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Please Read the article I attached below, then answer the following question:Varney and Hirshon (In the article below) list seven general rationales for providing ED-based public health surveillance. Surveillance is a critical form of communication for public health officials. Choose a real public health outbreak, disaster, or crisis. Provide one example of how any of the concepts described in this paper were actually used to improve public health. Describe the intervention for other classmates. Cite your reference (In APA format).- At least three paragraphs

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Emerg Med Clin N Am
24 (2006) 1035–1052
Update on Public Health Surveillance
in Emergency Departments
Shawn M. Varney, Lt Col, USAF, MCa,*,
Jon Mark Hirshon, MD, MPHb,c
59 MDW/MCED, 2200 Bergquist Drive, Suite 1, Lackland AFB,
TX 78236-5500, USA
Division of Emergency Medicine, Department of Emergency Medicine
and Department of Epidemiology and Preventive Medicine,
University of Maryland School of Medicine, Baltimore, MD, USA
The Charles McC. Mathias, Jr. National Study Center for Trauma and EMS,
University of Maryland School of Medicine, 701 West Pratt Street,
Fifth Floor, Baltimore, MD 21201, USA
The systematic collection and analysis of health data are important
actions required to help understand the health needs of a population.
When it is done to investigate a problem to contribute to generalizable
knowledge, it is defined as research [1]. If these activities are done
through the collection of health data in an ongoing manner to influence
the health of the public, it can be considered public health surveillance.
Considering that in 2003 there were an estimated 113.9 million emergency
department (ED) visits nationwide [2], EDs are an ideal location to collect de-identified information on the acute health needs and patterns of
the population of the United States. The systematic collection of data
from multiple EDs can also serve as a barometer of the overall status
of the US health system. While there are a number of logistical and infrastructural barriers that can impede the development of surveillance
systems, the potential benefits from these systems are significant. The
ability to analyze data; distribute results; and influence policy, funding,
and patients’ behavior are important outgrowths of public health surveillance in emergency departments.
* Corresponding author. Department of Emergency Medicine, 59 MDW/MCED, 2200
Bergquist Drive, Suite 1, Lackland AFB, TX 78236-5500.
E-mail address: (S.M. Varney).
0733-8627/06/$ – see front matter ! 2006 Elsevier Inc. All rights reserved.
What is public health surveillance?
Definition of surveillance
The Centers for Disease Control and Prevention (CDC) has defined public health surveillance as ‘‘the ongoing systematic collection, analysis and
interpretation of health data essential to the planning, implementation
and evaluation of public health practices, closely integrated with the timely
dissemination of these data to those who need to know. The final link in the
surveillance chain is the application of these data to prevention and control’’
[3]. Surveillance systems are used to prepare, execute, and assess public
health intervention programs and relay the acquired information to decision
makers. In the present age of heightened security awareness and threats of
bioterrorism, surveillance systems play an additional role in the early detection of health use anomalies. Through the rapid recognition of multiple
patients with similar symptoms suggestive of an atypical or biologic agent,
alerts are triggered so that public health professionals are notified of a potential threat.
Surveillance system components
Surveillance systems may range from rudimentary to complexdie, from
manual collection and documentation on sheets of paper to automated realtime data delivery. The steps required for a public health surveillance system
include data acquisition on a periodic and ongoing basis, timely data collation and analysis, and the application of these data by the proper public
health professionals. The basic components of a surveillance system include
equipment, personnel, and the required resources for the personnel to
analyze the data, communicate promptly and effectively, and maintain the
system adequately.
The ability to amass and analyze large amounts of information has markedly improved with the advent of current computer technology. Therefore,
essential equipment for an ED-based public health surveillance system now
includes a robust computerized database system with appropriate Internet
and networking capabilities, along with sophisticated software to analyze
data for areas of interest. The potential applications of data and the requirements for interoperability with collaborators, such as regional, state, or
national systems, dictate the necessary degree of complexity.
Fundamental personnel consist of individuals responsible for (1) data collection, (2) information analysis, and (3) timely response to material collected. Thus, many partners are involved, including health care providers
in physicians’ offices and EDs and public health professionals in local, state,
and federal agencies, as well as laboratory workers, researchers, academicians, and information technology (IT) experts. The ability to maintain multidirectional communication flow among these team members is critical for
a functional system.
Required additional resources include financial, institutional, and IT
(encompassing communication, data management, and data analysis). To
be effective, surveillance system development requires full endorsement
and involvement from interested public health, political, and private leaders
in many fields. Data sources may include standardized clinical databases
from hospitals, doctors’ offices, EDs, pharmacies, telephone health lines,
and others. The integration of these databases into a cohesive system
requires significant time and effort to garner support of critical partners
and to make the system fully operational.
Definition of syndromic surveillance
Syndromic surveillance describes a dynamic process of collecting real-time
or near real-time data on symptom clusters suggestive of a biological disease
outbreak. Ideally, these diseases will be detected early in the processdbefore
the definitive diagnosisdto enable a rapid response and mitigate adverse
outcomes [4,5]. Syndromic surveillance systems have secondary objectives
including determining the size, spread, and tempo of an outbreak, or even
providing reassurance that an outbreak has not occurred [4].
Initially, syndromic surveillance systems were designed for the early
detection of biological terrorism agents. The focus has evolved subsequent
to the 9/11 World Trade Center and anthrax terrorist attacks of 2001. Present emphasis lies on the timely collection, assimilation, and analysis of
health care data gathered from existing community systems to provide
immediate feedback to decision makers about unexpected disease clusters
or sentinel cases [4].
In contrast to the standard diagnosis-based disease surveillance (labs and
cultures), syndromic surveillance is prediagnosticdie, it recognizes a cluster
of symptoms, or the onset of a disease, before full-blown illness manifestation. Identifying a peak of unusual symptoms above the background/steady
state may allow a few extra days for further observation, evaluation, and
treatment before the severe illness becomes apparent by conventional diagnostic methods. Theoretically, early detection equates to earlier treatment
and decreased morbidity and mortality.
Syndromic surveillance systems tend to derive their data from two
sources: (1) clinical data from health care services (ED visits, clinic visits,
or Emergency Medical Services [EMS] records), and (2) alternative sources
(work or school absentee rates, pharmaceutical sales, calls to emergency or
information hotlines, Internet-based illness reporting systems) [6]. Each data
source has advantages. For example, clinical data sources provide the ability
to follow patients and, in the case of a public health emergency, to contact
infected individuals. These actions, however, would require significant
efforts and high-level approvals to override existing privacy and confidentiality safeguards. In addition, clinical data encourages bidirectional communication and fosters improved relationships between community providers
and public health staff, which is an important step in a functional public
health system. Alternative data sources, such as pharmacy sales including
over-the-counter products, may signal the occurrence of events before
people seek formal health care and may represent a broader sample of the
population at risk.
In one study of 3919 ED visits, Begier and colleagues [5] found good
overall agreement (kappa ¼ 0.639) between chief complaint and discharge
diagnosis, but substantial variability by specific syndromes. All ED patient
encounters were coded via a mutually exclusive algorithm into one of eight
syndromes: death, sepsis, rash, respiratory illness, gastrointestinal illness,
unspecified infection, neurologic illness, and other. They observed lower
agreement among sepsis, neurologic, and unspecified infection. Begier and
colleagues concluded that although there is good agreement for most
syndromes, the chief complaint better identifies illnesses with nonspecific
symptoms (ie, fever), while discharge diagnoses detect illnesses requiring
clinical evaluation (ie, sepsis and meningitis).
Another form of syndromic surveillance is ‘‘event-based’’ or ‘‘drop-in’’
surveillance, which lasts for a finite period or event. It relies on health
care providers in EDs and large clinics to collect nonroutine data. Such a system was implemented and proved useful during the 2000 Democratic
National Convention in California and the 2002 Winter Olympic Games
in Utah [7,8].
Although syndromic surveillance may be able to play a key role in early
recognition of disease outbreaks, it neither replaces traditional public health
surveillance nor supplants the critical role of an astute physician reporting
atypical diseases and events.
Why is surveillance important?
General rationales for ED-based public health surveillance
There are a number of rationales for the development of public health
surveillance based on ED visits [9]. These include:
1. Improved communication between health departments and emergency
departments for addressing ongoing local, regional, and state-level
2. Improved public health response to rapidly developing public health
3. Improved ability to correlate environmental events and visits.
4. Improved information on the scope and nature of ED visits for injuries
(both minor and major).
5. Improved documentation and evaluation of ED visits for infectious
6. Improved hospital-based patient record systems.
7. Influence policy discussions and decisions through improved data.
These rationales can be conceptually divided into those designed to improve the health of the public and those designed to improve the security
of the population.
Improving public health
Surveillance is an outcome-oriented science that provides information for
action. Public health surveillance focuses on health-related issues or their
preceding events. It plays a key role in protecting the public by devising
ways to improve health and to mitigate morbidity and mortality. In the context of public health, Teutsch and Churchill [10] described multiple ways
that surveillance data are useful: to estimate the magnitude of a health problem; to understand the natural history of a disease or injury; to detect
outbreaks or epidemics; to document the distribution and spread of a health
event; to test hypotheses about etiology; to evaluate control strategies; to
monitor changes in infectious agents; to monitor isolation activities; to
detect changes in health practice; to identify research needs and facilitate
epidemiologic and laboratory research; and to facilitate planning.
Surveillance allows for the monitoring and evaluation of the health of the
public. However, it is critical that appropriate public health professionals
then translate the information garnered from these efforts into action.
A feedback loop is thus developed to produce positive effects within the
monitored population. Timely and accurate health-related data, properly
collected and analyzed, allow public health leaders, politicians, and others
to act appropriately to mitigate disasters or epidemics through judicious
allocation of suitable resources.
A current example of ongoing surveillance of a potential public health
threat is the actions by national governments in Asia, the CDC, and the
World Health Organization (WHO) to monitor the current status of avian
influenza (bird flu), especially the influenza A (H5N1) virus [11]. While
H5N1 primarily affects fowl, there is concern for the potential personto-person transmission of the virus leading to a pandemic. Thus the CDC
has recommended enhanced surveillance for this disease in the United States
to promote its rapid diagnosis and to prevent its dissemination. If bird flu
were discovered in a patient in the United States, the CDC could rapidly
mobilize resources to limit the spread of infection and panic among the
Terrorism response/homeland security
According to the Advisory Panel to Assess Domestic Response Capabilities for Terrorism Involving Weapons of Mass Destruction, ‘‘a robust
public health system is fundamental to a long-term solution for a variety
of health issues, including terrorism’’ [12]. Public health surveillance
systems, such as those based on ED visits, are part of this solution. While it
is difficult to assess the magnitude of the threat, there is no question that all
societies are at risk from conventional explosives and, potentially, from
weapons of mass destruction. Within this global context of increased insecurity, it is important to be able to detect unusual diseases and events. The
ongoing, systematic collection of ED data to identify unusual diseases and
patterns may help shorten the time required to respond to biological or
chemical attacks and thus decrease the morbidity and mortality from these
weapons. Recognition on the national level can be seen by the increased
federal dollars allocated to public health, much of which has been used
for increased disease surveillance and response. Additionally, a number of
projects focusing on syndromic surveillance, such as the Electronic Surveillance System for the Early Notification of Community-Based Epidemics
(ESSENCE), were developed or tested through funding from the Defense
Advanced Research Project Agency (DARPA) and the Department of
Defense [13].
Stakeholders in developing surveillance systems
Health care facilities
The ED plays a key role in the development and use of a public health
surveillance system. Patients come into EDs 24 hours a day, 7 days
a week, every day of the year, making it an appropriate place for data gathering and collation. Health care providers in the ED simultaneously see multiple patients and often have high daily patient volumes. This enables the
derivation of the relative prevalence of symptom clusters that may represent
worrisome syndromes or epidemics. Outlying clinics frequently refer sicker
patients to local EDs, facilitating collection of information on more cases.
Emergency physicians are taught to have a high index of suspicion for
uncommon diseases, leading to broad differential diagnoses and clinical
acumen. They are the first physician contacts for patients in many situations
and may detect aberrations in the usual incidence of disease. From these
frontline positions, they need to be able to transmit their findings and concerns in a timely and accurate manner to the appropriate public health
authority. As a primary participant in the disease recognition process,
emergency physicians and other ED staff must be involved in surveillance
system development.
The information collecting process should be simple, quick, and easy to
implement with minimal or no impact on health care practitioners. Automatic classification of broad symptom categories for chief complaints can
be included as a part of triage. Alternatively, a computer can be placed in
a kiosk by the registration desk in the ED. Simple questions may identify
symptom clusters that the computer can analyze at regular intervals and
produce warnings or alerts to hospital personnel or public health agencies.
ED personnel end up participating in the surveillance process to some
degree whether they realize it or not. Simply observing patients and assimilating and documenting information (gathering chief complaints, identifying trends, and so forth) contributes. Passing the data to the public health
sector may mitigate morbidity and mortality. Automatic data entry from
multiple hospitals into a centralized repository may facilitate disease recognition and coordinate findings citywide, similar to a well-run emergency
medical services system. Ideally, a large funding source, such as state and
federal governments, should support this initiative in the interest of the
public’s health.
Public health agencies
Public health agencies and their staff play a pivotal role in monitoring
and managing the public’s health, from scrutinizing for disease outbreaks
to implementing quarantine measures. They function as the keystone of
a public health surveillance system and their involvement in system development and use is crucial. While EDs and other data sources, such as laboratory personnel and pharmacists, supply the input, public health
professionals must accept the collected data, analyze it, and then return recommendations and policy actions to appropriate officials. Timely reporting
is critical to allow public health professionals to perform their jobs.
As part of this involvement, bidirectional communication is vital between frontline providers, such as emergency physicians, and public health
experts. While it is important that accurate information be sent to the
health department in a timely manner, it is of equal significance that informed and authoritative health messages be disseminated to both health
care professionals and to the public. The information received by
emergency physicians and other practitioners influences the evaluation
and treatment of patients. Public health messages can assist in the effective
management of the behavior and responses of the community at large,
especially in times of crisis.
Of additional consequence in this partnership between health care and
public health is the understanding that system development requires the
support, financial and otherwise, of health departments and public health
professionals. An individual ED is not a surveillance system, although it
may function as a monitoring station within one. A public health surveillance system based on ED visits, as well as other potential data sources,
requires significant infrastructural support to receive large amounts of
health-related data and then to rapidly analyze it for unusual patterns or
increased disease frequency.
Information technology
With the increased ability to rapidly collect and analyze data from
multiple sources, the involvement and support of experts in information
technology are important aspects of the team effort to develop a functional
public health surveillance system. In general, data are not transmitted as
a continuous stream, but rather at periodic intervals (eg, hourly, daily,
weekly). Data can be collected and analyzed manually, but the greater
the automation, the more rapid and accurate the results are likely to be.
Automation can enhance the data collection and analysis process, minimizing delays and decreasing inaccuracy caused by the need to depend
on human interactions. Through the use of software that automatically
collects the number of visits (or other data parameter) by category, the
amount of effort required by health care providers in data input can be
significantly decreased. Advanced logic algorithms can help look fo …
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