Presentation on theme: "Event based surveillance systems"— Presentation transcript:
1 Event based surveillance systems Alicia BarrasaEPIET Introductory course 2011Lazareto, Menorca, Spain
2 Infectious diseasesArise from many different pathogens: viruses, bacteria, parasitesSpread in many different species: humans, insects, domestic and wild animals, aquatic animals and sometimes breach barrier between animal and humans (70% of emerging infections arise from animal population)Take many different routes of transmission: direct contact, vectors, food, environmentalAffect all populations in all regions of the world
3 Emerging and Re-emerging infectious diseases CryptosporidiosisDengue haemhorrhagic feverCholeraE. coli O157TyphoidDiphtheriaLassa feverMultidrug resistant SalmonellaE.coli non-O157MalariaLegionnaire’s diseaseBuruli ulcerShigellosisCholera O139RespiratoryinfectionKyasanur f.Lyme BorreliosisRestonVenezuelanequine encephalitisWest Nile FeverEchinococcosisYellow feverEbolahaemorrhagicfeverHuman monkeypoxInfluenza A (H5N1)RVF/VHFRoss River virusHendra virusBSEWest Nile VirusNipah VirusSARSHuman monkepoxO’nyong-nyong feverReston VirusRabiesnvCJDEpidemic Alert and Response (EAR), WHO Regional Office for EuropeEHECA(H1N1)v
4 Accidental and deliberate release of infectious agents Increased research, biotechnology is widely availableIncreased risk for accidental release (e.g. SARS 2004 from laboratory)World tensions remain and the deliberate release of infectious agents is no longer a remote threat.
5 International Health Regulation 1374 Venice Quarantine for Plague1851 Paris 1st International Sanitary Conference1947 Geneva WHO Epidemiological Information Service1951 Geneva International Sanitary Regulations1969 Geneva International Health Regulations2004 Regional consultationsNov Geneva Intergovernmental Working Group meetingFeb Geneva Intergovernmental Working Group meetingMay 2005 Geneva Revised IHR, World Health AssemblyThe history of international health regulations is believed to have begun with quarantine legislation enacted by the city of Venice in 1377 (1), and the principle of aiming for maximum protection with minimum restriction was laid down at the first international sanitary conference, held in 1851 (1). The International Health Regulations (IHR) are intended to provide a code of practice to be followed by all countries in order to control diseases that threaten international health. Cholera, plague, and yellow fever are the three diseases currently notifiable to the World Health Organization and subject to IHR control measures at ports of entry and departure from countries (1). The regulations are being revised in response to increasing international traffic and changing patterns of communicable diseases. Under the revised IHR, disease outbreaks will be notifiable only if they correspond to the case definition of a specified syndrome and represent events of urgent international importance (2). The routine occurrence of endemic diseases - such as cholera - will no longer be notifiable. The syndromes proposed are as follows:acute haemorrhagic feveracute respiratoryacute diarrhoealacute jaundiceacute neurological"other notifiable syndromes of presumed infectious origin"The criteria by which urgent international importance is to be judged are:high risk of international spreadunexpectedly high case fatality rateunusual occurrencenewly recognised syndromemedia interestpotential for imposition of trade or travel restrictionsA pilot study in 20 countries (including France, Russia and Uzbekistan) has been set up to evaluate the proposed new approach to notification. National health authorities will assess reports of outbreaks in their own countries in the light of the new case definitions and criteria for importance to see whether the new approach will facilitate the identification of and response to disease outbreaksThe International Health Regulations originated with the International Sanitary Regulations adapted at the International Sanitary Conference in Paris in The cholera epidemics that hit Europe in 1830 and 1847 made apparent the need for international cooperation in public health. In 1948, the World Health Organization Constitution came about. The Twenty-Second World Health Assembly (1969) adopted, revised and consolidated the International Sanitary Regulations, which were renamed the International Health Regulations (1969). The Twenty-Sixth World Health Assembly in 1973 amended the IHR (1969) in relation to provisions on cholera. In view of the global eradication of smallpox, the Thirty-fourth World Health Assembly amended the IHR (1969) to exclude smallpox in the list of notifiable diseases.During the Forty-Eighth World Health Assembly in 1995, WHO and Member States agreed on the need to revise the IHR (1969). The revision of IHR (1969) came about because of its inherent limitations, most notably:narrow scope of notifiable diseases (cholera, plague, yellow fever). The past few decades have seen the emergence and re-emergence of infectious diseases. The emergence of “new” infectious agents Ebola Hemorrhagic Fever and the re-emergence of cholera and plague in South America and India, respectively;dependence on official country notification; andlack of a formal internationally coordinated mechanism to prevent the international spread of disease.These challenges were placed against the backdrop of the increased travel and trade characteristic of the 20th century.The IHR (2005) entered into force, generally, on 15 June 2007, and are currently binding on 194 countries (States Parties) across the globe, including all 193 Member States of WHO.
6 IHR Decision Instrument 4 diseases that always have to be notified polio (wild type virus), smallpox, human influenza caused by a novel virus, SARS.Diseases that always lead to the use of the algorithm : cholera, pneumonique plague, yellow fever, VHF (Ebola, Lassa, Marburg), WNF, meningitis, others*Q1: serious repercussions for public health?Q2: unusual or unexpected?Q3: risk of international spread?Q4: risk of travel or traffic restrictions?Insufficient information : re-evaluate
8 International Health Regulation - 2005 To decide on need for notification any public health event can be assessed by the criteriaIs 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 or travel restrictions ?SurveillanceResponseObligation to establish core capacities:
9 Preparedness and response - ECDC Detection of public health threats related to infectious disease, or of unknown originRisk assessment, investigation and controlStrengthening preparedness of EU member statesStrengthening and building capacity through trainingProvision of technical advice and support to third countries upon request
10 Epidemic Intelligence DefinitionThe systematic collection and collation of information from a variety of sources, usually in real-time, which is then verified and analysed and, if necessary, activates responseObjectiveto speed up detection of potential health threats and allow timely response
12 Indicator based Surveillance Surveillance systemsOngoing and systematicCollection and analysis of dataInterpretation and dissemination of results related to health events of interestDiagnosis-based or Syndromic surveillanceFor actionOutbreak investigationImmunization programmesProgramme planning and evaluationOperational research hypothesisRisk assessments
13 Event based Surveillance Organized and rapid capture of information about events that are a potential risk to public health:Events related to the occurrence to the disease in humans (clusters, unusual patterns, unexpected deaths…)Events related to potential exposures (diseases in animals, contaminated food or water, environmental hazards…)
15 Event based Surveillance Sources of information:Hospitals/health care centres/emergency roomsVeterinary services, food agencyWest Nile Virus, Rift Valley FeverFoodborne outbreaksMeteorological dataPollutionHeatLaboratoriesIdentification of specific pathogensIncrease in demand for hepatitis serology
16 Event based Surveillance Sources of informationMediasystematic searching of newsoften in electronic formatInternational networks
17 Indicator vs event based Indicator basedEvent basedDefinitions- Clinical presentationCharacteristics of peopleLaboratory criteriaSpecific- ...events that are a potential risk- ...unusual events in the community- SensitiveTimeliness- Weekly / monthly(some may be immediate)- Possible delay between identification and notification- All events should be reported to the system immediately- Real time
18 Indicator vs event based Indicator basedEvent basedActorsInvolved in the systemMight not knowReporting structureClearly definedReporting formsReporting datesTeams to analyse data at regular intervalsNo predefined structureReporting forms flexible for quali and quantitative dataAt any timeTeams to confirm evens and prepare the response
19 Indicator vs event based Indicator basedEvent basedTrigger for action- a pre-defined thresholds- a confirmed eventResponse- depends on the delay between identification, data collection and analysis- depends on the confirmation of the event, but ideally is immediate
20 A small summaryIndicator and event based systems are tools for PH SurveillanceEvent based systems have already been successfully usedThe challenge: confirmation of the events
21 Public Health Surveillance during the 2012 Olympic and Paralympic Games Helen MaguireacknowledgementsBrian McCloskey, Director, HPS London regionEllen Heinsbroek, EPIET fellow, HPS Colindale
23 London 2012 Olympic and Paralympic Games - 26 Olympic sports in ~34 venues- 20 Paralympic sports in 17 venues- 10,500 Olympic and 4,200 Paralympic athletes- 21,000 media and broadcasters- Over 10.2 million tickets- 180,000 spectators per day in the Olympic Park- 17,000 people living in the Olympic Village
25 What influences our preparations for London 2012? - Politics- Media- Scale
26 Where do we start?What’s been learned before at other mass gatherings?What is the risk assessment?What’s proportionate in relation to the risk?What capability and capacity have we got?What aims /objectives for our surveillance ?
27 Experience of mass gatherings In Atlanta  and in Sydney  infectious diseases accounted for less than 1% of healthcare visitsIn Beijing …there were no problems ..
28 Experience of mass gatherings Winter Olympic Games, Torino Italy 20062 public and private microbiology laboratories provided test results data forStool cultureHepatitis A serology No difference to non-Olympic periodData reported once a week
29 Experience of mass gatherings Germany World Cup, 2006Burden of infectious disease did not increase during World CupMaintenance of daily data transmission in all Federal StatesAdditional free-text reporting for events through usual surveillance system-High sensitivitySyndromic surveillance was regarded as not necessary-as disease surveillance systems already in place
30 London Olympics Surveillance Aim To provide information on selected indicators (including infection related, syndromes, and environmental) as well as on events or incidents that impact on Olympic venues/staff/athletes/visitors -in order to rapidly identify any individual cases or outbreaks /incidents so that interventions can be implemented
31 Objectives 1 review existing systems completeness, sensitivity to unusual events /outbreaksflexibility, timeliness, ability to detect new pathogens2 identify gaps or limitations3 enhance existing or establish new systems
32 Enhance existing … Enhance reportable disease by clinicians Enhance laboratory capacity and reportingEnhance environmental monitoringCreate 24 on-call and rapid response teamsSyndromic surveillance, like most public health surveillance systems involves the collection of data at the local level. It’s definition covers a broad spectrum of very different pieces of information and employs the use of multiple types and sources of data. Generally these data sources precede clinical or laboratory diagnosis, and often involve the use of specific clinical signs, symptoms and syndromes identified as potential predictors of infectious disease of interest.
33 Epidemic Intelligence (existing and new ) Syndromic Surveillance (NHS Direct, Q Surveillance, RCGP, EDSSS, OOH)Notifications of Infectious DiseasesSurveillance at Olympic Village PolyclinicsEvent-Based SurveillanceLaboratory Reporting
34 Existing and new surveillance systems Surveillance of Undiagnosed Serious Infectious Illness (USII)Environmental monitoring at Centre for Radiation, Chemical (and Environmental Hazards Mortality Surveillance)34
35 1 Syndromic Surveillance Existing systemsNHS DirectGP-based syndromic surveillanceQ SurveillanceRoyal College General PractitionersNew systemsOut of Hours ProvidersEmergency Departments
36 1 Syndromic Surveillance out of hours To provide enhanced surveillance during weekends/holidays/eveningsWhat did we do?Established links with AdastraDaily data received from beginning of November 2009 for a single pilot siteData received in form of anonymised event recordsAnalysis by PCT using postcode districtAnalysis by ageAnalysis by Read code – for example, used groups of Read codes to construct an influenza-like illness indicatorComparison with existing syndromic surveillance systemsRecommendations made to Project Group
37 1 Syndromic Surveillance emergency departments To establish a surveillance network of EDs across EnglandWhat did we do?Established links with AdastraDaily data received from beginning of November 2009 for a single pilot siteData received in form of anonymised event recordsAnalysis by PCT using postcode districtAnalysis by ageAnalysis by Read code – for example, used groups of Read codes to construct an influenza-like illness indicatorComparison with existing syndromic surveillance systemsRecommendations made to Project Group37
38 2 Notifications of infectious diseases Health Protection UnitHPA Colindale:Departments (esp. Immunisation)Registered Medical PractitionerProper Officer - Local AuthorityHPA Colindale: Central Information ManagementNormal: fax: max. 3 daysEmergency: phone within 24 hrsMax. 3 days (methods differ by LA/HPU)Extra requirements Olympics:Olympic Venue AttendanceForms + HPZone to be changedSpeed up notificationsImprove consistency reportingReport published on internet
39 3. Surveillance at Olympic Village Requirement to notify infectious diseases compulsory for overseas athletic team doctorsCompulsory component of temporary registrationSame forms as medical practitionersNotification System being set upHPA presence in Olympic PolyclinicMonitoring of staff absencesOlympics Surveillance Systems – 3. Surveillance at Olympic Village
40 4. Event based surveillance What is a significant event?Standard factors – e.g. severity,Olympic factors – proximity to venue, affecting visitorsThe media!How do we identify significant eventsHPZone – dashboard – flagging events with an ‘Olympic flag’Regional reporting via teleconference or negative reportingMedia screening
42 HPA Colindale: Central Information Management 5 Lab reportingHPA Colindale:DepartmentsLaboratoriesHPU/RegionHPA Colindale: Central Information Management- Weekly, by law (Oct’10)- Automatic, with manual checking+sendingExtra requirements Olympics:Daily reporting: software changeAutomatic extraction softwareExceedance Algorithms: dailyAdapt for changes in testing,e.g. multiplex PCR- Weekly exceedance report published on intranet- Departments access via software
43 6. Surveillance of Undiagnosed Serious Infectious Illness To ensure early detection and response to new and emerging infectious disease threats.Case definitionAny person admitted to HDU/IDUwith a serious illness suggestive of an infectious process where the clinical presentation does not fit with any recognisable clinical pictureOR there is no clinical improvement in response to standard therapyAND initial laboratory investigations for infectious agents are negative
44 7 Surveillance at Centre for Radiation, Chemical and Environmental Hazards -increase to daily reporting
45 Olympic Surveillance Matrix: Early Detection SystemScenarioUK based surveillanceInternational Situational Analysis (horizon scanning)Syndromic Surv, (NHSD, Q, OOH)NOIDSOlympic Village PolyclinicsCRCELaboratory ReportingSyndromic Surveillance – ED*sentinelUSIIMortalityLocalized outbreak, small number of cases e.g. meningococcal*Localized outbreak, large number of cases e.g. measlesWidespread outbreak, small number of cases e.g. food poisoningWidespread outbreak, large number of cases e.g. influenzaIncrease in weather related disease,e.g. asthmaChemical, Environmental or Radiation incidentImported disease,e.g. plagueNewly emerging diseaseDeliberate release,e.g. anthrax