Issues in applied statistics for public health bioterrorism surveillance using multiple data streams: research needs

Data-fed, needs-driven: Designing analytical workflows fit for disease surveillance

Syndromic surveillance has been an important driver for the incorporation of "big data analytics" into animal disease surveillance systems over the past decade. As the range of data sources to which automated data digitalization can be applied continues to grow, we discuss how to move beyond questions around the means to handle volume, variety and velocity, so as to ensure that the information generated is fit for disease surveillance purposes. We make the case that the value of data-driven surveillance depends on a "needs-driven" design approach to data digitalization and information delivery and highlight some of the current challenges and research frontiers in syndromic surveillance.

Multivariate syndromic surveillance for cattle diseases: Epidemic simulation and algorithm performance evaluation

Multivariate Syndromic Surveillance (SyS) systems that simultaneously assess and combine information from different data sources are especially useful for strengthening surveillance systems for early detection of infectious disease epidemics. Despite the strong motivation for implementing multivariate SyS and there being numerous methods reported, the number of operational multivariate SyS systems in veterinary medicine is still very small. One possible reason is that assessing the performance of such surveillance systems remains challenging because field epidemic data are often unavailable. The objective of this study is to demonstrate a practical multivariate event detection method (directionally sensitive multivariate control charts) that can be easily applied in livestock disease SyS, using syndrome time series data from the Swiss cattle population as an example. We present a standardized method for simulating multivariate epidemics of different diseases using four diseases as examples: Bovine Virus Diarrhea (BVD), Infectious Bovine Rhinotracheitis (IBR), Bluetongue virus (BTV) and Schmallenberg virus (SV). Two directional multivariate control chart algorithms, Multivariate Exponentially Weighted Moving Average (MEWMA) and Multivariate Cumulative Sum (MCUSUM) were compared. The two algorithms were evaluated using 12 syndrome time series extracted from two Swiss national databases. The two algorithms were able to detect all simulated epidemics around 4.5 months after the start of the epidemic, with a specificity of 95%. However, the results varied depending on the algorithm and the disease. The MEWMA algorithm always detected epidemics earlier than the MCUSUM, and epidemics of IBR and SV were detected earlier than epidemics of BVD and BTV. Our results show that the two directional multivariate control charts are promising methods for combining information from multiple time series for early detection of subtle changes in time series from a population without producing an unreasonable amount of false alarms. The approach that we used for simulating multivariate epidemics is relatively easy to implement and could be used in other situations where real epidemic data are unavailable. We believe that our study results can support the implementation and assessment of multivariate SyS systems in animal health.

Using decision fusion methods to improve outbreak detection in disease surveillance

BACKGROUND

When outbreak detection algorithms (ODAs) are considered individually, the task of outbreak detection can be seen as a classification problem and the ODA as a sensor providing a binary decision (outbreak yes or no) for each day of surveillance. When they are considered jointly (in cases where several ODAs analyze the same surveillance signal), the outbreak detection problem should be treated as a decision fusion (DF) problem of multiple sensors.

METHODS

This study evaluated the benefit for a decisions support system of using DF methods (fusing multiple ODA decisions) compared to using a single method of outbreak detection. For each day, we merged the decisions of six ODAs using 5 DF methods (two voting methods, logistic regression, CART and Bayesian network - BN). Classical metrics of accuracy, prediction and timelines were used during the evaluation steps.

RESULTS

In our results, we observed the greatest gain (77%) in positive predictive value compared to the best ODA if we used DF methods with a learning step (BN, logistic regression, and CART).

CONCLUSIONS

To identify disease outbreaks in systems using several ODAs to analyze surveillance data, we recommend using a DF method based on a Bayesian network. This method is at least equivalent to the best of the algorithms considered, regardless of the situation faced by the system. For those less familiar with this kind of technique, we propose that logistic regression be used when a training dataset is available.

Artificial Intelligence for infectious disease Big Data Analytics

BACKGROUND

Since the beginning of the 21st century, the amount of data obtained from public health surveillance has increased dramatically due to the advancement of information and communications technology and the data collection systems now in place.

METHODS

This paper aims to highlight the opportunities gained through the use of Artificial Intelligence (AI) methods to enable reliable disease-oriented monitoring and projection in this information age.

RESULTS AND CONCLUSION

It is foreseeable that together with reliable data management platforms AI methods will enable analysis of massive infectious disease and surveillance data effectively to support government agencies, healthcare service providers, and medical professionals to response to disease in the future.

Global Research on Syndromic Surveillance from 1993 to 2017: Bibliometric Analysis and Visualization

Syndromic Surveillance aims at analyzing medical data to detect clusters of illness or forecast disease outbreaks. Although the research in this field is flourishing in terms of publications, an insight of the global research output has been overlooked. This paper aims at analyzing the global scientific output of the research from 1993 to 2017. To this end, the paper uses bibliometric analysis and visualization to achieve its goal. Particularly, a data processing framework was proposed based on citation datasets collected from Scopus and Clarivate Analytics’ Web of Science Core Collection (WoSCC). The bibliometric method and Citespace were used to analyze the institutions, countries, and research areas as well as the current hotspots and trends. The preprocessed dataset includes 14,680 citation records. The analysis uncovered USA, England, Canada, France and Australia as the top five most productive countries publishing about Syndromic Surveillance. On the other hand, at the Pinnacle of academic institutions are the US Centers for Disease Control and Prevention (CDC). The reference co-citation analysis uncovered the common research venues and further analysis of the keyword cooccurrence revealed the most trending topics. The findings of this research will help in enriching the field with a comprehensive view of the status and future trends of the research on Syndromic Surveillance.

Methodological challenges to multivariate syndromic surveillance: a case study using Swiss animal health data

BACKGROUND

In an era of ubiquitous electronic collection of animal health data, multivariate surveillance systems (which concurrently monitor several data streams) should have a greater probability of detecting disease events than univariate systems. However, despite their limitations, univariate aberration detection algorithms are used in most active syndromic surveillance (SyS) systems because of their ease of application and interpretation. On the other hand, a stochastic modelling-based approach to multivariate surveillance offers more flexibility, allowing for the retention of historical outbreaks, for overdispersion and for non-stationarity. While such methods are not new, they are yet to be applied to animal health surveillance data. We applied an example of such stochastic model, Held and colleagues' two-component model, to two multivariate animal health datasets from Switzerland.

RESULTS

In our first application, multivariate time series of the number of laboratories test requests were derived from Swiss animal diagnostic laboratories. We compare the performance of the two-component model to parallel monitoring using an improved Farrington algorithm and found both methods yield a satisfactorily low false alarm rate. However, the calibration test of the two-component model on the one-step ahead predictions proved satisfactory, making such an approach suitable for outbreak prediction. In our second application, the two-component model was applied to the multivariate time series of the number of cattle abortions and the number of test requests for bovine viral diarrhea (a disease that often results in abortions). We found that there is a two days lagged effect from the number of abortions to the number of test requests. We further compared the joint modelling and univariate modelling of the number of laboratory test requests time series. The joint modelling approach showed evidence of superiority in terms of forecasting abilities.

CONCLUSIONS

Stochastic modelling approaches offer the potential to address more realistic surveillance scenarios through, for example, the inclusion of times series specific parameters, or of covariates known to have an impact on syndrome counts. Nevertheless, many methodological challenges to multivariate surveillance of animal SyS data still remain. Deciding on the amount of corroboration among data streams that is required to escalate into an alert is not a trivial task given the sparse data on the events under consideration (e.g. disease outbreaks).

Animal health syndromic surveillance: a systematic literature review of the progress in the last 5 years (2011-2016)

This review presents the current initiatives and potential for development in the field of animal health surveillance (AHSyS), 5 years on from its advent to the front of the veterinary public health scene. A systematic review approach was used to document the ongoing AHSyS initiatives (active systems and those in pilot phase) and recent methodological developments. Clinical data from practitioners and laboratory data remain the main data sources for AHSyS. However, although not currently integrated into prospectively running initiatives, production data, mortality data, abattoir data, and new media sources (such as Internet searches) have been the objective of an increasing number of publications seeking to develop and validate new AHSyS indicators. Some limitations inherent to AHSyS such as reporting sustainability and the lack of classification standards continue to hinder the development of automated syndromic analysis and interpretation. In an era of ubiquitous electronic collection of animal health data, surveillance experts are increasingly interested in running multivariate systems (which concurrently monitor several data streams) as they are inferentially more accurate than univariate systems. Thus, Bayesian methodologies, which are much more apt to discover the interplay among multiple syndromic data sources, are foreseen to play a big part in the future of AHSyS. It has become clear that early detection of outbreaks may not be the principal expected benefit of AHSyS. As more systems will enter an active prospective phase, following the intensive development stage of the last 5 years, the study envisions AHSyS, in particular for livestock, to significantly contribute to future international-, national-, and local-level animal health intelligence, going beyond the detection and monitoring of disease events by contributing solid situation awareness of animal welfare and health at various stages along the food-producing chain, and an understanding of the risk management involving actors in this value chain.

Integrating novel data streams to support biosurveillance in commercial livestock production systems in developed countries: challenges and opportunities

Reducing the burden of emerging and endemic infectious diseases on commercial livestock production systems will require the development of innovative technology platforms that enable information from diverse animal health resources to be collected, analyzed, and communicated in near real-time. In this paper, we review recent initiatives to leverage data routinely observed by farmers, production managers, veterinary practitioners, diagnostic laboratories, regulatory officials, and slaughterhouse inspectors for disease surveillance purposes. The most commonly identified challenges were (1) the lack of standardized systems for recording essential data elements within and between surveillance data streams, (2) the additional time required to collect data elements that are not routinely recorded by participants, (3) the concern over the sharing and use of business sensitive information with regulatory authorities and other data analysts, (4) the difficulty in developing sustainable incentives to maintain long-term program participation, and (5) the limitations in current methods for analyzing and reporting animal health information in a manner that facilitates actionable response. With the significant recent advances in information science, there are many opportunities to develop more sophisticated systems that meet national disease surveillance objectives, while still providing participants with valuable tools and feedback to manage routine animal health concerns.

Four key challenges in infectious disease modelling using data from multiple sources

Public health-related decision-making on policies aimed at controlling epidemics is increasingly evidence-based, exploiting multiple sources of data. Policy makers rely on complex models that are required to be robust, realistically approximating epidemics and consistent with all relevant data. Meeting these requirements in a statistically rigorous and defendable manner poses a number of challenging problems. How to weight evidence from different datasets and handle dependence between them, efficiently estimate and critically assess complex models are key challenges that we expound in this paper, using examples from influenza modelling.

Disease prediction models and operational readiness

The objective of this manuscript is to present a systematic review of biosurveillance models that operate on select agents and can forecast the occurrence of a disease event. We define a disease event to be a biological event with focus on the One Health paradigm. These events are characterized by evidence of infection and or disease condition. We reviewed models that attempted to predict a disease event, not merely its transmission dynamics and we considered models involving pathogens of concern as determined by the US National Select Agent Registry (as of June 2011). We searched commercial and government databases and harvested Google search results for eligible models, using terms and phrases provided by public health analysts relating to biosurveillance, remote sensing, risk assessments, spatial epidemiology, and ecological niche modeling. After removal of duplications and extraneous material, a core collection of 6,524 items was established, and these publications along with their abstracts are presented in a semantic wiki at http://BioCat.pnnl.gov. As a result, we systematically reviewed 44 papers, and the results are presented in this analysis. We identified 44 models, classified as one or more of the following: event prediction (4), spatial (26), ecological niche (28), diagnostic or clinical (6), spread or response (9), and reviews (3). The model parameters (e.g., etiology, climatic, spatial, cultural) and data sources (e.g., remote sensing, non-governmental organizations, expert opinion, epidemiological) were recorded and reviewed. A component of this review is the identification of verification and validation (V&V) methods applied to each model, if any V&V method was reported. All models were classified as either having undergone Some Verification or Validation method, or No Verification or Validation. We close by outlining an initial set of operational readiness level guidelines for disease prediction models based upon established Technology Readiness Level definitions.

Gastrointestinal disease outbreak detection using multiple data streams from electronic medical records

BACKGROUND

Passive reporting and laboratory testing delays may limit gastrointestinal (GI) disease outbreak detection. Healthcare systems routinely collect clinical data in electronic medical records (EMRs) that could be used for surveillance. This study's primary objective was to identify data streams from EMRs that may perform well for GI outbreak detection.

METHODS

Zip code-specific daily episode counts in 2009 were generated for 22 syndromic and laboratory-based data streams from Kaiser Permanente Northern California EMRs, covering 3.3 million members. Data streams included outpatient and inpatient diagnosis codes, antidiarrheal medication dispensings, stool culture orders, and positive microbiology tests for six GI pathogens. Prospective daily surveillance was mimicked using the space-time permutation scan statistic in single and multi-stream analyses, and space-time clusters were identified. Serotype relatedness was assessed for isolates in two Salmonella clusters.

RESULTS

Potential outbreaks included a cluster of 18 stool cultures ordered over 5 days in one zip code and a Salmonella cluster in three zip codes over 9 days, in which at least five of six cases had the same rare serotype. In all, 28 potential outbreaks were identified using single stream analyses, with signals in outpatient diagnosis codes most common. Multi-stream analyses identified additional potential outbreaks and in one example, improved the timeliness of detection.

CONCLUSIONS

GI disease-related data streams can be used to identify potential outbreaks when generated from EMRs with extensive regional coverage. This process can supplement traditional GI outbreak reports to health departments, which frequently consist of outbreaks in well-defined settings (e.g., day care centers and restaurants) with no laboratory-confirmed pathogen. Data streams most promising for surveillance included microbiology test results, stool culture orders, and outpatient diagnoses. In particular, clusters of microbiology tests positive for specific pathogens could be identified in EMRs and used to prioritize further testing at state health departments, potentially improving outbreak detection.

The EpiCanvas infectious disease weather map: an interactive visual exploration of temporal and spatial correlations

Advances in surveillance science have supported public health agencies in tracking and responding to disease outbreaks. Increasingly, epidemiologists have been tasked with interpreting multiple streams of heterogeneous data arising from varied surveillance systems. As a result public health personnel have experienced an overload of plots and charts as information visualization techniques have not kept pace with the rapid expansion in data availability. This study sought to advance the science of public health surveillance data visualization by conceptualizing a visual paradigm that provides an 'epidemiological canvas' for detection, monitoring, exploration and discovery of regional infectious disease activity and developing a software prototype of an 'infectious disease weather map'. Design objectives were elucidated and the conceptual model was developed using cognitive task analysis with public health epidemiologists. The software prototype was pilot tested using retrospective data from a large, regional pediatric hospital, and gastrointestinal and respiratory disease outbreaks were re-created as a proof of concept.

A hierarchical Bayesian approach to multiple testing in disease mapping

We propose a Bayesian approach to multiple testing in disease mapping. This study was motivated by a real example regarding the mortality rate for lung cancer, males, in the Tuscan region (Italy). The data are relative to the period 1995–1999 for 287 municipalities. We develop a tri-level hierarchical Bayesian model to estimate for each area the posterior classification probability that is the posterior probability that the municipality belongs to the set of non-divergent areas. We show also the connections of our model with the false discovery rate approach. Posterior classification probabilities are used to explore areas at divergent risk from the reference while controlling for multiple testing. We consider both the Poisson-Gamma and the Besag, York and Mollié model to account for extra Poisson variability in our Bayesian formulation. Posterior inference on classification probabilities is highly dependent on the choice of the prior. We perform a sensitivity analysis and suggest how to rely on subject-specific information to derive informative a priori distributions. Hierarchical Bayesian models provide a sensible way to model classification probabilities in the context of disease mapping.

Timely detection of localized excess influenza activity in Northern California across patient care, prescription, and laboratory data

Timely detection of clusters of localized influenza activity in excess of background seasonal levels could improve situational awareness for public health officials and health systems. However, no single data type may capture influenza activity with optimal sensitivity, specificity, and timeliness, and it is unknown which data types could be most useful for surveillance. We compared the performance of 10 types of electronic clinical data for timely detection of influenza clusters throughout the 2007/08 influenza season in northern California. Kaiser Permanente Northern California generated zip code-specific daily episode counts for: influenza-like illness (ILI) diagnoses in ambulatory care (AC) and emergency departments (ED), both with and without regard to fever; hospital admissions and discharges for pneumonia and influenza; antiviral drugs dispensed (Rx); influenza laboratory tests ordered (Tests); and tests positive for influenza type A (FluA) and type B (FluB). Four credible events of localized excess illness were identified. Prospective surveillance was mimicked within each data stream using a space-time permutation scan statistic, analyzing only data available as of each day, to evaluate the ability and timeliness to detect the credible events. AC without fever and Tests signaled during all four events and, along with Rx, had the most timely signals. FluA had less timely signals. ED, hospitalizations, and FluB did not signal reliably. When fever was included in the ILI definition, signals were either delayed or missed. Although limited to one health plan, location, and year, these results can inform the choice of data streams for public health surveillance of influenza.

Syndromic surveillance: adapting innovations to developing settings

The tools and strategies of syndromic surveillance, say the authors, hold promise for improving public health security in developing countries.