Equine syndromic surveillance in Colorado using veterinary laboratory testing order data

Introduction The Risk Identification Unit (RIU) of the US Dept. of Agriculture's Center for Epidemiology and Animal Health (CEAH) conducts weekly surveillance of national livestock health data and routine coordination with agricultural stakeholders. As part of an initiative to increase the number of species, health issues, and data sources monitored, CEAH epidemiologists are building a surveillance system based on weekly syndromic counts of laboratory test orders in consultation with Colorado State University laboratorians and statistical analysts from the Johns Hopkins University Applied Physics Laboratory. Initial efforts focused on 12 years of equine test records from three state labs. Trial syndrome groups were formed based on RIU experience and published literature. Exploratory analysis, stakeholder input, and laboratory workflow details were needed to modify these groups and filter the corresponding data to eliminate alerting bias. Customized statistical detection methods were sought for effective monitoring based on specialized laboratory information characteristics and on the likely presentation and animal health significance of diseases associated with each syndrome. Methods Data transformation and syndrome formation focused on test battery type, test name, sub-mitter source organization, and specimen type. We analyzed time series of weekly counts of tests included in candidate syndrome groups and conducted an iterative process of data analysis and veterinary consultation for syndrome refinement and record filters. This process produced a rule set in which records were directly classified into syndromes using only test name when possible, and otherwise, the specimen type or related body system was used with test name to determine the syndrome. Test orders associated with government regulatory programs, veterinary teaching hospital testing protocols, or research projects, rather than clinical concerns, were excluded. We constructed a testbed for sets of 1000 statistical trials and applied a stochastic injection process assuming lognormally distributed incubation periods to choose an alerting algorithm with the syndrome-required sensitivity and an alert rate within the specified acceptable range for each resulting syndrome. Alerting performance of the EARS C3 algorithm traditionally used by CEAH was compared to modified C2, CuSUM, and EWMA methods, with and without outlier removal and adjustments for the total weekly number of non-mandatory tests. Results The equine syndrome groups adopted for monitoring were abortion/reproductive, diarrhea/GI, necropsy, neurological, respiratory, systemic fungal, and tickborne. Data scales, seasonality, and variance differed widely among the weekly time series. Removal of mandatory and regulatory tests reduced weekly observed counts significantly-by >80% for diarrhea/GI syndrome. The RIU group studied outcomes associated with each syndrome and called for detection of single-week signals for most syndromes with expected false-alert intervals >8 and <52 weeks, 8-week signals for neurological and tickborne monitoring (requiring enhanced sensitivity), 6-week signals for respiratory, and 4-week signals for systemic fungal. From the test-bed trials, recommended methods, settings and thresholds were derived. Conclusions Understanding of laboratory submission sources, laboratory workflow, and of syndrome-related outcomes are crucial to form syndrome groups for routine monitoring without artifactual alerting. Choices of methods, parameters, and thresholds varied by syndrome and depended strongly on veterinary epidemiologist-specified performance requirements.