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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.
