scholarly journals (P2-43) Utilizing a Unified Health Command Structure for Mass Gathering Preparedness and Response: Lessons Learned from the 2008 Pacific Arts Festival

2011 ◽  
Vol 26 (S1) ◽  
pp. s149-s150
Author(s):  
D.B. Bouslough ◽  
S. Lemusu ◽  
F. Avegalio
Keyword(s):  
Public Health ◽  
Interpersonal Violence ◽  
Hospital Setting ◽  
Respiratory Illness ◽  
American Samoa ◽  
Lessons Learned ◽  
Surveillance Data ◽  
Population Increase ◽  
Mass Gathering ◽  
Arts Festival

BackgroundThe Pacific Arts Festival is a mass-gathering event occurring every four years in Oceania. The 10th festival in American Samoa, July 20 to August 2, 2008, brought 2200 performers and 2500 tourists (a 15% population increase) from 27 Pacific nations to the island. Anticipated healthcare concerns included hospital surge (175% in 2004), HIV/STI transmission, imported/communicable diseases, food/water/sanitation-borne illness, interpersonal violence, and healthcare resource utilization.ObjectiveTo describe the preparedness and response efforts for this mass gathering event by emergency medical services, the hospital, and the department of health.MethodsA retrospective review of after-action reports, public health and emergency department surveillance records, and key-informant interviews was conducted. Descriptive statistics were used to evaluate data.ResultsA Unified Command structure was utilized for pre-/post-event response. Patient surveillance data was collected daily. During the festival 217 participants (42% female, 58% male, Average age 36) sought medical care. Acute illness (n = 166), injury (n = 39), other (n = 15), routine follow up (n = 9), chronic conditions (n = 6), mental health (n = 1), OB/GYN (n = 1) were complaints addressed. Predominant acute illnesses included headache (n = 49, 23%), respiratory illness (n = 30, 14%), musculoskeletal pain (n = 26, 12%), and gastroenteritis (n = 17, 8%). One fatality occurred among delegates. No public health outbreaks were reported. Visits per healthcare venue demonstrated a decentralization of patient surge from the hospital setting (37.4% venue aid stations, 28.1% delegation medical staff, 24% DOH clinic, 10.6% hospital).ConclusionA unified health command structure was effective in responding to this mass gathering event. Surveillance data was rapidly gathered and utilized to direct healthcare resources. Efforts to decentralize healthcare from the hospital were successful. Public health emergencies were avoided.

scholarly journals (P1-21) Medical Disaster Relief after the 2009 American Samoan Tsunami: Lessons Learned

2011 ◽  
Vol 26 (S1) ◽  
pp. s105-s106
Author(s):  
R. Partridge ◽  
D.B. Bouslough ◽  
L. Proano ◽  
S. Soliai-lemusu ◽  
F. Avegalio ◽  
...  
Keyword(s):  
Public Health ◽  
Disaster Response ◽  
American Samoa ◽  
Flood Damage ◽  
Lessons Learned ◽  
Capital City ◽  
Public Health Emergencies ◽  
The Pacific ◽  
American Samoan ◽  
Post Disaster

BackgroundTsunamis most commonly occur in the “Ring of fire” in the Pacific due to frequency of earthquakes and volcanic activity. Damaging tsunamis occur 1–2 times yearly. On September 29, 2009, an earthquake on the Pacific floor caused a tsunami that struck American Samoa, Samoa and Tonga, with only 20 minutes warning.ObjectiveTo evaluate the disaster response in American Samoa by emergency medical services (EMS), the territorial hospital, and the Department of Health.MethodsA retrospective review of EMS logs, public health records, hospital emergency department charts, and key-informant interviews over a 2-week period. Descriptive statistics were used to evaluate data.ResultsThree 5-meter waves struck the American Samoan islands, with land inundation as far as 700 meters. Many low- lying villages, including the capital city Pago Pago were affected. A total of 33 people (8 male, 23 female, including 3 children) were killed by the water, with approximately 150 significantly injured. EMS runs increased 250% from normal daily averages, with island-wide responses significantly delayed by flood damage. The hospital in Pago Pago, situated near the shore and only 10 meters above sea level, utilized 75 staff to evacuate 68 in-patients to high ground as soon as tremors were felt. This process was completed in 20 minutes with no associated morbidity or mortality. Patient injury patterns for the event are similar to recent literature reports. Mobile clinics and alternate care sites established at outlying dispensaries were used to decentralize healthcare from the hospital. DMAT/DMORT teams from Oregon and Hawaii supported local healthcare initiatives. Post-disaster public health surveillance focused on identifying and limiting food/water-borne illnesses, dengue fever, and influenza-like-illness outbreaks, as well as disaster related PTSD.ConclusionThe disaster response to the tsunami in American Samoa was effective. Disaster planning was appropriate and rapidly implemented. Post-disaster public health emergencies were minimized.

scholarly journals The ALERT Algorithm: How to Simply Define a Period of Elevated Disease Incidence

2014 ◽  
Vol 6 (1) ◽  
Author(s):  
Nicholas G. Reich ◽  
Derek Cummings ◽  
Johns Hopkins Bloomberg School of Public Zorn ◽  
Ann-Christine Nyquist ◽  
Trish M. Perl ◽  
...  
Keyword(s):  
Public Health ◽  
Disease Incidence ◽  
Respiratory Illness ◽  
Fast Response ◽  
Surveillance Data ◽  
Healthcare Settings ◽  
Increased Risk ◽  
Health Practitioners ◽  
Simple Rules ◽  
Public Health Practitioners

Despite the number of infections, hospitalizations, and deaths from influenza each year, developing the ability to predict the timing of these outbreaks has remained elusive. We have developed the Above Local Elevated Respiratory illness Threshold (ALERT) algorithm to help public health practitioners develop simple rules to define a period of increased disease incidence in a given location. The ALERT algorithm defines a period of elevated disease incidence in a community or hospital that systematically collects surveillance data on a particular disease. By defining this period of increased risk, the ALERT algorithm enables fast response to emerging outbreaks in healthcare settings.

scholarly journals What did Syndromic Surveillance Show During London 2012? Lessons for Mass Gatherings

2015 ◽  
Vol 7 (1) ◽  
Author(s):  
Dan Todkill ◽  
Helen Hughes ◽  
Alex Elliot ◽  
Roger Morbey ◽  
Obaghe Edeghere ◽  
...  
Keyword(s):  
Public Health ◽  
General Practitioner ◽  
Syndromic Surveillance ◽  
Lessons Learned ◽  
Surveillance Systems ◽  
Mass Gathering ◽  
Daily Number ◽  
Mass Gatherings ◽  
London 2012 ◽  
The Impact

This paper investigates the impact of the London 2012 Olympic and Paralympic Games on syndromic surveillance systems coordinated by Public Health England. The Games had very little obvious impact on the daily number of ED attendances and general practitioner consultations both nationally, and within London. These results provide valuable lessons learned for future mass gathering events.

scholarly journals Organizing a Mass Gathering Amidst a Rising COVID-19 Public Health Crisis: Lessons Learned From a Chinese Public Health Forum in Vancouver, BC

Cureus ◽  
2020 ◽  
Author(s):  
Jayneel Limbachia ◽  
Hollis Owens ◽  
Maryam Matean ◽  
Sophia S Khan ◽  
Helen Novak-Lauscher ◽  
...  
Keyword(s):  
Public Health ◽  
Lessons Learned ◽  
Mass Gathering ◽  
Health Crisis ◽  
Public Health Crisis ◽  
Chinese Public

scholarly journals Using ESSENCE to Detect Bomb-Making Activity: What’s Appropriate?

2018 ◽  
Vol 10 (1) ◽  
Author(s):  
Andrew Torgerson
Keyword(s):  
Public Health ◽  
Law Enforcement ◽  
Syndromic Surveillance ◽  
Chief Complaint ◽  
Surveillance Data ◽  
Chemical Mechanism ◽  
Mass Gathering ◽  
Surveillance Period ◽  
Saint Louis ◽  
Ed Visits

ObjectiveTo describe a novel application of ESSENCE by the Saint Louis County Department of Public Health (DPH) in preparation for a mass gathering and to encourage discussion about the appropriateness of sharing syndromic surveillance data with law enforcement partners.IntroductionIn preparation for mass gathering events, DPH conducts enhanced syndromic surveillance activities to detect potential cases of anthrax, tularemia, plague, and other potentially bioterrorism-related communicable diseases. While preparing for Saint Louis to host a Presidential Debate on October 9, 2016, DPH was asked by a partner organization whether we could also detect emergency department (ED) visits for injuries (e.g., burns to the hands or forearms) that could possibly indicate bomb-making activities.MethodsUsing the Electronic Surveillance System for the Notification of Community-Based Epidemics (ESSENCE), version 1.9, DPH developed a simple query to detect visits to EDs in Saint Louis City or Saint Louis County with chief complaints including the word “burn” and either “hand” or “arm.” A DPH epidemiologist reviewed the results of the query daily for two weeks before and after the debate (i.e., from September 25, 2016 to October 23, 2016). If any single ED visit was thought to be “suspicious” – if, for example, the chief complaint mentioned an explosive or chemical mechanism of injury – then DPH would contact the ED for details and relay the resulting information to the county’s Emergency Operations Center.ResultsDuring the 29 day surveillance period, ESSENCE detected 27 ED visits related to arm or hand burns. The ESSENCE query returned a median of 1 ED visit per day (IQR 0 to 2 visits). Of these, one was deemed to merit further investigation – two days before the debate, a patient presented to an ED in Saint Louis County complaining of a burned hand. The patient’s chief complaint data also mentioned “explosion of unspecified explosive materials.” Upon investigation, DPH learned that the patient had been injured by a homemade sparkler bomb. Subsequently, law enforcement determined that the sparkler bomb had been made without any malicious intent.ConclusionsDPH succeeded in using ESSENCE to detect injuries related to bomb-making. However, this application of ESSENCE differs in at least two ways from more traditional uses of syndromic surveillance. First, conventional syndromic surveillance is designed to detect trends in ED visits resulting from an outbreak already in progress or a bioterrorist attack already carried out. In this case, syndromic surveillance was used to detect a single event that could be a prelude to an attack. The potential to prevent widespread injury or illness is a strength of this approach. Second, conventional syndromic surveillance identifies potential outbreak cases or, in the case of a bioterrorist attack, potential victims. In this case, syndromic surveillance was used to identify a potential perpetrator of an attack. While public health and law enforcement agencies would ideally coordinate their investigative efforts in the wake of an attack, this practice has led to conversations within DPH about the appropriateness of routinely sharing public health surveillance data with law enforcement. 

An Observational Study Using English Syndromic Surveillance Data Collected During the 2012 London Olympics – What did Syndromic Surveillance Show and What Can We Learn for Future Mass-gathering Events?

2016 ◽  
Vol 31 (6) ◽  
pp. 628-634 ◽  
Author(s):  
Dan Todkill ◽  
Helen E. Hughes ◽  
Alex J. Elliot ◽  
Roger A. Morbey ◽  
Obaghe Edeghere ◽  
...  
Keyword(s):  
Public Health ◽  
Observational Study ◽  
Real Time ◽  
Syndromic Surveillance ◽  
Olympic Games ◽  
Surveillance Data ◽  
Surveillance Systems ◽  
Mass Gathering ◽  
Opening Ceremony ◽  
London 2012

AbstractIntroductionIn preparation for the London 2012 Olympic Games, existing syndromic surveillance systems operating in England were expanded to include daily general practitioner (GP) out-of-hours (OOH) contacts and emergency department (ED) attendances at sentinel sites (the GP OOH and ED syndromic surveillance systems: GPOOHS and EDSSS).Hypothesis/ProblemThe further development of syndromic surveillance systems in time for the London 2012 Olympic Games provided a unique opportunity to investigate the impact of a large mass-gathering event on public health and health services as monitored in near real-time by syndromic surveillance of GP OOH contacts and ED attendances. This can, in turn, aid the planning of future events.MethodsThe EDSSS and GPOOHS data for London and England from July 13 to August 26, 2012, and a similar period in 2013, were divided into three distinct time periods: pre-Olympic period (July 13-26, 2012); Olympic period (July 27 to August 12); and post-Olympic period (August 13-26, 2012). Time series of selected syndromic indicators in 2012 and 2013 were plotted, compared, and risk assessed by members of the Real-time Syndromic Surveillance Team (ReSST) in Public Health England (PHE). Student’s t test was used to test any identified changes in pattern of attendance.ResultsVery few differences were found between years or between the weeks which preceded and followed the Olympics. One significant exception was noted: a statistically significant increase (P value = .0003) in attendances for “chemicals, poisons, and overdoses, including alcohol” and “acute alcohol intoxication” were observed in London EDs coinciding with the timing of the Olympic opening ceremony (9:00 pm July 27, 2012 to 01:00 am July 28, 2012).ConclusionsSyndromic surveillance was able to provide near to real-time monitoring and could identify hourly changes in patterns of presentation during the London 2012 Olympic Games. Reassurance can be provided to planners of future mass-gathering events that there was no discernible impact in overall attendances to sentinel EDs or GP OOH services in the host country. The increase in attendances for alcohol-related causes during the opening ceremony, however, may provide an opportunity for future public health interventions.TodkillD, HughesHE, ElliotAJ, MorbeyRA, EdeghereO, HarcourtS, HughesT, EndericksT, McCloskeyB, CatchpoleM, IbbotsonS, SmithG. An observational study using English syndromic surveillance data collected during the 2012 London Olympics – what did syndromic surveillance show and what can we learn for future mass-gathering events?Prehosp Disaster Med. 2016;31(6):628–634.

scholarly journals (A225) Lessons Learned at the Commonwealth Games: A Mass-Gathering Sporting Event in New Delhi, India

2011 ◽  
Vol 26 (S1) ◽  
pp. s61-s61
Author(s):  
A. Madan
Keyword(s):  
Public Health ◽  
Mass Casualty ◽  
Lessons Learned ◽  
Mitigation Strategies ◽  
New Delhi ◽  
Sporting Events ◽  
Mass Gathering ◽  
Outbreak Response ◽  
Mass Gatherings ◽  
Commonwealth Games

Mass gatherings can be religious, political, socio-cultural, or sporting events, and vary in the form of processions, car races, conferences, fairs, etc. New Delhi hosted the 2010 Commonwealth Games, a mass gathering spread over a duration of 10 days with different venues and a high density of participants, spectators, security personnel, volunteers, and high-profile guests. Various organizations were involved in the planning and implementation of the games which called for a collaborative and coordinated effort to make the event a success. Security coverage was required for 23 sporting, 32 training, and seven non-sporting venues. Security arrangements were of utmost importance and required training, mobilization, and deployment of army, police, and other emergency workers, as well as establishing Standard Operating Procedures for responses to chemical, biological, radioactive, and nuclear events and availing specialized equipment. Areas of public health interventions in mass gathering include mass-casualty preparedness, disease surveillance and outbreak response, safety of water, food, and venues, health promotion, public health preparedness and response, pest and vector control, coordination and communication, healthcare facility capacity, and medical supplies. Methods adopted for the study included interviews with the stakeholders of the Commonwealth Games and use of secondary data to cite examples and support arguments. Existing knowledge must be documented and made available for use in planning for future mass gatherings. The size, duration, and interest of such events demands special attention toward preparedness and mitigation strategies to prevent or minimize the risk of ill health and maximizing the safety of people involved.

scholarly journals (P1-63) Post-Tsunami Hospital Evacuation Preparedness Improved by Development of Portable Medical Supply Caches

2011 ◽  
Vol 26 (S1) ◽  
pp. s119-s119
Author(s):  
D.B. Bouslough ◽  
E. Peters ◽  
C. Peters ◽  
S. Tuato'o
Keyword(s):  
Emergency Preparedness ◽  
Hospital Setting ◽  
American Samoa ◽  
Lessons Learned ◽  
Field Hospital ◽  
Medical Supply ◽  
Preparedness Planning ◽  
Hospital Units ◽  
Hospital Leadership ◽  
Medical Supplies

BackgroundOn September 29, 2009, an earthquake-caused tsunami struck American Samoa with only 20 minutes warning. Personnel successfully evacuated patients from the hospital within 20 minutes. The organization and transportation of medical supplies required for patient care took 90 minutes.ObjectiveTo describe a hospital evacuation exercise designed to identify critical medical supplies, and test their transport, and use in a field-hospital setting.MethodsA retrospective review of hospital emergency preparedness and Boy Scout Eagle Project minutes, participant surveys, and key-informant interviews was performed. Descriptive statistics were used to evaluate data.ResultsUnit supervisors hospital-wide were tasked with designing portable supply caches for the care of typical unit patients for 72 hours. Nine hospital units participated (ED, Surgery, Medicine, Pediatrics, Labor & Delivery, Maternity, Nursery/NICU, ICU, Hemodialysis) in the exercise. Unit evacuation teams (1 physician & 2 nurses) carried caches by foot to a nearby field clinic site (1/4 mile). Cache transport times ranged from 3 minutes (maternity ward) to 15.5 minutes (hemodialysis), averaging 11.2 minutes. Hospital leadership arrived in 4 minutes, and maintenance staff with portable power and oxygen in 23 minutes. Fifty-seven community volunteers (age 9 months – 60 years) under Eagle Scout candidate leadership were prepared as moulaged mock patients. Unit teams used evacuated supplies to provide medical care for 6 mock patients each, listing missing or insufficient supplies at exercise end. Cache supply deficits noted by participating teams included: portable oxygen (66%), blood pressure cuffs (44%), thermometers (44%), select pharmaceuticals (44%), and others. Reported cache deficits and exercise lessons learned were reported hospital-wide for incorporation into preparedness planning.ConclusionThe hospital unit medical supply cache exercise was effective in addressing prior evacuation deficits. Hospital collaboration with community service volunteers provides exercise realism for participants and increases community awareness for emergency preparedness.

scholarly journals Evaluation Activities from the National Syndromic Surveillance Program

2018 ◽  
Vol 10 (1) ◽  
Author(s):  
Sebastian Romano ◽  
Cassandra Davis ◽  
Krystal Collier ◽  
Sara Johnston ◽  
Hana Tesfamichael ◽  
...  
Keyword(s):  
Public Health ◽  
Syndromic Surveillance ◽  
Situational Awareness ◽  
Lessons Learned ◽  
Surveillance Data ◽  
Acceptance Testing ◽  
Surveillance Program ◽  
Local Health ◽  
State And Local ◽  
Surveillance Practice

ObjectiveThe objective of this session is to discuss syndromic surveillance evaluation activities. Panel participants will describe contexts and importance of selected evaluation and performance measurement activities in NSSP. Discussions will explore ways to strengthen evaluation in syndromic surveillance activities in the future.IntroductionSyndromic surveillance uses near-real-time Emergency Department healthcare and other data to improve situational awareness and inform activities implemented in response to public health concerns. The National Syndromic Surveillance Program (NSSP) is a collaboration among state and local health departments, the Centers for Disease Control and Prevention (CDC), other federal organizations, and other entities, to strengthen the means for and the practice of syndromic surveillance. NSSP thus strives to strengthen syndromic surveillance at the national and the state, and local levels through the coordinated activities of the involved partners and the development and use of advanced technologies, such as the BioSense platform. Evaluation and performance measurement are crucial to ensure that the various strategies and activities implemented to strengthen syndromic surveillance capacity and practice are effective. Evaluation activities will be discussed at this session and feedback from audience will be sought with the goal to further strengthen evaluation activities in the future.DescriptionSyndromic surveillance practice among NSSP grant recipients: findings from a telephone based survey – S. Romano This presentation will highlight the development and implementation of a survey among the NSSP grant recipients about their syndromic surveillance practice. The objectives of the survey was to develop knowledge and understanding about: a) characteristics of syndromic surveillance practice at the state and local level among jurisdictions that are NSSP grant recipients; b) challenges encountered by these jurisdictions in conducting syndromic surveillance; and c) strategies that may help address these challenges. The objectives and methods of the survey will be described in detail. The survey is expected to be implemented before the end of this year. Preliminary findings will be presented if available. Lessons learned and strategies to consider for strengthening syndromic surveillance practice will be discussed.Defining a sustainable approach to syndromic surveillance through the AZ BioSense Workgroup Charter – K. Collier, S. Johnston The Arizona BioSense Workgroup has developed a five year charter outlining the method and measures used for implementation and adoption of syndromic surveillance in Arizona. Membership consists of clinicians, IT and public health. The mission and vision help to establish a foundation for building capacity and quality of the syndromic surveillance data, improved population health and emergency response through timely and effective use of the data. Cross-cutting topics resulted in a process for assessing training needs, establishing protocols and evaluation of use cases, shared plans for situational awareness and making public health decisions. This talk will discuss the collaborative approach and how lessons learned will inform future activities.User Acceptance Testing to inform development and enhancement of the BioSense Platform – C. Davis Between June, 2016 and January, 2017, NSSP operationalized an updated BioSense Platform for conducting syndromic surveillance. The platform included ESSENCE, a software that enables analysis and visualization of syndromic surveillance data and the Access Management Center, a tool that enables jurisdictions to manage access to data. The development of and transition to the updated platform was informed by a User Acceptance Testing (UAT) that examined the functionality and usability of the platform and associated tools After webinar based orientation UAT, participants were requested to carry out specific tasks using the updated platform and tools in development. This presentation will discuss the objectives and methods of implementation of the UAT, findings from the UAT, and how these guided transition activities and the refinement of the platform applications.A quantitative and qualitative assessment of user support provided by the NSSP Service Desk – H. Tesfamichael, S. Romano A principal component of NSSP is the BioSense platform that includes health care visits related information, particularly related to emergency department visits, from across the U.S. BioSense and its associated tools, including ESSENCE, the Access Management Center, and Adminer, enable state and local health departments, and other, as appropriate, to use syndromic surveillance data to implement surveillance and assessment activities. The NSSP Service Desk provides technical support to BioSense users to assist with the use of the BioSense platform and its tools Users submit support request tickets through an online application. An analysis of information related to these tickets, including the context of the requests and their resolution status, was conducted to better understand the support needs of users and how well these were being addressed. This presentation will discuss the assessment, findings, and conclusions.How the Moderator Intends to Engage the Audience in Discussions on the TopicThe moderator will introduce the session and the panelists. The moderator will also invite questions and comments from the audience, and will facilitate the discussions. 

scholarly journals Lessons Learned from a DoD and Virginia Data Sharing Pilot using NSSP ESSENCE

2019 ◽  
Vol 11 (1) ◽  
Author(s):  
Erin E. Austin ◽  
Paul E. Lewis ◽  
Arden Norfleet ◽  
Jamaal Russell
Keyword(s):  
Public Health ◽  
Data Sharing ◽  
Syndromic Surveillance ◽  
Data Access ◽  
Pilot Project ◽  
Lessons Learned ◽  
Surveillance Data ◽  
Service Members ◽  
Local Health ◽  
Health Departments

ObjectiveThis panel will focus on the experiences from the Department of Defense (DoD) and Virginia Department of Health (VDH) data sharing project using the National Syndromic Surveillance Program (NSSP) ESSENCE and will discuss lessons learned, challenges, and recommendations within the following areas: 1) data sharing authority, 2) coordination and implementation of data sharing with a focus on personnel, training, and managing access and 3) communication between local, state, and federal agencies.IntroductionThe DoD and VDH both maintain local ESSENCE installations to monitor the health status of their military and civilian populations, respectively, and submit syndromic surveillance data to the NSSP ESSENCE to foster data sharing and collaborative initiatives among public health entities. Military Treatment Facilities (MTFs), housed on DoD installations, provide healthcare to all service members and their beneficiaries stationed in the area. Service members and their beneficiaries represent a substantial portion of the local community and interact with the civilian population throughout daily activities. Sharing syndromic surveillance data between DoD and public health jurisdictions can provide public health situational awareness among both civilian and military populations to support disease surveillance. DoD and VDH engaged in a pilot project to develop processes and procedures for data sharing, data access, and communication with the aim they can serve as best practices for other jurisdictions seeking to share syndromic surveillance data with DoD.DescriptionThe pilot project began in June 2018 with the Centers for Disease Control and Prevention (CDC) NSSP team providing technical support. NSSP ESSENCE users from the VDH state and local health departments across nine Virginia city/counties participated in the project. VDH shared syndromic surveillance data from 34 healthcare facilities (17 urgent cares, 3 emergency care centers, and 14 hospitals) with DoD, which shared syndromic surveillance data from 18 MTFs (16 clinics and 2 hospitals) in Virginia. To standardize the analysis of syndromic surveillance data and use of NSSP ESSENCE across project participants, myESSENCE tabs were created and shared by between VDH and DoD. The goal was to facilitate and enhance communication between local public health departments and their DoD counterparts through the sharing of syndromic surveillance data.How the Moderator Intends to Engage the Audience in Discussions on the TopicThe moderator will solicit feedback from the audience regarding their data sharing experiences with other entities or agencies, data sharing practices, and ideas for use cases when sharing syndromic surveillance data with DoD.

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