title: Evaluation of outbreak detection performance using multi-stream syndromic surveillance for influenza-like illness in rural Hubei Province, China: a temporal simulation model based on healthcare-seeking behaviors.
abstract: BACKGROUND
  Syndromic surveillance promotes the early detection of diseases outbreaks. Although syndromic surveillance has increased in developing countries, performance on outbreak detection, particularly in cases of multi-stream surveillance, has scarcely been evaluated in rural areas.
  
  
  OBJECTIVE
  This study introduces a temporal simulation model based on healthcare-seeking behaviors to evaluate the performance of multi-stream syndromic surveillance for influenza-like illness.
  
  
  METHODS
  Data were obtained in six towns of rural Hubei Province, China, from April 2012 to June 2013. A Susceptible-Exposed-Infectious-Recovered model generated 27 scenarios of simulated influenza A (H1N1) outbreaks, which were converted into corresponding simulated syndromic datasets through the healthcare-behaviors model. We then superimposed converted syndromic datasets onto the baselines obtained to create the testing datasets. Outbreak performance of single-stream surveillance of clinic visit, frequency of over the counter drug purchases, school absenteeism, and multi-stream surveillance of their combinations were evaluated using receiver operating characteristic curves and activity monitoring operation curves.
  
  
  RESULTS
  In the six towns examined, clinic visit surveillance and school absenteeism surveillance exhibited superior performances of outbreak detection than over the counter drug purchase frequency surveillance; the performance of multi-stream surveillance was preferable to signal-stream surveillance, particularly at low specificity (Sp <90%).
  
  
  CONCLUSIONS
  The temporal simulation model based on healthcare-seeking behaviors offers an accessible method for evaluating the performance of multi-stream surveillance.
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
authors.forename: Yunzhou
authors.initials: Y
authors.lastname: Fan
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
authors.forename: Ying
authors.initials: Y
authors.lastname: Wang
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
authors.forename: Hongbo
authors.initials: H
authors.lastname: Jiang
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
authors.forename: Wenwen
authors.initials: W
authors.lastname: Yang
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
authors.forename: Miao
authors.initials: M
authors.lastname: Yu
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; Division of Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Weirong
authors.initials: W
authors.lastname: Yan
authors.affiliation: Division of Global Health (IHCAR), Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
authors.forename: Vinod K
authors.initials: VK
authors.lastname: Diwan
authors.affiliation: School of Public Health, Fudan University, Shanghai, China.
authors.forename: Biao
authors.initials: B
authors.lastname: Xu
authors.affiliation: Institute of Public Health, Heidelberg University, Heidelberg, Germany.
authors.forename: Hengjin
authors.initials: H
authors.lastname: Dong
authors.affiliation: Future Position X (FPX), Gävle, Sweden.
authors.forename: Lars
authors.initials: L
authors.lastname: Palm
authors.affiliation: Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
authors.forename: Shaofa
authors.initials: S
authors.lastname: Nie
mesh_terms: D000041:Absenteeism; D000553:Ambulatory Care; D002681:China; D003198:Computer Simulation; D004196:Disease Outbreaks; D006801:Humans; D053118:Influenza A Virus, H1N1 Subtype; D007251:Influenza, Human / Q000175:diagnosis* / Q000453:epidemiology; D010342:Patient Acceptance of Health Care; D011159:Population Surveillance / Q000379:methods*; D012307:Risk Factors; D012423:Rural Health; D012424:Rural Population