Back to Top Skip to main content Skip to sub-navigation

Brief report: Using syndromic surveillance to monitor MIS-C associated with COVID-19 in Military Health System beneficiaries

Image of Air Force 1st Lt. Anthony Albina, a critical care nurse assigned to Joint Base Andrews, Md., checks a patient’s breathing and heart rate during an intubation procedure while supporting COVID-19 response operations in Cleveland, Jan. 20, 2022. Air Force 1st Lt. Anthony Albina, a critical care nurse assigned to Joint Base Andrews, Md., checks a patient’s breathing and heart rate during an intubation procedure while supporting COVID-19 response operations in Cleveland, Jan. 20, 2022.

Recommended Content:

Medical Surveillance Monthly Report

Background

SARS CoV-2 and the illness it causes, COVID-19, have exacted a heavy toll on the global community. Most of the identified disease has been in the elderly and adults. In April 2020, a rare hyperinflammatory syndrome called multisystem inflammatory syndrome in children (MIS-C) was reported in Europe in a number of children with SARS-CoV2 infections. The cluster was initially characterized as cases with symptoms compatible with Kawasaki's disease.1 Cases presented with symptoms including systemic hyperinflammation, persistent fever, and multisystem organ dysfunction. In the U.S., cases of MIS-C have been disproportionately reported among Hispanic and non-Hispanic Black children 6 to 12 years old who presented with severe symptoms.2 According to the Centers for Disease Prevention and Control (CDC), as of 3 May 2021, 3,742 cases of MIS-C were reported in the U.S., including 35 deaths.3

In an effort to detect potential cases of MIS-C in the Military Health System (MHS), the Armed Forces Health Surveillance Division (AFHSD) used the Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE), a syndromic surveillance system which uses outpatient data to monitor trends and increases in health care encounters that may represent changes in the incidence of disease. Users of ESSENCE employ the system to analyze MHS clinical data sources in near real-time, including diagnosis codes, free text chief complaint or reason-for-visit data fields, reportable medical events (RME), laboratory and radiology data, and prescription drug information to develop a picture of disease syndromes based on health care encounters.4,5 The goal of this analysis was to ascertain if user-built ESSENCE queries applied to records of outpatient MHS health care encounters are capable of detecting MIS-C cases that have not been identified or reported by local public health departments.

Methods

The AFHSD used ESSENCE to create a query based on the case definition of MIS-C developed by the CDC to identify potential MIS-C cases. The query included MIS-C-related International Classification of Diseases, 10th Revision (ICD-10) diagnosis codes and free text chief complaint and reason-for-visit data fields from records of outpatient medical encounters for health care beneficiaries of the MHS 20 years old or younger who sought care between Oct. 19, 2020 and March 12, 2021. The query was adapted from the CDC-developed syndromic surveillance query, but the AFHSD query was modified to exclude those codes which are not present in AFHSD ESSENCE (Z86.16 [personal history of COVID-19] and Z20.822 [exposure to COVID-19 or SARS-CoV-2 infection]). The AFHSD-developed query selected ICD-10 codes in any diagnostic position in the electronic medical record for any outpatient encounter during the study period. Chief complaints were retrieved from patients' "reason for visit" free text field for each health encounter. The search criteria for ESSENCE's free text queries are built around Boolean logical operators and regular expressions which allow for a high level of customization.6

Four ICD-10 codes and 12 chief complaints (Tables 1, 2) were used to create the automated ESSENCE MIS-C query for searching records of all outpatient health encounters at nearly 400 military treatment facilities (MTFs) in real-time. Demographic and military variables, including age (in years), sex, race/ethnicity, ICD-10 codes, patient identifiers, and location were extracted for analysis. All Direct CareDirect care refers to military hospitals and clinics, also known as “military treatment facilities” and “MTFs.”direct care outpatient encounters with 1 or more of the ICD-10 codes or chief complaints of interest were selected to create a list of potential cases. Data details were downloaded on a weekly basis, verified, and coded as confirmed MIS-C cases by registrars trained in infectious disease manual data abstraction associated with the Department of Defense (DoD) COVID-19 registry.

The CDC case definition was used to confirm MIS-C cases. This definition includes an individual under 21 years old presenting with fever (>100.4 °F/38.0 °C) or report of subjective fever lasting 24 hours or longer), laboratory evidence of inflammation and a positive test for SARS-CoV-2 infection by RT-PCR, serology, or antigen test or COVID-19 exposure within the 4 weeks prior to the onset of symptoms in the clinical setting of severe inflammatory illness without other identifiable etiology.3

Results

During the surveillance period, the AFHSD MIS-C ESSENCE query identified 60 encounters that met selection criteria. The month of February 2021 had the most MIS-C-related encounters with 15 (25%) occurring during this time (data not shown). Out of 60 possible cases, 40 (66%) were males and 36 (60%) were 0–8 years olds (mean=8.5 years) (data not shown). Half of the MIS-C-related encounters (n=30) were in the southeast region of the U.S., and 9 (15%) were in overseas military clinics (data not shown). The most common ICD-10 code recorded was "M30.3-Mucocutaneous lymph node syndrome (Kawasaki)." Of the 60 records identified as possible cases by ESSENCE, 10 cases of MIS-C were confirmed by the DoD COVID-19 health records review process (17%). Four (40%) of the 10 confirmed cases were male and 4 were female (40%). Information on sex was not available for 2 of the confirmed cases. Half of the confirmed cases were 7–10 years old (mean=12 years; range=7–18 years).

Editorial Comment

Monitoring disease progression of the COVID-19 pandemic for situational awareness has been the current focus of the syndromic surveillance. The emergence of MIS-C reported in military beneficiaries should widen the focus on how to monitor disease progression in diverse populations. Although MIS-C is a rare condition among children who have developed COVID-19, it is still of great concern to public health officials in the military health care system.4 The ability to detect individual cases of disease was not originally how syndromic surveillance was designed to function. The main objective of syndromic surveillance is to detect a cluster or outbreak of disease before diagnosis.

There are some limitations to using ESSENCE to detect MIS-C encounters. A proportion of ESSENCE records that were received were deidentified; these records were not used in the analysis. In addition, records of Purchased CareThe TRICARE Health Program is often referred to as purchased care. It is the services we “purchase” through the managed care support contracts.purchased care encounters were not included in the analysis. Given these limitations, the findings of this analysis should not be construed as a complete representation of MIS-C cases in the surveyed population. Moreover, because the use of ESSENCE was limited to outpatient clinic data, the current analysis did not include the more severe cases seen in emergency departments and urgent care centers which are visible through the civilian form of ESSENCE.

The purpose of the analysis was to create a query that could identify possible outpatient cases of MIS-C. The MIS-C query was able to capture 10 cases of the rare condition of MIS-C during the surveillance period while minimizing the number of encounters (n=60) which met the selection criteria out of millions of encounters. ESSENCE has shown the ability to detect potential cases of MIS-C through health encounters at MTFs across the MHS. This capability will expand the biosurveillance efforts of AFHSD in response to future emerging infectious diseases and other threats of military interest. Furthermore, civilian surveillance systems may use this or similar queries to identify previously unreported cases of MIS-C in the civilian population.

Author affiliations: Armed Forces Health Surveillance Division, Silver Spring, MD (Dr. Russell and Col. Vick).

References

1. Riphagen S, Gomez X, Gonzalez-Martinez C, et al. Hyperinflammatory shock in children during COVID-19 Pandemic. Lancet. 2020;395(10237):1607–1608.

2. Feldstein LR, Tenforde MW, Friedman KG, et al. Characteristics and outcomes of US children and adolescents with multisystem inflammatory syndrome in children (MIS-C) compared with severe acute COVID-19. JAMA. 2021;325(11):1074–1087. 

3. Centers for Disease Control and Prevention. Health Department-Reported Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) in the United States. Centers for Disease Control and Prevention. 11 May 2021. Accessed 1 June 2021. https://covid.cdc.gov/covid-data-tracker/#mis-national-surveillance

4. Burkom H, Loschen W, Wojcik R, et al. Electronic Surveillance System for the Early Notification of Community-Based Epidemics (ESSENCE): Overview, Components, and Public Health Applications. JMIR Public Health Surveill. 2021;7(6):e26303.

5. Scholl L, Liu S, Vivolo-Kantor A, et al. Development and Validation of a Syndrome Definition to Identify Suspected Nonfatal Heroin-Involved Overdoses Treated in Emergency Departments. J Public Health Manag Pract. 2021;27(4):369–378. 

6. Stein Z. National Syndromic Surveillance Program (NSSP). Free-text coding in NSSP-ESSENCE: Part 1. Accessed 1 December 2021. https://www.cdc.gov/nssp/tech-tips/free-text-coding/part1.html

7. Centers for Disease Control and prevention. Emergency Preparedness and Response. Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with Coronavirus Disease 2019 (COVID-19). Accessed 1 December 2021. https://emergency.cdc.gov/han/2020/han00432.asp

 TABLE 1. ICD-10 diagnostic codes used to identify possible cases of MIS-C

TABLE 2. "List of reasons for visit" used to query the chief complaint field of ESSENCE to identify posible cases of MIS-C

You also may be interested in...

Exertional Hyponatremia, Active Component, U.S. Armed Forces, 2006–2021

Article
4/1/2022
Marine Corps Cpl. Luis Alicea drinks water after a combat conditioning exercise at Naval Air Station Joint Reserve Base New Orleans, May 20, 2019. Photo By: Marine Corps Lance Cpl. Jose Gonzalez.

Exertional (or exercise-associated) hyponatremia refers to a low serum, plasma, or blood sodium concentration (below 135 mEq/L) that develops during or up to 24 hours following prolonged physical activity. Acute hyponatremia creates an osmotic imbalance between fluids outside and inside of cells.

Recommended Content:

Medical Surveillance Monthly Report

Exertional Heat Illness at Fort Benning, GA: Unique Insights from the Army Heat Center

Article
4/1/2022
Navy Petty Officer 3rd Class Ryan Adams is being used as an example victim for cooling a heat casualty at the bi-annual hot weather standard operating procedure training aboard Marine Corps Base Camp Lejeune, N.C., Aug. 24. Adams is demonstrating the "burrito" method used to cool a heat related injury victim. Photo by Pfc. Joshua Grant.

Exertional heat illness (hereafter referred to as heat illness) spans a spectrum from relatively mild conditions such as heat cramps and heat exhaustion, to more serious and potentially life-threatening conditions such as heat injury and exertional heat stroke (hereafter heat stroke).

Recommended Content:

Medical Surveillance Monthly Report

Exertional Rhabdomyolysis, Active Component, U.S. Armed Forces, 2017–2021

Article
4/1/2022
The Embry-Riddle Army ROTC Ranger Challenge team heads out on the 12-mile road march after completing the timed obstacle course event of the 6th Brigade Army ROTC Ranger Challenge January 14, 2022 at Fort Benning, Ga. The Titan Brigade’s Ranger Challenge took place at Fort Benning, Ga. January 13-15, 2022. Photo by Capt. Stephanie Snyder

Exertional rhabdomyolysis is a potentially serious condition that requires a vigilant and aggressive approach. Some service members who experience exertional rhabdomyolysis may be at risk for recurrences, which may limit their military effectiveness and potentially predispose them to serious injury.

Recommended Content:

Medical Surveillance Monthly Report

Heat Illness, Active Component, U.S. Armed Forces, 2021

Article
4/1/2022
Airmen participate in the 13th Annual Fallen Defender Ruck March at Joint Base San Antonio, Nov. 6, 2020. The event honors 186 fallen security forces, security police and air police members who have made the ultimate sacrifice. Photo By: Sarayuth Pinthong, Air Force.

From 2020 to 2021, the rate of incident heat stroke was relatively stable while the rate of heat exhaustion increased slightly

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Snapshot: Medical Separation from Service Among Incident Cases of Osteoarthritis and Spondylosis, Active Component, U.S. Armed Forces, 2016–2020

Article
3/1/2022
Marines hike to the next training location during Exercise Baccarat in Aveyron, Occitanie, France, Oct.16, 2021. Exercise Baccarat is a three-week joint exercise with Marines and the French Foreign Legion that challenges forces with physical and tactical training. Photo By: Marine Corps Lance Cpl. Jennifer Reyes

Osteoarthritis (OA) is the most common adult joint disease and predominantly involves the weight-bearing joints. This condition, including spondylosis (OA of the spine), results in significant disability and resource utilization and is a leading cause of medical separation from military service.

Recommended Content:

Medical Surveillance Monthly Report

Obesity prevalence among active component service members prior to and during the COVID-19 pandemic, January 2018–July 2021

Article
3/1/2022
Maintaining a healthy weight is important for military members to stay fit to fight. The body mass index is a tool that can be used to determine if an individual is at an appropriate weight for their height. A person’s index is determined by their weight in kilograms divided by the square of height in meters. (U.S. Air Force photo illustration by Airman 1st Class Destinee Sweeney)

This study examined monthly prevalence of obesity and exercise in active component U.S. military members prior to and during the COVID-19 pandemic. These results suggest that the COVID-19 pandemic had a small effect on the trend of obesity in the active component U.S. military and that obesity prevalence continues to increase.

Recommended Content:

Medical Surveillance Monthly Report

Brief Report: Refractive Surgery Trends at Tri-Service Refractive Surgery Centers and the Impact of the COVID-19 Pandemic, Fiscal Years 2000–2020

Article
3/1/2022
Cadet Saverio Macrina, U.S. Military Academy West Point, receives corneal cross-linking procedure at Fort Belvoir Community Hospital, Va., Nov. 21, 2016. (DoD photo by Reese Brown)

Since the official introduction of laser refractive surgery into clinical practice throughout the Military Health System (MHS) in fiscal year 2000, these techniques have been heavily implemented in the tri-service community to better equip and improve the readiness of the U.S. military force.

Recommended Content:

Medical Surveillance Monthly Report

Update: Malaria, U.S. Armed Forces, 2021

Article
3/1/2022
Mosquitos – like this one, collected as part of a military study in North Carolina – were used during USAMRDC’s initial RTS,S vaccine studies nearly 40 years ago. (Photo courtesy: AFC Kimberly Barrera)

Malaria infection remains an important health threat to U.S. service members who are located in endemic areas because of long-term duty assignments, participation in shorter-term contingency operations, or personal travel. In 2021, a total of 20 service members were diagnosed with or reported to have malaria.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance snapshot: Health care burden attributable to osteoarthritis and spondylosis, active component, U.S. Armed Forces, 2016–2020

Article
2/1/2022
Air Force security forces trainees climb a hill during a 3-mile ruck march to commemorate National Police Week at Joint Base San Antonio, May 13, 2019. Photo By: Sarayuth Pinthong, Air Force

This snapshot summarizes the total numbers of inpatient and outpatient encounters with an OA or spondylosis diagnosis in the first diagnostic position and the total numbers of unique individuals affected by these conditions during the same 5-year surveillance period.

Recommended Content:

Medical Surveillance Monthly Report

A new approach to categorization of ocular injury among U.S. Armed Forces

Article
2/1/2022
Air Force and Space Force Surgeon General Lt. Gen. Dorothy Hogg receives an eye exam from Air Force Reserve Maj. Leslie Wilderson at Joint Base Anacostia-Bolling, Washington, D.C., March 26, 2021. Photo By: Air Force Staff Sgt. Kayla White

Ocular injuries present an ongoing threat to readiness and retention of service members. This report describes a new approach to categorizing ocular injury using Military Health System data, the application of an algorithm to a dataset, and the verification of the results using an audit of clinical data.

Recommended Content:

Medical Surveillance Monthly Report

Diagnosis of hepatitis C infection and cascade of care in the active component, U.S. Armed Forces, 2020

Article
2/1/2022
Navy Petty Officer 2nd Class Cecil Dorse, left, and Navy Petty Officer 3rd Class Janet Rosas test blood samples aboard the Military Sealift Command hospital ship USNS Comfort while the ship is in New York City in support of the nation’s COVID-19 response, April 6, 2020. Photo By: Navy Petty Officer 2nd Class Sara Eshleman

Hepatitis C virus (HCV) infection rates are rising in the U.S. despite widely available tools to identify and effectively treat nearly all of these cases. This cross-sectional study aimed to use laboratory data to evaluate the prevalence of HCV diagnoses among active component U.S. military service members.

Recommended Content:

Medical Surveillance Monthly Report

Surveillance Snapshot: Lengths of Hospital Stays for Service Members Diagnosed with Sepsis, Active Component, U.S. Armed Forces, 2011–2020

Article
1/1/2022
The (left to right) Senior Airman Austin Shrewsbury, 88th Diagnostics and Therapeutic Squadron medical laboratory technician, works with student, Airman 1st Class Taylor Altman, 88th Diagnostics and Therapeutic Squadron medical laboratory technician, to identify bacteria of patient’s cultures inside the microbiology laboratory at Wright-Patterson Air Force Base medical center June 30, 2017.

Sepsis is a serious and life-threatening organ dysfunction caused by a dysregulated host response to infection. In the U.S., sepsis is a leading cause of in-hospital mortality and 1 of the most expensive conditions treated in U.S. hospitals.

Recommended Content:

Medical Surveillance Monthly Report

Description of a COVID-19 Beta Variant Outbreak, Joint Base Lewis-McChord, WA, February–March 2021

Article
1/1/2022
U.S. Army Soldiers from 1-17th Infantry Battalion, 2nd Stryker Brigade, 2nd Infantry Division, clear an objective during the training exercise Bayonet Focus 19-02 at Yakima Training Center, Wash., May 6, 2019. Bayonet Focus is a training exercise designed to assess Soldiers’ ability to preform tasks and complete objectives under conditions experienced during combat situations. (U.S. Army photo by Spc. Angel Ruszkiewicz)

This report describes an outbreak of SARS-CoV-2, the causative agent of COVID-19, that peaked during 21–26 February 2021 and was tied to a single military training event. A total of 143 laboratory-confirmed cases were identified.

Recommended Content:

Medical Surveillance Monthly Report

COVID-19 and Depressive Symptoms Among Active Component U.S. Service Members, January 2019–July 2021

Article
1/1/2022
With the holiday season upon us, the cold, dark days that winter brings, and the social distancing and movement restrictions brought about by COVID-19, it’s not uncommon for people to feel depressed. (Photo by Erin Bolling)

This study examined the rates of depressive symptoms in active component U.S. service members prior to and during the COVID-19 pandemic and evaluated whether SARS-CoV-2 test results (positive or negative) were associated with self-reported depressive symptoms.

Recommended Content:

Medical Surveillance Monthly Report

Update: Osteoarthritis and Spondylosis, Active Component, U.S. Armed Forces, 2016–2020

Article
12/1/2021
Osteoarthritis (OA) knee . film x-ray AP ( anterior - posterior ) and lateral view of knee show narrow joint space, osteophyte ( spur ), subchondral sclerosis, knee joint inflammation. Photo by: iStockPhoto

Osteoarthritis (OA), the most com­mon adult joint disease, is primarily a degenerative disorder of the entire joint organ, including the subchondral bone, synovium, and periarticular structures (e.g., tendons, ligaments, bursae). Spondylosis, often referred to as OA of the spine, is characterized by degenerative changes in the vertebral discs, joints, and vertebral bodies.

Recommended Content:

Medical Surveillance Monthly Report
<< < 1 2 3 4 5  ... > >> 
Showing results 1 - 15 Page 1 of 12
Refine your search
Last Updated: May 23, 2022

DHA Address: 7700 Arlington Boulevard | Suite 5101 | Falls Church, VA | 22042-5101

Some documents are presented in Portable Document Format (PDF). A PDF reader is required for viewing. Download a PDF Reader or learn more about PDFs.