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									              Use of a School Nurse Syndromic Surveillance System
         during the Novel Influenza A (H1N1) Outbreak in New York City
    Elisha Wilson, Joseph Egger, Kevin Konty, Marc Paladini, Oxiris Barbot, Don Weiss
           New York City Department of Health and Mental Hygiene, New York, NY
                     OBJECTIVE                            Figure 1. FevFlu syndrome and temperature >100.4 oF visits from
1) Describe a near real-time syndromic surveillance       the school nurse syndromic surveillance system.
system based on visits to the school nurse.
                                                                    FevFlu Syndrome      FevFlu Signal        Temperature >100.4         Temperature Signal
2) Demonstrate the utility of the school nurse
syndromic surveillance system during the H1N1
outbreak in New York City (NYC), Spring 2009.

                   BACKGROUND                                        800

In 2003, NYC implemented a web-based electronic                      600

health record system—the Automated Student Health                    400
Record (ASHR)—in public elementary and                               200
intermediate schools to improve care, to reduce                       0
paperwork, and to monitor delivery of healthcare                      Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09Mar-09 Apr-09 May-09 Jun-09

services. The syndromic surveillance program uses
data from ASHR to monitor trends in infectious            From May 11 to June 19, 2009, 419 schools reported
disease syndromes among school children.                  8,175 ILI cases to the active surveillance system. For
                                                          these schools, the percent ILI from active and
During the Spring 2009 H1N1 outbreak in NYC, an           syndromic surveillance were correlated over time
active surveillance program was instituted to monitor     (r=0.92, p<0.001), even though syndromic
influenza-like illness (ILI) in schools. Once a school    surveillance had a significantly lower percent ILI
reached a threshold of ILI visits, they were instructed   (p<0.001) (Figure 2). This difference may be due to
to report cases daily, by telephone.                      decreased reporting through syndromic surveillance
                      METHODS                             during the H1N1 outbreak.
For syndromic surveillance, school nurses enter chief     Figure 2. ILI and absenteeism from the active surveillance and
complaint, date, time, school, age, grade, classroom,     school nurse syndromic surveillance, during the H1N1 outbreak.
and zip code into ASHR. SAS is used to code
                                                                                        Active ILI       Syndromic ILI       Absenteesim
complaints into disease syndromes. Temporal trends                  0.8%                                                                        30.0%
are examined by graphs and thresholds are monitored                 0.7%
by cumulative sums (CuSum) analyses. For active                     0.6%
surveillance, school staff reported an aggregate                    0.5%

                                                                                                                                                        % Absent
number of ILI cases per school, once a threshold had
                                                           % ILI

                                                                    0.4%                                                                        15.0%
been met.                                                           0.3%
To demonstrate the utility of the school nurse                                                                                                  5.0%
syndromic surveillance system, we retrospectively                   0.0%                                                                        0.0%
compared this data to data obtained by active                          05/11/09   05/18/09   05/25/09     06/01/09       06/08/09   06/15/09

surveillance data. Data were matched by school and
date. ILI was defined as temperature of >100.4 oF                             CONCLUSIONS
and either cough or sore throat. Percent ILI was          The school nurse syndromic surveillance system uses
calculated using enrollment data.                         existing data from electronic student health records.
                       RESULTS                            Activity correlated well with an active surveillance
During the 2008-2009 school year, 1,192 schools           system established during a large citywide epidemic.
reported approximately 1.6 million school nurse           Improvements to the syndromic surveillance system
visits via syndromic surveillance. The daily number       and further integration of multiple data sources,
of visits with chief complaints of fever or achiness      including school absenteeism data are underway.
(FevFlu syndrome) and visits with temperature                                 REFERENCES
>100.4 oF were correlated over time (r=0.97,              Besculides M, Heffernan R, Mostashari F, Weiss D.
p<0.001) and showed similar daily CuSum signals           Evaluation of school absenteeism data for early
(Figure 1).                                               outbreak detection, New York City. BMC Public
                                                          Health. 2005;5:105.

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