1. Influenza Surveillance
Module-3
Influenza Surveillance
This morning I will discuss aspects of surveillance for human and avian influenza.

2. Outline
Describe the distinctions between seasonal, avian, and pandemic influenza surveillance in humans
Describe seasonal influenza surveillance as a framework for pandemic influenza surveillance in humans
Describe standard case definitions for surveillance
Describe ways to enhance local surveillance following a poultry outbreak of HPAI
In this talk we will outline the different goals and needs for seasonal and avian influenza surveillance in humans, emphasizing how global seasonal influenza surveillance provides a framework and context for avian influenza surveillance in humans.
We will also describe how to use different standard case definitions in surveillance (especially how and when to use the WHO case definition and how to determine when to collect specimens to test a person for the presence of influenza A(H5N1) virus) and discuss ways to enhance local surveillance following a poultry outbreak of HPAI.

3. Seasonal Influenza Pandemic Influenza
Surveillance
Pandemic Influenza
Preparedness
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.

4. Definition of terms
Seasonal (human) influenza: Influenza that occurs every year with gradual variations in the previous year’s virus surface proteins (drift).
Avian Influenza: a disease of birds that occasionally jumps species and infects humans. Ultimately is the source of new viruses in humans causing pandemics.
Pandemic: a worldwide surge in cases caused by the introduction of a new type A surface protein (shift).
Before looking at surveillance methods, it’s important to understand the nomenclature. Seasonal or human influenza is endemic and is seen every year at regular intervals. The same hemagglutinin type circulates around the globe year after year, mutating slightly as it goes. The result of these mutations is that over time, susceptibility is renewed because of changes in the surface proteins of the virus that allow it to evade the immunity built up by previous influenza infections. The season in which it occurs may be different in temperate climates, where it is a winter-time disease, and tropical climates where transmission probably occurs year round but is largely unstudied.
Avian influenza is a disease of birds that can occasionally infect humans when there is significant exposure. Avian influenza viruses are thought to be the reservoir for new types of influenza viruses that cause pandemics when they acquire the ability to circulate in humans. The factors that must be present to enable the virus to do this are unknown.
Pandemics occur when there is a shift in the type of HA with the introduction of a new type either by reassortment or through direct entry into the human population from avian species with a virus that has acquired the ability to spread easily from human-to-human.

5. Different Surveillance Priorities
Seasonal Human Influenza: describe epidemiology and burden of disease to make decisions about allocation of resources
Pandemic Influenza: recognize emergence early enough to contain or slow
Avian Influenza in humans: Detect as many cases as early as possible in order to:
Treat appropriately, prevent further transmission
Implement control in animals.
Fully investigate for additional cases
Contain if it represents an emerging pandemic
There are different surveillance priorities for human and avian influenza. For human influenza it would be impossible and unnecessary to count every single case.

6. WHO Global Influenza Surveillance Network
Monitor influenza viruses and make recommendations on influenza vaccine composition for Northern and Southern Hemispheres
Provide prototype influenza vaccine strains and standardized reagents for influenza vaccine production and testing
Obtain samples of unusual influenza strains
In 1947, WHO established the WHO Global Influenza Surveillance Network. The goals of the network include:
Monitor the influenza viruses in circulation and make annual recommendations on influenza vaccine composition for the Northern and Southern Hemispheres.
Detect, as early as possible, any unusual influenza strains in human populations that could be of pandemic potential (not primary objective).
Provide prototype influenza vaccine strains and standardized reagents for influenza vaccine production and testing. Although there is some collection of epidemiologic data, this system is essentially a virologic surveillance system created for vaccine strain selection.
The focus of this system is monitoring virus strain type and it provides very little in the way of epidemiological information.

7. WHO Global Influenza Surveillance Network
This maps shows the location of the National Influenza Centers and WHO Collaborating Centers that make up the WHO Global Surveillance Network. As of 2007, the network is currently comprised of 116 National Influenza Centers in 87 countries, with laboratories, and four WHO Collaborating Centers for Reference and Research of Influenza. There are four WHO Collaborating Centers that participate in the WHO Global Influenza Surveillance Network (in Victoria, Australia, Tokyo, Japan, London, England, and the Influenza Division at CDC).
Note that centers are concentrated in Europe and sparse in Asia, particularly S. E. Asia, and Africa. This is also reflected in the number of isolates and other data that are gathered from these areas.
Source: WHO Global Influenza Surveillance Network.

8. Global human influenza surveillance
This slide shows the percentage of specimens collected that are positive for influenza virus from different countries in the Americas. Following this over time gives an indication of the seasonality of the virus. Note the difference in seasonality above and below the equator. Viruses above and below the border may also be of slightly different antigen types. For this reason, decisions about the most appropriate vaccine for the northern and southern hemispheres are made separately, highlighting the need for data from many parts of the world in order to make the most accurate predictions.
Source: Viboud C, Alonso WJ, Simonsen L. Influenza in tropical regions. PLoS Med Apr;3(4):e89.

9. Limitations of the Global Influenza Surveillance Program
Incomplete acceptance by many countries
Lack of virologic data from much of the world
Very limited epidemiologic data
Basic epidemiology, burden of disease, and patterns of transmission of influenza in the tropics and most of the subtropics unknown
Not likely to detect pandemic in early stages
There is variable acceptance of the WHO Global Influenza Program internationally, especially in tropical and developing countries. Some countries may prefer to shift resources to the surveillance of other diseases. Some poorer countries that cannot afford annual influenza vaccination may not see a direct benefit to collecting isolates for others for their vaccine development. Because of the incomplete acceptance, we lack understanding about some key aspects of influenza activity in some regions. These include which virus strains predominate and whether there is influenza seasonality. The activity of other clinically similar respiratory viruses is even less well understood. Because of limited epidemiological data about viral respiratory disease, the burden of influenza and other respiratory viruses and the activity of influenza-like illness are poorly understood in these regions. As a result, it is not likely to detect early stages of pandemic influenza in these areas of the world.

10. Avian Influenza: A New Challenge
Starting in 1997…
Demonstrated need for improved surveillance and control of avian influenza
The appearance of avian influenza A (H5N1) in Hong Kong in 1997 raised concerns of the possible reoccurrence of a 1918-like global pandemic. The virus was detected as part of routine strain surveillance, however it was recognized that more information was needed, with improved surveillance, to detect and control this virus globally.

11. International Health Regulations
Member countries must:
Notify WHO of any potential PHEIC – beyond prescribed list
Enhance their events management – especially alert and response actions
Meet minimum core capacities –
notably in surveillance, response, and at points of entry

12. How do we accomplish all of these objectives with one surveillance system?
How do we accomplish all of the diverse needs and objectives of influenza surveillance with a single system? ?

13. Seasonal Influenza Surveillance

14. Objectives of a Seasonal Influenza Surveillance System Objectives
Describe the epidemiology of seasonal influenza and burden of disease
Provide isolates for identification of viruses and monitoring of resistance.
Provide country specific data for program planning and preparedness.
Serve as an early warning for outbreaks of avian or pandemic influenza
Given the risk of emergence of a new pandemic and the mortality pattern seen with the currently circulating avian strain, a fourth objective should be added to the traditional goals of a national influenza surveillance system. This objective is to provide an early warning of an emerging pandemic or outbreaks of human cases of avian influenza.The first three objectives can be accomplished with the institution of sentinel surveillance at selected health care facilities but creation of an early warning system would require the development of triggers for response and a community based program of education and awareness to inform health care workers and community leaders of the need to report certain types of events. The prior establishment of a sentinel system would provide the infrastructure and mechanisms for specimen transport and processing, response and containment activities, and a trained workforce.

15. Other Considerations Broad utility beyond influenza
Events of public health significance
Sustainable after H5N1 interest wanes
Can be integrated into existing systems
Avoid another silo (see bullet 2 above!)
Operates within the context of existing guidelines for investigation and response

16. National Seasonal Influenza Surveillance System
Premise: Quality data can be obtained from a few well run sites
Small amounts of good data are better than large amounts of bad data!
Sentinel syndromic surveillance for:
Severe Acute Respiratory Illness (SARI)
Influenza-like-Illness (ILI)
Established infrastructure can support early warning and response system
To meet these diverse needs two different but synergistic types of activities are needed. The first is the establishment of sentinel surveillance for severe acute respiratory infection and the second is establishment of an early warning system for outbreaks of Influenza A(H5N1) in humans or the emergence of a new pandemic virus.

17. National Seasonal Influenza Surveillance System
Characteristics of chosen sites
Representative of population
Practically feasible
Logistics of specimen transport
Acceptance
Number of institutions based on resources
Focal point at each hospital oversees collection and reporting of data and specimens
There are many issues to consider when choosing sentinel hospitals and clinics. These include politics, hospital and clinic logistics, whether the patient population served is representative of the region or country, and the staff acceptance of the system. Most important, however, is that hospitals be chosen that will have the greatest likelihood of success.
Logistics to transport specimens to a laboratory with the capacity to perform influenza testing must exist.
Some sites may choose to over sample some key populations, including minority groups, remote communities, travelers to H5N1 affected regions, and areas with intensive poultry husbandry.
One of the advantages of establishing a sentinel system is the infrastructure such that specimen transport and processing mechanisms, data processing, and response programs will be established to support the system. These can all be expanded and used in the event of a report of an unusual event such as a human case of avian influenza or the occurrence of an outbreak.

18. SARI Case Definition
Persons > 5 Years Old
Moderate-to-severe acute lower respiratory tract illness consisting of:
temperature > 38ºC AND
cough or sore throat AND
shortness of breath or difficulty breathing
Requiring hospitalization
Persons <= 5 Years Old
Use IMCI case definition for pneumonia and severe pneumonia
(Child with cough and tachypnea or “general danger signs”)
IMCI Case Definition
Pneumonia
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)
(Infants less than 2 months with fast breathing 60 breaths or more per minute
are referred for serious bacterial infection).
Severe pneumonia
Any child 2 months to 5 years of age with cough or difficult and any of the
following general danger signs:
• unable to drink or breastfeed
• vomits everything
• convulsions
• lethargic or unconscious
or chest indrawing or stridor in a calm child.

19. Data Collection from SARI Cases
Name
Age
Address or location
Gender
Occupation
Epidemiologic links to influenza A (H5N1)
Date of onset
Clinical signs and symptoms
Clinical specimens collected for testing
Outcome
A unique identifier to link the case to the laboratory specimen

20. Influenza-Like-Illness (ILI) in Ambulatory Patients
Addition of ILI surveillance in ambulatory setting may add to understanding of flu epidemiology
ILI: Acute illness with fever > 38 degrees, and cough or sore throat
Could sample cases for specimen and data collection
Aggregate data with case-counts of outpatient ILI cases by age group for the rest
Monitor trends in ILI over time
Increases in ILI cases above a baseline may indicate an epidemic

21. Building an Early Warning System around a Sentinel Surveillance System
Once sentinel surveillance is established, how does a country go about building an early warning system around it?

22. Considerations for an Early Warning System
H5N1 is of interest only because it’s the best candidate for the next pandemic strain
There’s no guarantee that this will happen
Therefore the real goal is to create an early warning system for an incipient pandemic
The emergence of a pandemic may not be linked to a poultry event
Many times humans are sentinel animal
Poor surveillance for H5 may allow emergence of human-to-human transmission before poultry disease is recognized

23. Early Warning System Components
Broad based recognition of “trigger events” that must be reported immediately.
Mechanism for reporting
Hotline
Local Health Dept.
Local Agriculture
Coordinating bodies
Response mechanism

24. Trigger Events

25. “Trigger” events in surveillance
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
To build an early warning system we must educate hospitals, clinics, traditional healers, others about “trigger” events. Triggers are risk factors or clinical criteria that might elevate your index of suspicion that some cases or clusters of SARI may be more likely to be caused by influenza A(H5N1) than other cases or clusters. 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 cases are more likely to have H5N1 then other SARI cases and require immediate investigation and lab testing. 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.

26. Triggers with an H5N1 Link
Cases of severe acute respiratory infection with a possible link to AI
Any case meeting WHO suspect, probable or confirmed case definition.
SARI cases in workers in poultry industry
Association with sick or dying poultry or wild birds
History of travel within the last 10 days to an area or region known to have circulating avian influenza
Triggers would include cases with severe acute respiratory infections and have been exposed to other people with severe acute respiratory infections, such as health care workers, family members, or acquaintances. This would certainly include cases of severe acute respiratory infection with a possible link to AI or representing an emerging pandemic:
Any case meeting WHO suspect, probable or confirmed case definition.
Occupational exposure such as health care workers exposed to SARI cases or workers in poultry industry
Clusters of 2 or more cases occurring within 7-10 days of each other in a family.
Clusters in a group of people with a social or occupational connection
Association with sick or dying poultry or wild birds
History of travel within the last 10 days to an area or region known to have circulating avian influenza

27. Triggers without H5N1 Link
Cases in Health Care Workers who care for patients with SARI or pneumonia
Clusters of 2 or more SARI cases in a 2 week period
2 people in a family
Cases in a small geographic area
Cases with social or occupational connection

28. Other Triggers for Investigation
Trends in the data
Increases in cases at a hospital compared to the same time in previous years
Change in the epidemiology of cases
Poultry events: excessive deaths
Rumors from informal data sources
news media
information hotlines

29. Mechanisms for Reporting and Detection
Toll free numbers
Other hotlines
Usual reporting channels
District health office
District agriculture workers
Monitoring of media and news reports
Create awareness in the reporters!
Must be accessible to private sector
As triggers are defined, and before awareness raising and training begins, clear mechanisms for reporting and detection need to be established, along with mechanisms of response. Here are some examples of mechanisms for trigger detection. It does little good for a health care worker to recognize a trigger event if he or she has no idea of how to report it. Keep in mind that it is very important to involve the private sector health care in the system.

30. Creating the Network

31. 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 with regular continuing education, as well as communication to the public regarding risk reduction and reportable events are essential for the success of the trigger reporting system. Public health reminders and inquiries may assure quality and improve surveillance sensitivity. Regular training refreshers at reporting institutions are a key component of maintaining the sensitivity of a passive surveillance system.

32. Linkages with Agriculture
Linkages at each administrative level: field, provincial, national
Need formalized communication mechanisms
Poultry die-offs that are reported or recognized by agriculture workers should immediately be notified through the established reporting mechanism.
Should prompt an active search for human cases.
Isolation of suspect human cases
Human cases should also be reported to the Ministry of Agriculture
May signal unrecognized poultry outbreak
Linkages to agriculture are vital to the early warning system. The appearance of influenza in bird and poultry populations will precede the appearance of the disease in humans but often goes unrecognized. Even when it is recognized, there are often delays in notifying human health authorities because of the lack of communication mechanism between the two groups. Formal channels of communication should be developed between the two at every administrative level to decrease the notification time.
Reports of die-offs in domestic poultry should prompt an immediate investigation for possible associated human cases (see next slide for details). Any suspect cases discovered should be isolated to prevent spread to other humans.
As there is still a reluctance to report poultry die-offs in some areas, or just a lack of recognition of the importance, sometimes human cases are the first to be recognized. These should be notified to the animal health authorities so that further investigation of possible poultry involvement can be carried out.

33. Enhancing surveillance during an animal (or human) outbreak
Active case finding among occupationally exposed.
Door-to-door surveys for ill people and poultry
Sensitization of community to report illness.
Include risk reduction messsages
Expand SARI and/or ILI surveillance to local hospitals, traditional healers and dispensaries.
Recruit private practices, NGO, religious institutions, and schools.
Include training on reporting procedures –mechanism must be clear.
Active networking with village health monitors
Telephone reporting hotlines
When outbreaks in either animal or human populations are discovered, surveillance should be enhanced in the region where virus is circulating. These enhancements include the following activities:
Active case finding among occupationally exposed. This would include an active search in poultry workers and door-to-door surveys in the surrounding community. In much of the world, most poultry husbandry is done in backyards and may not be known to the authorities.
Self-reporting/Fever self-monitoring: Poultry workers and the community need to be made aware of the importance of seeking treatment if they become ill. Instruct workers to be vigilant for the development of fever, respiratory symptoms, and/or conjunctivitis (i.e., eye infections) for 1 week after last exposure to avian influenza-infected or exposed birds or to potentially avian influenza-contaminated environmental surfaces.
Expanded involvement of health structures: Health care facilities should be aware that this sensitization activity is occurring and know who to notify if they detect a possible case. Facilities should implement screening / triage / reporting procedures of patients presenting with influenza like illness. Add non-public practices delivering healthcare to the reporting network including private practices, NGO and religious institution Expand SARI and/or ILI surveillance to local hospitals, traditional healers and dispensaries. Train all in the reporting network on procedures (forms, time for reporting, where, etc...)
Village health monitors and leaders can be important sources of information for outside investigators.
If the technology is available, telephone hotlines can be useful for rapid reporting of suspect events.

34. Rumor Reporting
Active collection and monitoring by district and National data collection centers
Develop network of informants
Monitor the news
Keep a file of report, response, and conclusion
Needs an informed public and media
Needs defined mechanism for reporting
Reporting of cases must use existing channels if possible. Case reporting may be initiated by a number of things:
Active media or rumor surveillance
Informal reports made by lay persons of clusters of animal disease or of atypical or severe respiratory infections among humans
In order to stimulate this kind of report, it is necessary that a relationship be developed with the news media and that specific local contacts in the public be well informed.
A well defined mechanism of reporting – a method and an individual or office clearly identified – in order for this to be successful.
Records of each report and what was done in response should be maintained.

35. Take home messages
Surveillance for human seasonal influenza can support a pandemic early warning system:
Provides necessary laboratory and response infrastructure.
Creates a data analysis system.
Creates a structure of ongoing interest
Can be embedded in an existing national integrated surveillance network.
Will provide data needed for pandemic planning.

36. Response

37. Rapid Response All reports of triggers deserve investigation
Investigation may end with a phone call
Should be documented
Trigger cases should have epidemiological data and laboratory specimens collected
Influenza as a ‘case study’ in outbreak preparedness and response for other outbreak prone diseases

38. Influenza Surveillance in the Context of IDSR
Integration of SARI surveillance into the national reporting scheme
Routine reporting and data analysis
Embedded sentinel system
A few select sites for close interation
Insure high quality data
Identification of trigger events as “epidemic thresholds”

39. Take home messages
Surveillance for avian influenza, a zoonotic disease that is rare in humans, requires alert health care providers and community members
Currently circulating AI is best candidate for next pandemic, therefore, timely recognition, reporting and testing of all suspected cases is essential
Integration of animal and human surveillance important to improve human case detection
To summarize, avian influenza is still an infrequent human disease. Therefore, surveillance for the disease requires and alert health care system and must involve the community.
Every suspect case should be detected in a timely manner and thoroughly investigated.
A well functioning sentinel system, in addition to providing needed national data for health care planning, can provide the infrastructure to support an early warning system. A good sentinel system will include mechanisms for reporting and investigation; infrastructure and standard operating procedures for specimen collection, transport, and processing; and data analysis capacity. All will be valuable for responding to reported trigger events from outside the sentinel system.
The appearance of avian influenza and other recent zoonoses has highlighted the need for closer collaboration and communications between animal and human health workers. Developing such will be of benefit for other conditions beyond avian influenza.

40. Take home messages
Surveillance for an emerging pandemic requires creation of an early warning system that has many parts:
Definition of events of interest – i.e. Triggers for investigation and broad education and awareness campaigns.
Mechanisms for rapid reporting to appropriate office.
Plan for response

41. WHO Reporting Requirements
The International Health Regulations require that certain types of health events be reported to WHO. The requirements for avian influenza are described in the following slides.

42. WHO H5N1 Reporting Case Definitions
Goal
Standardize reporting of cases
Comparability of data
Context
Countries with H5N1 or travelers
Not intended to be used as a screening criteria for laboratory testing or epidemiologic investigation
The WHO case definition is a reporting definition and not a surveillance definition. It was created to standardize reporting. This definition is most useful for countries with H5N1 in birds or humans or for the assessment of travelers to affected regions. As the epidemiology of H5N1 virus infection changes, so too should the reporting definition.

43. WHO H5N1 Case Definitions
Person under investigation
A person whom public health authorities have decided to investigate for possible H5N1 infection.
Suspected H5N1 case
A person presenting with unexplained acute lower respiratory illness with fever (>38 ºC ) and cough, shortness of breath or difficulty breathing
Epidemiologic linkage to exposure
Probable H5N1 case (notify WHO)
Suspected H5N1 case AND
abnormal CXR/respiratory failure; OR
Lab test positive for influenza A infection, but insufficient laboratory evidence for H5N1
A person dying of an unexplained acute respiratory illness with epi link
The WHO recently released a revised case definition for suspected H5N1 virus infection.
Suspected cases are those who present with an unexplained acute lower respiratory illness with fever and cough, shortness of breath, or difficulty breathing, and have one of several epidemiologic links. Those with the epidemiological links described above would be considered “triggers” events for investigation but do not require reporting to WHO.
Probable cases, however, require WHO notification. They include suspected H5N1 cases with an abnormal CXR or respiratory failure or are lab test positive for influenza A virus infection. They may also include all unexplained acute respiratory illnesses with one of several epidemiologic links.
Source: WHO case definitions for human infections with influenza A(H5N1) virus

44. WHO Suspect H5N1 Epidemiologic Links
Contact with a suspected, probable, or confirmed H5N1 case
Exposure to birds, their remains, or their feces where H5N1 infections have been suspected or confirmed in the last month
Consumption of raw or undercooked poultry products where H5N1 infections have been suspected or confirmed in the last month
Contact with a confirmed H5N1 infected animal other than poultry or wild birds
Handling samples suspected of containing H5N1 virus in a laboratory or other setting.
The epidemiologic links include:
Contact with a suspected, probable, or confirmed H5N1 case
Exposure to birds, their remains, or their feces where H5N1 infections have been suspected or confirmed in the last month
Consumption of raw or undercooked poultry products where H5N1 infections have been suspected or confirmed in the last month
Contact with a confirmed H5N1 infected animal other than poultry or wild birds
Handling samples suspected of containing H5N1 virus in a laboratory or other setting.
Source: WHO case definitions for human infections with influenza A(H5N1) virus

45. WHO H5N1 Case Definition Confirmed H5N1 Case (notify WHO)
A person meeting the criteria for suspect or probable case AND
One of the following positive results from laboratory testing:
Positive viral culture for H5N1
Positive PCR for A/H5
IFA Test positive for H5N1
At least 4-fold rise in H5-specific antibody in paired serum sample
Laboratory confirmation of a case of H5N1 can be carried out in a number of ways including culture, PCR, Immune Fluorescent Antibody, or a four-fold rise in antibody titer from paired sera. These test should be confirmed by a qualified laboratory at a WHO collaborating center.

46. Reporting
Nationally
Immediate reporting of suspected, probable and confirmed H5 cases and clusters to National Public Health Authorities
Use standard reporting forms—key elements on WHO web site
Weekly summarization of cases, even if there are none (zero reporting)
Information should be shared with all relevant partners inside the country, especially the animal health authorities
Central analysis and response
This slide and the next describe the type of reporting that should be done nationally and internationally.
Nationally
Immediate reporting of suspected, probable and confirmed H5 cases and clusters to National Public Health Authorities
Use standard reporting forms—key elements on WHO web site
Weekly summarization of cases, even if there are none (zero reporting)
Information should be shared with all relevant partners inside the country, especially the animal health authorities
Central analysis and response

47. IHR (2005) Member countries must:
Notify WHO of any potential PHEIC – beyond prescribed list
Enhance their events management – especially alert and response actions
Meet minimum core capacities –
notably in surveillance, response, and at points of entry
The “old” IHR requirements mandated reporting of cholera, yellow fever, and plague (and smallpox at one time, until its elimination)
The “new” IHRs have a decision algorithm to assess if a PHEIC exists, so it involves a new paradigm for reporting and (potentially) might include chemical spills or radiological events
The minimal core capacities of detection and reporting are described in the new IHR at three health levels – local, intermediate, and national

48. Assessing the Threat under IHR PHEIC
Always Notifiable
Smallpox
Poliomyelitis, wild-type
Human influenza, new sub-type
SARS
Other Events Potentially Notifiable
Examples: cholera, pneumonic plague, yellow fever, viral hemorrhagic fever, and West Nile fever
Other biologic, radiological, or chemical events may fit the decision algorithm and be reportable
An appropriate handout to give to the audience would be Annex 2 of the IHR

49. Making the Determination PHEIC
Criteria for Notification from Annex 2
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 or trade restrictions?
If any two of these four questions are “YES” then a determination should be made that a PHEIC exists.
The PHEIC must be reported to WHO, but then
WHO must concur
The IHR provides guidance to help discern and interpret these four questions
WHO makes final determination

50. Thank you !!!
Thank you
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.