Disease surveillance is an integral part of public health. These systems monitor disease trends and detect outbreaks, whereas they should be evaluated for efficacy. The United States Centres for Disease Control and Prevention publish Guidelines for Evaluating Surveillance Systems to encourage efficient and effective use of public health surveillance that are accepted worldwide.

This study reviews syndromic surveillance during natural and man-made disasters internationally. It aims to (1) review the performance of syndromic surveillance via pre-specified attributes during disaster and to (2) understand its strengths and limitations.

PubMed was systematically searched for the articles assessing syndromic surveillance during a disaster. A narrative review was carried out based on those articles. Updated Guidelines for Evaluating Public Health Surveillance Systems were used to review performance of systems.

5,059 studies from PubMed were evaluated, and 16 met inclusion criteria. The majority of these studies considered the implementation of syndromic surveillance useable during disaster events. Studies described systems giving relevant and timely information. Simplicity and timeliness were the most highlighted attributes.

Syndromic surveillance is simple, flexible, useful and usable during a disaster. Timely data can be obtained, but the quality of this type of data is sensitive to incomplete and erroneous reporting; because of this, a standardized approach is necessary to optimize these systems.

The 2017 solar eclipse was associated with mass gatherings in many of the 14 states along the path of totality. The Kentucky Department for Public Health implemented an enhanced syndromic surveillance system to detect increases in emergency department (ED) visits and other health care needs near Hopkinsville, Kentucky, where the point of greatest eclipse occurred.

EDs flagged visits of patients who participated in eclipse events from August 17–22. Data from 14 area emergency medical services and 26 first-aid stations were also monitored to detect health-related events occurring during the eclipse period.

Forty-four potential eclipse event-related visits were identified, primarily injuries, gastrointestinal illness, and heat-related illness. First-aid stations and emergency medical services commonly attended to patients with pain and heat-related illness.

Kentucky’s experience during the eclipse demonstrated the value of patient visit flagging to describe the disease burden during a mass gathering and to investigate epidemiological links between cases. A close collaboration between public health authorities within and across jurisdictions, health information exchanges, hospitals, and other first-response care providers will optimize health surveillance activities before, during, and after mass gatherings.

In the French mainland administrative region Nouvelle-Aquitaine, syndromic surveillance is based on hospital emergency data, mortality data, and data from associations belonging to the SOS Médecins network. The aim of the present article is to describe the functioning of this network and to illustrate its use for syndromic surveillance in Nouvelle-Aquitaine.

The SOS Médecins network participates in the syndromic surveillance system SurSaUD, developed by Santé publique France (SpF; the French National Public Health Agency; Saint-Maurice, Paris, France). Near real-time data are automatically transmitted daily to a data server and analyzed by SpF’s Nouvelle Aquitaine’s regional unit to identify, monitor, and evaluate the impact of expected and unexpected health events in the region.

The SOS Médecins network has five local associations spread across the region with 146 participating physicians. Data have been recorded for more than 10 years and represented nearly 481,000 visits in 2017. The resulting database has helped to identify and monitor seasonal epidemics and unexpected events, as well as measure the health impact of these events.

The data from the SOS Médecins network are an essential source in syndromic surveillance. They complement surveillance data from other sources. More specifically, mortality and emergency unit traffic reflect the most severe cases, while SOS Médecins data help early detection of epidemics and health events in the general population. The network has shown its responsiveness and its reliability, not only for the surveillance of seasonal epidemics, but also for the detection of unusual signals. It therefore constitutes an essential link in syndromic surveillance in France, and specifically in the Nouvelle-Aquitaine region.

Syndromic surveillance has been useful for routine surveillance on a variety of health outcomes and for informing situational awareness during public health emergencies. Following the landfall of Hurricane Maria in 2017, the New York City (NYC) Department of Health and Mental Hygiene (DOHMH) implemented an enhanced syndromic surveillance system to characterize related emergency department (ED) visits.

ED visits with any mention of specific key words (“Puerto,” “Rico,” “hurricane,” “Maria”) in the ED chief complaint or Puerto Rico patient home Zip Code were identified from the DOHMH syndromic surveillance system in the 8-week window leading up to and following landfall. Visit volume comparisons pre- and post-Hurricane Maria were performed using Fisher’s exact test.

Analyses identified an overall increase in NYC ED utilization relating to Puerto Rico following Hurricane Maria landfall. In particular, there was a small but significant increase in visits involving a medication refill or essential medical equipment. Visits for other outcomes, such as mental illness, also increased, but the differences were not statistically significant.

Gaining this situational awareness of medical service use was informative following Hurricane Maria, and, following any natural disaster, the same surveillance methods could be easily established to aid an effective emergency response.

Hurricane Maria caused catastrophic damage in Puerto Rico, increasing the risk for morbidity and mortality in the post-impact period. We aimed to establish a syndromic surveillance system to describe the number and type of visits at 2 emergency health-care settings in the same hospital system in Ponce, Puerto Rico.

We implemented a hurricane surveillance system by interviewing patients with a short questionnaire about the reason for visit at a hospital emergency department and associated urgent care clinic in the 6 mo after Hurricane Maria. We then evaluated the system by comparing findings with data from the electronic medical record (EMR) system for the same time period.

The hurricane surveillance system captured information from 5116 participants across the 2 sites, representing 17% of all visits captured in the EMR for the same period. Most visits were associated with acute illness/symptoms (79%), followed by injury (11%). The hurricane surveillance and EMR data were similar, proportionally, by sex, age, and visit category.

The hurricane surveillance system provided timely and representative data about the number and type of visits at 2 sites. This system, or an adapted version using available electronic data, should be considered in future disaster settings.

The aim of this study was to describe individuals seeking care for injury at a major emergency department (ED) in southern Puerto Rico in the months after Hurricane Maria on September 20, 2017.

After informed consent, we used a modified version of the Natural Disaster Morbidity Surveillance Form to determine why patients were visiting the ED during October 16, 2017–March 28, 2018. We analyzed visits where injury was reported as the primary reason for visit and whether it was hurricane-related.

Among 5 116 patients, 573 (11%) reported injury as the primary reason for a visit. Of these, 10% were hurricane-related visits. The most common types of injuries were abrasions, lacerations, and cuts (43% of all injury visits and 50% of hurricane-related visits). The most common mechanisms of injury were falls, slips, trips (268, 47%), and being hit by/or against an object (88, 15%). Most injury visits occurred during the first 3 months after the hurricane.

Surveillance after Hurricane Maria identified injury as the reason for a visit for about 1 in 10 patients visiting the ED, providing evidence on the patterns of injuries in the months following a hurricane. Public health and emergency providers can use this information to anticipate health care needs after a disaster.

In January 2017, Washington, DC, hosted the 58th United States presidential inauguration. The DC Department of Health leveraged multiple health surveillance approaches, including syndromic surveillance (human and animal) and medical aid station–based patient tracking, to detect disease and injury associated with this mass gathering.

Patient data were collected from a regional syndromic surveillance system, medical aid stations, and an internet-based emergency department reporting system. Animal health data were collected from DC veterinary facilities.

Of 174 703 chief complaints from human syndromic data, there were 6 inauguration-related alerts. Inauguration attendees who visited aid stations (n = 162) and emergency departments (n = 180) most commonly reported feeling faint/dizzy (n = 29; 17.9%) and pain/cramps (n = 34;18.9%). In animals, of 533 clinical signs reported, most were gastrointestinal (n = 237; 44.5%) and occurred in canines (n = 374; 70.2%). Ten animals that presented dead on arrival were investigated; no significant threats were identified.

Use of multiple surveillance systems allowed for near-real-time detection and monitoring of disease and injury syndromes in humans and domestic animals potentially associated with inaugural events and in local health care systems.

Competency of peripheral health workers in the detection and management of common syndromic conditions is crucial as they are the first point of contact for the majority of the Indian population.

We measured the competency of auxiliary nurse midwives (ANMs), and factors associated with inadequate competency, in the detection and management of common conditions-diarrhoea, acute respiratory tract infection, fever, malaria-through a cross-sectional study using condition specific validated clinical vignettes and structured questionnaires.

Out of 272 selected ANMs, 68% (95% CI 62–74%) were adequately competent. Factors independently associated with inadequate competency were unavailability of essential drugs in preceding month [adjusted odds ratio (AOR) = 1.95; 95% CI 1.1–3.5] and ever trained in integrated management of childhood illness (AOR = 2.4; 95% CI 1.4–4.1).

More than two third of the peripheral health workers were adequately competent to detect and manage common conditions. Ensuring uninterrupted drug availability and improved quality in service trainings might facilitate competency levels.

The 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.

Is an Ambulance Data Syndromic Surveillance System (ADSSS) feasible and of utility in enhancing the existing suite of PHE syndromic surveillance systems?

An 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.

The 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.

Further 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.

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).

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.

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.

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).

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.

TodkillD, HughesHE, ElliotAJ, MorbeyRA, EdeghereO, HarcourtS, HughesT, EndericksT, McCloskeyB, CatchpoleM, IbbotsonS, SmithG. 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.