Using an Emergency Department Syndromic Surveillance System to investigate the impact of extreme cold weather events

This report describes the development of novel syndromic cold weather public health surveillance indicators for use in monitoring the impact of extreme cold weather on attendances at EDs, using data from the 2010-11 and 2011-12 winters. A number of new surveillance indicators were created specifically for the identification and monitoring of cold weather related ED attendances, using the diagnosis codes provided for each attendance in the Emergency Department Syndromic Surveillance System (EDSSS), the first national syndromic surveillance system of its kind in the UK. Using daily weather data for the local area, a time series analysis to test the sensitivity of each indicator to cold weather was undertaken. Diagnosis codes relating to a health outcome with a potential direct link to cold weather were identified and assigned to a number of 'cold weather surveillance indicators'. The time series analyses indicated strong correlations between low temperatures and cold indicators in nearly every case. The strongest fit with temperature was cold related fractures in females, and that of snowfall was cold related fractures in both sexes. Though currently limited to a small number of sentinel EDs, the EDSSS has the ability to give near real-time detail on the magnitude of the impact of weather events. EDSSS cold weather surveillance fits well with the aims of the Cold Weather Plan for England, providing information on those particularly vulnerable to cold related health outcomes severe enough to require emergency care. This timely information aids those responding to and managing the effects on human health, both within the EDs themselves and in the community as a whole.

London 2012 Olympic and Paralympic Games: public health surveillance and epidemiology

Mass gatherings are regarded as potential risks for transmission of infectious diseases, and might compromise the health system of countries in which they are hosted. The evidence for increased transmission of infectious diseases at international sporting mass gatherings that attract many visitors from all over the world is not clear, and the evidence base for public health surveillance, epidemiology, and response at events such as the Olympics is small. However, infectious diseases are a recognised risk, and public health planning is, and should remain, a crucial part of the overall planning of sporting events. In this Series paper, we set out the planning and the surveillance systems that were used to monitor public health risks during the London 2012 Olympic and Paralympic Games in the summer of 2012, and draw attention to the public health issues-infectious diseases and chemical, radiation, and environmental hazards-that arose. Although the absolute risk of health-protection problems, including infectious diseases, at sporting mass gatherings is small, the need for reassurance of the absence of problems is higher than has previously been considered; this could challenge conventional public health surveillance systems. Recognition of the limitations of health-surveillance systems needs to be part of the planning for future sporting events.

Euro 2012 European Football Championship Finals: planning for a health legacy

The revised international health regulations offer a framework that can be used by host countries to organise public health activities for mass gatherings. From June 8, to July 1, 2012, Poland and Ukraine jointly hosted the Union of European Football Associations European Football Championship Finals (Euro 2012). More than 8 million people from around the world congregated to watch the games. Host countries and international public health agencies planned extensively to assess and build capacity in the host countries and to develop effective strategies for dissemination of public health messages. The effectiveness of public health services was maximised through rapid sharing of information between parties, early use of networks of experienced individuals, and the momentum of existing national health programmes. Organisers of future mass gatherings for sporting events should share best practice and their experiences through the WHO International Observer Program. Research about behaviour of large crowds is needed for crowd management and the evidence base translated into practice. A framework to measure and evaluate the legacy of Euro 2012 is needed based on the experiences and the medium-term and long-term benefits of the tournament.

Hajj: infectious disease surveillance and control

Religious festivals attract a large number of pilgrims from worldwide and are a potential risk for the transmission of infectious diseases between pilgrims, and to the indigenous population. The gathering of a large number of pilgrims could compromise the health system of the host country. The threat to global health security posed by infectious diseases with epidemic potential shows the importance of advanced planning of public health surveillance and response at these religious events. Saudi Arabia has extensive experience of providing health care at mass gatherings acquired through decades of managing millions of pilgrims at the Hajj. In this report, we describe the extensive public health planning, surveillance systems used to monitor public health risks, and health services provided and accessed during Hajj 2012 and Hajj 2013 that together attracted more than 5 million pilgrims from 184 countries. We also describe the recent establishment of the Global Center for Mass Gathering Medicine, a Saudi Government partnership with the WHO Collaborating Centre for Mass Gatherings Medicine, Gulf Co-operation Council states, UK universities, and public health institutions globally.

The impact of thunderstorm asthma on emergency department attendances across London during July 2013

BACKGROUND

This study illustrates the potential of using emergency department attendance data, routinely accessed as part of a national syndromic surveillance system, to monitor the impact of thunderstorm asthma.

METHODS

The Emergency Department Syndromic Surveillance System (EDSSS) routinely monitors anonymised attendance data on a daily basis across a sentinel network of 35 emergency departments. Attendance data for asthma, wheeze and difficulty breathing are analysed on a daily basis.

RESULTS

A statistically significant spike in asthma attendances in two EDSSS emergency departments in London was detected on 23 July 2013, coinciding with a series of large violent thunderstorms across southern England. There was also an increase in the reported severity of these attendances.

CONCLUSIONS

This preliminary report illustrates the potential of the EDSSS to monitor the impact of thunderstorms on emergency department asthma attendances. Further work will focus on how this system can be used to quantify the impact on emergency departments, thus potentially improving resource planning and also adding to the thunderstorm asthma evidence-base.

Developing a new syndromic surveillance system for the London 2012 Olympic and Paralympic Games

Syndromic surveillance is vital for monitoring public health during mass gatherings. The London 2012 Olympic and Paralympic Games represents a major challenge to health protection services and community surveillance. In response to this challenge the Health Protection Agency has developed a new syndromic surveillance system that monitors daily general practitioner out-of-hours and unscheduled care attendances. This new national system will fill a gap identified in the existing general practice-based syndromic surveillance systems by providing surveillance capability of general practice activity during evenings/nights, over weekends and public holidays. The system will complement and supplement the existing tele-health phone line, general practitioner and emergency department syndromic surveillance systems. This new national system will contribute to improving public health reassurance, especially to meet the challenges of the London 2012 Olympic and Paralympic Games.

Establishing an emergency department syndromic surveillance system to support the London 2012 Olympic and Paralympic Games

BACKGROUND

The London 2012 Olympic and Paralympic Games is a mass gathering event that will present a major public health challenge. The Health Protection Agency, in collaboration with the College of Emergency Medicine, has established the Emergency Department Sentinel Syndromic Surveillance System (EDSSS) to support the public health surveillance requirements of the Games.

METHODS

This feasibility study assesses the usefulness of EDSSS in monitoring indicators of disease in the community. Daily counts of anonymised attendance data from six emergency departments across England were analysed by patient demographics (age, gender, partial postcode), triage coding and diagnosis codes. Generic and specific syndromic indicators were developed using aggregations of diagnosis codes recorded during each attendance.

RESULTS

Over 339,000 attendances were recorded (26 July 2010 to 25 July 2011). The highest attendances recorded on weekdays between 10:00 and 11:00 and on weekends between 12:00 and 13:00. The mean daily attendance per emergency department was 257 (range 38-435). Syndromic indicators were developed including: respiratory, gastrointestinal, cardiac, acute respiratory infection, gastroenteritis and myocardial ischaemia. Respiratory and acute respiratory infection indicators peaked during December 2010, concomitant with national influenza activity, as monitored through other influenza surveillance systems.

CONCLUSIONS

The EDSSS has been established to provide an enhanced surveillance system for the London 2012 Olympics. Further validation of the data will be required; however, the results from this initial descriptive study demonstrate the potential for identifying unusual and/or severe outbreaks of infectious disease, or other incidents with public health impact, within the community.

Patterns of early transmission of pandemic influenza in London - link with deprivation

Please cite this paper as: Balasegaram et al. (2012) Patterns of early transmission of pandemic influenza in London – link with deprivation. Influenza and Other Respiratory Viruses 6(3), e35–e41.

Background  During the early containment phase in England from April to June 2009, the national strategy for H1N1 pandemic influenza involved case investigation and treatment, and tracing and prophylaxis of contacts.

Objective  To describe the relationship between early transmission of H1N1 pandemic influenza in London and age and socio‐economic status.

Methods  Epidemiological data on cases of pandemic flu in London reported to the London Flu Response Centre were analysed to determine patterns of transmission.

Results  There were 3487 reported cases (2202 confirmed, 1272 presumed and 14 probable) from 20 April to 28 June 2009, during the ‘containment’ period. The highest report rate of 206 per 100 000 (95% CI 195–218) was seen in primary school–age children (5−11 years) followed by 129 (95% CI 119–139) in secondary school–age children (12–18 years). Reports of cases were initially concentrated in affluent areas but overall showed a clear trend with deprivation and risk ratio of 2·32 (95% CI 1·94–2·78) between the most deprived and the least deprived.

Conclusion  Early transmissions were highest amongst school‐aged children but linked with socio‐economic deprivation across all age groups.

From containment to community: Trigger points from the London pandemic (H1N1) 2009 influenza incident response

OBJECTIVE

In the UK, during the first wave of pandemic (H1N1) 2009 influenza, a national 'containment' strategy was employed from 25 April to 2 July 2009, with case finding, treatment of cases, contact tracing and prophylaxis of close contacts. The aim of the strategy was to delay the introduction and spread of pandemic flu in the UK, provide a better understanding of the course of the novel disease, and thereby allow more time for the development of treatment and vaccination options.

STUDY DESIGN

Descriptive study of the management of the containment phase of pandemic (H1N1) 2009 influenza.

METHODS

Analysis of data reported to the London Flu Response Centre (LFRC).

RESULTS

The average number of telephone calls and faxes per day from health professionals before 15 June 2009 was 188, but this started to rise from 363 on 12 June, to 674 on 15 June, and peaked on 22 June at 2206 calls. The number of cases confirmed [by pandemic (H1N1) 2009 influenza specific H1 and N1 polymerase chain reaction] in London rose to a peak of 200 cases per day. There were widespread school outbreaks reporting large numbers of absences with influenza-like illnesses. Activity in the LFRC intensified to a point where London was declared a 'hot spot' for pandemic (H1N1) 2009 influenza on 19 June 2009 because of sustained community transmission. The local incident response was modified to the 'outbreak management phase' of the containment phase.

CONCLUSIONS

The sharp rise in the number of telephone calls and the rise in school outbreaks appeared to be trigger points for community transmission. These indicators should inform decisions on modifying public health strategy in pandemic situations.

Syndromic surveillance to assess the potential public health impact of the Icelandic volcanic ash plume across the United Kingdom, April 2010

The Health Protection Agency and Health Protection Scotland used existing syndromic surveillance systems to monitor community health in the UK following the volcanic eruption in Iceland in April 2010.

Syndromic surveillance to assess the potential public health impact of the Icelandic volcanic ash plume across the United Kingdom, April 2010

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Pandemic (H1N1) 2009: setting up a multi-agency regional response centre--a toolkit for other public health emergencies

The H1N1 pandemic emerged from Mexico in April 2009. In the UK, local Health Protection Units were quickly overwhelmed with calls from health professionals seeking public health advice on this novel virus. The Health Protection Agency (HPA) led the initial response and established regional flu response centres (FRCs). In London, the HPA's flu response moved swiftly from four in-house emergency operations centres to a fully functional multiagency response centre in rented office space, working with a new database, IT and telephone systems to provide a regional response. Surge capacity was sought from the National Health Service (NHS) and other agencies. The London FRC transferred to NHS leadership supported by the existing management team to assist the NHS in London prior to the opening of the National Pandemic Flu Service. Structured debriefs were undertaken, identifying lessons for future evolving incidents. This paper gives an overview of the activation, resilience and decommissioning of the London FRC, incorporating the lessons identified and key recommendations into a toolkit for future emergency evolving incidents that adopt a regional response centre model.

Investigations and control measures following a case of inhalation anthrax in East London in a drum maker and drummer, October 2008

The patient is believed to have acquired the infection from making animal hide drums. Environmental investigations identified one drum and two pieces of animal skins contaminated with anthrax spores.

Investigations and control measures following a case of inhalation anthrax in East London in a drum maker and drummer, October 2008

We discuss the investigations and control measures undertaken following the notification of a fatal case of inhalation anthrax in East London. The patient is believed to have acquired the infection from making animal hide drums. Environmental investigations identified one drum and two pieces of animal skins contaminated with anthrax spores.

Improving molecular detection of Candida DNA in whole blood: comparison of seven fungal DNA extraction protocols using real-time PCR

The limitations of classical diagnostic methods for invasive Candida infections have led to the development of molecular techniques such as real-time PCR to improve diagnosis. However, the detection of low titres of Candida DNA in blood from patients with candidaemia requires the use of extraction methods that efficiently lyse yeast cells and recover small amounts of DNA suitable for amplification. In this study, a Candida-specific real-time PCR assay was used to detect Candida albicans DNA in inoculated whole blood specimens extracted using seven different extraction protocols. The yield and quality of total nucleic acids were estimated using UV absorbance, and specific recovery of C. albicans genomic DNA was estimated quantitatively in comparison with a reference (Qiagen kit/lyticase) method currently in use in our laboratory. The extraction protocols were also compared with respect to sensitivity, cost and time required for completion. The TaqMan PCR assay used to amplify the DNA extracts achieved high levels of specificity, sensitivity and reproducibility. Of the seven extraction protocols evaluated, only the MasterPure yeast DNA extraction reagent kit gave significantly higher total nucleic acid yields than the reference method, although nucleic acid purity was highest using either the reference or YeaStar genomic DNA kit methods. More importantly, the YeaStar method enabled C. albicans DNA to be detected with highest sensitivity over the entire range of copy numbers evaluated, and appears to be an optimal method for extracting Candida DNA from whole blood.