1. Epidemic intelligence with the IHR Preben Aavitsland Department of Infectious Disease Epidemiology Norwegian Institute of Public Health at EpiTrain V, Vilnius, October 25 2007

2. Epidemic intelligence Definition: All the activities related to early identification of potential health threats, their verification, assessment and investigation as a basis for recommending control measures. That is: detecting and investigating events (outbreaks and others)

3. Two main objectives of surveillance Measuring distribution of cases of disease by time, place, and person –Emphasis on medium and long term changes Detecting unusual events (outbreaks) –A) Detecting sudden changes in numbers –B) Detecting events (event surveillance) –This is part of epidemic intelligence

4. Epidemic intelligence framework

5. The IHR surveillance system National IHR Focal Point WHO/Euro IHR Focal Point Local level assess national events using annex 2 do surveillance notify (art 6), inform (art 8), consult in confidence events that may be pheic assess and decide pheic or not

6. Notification is a start of a dialogue (i.e. not a big deal) Potential pheic notified by country Pheic declared by WHO Dialogue High sensitivity, low positive predictive value

7. Article 6. Notification Assess national events using Annex 2 National IHR Focal Point notify WHO IHR Focal Point of all events which may constitute a public health emergency of international concern Afterwards, continue to give WHO updated information

8. Decision instrument (annex 2) to determine whether an event may be a public health emergency of international concern (pheic) Simlified by Baker & Fidler, 2006

9. Any event of potential international public health concern, including those of unknown causes or sources A case of the following diseases is unusual or unexpected and may have serious public health impact, and thus shall be notified: Smallpox, Poliomyelitis due to wild-type poliovirus, Human influenza caused by a new subtype, Severe acute respiratory syndrome (SARS). YesNoYesNo Is the public health impact of the event serious? Is the event unusual or unexpected? Is there a significant risk of international spread? Is there a significant risk of international travel and trade restrictions? Two or more yes notify WHO. Events detected by national surveillance system

10. Question I Is the public health impact of the event serious?

11. Question I Is the public health impact of the event serious? 1.Is the number of cases and/or number of deaths for this type of event large for the given place, time or population? 2.Has the event the potential to have a high public health impact? 3.Is external assistance needed to detect, investigate, respond and control the current event, or prevent new cases? Answer yes if you have answered yes to questions 1, 2 or 3 above.

12. Question II Is the event unusual or unexpected?

13. Question II Is the event unusual or unexpected? 1.Is the event unusual? 2.Is the event unexpected from a public health perspective? Answer yes if you have answered yes to questions 1 or 2 above.

14. Question III Is there a significant risk of international spread?

15. Question III Is there a significant risk of international spread? 1.Is there evidence of an epidemiological link to similar events in other States? 2.Is there any factor that should alert us to the potential for cross border movement of the agent, vehicle or host? Answer yes if you have answered yes to questions 1 or 2 above.

16. Question IV Is there a significant risk of international travel or trade restrictions?

17. Question IV Is there a significant risk of international travel or trade restrictions? 1.Have similar events in the past resulted in international restriction on trade and/or travel? 2.Is the source suspected or known to be a food product, water or any other goods that might be contaminated that has been exported/imported to/from other States? 3.Has the event occurred in association with an international gathering or in an area of intense international tourism? 4.Has the event caused requests for more information by foreign officials or international media? Answer yes if you have answered yes to questions 1 or 2 above.

18. Article 8. Consultation If event not notifiable according to Article 6 / Annex 2 Keep WHO informed Consult with WHO an appropriate health measures Ask WHO for assistance if needed Event may later become notifiable accordning to Article 6 / Annex 2

19. Article 9.2. Threat in other country Inform WHO about threats in other countries When you have detected import or export of human cases; vectors which carry infection or contamination; or goods that are contaminated.

20. Article 9.1. Other reports National IHR Focal Point WHO Local level Mass media, GPHIN, MediSYS, Google, NGOs, ProMED etc + other countries give information (art 10) verify (art 10) do surveillance (art 9)

21. WHO actions Offer to collaborate to assess events (art 10.3) Share information with other countries (art 10.4 and 11) Determine whether the event is a pheic (art 12) Assist in the response to the event (art 13) Give temporary recommendations (art 15)

22. Example: Measles in Norway 16 cases of measles in nomadic families from England (Travellers), mostly children –One bacterial pneumonia –One otitis media They live in caravans at camping sites Some of them travel back and forth to England Index case was child infected in wedding in England No cases so far in indigenous population Measles elminiated in Norway; high vaccination coverage

23. Question I Is the public health impact of the event serious? 1.Is the number of cases and/or number of deaths for this type of event large for the given place, time or population? 2.Has the event the potential to have a high public health impact? 3.Is external assistance needed to detect, investigate, respond and control the current event, or prevent new cases? Answer yes if you have answered yes to questions 1, 2 or 3 above.

24. Question II Is the event unusual or unexpected? 1.Is the event unusual? 2.Is the event unexpected from a public health perspective? Answer yes if you have answered yes to questions 1 or 2 above.

25. Question III Is there a significant risk of international spread? 1.Is there evidence of an epidemiological link to similar events in other States? 2.Is there any factor that should alert us to the potential for cross border movement of the agent, vehicle or host? Answer yes if you have answered yes to questions 1 or 2 above.

26. Question IV Is there a significant risk of international travel or trade restrictions? 1.Have similar events in the past resulted in international restriction on trade and/or travel? 2.Is the source suspected or known to be a food product, water or any other goods that might be contaminated that has been exported/imported to/from other States? 3.Has the event occurred in association with an international gathering or in an area of intense international tourism? 4.Has the event caused requests for more information by foreign officials or international media? Answer yes if you have answered yes to questions 1 or 2 above.

27. Any event of potential international public health concern, including those of unknown causes or sources A case of the following diseases is unusual or unexpected and may have serious public health impact, and thus shall be notified: Smallpox, Poliomyelitis due to wild-type poliovirus, Human influenza caused by a new subtype, Severe acute respiratory syndrome (SARS). YesNoYesNo Is the public health impact of the event serious? Is the event unusual or unexpected? Is there a significant risk of international spread? Is there a significant risk of international travel and trade restrictions?

28. The Kon-fu-tse principle of surveillance Notify to WHO the events that you would like to know about if they occured in your neighbour country. If in doubt, notify!

29. Exercise For each event: Assess the events using annex 2 and decide whether to notify WHO under article 6 / annex 2 Also decide whether to inform WHO under article notify under 9.2 If you decide not to notify or are uncertain, what other information do you need?

30. Event number 1 The cruise ship Queen of Narva arrives in Riga port. On board there are 1200 tourists from USA and Canada and a crew of 400. The captain informs you that there is an utbreak of acute gastroenteritis on board. During the last couple of days, some 200 people on board have had vomiting and diarrhoea. Many of them are already well. Five old ladies are in the hospital on board.

31. Event number 2 The doctor at the tuberculosis hospial calls you. They have recently diagnosed sputum-positive pulmonary tuberculosis in a Somali immigrant who had recently arrived. The man has explained that he arrived last week on board a flight from Etiopia and changed planes in Frankfurt. The doctor believes that the patient was infectious during the flight.

32. Event number 3 At the national surveillance centre you receive reports of around 100 shigellosis cases from several cities in one region of the country during just one week. Usually there are only 100 cases a year. You believe that there may be a foodborne outbreak related to a dairy product. Journalists have started calling you to get comments.

33. Event number 4 Five hundred teenaged folk singers from Estonia, Latvia and Lithuania are gathered in a village outside Vilnius for the annual song festival. They live in tents. On Friday evening, a young girl is admitted to hospital with meningitis symptoms. The next morning the hospital calls you to inform that it is meningococcal disease, group C. They also tells you that another, possible case from the festival has been admitted the same morning.

34. Event number 5 The local doctor tells you that he has detected an outbreak of measles involving five children age 1-6 years in a group of traveller families (Rom) that has just arrived from your neighbour country in their vans and settled in his city (10 000 inhabitants). They are some 75 people. He fears further spread, and informs you that the vaccination coverage in the local population is around 80%.

35. Event number 6 The national food authority calls you to inform you that the producer of a popular brand of cured sausage has found enterohemorrhagic E coli in a batch of sausages and are withdrawing it from the market. The sausage is mainly sold domestically, but some is exported to EU countries. It is also sold to tourists in airports as a national delicatessen.

36. Event number 7 From your surveillance system you detect an increasing number of syphilis among men who have sex with men. You conclude that there is an outbreak linked to gay clubs in the capical. Some patients have informed you that they have met foreigners in the clubs, and other patients tell you that they have been to gay clubs in Amsterdam recently.

37. Event number 8 The tropic medicine hospital calls you. Two nurses have been diagnosed there with malaria. They had been to Kenya, but they used only homoepathic drugs against malaria because they were afraid of side effects of other chemoprophylaxis.

38. Event number 9 The local doctor in a small countryside community calls you. He reports an outbreak of gastroenteritis in guests who attended a church lunch last Sunday. He thinks it was caused by staphylococcal toxins in some of the food. Most patients are old.

39. Event number 10 The chief of the childrens hospital calls you. They have just confirmed cholera in a child aged two years. The child was from a Pakistani immigrant family, and they had just come home from a vist to their native village in Pakistan when the child got profuse diarrhoea. The child is seriously ill. None of the other family members are sick.

40. Results from five groups