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1.  SAGES Update: Electronic Disease Surveillance in Resource-Limited Settings 
Objective
The Suite for Automated Global Electronic bioSurveillance (SAGES) is a collection of modular, flexible, open-source software tools for electronic disease surveillance in resource-limited settings. This demonstration will illustrate several new innovations and update attendees on new users in Africa and Asia.
Introduction
The new 2005 International Health Regulations (IHR), a legally binding instrument for all 194 WHO member countries, significantly expanded the scope of reportable conditions and are intended to help prevent and respond to global public health threats. SAGES aims to improve local public health surveillance and IHR compliance with particular emphasis on resource-limited settings. More than a decade ago, in collaboration with the US Department of Defense (DoD), the Johns Hopkins University Applied Physics Laboratory (JHU/APL) developed the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE). ESSENCE collects, processes, and analyzes non-traditional data sources (i.e. chief complaints from hospital emergency departments, school absentee data, poison control center calls, over-the-counter pharmaceutical sales, etc.) to identify anomalous disease activity in a community. The data can be queried, analyzed, and visualized both temporally and spatially by the end user. The current SAGES initiative leverages the experience gained in the development of ESSENCE, and the analysis and visualization components of SAGES are built with the same features in mind.
Methods
SAGES tools are organized into four categories: 1) data collection, 2) analysis & visualization, 3) communications, and 4) modeling/simulation/evaluation. Within each category, SAGES offers a variety of tools compatible with surveillance needs and different types or levels of information technology infrastructure. SAGES tools are built in a modular nature, which allows for the user to select one or more tools to enhance an existing surveillance system or use the tools en masse for an end-to-end electronic disease surveillance capability. Thus, each locality can select tools from SAGES based upon their needs, capabilities, and existing systems to create a customized electronic disease surveillance system. New OpenESSENCE developments include improved data query ability, improved mapping functionality, and enhanced training materials. New cellular phone developments include the ability to concatenate single SMS messages sent by simple or Smart Android cell phones. This ‘multiple-SMS’ message ability allows use of SMS technology to send and receive health information exceeding normal SMS message length in a manner transparent to the users.
Conclusions
The SAGES project is intended to enhance electronic disease surveillance capacity in resource-limited settings around the world. We have combined electronic disease surveillance tools developed at JHU/APL with other freely-available, interoperable software tools to create SAGES. We believe this suite of tools will facilitate local and regional electronic disease surveillance, regional public health collaborations, and international disease reporting. SAGES development, funded by the US Armed Forces Health Surveillance Center, continues as we add new international collaborators. SAGES tools are currently deployed in locations in Africa, Asia and South America, and are offered to other interested countries around the world.
PMCID: PMC3692858
software; surveillance; electronic; open-source
2.  Developing open source, self-contained disease surveillance software applications for use in resource-limited settings 
Background
Emerging public health threats often originate in resource-limited countries. In recognition of this fact, the World Health Organization issued revised International Health Regulations in 2005, which call for significantly increased reporting and response capabilities for all signatory nations. Electronic biosurveillance systems can improve the timeliness of public health data collection, aid in the early detection of and response to disease outbreaks, and enhance situational awareness.
Methods
As components of its Suite for Automated Global bioSurveillance (SAGES) program, The Johns Hopkins University Applied Physics Laboratory developed two open-source, electronic biosurveillance systems for use in resource-limited settings. OpenESSENCE provides web-based data entry, analysis, and reporting. ESSENCE Desktop Edition provides similar capabilities for settings without internet access. Both systems may be configured to collect data using locally available cell phone technologies.
Results
ESSENCE Desktop Edition has been deployed for two years in the Republic of the Philippines. Local health clinics have rapidly adopted the new technology to provide daily reporting, thus eliminating the two-to-three week data lag of the previous paper-based system.
Conclusions
OpenESSENCE and ESSENCE Desktop Edition are two open-source software products with the capability of significantly improving disease surveillance in a wide range of resource-limited settings. These products, and other emerging surveillance technologies, can assist resource-limited countries compliance with the revised International Health Regulations.
doi:10.1186/1472-6947-12-99
PMCID: PMC3458896  PMID: 22950686
Electronic biosurveillance; Software development; Public health; Disease outbreak; Resource-limited settings
3.  Enhanced health event detection and influenza surveillance using a joint Veterans Affairs and Department of Defense biosurveillance application 
Background
The establishment of robust biosurveillance capabilities is an important component of the U.S. strategy for identifying disease outbreaks, environmental exposures and bioterrorism events. Currently, U.S. Departments of Defense (DoD) and Veterans Affairs (VA) perform biosurveillance independently. This article describes a joint VA/DoD biosurveillance project at North Chicago-VA Medical Center (NC-VAMC). The Naval Health Clinics-Great Lakes facility physically merged with NC-VAMC beginning in 2006 with the full merger completed in October 2010 at which time all DoD care and medical personnel had relocated to the expanded and remodeled NC-VAMC campus and the combined facility was renamed the Lovell Federal Health Care Center (FHCC). The goal of this study was to evaluate disease surveillance using a biosurveillance application which combined data from both populations.
Methods
A retrospective analysis of NC-VAMC/Lovell FHCC and other Chicago-area VAMC data was performed using the ESSENCE biosurveillance system, including one infectious disease outbreak (Salmonella/Taste of Chicago-July 2007) and one weather event (Heat Wave-July 2006). Influenza-like-illness (ILI) data from these same facilities was compared with CDC/Illinois Sentinel Provider and Cook County ESSENCE data for 2007-2008.
Results
Following consolidation of VA and DoD facilities in North Chicago, median number of visits more than doubled, median patient age dropped and proportion of females rose significantly in comparison with the pre-merger NC-VAMC facility. A high-level gastrointestinal alert was detected in July 2007, but only low-level alerts at other Chicago-area VAMCs. Heat-injury alerts were triggered for the merged facility in June 2006, but not at the other facilities. There was also limited evidence in these events that surveillance of the combined population provided utility above and beyond the VA-only and DoD-only components. Recorded ILI activity for NC-VAMC/Lovell FHCC was more pronounced in the DoD component, likely due to pediatric data in this population. NC-VAMC/Lovell FHCC had two weeks of ILI activity exceeding both the Illinois State and East North Central Regional baselines, whereas Hines VAMC had one and Jesse Brown VAMC had zero.
Conclusions
Biosurveillance in a joint VA/DoD facility showed potential utility as a tool to improve surveillance and situational awareness in an area with Veteran, active duty and beneficiary populations. Based in part on the results of this pilot demonstration, both agencies have agreed to support the creation of a combined VA/DoD ESSENCE biosurveillance system which is now under development.
doi:10.1186/1472-6947-11-56
PMCID: PMC3188469  PMID: 21929813
4.  SAGES: A Suite of Freely-Available Software Tools for Electronic Disease Surveillance in Resource-Limited Settings 
PLoS ONE  2011;6(5):e19750.
Public health surveillance is undergoing a revolution driven by advances in the field of information technology. Many countries have experienced vast improvements in the collection, ingestion, analysis, visualization, and dissemination of public health data. Resource-limited countries have lagged behind due to challenges in information technology infrastructure, public health resources, and the costs of proprietary software. The Suite for Automated Global Electronic bioSurveillance (SAGES) is a collection of modular, flexible, freely-available software tools for electronic disease surveillance in resource-limited settings. One or more SAGES tools may be used in concert with existing surveillance applications or the SAGES tools may be used en masse for an end-to-end biosurveillance capability. This flexibility allows for the development of an inexpensive, customized, and sustainable disease surveillance system. The ability to rapidly assess anomalous disease activity may lead to more efficient use of limited resources and better compliance with World Health Organization International Health Regulations.
doi:10.1371/journal.pone.0019750
PMCID: PMC3091876  PMID: 21572957
5.  Methodologies for data collection 
BMC Proceedings  2008;2(Suppl 3):S5.
Background
Electronic disease surveillance systems can be extremely valuable tools; however, a critical step in system implementation is collecting data. Without accurate and complete data, statistical anomalies that are detected hold little meaning. Many people who have established successful surveillance systems acknowledge the initial data collection process to be one of the most challenging aspects of system implementation.
Methods
This discussion will describe the various methods for collecting data as well as describe some of the more common data feeds used in surveillance systems today. Given that every city/region/country looking to establish a surveillance capability has varying degrees of automated data, alternative data collection methods must be considered.
Results
While it would be ideal to collect automated electronic data in a real-time fashion without human intervention, data may also be effectively collected via telephone (both mobile and land lines), fax, and email. Another consideration is what type of data will be used in a surveillance system. If one data source is of high value to one locality, it should not be assumed that it will be as useful in another area. Determining what data sources work best for a particular area is a critical step in system implementation.
Conclusion
Regardless of data type and how they are collected, surveillance systems can be successful if the implementers and end users understand the limitations of both the data and the collection methodology and incorporate that knowledge into their interpretation procedures.
PMCID: PMC2587691  PMID: 19025682
6.  A systems overview of the Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE II) 
The Electronic Surveillance System for the Early Notification of Community-Based Epidemics, or ESSENCE II, uses syndromic and nontraditional health information to provide very early warning of abnormal health conditions in the National Capital Area (NCA). ESSENCE II is being developed for the Department of Defense Global Emerging Infections System and is the only known system to combine both military and civilian health care information for daily outbreak surveillance. The National Capital Area has a complicated, multijurisdictional structure that makes data sharing and integrated regional surveillance challenging. However, the strong military presence in all jurisdictions facilitates the collection of health care information across the region. ESSENCE II integrates clinical and nonclinical human behavior indicators as a means of identifying the abnormality as close to the time of onset of symptoms as possible. Clinical data sets include emergency room syndromes, private practice billing codes grouped into syndromes, and veterinary syndromes. Nonclinical data include absenteeism, nurse hotline calls, prescription medications, and over-the-counter self-medications. Correctly using information marked by varying degrees of uncertainty is one of the more challenging as pects of this program. The data (without personal identifiers) are captured in an electronic format, encrypted, archived, and processed at a secure facility. Aggregated information is then provided to users on secure Web sites. When completed, the system will provide automated capture, archiving, processing, and notification of abnormalities to epidemiologists and analysts. Outbreak detection methods currently include temporal and spatial variations of odds ratios, autoregressive modeling, cumulative summation, matched filter, and scan statistics. Integration of nonuniform data is needed to increase sensitivity and thus enable the earliest notification possible. The performance of various detection techniques was compared using results obtained from the ESSENCE II system.
doi:10.1007/PL00022313
PMCID: PMC3456555  PMID: 12791777
Evaluation; Nontraditional; Surveillance; Syndromes; Test bed

Results 1-6 (6)