1. October 4, 2004 Building Steps for Canada’s New Integrated Enteric Pathogen Surveillance Program 12th Annual APHEO Conference October 4, 2004 Niagara Falls, Ontario Barbara J. Marshall Public Health Agency of Canada

2. October 4, 2004 Building Steps for Canada’s New Integrated Enteric Pathogen Surveillance Program The aim of this presentation: To create awareness of the new national integrated pathogen surveillance system to be piloted in Ontario

3. October 4, 2004 Enteric Pathogen Transmission Human / Animal / Food/Water Interface

4. October 4, 2004 Current Situation of Enteric Disease Surveillance in Canada 1.Current surveillance systems only report a small fraction of the actual cases of enteric disease (limited to lab confirmed and reported and the most severe) 1 report for every 313 cases (Majowicz, S. et. al.,2004) 2. The etiologic agent remains unknown in a large proportion of the reported cases. (mainly outbreak-related)

5. October 4, 2004 3. Even if the etiologic agent is found, the source of the contamination remains unknown in a large proportion of the reported cases of enteric disease. 4. There is no link between pathogen exposure levels through food or water and human illness. Current Situation of Enteric Disease Surveillance in Canada

6. October 4, 2004 5. Under-reporting of the sources, etiologic agents and the pathways for transmission of human enteric diseases. 6. Consequently, information for public health, water treatment and delivery, and food safety management of enteric disease pathogens is limited. Current Situation of Enteric Disease Surveillance in Canada

7. October 4, 2004 The Case for C-EnterNet Human Under-reporting Humans Unknown Sources Humans Unknown Microbes C-EnterNet Retail Food Food/Animal Water Minimal Data on Exposure from:

8. October 4, 2004 More complete, accurate and comprehensive data about the occurrence of enteric disease in Canada More comprehensive and timely information on exposure More valid information about the link between exposure and disease Current Situation of Enteric Disease Surveillance in Canada What information is needed?

9. October 4, 2004 Enteric Disease Surveillance in Canada M otivation to Change The need for enhanced, active, integrated surveillance of enteric pathogens has been acknowledged both in Canada and abroad. Auditor General Reports (1999 & 2002) Naylor Report (2003) Haines Report (2004) CIHR Risk Assessment Report (2004) US Institute of Medicine’s 1992 Report

10. October 4, 2004 C-EnterNet is a pilot sentinel surveillance project being developed as the national integrated enteric pathogen surveillance program It was initiated to address the needs of the Public Health Agency of Canada, Agriculture and Agri-Food Canada and Canadians C-EnterNet will provide information to integrate and strengthen the science, policy, and health promotion, protection & prevention activities related to food and water safety in Canada

11. October 4, 2004 iPHIS Strategic Collaborations with other National Initiatives CNPHICNPHI Community Physicians Local Laboratories Reference Laboratories ASAP NSAGI C-EnterNet NND CIOSC PulseNet Canada NESP Public Health Units CSCCSC Information & isolate flow Outbreak Response

12. October 4, 2004 C-EnterNet : Objectives 1.Detect changes in pathogen exposure levels from food, animal and water sources as well as human enteric disease related to changes in policy or practices 2.Determine proportion of human cases due to water, food, animal contact 3.Provide information for early warning (pre- exposure) for problems in the agri-food chain 4. Enhancing analysis, interpreation and reporting of laboratory and epidemiological data for the public health and agri-food sectors at all levels

13. October 4, 2004 Proposed Framework Targeted reservoirs and vehicles of transmission Food animal production Humans Companion animals Wildlife Food Water Food vegetable production Land foodborne waterborne by contact person to person Food in process

14. October 4, 2004 Proposed Framework Data collection and integration Animal sources: - On-farm samples* -Slaughter samples* Food sources: - Retail samples* Human sources: - Stool /Laboratory samples * -Hospital data -Drug sales Water sources: -Source water sampling* - Drinking water samples* -Recreational water sample * Enhanced lab testing possible

15. October 4, 2004 Proposed Framework Challenge 2: Data Integration, Analysis, & Interpretation Animal sources Food sources Human sources Water sources Information to local, regional, provincial and national level

16. October 4, 2004 313 community cases of gastrointestinal illness 73 cases visit physician 19 have stool requested 15 submit the stool 14 stools tested 1.56 stools positive 1.24 positives reported locally 1 positive reported to province Majowicz, S. et. al.,2004 (Submitted) Enhanced, systematic lab testing Enhanced, systematic epi investigation Syndromic surveillance Proposed Framework for C-EnterNet: Continuous surveillance activities

17. October 4, 2004

18. Objective 1: Monitoring of cases and exposure - Enhanced monitoring of gastrointestinal diseases in population - On-going monitoring of enteric pathogen exposure C-EnterNet Analytical Methodology

19. October 4, 2004 C-EnterNet Analytical Methodology Objective 2: Attribution On-going assessment of attribution of gastrointestinal disease burden from various sources Methods: Case-control studies Outbreak method Pathogen distribution methods

20. October 4, 2004 Attribution: Case-control studies Compare cases to non cases over a range of possible risk factors Specific design with controls and data on possible risk factors required Valuable information Difficult and costly to implement >Interesting as a research study

21. October 4, 2004 Attribution: Outbreak Method Uses available surveillance data: easy to implement at low cost Limited to outbreak cases Limited to pathogens and sources investigated Problem of representativeness

22. October 4, 2004 Attribution: Pathogen Distribution Methods Assume high pathogen specificity to source Such specificity can be achieved at various levels: species, types, subtypes (ARA, ribotyping, etc.) Surveillance can be done at the right level: easy to implement at moderate cost

23. October 4, 2004 C-EnterNet Initial Accomplishments to Date Step 1: Scientific Team Literature Review Background Research Stakeholder Consultations Advisory Committee Ideal surveillance system elaborated

24. October 4, 2004 Initial Accomplishments Cost evaluation with three options Business Case Business Plan Ontario Ministry of Health & Long Term Care : Endorse proposal

25. October 4, 2004 Next Steps… Selection of pilot sentinel site* and agreement with all the local stakeholders (*Criteria) Initiation of surveillance activities Data analysis Assessment of pilot Implementation of national network of local sentinel sites

26. October 4, 2004 C-EnterNet Central Sentinel Sites Across Canada Surveillance components: Human Food On-farm Water C-EnterNet’s Network of Sentinel Sites Across Canada Surveillance Activities Continuous _____________ Episodic

27. October 4, 2004 Thank-you ! Contact: barbara_marshall @phac-aspc.gc.ca