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

2. 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

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

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

5. 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

6. 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

7. 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

8. 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

9. 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
APSED (2010)

10. 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

11. 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

12. 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

13. 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

14. 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.

15. 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

16. 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

17. 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

18. 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

19. 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)

20. 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.

21. 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.

22. 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

23. Regional surveillance and risk assessment

24. 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

25. 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

26. 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

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

28. 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

30. 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 (Login by Country counted only once per day)
Most Member States regularly use EIS
Over 3000 logins

31. 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

32. 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

33. Algorithm for rapid risk assessment

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

35. 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

36. 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!