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Influenza Surveillance Systems in an International Setting Case Study 1 1.

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Presentation on theme: "Influenza Surveillance Systems in an International Setting Case Study 1 1."— Presentation transcript:

1 Influenza Surveillance Systems in an International Setting Case Study 1 1

2 Learning Objectives Define the surveillance objectives, methods of hospital selection, and key data collection priorities for sentinel surveillance for seasonal influenza and severe respiratory diseases List appropriate surveillance strategies and trigger criteria needed for the early detection of Influenza A(H5N1) in hospitals and communities List appropriate surveillance strategies and trigger criteria needed for a broader pandemic early warning system Describe how a sentinel site surveillance system for influenza provides an important support function for a pandemic early warning system Identify five ways to enhance human, avian, and pandemic influenza surveillance activities in areas where there are known Influenza A(H5N1) outbreaks in poultry 2

3 Outline Introduction to the scenario Routine Surveillance for Respiratory Disease and Seasonal Influenza Influenza A(H5N1) and Pandemic Early Warning Surveillance 3

4 Introduction 4

5 Introduction to the Republic of Pegu Developing country Southeast Asia 21 provinces Population: 50 million 5

6 Geography 6 Monsoon climate Anawrahta Bordered by 5 countries Migrants Population: 75% rural No highway access

7 Health Care Kinds of facilities  Teaching hospitals  Specialist hospitals  Provincial hospitals  District hospitals  Local health stations  Traditional clinics  12 traditional medicine hospitals Each province  16-50 bed hospital Each district  Medical officer, public health, and medicine 7 Pegu Provincial Hospitals Anawrahta Pelu Jaghai Dava Ghar

8 Influenza Laboratory Testing 8 Provincial HospitalTraditional Hospital National Laboratory PCR Diagnosis Regional Laboratories Serological Diagnosis Closest WHO Reference Laboratory is in a neighboring country No laboratory testing

9 Surveillance Infrastructure National notifiable disease surveillance system  Immediate reporting  Diphtheria  Cholera  Yellow fever  Routine reporting (3 days)  Standard reporting form 9

10 Part I: Routine Surveillance for Respiratory Disease and Seasonal Influenza 10

11 Question 1 The main goals of routine (seasonal) influenza surveillance include all of the following EXCEPT: a.Describe virus circulation and provide virus isolates for vaccine development b.Provide rapid response to seasonal outbreaks c.Define the epidemiology and patterns of viral circulation d.Provide a support mechanism for pandemic early warning and monitoring systems Answer: b. 11

12 Question 2 What surveillance approach might be used to achieve these goals? a.Universal surveillance b.Sentinel site surveillance c.Influenza registry d.Laboratory-based reporting Answer: b. Sentinel site surveillance for: Hospitalizations due to respiratory disease Outpatient visits for influenza-like illness 12

13 Arrival in Pegu You are to : Evaluate the influenza and respiratory disease surveillance infrastructure Work with the MOH to develop a protocol to implement a sustainable national influenza surveillance system 13

14 The Pegu Deputy Director Situation: Due to mass poultry die-offs Team: Chief Surveillance Officer and the Director of Epidemiology, and you  Develop guidelines for expanding their national pneumonia and influenza surveillance system  Use money from World Bank to develop pandemic early warning network 14

15 Current Case Identification Clinician initiated pnuemonia and influenza surveillance among hospitalized patients Doctors select hospitalized patients  No case definitions  Nasopharyngeal and serum specimens submitted to regional laboratories Regional laboratories test sera National laboratories test high-priority specimens and confirm positive influenza A results from regional laboratories 15

16 Current Laboratory Testing Regional laboratories test clinical specimens  Acute and convalescent samples for serum specimens  90% of specimens tested within 9 days National laboratory conducts PCR for severe cases  Confirmatory tests within 24-48 hours  Detailed characterization performed at WHO reference laboratory Number of influenza A specimens shared with WHO unknown 16

17 Current Surveillance Reports Routine reports monthly  Based on total counts of patients discharged with pneumonia, ARI, or clinician-defined influenza Data presented by  Age  Gender 1% diagnosed with laboratory confirmed influenza  3-4% of specimens tested at National Laboratory are influenza positive, annually 17

18 Current Data Collection on Pneumonia Cases Standard patient-level data form for any patient tested for influenza Consistent and accurate data entry  Case demographics  Date of admission  Date of data entry Limited completeness / updating of fields  Specimen collection  Date of illness onset  Fever  Final laboratory results 18

19 Your Data Collection All 21 provincial hospitals submit P & I data  4 of 6 you visited report data monthly Criteria for “pneumonia” discharge are unclear National laboratory confirms influenza A, B, and subtypes Involvement with WHO FluNet unclear Data do not suggest seasonality Two hospitals account for 70% of pneumonia cases Feedback to physicians occurs rarely, if ever 19

20 Question 3 Does this system achieve the objectives for seasonal/human influenza surveillance that were discussed earlier? Why or why not? Before we answer… 20

21 Remember…. Does this system achieve the objectives for seasonal/human influenza surveillance that were discussed earlier? Why or why not? Objectives of virologic surveillance  Describe the epidemiology and burden of disease of influenza, and  Provide virologic isolates for vaccine development 21

22 Question 3 Does this system achieve the objectives for seasonal/human influenza surveillance that were discussed earlier? Why or why not? Consider:  Timeliness 22 Answer: Not many metrics have been defined Lag of up to 9 days for testing refrigerated specimens is long May affect influenza confirmation rate

23 Question 3 What might be appropriate indicators for timeliness? Data reporting, time from:  From sentinel site to the next administrative level  From administrative level to the national level Time interval between date of onset of fever and specimen collection Specimen testing, time from:  Collection to laboratory  Receipt of specimen to test result  Laboratory result to informing referring institution and physician 23

24 Question 3 Does this system achieve the objectives for seasonal/human influenza surveillance that were discussed earlier? Why or why not? Consider:  Timeliness  Acceptability 24 Answer: Lack of feedback to physicians limits acceptability to physicians

25 Question 3 Does this system achieve the objectives for seasonal/human influenza surveillance that were discussed earlier? Why or why not? Consider:  Timeliness  Acceptability  Representativeness 25 Answer: Large % of cases from only 2 hospitals Many hospitals not reporting regularly Need more information to determine representativeness of population

26 Question 3 Does this system achieve the objectives for seasonal/human influenza surveillance that were discussed earlier? Why or why not? Consider:  Timeliness  Acceptability  Representativeness  Completeness 26 Answer: Some sites over-represented compared to others Laboratory data variable Need to re-train clinicians and data- entry staff

27 Question 3 Does this system achieve the objectives for seasonal/human influenza surveillance that were discussed earlier? Why or why not? Consider:  Timeliness  Acceptability  Representativeness  Data Validity / Data Quality 27 Answer: No case definition limits ability to Determine baseline Interpret trends Estimate rates of illness Assess risk factors Incomplete reporting by most facilities Long refrigeration affects specimen quality

28 Question 3 Does this system achieve the objectives for seasonal/human influenza surveillance that were discussed earlier? Why or why not? Consider:  Timeliness  Acceptability  Representativeness  Data Validity / Data Quality  Flexibility 28 Answer: With appropriate laboratory facilities, the system may be flexible enough to identify respiratory pathogens in circulation With case definitions, the system could be expanded to capture a wider range of diseases

29 Your Recommendations Develop a standard case definition for “severe acute respiratory illness” Formally identify sentinel sites Training for sentinel site clinicians Routinely send influenza isolates to WHO collaborating centers, and enter into WHO/Flu-Net Implement a plan for regular feedback of surveillance information to clinicians Immediate notification and response for high priority cases and clusters 29

30 Your Recommendations Performance indicators for objective monitoring and evaluation Increase laboratory PCR testing Additional laboratory quality control 30

31 Your Next Task Work with MOH of Pegu Write a formal set of national guidelines  Outline the approach to establish sentinel surveillance  Standard case definition of SARI among hospitalized inpatients  Standard case definition if ILI among outpatients 31

32 Question 4 What criteria will you use to decide where sentinel hospitals should be located? Answer: 1.Representative of a defined population 2.Reasonable logistics within the hospital for 1.Case identification 2.Specimen collection 3.Specimen transportation 3.Politically acceptable 4.Practically Feasible 5.Added benefit: Location in “high risk” location 32 Number of facilities selected will be based on local resources Each facility should have a focal point to oversee collection and reporting of data and specimens

33 CDC/WHO SARI Case Definition for persons > 5 years old Lower respiratory tract illness consisting of ALL of the following:  Sudden onset of fever over 38°C, AND  Cough or sore throat, AND  Shortness of breath or difficulty breathing, AND  Requiring hospital admission 33

34 CDC/WHO Case Definition for persons < 5 years old Any child 2 months to 5 years of age with cough or difficult breathing and:  breathing faster than 50 breaths / minute (2 – 12 months)  breathing faster than 40 breaths / minute ( 1 – 5 years) or, Any child 2 months to 5 years of age with cough or difficulty breathing and any of the following general danger signs:  Unable to drink or breastfeed  Vomits everything  Convulsions  Lethargic or unconscious  Chest indrawing or stridor in a calm child AND Requiring hospitalization 34

35 Question 5 Which of the following are reasons why good SARI case definitions are a key data collection priority in Pegu? a.The use of a SARI case definition provides some standardization of reporting across hospitals and regions. b.Testing defined SARI cases will yield circulating pathogens and strains c.Surveillance using a good SARI case definition will yield a better understanding of epidemiology and burden of respiratory disease d.It could detect emergence of a new pathogen e.All of the above Answer: e. 35

36 Question 6 True or False: One drawback of Pegu’s case definition is that it is not sensitive enough Answer: False. Pegu’s case definition is sensitive. This is actually a drawback because the country’s single national laboratory could become overwhelmed with cases 36

37 Question 7 What kinds of data should be collected from the SARI cases from which specimens are being collected and why? Consider:  General information 37 Answer: Unique identification number* Medical record number* Name (and parent’s name, if a minor)* Date of Birth* Sex* Address* Date of onset of symptoms* Date of collection of epidemiologic data* Part of an outbreak investigation Inpatient or outpatient

38 Question 7 What kinds of data should be collected from the SARI cases from which specimens are being collected? Consider:  General information  Specimen 38 Answer: Throat swab – date of collection* Nasal swab– date of collection Other specimen (if collected) – date of collection

39 Question 7 What kinds of data should be collected from the SARI cases from which specimens are being collected? Consider:  General information  Specimen  Clinical signs, symptoms 39 Answer: Fever >38* Cough* Sore throat* SOB/Difficulty breathing* IMCI danger signs (per WHO protocols)* Diarrhea

40 Question 7 What kinds of data should be collected from the SARI cases from which specimens are being collected? Consider:  General information  Specimen  Clinical signs, symptoms  Risk factor information 40 Answer: Occupation * Contact with: Suspected H5N1 cases Sick or dead poultry or wild birds* Severe respiratory illness cases Travel Eating raw or undercooked poultry products

41 Question 7 What kinds of data should be collected from the SARI cases from which specimens are being collected? Consider:  General information  Specimen  Clinical signs, symptoms  Risk factor information  Pre-existing medical 41 Answer: Liver disease* Kidney disease* Immune compromised state* Neuromuscular dysfunction* Diabetes* Heart disease* Lung disease* Smoking history*

42 Question 7 What kinds of data should be collected from the SARI cases from which specimens are being collected? Consider:  General information  Specimen  Clinical signs, symptoms  Risk factor information  Pre-existing medical  Treatment history 42 Answer: Vaccination against influenza within the past year* Currently taking anti viral medicine

43 Question 7: Key Points Laboratory-Epidemiology link is critical  There must be a system in place where the same unique identifier is place on both sets of data 43

44 Chief Surveillance Officer Response Concerned about having too many hospitals report too many SARI cases, overwhelming the laboratory Random sampling at hospitals may be complicated for staff Instead suggests sampling all SARI cases from a few hospitals 44

45 Surveillance for Less Severe Influenza Chief Surveillance Officer would like to include less severe, more common, influenza cases in the system Can be provided by outpatient surveillance WHO criteria for influenza-like illness  Sudden onset of fever over 38C  Cough or sore throat  Absence of other diagnoses 45

46 Question 8 How could the sentinel site system be expanded to include some less severe influenza cases? Answer: Implement ILI surveillance in outpatient clinics of SARI sentinel-site hospitals Weekly counts of ILI outpatient visits testing positive for influenza Choose small sample of cases for specimen and epidemiologic data collection 46

47 SARI and ILI Surveillance Outpatient ILI surveillance at 5 SARI sentinel site hospitals Systematically select first 2 cases each day for laboratory and epidemiologic investigation Sentinel hospitals will provide weekly tally of total ILI cases at facilities 47

48 Part II: Influenza A(H5N1) and Pandemic Early Warning Surveillance 48

49 Media Reports Mass deaths of flocks of chickens, geese, waterfowl Southeastern Pegu Ministry of Agriculture investigation 3 chicken samples ‘weakly positive’ for Influenza A (H5N1) No systematic avian surveillance exists 49

50 Question 9 Are you confident that a hospitalized human case of Influenza A(H5N1) would be recognized and responded to? Why or why not? Answer: No.  There is no system of 24-hr SARI notification and prioritization for influenza A (H5N1) testing  Rapid detection is needed: Treatment is most effective if given within 48 hours, but infectiousness may occur 24 hrs prior to onset – need to quickly identify cases and contacts 50

51 Question 10 How might surveillance for seasonal influenza support efforts to recognize an emerging pandemic or detect human cases of Influenza A (H5N1)? a.By counting cases b.By creating a logistical network c.By establishing case definitions and reporting criteria d.By tapping into Pegu’s health budget e.By enhancing laboratory capacity f.None of the above Answer: b, d. 51

52 Question 10: Additional Answers During a pandemic, data from the routine sentinel site surveillance system will help describe the:  Changing geographic location of the virus  Trend in cases  Severity of the pandemic 52

53 Question 10: Key Points As routine SARI surveillance is instituted, data will be more complete and standardized Sentinel-based surveillance is feasible for most countries to track a pandemic 53

54 Your Recommendations Clinicians at sentinel hospitals and non sentinel-site hospitals need to be trained in influenza A (H5N1) screening criteria Criteria can elevate index of suspicion about SARI cases Surveillance officer agrees that trigger criteria could help prioritize SARI cases for immediate laboratory testing 54

55 Question 11 True or False: The proposed epidemiologic “trigger criteria” below could be used to prioritize SARI cases for immediate reporting and laboratory testing for Influenza A (H5N1) 1. Travel within last 3 weeks to an area with known H5N1 circulation 2. Hospitalized for SARI 3. Meets the WHO suspect, probable, or confirmed H5N1case definition 4. Close contact with WHO suspect, probable, or confirmed case 5. Occupational exposure 6. SARI in a previously healthy individual 7. Consumption of raw /undercooked poultry or wild bird products 8. Handling samples (animal or human) suspected of containing H5N1 virus in a laboratory or other setting 55 Answers 1. False 2. False 3. True 4. True 5. True 6. False 7. True 8. True

56 Chief Surveillance Officer Response “What if the next pandemic isn’t caused by Influenza A (H5N1), but some other respiratory pathogen that isn’t associated with poultry or wild bird exposure? “We should learn our lesson from SARS and design a system that can also detect a respiratory pathogen that is spreading between humans and causing severe disease.” 56

57 Question 12 Consider the following series of questions about epidemiologic trigger criteria that might raise the index of suspicion about whether a respiratory pathogen of pandemic potential could be circulating in the population. Clusters of 2 or more SARI cases occurring within 7-10 days of each other are suspicious under all circumstances EXCEPT: a.If they are in a family b.If they all have a social connection c.If they all ate cooked chicken d.If they all have an occupational connection Answer: C 57

58 Question 13 Consider the following series of questions about potential epidemiologic trigger criteria… SARI in health care workers who care for patients with ______. a.Pneumonia b.Chronic respiratory disease c.Poultry exposure d.Previous hospitalization Answer: a. Pneumonia 58

59 Question 14 Consider the following series of questions about potential epidemiologic trigger criteria… Changes in the _________of SARI cases such as a shift in the age group affected or changes in mortality rates a.severity b.recommended treatment c.epidemiology d.clinical presentation Answer: e. epidemiology 59

60 Question 15 Consider the following series of questions about potential epidemiologic trigger criteria… Any unexplained death due to SARI in persons _____________. a.aged 5-40 b.aged < 5 c.without underlying medical conditions d.in countries with known circulation of possible pandemic respiratory viruses Answer: a. 60

61 Question 16 Consider the following series of questions about potential epidemiologic trigger criteria… An increase in the numbers of cases occurring in a facility compared to the same season in a previous year is considered a potential trigger for raising the index of suspicion about whether a respiratory pathogen of pandemic potential could be circulating in the population. a.True b.False Answer: a. True 61

62 Questions 12-16: Key Points Surveillance for CLUSTERS of SARI is critical Even for an influenza A(H5N1) pandemic, most cases would not have a poultry link See Trigger Criteria Summary Handout 62

63 Trigger Criteria Decisions National clinician education about trigger criteria and reporting  At hospitals within the sentinel system  At hospitals outside the sentinel system Cases meeting criteria  Immediate notification to Provincial Medical Officer via toll-free phone number  Oropharyngeal and nasopharyngeal swabs 63

64 Finalize the Guidelines Trigger cases can facilitate timely diagnosis of other respiratory pathogens of pandemic potential, if negative for influenza  Detailed laboratory testing algorithm is planned WHO case definitions used for international reporting purposes 64

65 Laboratory Samples H5-positive poultry specimens  From southeastern province, Pelu Jaghai  Sent to WHO reference laboratory Province is rural  Hospital care may not be sought  Community-level surveillance needed 65

66 Question 17 How could Influenza A (H5N1) and pandemic early warning surveillance be expanded beyond the hospitals in Pegu? Match the method on the left with its description on the right. 66 MethodDescription Enhanced passive surveillancea. Passive identification from media reports, the public, professional groups, and the WHO surveillance network Communication with the general population b. Include these facilities in education and awareness training to report trigger criteria Involvement of traditional medicine hospitals c. Outreach to health care gatekeepers - health care providers, laboratorians, drug dispensers, traditional healers, religious leaders, and others. Rumor surveillanced. Public service messages in print, radio, and television

67 Pegu Accomplishments MOH will train a team in each province, using polio surveillance officer as “bird flu person” Surveillance foundations in place  Case definitions  WHO reporting  Early warning system plans  Trigger criteria for laboratory testing and public health investigation  Gatekeeper training  Sentinel sites 67

68 The next day… Pelu Jaghai reports another large poultry die- off  In farms in backyard populations  Specimens from Ministry of Agriculture sent to the National Laboratory Ministry of Health wants to establish active human surveillance 68

69 Question 18 Which of the following are surveillance enhancements for human disease that could be recommended for the affected province?  Teach Pegu’s traditional healing methods to it regional epidemiologists  Door to door surveillance for ill people and chickens  Initiate school-wide influenza shots  SARI surveillance among healthcare workers at local facilities  Active case finding among the occupationally exposed  Dismiss rumors of clusters within health care workers, families or village contacts  Recruit private practices, NGO’s, religious institutions, and schools into the surveillance system for H5N1 and pandemic trigger criteria  Refresher training on reporting procedures  Confirm availability of telephone reporting hotlines 69

70 Question 18: Key Points Active surveillance is key in this context Make surveillance more active in the hospital and community settings Backyard poultry husbandry may not be known to authorities  Poultry workers and community need to know importance of seeking treatment  Make healthcare facilities aware of community education and reporting mechanisms Village health monitors and leaders can be important sources of information for outside investigators 70

71 Later that evening… You learn of two possible human cases in neighboring Dava Ghar province No poultry outbreaks have ever been reported here! You are asked to extend your stay and participate in the outbreak investigation You travel with the District Epidemiologist and two local officials to Dava Ghar Province 71

72 Continue to Outbreak Investigation Case Study 72


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