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Syndrome Definitions for Diseases Associated with Critical Agents

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					Syndrome Definitions for
Diseases Associated with
Critical Agents


National Syndromic Surveillance Conference
New York, NY
24 October 03
Participating Agencies

! National Center for Infectious Diseases and
   Epidemiology Program Office, Centers for Disease
   Control and Prevention, Atlanta, Georgia

! Division of Preventive Medicine, Walter Reed Army
    Institute of Research, Silver Spring, Maryland

! Emergency Medical Associates of New Jersey
    Research Foundation, Livingston, New Jersey

! Bureau of Epidemiology Services, New York City
    Department of Health and Mental Hygiene, New
    York City, New York

! Harvard Medical School and Harvard Pilgrim Health
    Care, Boston, Massachusetts
Problem

• Would like to identify outbreaks faster
than traditional methods

• Lack of universally applied syndrome
definitions or code groups
Objectives
• Determine appropriate syndromic
  groups for infectious disease
  surveillance and for surveillance of
  agents of bioterrorism.

• Review and compare different sources
  of medical data to best develop ICD-9-
  CM code groups applicable to multiple
  users.
Collaboration Timeline


11/02       12/02       1/03          2/03     4/03    10/03
WRAIR       Harvard     EMA           NY       Test  Final
CDC         Pilgrim                   DOH      Codes Codes on
                                                     CDC/GEIS
                                                     websites




Establish    Define     Map codes        Test code    Customize
syndrome     syndrome   to syndrome        group      Syndrome
groups       groups     groups          performance     groups
Which ICD9 Codes Should We Map
to Syndrome Groups?
• Clinical decision
  – What are the diseases we are trying to detect?
     • Define the syndromes
  – What diagnoses fit under this syndrome definition?

• Trend analysis
  – How frequently are candidate codes used?
  – Is there an expected trend for the syndrome?
  – Is there a “gold standard” for comparing the trend?
     • How well do other ICD9s correlate with the gold standard?
     • Do any ICD9s show the same peak/trend earlier?
Which Syndrome Groups Should
We Choose?

Botulism                            Botulism-like
VHF                                 Hemorrhagic Illness
Plague (Bubonic)                    Lymphadenitis
Anthrax (cutaneous), Tularemia      Localized Cutaneous Lesion
Anthrax (gastrointestinal)          Gastrointestinal
Anthrax (inhalational), Tularemia   Respiratory
Plague (pneumonic)
Small Pox                           Rash
Syndrome Groups Selected by
Consensus

• Botulism-like         •   Rash
• Hemorrhagic Illness   •   Neurological
• Lymphadenitis         •   Specific Infection
• Localized             •   Fever
  Cutaneous Lesion      •   Severe illness or
• Gastrointestinal          death potentially
• Respiratory               due to infectious
                            disease
Syndrome Definition- Respiratory
Example
   Syndrome                         Definition                          Cat A Agent

   Respiratory   ACUTE infection of the upper and/ or lower             Anthrax -
                 respiratory tract (from the oropharynx to the lungs,   inhalation
                 includes otitis media)
                 SPECIFIC diagnosis of acute respiratory tract
                 infection (RTI) such as pneumonia due to               Tularemia
                 parainfluenza virus
                 ACUTE non-specific diagnosis of RTI such as            Plague -
                 sinusitis, pharyngitis, laryngitis                     pneumonic
                 ACUTE non-specific symptoms of RTI such as
                 cough, stridor, shortness of breath, throat pain
                 EXCLUDES chronic conditions such as chronic
                 bronchitis, asthma without acute exacerbation,
                 chronic sinusitis, allergic conditions (Note:
                 INCLUDE acute exacerbation of chronic illnesses.)
How often are candidate codes used?

  DoD
  NCA
                                         Category 1
                       11
  EMA               Syndrome
   NJ                                    Category 2
                     Groups

 Harvard                                 Category 3
 Pilgrim


Review utilization of 6000+ codes for one year in 3
different clinical outpatient databases
Workgroup Tool
Category 1 - Codes that reflect general symptoms
of the syndrome group and for the bioterrorism
diseases of highest concern or those diseases highly
approximating them.

Category 2 - Codes that might normally be placed
in the syndrome group, but daily volume could
overwhelm or otherwise detract from the signal
generated from the Category 1 code set alone.

Category 3 - Specific diagnoses that fit into the
syndrome category but occur infrequently or have
very few counts. May be excluded to simplify
syndrome category code sets.
Final Syndrome List and Codes
Customize Syndrome Groups

Standard Set                     WRAIR Set
  - Botulism-like                 Botulism-like
  - Hemorrhagic Illness           Hemorrhagic Illness
  - Lymphadenitis
  - Localized Cutaneous Lesion
  - Gastrointestinal              Gastrointestinal
  - Respiratory                   Respiratory
  - Rash                          Rash
  - Specific Infection
  - Fever                         Fever
  - Neurological                  Neurological
  - Severe Illness or Death       Shock/Coma
    Potentially Due to
    Infectious Disease
Comparison of Gastrointestinal Syndromes -
NCA




                                                  % o f % of   % o f Ne w
icd 9    Dx                                       OLD NEW -AP P
789.00   P a in, a b d o mina l, s ite NOS          0.0   28.5         0.0
558.9    Ga s tro e nte ritis , no ninfct NEC      29.1   13.0        23.0
789.07   P a in, a b d o mina l, g e ne ra lize d   0.0    8.2         0.0
787.91   Dia rrhe a NOS                            15.0    6.7        11.9
787.01   Na us e a with vo miting                  13.7    6.1        10.9
787.2    Dys p ha g ia                              0.0    5.8        10.3   Correlation with Old GI
578.1    Blo o d in s to o l                        0.0    3.7         6.5
008.8    Ente ritis , vira l NOS                    7.4    3.3         5.8   New:      R = 0.934
009.0    Ente ritis , infe ctio us NOS              6.1    2.7         4.8   New (minus): R = 0.987
578.9    He mo rrha g e , g a s tro int. NOS        0.0    2.5         4.5
535.00   Ga s tritis , a cute w/o he mo r.          4.7    2.1         3.7
787.02   Na us e a a lo ne                          3.5    1.5         2.7
  Comparison of Fever & Specific Infections -
  NCA




                                           FEVER S
                                             % of      % of
                                     % o f NEW % o f S P E C
icd 9  Dx                            N E W +fmm OLD IN F
780.6 Fe ve r                          82.6 25.3 84.3     0.0
038.9 S e p tice mia NOS                 7.1   2.2 7.3    0.0
780.31 Co nvuls io ns , fe b rile        4.8   1.5 4.9    0.0
088.81 Lyme d is e a s e                 4.2   1.3 0.0  38.5
078.2 S we a ting fe ve r                0.6   0.2 0.0    5.6
034.1 S ca rle t fe ve r                 0.0   0.0 3.1  27.8
066.1 Fe ve r, tick-b o rne              0.0   0.0 0.0  14.0
729.1 Mya lg ia /myo s itis NOS          0.0 44.0  0.0    0.0
780.79 Ma la is e a nd fa tig ue NEC     0.0 25.1  0.0    0.0
Create New Syndrome Groups
                    Viral infection NEC
                    Viral infection NOS
                    Acute nasopharyngitis
                    Acute pharyngitis
       FEVER        Acute laryngitis and tracheitis
                    Acute laryngitis
                    Acute tracheitis
         +          Acute tracheitis w/o obstruction
                    Acute laryngotracheitis
    RESPIRATORY     Acute laryngotracheitis w/o obstruction
                    Upper resp infection of multiple or unspecified sites
                    Acute laryngopharyngitis
                    Upper resp infection of multiple sites
                    Upper resp infection of unspecified sites
                    Acute bronchitis and bronchiolitis
                    Acute bronchitis
                    Acute bronchiolitis
   INFLUENZA-LIKE   Acute bronchiolitis due to other infectious organism
                    Other and unspecified diseases of upper resp tract
    ILLNESS (ILI)   Viral pneumonia
                    Influenza
                    Influenza with pneumonia
                    Influenza with other respiratory manifestation
                    Influenza with other manifestation
                    Bronchitis not specified as acute or chronic
                    Fever
                    Throat pain
                    Cough
Trend Analysis
- Is there an expected trend for the syndrome?
- Is there a “gold standard” for comparing the trend?
       • How well do other ICD9s correlate with the
         gold standard?
       • Do any ICD9s show the same peak/trend
         earlier?
One Approach

1. Begin with a larger set of potential ICD9s
   identified clinically
2. Select those with counts>10 per day
3. Daily and Weekly analyses
  a)   Correlation matrix/ Lagged Correlation
  b)   Factor analysis
  c)   Regression
  d)   Signal-Noise
  e)   Testing sensitivity/ timeliness for known
       outbreaks
 Pneumonia, Bronchitis, Asthma, Chest pain
 & Influenza NCA 1999-2002
   80




   60




   40




   20




    0

        99 9 99 99 9 999 99 9 000 000 000 0 00 0 00 0 00 00 1 001 001 001 001 001 0 02 0 02 00 2 002 002 002
     19    1    1    1   1    2    2    2    2    2    2    2    2    2    2    2    2    2    2    2    2    2     2
3 /1/ 5/1/ 7/1/ 9/1/ 1/1/ 1/1/ 3/1/ 5/1/ 7/1/ 9/1/ 1/1/ 1/1/ 3/1/ 5/1/ 7/1/ 9/1/ 1/1/ 1/1/ 3/1/ 5/1/ 7/1/ 9/1/ 1/1/
                       1                            1                             1                             1
            asthma_49390                         bronchitis_490                      bronchitis_4660
            chestpain_78650                      influenza_all                       pneumonia_486
            7 per. Mov. Avg. (asthma_49390)      7 per. Mov. Avg. (bronchitis_490)   7 per. Mov. Avg. (bronchitis_4660)
            7 per. Mov. Avg. (chestpain_78650)   7 per. Mov. Avg. (influenza_all)    7 per. Mov. Avg. (pneumonia_486)
            0
                5
                    10
                         15
                              20
                                   25
                                                                                                           30
 3/1/1999

 5/1/1999

 7/1/1999

 9/1/1999

11/1/1999

 1/1/2000

 3/1/2000

 5/1/2000
                                                                                                           NCA 1999-2002




 7/1/2000

 9/1/2000

11/1/2000

 1/1/2001

 3/1/2001

 5/1/2001

 7/1/2001

 9/1/2001

11/1/2001

 1/1/2002

 3/1/2002
                                                                                                           Trend Analysis Strep vs. Pneumonia -




 5/1/2002

 7/1/2002

 9/1/2002
                                                                           7 per. Mov. Avg. (strep_0340)




11/1/2002
                                        7 per. Mov. Avg. (pneumonia_486)
      Pneumonia, Bronchitis, Asthma, and
      Chest Pain - EMA 1996-2003
100




 10




                                              7 per. Mov. Avg. (49390 - ASTHMA W/O STATUS ASTHMATICUS)

                                              7 per. Mov. Avg. (78650 - CHEST PAIN, UNSPECIFIED)

                                              7 per. Mov. Avg. (490 - BRONCHITIS NOS)

                                              7 per. Mov. Avg. (486 - PNEUMONIA, ORGANISM NOS)



 1
 1/1/96   7/1/96   1/1/97   7/1/97   1/1/98    7/1/98   1/1/99   7/1/99   1/1/00   7/1/00   1/1/01   7/1/01   1/1/02   7/1/02   1/1/03
NCA Correlation with Pneumonia (weekly
counts)
strep            0.47917   asthma                0.43071
                 <.0001                          <.0001

otitis           0.73643   dyspnea               0.15478
(icd9 = 382.9)   <.0001                          0.0282

sinusitis        0.72223   chest pain            0.14099
(icd9 = 461.9)   <.0001                          0.0459

pharyngitis      0.64767   flu                   0.61175
(icd9 = 462)     <.0001    (icd9 = 487.0)        <.0001

uri              0.87458   flu                   0.64298
(icd9 = 465.9)   <.0001    (icd9 = 487.1)        <.0001

bronch1          0.87648   flu                   0.49470
(icd9 = 466.0)   <.0001    (icd9 = 487.8)        <.0001

bronch2          0.37375   influenza             0.74607
(icd9 = 490)     <.0001    (487.0+487.1+487.8)   <.0001
EMA correlation with pneumonia (weekly
counts)

     bronch1       0.90913   asthma      0.60092
                    <.0001
                                         <.0001
     otitis        0.86519
                    <.0001
                             chestpain   0.50588
     uri           0.85175               <.0001
                    <.0001

     sinusitis     0.83382   strep       0.04141
                    <.0001
                                         0.4245
     bronch2       0.72135
                    <.0001
                             dyspnea     0.04701
     pharyngitis   0.71575               0.3646
                    <.0001
EMA correlation with pneumonia (weekly
counts)

     bronch1       0.90913   asthma      0.60092
                    <.0001
                                         <.0001
     otitis        0.86519
                    <.0001
                             chestpain   0.50588
     uri           0.85175               <.0001
                    <.0001

     sinusitis     0.83382   strep       0.04141
                    <.0001
                                         0.4245
     bronch2       0.72135
                    <.0001
                             dyspnea     0.04701
     pharyngitis   0.71575               0.3646
                    <.0001
          Lagged Correlation with Pneumonia - EMA
                               Lagged Correlation with Pneumonia   EMA




              0.9



                                                                             pneumonia
                                                                             bronch1
              0.7                                                            otitis
                                                                             uri
                                                                             sinusitis
                                                                             bronch2
Correlation




                                                                             pharyngitis
              0.5
                                                                             asthma
                                                                             chestpain
                                                                             dyspnea
                                                                             strep
              0.3




              0.1



                     -3   -2   -1             0              1      2    3
              -0.1
                                    Number of weeks lagged
      Lagged Correlation with Pneumonia - NCA
                        Lagged Correlation with Pneumonia
 1


0.9


0.8


0.7


0.6

                                                                    strep
0.5                                                                 otitis
                                                                    sinusitis
0.4                                                                 pharyngitis
                                                                    uri
                                                                    bronch1
0.3
                                                                    bronch2
                                                                    asthma
0.2                                                                 dyspnea
                                                                    chestpain

0.1                                                                 influenza
                                                                    pneumonia

 0
       -3    -2    -1                0                1     2   3
Summary

• Different methods yield similar results
  (Pneumonia, Bronchitis, Otitis, URI)
• Visual examination may be sufficient
• Very important for users evaluate their
  data and select code sets that are a
  good fit
Access to Code Groups and
Definitions

DoD-GEIS
http://www.geis.ha.osd.mil/GEIS/SurveillanceActi
  vities/ESSENCE/ESSENCE.asp

CDC
http://www.bt.cdc.gov/surveillance/syndromedef
Contributors
•   Walter Reed Army Institute of Research
       Julie Pavlin
       Virginia Foster
       Nicola Marsden-Haug

•   Centers for Disease Control and Prevention
       Sandra Berrios-Torres
       Lori Hutwagner
       Sam Groseclose
       Tracee Treadwell

•   Emergency Medical Associates of New Jersey Research Foundation
       Dennis Cochrane
       Jonathan Rothman

•   New York City Department of Health
       Farzad Mostashari

•   Harvard Medical School and Harvard Pilgrim Health Care
       Richard Platt
       Blake Caldwell
       Katherine Yi
Acknowledgements

• Howard Burkom
   The Johns Hopkins Applied Physics
   Laboratory

• Eugene Elbert, Jay Mansfield and Christina
  Polyak
   Walter Reed Army Institute of Research,
   Division of Preventive Medicine
END
Syndrome Definitions
Syndrome              Definition
Botulism-like         ACUTE symptoms or condition that may represent exposure to botulinum toxin, including palsy, ptosis, dilated
                      pupils, dry mouth, diplopia, descending muscle paralysis.

Fever                 Febrile illness of unspecified origin, including fever and septicemia, unspecified viral illness. EXCLUDE if more
                      specific diagnostic code is present.

Gastrointestinal      ACUTE infection of the upper and/or lower gastrointestinal tract, including specific diagnosis such as Salmonella
                      gastroenteritis; or non-specific symptoms such as nausea, vomiting or diarrhea. EXCLUDES any chronic conditions
                      such as IBS.

Hemorrhagic Illness   SPECIFIC diagnosis of any virus that causes viral hemorrhagic fever (VHF), e.g. Yellow Fever, Dengue, Lassa,
                      Marburg, Ebola. ACUTE symptoms including bleeding gums, hematemesis, bruising,, thrombocytopenia, or
                      decreased clotting factors.

Neurological          ACUTE neurological infection of the CNS, including pneumoccocal meningitis, viral encephailitis, encephalopathy;
                      or symptoms such as meningismus, delerium.

Rash                  ACUTE condition that may present as consistent with smallpox (macules, papules, vesicles predominantly of
                      face/arms/legs). Other diagnosis including chicken pox and viral exanthem. EXCLUDES allergic or inflammatory
                      skin conditions such as rosacea.

Respiratory           ACUTE infection of the upper and/ or lower respiratory tract, including pneumonia, otitis media, parainfluenza virus,
                      sinusitis, pharyngitis, laryngitis, cough, stridor, or throat pain. EXCLUDES chronic conditions such as asthma,
                      chronic sinusitis, or allergic conditions.

Shock / Coma          ACUTE onset of shock or coma from potentially infectious causes, inlcuding sudden death (<24 hours after onset of
                      symptom), death in E.R., intrauterine deaths and still births. EXCLUDES shock from trauma, induced fetal abortions
                      and unattended deaths.