French Syndromic Surveillance System Research Articles

Investigation of a cluster of acute epiglottitis in Vendée, western France, October – December 2022

ObjectivesIn our investigation of an episode of clustered acute epiglottitis occurring in Vendée, western France, between October and December 2022, we described the reported cases and confirmed its unusual character at several geographic levels. MethodsThe investigation relied on three data sources: hospitalization and emergency department reports; national reference centre data; and data from the French syndromic surveillance system. ResultsThe six patients were male, with an average age of 42 years [32–66]; all were hospitalized in an ICU, and one of them died. Documented risk factors for epiglottitis (active smoking, regular alcohol consumption, overweight) were present in the majority of cases. No causal pathogen was identified. Syndromic surveillance data confirmed increased acute epiglottitis at the local, regional and national levels. ConclusionWe not only characterized the episode of serious clustered acute epiglottitis in Vendée, but also observed a nationwide increase in this pathology occurring concomitantly with increased circulation in France of streptococcus A.

Expert consultation using the on-line Delphi method for the revision of syndromic groups compiled from emergency data (SOS Médecins and OSCOUR®) in France

BackgroundConsultation data from emergency general practitioners known as SOS Médecins and emergency departments (ED) from OSCOUR® network to the French syndromic surveillance system SurSaUD® (Surveillance sanitaire des urgences et décès). These data are aggregated and monitored on a daily basis through groupings of one or more medical symptoms or diagnoses (“syndromic groups” (SG)).The objective of this study was to evaluate, revise and enrich the composition of SGs through a consensus of experts who contributed or have experience in syndromic surveillance.MethodsThree rounds of a Delphi survey were organised, involving 15 volunteers from SOS Médecins and 64 ED physicians in the OSCOUR® network as well as 8 international epidemiologists. Thirty-four SOS Médecins and 40 OSCOUR® SGs covering major medical specialities were put to the experts, along with their diagnostic codes and their surveillance objectives. In each round, the experts could retain or reject the codes according to the surveillance objective. The panel could also put forward new diagnostic codes in the 1st round, included in subsequent rounds. Consensus was reached for a code if 80% of participants had chosen to keep it, or less than 20% to reject it.ResultsA total of 12 SOS Médecins doctors (80%), 30 ED doctors (47%) and 4 international experts (50%) participated in the three rounds. All of the SGs presented to the panel included 102 initial diagnostic codes and 73 additional codes for SOS Médecins, 272 initial diagnostic codes and 204 additional codes for OSCOUR®. At the end of the 3 rounds, 14 SOS Médecins (40%) and 11 OSCOUR® (28%) SGs achieved a consensus to maintain all of their diagnostic codes. Among these, indicators of winter seasonal surveillance (bronchiolitis and gastroenteritis) were included.ConclusionThis study involved a panel of national experts with international representation and a good level of involvement throughout the survey. In the absence of a standard definition, the Delphi method has been shown to be useful in defining and validating syndromic surveillance indicators.

Syndromic surveillance: A key component of population health monitoring during the first wave of the COVID-19 outbreak in France, February-June 2020.

The French syndromic surveillance (SyS) system, SurSaUD®, was one of the systems used to monitor the COVID-19 outbreak. This study described the epidemiological characteristics of COVID-19-related visits to both emergency departments (EDs) and the network of emergency general practitioners known as SOS Médecins (SOSMed) in France from 17 February to 28 June 2020. Data on all visits to 634 EDs and 60 SOSMed associations were collected daily. COVID-19-related visits were identified using ICD-10 codes after coding recommendations were sent to all ED and SOSMed doctors. The time course of COVID-19-related visits was described by age group and region. During the lockdown period, the characteristics of ED and SOSMed visits and hospitalisations after visits were described by age group and gender. The most frequent diagnoses associated with COVID-19-related visits were analysed. COVID-19 SyS was implemented on 29 February and 4 March for EDs and SOSMed, respectively. A total of 170,113 ED and 59,087 SOSMed visits relating to COVID-19 were recorded, representing 4.0% and 5.6% of the overall coded activity with a peak in late March representing 22.5% and 25% of all ED and SOSMed visits, respectively. COVID-19-related visits were most frequently reported for women and those aged 15-64 years, although patients who were subsequently hospitalised were more often men and persons aged 65 years and older. SyS allowed for population health monitoring of the COVID-19 epidemic in France. As SyS has more than 15 years of historical data with high quality and reliability, it was considered sufficiently robust to contribute to defining the post-lockdown strategy.

Description of low back pain attendances in French ED

Abstract Background Low back pain (LBP) is one of the leading contributors to disease burden worldwide [1]. In 2018, French health care insurance launched a population awareness campaign in order to promote effective behaviour change in France. Because LBP acute episodes often lead to emergency visits, Santé publique France, the French Public Health Agency and the Federation of Observatories for Emergency Medecine, performed a pre-campaign situational analysis of LBP in the French emergency department (ED) involved in the OSCOUR® network. Methods The OSCOUR network is part of the French syndromic surveillance system SurSaUD® [2] coordinated by Santé publique France since 2004. In 2017, the system collects daily individual data from about 700 ED representing 92% of the French ED attendances. Those data contain demographic, administrative and medical information including discharge diagnosis coded according ICD-10. ED attendances with a diagnosis related to LBP were analyzed from 2014 to 2017. Temporal distribution of LBP attendances, hospitalizations after discharge and stay duration in ED services were also analyzed. Results From 2014 to 2017, 504 ED were included in the analysis and LBP represented 1.12% (N = 481,291) of ED all visits. This proportion remained stable over the period. 60% of LBP attendances concerned 18 to 50 years old adults and almost 10% were hospitalized after discharge. This proportion increased with age to reach 43% for the 85 years old and more. LBP attendances were more frequent on Monday. Median stay duration were almost 3 hours but increased with age and for hospitalized patients. Conclusions The broad coverage of the ED OSCOUR® network on the whole territory and the strong partnership between epidemiologists and clinicians enable Santé publique France to produce reliable results which are also consistent with ED physician’s perception. Finally those results can be used as a reference contributing to evaluate potential benefits of this campaign. Key messages This description of low back pain ED attendances is consistent with emergency physicians perception on field and can be used as a reference to evaluate potential benefits of the prevention campaign. The national coverage of the ED OSCOUR® network and the strong partnership with emergency physicians enable Santé publique France to produce relevant description on the main causes of ED attendances.

Early evaluation of impacts of cold waves and floods during winter 2018 in France

ObjectiveThe presentation describes the results of the daily monitoring of health indicators conducted by the French public health agency during the major floods and the cold wave that occurred in January 2018 in France, in order to early identify potential impact of those climatic events on the population.IntroductionThe Seine River rises at the north-East of France and flows through Paris before emptying into the English Channel. On January 2018 (from 22th January to 11th February, Weeks 4 to 6), major floods occurred in the Basin of Seine River, after an important rainy period. This period was also marked by the occurrence on the same area of a first cold wave on Week 6 (from 5th to 7th February), including heavy snowfall and ice conditions from 9th to 10th February. A second similar cold wave occured from 28th February and 1st March.Floods of all magnitude are known to have potential health impacts on population [1], both at short, medium and long term both on physical (injuries, diarrhoeal disease, Carbon Monoxyde poisoning, vector-borne disease) and mental health. Extreme cold weather have also the potential to further impact on human health through direct exposure to lower temperatures, and associated adverse conditions, such as snow and ice [2]. Such situations may be particularly associated to direct impact like hypothermia, frostbite and selected bone/joint injuries).MethodsSince 2004, the French Public Health Agency (Santé publique France) set up a national syndromic surveillance system SurSaUD, enabling to ensure morbidity and mortality surveillance [3]. In 2018, morbidity data were daily collected from a network involving about 700 emergency departments (ED) and 58 emergency general practitioners’ associations SOS Médecins. 92% of the national ED attendances and 95% of national SOS Médecins visits are caught by the system.Both demographic (age and gender), administrative (date and location of consultation, transport) and medical information (chief complaint, medical diagnosis using ICD10 codes in ED and specific thesauri in SOS Médecins associations, severity, hospitalization after discharge) are recorded for each patient.The daily and weekly evolution of the number of all-cause ED attendances and SOS Médecins consultations during the flooding period were compared to the evolution on the two previous years. The number of hospitalisations after ED discharge was also monitored. The immediate health impact of floods and cold waves was assessed by monitoring eight syndromic indicators: gastroenteritis, carbon monoxide poisoning, burnt, stress, faintness, drowning, injuries and hypothermia.Analyses were performed by age group (<15 years, 15-64 years, more than 65 years) and at different geographical levels (national, Paris region and districts located in the Basin of Seine River).ResultsIn 2018, syndromic surveillance did not show any major impact on all-cause ED attendances and SOS Médecins consultations from week 4 to week 6, neither in Paris area nor in other areas along the Seine River. The recorded numbers were comparable to the two precedent years in all age groups.A decrease of the all-cause ED attendances was observed during the 1st day with ice conditions in Normandy and Paris, mainly in children and adults aged 15-64 years.During week 6 in Paris area, an increase of ED attendances was observed for injuries (+4% compared to the past weeks – figure 1) and to a lesser extent for hypothermia and frostbite (16 attendances compared to less than 9 for the past weeks). Similar increase in injuries were observed in Normandy during the second cold wave (Figure 1).ConclusionsDuring the flood episode, the rising water level was slow with foreseeable evolution, compared to other sudden flood events occurring in south of France in 2010 due to violent thunderstorms. This progressive evolution allows French authority to deploy wide specific organization in order to mitigate impact on concerned populations. That may explain the absence impact observed in ED at regional and national levels during the flood disaster. The evolution of injuries during 2018 episode is attributable to the cold wave that occurred simultaneously.As the French syndromic surveillance system is implemented on the whole territory and collects emergency data routinely since several years, it constitutes a reactive tool to assess the potential public health impact of both sudden and predictable disasters. It can either contribute to adapt management action or reassure decision makers if no major impact is observed.

Flexibility of ED surveillance system to monitor dengue outbreak in Reunion Island

Flexibility of ED surveillance system to monitor dengue outbreak in Reunion Island

Impact of a new diagnoses thesaurus on the French ED syndromic surveillance system

Impact of a new diagnoses thesaurus on the French ED syndromic surveillance system

Use of the OSCOUR network data to describe low back pain attendances in French ED

ObjectiveThe study describes the characteristics of attendances for low back pain (LBP) in the French emergency departments (ED) network Oscour®, in order to give an overview of this disease before launching a prevention campaign.IntroductionLBP is one of the leading contributors to disease burden worldwide [1]. In France, LBP is a frequent reason of general practice consultations. According to a study published in 2017 and based on 2014 data issued of the National Health Insurance Cross-Schemes Information System (Sniiram) [2], this pathology stands for 30% of thickness leave and 4 of 5 people will suffer of low back pain during their own life. Most often, LBP is a chronic pathology with acute episodes which most often require emergency care.In order to prevent chronicity, French health care insurance launched into a mainstream national prevention campaign during spring 2018. This campaign was also targeted for health professional to inform them of the best recommendations to provide to their patients. Then the French society of emergency medicine (SFMU) has been asked to relay this campaign to emergency departments (ED) where LBP is a frequent reason of attendance.Since 2004, the French syndromic surveillance system SurSaUD® [3] coordinated by the French Public Health Agency (Santé publique France) daily collects morbidity data from the emergency departments (ED) network Oscour®. Almost 92% of the French ED attendances were recorded by the system in 2017.The availability of this large ED dataset on the whole territory since several years gives the opportunity to describe LBP attendances before the potential fallout of the national prevention campaign.MethodsFor each ED attendance, the SurSaUD® system daily collects individual data containing demographic (age, gender, zip code), administrative (ED unit, date of attendance, transport…) and medical information (medical diagnosis (ICD10), chief complaint, severity, hospit.). These data are routinely analyzed to detect and follow-up various expected or unusual public health events all over the territory [3] and also constitute a large database to perform in-depth studies on specific public health issues.ED attendances with a medical diagnosis of LBP have been identified using at least one of the following ICD10 codes “M545”, “M5450”, “M5456”, “M5457”, “M5458”, “M5459”. Those data have been analyzed from 01/01/2014 to 31/12/2017 (504 ED) for the following age groups; less than 18 years old (yo), 18 to 34 yo, 35 to 49 yo, 50 to 64 yo, 65 to 84 yo and 85 yo and over, at national and regional levels. ED attendances have been also described by month, day of week and hour of day. Hospitalizations after discharge, stay duration in ED services, transport and associated diagnoses were also analyzed.ResultsFrom 2014 to 2017, 481,291 ED attendances for LBP were recorded corresponding to 1.12% of the total number of ED attendances with a coded diagnosis. 60% of annual ED attendances for LBP concern 18 to 50 years old adults. The proportion of LBP attendances among the all-cause activity remains stable between 2014 and 2017.At the regional level, LBP proportion among the all-cause activity is similar to the national value in metropolitan regions (0.8% in Brittany to 1.6% in Corsica) and is lower than the national value in overseas regions (0.4% in Mayotte to 0.8% in Guyane) except for Saint-Barthélémy (1.8%).At the national level, almost 10% of ED attendances for LBP are hospitalized after discharge. This proportion increases with age to reach 43% for the 85 years old and more. Proportion of hospitalization ranges between 5.6% (in Paris area) and 17.1% (in Brittany) in metropolitan regions and between 2.8% (Guyane) and 9.3% (Reunion island) in overseas regions.From 2014 to 2017, ED attendances for LBP remain stable by month. However, we observed a slight decrease along the week with more attendances on Monday (17.8% of LBP attendances) than the other days. The attendances are more frequent in the morning (between 6 and 12 AM).At the national level, mean stay duration for LBP attendances in ED is almost 5 hours whereas median stay duration is 2 hours and 45 minutes. Stay duration is longer for patient arrived during night hours (from midnight to 6 AM) and for those hospitalized after discharge. Stay duration is also increasing with age. At the regional level, mean stay duration varies from 3 to more than 6 hours.ConclusionsThe broad coverage of the French ED network on the whole territory since several years enables to give an overview of ED attendances for acute LBP and their characteristics.One strength of the system is its strong partnership between epidemiologists and the ED physicians. It enables to verify that the results of the study are consistent with their perception on the field.The results of this study will be used as reference to evaluate potential benefits of this campaign.Finally, this study is a good illustration of how the syndromic surveillance system in collaboration with ED physicians, can quickly provide valuable data to support political strategies.

Twitter: a complementary tool to monitor seasonal influenza epidemic in France?

ObjectiveTo investigate whether Twitter data can be used as a proxy for the surveillance of the seasonal influenza epidemic in France and at the regional level.IntroductionSocial media as Twitter are used today by people to disseminate health information but also to share or exchange on their health. Based on this observation, recent studies showed that Twitter data can be used to monitor trends of infectious diseases such as influenza. These studies were mainly carried out in United States where Twitter is very popular1-4. In our knowledge, no research has been implemented in France to know whether Twitter data can be a complementary data source to monitor seasonal influenza epidemic.MethodsFor this exploratory study, an R program allowing to the collection, pre-processing (geolocation and classification) and analysis of Tweets related to influenza-like illness was developed.CollectionStream API was used to collect Tweets in French language that contained terms “grippe”,”grippal”, “grippaux” without to specify geolocation coordinates.Pre-processIn order to identify Tweets localized in France, a combination of automated filters has been implemented. At the end, were retained:● Tweets with geolocation coordinates in France (GPS coordinates, country code, country, place name)● Tweets whose place indicated in user’s profile matched with a city, department or region of France● Tweets included FR-related time zone but excluding all Tweets reporting a FR time zone but a non-FR place-code.In the second time, a support vector machine (SVM) classifier was used to filter out noise from the database. To train the classifier, 1500 Tweets were randomly sampled. Each of these 1500 training Tweets was manually inspected and tagged as valid or invalid according to the likelihood that they indicated influenza-like illness. This hand-tagged training set was converted to vector representation using their term-frequency-inverse document frequency (TF-IDF) scores. These TF-IDF vectors were then input to the SVM for training. To evaluate performances of the classifier: accurency, recall and F- measure were calculated from a 1000 randomly sampled Tweets manually tagged.AnalysisData collected over the period from August 8, 2016 to March 26, 2017 were compared to those of the French syndromic surveillance system SurSaUD® (OSCOUR® and SOS Médecins network)5 by Spearman's rank correlation coefficient.EthicalIn accordance to the National Commission on Informatics and Liberty, information about user account were removed in database except location variables. Usernames contained in the text of the tweet have also been deleted.ResultsOver the study period, the system collected 238,244 influenza-related Tweets of which 130,559 were located in France. After a cleaning step, 22,939 Tweets were classified by the algorithm as an influenza-like illness (ILI). The performances of the classifier were 0.739 for accuracy, 0.725 for recall and 0.732 for F-measure. Figure 1 shows that the weekly number of ILI Tweets follows the same trend as the weekly number of ED visits and physicians consultations for ILI. Regardless of data source, Spearman's correlation coefficients were positive and statistically significant at the national level and for each region of France (Table 1).ConclusionsThis exploratory study allowed to show that Twitter data can be used to monitor the epidemic of seasonal influenza in France and at regional level, in complementarity with existing systems. The system needs to be improved to confirm the trends observed during the next influenza epidemic.

Early assessment of public health impacts of major floods in France in June 2016 and winter 2018

Introduction The Seine River rises at the northeast of France and flows through Paris before emptying into the English Channel. On June 2016 (week 22) and January 2018 (weeks 4 to 6), major floods occurred in the Basin of Seine River, after important rainy periods. The second period was also marked by the occurrence on the same area of a cold wave including heavy snowfall and ice conditions on week 6. Floods are known to have potential health impacts on population living in those regions, both at short-, medium- and long-term both on physical and mental health. The objective of the study is to present the results of the daily monitoring of health indicators conducted by the French public health agency (SpFrance) during the two major floods, in order to early identify potential impact of those disasters on the population. Methods Since 2004, SpFrance set up a national syndromic surveillance system SurSaUD, enabling to ensure morbidity and mortality surveillance. Morbidity data are daily collected from a network involving emergency departments (ED) and emergency general practitioners’ associations SOS Medecins. Both administrative (age, gender, date and location of consultation) and medical information (medical diagnosis using ICD10 codes in ED and specific thesauri in SOS Medecins associations) are recorded for each patient. The daily and weekly evolution of the number of all-cause ED attendances and SOS Medecins consultations during the flood periods were compared to the evolution on the two previous years. The number of hospitalisations after ED discharge was also monitored. The immediate health impact of floods was assessed by monitoring eight syndromic indicators related to flood exposure: gastroenteritis, carbon monoxide poisoning, burnt, stress, faintness, drowning, injuries and hypothermia. Analyses were performed by age group and at different geographical levels (national, Paris region and districts located in the Basin of Seine River). Results During week 22-2016, a decrease of total number of ED attendances all ages and more specifically for children aged less than 15 years old was observed in region Centre (−15% compared with weeks 21 and 23) and to a lesser extent in Paris area (−4% and −12% respectively compared with week 21 and week 23). Locally, in the most impacted cities, an increase of total ED attendances was also observed for people aged 65 years and more. At the opposite, the number of all-cause SOS Medecins consultations remained stable in all age groups. Analysis by syndromic indicator did not show unusual variations during the first flood period. In 2018, syndromic surveillance did not show any major impact on all-cause ED attendances and SOS Medecins consultations from week 4 to week 6, neither in Paris area nor in other areas along the Seine River. The numbers were comparable to the two precedent years in all age groups. During week 6 in Paris area, an increase of ED attendances was observed for injuries (+4% compared to the past weeks) and to a lesser extent for hypothermia (16 attendances compared to less than 9 for the past weeks). Conclusion For both flood episodes the rising water level was slow with foreseeable evolution, compared to other sudden flood events occurring in south of France in 2010 due to violent thunderstorms. This progressive evolution allows French authority to deploy wide specific organization in order to mitigate impact on concerned populations. That may explain the limited impact observed during the two flood disasters. The evolution of injuries during 2018 episode is attributable to the cold wave that occurred simultaneously. As the French syndromic surveillance system is implemented on the whole territory and collects emergency data routinely since several years, it constitutes a reactive tool to assess the potential public health impact of both sudden and predictable disasters. It can either contribute to adapt management action or reassure decision makers if no major impact is observed.

Increase of Scarlet fever in March 2017 in France: right or wrong signal?

Objective: Describe a case study of validation of a scarlet fever outbreak using syndromic surveillance data sources.Introduction: Since 2004, the French syndromic surveillance system SurSaUD® [1] coordinated by the French Public Health Agency (Sante publique France) daily collects morbidity data from two data sources: the emergency departments (ED) network Oscour® and the emergency general practitioners’ associations SOS Médecins. Almost 92% of the French ED attendances are recorded by the system. SOS Médecins network is a group of 62 associations of general practitioners, dispatched all over the territory. Sante publique France received data from 61 out of 62 associations. Both data sources collect medical diagnosis, using ICD10 codes in the ED network and specific medical thesaurus in SOS Médecins associations.These data are routinely analyzed to detect and follow-up various expected or unusual public health events all over the territory [2]. The system is also used for reassurance of decision makers. In that framework, in March 2017, the French Ministry of Health requested Santé publique France to validate a potential scarlet fever outbreak in France.Methods: ED attendances for scarlet fever were identified using the ICD10 code “A38”. SOS Médecins visits with the specific code corresponding to “scarlet fever” were considered.The weekly numbers of ED attendances and SOS Médecins visits for scarlet fever were analyzed from 02/01/2017 (week 5) to 03/31/2017 (week 13) by age group (all ages and less than 15 years old, scarlet fever affecting mainly children) and were compared to the numbers of attendances and visits registered during the same period of the two previous years.Analysis was conducted both at national and regional levels. In order to take into account the improvement of data quality during the study period, we also calculated proportion of attendances and visits for scarlet fever among the overall attendances (respectively visits) with medical coded information.Results: The number of SOS Médecins visits for scarlet fever started to increase in week 9 of 2017. Almost 95% of visits concerned children aged less than 15 years old. SOS Médecins visits for scarlet fever represented 0.24% of the overall visits for the 2 age groups for weeks 11, 13 and 14. This proportion was never reached in 2015 and was observed twice in 2016, but later in the year (weeks 25 and 26).The regional analysis showed that all French metropolitan regions contributed to the increase, even if Paris region was the most impacted. More specifically, cases were mainly located in the east part of the Paris region (in Seine-et-Marne).In the OSCOUR® network, the analysis of the number of attendances for scarlet fever at the national level shows a limited increase from week 9 to week 12. Weekly proportion of ED attendances for scarlet fever among the total coded attendances remained comparable to those observed the two previous years on the same period.The regional analysis also showed that 35% of attendances for scarlet fever during this period were observed in Paris area. But, number of attendances for scarlet fever in this region was comparable during this period to numbers observed the two previous years.Conclusions: The analysis of emergency syndromic data sources enables to confirm an increase of consultations for scarlet fever in SOS Médecins associations from weeks 9 to 14, mainly for children less than 15 years old.The large implementation of the SOS Médecins associations on the whole territory allowed us to provide a geographical location of the outbreak: mainly in the east part of Paris area. The temporal pattern of scarlet fever visits in this region may be in favor of a small cluster of cases.The availability of data collected routinely during a long period of time by the syndromic surveillance system enables to evaluate that the outbreak occurred earlier than the previous years, but the intensity of the outbreak was similar to those observed previously.Scarlet outbreak was not confirmed through the ED network, even if a limited increase was observed during the same period of time. The investigation of this outbreak in ED network revealed a miscoding practice in one ED structure, resulting locally in a larger number of attendances than in the other ED of Paris area.Finally, this case study led to improve data quality and highlighted the importance of the validation step of alarms by epidemiologists, even in an automatized system.

User-friendly Rshiny web applications for supporting syndromic surveillance analysis

ObjectiveThe presentation describes the design and the main functionalitiesof two user-friendly applications developed using R-shiny to supportthe statistical analysis of morbidity and mortality data from the Frenchsyndromic surveillance system SurSaUD.IntroductionThe French syndromic surveillance system SursaUD® has beenset up by Santé publique France, the national public health agency(formerly French institute for public health - InVS) in 2004. In 2016,the system is based on three main data sources: the attendancesin about 650 emergency departments (ED), the consultations to62 emergency general practitioners’ (GPs) associations SOSMédecins and the mortality data from 3,000 civil status offices [1].Daily, about 60,000 attendances in ED (88% of the nationalattendances), 8,000 visits in SOS Médecins associations (95% ofthe national visits) and 1,200 deaths (80% of the national mortality)are recorded all over the territory and transmitted to Santé publiqueFrance.About 100 syndromic groupings of interest are constructed fromthe reported diagnostic codes, and monitored daily or weekly, fordifferent age groups and geographical scales, to characterize trends,detect expected or unexpected events (outbreaks) and assess potentialimpact of both environmental and infectious events. All-causesmortality is also monitored in similar objectives.Two user-friendly interactive web applications have beendeveloped using the R shiny package [2] to provide a homogeneousframework for all the epidemiologists involved in the syndromicsurveillance at the national and the regional levels.MethodsThe first application, named MASS-SurSaUD, is dedicated to theanalysis of the two morbidity data sources in Sursaud, along with dataprovided by a network of Sentinel GPs [3]. Based on pre-aggregateddata availaible daily at 10:30 am, R programs create daily, weeklyand monthly time series of the proportion of each syndromic groupingamong all visits/attendances with a valid code at the national andregional levels. Twelve syndromic groupings (mainly infectious andrespiratory groups, like ILI, gastroenteritis, bronchiolitis, pulmonarydiseases) and 13 age groups have been chosen for this application.For ILI, 3 statistical methods (periodic regression, robust periodicregression and Hidden Markov model) have been implementedto identify outbreaks. The results of the 3 methods applied to the3 data sources are combined with a voting algorithm to compilethe influenza alarm level for each region each week: non-epidemic,pre/post epidemic or epidemic.The second application, named MASS-Euromomo, allowsconsulting results provided by the model developed by the Europeanproject EuroMomo for the common analysis of mortality in theEuropean countries (www.euromomo.eu). The Euromomo model,initially developed using Stata software, has been transcripted inR. The model has been adapted to run in France both at a national,regional and other geographical administrative levels, and for 7 agegroups.ResultsThe two applications, accessible on a web-portal, are similarlydesigned, with:- a dropdown menu and radio buttons on the left hand side to selectthe data to display (e.g. filter by data source, age group, geographicallevels, syndromic grouping and/or time period),- several tab panels allowing to consult data and statistical resultsthrough tables, static and dynamic charts, statistical alarm matrix,geographical maps,... (Figure 1),- a “help” tab panel, including documentations and guidelines,links, contact details.The MASS-SurSaUD application has been deployed in December2015 and used during the 2015-2016 influenza season. MASS-Euromomo application has been deployed in July 2016 for the heat-wave surveillance period. Positive feedbacks from several users havebeen reported.ConclusionsBusiness Intelligence tools are generally focused on datavisualisation and are not generally tailored for providing advancedstatistical analysis. Web applications built with the R-shiny packagecombining user-friendly visualisations and advanced statistics can berapidly built to support timely epidemiological analyses and outbreakdetection.Figure 1: screen-shots of a page of the two applications

Spatial analysis of SS population coverage based on emergency regional healthcare

ObjectiveTo analyse population coverage of syndromic surveillance(SS)based on emergency care data by studying i)the attractiveness ofrespectively SOS Médecins (Emergency care general practitioners)and Hospital emergency departments in the Centre-Val de Loireregion and ii) the contribution of ecological deprivation factors inemergency access to healthcare.IntroductionSOS Médecins France (SOS Med) is the first private and permanentnetwork of general practitioners providing emergency care in France.Besides Hospital emergency departments (HED), SOS Med istherefore a major source of data for detecting and measuring near-real-time health phenomena. The emergency services provided by theSOS Med have been subject to important changes in the recent years.Their services are enriched by a medical consultation center togetherwith extended working hours. Besides, the south of the region ismarkedly affected by a declining number of medical practitionersThis study was conducted to analyze the regional population coverageof emergency healthcare data provided by HED and SOS Med tothe French syndromic surveillance system (SurSaUD®) takinginto account distance, health care offer, demographic factors andecological deprivation factors.MethodsAn analysis of the activities and geographic attraction was carriedout based on the data respectively provided by the three regional SOSMed and three HED (Bourges, Orléans and Tours). Quasi-Poissonregression modelling was used to identify the factors influencing theattractiveness of each organization. Next, the findings were refinedthrough spatial analysis of the attractiveness of HED and SOS Medand analysis of the contribution of deprivation based on socio-economical and healthcare facilities ecological indexes.ResultsIn terms of age group, children under 2 years required the largestservice consultations as well as seniors over 75 who sought moreemergency visits at home. The SOS Med were almost always active inurban areas and at least once in two due to continuity of care. So theyare an efficient source of general medical care given present workhours. Distance as an influential factor may explain the differencesin attraction to the support type. The extent of the attraction appearsin 36% SOS Med Bourges and 14% for SOS Med Orleans. Addthe extent of attraction for SOS, remote consultation for SOS Medassociations are a good use of care in general practice in present workhours scheme.In terms of monitoring of epidemics, we note that the SOSMédecins associations are most active in winter, particularly duringthe seasonal epidemics of influenza. This can be explained by the factof patient referrals during calls. The most serious cases are redirectedto the ED and cases of general medicine to the SOS Médecins.It is also important to note that the attraction of ED ofCHR Orléanscovers more or less important a large part of the regional territory,which is not visible to the ED ofCH Bourges. It should neverthelessbe noted that theCHR Orleansa larger bed capacity than theCH Bourges.ConclusionsThis research has analysed the changes taking place in the SOSmédecins associations in the Centre-Val de Loire region. Findingsshows that these associations help ensure access to general medicalcare in a context of strongly reduced medical demography althoughwith an uneven, primarily urban, geographical coverage. Withbetter knowledge of the geographic span and sources and types ofemergency care provision, further research can be undertaken tofurther refine and interpret the data.

Syndromic surveillance and UEFA Euro 2016 in France – Health impact assessment

ObjectiveTo describe the surveillance indicators implemented for the healthimpact assessment of a potential health event occurring before, duringor after the UEFA Euro 2016 football matches in order to timelyimplement control and prevention measures.IntroductionFrance hosted 2016 UEFA European Football Championshipbetween June 10 and July 10. In the particular context of severalterrorist attacks occurring in France in 2015 [1], the French nationalpublic health agency « Santé publique France » (formerly FrenchInstitute for Public Health Surveillance-InVS) was mandated bythe Ministry of Health to reinforce health population surveillancesystems during the UEFA 2016 period. Six French regions and10 main stadiums hosted 51 matches and several official andnonofficial dedicated Fan Zones were implemented in many citiesacross national territory. Three types of hazard have been identified inthis context: outbreak of contagious infectious disease, environmentalexposure and terrorist attack.The objectives of health surveillance of this major sportingevent were the same as for an exceptional event including massgathering [2] : 1/ timely detection of a health event (infectiouscluster, environmental pollution, collective foodborne disease...)to investigate and timely implement counter measures (control andprevention), 2/ health impact assessment of an unexpected event.The French national syndromic surveillance system SurSaUD® wasone of the main tools for timely health impact assessment in thecontext of this event.MethodsFrench national syndromic SurSaUD® system has been setup in 2004 and supervised by Santé publique France for 12 years.It allows the daily automatic collation of individual data from over650 emergency departments (ED) involved in the OSCOUR®network and 61 emergency general practitioners’ (GPs) associations(SOS Médecins) [3]. About 60,000 attendances in ED (88% of thenational attendances) and 8,000 visits in SOS Médecins associations(95% of the national visits) are daily recorded all over the territoryand transmitted to Santé publique France.Medical information such as provisional medical diagnosiscoded according to the International Classification of Diseases, 10thRevision (ICD-10) for EDs and specific thesaurus for SOS Médecinsis routinely monitored through different syndromic indicators (SI).SI are defined by medically relevant clusters of one or severaldiagnoses, serving as proxies for conditions of public health interest.From June 10 to July 10, 19 SI were daily analyzed throughautomatic national and regional dashboards. SI were divided into3 groups of public health surveillance interest :1/ description of population health: injuries, faintness, myocardialinfarction, alcohol, asthma, heat-related symptoms, anxious troubles ;2/ infectious diseases/symptoms with epidemic potential ordiseases/symptoms linked with an environmental exposure: fever,fever associated with cutaneous rash, meningitis, pneumonia,gastroenteritis, collective foodborne disease ;3/ symptoms potentially linked with a CBRN-E exposure:influenza-like illness, burns, conjunctivitis, dyspnea/ difficultybreathing, neurological troubles, acute respiratory failure.Daily analysis were integrated into specific UEFA 2016surveillance bulletins and daily sent to the Ministry of Healthincluding week-ends.ResultsSI followed during the UEFA Euro 2016 period were nonspecificand potentially affected or influenced by several events appart fromthe championship. Between June 10 and July 10, two moderateheat-wave periods occurred on a large part of mainland France : thefirst one from June 22 to 25 (beginning in the West-South of Franceand then moving North and East of the country) and the secondone from July 8 to 11 in the East-South. An increase in heat-relatedindicators (hyperthermia/heat stroke, dehydration, hyponatremia andburns) has been observed during both periods in five French regionsincluding four hosting regions. Only minor increases in the other SIfollowed during the Euro 2016 period were observed.ConclusionsHealth surveillance implemented during 2016 UEFA EuropeanFootball Championship through a daily analysis of non-specificSI from the French syndromic surveillance system SurSaUD® didnot show any major variation associated with the sporting event.The observed variations were related with specific environmentalconditions (heat-waves). Together with the health surveillancesystem, preventive plans were set up during the event essentially byoffering flyers with information and useful tips on the main preventiveattitudes and measures to adopt in a summer festive context (risksassociated with alcohol and drug intake, injuries, heat and sunexposure, dehydration, unprotected sexual behaviour...).

Impact of the 2015 July Heat Waves in France on Heat-Related Causes

Presentation of the impact of two major heat waves occurring in July 2015 in France on heat-related causes in emergency health care facilities, using the French syndromic surveillance system SurSaUD®.

Real-Time Health Impact Assessment Of A Major Air Pollution Episode May Underestimate The Problem, March 2014, France

Introduction On 6-18 March 2014, a major episode of air pollution (PM10 concentrations exceeding 100 µg/m3 locally for several days) affected almost all France as well as other European countries, with impact in French media and policy-makers. We monitored health impact in France and consulted on actions taken in other countries. Methods From 6 to 25 March 2014, we monitored selected morbidity indicators a priori linked to air pollution using the French syndromic surveillance system SurSaUD® that covers 70% of emergency department visits and almost all doctors' house calls. On May 6, we sent a short questionnaire to 15 international experts asking how their countries/cities assessed the health impacts of such episodes. Results At the national level, no health impact could be detected during and after the episode. However, in the Paris area that faced the highest levels of air pollution, reported emergency department visits for asthma increased with a peak on 20 March (n=152), three times higher than during the reference period. Fourteen of 15 international experts indicated that they assess health impacts of such episodes a posteriori through time series analyses, while one reported real-time syndromic surveillance during the episode. Discussion Even if syndromic surveillance gives timely information on potential local health problems, international experts reported difficulties detecting real-time impact. Dialogue is needed with authorities requesting real-time health impact assessments as waiting for reported health outcome may delay prevention measures. But can the science of epidemiology better meet the authorities' needs?

Chikungunya Epidemic in the French Overseas Territories using Syndromic Surveillance

In December 2013, an emergence of chikungunya was observed in the French Caribbean region. The French syndromic surveillance system SurSaUD, based on the daily collection of attendances on emergency departments and calls to associations SOS Medecins, ensure a complementary surveillance with the specific system based on a sentinel general practitioners network. This study describes the temporal pattern of the chikungunya epidemic and the characteristics of patients in the French overseas territories of Americas using the syndromic surveillance system.

The French Emergency Department OSCOUR Network: Evaluation After a 10-year Existence

Implemented 10 years ago, the French syndromic surveillance system Oscour, based on emergency departments, has been assessed using four major evaluation criteria in syndromic surveillance: stability and regularity of data transmission, the coverage at the national level, data quality, particularly for medical information and the utility of the system for the public health surveillance. In 2014, about 40,000 daily attendances are extracted automatically from 600 ED departments located all over the territory, covering 80% of the national attendances. About 12,800 different ICD10 codes have been used in 2013, enabling a large public health surveillance.

Determinants of Daily Attendances in Emergency Departments for Asthma in the Paris Area

Asthma is one of the numerous syndromic indicators daily monitored at the regional and national levels by the French syndromic surveillance system based on the emergency departments Oscour network. This indicator presents important daily fluctuations and can be influenced by several environmental, infectious and societal factors. Particularly the short-term impact on asthma of episodes like the air pollution peak experienced in March 2014 and the thunderstorm occurred in July 2014 has been analysed by age group on the Paris area, as well as the effect intrinsic factors (day-of-week, seasonal period, holidays).

Syndromic Surveillance of Acute Liver Failure in Emergency Departments (France, 2010-2012)

Our objectives were to explore the relevance of emergency departments' (ED) data, collected daily through the French syndromic surveillance system (414 EDs, 65% attendances), to describe the characteristics of patients with acute liver failure (ALF). Data corresponding to ICD10 codes related to hepatitis diagnosis that include ALF ICD10 code (K720) were extracted and analyzed. During 2010-2012, 246 730 attendances with hepatitis were recorded of which 2 475 (1%) were linked to ALF. Patients with ALF were male (60%), their median age was 55 years. This study shows the relevance of French syndromic surveillance data to assess the burden of ALF.