The Development and Growth of the English National Real-Time Syndromic Surveillance Program: Key Developments and Lessons Learned From the First Two Decades.

Syndromic surveillance now forms an integral part of the surveillance for a wide range of hazards in many countries. Establishing syndromic surveillance systems can be difficult due to the many different sources of data that can be used, cost pressures, the importance of data security, and the presence of different (and rapidly evolving) technologies. Here we describe major points in the development of the UK Health Security Agency English real-time syndromic surveillance service over its first 2 decades (1998 to 2018). We identify the key wider themes that we believe are important in ensuring a sustainable and useful syndromic surveillance service. We conducted semistructured interviews with current members of the UK Health Security Agency syndromic surveillance team who were involved from the earliest stages and previous senior colleagues who were supportive of the syndromic surveillance work during the early phases. For this viewpoint, we partitioned the development of syndromic surveillance in England into 3 time periods: 1998 to 2005 ("the beginnings"); 2006 to 2011 ("the growth phase"); and 2012 to 2018 ("mainstream"). We asked the interviewees for their views about the development of syndromic surveillance, and in particular the main drivers and events, the team and system, and outputs and uses. The results from the interviews highlighted some key themes including the integration of syndromic surveillance into the public health system, creativity, good collaboration and teamwork, leadership and determination to persevere, and agility and the ability to adapt to new threats. Using the results of the discussions and our personal experience of running the syndromic surveillance service from inception and over decades, we constructed a set of recommendations for establishing and running sustainable syndromic surveillance systems. In this age of increased automation, with the ability to transfer data in real-time and to use machine learning and artificial intelligence, we are approaching a "new age of syndromic surveillance." We consider that the focus on the public health questions, relationships, collaboration, leadership, and true teamwork should not be underestimated in the success of and usefulness of real-time syndromic surveillance systems.