1. Laboratory Integration in Influenza Surveillance Dr Geethani Wickramasinghe NIC- Sri Lanka

2. Introduction  Sri Lanka is a developing country with limited resources  There was no organized continuous influenza surveillance until recent past (2007)  Initially, only outbreak surveillance 1998 - Inf A H3N2 Sydney 5/97  Influenza surveillance was initiated under AI preparedness plan of GISN  Focal point- Epidemiology unit of MoH

3. National influenza network  ILI surveillance 2005 - started from Western province in Childrens hospital (LRH), Colombo 2007 - Extended to sentinel sites, 20 sites to include all the provinces  SARI surveillance 3 sites (LRH, GH/Matara, TH Peradeniya) -2010  Network of labs -1 NIC & 2 provincial (Southern & Central)

4.  Training programmes were conducted by the Epi – Lab team in these sites. ICN were trained in collection of samples & proper transport. Introduced case definitions  At the start VTM & swabs were prepared by the NIC & distributed to these sites. Now commercial swabs & media are used

5.  Each site – 30 specimens / month to NIC  Laboratory methods Initially - DFT & Virus isolation Rapid tests were not used Later molecular techniques  Conventional PCR initially  rt Rt PCR introduced in 2009  2010 - Changed testing protocols All specimens - PCR Positives – virus isolation SARI samples - PCR & DFT for all respiratory viruses

6.  Participated in WHO EQA programmes since 2007 – 9 panels -now 100% performance  Laboratory Accreditation by CDC in 2010  Funds WHO, WB, CDC - Equipments, Reagents Tsunami Funds/pasteur institute - Training programmes

8. DistrictWeek Ending Sentinel HospitalDate of Report Definition of ILI : Person with the Fever of Rapid onset (over 38 0 C). cough and sore throat, in the absence of another diagnosis Date (Day, week) Number of New Visits Total< 1 year1 – 4 years5-9 years10-14 years15-49 years50-64 yearsOver 65 Total Visit# ILITotal Visit# ILITotal Visit# ILITotal Visit# ILITotal Visit# ILITotal Visit# ILITotal Visit# ILITotal Visit# ILI Monday Tuesday Wednesday Thursday Friday Saturday Sunday Total for Week Population Incidence Rate (per 100,000) ICN Signature Weekly Data Collection Form for Cases of Influenza- Like Illness (ILI)

11. Dissemination of information  Data reporting – by telephone, fax & emails weekly / monthly print reports  To the Epidemiology unit & MoH  During the pandemic - daily reports  Weekly data to Flunet  Monthly technical committee meetings - human/animal surveillance, Epid unit, Health Education Bureau for communication, control activities  During the pandemic - guideline preparation & management protocols, control & preventive strategies - by the technical committee

12. Dissemination of data  Hospital performance published monthly in WER and Unit Website & presented at the monthly AI/PI technical committee meeting  Also presented quarterly for the Quarterly Review Meeting of Epidemiologists & published in Quarterly Epidemiological Bulletin

13. Data Compilation and Feed back  National level feedback Weekly Epidemiological Report (WER) Quarterly Epidemiological Bulletin www.epid.gov.lk

14. ILI surveillance in SL - 2005- 2009

15. ILI Surveillance – Samples Received from sentinel sites - 2010 NIC/MRI

16. Virus activity in Sri Lanka from 2005 - 2008

17. Rain fall pattern from 2006 - 2010

18. PA(H1N1) cases from June 2009–May 2011

19. Age Distribution of Confirmed cases & deaths in 2009 & 2010 NIC/MRI

20. Liaison with reference laboratories  Sharing of Influenza viruses with ref labs WHO CC – Melbourne, Ausralia & Hong Kong University Inf sub types & un-typed viruses - 2-3/year, World Courier- Global funds Benefits - Confidence - Sub typing of untypable viruses - Anti-viral susceptibility monitoring - Gene sequencing

21. Problems  Inadequate collection of specimens from some sentinel sites  Difficulty in transport of specimens from distance sites  Poor performance of sub-national laboratories  Initiation of anti-viral susceptibility monitoring & sequencing studies by the NIC

22. Control activities  Health Education  School closure  Vaccine recommendations 2010 - Introduced mono-valent Pandemic influenza vaccine 2011 – Seasonal vaccine was registered for the first time in SL depending on the Inf surveillance data

23. Future  Improvement of sub-national laboratories  Improvement of routine surveillance activities  Disease burden studies  Initiation of drug resistance monitoring  Collaborative research with animal surveillance center – VRI  Gene sequencing

24. Thank you