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

2. 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

3. 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

4. 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.

5. 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 Geneva Intergovernmental Working Group meeting
Feb 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 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.

6. 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

7. IHR Decision Instrument

8. 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:

9. 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

10. 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

11. 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

12. 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

13. 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…)

14. 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

15. 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

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 22

23. 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

24. 24

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

26. 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 ?

27. 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 ..

28. 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

29. 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

30. 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

31. 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

32. 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.

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. NOIDS

42. 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

43. 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

44. 7 Surveillance at Centre for Radiation, Chemical and Environmental Hazards
-increase to daily reporting

45. 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

46. 289 days to go!