Objectives. Disease surveillance combines data collection and analysis with dissemination of findings to decision makers. The timeliness of these activities affects the ability to implement preventive measures. Influenza surveillance has traditionally been hampered by delays in both data collection and dissemination. Methods. We used statistical process control (SPC) to evaluate the daily percentage of outpatient visits with a positive point-of-care (POC) influenza test in the University of Utah Primary Care Research Network. Results. Retrospectively, POC testing generated an alert in each of 4 seasons (2004–2008, median 16 days before epidemic onset), suggesting that email notification of clinicians would be 9 days earlier than surveillance alerts posted to the Utah Department of Health website. In the 2008-09 season, the algorithm generated a real-time alert 19 days before epidemic onset. Clinicians in 4 intervention clinics received email notification of the alert within 4 days. Compared with clinicians in 6 control clinics, intervention clinicians were 40% more likely to perform rapid testing ( ) and twice as likely to vaccinate for seasonal influenza ( ) after notification. Conclusions. Email notification of SPC-generated alerts provided significantly earlier notification of the epidemic onset than traditional surveillance. Clinician preventive behavior was not significantly different in intervention clinics. 1. Introduction Influenza causes significant morbidity and mortality in the United States (US), with associated costs of 10–77 billion dollars [1–3]. Current US influenza surveillance activities include the reporting of the percentage of outpatient visits due to influenza-like illness (ILI), reports of laboratory-confirmed influenza hospitalizations and pediatric deaths, pneumonia- and influenza-associated mortality, and viral culture for subtyping [4]. The reporting lag associated with these surveillance measures is 1–4 weeks, which limits the implementation of prevention and control activities [5–7]. This has led to investigation of alternate data sources and analytic techniques that provide earlier notification of influenza activity. An article reviewing the timeliness of alternate data sources for influenza surveillance found that over-the-counter pharmaceutical sales, emergency visits, absenteeism, and health advice calls appeared to be more timely than ILI reporting or virological confirmation, by 3–24 days [8]. This lag results from both the timing of the surveillance event relative to the epidemic onset (affecting viral culture
References
[1]
W. W. Thompson, D. K. Shay, E. Weintraub et al., “Mortality associated with influenza and respiratory syncytial virus in the United States,” Journal of the American Medical Association, vol. 289, no. 2, pp. 179–186, 2003.
[2]
W. W. Thompson, D. K. Shay, E. Weintraub et al., “Influenza-associated hospitalizations in the United States,” Journal of the American Medical Association, vol. 292, no. 11, pp. 1333–1340, 2004.
[3]
N. A. M. Molinari, I. R. Ortega-Sanchez, M. L. Messonnier et al., “The annual impact of seasonal influenza in the US: measuring disease burden and costs,” Vaccine, vol. 25, no. 27, pp. 5086–5096, 2007.
[4]
Centers for Disease Control and Prevention, “Overview of influenza surveillance in the United States,” 2009, http://www.cdc.gov/flu/weekly/pdf/overview.pdf.
[5]
H. Matlof, R. A. Murray, I. Kamei, and G. A. Heidbreder, “Influenza in Los Angeles County, 1968-69,” HSMHA Health Reports, vol. 86, no. 2, pp. 183–192, 1971.
[6]
P. Quenel, W. Dab, C. Hannoun, and J. M. Cohen, “Sensitivity, specificity and predictive values of health service based indicators for the surveillance of influenza A epidemics,” International Journal of Epidemiology, vol. 23, no. 4, pp. 849–855, 1994.
[7]
B. Miller, H. Kassenborg, W. Dunsmuir et al., “Syndromic surveillance for influenzalike illness in an ambulatory care network,” Emerging Infectious Diseases, vol. 10, no. 10, pp. 1806–1811, 2004.
[8]
L. Dailey, R. E. Watkins, and A. J. Plant, “Timeliness of data sources used for influenza surveillance,” Journal of the American Medical Informatics Association, vol. 14, no. 5, pp. 626–631, 2007.
[9]
J. Baumbach, M. Mueller, C. Smelser, B. Albanese, and C. M. Sewell, “Enhancement of influenza surveillance with aggregate rapid influenza test results: New Mexico, 2003–2007,” American Journal of Public Health, vol. 99, supplement 2, pp. S372–S377, 2009.
[10]
R. Lazarus, K. Kleinman, I. Dashevsky et al., “Use of automated ambulatory-care encounter records for detection of acute illness clusters, including potential bioterrorism events,” Emerging Infectious Diseases, vol. 8, no. 8, pp. 753–760, 2002.
[11]
Centers for Disease Control and Prevention, 2009, http://www.cdc.gov/flu/weekly/fluactivity.htm.
[12]
Centers for Disease Control and Prevention, “Current trends influenza surveillance summary—United States, 1982-1983 season,” Morbidity and Mortality Weekly Report, vol. 32, no. 29, pp. 373–377, 1983.
[13]
Centers for Disease Control and Prevention, “Influenza-testing and antiviral-agent prescribing practices-Connecticut, Minnesota, New Mexico, and New York, 2006-07 influenza season,” Morbidity and Mortality Weekly Report, vol. 57, no. 3, pp. 61–65, 2008.
[14]
World Health Organization, “WHO recommendations on the use of rapid testing for influenza diagnosis,” 2008, http://www.who.int/csr/disease/avian_influenza/guidelines/RapidTestInfluenza_web.pdf.
[15]
L. H. Gren, Outpatient influenza surveillance: bridging the gap between between clinical medicine and public health [dissertation], University of Utah, Salt Lake City, Utah, USA, 2010.
[16]
US Census, Table GCT-PH1. Population, Housing Units, Area, and Density. Census 2000 Summary File 1 (SF1) 100-Percent Data, 2000, http://factfinder.census.gov.
[17]
US Census, “State & County QuickFacts,” 2009, http://quickfacs.census.gov.
[18]
A. S. Monto, S. Gravenstein, M. Elliott, M. Colopy, and J. Schweinle, “Clinical signs and symptoms predicting influenza infection,” Archives of Internal Medicine, vol. 160, no. 21, pp. 3243–3247, 2000.
[19]
G. Boivin, I. Hardy, G. Tellier, and J. Maziade, “Predicting influenza infections during epidemics with use of a clinical case definition,” Clinical Infectious Diseases, vol. 31, no. 5, pp. 1166–1169, 2000.
[20]
Utah Department of Health, “Influenza summary report 2005-06 season,” 2008, http://health.utah.gov/epi/disease/flu/ClinicianPublicHealth/PH_DiseaseStatus/u2005/influseasonSum.pdf.
[21]
D. C. Montgomery, Introduction to Statistical Quality Control, Wiley, Hoboken, NJ, USA, 5th edition, 2005.
[22]
Utah Department of Health, “Utah public health influenza surveillance program,” 2009, http://www.health.utah.gov/epi/diseases/flu/SurvInfo.htm.
[23]
Centers for Disease Control and Prevention, “MMWR week fact sheet,” 2009, http://www.cdc.gov/ncphi/disss/nndss/phs/mmwrweek/MMWR_Week_Fact_Sheet.doc.
[24]
Centers for Disease Control and Prevention, “Seasonal flu vaccine,” 2009, http://www.cdc.gov/flu/about/qa/fluvaccine.htm.
[25]
Centers for Disease Control and Prevention, “Interim recommendations for the use of influenza antiviral medications in the setting of oseltamivir resistance among circulating influenza A (H1N1) viruses, 2008-09 influenza season,” 2008, http://www.cdc.gov/flu/professionals/antivirals/.
[26]
B. Miller, H. Kassenborg, W. Dunsmuir, et al., “Syndromic surveillance for influenza like illness in an ambulatory care network,” Emerging Infectious Diseases, vol. 10, no. 10, pp. 1806–1811, 2004.
[27]
D. P. Ritzwoller, K. Kleinman, T. Palen et al., “Comparison of syndromic surveillance and a sentinel provider system in detecting an influenza outbreak–Denver, Colorado, 2003,” Morbidity and Mortality Weekly Report, vol. 54, pp. 151–156, 2005.
[28]
Z. Nagykaldi, J. W. Mold, K. K. Bradley, and J. E. Bos, “Bridging the gap between public and private healthcare: influenza-like illness surveillance in a practice-based research network,” Journal of Public Health Management and Practice, vol. 12, no. 4, pp. 356–364, 2006.
[29]
P. Effler, M. Ching-Lee, A. Bogard, M. C. Ieong, T. Nekomoto, and D. Jernigan, “Statewide system of electronic notifiable disease reporting from clinical laboratories: comparing automated reporting with conventional methods,” Journal of the American Medical Association, vol. 282, no. 19, pp. 1845–1850, 1999.
[30]
J. M. Overhage, S. Grannis, and C. J. McDonald, “A comparison of the completeness and timeliness of automated electronic laboratory reporting and spontaneous reporting of notifiable conditions,” American Journal of Public Health, vol. 98, no. 2, pp. 344–350, 2008.
Utah Department of Health, Epidemiology Newsletter, May 2004. Salt Lake City, Utah, USA, 2004, http://health.utah.gov/epi/newsletter/04may/May_2004_newsletter.pdf.
[33]
P. J. Gavin and R. B. Thomson Jr., “Review of rapid diagnostic tests for influenza,” Clinical and Applied Immunology Reviews, vol. 4, no. 3, pp. 151–172, 2004.
[34]
A. B. Bonner, K. W. Monroe, L. I. Talley, A. E. Klasner, and D. W. Kimberlin, “Impact of the rapid diagnosis of influenza on physician decision-making and patient management in the pediatric emergency department: results of a randomized, prospective, controlled trial,” Pediatrics, vol. 112, no. 2 I, pp. 363–367, 2003.
[35]
Utah Department of Health, Utah—Weekly Influenza Summary, 2008, http://health.utah.gov/epi/diseases/influenza/surveillance/2008-09_Season/PH&C_042909_wk16_flu_posting.pdf.
[36]
P. H. Gesteland, M. A. Allison, C. J. Staes, et al., “Clinician use and acceptance of population-based data about respiratory pathogens: implications for enhancing population-based clinical practice,” in Proceedings of the AMIA Annual Symposium, pp. 232–236, 2008.
[37]
C. G. Grijalva, K. A. Poehling, K. M. Edwards et al., “Accuracy and interpretation of rapid influenza tests in children,” Pediatrics, vol. 119, no. 1, pp. e6–e11, 2007.
[38]
A. R. Falsey, Y. Murata, and E. E. Walsh, “Impact of rapid diagnosis on management of adults hospitalized with influenza,” Archives of Internal Medicine, vol. 167, no. 4, pp. 354–360, 2007.
[39]
P. H. Gesteland, M. H. Samore, A. T. Pavia, et al., “Informing the front line about common respiratory viral epidemics,” in Proceedings of the AMIA Annual Symposium, pp. 274–278, 2007.
[40]
G. Krause, G. Ropers, and K. Stark, “Notifiable disease surveillance and practicing physicians,” Emerging Infectious Diseases, vol. 11, no. 3, pp. 442–445, 2005.
[41]
A. P. Janssen, R. R. Tardif, S. R. Landry, and J. E. Warner, ““Why tell me now?” The public and healthcare providers weigh in on pandemic influenza messages,” Journal of Public Health Management and Practice, vol. 12, no. 4, pp. 388–394, 2006.
[42]
L. H. Gren, S. C. Alder, and E. A. Joy, Clinicians’ Preferred Method of Communication in a Practice-Based Research Network, Poster-Utah Public Health Association, Midway, Utah, USA, 2008.
