Efficient algorithms for real-time syndromic surveillance.

[Display omitted] • We develop algorithms that use routinely collected data on emergency department presentations to detect outbreaks of influenza-like diseases. • Each algorithm monitors one or more exponentially weighted moving averages (EWMA) of the time between presentations. • Each algorithm detects an outbreak when one EWMA becomes sufficiently smaller than expected, conditional on the time of year, time of day, and day of the week. • Algorithms that concurrently monitor multiple EWMAs provide significantly earlier detection of outbreaks than algorithms that monitor one EWMA. Outbreaks of influenza-like diseases often cause spikes in the demand for hospital beds. Early detection of these outbreaks can enable improved management of hospital resources. The objective of this study was to test whether surveillance algorithms designed to be responsive to a wide range of anomalous decreases in the time between emergency department (ED) presentations with influenza-like illnesses provide efficient early detection of these outbreaks. Our study used data on ED presentations to major public hospitals in Queensland, Australia across 2017–2020. We developed surveillance algorithms for each hospital that flag potential outbreaks when the average time between successive ED presentations with influenza-like illnesses becomes anomalously small. We designed one set of algorithms to be responsive to a wide range of anomalous decreases in the time between presentations. These algorithms concurrently monitor three exponentially weighted moving averages (EWMAs) of the time between presentations and flag an outbreak when at least one EWMA falls below its control limit. We designed another set of algorithms to be highly responsive to narrower ranges of anomalous decreases in the time between presentations. These algorithms monitor one EWMA of the time between presentations and flag an outbreak when the EWMA falls below its control limit. Our algorithms use dynamic control limits to reflect that the average time between presentations depends on the time of year, time of day, and day of the week. We compared the performance of the algorithms in detecting the start of two epidemic events at the hospital-level: the 2019 seasonal influenza outbreak and the early-2020 COVID-19 outbreak. The algorithm that concurrently monitors three EWMAs provided significantly earlier detection of these outbreaks than the algorithms that monitor one EWMA. Surveillance algorithms designed to be responsive to a wide range of anomalous decreases in the time between ED presentations are highly efficient at detecting outbreaks of influenza-like diseases at the hospital level. [ABSTRACT FROM AUTHOR]