Abstract The COVID-19 pandemic is exerting major pressures on society, health and social care services and science. Understanding the progression and current impact of the pandemic is fundamental to planning, management and mitigation of future impact on the population. Surveillance is the core function of any public health system, and a multi-component surveillance system for COVID-19 is essential to understand the burden across the different strata of any health system and the population. Many countries and public health bodies utilise ‘syndromic surveillance’ (using real-time, often non-specific symptom/preliminary diagnosis information collected during routine healthcare provision) to supplement public health surveillance programmes. The current COVID-19 pandemic has revealed a series of unprecedented challenges to syndromic surveillance including: the impact of media reporting during early stages of the pandemic; changes in healthcare-seeking behaviour resulting from government guidance on social distancing and accessing healthcare services; and changes in clinical coding and patient management systems. These have impacted on the presentation of syndromic outputs, with changes in denominators creating challenges for the interpretation of surveillance data. Monitoring changes in healthcare utilisation is key to interpreting COVID-19 surveillance data, which can then be used to better understand the impact of the pandemic on the population. Syndromic surveillance systems have had to adapt to encompass these changes, whilst also innovating by taking opportunities to work with data providers to establish new data feeds and develop new COVID-19 indicators. These developments are supporting the current public health response to COVID-19, and will also be instrumental in the continued and future fight against the disease.

Calls to a UK national telephone health helpline (NHS Direct) have been used for syndromic surveillance, aiming to provide early warning of rises in community morbidity. We investigated whether self-sampling by NHS Direct callers could provide viable samples for influenza culture. We recruited 294 NHS Direct callers and sent them self-sampling kits. Callers were asked to take a swab from each nostril and post them to the laboratory. Forty-two per cent of the samples were returned, 16.2% were positive on PCR for influenza (16 influenza A(H3N2), three influenza A (H1N1), four influenza B) and eight for RSV (5.6%). The mean time between the NHS Direct call and laboratory analysis was 7.4 days. These samples provided amongst the earliest influenza reports of the season, detected multiple influenza strains, and augmented a national syndromic surveillance system. Self-sampling is a feasible method of enhancing community-based surveillance programmes for detection of influenza.

Routine primary care data provide the means to monitor a variety of syndromes which could give early warning of health protection issues. In the United Kingdom, a national syndromic surveillance system, operated jointly by the UK Health Protection Agency (HPA) and NHS Direct (a national telephone health helpline), examines symptoms reported to NHS Direct. The aim of the system is to identify an increase in syndromes indicative of common infections and diseases, or the early stages of illness caused by the deliberate release of a biological or chemical agent. Data relating to 11 key symptoms/syndromes are received electronically from all 22 NHS Direct call centres covering England and Wales and analysed by the HPA on a daily basis. Statistically significant excesses in calls are automatically highlighted and assessed by a multi-disciplinary team. Although the surveillance system has characterised many sudden rises in syndromes reported to NHS Direct, no evidence of a biological or chemical attack has been detected. Benefits of this work, however, are early warning and tracking of rises in community morbidity (e.g. influenza-like illness, heatstroke); providing reassurance during times of perceived high risk (e.g. after the 7 July 2005 London bombs and December 2005 Buncefield oil depot fire); and timely surveillance data for influenza pandemic planning and epidemic modeling.

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Syndromic surveillance is vital for monitoring public health during mass gatherings. The London 2012 Olympic and Paralympic Games represents a major challenge to health protection services and community surveillance. In response to this challenge the Health Protection Agency has developed a new syndromic surveillance system that monitors daily general practitioner out-of-hours and unscheduled care attendances. This new national system will fill a gap identified in the existing general practice-based syndromic surveillance systems by providing surveillance capability of general practice activity during evenings/nights, over weekends and public holidays. The system will complement and supplement the existing tele-health phone line, general practitioner and emergency department syndromic surveillance systems. This new national system will contribute to improving public health reassurance, especially to meet the challenges of the London 2012 Olympic and Paralympic Games.