093712000723242437

09/20/2009-09/26/20093850001803262638

09/27/2009-10/03/20093970001921292939

10/04/2009-10/10/2009401500039111666640

10/11/2009-10/17/20094143000832213013041

10/18/2009-10/24/20094225600027315658658642

10/25/2009-10/31/20094362700054922301408140843

11/01/2009-11/07/20094485801169822601820182044

11/08/2009-11/14/20094574001052932241497149745

11/15/2009-11/21/200946440000297514688888846

11/22/2009-11/28/20094721310014104139639647

11/29/2009-12/05/2009481150007811921321348

12/06/2009-12/12/2009493000037113818149

12/13/2009-12/19/200950230001704444450

12/20/2009/12/26/200951150001111282851

12/27/2009-01/02/20105217000700242452

01/03/2010-01/09/201011300070323231

01/10/2010-01/16/20102800020212122

01/17/2010-01/23/20103700070115153

01/24/2010-01/30/20104500041111114

01/31/2010-02/06/201058000102121215

02/07/2010-02/13/201061300040017176

02/14/2010-02/20/201071100001012127

02/21/2010-02/27/201086000201998

02/28/2010-03/06/201094000300779

03/07/2010-03/13/20101030000003310

03/14/2010-03/20/20101100011002211

03/21/2010-03/27/20101210001002212

03/28/2010-04/03/20101300002002213

04/04/2010-04/10/20101401001002214

04/11/2010-04/17/20101510000001115

04/18/2010-04/24/20101600001001116

04/25/2010-05/01/20101700000000017

05/02/2010-05/08/20101850000005518

05/09/2010-05/15/20101910000001119

05/16/2010-05/22/20102000000000020

05/23/2010-05/29/2010210000000021

05/30/2010-06/05/2010220000000022

06/06/2010-06/12/2010230000000023

YTD Totals:3541222288327102974867486YTD Totals:

Last report:00000000Last report:

Change:354122228832710297486Change:

Sheet3

*

Figure 2. CT ILINet Physician Provider % Influenza-like Illness (ILI) Visits vs. Hospital Emergency Department Syndromic Surveillance (HEDSS) System % Fever/Flu ED Visits (April 2009-April 2010)

MMWR Weeks (April 2009 April 2010)

*

Graph_Rates

3.78545006173.77605873874.1582830315

3.96000526254.29464906182.8764805415

3.84310618073.83382484933.355271648

3.96970807384.20537897314.0201654602

4.17374423684.14916634853.6916677499

3.995433794.30052476643.8905459733

4.35987903234.61313480464.0887226082

4.36979035114.37697659714.0033477472

4.26821235674.51440053583.7974683544

5.14388489214.64012654893.9300097209

5.15253423014.94648916734.1074474133

4.72704714644.14883962143.5153019024

5.0473186124.82305936073.7999441185

4.71665314644.135856623648

4.40126419294.666079738449

4.10204540355.032467532550

5.09911141495.743286650451

6.25600219517.784342688352

5.60576453359.4194072271

5.41769041777.10273374112

4.96417604916.54016445293

4.54035175256.14976805834

4.59572376516.121642975

5.181154944.81962481966

4.75328748945.10735611747

4.66718668754.62962962968

4.68888607274.89109169179

4.56719273084.231779836810

4.68629961594.839128178511

4.53240104884.628901127712

4.3803143524.446262956913

4.0010193685.082932049214

4.58250988144.888496913215

4.69739174475.210420841716

4.17876530744.42004504517

4.37763713084.267366385918

3.83405902274.375951293819

3.82173856724.259559098320

4.12729985084.590248962721

3.77111431194.049844236822

3.59749071823.95610350923

3.93208221633.60396039624

4.00793650794.430551780425

4.24283765353.921052631626

4.23752057053.28602480527

3.38528359733.549540347328

3.19162517553.421717171729

3.60906217072.980392156930

3.26440369363.027834351731

3.92857142863.309660994232

3.49367748663.255069370333

3.44513780553.368983957234

2011-12

2012-13

2013-14

MMWR week

Percent of total admissions

Figure 3: Connecticut Hospital Admissions Syndromic Surveillance (HASS) System, Percent of total statewide admissions for pneumonia; 2011-12, 2012-13, 2013-14

Data

2007-082008-092009-102010-112011-122012-132013-14

MMWR WEEKtotal admissionsPneumoniatotal admissionsPneumoniatotal admissionsPneumoniatotal admissionsPneumonia

####%#%#%#%

3522326426679092793.5381103073.7976272883.7874553104.16

3628925330471932653.6876013013.9671953094.2970922042.88

3727227835678462513.2075722913.8477992993.8377492603.36

3827524734584783143.7081873253.9781803444.2177363114.02

3930129232284223023.5982423444.1778573264.1576932843.69

4028729932780382953.6778843154.0078133364.3077113003.89

4128732532482203674.4679363464.3675223474.6174843064.09

4227635934780413284.0879183464.3779053464.3871692874.00

4328528438278303023.8675913244.2774653374.5171892733.80

4431934543481653183.8983404295.1475863524.6472012833.93

4533036445578463033.8683264295.1576623794.9570362894.11

4632135044880163474.3380603814.7377133204.1572542553.52

4730931837171503234.5269743525.0570083384.8271582723.80

4831934239983933524.1986294074.7279793304.14

4935939637580923264.0385433764.4079513714.67

5033135236685033514.1388983654.1080084035.03

5130634232269753304.7373153735.1077834475.74

5239338742875374846.4272894566.2667705277.78

137940844387585065.7881884595.6173896969.42

246537843179714645.8281404415.4280115697.10

341837940582014305.2478163884.9679055176.54

437137539082323584.3580173644.5475454646.15

537240342176403905.1081383744.6075964656.12

641745343087764294.8980874195.1869303344.82

746545643390394134.5782893944.7578714025.11

846742339683544265.1076923594.6772363354.63

949840342782724235.1178913704.6976673754.89

1049139136182443914.7483643824.5772313064.23

1143039634881554195.1478103664.6977083734.84

1240034238479414365.4980093634.5376263534.63

1341934635182483954.7977623404.3873323264.45

1440235137482723894.7078483144.0074763805.08

1535936931181744084.9980963714.5879373884.89

1630437132973203825.2278983714.7074853905.21

1731432633382553944.7779213314.1871043144.42

1830534132581023704.5775843324.3872413094.27

1928328830381533694.5382683173.8378843454.38

2029832231278523294.1977192953.8280293424.26

2130832033682323544.3080443324.1377123544.59

2235436129380033984.9776372883.7773832994.05

2332632927379973604.5078112813.6073812923.96

2431034627381233424.2178333083.9375752733.60

2527336527779213304.1775603034.0173583264.43

2629631223876482863.7473303114.2476002983.92

2729731525476683294.2972923094.2478212573.29

2825828925881303033.7378282653.3978322783.55

2927526828681702863.5078332503.1979202713.42

3025127125978672523.2075922743.6176502282.98

3126325123780072453.0676892513.2673652233.03

3224327221978982563.2478403083.9374632473.31

3322224126077552483.2076712683.4974962443.26

3424326224377153224.1776922653.4574802523.37

..

*

Figure 4. Temporal and Regional Trends during the Novel H1N1 Influenza Pandemic, Connecticut Hospital Emergency Department Syndromic Surveillance (HEDSS) System: Percent of ED visits for fever/flu syndrome category, April 12, 2009 April 24, 2010

Chart1

0.05542123860.04258339250.05351875260.04077761970.044315484

0.04916512060.03551136360.05337450370.04444444440.0465235174

0.10006615940.06799784130.09594496740.08142857140.0756123536

0.08277814790.05546955620.07552392250.07402361490.0641699018

0.07037614840.04397961920.04995871180.06648817490.0612435718

0.09883170190.0571955720.06849860610.06739032110.0723562152

0.11171056810.05826636050.0715378730.05913043480.0816411107

0.13919247120.06270967740.0939024390.07660359940.0877714286

0.15553536270.0927723840.0933601610.08890807080.0999555753

0.14680030840.11524522830.11315789470.09149209060.0872206025

0.12190049590.1129607610.1028618830.09122653860.0759162304

0.08027369830.07290886390.08373015870.07857142860.0660402685

0.06429691580.05344918380.07896924360.07009142360.0516802444

0.05380839850.0385789620.05623164080.05347593580.0471371505

0.04674945220.03840722960.05709107390.05712979890.0453212477

0.04947634530.04615809840.06177156180.04314259760.0414522584

0.05247597930.03821857230.04921339250.05392156860.0346496815

0.0559312740.04249370980.04622871050.04149184150.0419618529

0.04943032430.03670953910.02366863910.04616763780.0432291667

0.05373785450.03768020970.06258148630.05086245020.0356143475

0.05398410060.05225726650.05095026280.05239982390.0446941976

0.06189967980.04729546070.05154236630.05682289510.0438551759

0.06132243160.05622617530.06303939960.06720890410.0459117875

0.05574973790.05176533050.06980961020.06353944560.0463931349

0.05682931610.04671968190.05875347360.05942432680.0442825112

0.04906666670.0509612450.06739811910.06112132350.0454174599

0.06068292680.0509612450.07445887450.06322640630.0451977401

0.07008347890.08442710180.13749060860.09098824550.0625854058

0.09256868890.11179758750.21389459270.16368179930.0938656795

0.12777486450.14691702610.21886296420.20188161510.1387918123

0.15110585850.1702878870.1551661190.18623159570.1500353857

0.14360313320.12911795960.11588330630.11736263740.124252988

0.12448060940.09652628340.10020120720.10279488390.0970817683

0.10150238180.07671149140.07731092440.08304498270.0839520274

0.09175738720.05822368420.06287944490.06908548710.0554517134

0.07091254750.05670426070.07688744790.05809768640.0509080083

0.07520837370.05397251090.06990881460.06748140280.0659139457

0.07205806120.0672074160.06645187270.0540284360.0612984118

0.06928532460.05172923440.07077072220.05380059230.0500287522

0.06354515050.05070866140.06074140240.04850934820.0447849146

0.06522131890.05542658150.06337448560.05357989570.0539691605

0.06551724140.05204236010.06317473010.05805515240.0550979835

0.06879194630.0577213660.05901911890.06012950970.0602731591

0.05932510890.04902296880.0630888980.07068803020.0519633894

0.04886236480.04857055030.0584772370.05104305370.0495659479

0.05670407560.03932082220.05409836070.060.0469455311

0.05481309320.04726516050.04671280280.0545630130.0395480226

0.04962636520.04302627780.05244122970.0605370960.0392766318

0.04100946370.03832853030.05188488040.04510250570.0377875137

0.05437536540.0343750.05528089890.05121170550.0410882843

0.04581901490.03853839570.06027164690.04575786460.0422416221

0.05018753350.03823701110.05089576550.04622764940.0368841178

0.05359200920.03401162790.05111294310.04681046350.0423131171

Spring 2009 H1N1 Wave

Fall 2009 H1N1 Wave

Region 1

Region 5

Region 4

Region 3

Region 2

Region 1

Region 2

Region 3

Region 4

Region 5

MMWR Week

Sheet1

Region1Region2Region3Region4Region5

MMWRTotalFev/Flu%TotalFev/Flu%TotalFev/Flu%TotalFev/Flu%TotalFev/Flu%

1553772985.54%28181204.26%23731275.35%2109864.08%37911684.43%

1653902654.92%28161003.55%22671215.34%2205984.44%39121824.65%

17604660510.01%37062526.80%27622659.59%21001718.14%46953557.56%

1860044978.28%38762155.55%25291917.55%22021637.40%43792816.42%

1957694067.04%37291644.40%24221215.00%22411496.65%42782626.12%

2063346269.88%37942175.72%25111726.85%22111496.74%43123127.24%

21630270411.17%34842035.83%26141877.15%23001365.91%48263948.16%

22658891713.92%38752436.27%24602319.39%21671667.66%43753848.78%

236603102715.55%37083449.28%24852329.34%23172068.89%450245010.00%

24648595214.68%413947711.52%266030111.32%23392149.15%41163598.72%

25625176212.19%336438011.30%241124810.29%22912099.12%38202907.59%

2659924818.03%40052927.29%25202118.37%23801877.86%37252466.60%

2757393696.43%37982035.34%24061907.90%22971617.01%39282035.17%

2855012965.38%36031393.86%23831345.62%22441205.35%37551774.71%

2954762564.67%35411363.84%22071265.71%21881255.71%37511704.53%

3055382744.95%36181674.62%25741596.18%2202954.31%34981454.15%

3154122845.25%31661213.82%24791224.92%22441215.39%39251363.46%

3254713065.59%35771524.25%24661144.62%2145894.15%36701544.20%

3357052824.94%37321373.67%2028482.37%22311034.62%38401664.32%

3450432715.37%30521153.77%23011446.26%22611155.09%39311403.56%

3554092925.40%32341695.23%24731265.10%22711195.24%38261714.47%

3656223486.19%36791744.73%25611325.15%24111375.68%39221724.39%

3756263456.13%31481775.62%26651686.30%23361576.72%38771784.59%

3857223195.57%37671955.18%22061546.98%23451496.35%37291734.64%

3951032905.68%30181414.67%25191485.88%21541285.94%35681584.43%

4056252764.91%32771675.10%25521726.74%21761336.11%36771674.54%

4151253116.07%32771675.10%23101727.45%21511366.32%35401604.52%

4251513617.01%28192388.44%266236613.75%22972099.10%36592296.26%

4354235029.26%339938011.18%292262521.39%240139316.37%37823559.39%

44572173112.78%394157914.69%304366621.89%255151520.19%400655613.88%

45592389515.11%368262717.03%273942515.52%251346818.62%423963615.00%

46612888014.36%376448612.91%246828611.59%227526711.74%401649912.43%

47577671912.45%32533149.65%248524910.02%211121710.28%34613369.71%

48545855410.15%32722517.67%23801847.73%20231688.30%35022948.40%

4951444729.18%30401775.82%23061456.29%20121396.91%32101785.55%

5052603737.09%31921815.67%21591667.69%19451135.81%33591715.09%

5151593887.52%29831615.40%23031616.99%18821276.75%32772166.59%

5257874177.21%34522326.72%24831656.65%21101145.40%35892206.13%

154993816.93%33831755.17%20631467.08%20261095.38%34781745.00%

253823426.35%31751615.07%22391366.07%1979964.85%33941524.48%

355353616.52%34461915.54%24301546.34%21091135.36%35021895.40%

455103616.55%33051725.20%25011586.32%20671205.81%35211945.51%

553643696.88%33091915.77%24061425.90%21621306.01%33682036.03%

655123275.93%29171434.90%24411546.31%21221507.07%33871765.20%

753622624.89%32531584.86%25481495.85%22531155.10%35711774.96%

850792885.67%33571323.93%24401325.41%21501296.00%33231564.69%

951632835.48%33641594.73%23121084.67%20711135.46%33631333.95%

1052192594.96%34631494.30%22121165.24%21971336.05%35391393.93%

1153892214.10%34701333.83%24671285.19%2195994.51%36521383.78%

1251312795.44%35201213.44%22251235.53%21871125.12%36021484.11%

1352382404.58%35031353.85%23561426.03%2098964.58%35511504.22%

1455992815.02%34261313.82%24561255.09%22931064.62%36331343.69%

1552062795.36%34401173.40%24261245.11%21791024.68%35451504.23%

Conclusions and Recommendations Various syndromic and other advanced surveillance systems all provide valuable data useful for state and local jurisdiction efforts to detect outbreaks, identify emerging disease, and track influenza The value of ED-based and other syndromic surveillance systems in providing real-time data cannot be understatedContinued efforts to automate these systems will also reduce the demand on increasingly limited public agency resources and allow agencies to maintain a wide network of systems resulting in a superior level of public health preparedness

Acknowledgements The CT DPH Influenza & BT Surveillance Teams (2003 - present): Zygmunt F. Dembek, PhD, MS, MPH*; Maria T. Andrews, MPH*; Roxanne Ryan*; Sara A. Niesobecki, MS* & other interns; Brenda Esponda, BS, BA; Jianxin Sun, MD, PhD; Amanda Morrison, MPH*; Stephanie Petrahai, MPH*; & Nancy Barrett, MS, MPH; Susan Petit, MPH, Heather Altier, BA; Zack Fraser, BS; Field Epidemiologists: Jessica Brockmeyer, MPH; Kasia Frenette, MPH*; Paul Gacek, MPH; Jaime Krasnitski, MPH; Lisa LoBianco Pippa, MPH*; Ava Nepaul, MPH*; Katherine M. Purviance, MPH*; Kristen Soto, MPH; along with Terry Rabatsky-Ehr, MPH; Randall S. Nelson, DVM, MPH; Pat Mshar, MPH*; & Matthew L. Cartter, MD, MPH; Lynn Sosa-Bergeron, MD; James L. Hadler, MD, MPH*; CDC EIS Officers; & lab support by Tim Brennan, Diane Barden, & others; (*former team member) Questions? alan.siniscalchi@ct.gov

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