Event based surveillance systems

Alicia Barrasa

EPIET Introductory course 2011

Lazareto, Menorca, Spain

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

Infectious diseases

Emerging and Re-emerging infectious diseases

Cryptosporidiosis

Dengue haemhorrhagic feverCholera

E. coli O157

Typhoid

Diphtheria

E. coli O157

Lassa fever

Dengue haemhorrhagic fever

Cholera

Multidrug resistant Salmonella

E.coli non-O157Malaria

Legionnaire’s disease

Buruli ulcer

Shigellosis

Typhoid

Shigellosis

Cholera O139

Respiratoryinfection

Kyasanur f.Lyme Borreliosis Reston

Venezuelanequine encephalitis

West Nile Fever

EchinococcosisYellow fever

Ebola haemorrhagicfever Human

monkeypox

Influenza A (H5N1)

RVF/VHF

Ross River virus

Hendra virus

BSEWest 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

A(H1N1)v

EHEC

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

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

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 ?

Obligation to establish core capacities:

• Surveillance

• Response

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

Data EventsCollectAnalyseInterpret

CaptureFilterVerify

Assess

Investigate

Signal

Control measures

Public health Alert

Disseminate

Event monitoring“Surveillance” systems

Event-based surveillanceIndicator-based surveillance

Epidemic Intelligence

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…)

Data EventsCollectAnalyseInterpret

CaptureFilterVerify

Assess

Investigate

Signal

Control measures

Public health Alert

Disseminate

Event monitoring“Surveillance” systems

Event-based surveillanceIndicator-based surveillance

Risk assessment

Risk Management

Early warning

Response

Epidemic Intelligence

Event based SurveillanceSources 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 duringthe 2012 Olympic and Paralympic Games

Helen Maguire

acknowledgements

Brian McCloskey, Director, HPS London region

Ellen Heinsbroek, EPIET fellow, HPS Colindale

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

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 ..

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

Experience of mass gatherings

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

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London Olympics Surveillance

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

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Enhance reportable disease by clinicians

Enhance laboratory capacity and reporting

Enhance environmental monitoring

Create 24 on-call and rapid response teams

Enhance existing …

1. Syndromic Surveillance (NHS Direct, Q Surveillance, RCGP, EDSSS, OOH)

2. Notifications of Infectious Diseases

3. Surveillance at Olympic Village Polyclinics

4. Event-Based Surveillance

5. Laboratory Reporting

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Epidemic Intelligence(existing and new )

Surveillance of Undiagnosed Serious Infectious Illness (USII)

Environmental monitoring at Centre for Radiation, Chemical (and Environmental Hazards Mortality Surveillance)

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Existing and new surveillance systems

1 Syndromic Surveillance

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Existing systems

NHS Direct

GP-based syndromic surveillance

• Q Surveillance

• Royal College General Practitioners

New systems

Out of Hours Providers

Emergency Departments

To provide enhanced surveillance during weekends/holidays/evenings

1 Syndromic Surveillance out of hours

To establish a surveillance network of EDs across England

1 Syndromic Surveillance emergency departments

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Health Protection Unit

HPA Colindale:

Departments (esp. Immunisation)

Registered Medical Practitioner

Proper Officer - Local Authority

HPA Colindale: Central Information Management

Normal: fax: max. 3 daysEmergency: phone within 24 hrs

Max. 3 days (methods differ by LA/HPU)

Report published on internet

Extra requirements Olympics:

Olympic Venue Attendance • Forms + HPZone to be changed

Speed up notifications

Improve consistency reporting

2 Notifications of infectious diseases

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

39Olympics 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

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5 Lab reporting

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HPA Colindale:

Departments

Laboratories

HPU/Region

HPA Colindale: Central Information Management

- Weekly, by law (Oct’10)- Automatic, with manual checking+sending

- Weekly exceedance report published on intranet- Departments access via software

Extra requirements Olympics:

Daily reporting: software change Automatic extraction software Exceedance Algorithms: dailyAdapt for changes in testing,

• e.g. multiplex PCR

6. Surveillance of Undiagnosed

Serious Infectious Illness To ensure early detection and response to new and emerging infectious disease threats.

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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

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Olympic Surveillance Matrix: Early Detection

Surveillance 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*sentinel

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. asthmaChemical, Environmental or Radiation incident

*

Imported disease, e.g. plague

*Newly emerging disease *Deliberate release, e.g. anthrax

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289 days to go!46