Syndrome Reporting Information System™
DRAFT User Guide
Syndrome Reporting Information System™
DRAFT User Guide
Table of Contents
Key to mitigating disease epidemics is situational awareness, both before an outbreak occurs and during an outbreak. Physicians, veterinarians and their assistants will see many of the first cases. A large number of professionals who, though not usually considered to be part of the “clinical” community, also see ill people or animals and collect related data, which is of great value to public health officials (PHOs). Emergency medical technicians, school nurses, animal control personnel, laboratory technicians, and medical investigators fit into this “other” clinical group.
The Syndrome Reporting Information System™ (SYRIS) is a JAVA-based, platform independent system that runs on most PCs and laptops, and does not require a Web browser. SYRIS™ supports two-way disease information reporting and data sharing for these medical professionals.
SYRIS provides a fast, reliable, portable method for reporting suspicious or novel symptoms that may be part of a known disease or disease-complex. SYRIS reporting is based on symptom complexes known as syndromes. Syndromes can be defined with a high degree of specificity (e.g., hemorrhagic fever syndromes) or can be made more general, reflecting common medical care parlance.
SYRIS functions mainly as a data integration tool: data from all SYRIS users is summarized for PHOs to view as temporal graphs and map layers. SYRIS greatly facilitates identification of epidemic disease factors and locations, and also provides a means of distributing medical alerts to all SYRIS users.
The SYRIS design protects patient confidentiality for all types of data reporting because it does not use patient-specific information. PHOs may privately contact a physician or other health professional to obtain patient-specific information if they believe such information is needed to protect public health.
Users must have a valid login (user name and password) in order to enter data into SYRIS. Logins are normally set up by a PHO as they bring users onto the system. A Database Administrator may instead perform this function in some situations. Each user must provide a valid email address before a login can be created.
A SYRIS “community” (user role) is assigned when the user login is created, which regulates the type of reporting screen and SYRIS features that are available to the user. SYRIS user roles are as follows:
· Physician: Can report a Medical Syndrome case.
· Veterinarian: Can report a Veterinary Syndrome case and use the Veterinary GIS Analysis window.
· School Nurse: Can report a School Absenteeism case and view Absenteeism Analysis graphs.
· Animal Control Officer: Can report an Animal Control case and use the Animal Control Analysis window.
· Laboratory Technician: Can report Lab Results for Respiratory Samples, CNS Samples and Stool Samples.
· Emergency Medical Services: Can report an EMS case and use the EMS GIS Analysis window.
· Office of the Medical Investigator (OMI): Can report an OMI case and view the OMI Analysis window, which includes graphs of each OMI syndrome.
· Public Health Official (PHO): Can update Information Panel and Public Health Alerts information; view PHO GIS Analysis tools (all graphs for all syndromes and user roles); create Public Health Alarms; and view, create, and delete user records.
All SYRIS users can view the Information Panel, Local Map, Public Health Alerts and Contact Information, regardless of user role, as soon as SYRIS is started. Once a user logs in, all available tabs will be displayed so that the user can click on the desired tab. The available tabs will vary, depending upon user role.
Note: Screen shots used in this Guide are from a Macintosh. The display is almost identical on a PC, except for slight differences in the style of the tabs and scroll bars.
SYRIS installation is fast and easy, and can be accomplished by any SYRIS user. Installation steps include the following:
1. Go to the correct web page.
2. The web page will check for JAVA™ 1.3 or later, and will provide a link to download JAVA if needed. There is no charge for this software.
3. The user can then download SYRIS from the web page.
Specific installation instructions will be provided upon licensing SYRIS for use.
The first time a user logs into SYRIS, the SYRIS Software Agreement is displayed. The user should scroll to the bottom of the window and click the Agree button in order to start SYRIS.
SYRIS displays the Login window upon startup. Each user’s local PHO or Database Administrator will provide the user name and initial password. The login process is the same, regardless of user role.
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
To log in:
1. Enter the User Name (email address). This field is case sensitive.
2. Enter a valid Password. Passwords must be alphanumeric and include at least four characters. This field is case sensitive.
3. Click the Login button at the bottom of the window.
SYRIS users should check their user profile information when first logging in to ensure the information is complete and correct. Users can update this information and can enter a new password when needed. See the Contact Information Tab topic for more information.
Users can view local alerts of diseases of potential public health importance in the Information of Immediate Local Importance panel without logging in. Alerts are provided by the local public health department at the city, county, or state level, depending on population density. When a PHO updates this information, SYRIS updates the database immediately and displays the new information on every SYRIS screen that is in use. Thus, PHOs can keep the local clinical community (and other authorized users) up-to-date on disease outbreaks of public health significance.
Any SYRIS user can click the Public Health Alerts tab to quickly view an epidemiologic summary. This tab displays the local PHO assessments for each syndrome that medical staff report. Only PHOs can add or change this information. SYRIS updates the information immediately so that it is available to all SYRIS users.
The summary overview (a summary of public health analysis of human disease patterns in a community) is displayed as six separate panels on the Alerts tab. Each panel provides an overview of information about a syndrome. If the overview contains lengthy information, the panel includes a scroll bar at the right edge. Click the upward or downward pointing arrows to view all overview information in the panel.
For additional details, click the Details button at the bottom of the syndrome panel. The Public Health Alerts tab changes to display graphs for Lab Data and Raw Report Count. The syndrome overview information is displayed in the Detailed Information panel at the bottom of the window. Click the scroll arrows to view all information in the panel. Geographic locations where the syndrome occurred are plotted on the Local Map. For navigation instructions, see the Local Map topic.
To return to the Overview, click the Return to Syndrome Overview button at the bottom of the window.
This tab allows SYRIS users to view, and add or update their information when needed. To navigate, users can click in a field, or press the Tab keyboard key to move forward to the next field, or press the Shift+Tab keys to move backward to the previous field.
To enter or change user information:
1. Title/Name: Enter the person’s Title, First and Last Names. This information is entered by the PHO but can be changed if needed. To change this field, select the information, then type the new information. A middle name or initial may also be entered in the Middle Name field if desired.
2. Community: This information is entered by the PHO and cannot be changed by other SYRIS users. Contact your local PHO if a question arises.
3. This field displays the user’s Work Zip Code. This information is entered by the PHO but can be changed if needed. To change this field, click the arrow, then select the correct code from the list.
4. Type the user’s Work Location. For example, Univ. of CA. Do not include the address.
5. Type the user’s Work Phone, including area code. For example, 505-444-3333.
6. Type the user’s Cell Phone, including area code. For example, 505-444-3334.
7. Type the user’s Pager number, if applicable, including area code.
8. Type the user’s FAX number, if applicable, including area code.
9. The user’s E-Mail address is entered by the PHO but can be changed if needed. To change this field, select the information, and then type the new information.
10. The user’s initial Password is entered by the PHO but can be changed if needed. To change this field, select the information, and then type the new information.
11. Click any button or tab and SYRIS will save the new information. Whenever new information is entered and the user clicks any function button or navigates away from the window by clicking a tab, SYRIS automatically saves the new information. This “automatic save” feature prevents accidental loss of data.
Upon login, the map displays the geographic area that is associated with the local PHO’s jurisdiction. When Details are selected for a syndrome, the map view changes to display the geographic area where cases have occurred that are associated with the syndrome.
Navigation buttons allow users to zoom in or out, or to move up, down, left and right. The map can be viewed as a series of layers, some of which are more or less transparent, some of which are colored in various shades, and some of which represent borders of counties, states and zip codes.
Various features of the map can be turned on or off in "groups" (e.g., all of the human syndromes), or individually. The default setting (when the map is first displayed) is to have all features turned on.
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
A user can, for example, choose to turn off the veterinary syndromes by clicking the OFF button to the left of the veterinary group of syndromes. The map display changes to the following view:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
If most of the layers are turned on, the displayed information can be overwhelming or unclear. SYRIS users can turn off individual syndromes or entire groups of syndromes to customize their map view. Active buttons (turned ON) appear with a blue background. Inactive buttons (turned OFF) appear with a gold background.
To turn a group of features off, click the OFF button to the left of the group. Click the ON button to the left of a group of features to turn them on. To turn off an individual button, click the button once. To turn it back on, click the button again.
The feature groups control the map display as follows:
· Map: This group of features allows users to show or hide zip codes, counties, towns, highways, interstates, and shields (highway identifiers).
· Human: This group of features allows users to show or hide the human syndromes: CNS, Hepatitis, ARDS, Fever with Skin Rash, Influenza-like Illness, and Severe Diarrhea.
· Veterinary: This group of features allows users to show or hide the veterinary syndromes: Lymphadenopathy, Pneumonitis, Neurological/Lameness, Downer, Severe Diarrhea, Off Feed/Wasting, Vesicular Lesions, and Drooling.
· EMS: This group of features allows users to show or hide the EMS syndromes: Trauma; Neurological/Stroke; Respiratory; Neurological/Delirium; Cardiac; and Vomiting, Diarrhea, or Dehydration.
· AC: This is a single button that allows users to show or hide the number of animals caught.
Rest the mouse cursor over a button to view a brief description of its function.
To use the navigation features:
1. Zoom: The arrow buttons to the right of the map allow users to zoom in or out. Click an upward-pointing arrow to zoom in; click a downward-pointing arrow to zoom out. The arrows vary in size to indicate whether they zoom by a larger or smaller amount. (Rest the mouse cursor over a button to view its zoom factor.)
2. Return to Default: Click the circle button in the center of the arrow buttons to the right of the map to return to the default map setting. (Rest the mouse cursor over this button to view its description.)
3. Move: The small single arrows at the edges of the map allow users to move up, down, left, or right in the map. Click an arrow once to move slightly in its direction. Click again to move further in that direction. Click and hold the mouse button to scroll in that direction; release the mouse button to stop scrolling.
Each SYRIS user role has an associated analysis tab that allows those users to view case data in graph form, along with the geographic mapping data of where the cases occurred. The graphs provide a quick visual format and an easy method for comparing sets of data.
The numbers on the horizontal x-axis represent the past 30 days, with the current date shown (or implied) at the right end of the axis. The left end of the axis represents the 30th previous day. The example shown was created on July 26th; the 30th previous day, June 27th, appears at the left end of the axis. The numbers 1, 5, 9, 13, 18, and 23 serve as data markers for the first, fifth, ninth, thirteenth, eighteenth and twenty-third days of July.
The vertical y-axis is an integer number that represents a total, such as the number of cases reported for a syndrome, or the number of cases of absenteeism reported by school nurses, or the number of laboratory samples analyzed on a particular day in a clinical lab.
For example, a user might see the following graphs after reporting a case of "Influenza-like Illness" (ILI) as a human clinical syndrome:
The y-axis in the top graph represents the number of respiratory samples received and analyzed by a local clinical laboratory on any given day within the past 30 days (the colors represent specific organisms and are further described in the Laboratory Users topic). The bottom graph displays the raw report count of individual ILI cases: two cases were reported on the 27th of the previous month and one case per day was reported on the 1st, 5th, 15th, 21st and 22nd of the current month.
See the Analysis topic for each user role for more information on using associated graphs.
SYRIS is designed to run in any system environment that includes JAVA™ 1.3 (free from Sun Microsystems) or better. Examples of systems that meet this requirement are Windows 98 and better, Macintosh OS/X, Linux, and Solaris. SYRIS has been routinely tested in the Windows XP and MAC OS/X environments. Please contact ARES Corporation if there are concerns about a particular environment or usage scenario.
SYRIS currently operates on standard desktop and laptop computers that run Windows, Macintosh, and UNIX operating systems, and will soon be capable of operating on Palm/PDA devices. Unlike other systems, SYRIS requires no web-browser or other software; most calculations and graphics are done locally, minimizing the need for high-speed network connections and saving time. There are few, if any compatibility problems, which are common with browser-based software.
Installation is simple, and updates are automated via the Internet. The SYRIS database is maintained on a server or distributed network of servers. Information is displayed to users on a “need-to-know basis,” based on factors such as user role and geographic location.
Unlike most syndrome surveillance software available at this time, SYRIS provides these advantages for system users:
SYRIS requires the following hardware and software specifications, at a minimum.
Hardware:
Software:
Source for the SYRIS GIS mapping feature is as follows:
The information entered by SYRIS users is instantaneously transmitted to the SYRIS database. All SYRIS data are encrypted in the process to limit the ability of hackers to read or damage the data.
The entire SYRIS database, or any portion of it, can be immediately downloaded in flat-database format and quickly imported into commonly-used statistical analysis packages (e.g., JMP, SAS, or SPSS). Because data users have individual preferences for these packages, a “generic” Excel spreadsheet format is used for database retrieval.
These SYRIS features will soon be available:
· Palm/PDA: The ability to run SYRIS on handheld Palm/PDA devices via the JAVA Runtime environment.
· Automated statistical functions for public health analysts and epidemiologists: The ability to select specific data from any of several types of statistical tests (e.g. Chi-square, ANOVA, and time-trend analysis), with SYRIS performing the statistical analysis.
· Syndrome map time-lapse movies: The ability to create and view a time-lapse movie of a syndrome-report map on demand so that PHOs can view a visual time trend analysis.
· Advanced geographic mapping: The ability to show or hide land cover, land use, state of vegetation health, bodies of water, and census socioeconomic data (median income, age by zip, percentage of minorities, number per household, and population density by zip code). Near real-time data from NASA satellites will be downloaded automatically into the map server.
These features will accommodate both local jurisdictions’ and national-level data. Public health officials, law enforcement, and authorized political decision-makers (e.g., governors' and mayors' offices) will be able to visualize data flow in real time as they consult with public health epidemiologists to gain an in-depth understanding of both natural and intentionally-induced disease outbreaks.
Public health officials (PHOs) are interested only in patients that clinicians judge to be truly ill with a presumed infectious disease. In other words, it is the clinicians' judgments of severity of illness that SYRIS captures and communicates to PHOs. Patients with a sore throat, mild fever and cough don’t really fit into “influenza-like illness,” and certainly not into ARDS. SYRIS is designed to balance the need for useful information against the risks of “noisy” information by calling out those syndromes that are strongly associated with serious disease, and then making it easy for clinicians to report cases that in their judgment align with one of the syndromes.
Except for a few weeks out of the year, most studies show that in primary care offices, only a few (less than five) patients per month are seriously ill with a probable infectious disease. It is these few patients that public health officials hope to capture via syndrome-based reporting.
The Public Health Alerts page allows a PHO to enter and view detailed syndrome information, including lab data, raw report counts, and a map of the geographic location(s) that are affected. Other SYRIS users can view the information but cannot update it.
PHOs usually are responsible for setting up new users in SYRIS and providing the user name and password to each user. SYRIS simplifies this task by treating each user’s email address as the user name, which also ensures that communication information is available should a PHO need to communicate directly with a user.
The Clinician Information tab allows fast, easy entry of user information. This tab also allows deletion of a user record, and the ability to move forward or backward through user records. This tab includes function buttons that are not available to other SYRIS users, who view their user information on the Contact Information tab.
To create a user login:
1. Click the Clinician Information tab.
2. Enter the user’s Title, First and Last name. A middle name or initial may also be entered in the Middle Name field if desired.
3. Click the arrow, and then select a Community (user role) from the list.
4. Click the arrow, and then select the user’s Work Zip Code from the list.
5. Enter the user’s E-Mail address.
6. Enter a Password of at least four characters. (The password can be a simple, temporary password that the user must then change after logging into SYRIS for the first time.)
7. Click any button or tab and SYRIS will save the new information. Whenever new information is entered and the user clicks any function button or navigates away from the window by clicking a tab, SYRIS automatically saves the new information. This “automatic save” feature prevents accidental loss of data.
SYRIS organizes syndromes around organ systems, utilizing descriptors that characterize severely ill human or animal patients. These syndromes allow SYRIS users to quickly select a single option that identifies a certain set of disease-indicating factors, instead of selecting a number of individual options to describe the patient’s condition. This speeds data entry and also provides the basis for quick trend analysis and graphical views for evaluation by public health officials.
Each SYRIS user role that reports on patient conditions has a unique set of syndromes. PHOs can view case details and related graphs for all syndromes.
SYRIS uses six human (medical) syndromes. For more information, see the Medical Users section.
SYRIS uses eight animal (veterinary) syndromes. For more information, see the Veterinary Users section.
SYRIS uses six Emergency Medical Services (EMS) syndromes. For more information, see the EMS Users section.
SYRIS uses eight Medical Investigator syndromes. For more information, see the Medical Investigator Users section.
SYRIS includes a wide variety of analytic tools for PHOs, including statistical assessments and GIS-mapping services. In their role as analysts, PHOs may evaluate raw data, display animal and human syndromes on various maps, view trends in laboratory isolates syndrome reports, and review data from animal control and environmental health offices in their local region.
PHOs can share their data with colleagues easily, and no special training is required in order to use any of the tools. PHOs can instantly communicate alerts or advice to other SYRIS users. Physicians, political decision-makers, veterinarians and other PHOs may view the analyses.
A sample scenario for PHO analysis follows.
1. The PHO logs into SYRIS, and then clicks the Public Health GIS Analysis tab. The PHO will see a display similar to this example, which uses Albuquerque, New Mexico and the surrounding geographical area.
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
The associated area is displayed on the map. For information on using map features, see the Geographic Mapping topic.
To the left of the map, SYRIS displays a graph for each syndrome of total cases that were reported during the past 30 days (i.e., the number of cases per day for all classes of syndromes: human, veterinary, EMS, and OMI).
2. There are cases in the foothills of the Sandia Mountains (zip code 87110), an area known to periodically harbor plague-infested fleas. At this point, the PHO might be interested in specific case reports. The PHO can obtain this information by clicking the Export Raw Data button, and the SYRIS database is downloaded immediately to the PHO’s desktop.
Most database programs (e.g., Excel, LOTUS, and Microsoft Access) can open the downloaded SYRIS file with the click of a button. This example uses Excel, which appears as a spreadsheet showing all cases of all syndromes in the SYRIS database, part of which is shown below. Other SYRIS users may request this information from their local PHO.
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
3. Noticing that there are cases of severe respiratory disease in humans in the same locale as the suspected case of cat plague, the PHO can immediately update the alert on the SYRIS Information Panel and on the Public Health Alerts page devoted to respiratory illness. The updated Information Panel would look similar to the example shown below.
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
The updated Information Panel is now displayed on every SYRIS screen that is in use. Thus, PHOs can keep the local clinical community (and other authorized users) up to date on disease outbreaks of public health significance.
SYRIS updates the database as soon as a SYRIS user enters new case data. SYRIS then checks the data to see if the new information matches alarm criteria set by PHOs.
Only PHOs can create an alarm. The alarm feature allows a PHO to select one or more conditions. SYRIS will notify all specified PHOs when the conditions are present.
To create an alarm:
1. Click the Public Health Alarm tab, and then click the New Alarm button.
2. Type a name for the alarm in the New Alarm Name popup window and click the OK button. The name appears in the Current Alarms panel at the left of the window.
3. Click the arrow in the Alarm If field, and then select an alarm condition from the list.
4. If desired, the PHO can add or delete additional alarm conditions. To add a condition, click the …and button and repeat the previous step. To delete a condition, click the Delete Condition button.
5. Specify who should be notified if the alarm conditions occur. To do this, click the arrow in the Notify field at the bottom left corner of the window, then select a name from the list.
In this example, the PHO has created an alarm called “Serious Respiratory Disease,” which will cause an alarm for any case of Influenza-like Illness in which the patient has both an abnormal chest X-ray and an abnormal oxygen saturation level.
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
To create another alarm, click the New Alarm button and repeat steps 1-5.
SYRIS displays the names of all alarms in the Current Alarms panel at the left of the window. An alarm can be deleted if it is no longer needed.
To delete an alarm:
1. Click the alarm name in the Current Alarms panel.
2. Click the Delete This Alarm button.
Physicians commonly describe patients with phrases such as “a 30 year old female with fever and suspected central nervous system (CNS) infection,” or “an elderly male with fever and influenza-like illness.” Because such descriptors have wide acceptance, SYRIS uses this syndrome-complex approach to identify patients that are likely to warrant attention such that reporting to public health officials is indicated. The goal is early identification of diseases of potential public health importance.
SYRIS organizes human syndromes around organ systems, utilizing descriptors that characterize severely ill patients. These syndrome complexes were developed as a result of exhaustive discussions among public health officials (PHOs) and practicing clinicians. The complexes capture the vast majority of diseases of public health importance, including, but not limited to, diseases that could occur as a result of bioterrorism: the intentional introduction of infectious organisms or toxins to create morbidity and panic in a population.
Descriptions of the six SYRIS medical (human) syndromes follow. These descriptions are not “case definitions,” but serve as guidelines for clinicians to consider when seeing a patient who appears to be seriously ill with a presumed infectious cause, in the clinician’s judgment.
1. Influenza-like Illness (ILI): Marked myalgias, fever, general severe prostration or fatigue, headache with or without cough and with or without sore throat. ILI is, by definition, a severe illness and is not compatible with a “cold,” isolated rhinosinusitis, or sore throat alone.
2. Acute Hepatitis (Hep): Any suspected infectious hepatitis (with or without fever). Specific exclusions: alcoholic hepatitis.
For Hep cases, SYRIS is trying to capture patients who, in the physician’s clinical judgment, have a probably infectious cause of hepatitis (e.g., acute Hep A, Hep B, CMV, or even Hep C, although the latter is thought to be unusual). If, in the physician’s clinical judgment, they are seeing a case of drug-induced hepatitis, alcoholic hepatitis, or obstructive biliary disease, the patient probably should not be reported.
3. Acute Respiratory Distress Syndrome (ARDS): Sudden onset of dyspnea or tachypnea, hypoxemia, and diffuse infiltration on chest X-ray. Specific exclusions: suspected cardiogenic shock or congestive heart failure, toxic gas inhalation (e.g., chlorine or phosgene), farmer’s lung.
For ARDS cases, it is helpful to PHOs if the physician provides some clinical data: signs, symptoms, and any routine labs that were obtained. ARDS has a specific definition, but PHOs are interested in any patient, of any age, who has a diffuse pneumonitis associated with low pO2 levels or severe retractions upon examination.
4. Fever with Skin Rash: Any non-localized skin rash when associated with fever. May be accompanied by other findings of importance, such as lymphadeopathy, mucosal erosions or lesions, splenomegaly and changes in WBC or platelet count. Specific exclusions: cellulitis from wound infection, infected contact dermatitis, secondarily infected psoriasis or eczema.
Note: A description of the location of the rash (e.g., extremities, hands, feet, and trunk) and appearance of the rash (macular, maculo-papular, or vesicular) is highly desirable.
This is perhaps the single most significant syndrome from a PHO’s viewpoint. There are many kinds of skin rashes, but there are very few cases where skin rash is accompanied by fever (except in young children). Fever with skin rash in older children, adolescents and adults, is usually representative of a worrisome infectious disease. PHOs are intensely interested in patients and animals with this syndrome. In particular, describe the distribution of the rash and the kind of rash: vesicular, macular, etc.
5. Fever with Central Nervous System (CNS) Findings: Encephalopathy, delirium, mental status changes or meningismus associated with fever. Specific exclusions: fever in the setting of acute cerebrovascular accident; fever with suspected drug or alcohol abuse or overdose; febrile seizures in children.
Fever with neurologic findings is usually a manifestation of a disease of public health importance. It may overlap with other syndromes, such as fever with skin rash, so the selected syndrome classification should be based on the clinician’s judgment of where the patient best fits.
6. Fever with Severe Diarrhea: More than 5 bowel movements in 24 hours that are poorly formed, or have much mucous or blood. May also be accompanied by vomiting. Specific exclusions: suspected inflammatory bowel disease.
For this syndrome, it is helpful if you provide some clinical data: signs, symptoms and any routine labs that you might have obtained (such as a WBC count).
When entering a medical case, it is helpful to PHOs if the physician provides some clinical data: signs, symptoms and any routine labs that were obtained (such as a WBC count). PHOs are only interested in cases that a physician judges, based on clinical experience, to be out of the ordinary in terms of severity, demographics, or associated signs and symptoms.
For example, bloody diarrhea in an adult with colitis symptoms, or diarrhea in a child with a skin rash, might strike a physician as unusual, whereas mild diarrhea in a young child without other serious symptoms might not. PHOs depend on the clinical eye to determine if there seems to be something odd about a case. PHOs are particularly concerned if there is a skin rash, splenomegaly, lympadenopathy or hepatomegaly in a patient, as these clinical indicators may point to a serious infectious disease of public health importance.
For Laboratory and X-ray data, PHOs are interested in a few simple lab tests that may have been obtained. If any of these tests (e.g., WBC, platelet count, chest X-ray or O2 saturation) were obtained as part of the workup of the patient, please indicate the results. In particular, if the chest X-ray is abnormal, describe as closely as possible with the buttons on the page (e.g., Infiltrate, Wide mediastinum, etc.) if any of these findings are present.
Entering a case is fast and easy. To enter data, a medical user simply selects from a drop list or clicks the radio (round) button next to each category that applies. After a new case is entered, SYRIS immediately adds it to the Raw Reports graph on the Public Health Alerts tab so that it is available to other SYRIS users.
· If an incorrect button is selected in a category, click the correct button, and SYRIS “deselects” the first button.
· To deselect any button, click it a second time.
To enter a case, a medical user logs into SYRIS and clicks the Report Syndrome button. SYRIS opens the Medical Syndrome reporting window. The window opens with the Demographics tab active. Users must first enter the demographic data, then the syndrome information.
Demographics refer to patient characteristics that have public health relevance, but do not include patient name, address or other patient-specific information in order to protect patient confidentiality.
The only required data are home or work zip code and selection of a syndrome. To enter Demographics data:
Geographic Information: A home or work zip code is required.
1. ZIP Code: Click the arrow, and then select the home zip code from the list; if you start to type the zip code, the pull-down list will zero in on a smaller subset of zip codes. You may instead enter one via the keyboard in the optional field (for example, a work zip code if the home zip code is unknown.) The zip codes listed are unique to a user’s area (SYRIS maintains a database for every public health jurisdiction).
2. ZIP Code Work: Following the instructions for Home Zip Code, select the work zip code. This field is optional.
3. Recent Travel: If the patient has traveled outside her home area recently, indicate “yes” next to Recent Travel, and indicate if it is U.S. or international travel. The pull down menu will allow users to specify which part of the U.S. or the world, if desired.
Patient Specific Information: This information is optional but desired for statistical purposes.
1. Age Range: Click the radio (round) button that precedes the patient’s age group.
2. Gender: Click the radio button that indicates the patient’s gender.
3. Admitted: Click the radio button that indicates whether the patient was admitted to a care facility.
Pick a Syndrome: This information is required. Click the radio button for the syndrome that best describes the patient’s condition. See the Medical (Human) Syndromes and Medical Case Overview topics for more information.
After entering the Demographics data, click the Syndrome tab to continue. A user may also click the Submit Report button to report the case without additional syndrome (clinical) information. SYRIS does not require that the clinical information be entered but it is encouraged as it helps identify possible disease trends.
The steps are the same to enter any type of syndrome information. Note that some of the options appear as grayed text. If the associated symptom or sign is selected, these options will become active and appear as black text. To enter the syndrome details for a case:
1. Symptoms (Reported by the patient): Click the radio button for Yes or No next to any of the symptoms that apply.
2. Clinical Signs (from Physical Examination): Click the radio button next to each Sign to indicate any that are present, based on the physician’s physical exam.
3. Laboratory and X-ray data: Click next to each result that applies, if any of this data was obtained as part of the workup of the patient. In particular, if the chest X-ray is abnormal, select buttons to describe as closely as possible (Infiltrate, Wide Mediastinum, etc.) if any of these findings are present.
4. Click the Submit Report button at the bottom of the window to save the new information. SYRIS displays the new case in the Raw Reports Count graph on the Public Health Alerts tab.
5. To exit without saving the case information, click the Cancel Report button.
6. Click the Report Syndrome button to add a new case.
A 30-year old male comes into a physician’s office with cough, myalgias, high fever (39.7 degrees C), a mild cough and a sore throat, without rhinorrhea or conjunctival complaints. The patient is an avid runner and hiker, and has just returned from a 10-day backpacking trip in the nearby mountains. He was careful to drink only boiled water, and has no gastrointestinal complaints.
Upon examination, there is palpable lymphadenopathy in the cervical chain, scattered rhonchi and moderate enlargement of the spleen. A CBC shows a platelet count of 52,000, but is otherwise unremarkable. A chest X-ray is normal.
The physician judges that this patient is acutely and at least moderately ill. She is concerned about the splenomegaly and low platelet count, but does not yet have enough information to make a diagnosis. The physician decides that the severity and novelty of the case warrants entry into SYRIS. The physician logs in and enters the pertinent information:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
She decides that the patient best fits into the Influenza-like Illness syndrome, even though it is highly unlikely that the actual diagnosis will turn out to be influenza. The physician completes the Influenza-like Illness syndrome window as follows:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
The physician clicks the Submit Report button and the data are transferred immediately into the SYRIS database (where PHOs can access it within seconds).The new data are reflected in the graphs and map for that syndrome on the Public Health Alerts tab:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
The Public Health Alerts tab displays:
· All similar cases reported over the past 30 days in the Raw Report Count graph, including the new case;
· A map showing all cases of the syndrome; and
· Any relevant laboratory information in the Lab Data graph.
If the physician scrolls the mouse cursor over a bar in the Lab Data graph, the actual count of organisms that make up each of the colors in the bar will appear:
In this way, the physician can be aware of organisms (as reported by laboratories) that may be present in the community. It is a limited, but useful set of information that augments the clinical information. For more information on using graphs, see the Analysis Graphs topic.
The information is also available for review and analysis by PHOs. A PHO may contact the physician directly if concerned that the case is part of a trend that they would like to investigate quickly.
SYRIS provides an easy structure for veterinary reporting, spanning the most common syndromes in a wide variety of animals: domestic and feral dogs and cats, dairy and beef cattle, sheep, pigs, and zoo species (including birds and large mammals). Clinical observations compatible with these syndromes can warn of human disease as well.
For example, in New Mexico, a few human plague cases occur every year, and most of them are fatal, as the disease is not considered in most physicians’ differential diagnosis. However, domestic cats that wander outside are subject to plague as well, and in most years feline plague precedes human plague. Veterinarians make a feline plague diagnosis most often based upon examination: massive swelling of lymph nodes that drain through the skin in association with fever.
SYRIS provides the means for veterinarians’ observations to be easily shared with physicians. Thus, a warning can be provided for the presence of infected fleas and rodents in the community. Sharing of this data has importance for pet owners, farmers and ranchers, zoological veterinarians, and for physicians and emergency medical personnel in rare circumstances (i.e., in a bioterrorism event, where both animals and humans become ill).
Descriptions of the eight SYRIS veterinary syndromes follow. These syndromes span most (although not all) infectious diseases in most species of animals.
1. Lymphadenopathy with Fever: non-localized lymph node swelling of suspected infectious cause. Specific exclusions: known neoplasia, mastitis in mammals, lymphadenitis associated with wound infection, or localized skin trauma.
2. Severe Diarrhea: Stooling inconsistent with diet. Specific exclusions: none.
3. Off Feed/Wasting: Weight loss associated with presumed infectious or degenerative disease. Specific exclusions: oral cavity or gastrointestinal trauma.
4. Neurological/Lameness: Limping or behavioral change due to non-traumatic cause(s).
5. Vesicular Lesions: Self-explanatory. Includes lesions on mouth, tongue, oral mucosa, ocular mucosa, hooves, feet, or skin.
6. Pneumonitis: Any serious respiratory illness associated with fever. No specific exclusions.
7. Downer Animal: Any animal of any species that will not voluntarily assume a standing position. Specific exclusions: trauma.
8. Drooling/Slobbering: Excessive slobbering that appears to be associated with either diffuse inflammation of the oral cavity, upper respiratory lymphadenopathy, or lesions on the tongue. May overlap with Vesicular Lesions; veterinary professionals should use their clinical judgment to best categorize a specific case.
As veterinarians are aware, each syndrome describes a variety of diseases.
For veterinary cases, SYRIS requests a few key pieces of information that will help PHOs decide if a case warrants further investigation (including special laboratory tests that may not be routinely available), and if the suspicion of serious communicable disease exists. If so, public health officials might choose to update the Information Panel’s Alert message in the SYRIS login window.
Geographic Information: A Site Descriptor and a Zip Code are required. The County and State are optional but desired for statistical purposes.
1. Site Descriptor: Click the arrow, and then select the Descriptor from the list. This field is required.
2. ZIP Code: Click the arrow, and then select the owner’s Zip Code from the list. This field is required.
3. County: Type the name of the county where the animal resides. This field is optional.
4. State: Type the name of the state where the animal resides. This field is optional.
Patient Specific Information: Only Animal Classification is required. The other fields are optional but desired for statistical purposes.
1. Recent Transport: Click the radio (round) button for Yes or No to indicate whether the animal was recently transported.
2. Age Range: Click the radio button that precedes the patient’s age group.
3. Gender: Click the radio button that indicates the patient’s gender.
4. Animal Classification: Click the radio button that indicates the patient’s species. This field is required.
Pick a Syndrome: This information is required. Click the radio button for the syndrome that best describes the patient’s condition. See the Veterinary Syndromes topic for more information.
1. Click the Submit Report button at the bottom of the window to save the new information.
2. To exit without saving the case information, click the Cancel Report button.
3. Click the Report Syndrome button to add a new case.
4. To exit without saving the case information, click the Cancel Report button.
5. Click the Report Syndrome button to add a new case.
Veterinary professionals may view all reports of veterinary syndromes in their region (with graphs and map-based detail) or anywhere outside of the public health jurisdiction in which they reside (with maps alone). These analysis tools are available on the Veterinary GIS analysis tab, once the vet logs into SYRIS.
After clicking on the Veterinary GIS Analysis tab, SYRIS displays the following:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
The right panel displays the GIS map, which is centered on the public health jurisdiction where the user is registered (in this example, the map is centered on Albuquerque, New Mexico). For more information on using the map features, see the Geographic Mapping topic.
The left panel displays a set of graphs representing the number of reports of veterinary cases in each of the syndromes over the past 30 days (which is a reasonable time period for monitoring an epidemic). These graphs display the same time period, and the user can scroll up and down to visually compare the number of cases reported in one syndrome versus any other syndrome.
To see if there is any correlation between a specific veterinary syndrome and a specific human syndrome, turn off all of the veterinary buttons and select the veterinary syndrome of interest, and do the same for the human syndromes.
Performing this kind of analysis may assist in making a diagnosis. For example, if veterinary lymphadenopathy is found in the same areas where human influenza-like illness or ARDS are present, the possibility of tularemia is raised (as are several other less common diseases). The specific case details are in the SYRIS database, which is controlled by local PHOs. For more information, see the Public Health Officials topic. The vet would need to contact the PHO to obtain a file of these database records.
More commonly, veterinarians are concerned about infectious disease in the non-human population (i.e., not what physicians refer to as “zoonotic” disease). Having GIS tools readily at hand can assist with many veterinary diagnoses. For example, consider a domestic (residential pet) cat that has lymphadenopathy. If there are other cases of lymphadenopathy in known plague infested areas, the likely diagnosis in the feline patient is also plague. If plague has already been confirmed by local public health laboratories, there will likely be comments on the SYRIS Information Panel or the Public Health Alerts tab.
Thus, GIS tools can assist the office-based as well as large-animal veterinarian. In addition, veterinary syndromes (and veterinarians’ judgment about diagnoses based on syndromes reported in acutely ill animals) will be of enormous use to physicians who may be dealing with zoonotic disease. SYRIS provides rapid exchange of information among professionals who are seeing different but equally important pieces of the infectious disease background in their patients.
A veterinarian in an urban office is examining a cat, brought in by the owner because the pet has been lethargic and disinterested in food. The veterinarian notices that the cat has a fever, and large draining lymph nodes on his neck and upper chest. The vet knows that this is an unusually ill animal, and that it almost certainly is suffering from an infectious disease that could be communicable to humans (e.g., plague or tularemia). The vet decides to report this case via SYRIS to the local public health authorities.
The vet logs into SYRIS and clicks the Report Syndrome button. SYRIS opens the Veterinary Syndrome reporting window. The vet enters the case information, as shown:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
After entering the case, the vet clicks the Submit Report button to send the new case to the SYRIS database. The vet then checks the Veterinary GIS Analysis tab:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
The Veterinary GIS tab shows the new case (entered on July 23, 2004, in this example) in the Lynphadenopathy syndrome graph in the left panel of the window. The GIS map displays shading in the zip code from which the animal came (in this example, the county south of Albuquerque). See the GIS Veterinary Analysis topic for more information on using this tab.
The EMS community is an excellent source of highly valuable information that can help to identify the earliest cases of serious infectious disease in an epidemic. EMS professionals are often the first to see seriously ill patients at home, where evaluation is often performed several hours before a physician completes an examination if the patient is transported to an emergency room. In addition, EMS ambulances often cover very large geographic areas—much larger than a single hospital or physician’s office catchment area. Thus, EMS personnel may be the first to appreciate the widespread nature of a disease outbreak (i.e., the “scope” of the disease). SYRIS helps EMS officials to easily report their data to other SYRIS users who need it for planning, preparation, and response.
Entering a case is fast and easy. To enter data, an EMS user simply selects from a drop list or clicks the radio (round) button next to each category that applies. After a new case is entered, SYRIS immediately adds it to the appropriate Raw Reports graph on the EMS GIS Analysis tab. Thus the new information is available for review and analysis by other EMS users or PHOs.
· If an incorrect button is selected in a category, click the correct button, and SYRIS “deselects” the first button.
· To deselect any button, click it a second time.
Descriptions of the six SYRIS EMS syndromes follow.
1. Trauma: Physical injury (burn, crush, penetrating wound) of external origin (including self-inflicted injury), to any part of the body that significantly compromises function. Specific exclusions: stroke, thromboembolic disorders, metabolic bone disease other than osteoporosis, injury limited to the teeth or tongue.
2. Neurologic/Stroke Syndrome: Localized neurological findings of acute onset, judged to be vascular in origin based on clinical and past medical history. Specific exclusions: intoxination or intoxication.
3. Severe Respiratory Syndrome: Sudden onset of dyspnea or tachypnea, with abnormal hemoglobin oxygen saturation. Specific exclusions: cardiogenic pulmonary edema.
4. Neurologic/Delirium: Acute onset of abnormal mental status in the absence of trauma. Specific exclusions: acute alcohol intoxication or suspect overdose of prescription or non-prescription medication or drugs.
5. Vomiting, Diarrhea with Dehydration: Severe gastrointestinal fluid loss due to presumed infectious or toxic cause (including “food poisoning”). Specific exclusions: upper GI bleeding due to suspected variceal disease, medications, ulcers, or trauma.
6. Cardiac Syndrome: Chest pain (non-pleuritic), with or without shortness of breath; or acute onset pulmonary edema judged to be due to cardiovascular causes such as malignant hypertension, acute coronary syndrome (ACS), or congestive heart failure.
For EMS cases, SYRIS requests a few key pieces of information that will help PHOs decide if a case warrants further immediate investigation should there be a suspicion of serious communicable disease. If so, public health officials might choose to update the Information Panel in the SYRIS login window after further interviewing treating physicians as well as EMS staff.
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
After logging in, the EMS user clicks the Report EMS Case button to open the reporting window. See the Sample EMS Case topic for an example of this reporting window.
A Zip Code and choice of syndrome are required. The other fields are optional but desired for statistical purposes.
1. Date: Click the arrow, and then select the day from the list. Click the arrow, and then select the month from the list. Click the arrow, and then select the year from the list. This field is required.
2. Pick-up ZIP Code: Click the arrow, and then select the patient’s Zip Code from the list. This field is required.
3. Gender: Click the radio button that indicates the patient’s gender.
4. Age Range: Click the radio button that precedes the patient’s age group.
5. Call Type: This information is required. Click the radio button for the syndrome that best describes the patient’s condition. See the EMS Syndromes topic for more information.
6. Comments: This information is optional. Click in this field, and type any additional comments regarding the patient’s condition.
7. Click the Submit Report button to save the new case.
8. To exit without saving the case information, click the Cancel Report button.
9. Click the Report Syndrome button to add a new case.
After entering the case, any registered EMS user can view other EMS reports on a map by clicking on the EMS GIS Analysis tab:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
The right panel displays the GIS map, which is centered on the public health jurisdiction where the user is registered (in this example, the map is centered on Albuquerque, New Mexico). Users can think of the map as a set of “overlays” or “overlapping factors”. In the EMS GIS Analysis map, these overlays are grouped into three categories:
· Geographic Map features
· Human Syndromes
· EMS Syndromes
For more information on using the map features, see the Geographic Mapping topic.
The left panel displays a set of graphs representing the number of reports of EMS cases for each syndrome over the past 30 days. These graphs display the same time period, and the user can scroll up and down to visually compare the number of cases reported in one syndrome versus any other syndrome.
Performing this kind of analysis may assist in making a diagnosis. For example, if EMS teams identify respiratory illness in the same areas where physicians report that influenza-like illness or ARDS are present, the possibility of an easily transmissible disease is raised (e.g., a new variety of influenza) and minimally transmissible disease is less likely (e.g., SARS-Coronavirus).
The Massachusetts Metropolitan Response Service dispatches an ambulance to the home of a 68‑year-old male with known congestive heart failure. The reason for the call is acute onset of shortness of breath.
Upon arrival, the EMS team does a thorough evaluation and notes the following: the patient has a high temperature and appears confused. The respiratory rate is slightly elevated at 16 breaths per minute, and there are no signs of trauma. The patient is unable to identify his wife, who is standing in the room, and complains of a headache. He doesn’t know the day of the week nor the current month. After consultation with a physician in a local ER, the EMS staff decides to log the case in SYRIS.
An EMS team member enters his login name and password, and then clicks the Report EMS Case button. SYRIS displays the Report an EMS Call reporting window.
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
Using their judgment, the EMS team believes that it is unlikely that the patient’s chronic congestive heart failure is responsible for his delirium. Also, given that no focal neurological signs were identified in their assessment, the EMS team rules out acute stroke as a likely explanation for the mental status changes. The EMS team member selects the patient’s Zip Code, gender and approximate age. He then selects the Neurological/Delirium syndrome, as the team believes this category best describes the patient’s condition. The EMS team member enters brief Comments and clicks the Submit Report button to add the case to the SYRIS database.
The new case information can then be viewed on the EMS GIS Analysis tab by other EMS users, or can be viewed by other SYRIS users on their own Analysis tabs.
The regional or local Office of the Medical Investigator (OMI) has access to a highly significant set of data: autopsy and clinical information in cases of “unexpected” or “sudden” death. (For purposes of this Guide, the term “Office of the Medical Investigator” is intended to be synonymous with “Office of the Coroner” or “Office of the Medical Examiner.”) Certain syndromes reported to medical examiners investigating cause of death have a high Bayesian positive-predictive value for the presence of infectious disease.
SYRIS focuses on capturing the registration of cause of death, especially in cases of unexpected or sudden death. This information can help identify whether a new disease-causing organism has entered the community. The presence of a presumed infectious disease is based upon the OMI’s judgment of the category that the deceased fits into.
Entering a case is fast and easy. To enter data, an OMI user simply selects from a drop list or clicks the radio (round) button next to each category that applies. After a new case is entered, SYRIS immediately adds it to the appropriate Raw Reports graph on the OMI Analysis tab, where it can be viewed by other OMI users and PHOs.
· If an incorrect button is selected in a category, click the correct button, and SYRIS “deselects” the first button.
· To deselect any button, click it a second time.
Coroners have used an essentially standard set of syndromes to describe cases that come to autopsy or for death certification. SYRIS has been designed to utilize these eight OMI syndromes, as follows:
· Flu-like Symptoms (defined as myalgias and fever)
· Fever and Respiratory Symptoms (any respiratory symptom)
· Encephalopathy (mental status changes that appear to be due to diffuse processes in the brain)
· Descending Paralysis
· New Fatal rash (death in the setting of an acute, general non-localized skin rash)
· New Jaundice
· Acute Bloody Diarrhea
· Other unexplained death
Unexpected death (in otherwise healthy people) with signs and symptoms consistent with the first two syndromes listed above has a 70-75% positive predictive value (PPV) for infectious disease (usually bacterial). Encephalopathy has a 50% PPV for infectious disease. The significance of the other syndromes is not yet known; however, routine reporting of these syndromes via SYRIS can help to quantify and further delineate previously unappreciated causes of death.
To enter a case, an OMI staff member logs in, and then clicks on the Report OMI Case button.
The only required data for completing a case report are a Zip code (of the patient’s home unless there are extenuating circumstances, such as travel distant from home) and a syndrome (Case Type). The other information is optional but desired for statistical purposes.
1. Date: The current date is automatically entered by SYRIS, but can be changed if needed. Click the arrow, and then select the day from the list. Click the arrow, and then select the month from the list. Click the arrow, and then select the year from the list.
2. Pick-up ZIP Code: Click the arrow, and then select the patient’s Zip Code from the list. This field is required.
3. Gender: Click the radio button that indicates the patient’s gender.
4. Age Range: Click the radio button that precedes the patient’s age group.
5. Case Type: Click the radio button for the syndrome that best describes the person’s condition. See the EMS Syndromes topic for more information. This field is required.
6. Comments: Click in this field, and type any additional comments regarding the person’s condition.
7. Click the Submit Report button to save the new case.
8. To exit without saving the case information, click the Cancel Report button.
9. Click the Report Syndrome button to add a new case.
An elderly female dies unexpectedly on July 21, 2004. Her husband contacts the police, who contact the local OMI. OMI speaks with the husband and learns that his wife had been well until a few days ago, when she had shaking chills and muscle aches. She went to bed, fell asleep and then was discovered dead in the morning. The OMI decides to enter a case report into SYRIS:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
The OMI submits the case information by clicking the Submit Report button.
The new case information can then be viewed on the OMI Analysis tab:
SYRIS displays the syndromes on the OMI Analysis tab as side-by-side graphs for quick comparison. The eight tiled graphs show OMI reports for each SYRIS syndrome over the past thirty days. Note that the case just reported (dated July 21) appears in the OMI Flu-like Symptoms graph in the upper left corner.
After reviewing this data, a PHO may be concerned enough to add the OMI information to the Information Panel or Public Health Alerts tab so it is available to all SYRIS users, as shown here:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
Raw data from OMI reports (and reports from clinicians) can be requested from local public health officials. See the Public Health Officials topic for more information.
School nurses are highly trained professionals who routinely make medical triage decisions. In an elementary school of 400 students, four or five students per day may visit the nurse’s office for acute illness or injury. Also, in most schools, the nurse is responsible for recording daily absences and reporting unusual cases of skin rash or fever to local PHOs. Much of this valuable information is merely recorded on paper and filed away for use in annual and semi-annual reports, when it could be utilized as an early indicator of infectious disease (especially communicable infectious disease).
Because students are usually grouped by age into separate buildings or campuses, there is further value to school nurses’ observations. High absenteeism in one age group (e.g., middle school students, age 12 to 14) that spares high school, junior high and elementary school students provides a strong indication of the source of the illness, even in some cases suggesting the specific diagnosis or etiologic infectious disease agent.
Entering a case is fast and easy. To enter data, a Nurse user simply selects from a drop list or clicks the radio (round) button next to each category that applies. After a new case is entered, SYRIS immediately adds it to the appropriate Raw Reports graph on the Absenteeism Analysis tab, where it can be viewed by other Nurse users and PHOs.
· If an incorrect button is selected in a category, click the correct button, and SYRIS “deselects” the first button.
· To deselect any button, click it a second time.
To enter a report of school absenteeism, the nurse logs in, and then clicks the Report School Absenteeism button.
All data are required to complete an absenteeism report, except Comments; however, brief comments are encouraged to provide clarification or to note specific symptoms.
1. Date: The current date is automatically entered by SYRIS, but can be changed if needed. Click the arrow, and then select the day from the list. Click the arrow, and then select the month from the list. Click the arrow, and then select the year from the list.
2. School: Click the arrow, and then select the correct school from the alphabetized list.
3. Total Number of Students: Click in this field and type the total number of students enrolled at the school.
4. Number of Students Absent: Click in this field and type the total number of students who are absent on the date being reported.
5. Comments: Click in this field, and type any additional comments regarding the students’ symptoms or to note unusual circumstances or concerns.
6. Click the Submit Report button to save the new case.
7. To exit without saving the case information, click the Cancel Report button.
8. Click the Report Syndrome button to add a new case.
After an absenteeism case is entered, SYRIS adds its date and case totals to the elementary, middle school, junior or senior high school “school type,” and updates the appropriate Absenteeism Analysis graph. SYRIS also immediately transmits the information to the local PHOs for review and analysis. Raw data can be requested from the local PHO; see the Public Health Officials topic for more information.
In this example, the total number of students (shown in green) and the total number of absences (shown in red) reported each day over the past 30-day period are plotted on the graph for the appropriate school type. No absences during the last 30 days have been reported for Middle School students, so this graph displays no data.
If the user moves the mouse cursor over a bar in a graph, the exact numbers of present and absent students is displayed:
A number of students in an Albuquerque middle school are absent, as reported on July 14, 2004. The school nurse enters the school and student totals information, and adds a comment that she believes this to be an unusually high number of absentees for this time of year.
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
On the following day (July 15), there are even more absentees, so the nurse enters another report in SYRIS:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
SYRIS adds the new data to the school type totals in the database, and the nurse views the updated numbers in the Middle School graph on the Absenteeism Analysis tab:
The nurse’s report includes comments that at least six of the absent students’ parents reported that their children have a high fever and a skin rash. This is something that the public health department would immediately note upon their review of the data, and they might arrange for parents to take their children either to private physicians or to public health clinics for further evaluation.
The PHOs may decide that this information warrants an alert on the “Public Health Alerts” page:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
Every day, animal control officials, veterinarians, and veterinary assistants pick up and evaluate stray animals, an occasional bird that is obviously sick, and even collect insect samples (e.g., mosquitos) to look for the presence of vector-borne infectious disease. This information has important implications for clinicians, PHOs and even emergency-management officials.
For example, when multiple stray animals are picked up and taken to the local animal shelter for evaluation, often some or most of them are very ill and are euthanized. While this may occasionally happen on a routine basis, were the percentage of ill animals to suddenly change, it could signal the arrival of a pathogen into the community that was either not previously present or caused only a very low incidence of disease.
If mosquitos are collected in wet areas during summer months, and then sent to the local county health lab for PCR analysis for encephalitis virus, a sudden change in percent positivity or the identification of a new encephalitis virus would be of great concern for hospitals, physicians, veterinarians and public health officials.
Entering a case is fast and easy. To enter data, an animal control user simply selects from a drop list or clicks the radio (round) button next to each category that applies. After a new case is entered, SYRIS immediately adds it to the appropriate Raw Reports graph on the Animal Control Analysis tab, where it can be viewed by other animal control users and PHOs.
· If an incorrect button is selected in a category, click the correct button, and SYRIS “deselects” the first button.
· To deselect any button, click it a second time.
To enter an animal control report, an animal control or environmental health official logs in, and then clicks the Report Animal Control Data button.
All data (in either the animal control or etymology fields or both) is required to complete an animal control report, except Comments; however, brief comments are encouraged to provide clarification or to note specific symptoms. The observations of trained animal control and environmental health officials can be extremely informative to public health offices and clinicians in the surrounding community.
1. Date: The current date is automatically entered by SYRIS, but can be changed if needed. Click the arrow, and then select the day from the list. Click the arrow, and then select the month from the list. Click the arrow, and then select the year from the list.
2. ZIP Code: Click the arrow, and then select a Zip Code from the list to indicate where animals were caught or mosquitos were collected.
3. Animals Caught: Click in this field and type the total number of animals that were caught.
4. Animals Euthanized: Click in this field and type the total number of animals that were euthanized.
5. Mosquitos Caught: Click in this field and type the total number of mosquitos that were caught for observation or taken to the local animal shelter.
6. Tested Positive for Encephalitis: Click in this field and type the total number of mosquitos that tested positive for encephalitis.
7. Comments: Click in this field, and type any additional comments to provide clarification or to note specific symptoms.
8. Click the Submit Report button to save the new case.
9. To exit without saving the case information, click the Cancel Report button.
10. Click the Report Syndrome button to add a new case.
Animal control (AC) and environmental health (EH) officials can see reports of all relevant cases reported in their community by clicking on the Animal Control Analysis tab:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
It is easy to see how many animals were caught and taken to animal control by looking at the Animals Euthanized graph on the left side of the screen. The top of each bar indicates the total caught; the red color indicates how many animals were euthanized.
The Mosquitoes with Encephalitis graph indicates how many mosquitos were trapped over the past 30 days and of those, how many were positive for some encephalitis virus (as determined by the local laboratory that performed the analysis). This information is obviously critical to PHOs, clinicians, and veterinarians, by helping to identify vector borne disease and the sentinel signs of other infectious disease that may be in the community.
Five animals were caught in the Alameda area of Albuquerque, NM and were brought to the local animal shelter for evaluation. The animals were obviously thin and had lymphadenopathy in the groin area. One dog was so ill the decision was made to euthanize it.
An animal control official decides to report this case in SYRIS and clicks on the Report Animal Control Data button to open the reporting window:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
The official selects the date, and then selects the zip code where the animals were captured. He enters the number of animals caught and euthanized information. This is all the information that is required to submit the report; however, the official has decided to include some observations in the comment field too. This information is invaluable to public health officials as it represents the professional judgment of animal control officials in selecting key points to emphasize.
The official clicks the Submit Report button and the information is immediately reflected on the Animal Control Analysis tab:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
The Animals Euthanized graph includes the new report, and the map has highlighted the 87114 zip code (in pale yellow) that was previously white. This new data are added to other reports that occurred on the same day, so the graph reflects 11 total animals caught and 3 total animals euthanized:
Thus, animal control information can be immediately disseminated to all SYRIS users. This time-critical information can be collected, analyzed and distributed in a very short period of time.
The clinical laboratory has long been the main source of public health officials’ data. Large clinical labs receive samples from a wide variety of offices, emergency rooms, and even ranches and farms. To date, it has been difficult to integrate this information in a timely manner to serve the early warning function that has become paramount in recent years, as imported diseases have entered into human and animal populations of the U.S. The looming threat of bioterrorism has also increased the importance of laboratory-based surveillance.
The value of laboratory data are further enhanced when combined with clinical reports from veterinarians, physicians, school nurses, EMS professionals, and environmental health reports. SYRIS simplifies lab reporting and automates the process by which this important data gets to multiple users in the clinical and public health community.
Entering a case is fast and easy. To enter data, a Laboratory user simply selects from a drop list or clicks the radio (round) button next to each category that applies. After a new case is entered, SYRIS immediately adds it to the appropriate Lab Data and Raw Reports graphs on the Public Health Alerts tab, where they can be viewed by other SYRIS users and PHOs.
· If an incorrect button is selected in a category, click the correct button, and SYRIS “deselects” the first button.
· To deselect any button, click it a second time.
To enter a Laboratory report, a Lab user logs in, and then clicks the Report Lab Results button.
The Lab reporting window is organized by “station” or “sample type” because large laboratories normally sort clinical samples in this manner. Respiratory Samples is the default page that first appears, listing types of organisms that are most commonly found in respiratory fluids in patients with infectious disease. Reporting of CNS Samples is found under the second tab, which lists types of organisms that are most commonly found in cerebro spinal fluids in patients with infectious disease. Stool Samples is the third tab, which lists types of organisms that are most commonly found in the stool of patients with infectious disease. The Lab user clicks on one of these tabs to enter the lab results data; a separate report must be entered for each tab.
The Start and End dates, Total Samples Tested and number of Positive Results are required to complete a Lab report. A date range is used for Lab reporting because labs often report results on a weekly or similar basis.
The Comments field allows laboratory technicians to provide their observations that may be of great importance to the clinical and public health communities. For example, a laboratory technician might note that a virus is being cultured (e.g., by appearance on HeLa cells) but can not be subtyped. Or Lab personnel may comment that a large number of negative samples have been reported out, and this is an unusual event (a “pertinent negative”). Comments are optional; however, brief comments are encouraged to provide clarification or to note unusual circumstances or concerns.
1. Report Start Date: Enter the date on which sample testing began. The current date is automatically entered by SYRIS, but can be changed if needed. Click the arrow, and then select the day from the list. Click the arrow, and then select the month from the list. Click the arrow, and then select the year from the list.
2. Report End Date: Enter the date on which sample testing ended. The current date is automatically entered by SYRIS, but can be changed if needed. Click the arrow, and then select the day from the list. Click the arrow, and then select the month from the list. Click the arrow, and then select the year from the list.
3. Samples tab: The Respiratory Samples tab is the default. Click on the CNS Samples or Stool Samples tab to enter these types of test results.
4. Total Samples Tested: Click in this field on the appropriate tab, and enter the total number of samples tested for Respiratory, CNS, or Stool samples.
5. Positive Tests: Click in the appropriate organism field(s), and enter the total number of positive results for Respiratory, CNS, or Stool samples.
6. Comments: Click in this field, and type any additional comments regarding the test results or to note unusual circumstances or concerns.
7. Click the Submit Report button to save the new results information.
8. To exit without saving the case information, click the Cancel Report button.
9. Click the Report Syndrome button to add a new case.
The Respiratory Samples tab appears in the Lab Reporting window by default:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
If the user clicks on the CNS Samples tab, a list of CNS organisms appears:
If the user clicks on the Stool Samples tab, a list of stool organisms appears:
Thirty respiratory samples were received on July 18 and July 19, which were “batched” for analysis and reported on July 24, 2004. A SYRIS Laboratory user enters the dates and samples information on the Respiratory Samples tab:
After entering the data, the lab user clicks the Submit Report button, and the data are immediately transmitted to the SYRIS database where other SYRIS users can view it.
When data from laboratories is submitted it is automatically graphed for users to see on each relevant syndrome’s detail page on the Public Health Alerts tab, and color coded to represent the specific organisms of importance that were isolated to that syndrome. In this example, the new Respiratory Samples data can be viewed by clicking on the Public Health Alerts tab, then clicking the ILI Details button to view the associated graphs and map:
(The data in this and all graphics are notional and
do not represent actual patient or public health data from any jurisdiction.)
The graph reflects lab reports from July 18, July 19, and July 20. Move the mouse cursor over the graph and
The ILI Lab Data graph indicates that a number of different organisms have been isolated over the past few weeks by the local laboratory, because the graph displays several colors in each bar. If a user slowly moves the mouse cursor over one of the bars, SYRIS displays results details for each color in the bar.
For example, start moving the mouse cursor at the bottom of the column on July 17 and the graph display now indicates that 6 out of 15 respiratory samples were positive for Influenza A:
Sliding the mouse cursor slowly up the same column, the graph display indicates that 2 of the samples were positive for Influenza B:
The top of each bar is displayed in white, representing the total number of negative samples. SYRIS makes it easy to determine how many samples were positive and for which organism.
This up-to-the minute information can then be used by PHOs to update public health alerts. In this situation, PHOs might change the SYRIS Public Health Alerts record to indicate that there seems to be substantial Influenza A in the community.