Meeting the International Health Regulations (2005) surveillance core capacity requirements at the subnational level in Europe: the added value of syndromic surveillance.

BACKGROUND: The revised World Health Organization's International Health Regulations (2005) request a timely and all-hazard approach towards surveillance, especially at the subnational level. We discuss three questions of syndromic surveillance application in the European context for assessing public health emergencies of international concern: (i) can syndromic surveillance support countries, especially the subnational level, to meet the International Health Regulations (2005) core surveillance capacity requirements, (ii) are European syndromic surveillance systems comparable to enable cross-border surveillance, and (iii) at which administrative level should syndromic surveillance best be applied? DISCUSSION: Despite the ongoing criticism on the usefulness of syndromic surveillance which is related to its clinically nonspecific output, we demonstrate that it was a suitable supplement for timely assessment of the impact of three different public health emergencies affecting Europe. Subnational syndromic surveillance analysis in some cases proved to be of advantage for detecting an event earlier compared to national level analysis. However, in many cases, syndromic surveillance did not detect local events with only a small number of cases. The European Commission envisions comparability of surveillance output to enable cross-border surveillance. Evaluated against European infectious disease case definitions, syndromic surveillance can contribute to identify cases that might fulfil the clinical case definition but the approach is too unspecific to comply to complete clinical definitions. Syndromic surveillance results still seem feasible for comparable cross-border surveillance as similarly defined syndromes are analysed. We suggest a new model of implementing syndromic surveillance at the subnational level. In this model, syndromic surveillance systems are fine-tuned to their local context and integrated into the existing subnational surveillance and reporting structure. By enhancing population coverage, events covering several jurisdictions can be identified at higher levels. However, the setup of decentralised and locally adjusted syndromic surveillance systems is more complex compared to the setup of one national or local system. SUMMARY: We conclude that syndromic surveillance if implemented with large population coverage at the subnational level can help detect and assess the local and regional effect of different types of public health emergencies in a timely manner as required by the International Health Regulations (2005).

Thrombolysis and clinical outcome in patients with stroke after implementation of the Tyrol Stroke Pathway: a retrospective observational study.

BACKGROUND: Intravenous thrombolysis for ischaemic stroke remains underused worldwide. We aimed to assess whether our statewide comprehensive stroke management programme would improve thrombolysis use and clinical outcome in patients. METHODS: In 2008-09, we designed the Tyrol Stroke Pathway, which provided information campaigns for the public and standardised the entire treatment pathway from stroke onset to outpatient rehabilitation. It was commenced in Tyrol, Austria, as a long-term routine-care programme and aimed to include all patients with stroke in the survey area. We focused on thrombolysis use and outcome in the first full 4 years of implementation (2010-13). FINDINGS: We enrolled 4947 (99%) of 4992 patients with ischaemic stroke who were admitted to hospitals in Tyrol; 675 (14%) of the enrollees were treated with alteplase. Thrombolysis administration in Tyrol increased after programme implementation, from 160 of 1238 patients (12·9%, 95% CI 11·1-14·9) in 2010 to 213 of 1266 patients (16·8%, 14·8-19·0) in 2013 (ptrend 2010-13<0·0001). Differences in use of thrombolysis in the nine counties of Tyrol in 2010 (range, 2·2-22·6%) were reduced by 2013 (12·1-22·5%). Median statewide door-to-needle time decreased from 49 min (IQR 35-60) in 2010 to 44 min (29-60) in 2013; symptomatic post-thrombolysis intracerebral haemorrhages occurred in 28 of 675 patients (4·1%, 95% CI 2·8-5·9) during 2010-13. In four Austrian states without similar stroke programmes, thrombolysis administration remained stable or declined between 2010 and 2013 (mean reduction 14·4%, 95% CI 10·9-17·9). Although the 3-month mortality was not affected by our programme (137 [13%] of 1060 patients in 2010 vs 143 [13%] of 1069 patients in 2013), 3-month functional outcome significantly improved (modified Rankin Scale score 0-1 in 375 [40%] of 944 patients in 2010 vs 493 [53%] of 939 in 2013; score 0-2 in 531 [56%] patients in 2010 and 615 [65%] in 2013; ptrend 2010-13<0·0001). INTERPRETATION: During the period of implementation of our comprehensive stroke management programme, thrombolysis administration increased and clinical outcome significantly improved, although mortality did not change. We hope that these results will guide health authorities and stroke physicians elsewhere when implementing similar programmes for patients with stroke. FUNDING: Reformpool of the Tyrolean Health Care Fund.

Non-infectious events under the International Health Regulations (2005) in Europe--a case for syndromic surveillance.

The scope of the International Health Regulations of 2005 (IHR (2005)) has been expanded. The IHR (2005) are no longer limited to a specific set of infectious diseases, instead they prescribe detection and assessment of any event of potential public health concern regardless of its source or origin. We examine events of non-infectious origin that might fulfill the criteria of a potential public health emergency of international concern under the IHR (2005). These comprise predominately events related to food safety, but also events related to drug safety or of chemical or industrial origin. We argue that to identify these events and assess health effects related to them, existing disease surveillance systems should be augmented with less specific indicator-based syndromic surveillance strategies that use available routine health-related service data for monitoring purposes.

Validity and timeliness of syndromic influenza surveillance during the autumn/winter wave of A (H1N1) influenza 2009: results of emergency medical dispatch, ambulance and emergency department data from three European regions.

BACKGROUND: Emergency medical service (EMS) data, particularly from the emergency department (ED), is a common source of information for syndromic surveillance. However, the entire EMS chain, consists of both out-of-hospital and in-hospital services. Differences in validity and timeliness across these data sources so far have not been studied. Neither have the differences in validity and timeliness of this data from different European countries. In this paper we examine the validity and timeliness of the entire chain of EMS data sources from three European regions for common syndromic influenza surveillance during the A(H1N1) influenza pandemic in 2009. METHODS: We gathered local, regional, or national information on influenza-like illness (ILI) or respiratory syndrome from an Austrian Emergency Medical Dispatch Service (EMD-AT), an Austrian and Belgian ambulance services (EP-AT, EP-BE) and from a Belgian and Spanish emergency department (ED-BE, ED-ES). We examined the timeliness of the EMS data in identifying the beginning of the autumn/winter wave of pandemic A(H1N1) influenza as compared to the reference data. Additionally, we determined the sensitivity and specificity of an aberration detection algorithm (Poisson CUSUM) in EMS data sources for detecting the autumn/winter wave of the A(H1N1) influenza pandemic. RESULTS: The ED-ES data demonstrated the most favourable validity, followed by the ED-BE data. The beginning of the autumn/winter wave of pandemic A(H1N1) influenza was identified eight days in advance in ED-BE data. The EP data performed stronger in data sets for large catchment areas (EP-BE) and identified the beginning of the autumn/winter wave almost at the same time as the reference data (time lag +2 days). EMD data exhibited timely identification of the autumn/winter wave of A(H1N1) but demonstrated weak validity measures. CONCLUSIONS: In this study ED data exhibited the most favourable performance in terms of validity and timeliness for syndromic influenza surveillance, along with EP data for large catchment areas. For the other data sources performance assessment delivered no clear results. The study shows that routinely collected data from EMS providers can augment and enhance public health surveillance of influenza by providing information during health crises in which such information must be both timely and readily obtainable.

Emergency medical helicopter operations for avalanche accidents.

BACKGROUND: In the European Alps emergency medical helicopter services are regularly involved in avalanche rescue missions. How the helicopter emergency medical system best supports avalanche rescue missions is controversial. AIM OF THE STUDY: To study advantages and limitations of the early dispatch of emergency medical helicopters after avalanche accidents. METHODS: Data on rescue mission characteristics and patterns and severity of medical emergencies were obtained for 221 helicopter avalanche rescue missions performed in the Austrian province of Tyrol between October 2008 and June 2011. RESULTS: A buried avalanche victim had to be searched for in only 12 (5.5%) of the 221 rescue missions, whereas medical emergencies were encountered at the scene in 24 missions (11%). Survival rate for totally buried victims extricated after helicopter arrival was significantly lower than for victims extricated before helicopter arrival (19% versus 74%, p=0.0002). In 124 missions (56%) no victim was present at the scene when the helicopter arrived. Medical emergencies involved normothermic cardiac arrest (n=11), severe accidental hypothermia (n=6), critical trauma (n=7) and hypothermia combined with critical trauma (n=1). Survival rate at hospital discharge was 27% for arrested normothermic patients and 50% for trauma and hypothermia patients. CONCLUSIONS: Medical emergencies are encountered at avalanche scenes twice as often as there is need to search for totally buried victims, clearly supporting the immediate dispatch of medical crew members to the accident site. The high rate of emergency medical helicopter operations to avalanche incidents where no victim is injured or buried may be characteristic for densely populated mountainous regions and can be reduced by a restrictive dispatch policy after avalanche accidents without clear information about human involvement.

Lunar phases are not related to the occurrence of acute myocardial infarction and sudden cardiac death.

BACKGROUND: Mass media deliver pertinacious rumours that lunar phases influence the progress and long-term results in several medical procedures. Peer reviewed studies support this, e.g. in myocardial infarction, others do not. METHODS: We looked retrospectively at the dates of cardiac arrests (CA; n=368) of cardiac origin and of acute myocardial infarctions (AMI) with consecutive thrombolytic therapy or acute PTCA (n=872) and at the lunar phases at the corresponding dates. Medical data had been collected prospectively on the patient's admission. The lunar phases were defined as full moon+/-1 day, new moon+/-1 day and the days in between as waning and waxing moon. The incidence of these cardiac events at each phase was calculated as days with a case divided by the total number of days of the specific moon phase in the observation period (1992-1998). Wilcoxon Rank Test was used for statistical analysis. RESULTS: AMI and CA occurred on equal percentages of days within each lunar phase: AMI on 35% of all days with new moon, on 38% of full moon days, on 39% waning, and on 41% of the waxing moon days; CA on 19, 17, 16 and 16% of all days of the respective lunar phase. This difference was not significant. CONCLUSION: Lunar phases do not appear to correlate with acute coronary events leading to myocardial infarction or sudden cardiac death.