Event based surveillance systems Alicia Barrasa EPIET Introductory course 2011 Lazareto, Menorca, Spain

Infectious diseases Arise from many different pathogens: viruses, bacteria, parasites Spread 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, environmental Affect all populations in all regions of the world

Emerging and Re-emerging infectious diseases Cryptosporidiosis Dengue haemhorrhagic fever Cholera E. coli O157 Typhoid Diphtheria Lassa fever Multidrug resistant Salmonella E.coli non-O157 Malaria Legionnaire’s disease Buruli ulcer Shigellosis Cholera O139 Respiratory infection Kyasanur f. Lyme Borreliosis Reston Venezuelan equine encephalitis West Nile Fever Echinococcosis Yellow fever Ebola haemorrhagic fever Human monkeypox Influenza A (H5N1) RVF/VHF Ross River virus Hendra virus BSE West Nile Virus Nipah Virus SARS Human monkepox O’nyong-nyong fever Reston Virus Rabies nvCJD Epidemic Alert and Response (EAR), WHO Regional Office for Europe EHEC A(H1N1)v

Accidental and deliberate release of infectious agents Increased research, biotechnology is widely available Increased 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.

International Health Regulation 1374 Venice Quarantine for Plague 1851 Paris 1st International Sanitary Conference 1947 Geneva WHO Epidemiological Information Service 1951 Geneva International Sanitary Regulations 1969 Geneva International Health Regulations 2004 Regional consultations Nov 2004 Geneva Intergovernmental Working Group meeting Feb 2005 Geneva Intergovernmental Working Group meeting May 2005 Geneva Revised IHR, World Health Assembly The 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 fever acute respiratory acute diarrhoeal acute jaundice acute neurological "other notifiable syndromes of presumed infectious origin" The criteria by which urgent international importance is to be judged are: high risk of international spread unexpectedly high case fatality rate unusual occurrence newly recognised syndrome media interest potential for imposition of trade or travel restrictions A 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 outbreaks The International Health Regulations originated with the International Sanitary Regulations adapted at the International Sanitary Conference in Paris in 1851. 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).[1] 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; and lack 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.

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

IHR Decision Instrument

International Health Regulation - 2005 To decide on need for notification any public health event can be assessed by the criteria 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 travel restrictions ? Surveillance Response Obligation to establish core capacities:

Preparedness and response - ECDC Detection of public health threats related to infectious disease, or of unknown origin Risk assessment, investigation and control Strengthening preparedness of EU member states Strengthening and building capacity through training Provision of technical advice and support to third countries upon request

Epidemic Intelligence Definition The 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 response Objective to speed up detection of potential health threats and allow timely response

Epidemic Intelligence Indicator-based surveillance Event-based surveillance “Surveillance” systems Event monitoring Data Events Collect Analyse Interpret Capture Filter Verify Signal Assess Public health Alert Disseminate Investigate Control measures

Indicator based Surveillance Surveillance systems Ongoing and systematic Collection and analysis of data Interpretation and dissemination of results related to health events of interest Diagnosis-based or Syndromic surveillance For action Outbreak investigation Immunization programmes Programme planning and evaluation Operational research hypothesis Risk assessments

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…)

Epidemic Intelligence Indicator-based surveillance Event-based surveillance “Surveillance” systems Event monitoring Data Events Collect Analyse Interpret Capture Filter Verify Risk assessment Early warning Signal Assess Public health Alert Disseminate Investigate Risk Management Response Control measures

Event based Surveillance Sources of information: Hospitals/health care centres/emergency rooms Veterinary services, food agency West Nile Virus, Rift Valley Fever Foodborne outbreaks Meteorological data Pollution Heat Laboratories Identification of specific pathogens Increase in demand for hepatitis serology

Event based Surveillance Sources of information Media systematic searching of news often in electronic format International networks

Indicator vs event based Indicator based Event based Definitions - Clinical presentation Characteristics of people Laboratory criteria Specific - ...events that are a potential risk - ...unusual events in the community - Sensitive Timeliness - Weekly / monthly (some may be immediate) - Possible delay between identification and notification - All events should be reported to the system immediately - Real time

Indicator vs event based Indicator based Event based Actors Involved in the system Might not know Reporting structure Clearly defined Reporting forms Reporting dates Teams to analyse data at regular intervals No predefined structure Reporting forms flexible for quali and quantitative data At any time Teams to confirm evens and prepare the response

Indicator vs event based Indicator based Event based Trigger for action - a pre-defined thresholds - a confirmed event Response - depends on the delay between identification, data collection and analysis - depends on the confirmation of the event, but ideally is immediate

A small summary Indicator and event based systems are tools for PH Surveillance Event based systems have already been successfully used The challenge: confirmation of the events

Public Health Surveillance during the 2012 Olympic and Paralympic Games Helen Maguire acknowledgements Brian McCloskey, Director, HPS London region Ellen Heinsbroek, EPIET fellow, HPS Colindale

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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

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What influences our preparations for London 2012? - Politics - Media - Scale

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 ?

Experience of mass gatherings In Atlanta [1996] and in Sydney [2000] infectious diseases accounted for less than 1% of healthcare visits In Beijing …there were no problems ..

Experience of mass gatherings Winter Olympic Games, Torino Italy 2006 2 public and private microbiology laboratories provided test results data for Stool culture Hepatitis A serology  No difference to non-Olympic period Data reported once a week

Experience of mass gatherings Germany World Cup, 2006 Burden of infectious disease did not increase during World Cup Maintenance of daily data transmission in all Federal States Additional free-text reporting for events through usual surveillance system -High sensitivity Syndromic surveillance was regarded as not necessary -as disease surveillance systems already in place

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

Objectives 1 review existing systems completeness, sensitivity to unusual events /outbreaks flexibility, timeliness, ability to detect new pathogens 2 identify gaps or limitations 3 enhance existing or establish new systems

Enhance existing … Enhance reportable disease by clinicians Enhance laboratory capacity and reporting Enhance environmental monitoring Create 24 on-call and rapid response teams Syndromic 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.

Epidemic Intelligence (existing and new ) Syndromic Surveillance (NHS Direct, Q Surveillance, RCGP, EDSSS, OOH) Notifications of Infectious Diseases Surveillance at Olympic Village Polyclinics Event-Based Surveillance Laboratory Reporting

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

1 Syndromic Surveillance Existing systems NHS Direct GP-based syndromic surveillance Q Surveillance Royal College General Practitioners New systems Out of Hours Providers Emergency Departments

1 Syndromic Surveillance out of hours To provide enhanced surveillance during weekends/holidays/evenings What did we do? Established links with Adastra Daily data received from beginning of November 2009 for a single pilot site Data received in form of anonymised event records Analysis by PCT using postcode district Analysis by age Analysis by Read code – for example, used groups of Read codes to construct an influenza-like illness indicator Comparison with existing syndromic surveillance systems Recommendations made to Project Group

1 Syndromic Surveillance emergency departments To establish a surveillance network of EDs across England What did we do? Established links with Adastra Daily data received from beginning of November 2009 for a single pilot site Data received in form of anonymised event records Analysis by PCT using postcode district Analysis by age Analysis by Read code – for example, used groups of Read codes to construct an influenza-like illness indicator Comparison with existing syndromic surveillance systems Recommendations made to Project Group 37

2 Notifications of infectious diseases Health Protection Unit HPA Colindale: Departments (esp. Immunisation) Registered Medical Practitioner Proper Officer - Local Authority HPA Colindale: Central Information Management Normal: fax: max. 3 days Emergency: phone within 24 hrs Max. 3 days (methods differ by LA/HPU) Extra requirements Olympics: Olympic Venue Attendance Forms + HPZone to be changed Speed up notifications Improve consistency reporting Report published on internet

3. Surveillance at Olympic Village Requirement to notify infectious diseases compulsory for overseas athletic team doctors Compulsory component of temporary registration Same forms as medical practitioners Notification System being set up HPA presence in Olympic Polyclinic Monitoring of staff absences Olympics Surveillance Systems – 3. Surveillance at Olympic Village

4. Event based surveillance What is a significant event? Standard factors – e.g. severity, Olympic factors – proximity to venue, affecting visitors The media! How do we identify significant events HPZone – dashboard – flagging events with an ‘Olympic flag’ Regional reporting via teleconference or negative reporting Media screening

NOIDS

HPA Colindale: Central Information Management 5 Lab reporting HPA Colindale: Departments Laboratories HPU/Region HPA Colindale: Central Information Management - Weekly, by law (Oct’10) - Automatic, with manual checking+sending Extra requirements Olympics: Daily reporting: software change Automatic extraction software Exceedance Algorithms: daily Adapt for changes in testing, e.g. multiplex PCR - Weekly exceedance report published on intranet - Departments access via software

6. Surveillance of Undiagnosed Serious Infectious Illness To ensure early detection and response to new and emerging infectious disease threats. Case definition Any person admitted to HDU/IDU with a serious illness suggestive of an infectious process where the clinical presentation does not fit with any recognisable clinical picture OR there is no clinical improvement in response to standard therapy AND initial laboratory investigations for infectious agents are negative

7 Surveillance at Centre for Radiation, Chemical and Environmental Hazards -increase to daily reporting

Olympic Surveillance Matrix: Early Detection System   Scenario UK based surveillance International Situational Analysis (horizon scanning) Syndromic Surv, (NHSD, Q, OOH) NOIDS Olympic Village Polyclinics CRCE Laboratory Reporting Syndromic Surveillance – ED *sentinel USII Mortality Localized outbreak, small number of cases e.g. meningococcal * Localized outbreak, large number of cases e.g. measles Widespread outbreak, small number of cases e.g. food poisoning Widespread outbreak, large number of cases e.g. influenza Increase in weather related disease, e.g. asthma Chemical, Environmental or Radiation incident Imported disease, e.g. plague Newly emerging disease Deliberate release, e.g. anthrax

289 days to go!