WHO Public Health Emergency Surveillance CK Lee Team Leader, Emerging Disease Surveillance and Response 10 September 2014

How to detect a potential threat? Surveillance: “Systematic ongoing collection, collation, and analysis of data and the timely dissemination of information to those who need to know so that action can be taken” Data collection analysis Timely dissemination Response

“Usual” sequence of events Primary Case 1st case at HC Report to DMO Samples taken Lab result Response begins Opportunity for control Days

Ideal sequence of events Response begins PRIM HC REP SAMP RES Potential cases prevented Days

IHR (2005) as a Global Instrument A global legal framework for protecting global public health security A shared risk management for a shared vulnerability, calling for regional and international alert and response systems national surveillance and response systems (IHR core capacities) In force since June 2007 7 years of implementation

APSED as a Regional Tool The Asia Pacific Strategy for Emerging Diseases (APSED) A bi-regional tool to help two WHO Regions (SEAR and WPR) meet IHR core capacity requirements A common framework highlighting a shared vision and a set of agreed priorities Developed in 2005 and updated in 2010

APSED addressing cross-cutting issues Focus Areas of APSED APSED (2010) Surveillance, Risk Assessment and Response Laboratory Zoonoses Infection Prevention and Control Risk Communication Public Health Emergency Preparedness Regional Preparedness, Alert and Response Monitoring and Evaluation APSED (2005) Surveillance and Response Laboratory Zoonoses Infection Control Risk Communication APSED addressing cross-cutting issues

FOCUS AREA 1: Surveillance, Risk Assessment and Response APSED (2010) Surveillance, Risk Assessment and Response Laboratory Zoonoses Infection Prevention and Control Risk Communication Public Health Emergency Preparedness Regional Preparedness, Alert and Response Monitoring and Evaluation Sensitive and timely surveillance systems can trigger early alerts and rapid response to minimize the impact of a potential outbreak. Key components Event-based surveillance Indicator-based surveillance Risk assessment capacity Rapid response capacity Field Epidemiology Training

Protect and improve health for community Historical overview Protect and improve health for community Gather intelligence Descriptive analysis EBS IBS EBS RRT GOARN FET Risk assessment – to facilitate the added value for decision making from the data collected APSED - 2005 APSED (2010)

Surveillance, Risk assessment and Response Event-based Surveillance Rapid detection, reporting, confirmation and assessment of public health events including: clusters of disease rumours of unexplained deaths Commonly: Immediate reporting Response Linked to surveillance National and subnational capacity to respond to alerts Indicator-based Surveillance Routine reporting of cases of disease, including: notifiable dis. surveillance systems sentinel surveillance laboratory-based surveillance Health care facility-based Weekly, monthly reporting Risk Assessment

EBS/IBS: complementary Event-based surveillance Indicator-based surveillance Reporting Ad-hoc Pre-defined Source of information Media Schools, companies Health care facilities General public, community leaders Official government source, designated disease reporting facilities/units Trigger for initial action Captured event followed by initial risk assessment Pre-defined threshold Check with official information! MOH/WHO CO Official notice regarding event Laboratory confirmation IBS data

EBS/IBS: pros and cons Event-based surveillance Indicator-based surveillance Advantages Rapid detection Well structured Disadvantages Sensitivity, predictive positive value depends on source/country Need for verification Only applicable for diseases under surveillance Delayed detection due to scheduled reporting system Check with official information! MOH/WHO CO Official notice regarding event Laboratory confirmation IBS data

Measles in Ha Noi, Viet Nam, April 2014 EBS: Key achievements Continue to be the main mechanism to detect outbreaks 81%: standard operating procedures (SOP) available Outbreak detection: Human infections with avian influenza in China in 2013–2014 Suspected avian influenza cluster in Lao People’s Democratic Republic and Palau Measles outbreaks in the Philippines in 2013, in Viet Nam and Papua New Guinea in 2013–2014 MERS-CoV in Malaysia and the Philippines Measles in Ha Noi, Viet Nam, April 2014 AFP Results-based ILI/SARI surveillance have been strengthened in high risk area , Lao and Vietnam. CAM, Lao MOG there were enhanced surveillance for hospitalized case of flu. Some of them project based surveillance Lao insitutionalized web-based system have been introduced but tool exist but IT capacity is limitted to be able to make use of this tool

Malaysia: Early detection and prompt response The first case of MERS-CoV April 2014, Malaysia reported its first laboratory-confirmed case of MERS-CoV infection in a returning pilgrim from KSA Strong core capacity can lead to timely detection and response Timely sharing of information of can contribute to informed risk assessments and public health action Source: Eurosurveillance Source: Associated Press Health alert cards to travellers and flight crews returning from Middle East countries. Surveillance system and Malaysia Influenza Surveillance System (MISS) , surveillance of ILI, and severe acute respiratory infection (sARI) Laboratory capacity Guidance for management of MERS-CoV cases emphasizing the importance of infection prevention and control measures among healthcare workers and continuously monitoring their implementation. Strengthening preparedness reduced risk Malaysia has 200,000 Umrah pilgrims per year. Following preparation led the timely detection and control.

FET/P: key achievements Mongolia 12 countries have FET/P program, of which 6 have started since APSED(2005) including: 2 FETP: Viet Nam, Singapore 4 FET: Lao People’s Democratic Republic Mongolia Cambodia Papua New Guinea Republic of Korea China Japan Lao PDR The Philippines Cambodia Viet Nam Malaysia Singapore Papua New Guinea FET (Modified program) FETP (Conventional program) 2 conventional programs: Vietnam, Singapore 4 modified programs: Lao PDR (1 year, 2009) Mongolia (1 year, 2009) Cambodia (6-month program ,2011) PNG (6-month, 2013) Australia

FOCUS AREA 2: Laboratory APSED (2010) Surveillance, Risk Assessment and Response Laboratory Zoonoses Infection Prevention and Control Risk Communication Public Health Emergency Preparedness Regional Preparedness, Alert and Response Monitoring and Evaluation Timely, accurate laboratory diagnosis in a safe environment is a cornerstone of any health system confronting emerging diseases Key components Accurate laboratory diagnosis Laboratory support for surveillance and response Coordination and laboratory networking Laboratory Biosafety

Country X Reference Laboratory Reference Laboratory Reference International Technical support EQA programmes Not characterized Reference Laboratory Reference Laboratory National level Technical support EQA programmes Biosafety Country X Confirmation testing Not characterized LAB LAB LAB Sub-national level

Global Influenza Surveillance & Response System (GISRS) in the Western Pacific 21 National Influenza Centres (NICs) in 15 countries 3 Collaborating Centres National Influenza Centres H5 Reference Laboratories WHO Collaborating Centres on Influenza

Performance of laboratories participating in WHO influenza EQAP Western Pacific Region, 2007–2013 Weekly Epidemiological Record (WER), 24 Jan 2014, vol. 89, 4 (pp 37–45)

Laboratory preparedness for MERS-CoV in WPR 21-question web-based survey; voluntary and confidential 22 national-level laboratories in 19 countries invited; 19 participated. Conducted over the past month Category Proportion % In-country molecular testing in place 16/19 84   Immediately ready to test 1 – 50 samples 7/16 > 50 samples 9/16 Laboratories having tested suspected samples 8/16 Participated in an EQA for MERS-CoV 10/16 In-country testing not available but via referral 3/19 16 Focused on determining: Availability of protocols, guidance and reagents Test runs, number of specimens tested to date, immediate capacity Referral, including staff certified to ship infectious substances Rapid publication for Western Pacific Surveillance and Response (WPSAR) Journal; aggregated data, no laboratory- or country-specific details Countries with no testing capacity but referral only have IATA certified staff for shipping WPR Member States have capacity to test for MERS-CoV at national level or have a referral system in place, however, performance of testing needs to be determined.

External Quality Assessment (EQA) for Emerging Infectious Diseases Dengue as a pathfinder Based on existing programs, e.g. for influenza 19 national laboratories in 18 countries in WPR Assessed both molecular and serological testing Revealed good dengue diagnostics proficiency 15/19 (~80%) laboratories with perfect score Technical support to laboratories with lower score Next round to include dengue, Zika and chikungunya viruses (dengue-like illness) and laboratories in SEAR.

FOCUS AREA 7: Regional Preparedness, Alert & Response APSED (2010) Surveillance, Risk Assessment and Response Laboratory Zoonoses Infection Prevention and Control Risk Communication Public Health Emergency Preparedness Regional Preparedness, Alert and Response Monitoring and Evaluation Enduring regional system and cooperation is critical in protecting against emerging diseases. Because borders pose no barrier to infectious diseases, strong systems that interact effectively are needed in every country Key components Regional surveillance and risk assessment Regional information-sharing system Regional preparedness and response

Regional surveillance and risk assessment

WPRO FET Fellowship Training Programme Continue WPRO FET Fellowship Training Programme to provide on-job-training on surveillance and risk assessment Ten fellows participated from 5 Member States last TAG year A total of 50 fellows from 13 Member States since 2010. WPRO FETP fellowship program

Threats to public health and the IHR (2005) International Health Regulations (2005) Infectious diseases Food safety Chemical safety Radionuclear safety Accidental & deliberate release Product safety Environmental hazards Consequences of natural disasters

Regional event-based surveillance Reported Events 2008–2009† 2009–2010 2010–2011 2011–2012 2012–2013 2013–2014 n = 206 n = 218 n = 357 n = 297 n = 222 n = 295 Infectious Diseases* 142 174 206 114 71 61 Animal H5N1** 35 26 136 86 305 222 Disasters and others*** 16 9 7 92 50 12 Chemical 13 8 2 1 Information source of initial reports Unofficial(e.g. Media reports) 147 162 203 100 62 41 Official(e.g. IHR NFPs, WHO COs) 59 56 154 194 160 254 † Fiscal year for TAG(technically advisory group meeting): July – Next June * Excluding animal avian influenza events ** Based on FAO report since 2012 ** Others include 'Pharmaceutical-related', 'Unknown', and 'Food-related'; Monitoring and reporting of disaster events became formalized mid 2011 and in 2013 became further modified based on the official Centre for Research on the Epidemiology of Disasters (CRED) criteria Ihr fos I’m happy to change anything Event

Event Management System (EMS) World Health Organization Event Management System (EMS) 22 April 2017 Total number of Events >4000

World Health Organization EMS - Number of Events by Year and Source of Information Year 2001 to 2014 (as of 20 June 2014) 22 April 2017

EIS login by WPR countries, 15 June 2007 to 30 June 2014 (Login by country counted only once per day) EIS logins by WPR Countries, 1 July 2013 to 30 June 2014 (Login by Country counted only once per day) Most Member States regularly use EIS Over 3000 logins

WPRO risk assessment tool Documented risk assessment for 18 major public health events for 8 countries WPRO risk assessment tool WHO Country office-Regional Office-Headquarters joint risk assessment: avian influenza A(H7N9) and Zika virus

Criteria for initial screening Unusual/unexpected Higher than expected mortality/morbidity Cluster of cases/deaths with similar syndromes High potential for spread Related to commercial product Potential for international travel/trade impact

Algorithm for rapid risk assessment

Regional Surveillance of Priority Diseases Upgrade format for surveillance report Dengue HFMD Seasonal influenza(ILI) Avian Influenza 123 reports have been published

Recent publications in WPSAR SARI surveillance evaluation in New Zealand Event Based Surveillance in Papua New Guinea Surveillance of Dengue in Lao PDR, 2006–2012 Outbreak articles Cholera in Papua New Guinea Dengue in Solomon Islands Rubella in Japan Measles in Australia Diarrhoea in Kiribati Indexed in PubMed/MEDLINE

Summary Intelligence from surveillance promotes early warning of potential public health events EBS is needed for detecting the unexpected IBS is needed as reliable baseline data for short term warning and long term planning Risk assessment provides structured approach for defensible decisions for response and communication A Region-wide surveillance system: regularly sharing of data on priority emerging diseases for control and policy development. Thank you!