1. Surveillance of unusual events in the context of influenza
This morning I will discuss aspects of surveillance for human and avian influenza.

2. Identify new or changing risks and take appropriate actions through:
Early detection of
Novel pathogens
Variations of old pathogens
Understand trends and patterns of disease
To inform public health policy: who should be targeted, what interventions are useful, etc.
Monitor behavior of disease: what is "usual"? getter worse? Changing target? Pathogen shifting its character?

3. H5? H7? SARS? Other? Things to Consider
Early detection needed to adequately respond to emerging pathogens,
Routine surveillance of ILI and SARI too blunt an instrument to pick up signal of an emerging pathogen, even if universal reporting
Syndromes are nonspecific
Lots of other things cause both
Will have widespread circulation before picked up
Routing surveillance will provide the baseline data that will allow interpretation of significance of new event
H5?
H7?
SARS?
It should be remembered that H5N1, while it has a high mortality in those individuals who acquire it, is a very rare condition. The reason that the health community is so concerned is because of it’s potential to evolve into a virus that is transmissible from human-to-human and so launch a pandemic. Therefore, it should always be kept in mind when thinking about the design of an early warning system that the real goal is to detect the emergence of a pandemic. Once a pandemic starts, the virus will spread from human-to-human and it may do so in a very short period of time. This means that very early on in a pandemic, only a small fraction of cases will have a linkage to poultry – all of the others will have acquired the disease from human contact and only by coincidence would have had poultry contact. Therefore, it is important to design a system that detects not only cases of severe respiratory disease with epidemiologic links to sick or dying poultry/poultry products but which also detects early patterns of human-to-human transmission of severe respiratory disease.
Other?

4. Strategy for detection and reaction
IHR (2005) requires every country to develop the capacity to detect and evaluate events that may have international implications.
This requires and early detection and response system
Establishing a routine monitoring program will establish the infrastructure to support early detection and will provide the historical context
In addition will provide critical data to inform health policy
Participating in a global system will aid in understanding your data and to forecast future seasons
Requires standardization

5. What type of surveillance
World Health Organization
What type of surveillance
11 June 2018
Event based surveillance: early warning
Indicator based surveillance: routine influenza surveillance
Sentinel ILI and SARI surveillance to gather quality data
Enhanced surveillance where necessary

6. Enhanced surveillance
Complementary systems
Routine Influenza
Surveillance
Early Warning
Surveillance
During this presentation, keep in mind that there is an interrelationship – or synergy - between seasonal influenza and pandemic influenza preparedness. Actions we take now to address seasonal influenza will help with pandemic influenza preparedness, and vice-versa.
Enhanced surveillance

7. What's the Difference? Early warning Routine Influenza Surveillance
Detection of unusual events
Needs to happen very early on in the course of the event
Needs broad based involvement to be effective
Routine Influenza Surveillance
Collection of epidemiological and virological data on a regular basis
Regularly reported, analyzed and reported back
Describes the epidemiology of flu including persons at risk, seasonality, and disease burden.
Usually sentinel based

8. Early warning – somebody needs to react
Most effective tool is alert health care providers.
Recognition of something unusual: a signal event such as a cluster, unusual presentation, unusual course. (e.g. Lyme, HIV, Nipah, novel influenzas)
Signal events can be predefined to an extent but hard to predict a novel pattern – Kaposi's sarcoma
Mechanism for reporting
Simple and clear system, hotlines, focal point
Mechanism for investigation and evaluation
Field investigators
Lab capacity

9. Routine surveillance – quality data
Data quality is crucial, more important than quantity
Must know the context: who, how, where, why
Not critical (or feasible!) to capture every case of anything but must understand what is being missed
Consistency in reporting
Aberrations are important signals

10. 3 Primary Components of an Early Warning System
Keystone is broad based recognition of “trigger events” that must be reported immediately.
Mechanism for reporting
Hotline
Local Health Dept.
Local Agriculture
Coordinating bodies
Response mechanism
An effective early warning system would have many parts but these could be summarized by the following:
Broad based recognition of signal or trigger events. The emphasis here is on “broad”. As the system needs to pick up a rare event, it has to be extremely sensitive.
Creating awareness of trigger events is of little value if there is no mechanism for reporting the events to the appropriate authorities who can investigate and respond. There are many ways to do this but there must be reporting mechanisms that are widely accessible to the community that is being asked to report.
Finally, there must be a mechanism for responding and intervening. This would include investigators who are trained in outbreak investigation techniques and containment strategies who are well equipped.
This file has been released into the public domain by the copyright holder,

11. “Trigger” events in event surveillance
Unusual cases or events that elevate the index of suspicion of a possible emergence of something unusual
Typically looking for
Infection of influenza type in human infection normally not infecting humans (H5, H9, H7 etc.
Disease of unusual severity or atypical clinical appearance
Change in animal infection patterns
Unusual cluster of cases
To build an early warning system we must educate clinicians in hospitals and clinics, traditional healers, and others about “trigger” events. Triggers are unusual cases or events that elevate the index of suspicion of a possible human case of avian influenza or signal the emergence of a new pandemic virus. Triggers may lead to the diagnosis of avian influenza in humans or signal the emergence of human-to-human spread of a new type of influenza or other respiratory virus. These will largely include SARI cases that are more likely then other SARI cases to be the result of Influenza A(H5N1) or another possible pandemic pathogen. An investigation should occur before any laboratory confirmation is received. ALL cases that meet trigger criteria must have specimens collected and tested for influenza A (H5N1) and seasonal strains.

12. Sources of Information
Health Care Workers
Teachers
Community Leaders
Pharmacists
News media
Rumors from informal data sources
information hotlines
Animal Health Sector
Animal events: excessive deaths
Non human events, such as the die off of large numbers of poultry should be investigated for possible associated human cases.
Rumor reporting – the collection of information from non-traditional reporting sources such as media reporters should also be considered as part of an early warning surveillance system. To be successful, this needs to be formalized with the active participation of media workers.

13. Education and Awareness
Training of health care providers
Should include non-mainstream providers and consider dispensers.
Involve media, educate reporters
Nationwide public education and awareness
Risk reduction and reportable events
Regular training refreshers/public education
Public health reminders and inquiries
Nationwide training of health care workers, including Educational activities should also include non-mainstream providers and dispensers needs to be undertaken. This should include clinicians who work at hospitals/clinics designated as sentinel sites as well as non sentinel-site facilities. This education and awareness program should include regular continuing education, as well as communication to the public (the media) regarding risk reduction and reportable events is necessary for the success of the trigger reporting system. media and reporters. Another way to get the message out to the national public is to provide Public health reminders and inquiries that may also assure quality and improve surveillance sensitivity of the trigger events being reported by the population at large. Regular training refreshers at reporting institutions are a key component of maintaining the sensitivity of a population-based reporting system.
Photo: Diane Gross, CDC

14. World Health Organization
Sharing of event-based information
Locally, regionally and internationally
11 June 2018
WHO IHR Contact Point
National IHR Focal Point
Notifications
Consultations
Reports
Event Information Site
◄ Verification requests
Local Focal Point

15. Identify, Verify, Assess, Assist, Inform at all levels
World Health Organization
Identify, Verify, Assess, Assist, Inform at all levels
11 June 2018
States Parties
WHO and UN
Others sources
Event risk assessment
Disseminate information
Verification
Screening & Initial assessment
Informal / Unofficial information
Formal reports
Other partners
GOARN and other technical partners
Assist - Respond
WHO has established a single, reproducible process for the management of acute public health risks centred around the public health needs and field assessments.
WHO collects, triangulates, verifies, assesses event-related information derived from official unofficial sources for public health action.
Based on the risk assessment, WHO can provide rapid and scalable technical support including the deployment of field response teams. We have in place standardised procedures for deployment, personal safety and security, logistics systems of prepositioned supplies, material and equipment kits adapted to field conditions and needs, and staff experienced outbreak responses.
Unprecedented situations and low likelihood, high consequence events, in particular, require staff and systems that are adaptable, flexible, innovative and experienced.
Importance of international disease surveillance.
Disease surveillance needs to be understood in a very broad sense. Combining information from indicator and event based surveillance.
Informed risk assessment and informed decisions are only possible with adequate information which is gathered from a broad variety of sources.

16. Hazard Detection and Risk Assessment Suite of tools
World Health Organization
Hazard Detection and Risk Assessment Suite of tools
11 June 2018
Hazard Detection and Risk Assessment Platform
Ever increasing number of search engines, data streams and specialized information provider leads to information overload
Need for adequate tools.
Main objectives
Identify new public health risks – the unknown
Monitor information available in the public domain related to on-going events including the perception of recommendations
Combine all information sources, unofficial and official, in one common platform
Automated analysis
Filter out non-relevant information, highlight critical information
De-duplication
Grouping
Categorization
Ranking / prioritization of information
Alert on critical items
Share the workload
Share according area of expertise, geographical location/mandate, different time zones
Avoid duplication of effort in conducting hazard detection and to carry out a joint risk assessment
Allow to add share additional content
Provide access to contextual information to allow informed risk assessment and decision making
Document decisions and tasks related to media monitoring
Document the workload associated with media monitoring

18. An Example: MERS-CoV
First case was investigated by a curious physician who saw something unusual
Led to the discovery of the virus
Outbreak in Jordan detected, reported, and investigated even before MERS-CoV was described
Clinicians noted an unusual clustering of pneumonia among health care workers
Similar discovery of outbreak at health care facility in Al Ahsa, KSA
Initially MERS not suspected but unusual pattern was reported.

19. Role of SARI surveillance
Existing system in Jordan provided:
Historical trend data to understand if the virus had been circulating for some time
Specimens stored from SARI surveillance allowed retrospective testing to look for cases.
System formed the basis for monitoring for reappearance of the virus.

20. Role of SARI surveillance
Established infrastructure:
Labs were already in place and could adopt testing for nCoV
Trained responders, including FETP
Epidemiologists used to thinking about respiratory data
Reporting mechanisms
Reference laboratory connection established

21. Conclusions
Routine respiratory disease surveillance and event based early warning systems are both critical parts of an effective surveillance system
One is for health policy decisions and management
The other is for detection of outbreaks
Routine surveillance provides the context in which to understand events
Historical data critical to understanding an outbreak
Routine system will establish infrastructure and experience in dealing with respiratory disease data that will be critical for outbreak response
The data will be even more valuable when shared and compared to others…
As you could see on a few of the following graphs (*may want to flip forward influenza/pneumonia mortality graph, or asthma hospitalizations graph) a baseline calculated using the expected cases can also be useful when looking at your surveillance data. This baseline helps when analyzing surveillance data, as it shows what you might expect the number of cases to be. Expected cases are often calculated using historical data, such as using the mean number of cases for the last five years. Expected cases (or a baseline) is not a threshold, but helps you identify what might be normal or abnormal.

22. شكرا 謝謝 با تشکر از شما Merci! Go raibh maith agat Thank you शुक्रिया