nato science for peace and security programme advanced research

INTERNET‐BASED INTELLIGENCE FOR PUBLIC HEALTH EMERGENCIES AND DISEASE OUTBREAK

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NATO SCIENCE FOR PEACE AND SECURITY PROGRAMME

ADVANCED RESEARCH WORKSHOP

NATO Public Diplomacy Division, Bd. Leopold III, B‐1110 Brussels, Belgium

fax +32 2 707 4232 : e‐mail [email protected]

MARCH 13‐15, 2011

DAN PANORAMA HOTEL HAIFA

HAIFA, ISRAEL


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ORGANIZING COMMITTEE

Co‐Directors

Emilio Mordini Manfred Green

Centre for Science, Society and Citizenship, Rome, Italy

School of Public Health at Haifa University, Haifa, Israel

Committee Members

François M.H. Géré Toby Merlin

Institut Français d'Analyse Stratégique, Paris, France Influenza Coordination Unit Centers for Disease Control and Prevention, Atlanta, USA

Secreteriat:

Centre for Science, Society and Citizenship

Piazza Capo di Ferro 23, 00186 Rome, Italy

Phone: +39 0645551042/3 ‐ Fax: +39 0645551044

Email: [email protected]


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Need A number of initiatives aimed at identifying health crises earlier than existing official monitoring systems are in progress. Web crawlers – automated software programs that scour the web for information – are increasingly used to find patterns that may signify an emerging threat. “Over the past 15 years, Internet technology has become integral to public health surveillance. Systems using informal electronic information have been credited with reducing the time to recognition of an outbreak, preventing governments from suppressing outbreak information, and facilitating public health responses to outbreaks and emerging diseases” 1. Yet Internet‐based systems for outbreak detection still lack a calm and reflective evaluation, which includes not only an assessment of their technical reliability but also a careful analysis of their policy and regulatory implications. The main issues include; 1) Whether web‐crawler systems are truly able to extract reliable data on emerging crises from the Internet; 2) How it is possible to deal with information overload, false reports, lack of specificity of signals; 3) How it is possible to exploit new mobile technologies to engage directly with citizens to report illness; 4) How it is possible to minimize the risk that affected groups might deliberately provoke false alarms; 5) Whether it is possible to also apply this technology to the early detection of other kinds of crisis (e.g., conflicts, environmental disasters, financial crisis, etc). 6) How it is possible to improve the coverage of developing countries, where news sources are fewer; 7) Political impact given that Internet based systems bypass state based epidemiological surveillance. 8) How it is possible to implement public verification and follow‐up procedures; 9) Privacy concerns for strategies that have the potential to identify individual internet activity. Importance The potential threat of infectious diseases to the security of human life and global stability is very real. In a closely interconnected and interdependent world, new infectious diseases may adversely affect economic growth, trade, tourism, business and industry, and social stability as well as public health2. Severe high‐mortality rate pandemics due to highly‐transmissible viruses are a real threat for the world in the 21st century. Over the past three decades, scientists have identified more than 30 "new" infectious diseases, including HIV/AIDS, SARS, Ebola, and the West Nile Virus. In addition, the risk of infectious diseases crossing species boundaries may be more frequent, as in the case of “mad cow disease” and the threat of “swine flu.”

Public health measures to control and fight emerging infectious diseases are still limited3. Governments have to weigh the benefits and harms of exposing people, communities and whole countries to possible discrimination and economic insult through epidemic controls. A range of negative outcomes are possible including a population's refusal to accept preventive measures or treatment regimens such as isolation and quarantine. Inappropriate public health responses may cause social disruption and civil disobedience. Beyond the immediate human health toll of epidemic crises, there may be damage inflicted by stereotyping, stigmatization and staggering economic losses. Another aspect of epidemics in our age is that it is hard to distinguish a natural disease outbreak from an intentionally caused biological threat. The combined danger arising from the bioterrorist threats to public order and the emergence of naturally‐occurring new infections demand novel solutions and particular attention.

1 Brownstein JS, Freifeld CC, Madoff LC. (2009) Digital disease detection‐‐harnessing the Web for public health surveillance. N Engl J Med. 21;360(21):2153‐5, 2157 2 Klaucke D. (2002) Globalization and Health: A Framework for Analysis and Action. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the consequences and the Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections. 3 Smolinski, M, Hamburg, MA, Lederberg, J (2001) Microbial Threats to Health; Emergence, Detection, and Response. Institute of Medicine of the National Academies: Washington DC.


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If fighting new epidemics is not easy, predicting them is still more difficult4. The spread of infections depends on several factors, related to the nature of the microbiological agent, peoples’ behaviour, socio‐economic conditions and the like. Despite established links between microbiological, ecological, geographical, socio‐economic variables and epidemics, surveillance systems to forecast epidemics are far from being accurate. False alarms can have huge economic costs and can seriously undermine public confidence. As a consequence, our ability to deal effectively with new and emerging epidemics chiefly relies on early detection. Early detection of disease activity, when followed by a rapid response, can reduce the impact of outbreaks and allow essential medical, social and economic countermeasures to be taken.

Timeliness Early detection of disease outbreak has traditionally relied on microbiological and clinical data. Yet since 1990s new surveillance systems have been created to monitor indirect signals of disease activity. Among these indirect methods some rely on obvious indicators, such as the volume of over‐the‐counter drug sales5 or the number of calls to telephone triage advice lines6; other more innovative methods are based on electronic communication monitoring . The aim of these innovative methods is to detect health crises earlier than official monitoring systems. The Program for Monitoring Emerging Diseases (PROMed‐mail) was founded in 1994 by the International Society for Infectious Diseases, and it is likely to be the most ancient online, publicly available, reporting system. ProMED uses the Internet to disseminate information on outbreaks by e‐mailing and posting

case reports, including many gleaned from readers, along with expert commentary. Founded in 1997, GPHIN, Global Public Health Intelligence Network, is an Internet‐based 'early warning' system for potential public health threats including chemical, biological, radiological and nuclear (CBRN). GPHIN has been developed by the Canada's Centre for Emergency Preparedness and Response (CEPR). GPHIN retrieves relevant articles from news aggregators every 15 minutes, using extensive search queries. The system monitors on a worldwide, 24/7 basis, with media sources in six languages (Arabic, Chinese, English, French, Russian and Spanish) and provides relevant information on disease outbreaks and other public health events. The automatic system filters and categorizes information, which is further processed by human analysis. More recently a new generation of web application hybrids (mushups), which combine information from multiple sources into a single representation, have been used to mine, categorize, filter, and visualize online intelligence about epidemics in real time. Current systems include Healthmap, Google Flu Trends, MediSys, Argus, EpiSPIDER, BioCaster, and the Wildlife Disease Information Node. Text‐processing algorithms are used to determine the relevance of the information, which is then sorted by disease and location, with duplicate articles filtered out. The mining power of these systems is constantly increasing, for instance, Healthmap searches 20,000 websites every hour, tracking about 75 infectious diseases, including malaria, cholera, Ebola, and recently also swine flu. An average of 300 reports are collected each day, about 90% of which come from news media sources. Current systems combine similar types of media, yet the introduction of new automated analysis of online video materials and radio broadcasts, and the possibility to aggregate different types of media, will soon provide still more robust and sophisticated systems.

ProMED and GPHIN played critical roles in informing public health officials of the outbreak of SARS, or severe acute respiratory syndrome, in Guangdong, China, as early as November 2002, by identifying informal reports on the Web through news media and chat‐room discussions. Yet the use of using electronic tools to monitor for infection outbreaks went to the limelight only with the recent outbreak of swine flu in Mexico when Google Flu Trends, which aggregates and analyzes search queries to detect online early sign of flu epidemics, found a peak in telltale flu‐related search terms about two weeks in advance of the actual outbreak. In other words,

4 Tait, J., Meagher, L., Lyall, C., Suk, J. (2006) Foresight. Infectious Diseases: preparing for the future. Risk Analysis. Office of Science and Innovation, London 5 Magruder, S., (2003) Evaluation of over‐the‐counter pharmaceutical sales as a possible early warning indicator of public health. Johns Hopkins University APL Technical Digest 24, 349–353 6 Espino, J., Hogan, W. & Wagner, M. (2003) Telephone triage: A timely data source for surveillance of influenza‐like diseases. Proc AMIA Symp 215–219


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Google data may have been able to provide an early warning of the swine flu outbreak, if the system were adopted as a reference system. When on April 25, 2009 the World Health Organisation (WHO) declared a "public health emergency of international concern", it was too late to contain the disease and stop its spread. Could the spread of the virus have been stopped if public health groups had paid better attention online earlier? The answer is likely to be “yes”. John Brownstein, an assistant professor of pediatrics at Harvard University and co‐creator of the Health Map service (one of the new digital detection devices for infectious diseases), believes the swine flu outbreak represents a "different era" in the world of information flow and communication. "The speed at which we are receiving data of this outbreak and new reports in different countries, different provinces is just astonishing" he said7.

Early detection of an infectious disease outbreak is an important element of security policies. Infectious disease outbreak are not only medical events, but complex socio‐economic incidents which affect the whole of society in several ways, not to mention the possibility of the occurrence of bioterrorist attacks. Rapid disease identification allows to implement public health intervention and to establish the necessary social, economical and political countermeasures, which improve public resilience and reduce the risk of disruptive societal reactions. Yet many countries, often in the same world regions in which new infectious diseases are emerging, lack capacity for early detection and sometimes tend to not fully disclose the nature and extent of an outbreak in order to avoid a negative economic impact. The Internet offers solutions to some of these challenges. Freely available Web‐based sources of information may allow us to detect disease outbreaks earlier with reduced cost and increased reporting transparency. A vast amount of real‐time information about infectious disease outbreaks is found in various forms of Web‐based data streams. These range from official public health reporting to informal news coverage to individual accounts in chat rooms and blogs. However infectious disease intelligence, like any other kind of intelligence, should never be considered a trivial issue. On the contrary it always requires a careful, technical and political, critical assessment. This ARW aims to initiate such a critical assessment by gathering a multidisciplinary pool of experts and launching a high level conversation on the main technical, regulatory and political issues raised by this new technology.

General Approach The workshop will provide a flexible framework within which to assess emerging systems of global epidemiological surveillance based on monitoring online communications and the World Wide Web. We aim to gather information from different perspectives and provide a pluralistic picture of the issue. The workshop will allow a full exchange of opinions to take place and promote open debate among participants. These participants will be both men and women from academia, international organisations, civil society organizations, national and international regulatory bodies and security agencies. During the three‐day workshop, the main speakers will present a full picture of the situation from their own perspectives to a selected audience, including other speakers, chairs, and participants, up to max 40 persons in total. This should allow ample opportunity for each participant to ask questions, debate points or refute one or more of the statements made by the speakers. Papers will be collected, edited, and published in a book.

7 CBC News, May 1, 2009 , http://www.cbc.ca/technology/story/2009/05/01/tech‐090501‐online‐tools‐pandemic.html


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SUNDAY, MARCH 13 15:00 ‐ 17:00 Registration and Coffee

SESSION 1 OPENING Chair: Manfred Green, Israeli Co‐Director

17:00 – 17:20 Welcome by Manfred Green, Israeli Co‐Director

17:20 – 17:40 Welcome and scope of the workshop by Emilio Mordini, NATO country Co‐Director

Key notes delivered by 17:40– 18:10 Marjorie P. Pollack, Deputy Editor Epidemiology & Surveillance, Moderator ProMED‐mail

Digital Detection of Diseases: where we are, where we go

18:10 ‐ 18:40 General Discussion

18:40 – 19:00 Chair’s conclusive remarks and adjourn

19.00 Get together Reception

MONDAY, MARCH 14 SESSION 2 EARLY DETECTION OF DISEASE OUTBREAKS BY USING THE INTERNET, THE CONTEXT Chair: Toby L. Merlin Deputy Director, Influenza Coordination Unit, US Centers for Disease

Control and Prevention

09:00 ‐09:10 Chair’s general introduction

09:10 – 09:30 Tamar Shohat, Director, Israel Center for Disease Control The use of multi sources digital data bases for influenza surveillance

09:30 – 09:50 Discussion

09:50 ‐ 10:10 Predrag Kon, Head of the Department for immunization at Institute of Public Health Internet based intelligence service during pandemic influenza season 2009/2010 in Serbia


10:30 – 11:00 Break

11:00 – 11:20 Marc Gastellu Etchegorry, Director of the International Department, French Institute for Public Health Surveillance, EpiSouth project Sources of Information in Epidemic Intelligence


11:40 – 12:00 Massimo Ciotti, Preparedness and Response Unit, European Centre for Disease Prevention and Control Epidemic intelligence in the European Union: the role of Internet



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12:20‐12:40 Laetitia Vaillant Global Health Security Action Group, Institute for Public Health Surveillance

Epidemic intelligence in France and within the GHSAG community 12:40 ‐ 13:00 Discussion


13:10 – 14:30 Lunch

SESSION 3

INTERNET, PUBLIC HEALTH AND COMMUNICATION

Chair: Emilio Mordini, Centre for Science, Society and Citizenship

14.30 – 14:40 Chair’s general introduction

14:40 – 15:00 Donato Greco, Italian National Institute of Health New Communication Strategies in Epidemics


15:20 – 15:40 Ben Reis, Assistant Professor, Harvard Medical School, Affiliated Faculty, Harvard‐MIT Division of Health Sciences and Technology Social networks and health


16:00 – 16:20 Break

16:20 – 16:40 Anat Gesser‐Edelsburg Health Promotion‐School of Public Health, University of Haifa Strategies of persuasion on the Internet


17:00 – 17:20 Yair Amikan, Head, Department of Information, Ministry of Health Transparency in Public Health Communication


17:40 – 18:00 Goran Belojevic, Institute of Hygiene and Medical Ecology, School of Medicine, University of Belgrade Internet Based Health Communication – Analysis of Messages on the Websites of Serbian Public Health Institutes

18:00 ‐ 18:20 Discussion


20:30 Conference dinner


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TUESDAY, MARCH 15

SESSION 3 THE COMPLEX RELATION BETWEEN SECURITY AND PUBLIC HEALTH Chair: François M.H. Géré, Institut Français d'Analyse Stratégique

09:00‐09:10 Chair’s general introduction

09:10 – 09:40 Deborah Cohen, British Medical Journal

WHO and the “pandemic flu conspiracies” 09:40 – 10:00 Discussion

10:00 ‐ 10:20 Michael Hopmeier, Director, Unconventional Concepts

Public Health, Intelligence and National Security: an approach for the 21st Century 10:20 – 10:40 Discussion

10:40 – 11:00 Break

11:00 – 11:20 Iris Hunger Research Group for Biological Arms Control, University of Hamburg

Internet Based Intelligence and Bioterrorism11:20 – 11:40 Discussion

11:40 – 12:00 Richard B. Schwartz, Chairman Emergency Medicine Georgia Health Sciences University, Vice

Chairman National Disaster Life Support Foundation (NDLSF) A Health Security Card (HSC) for Disasters and Public Health Emergencies


12:20 ‐ 13:00 FINAL ROUND TABLE: LESSON LEARNED AND FUTURE DIRECTIONS Manfred Green, Emilio Mordini, Toby l. Merlin, François M.H. Géré

13: 00 Adjourn & Lunch


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Participants Valeria Balestrieri Centre for Science, Society and Citizenship ITALY

Yair Amikan Department of Information, Ministry of Health ISRAEL

Artak Barseghyan Academy of Armenia Engineering ARMENIA

Goran Belojevic Institute of Hygiene and Medical Ecology, School of Medicine, University of Belgrade

SERBIA

Massimo Ciotti Preparedness and Response Unit, European Centre for Disease Prevention and Control

EUROPEAN UNION

Daniel Cohen Dept of Epidemiology, Tel Aviv University ISRAEL

Deborah Cohen British Medical Journal UNITED KINGDOM

Marc Gastellu Etchegorry French Institute for Public Health Surveillance, EpiSouth project FRANCE

François M.H. Géré Institut Français d'Analyse Stratégique FRANCE

Anat Gesser‐Edelsburg Health Promotion‐School of Public Health, University of Haifa ISRAEL

Donato Greco Italian National Institute of Health ITALY

Manfred Green School of Public Health at Haifa University ISRAEL

Michael Hopmeier Unconventional Concepts UNITED STATES

Iris Hunger Research Group for Biological Arms Control, University of Hamburg GERMANY

Predrag Kon Department for immunization at Institute of Public Health SERBIA

Toby Merlin Influenza Coordination Unit Centers for Disease Control and Prevention

UNITED STATES

Emilio Mordini Centre for Science, Society and Citizenship ITALY

Adkham Paiziev Uzbek Academy of Science and Ministry of Public Health

UZBEKISTAN

Marjorie P. Pollack Epidemiology & Surveillance, and ProMED‐mail UNITED STATES

Ben Reis Harvard Medical School, Children's Hospital Informatics Program, Harvard‐MIT Division of Health Sciences and Technology

UNITED STATES

Tamar Shohat Israel Center for Disease Control ISRAEL

Richard B. Schwartz Emergency Medicine Georgia Health Sciences University, National Disaster Life Support Foundation (NDLSF)

UNITED STATES

Laetitia Vaillant Global Health Security Action Group, French Institute for Public Health Surveillance

FRANCE

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EpiSouth

Mediterranean Early Warning and alert System

M. GASTELLU ETCHEGORRY, F. AÏT-BELGHITI, C. GIESE and P. BARBOZA

for the WP 6 Steering Group

International Department Institut de Veille Sanitaire (InVS),

France

Globalisation of health crisis

International threats Access to information

Mediterranean countries share common history, populations, ecosystem… and threats

Existing EWS (WHO, ECDC, OIE, FAO…) do not fulfil totally Mediterranean needs

Participating countries

EpiSouth

Dec 2006-June 2010

Objective “Create a framework of collaboration on

epidemiological issues and communicable diseases

control in the Mediterranean region”.

Funding DG-Sanco (EU countries only) + EU- RELEX (TAIEX)

Italian Ministry of Health

Participating countries

1st Phase

EpiSouth

Start: 15 October 2010 -- Duration: 2 ½ years Focus :

Increase health security in in the Mediterranean AreaPreparedness to common health threats

Funding:EU : DG-SANCO (EAHC) & DEVC, ECDC Italian Ministry of Health All participating countries

2nd Phase

EpiSouth 1st Phase

Cross-border-epidemic intelligence (InVS, France).Vaccine preventable diseases in migrants (NICPD, Bulgaria).Emerging zoonoses (HCDCP, Greece)

Training (ISCIII, Spain)Networking (Venetia, Italia)

Coordination (ISS, Italy)Communication (ISS, Italy)Evaluation (Venetia, Italy)

8 WP managed by EU Public Health Institutes

Episouth Network Added Values

1st phaseTrust and cohesion among focal points and leaders

Awareness on regional and cross-border issues

Proved feasibility

Majors challenges remain

Governance

Sustainability

Formalisation

To be addressed during the 2nd phase : EpiSouth Plus

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EpiSouth + 2nd Phase

Governance

CoordinationWork packages (PHI)

Leaders, co-leaders, steering committees

2 focal points per countriesCrossroad of reception and dissemination

Technical WPs

WP 4 Laboratory network

WP Leaders :Institut Pasteur (France) & Refik Saydam National Hygiene Center, MoH Turkey

WP 5 Generic Preparedness & Risk management

WP Leaders :Instituto de Salud Carlos III (Spain) & Institut National de Santé Publique of Algeria.

WP6 Early warning system

WP Leaders : InVS (France) & Middle East Consortium on Infectious Disease Surveillance (MECIDS) [Israel + Jordan + Palestine

WP 7 Data collection & assessments for IHR Preparedness & Risk management

WP Leaders : Istituto Superiore di Sanità (ISS) Italy &WHO-LYON

Horizontal WPs

WP 1 Coordination

WP Leaders : Istituto Superiore di Sanità (ISS) Italy & Ministry of health of Tunisia

WP 2 Dissemination

WP Leaders : Istituto Superiore di Sanità (ISS) Italy) & Institute of Public Health of Montenegro

WP3 Evaluation

WP Leaders : Azienda Sanitaria Locale Torino 1 (ASLTO1) Italy

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EpiSouth

Epidemic intelligence and Early warning

EpiSouth E.I. Global Concept

International threats

EpiSouth E.I.

Consists in 5 mains steps (# InVS) DetectionSelectionValidation Analysis & interpretationInformation dissemination

But tailored to EpiSouth needs (geographical criteria +++)

Not exhaustive but aims at covering most countries needs

Only verified information shared

Reduces duplication

Communication

Two main communication supportsIn English Only new & verified events Available online in the EpiSouth site http://www.episouth.org

e-WebEpiSouth Weekly epidemiological Bulletin

Thematic notesad hoc basis Complex, not well known or multiple countries issues (CCHF, WNV, A/H1N1, Alkhurma virus…)

Cross border EW

Mediterranean Alert Early warning systemSecured web site (confidential)To share national alertsOperational since November 09

Accessible to EpiSouth FP NPHI MoH

Majors Stakeholders WHO ECDC EU commission

Complements existing systems WHOE.U. / ECDC

Focus of the 2nd phase / Lessons

Maintain EI and Cross-border activities

Synergies / interoperability /other network institutions WHO, OIE, ECDC, EU (EWRS and alert systems…)Regional Network MECIDS, SEEHN, etc.Develop articulation with Diseases surveillance Thematic networks Work packages

Involvement of non EU countries

Collaboration with partners: WHO, ECDC…

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West Nile virus circulation in the

EpiSouth countries

as of 7th October 2010

Mediterranean WN Context

Since 1st documented outbreak in 1951 in Israel, circulation documented almost worldwide

Large human outbreaks EpiSouth & neighboring areas Romania (1996-1997) Tunisia (1997); Israel (2000) Russia (1999)

Up to 2010, restricted to limited geographical settings

Surveillance biases Number of reported neurological cases grossly underestimate circulation in human

Not all countries have specific surveillance system

West Nile 2010

Mid August 2010

signals of WNV (cases and deaths)

circulation ?2nd September

EpiSouth survey on

WN surveillance systems, availability of national WNV laboratoryEpidemiological context; cases definition and recent cases…

24 countries participated

1st July and 7th Oct.

8 countries reported WN outbreaks

Human cases and deaths Equine casesCountries Cases Deaths CountriesGreece(*) 257 31 GreeceIsrael 65 3Italy 1 0 ItalyRomania 41 4Spain 2 0 Spain (**)Turkey(*) 7 3

MoroccoBulgaria (**)

Total 373 41 140(*) First outbreak ever reported (**) First equine cases reported to OIE

Distribution of WNV cases and deaths. EpiSouh countries 1st July / 7 October 2010

Surveillance (23 responding countries)

WN Reference Laboratory15 operational4 non functional1 external reference laboratory 4 no reference laboratory

14 specific Human Surveillance of which:9 permanent (year long) passive surveillance2 seasonal only3 permanent surveillance + enhanced seasonal system in at-risk areas.

Veterinary surveillance11 equine permanent3 seasonal equine 6 countries have also implemented a bird sentinel surveillance system

Limits/discussion

Objective : Rapid information for decision (e.g. blood donors)Limits : Information collected in a very short time

Number of items wilfully limited Does not allow in-depth analysis.

Issues : In 2010, unprecedented reported viral circulation in the areaContributed to raise awareness Exchange of information and description of WN circulation Heterogeneity of strategies and resources available for WN surveillance

Among 11 EpiSouth countries with specific WNV (humans and horses) surveillance and operational lab : 7 diagnosed human or horses casesNo countries without specific WNV surveillance system reported case

Origin of high viral circulation not clearly understood.

Lack of virological data (lineage, phylogenetic…)

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The progressive expansion of the Novel A(H1N1)v epidemic in the EpiSouth region

(Mediterranean and Balkans)

Focus on EpiSouth region

Source of data: EpiSouth countries

Data collected:Confirmed casesCase definition and case management strategiesDeaths / severe casesCommunity transmission: circulation intensity Imported VS local cases

Descriptive analysis on a weekly basis

Information shared with the network:Daily bulletin (since 06 May to 26 June); Twice a week (in June) Weekly bulletin (from July)

Chronological A(H1N1) evolution (detected cases reported)

08 June 2009 13 July 2009

11 May 2009 31 May 2009

Evolution by « sub-region »

Cumulative A(H1N1)2009 confirmed cases, EpiSouth sub-regions, as of 28 July (week 31).

Exportation of cases: Imported cases and countries of origin

Imported VS local cases

(for 12/13 countries providing data)

Countries of origin (imported cases)

Main trends: Canada and USA exported in Egypt, Lebanon, Saudi Arabia, Morocco (Students and expatriate population back for summer)

Europe exported in Tunisia and Algeria

Saudi Arabia in the Middle East neighbouring countries (e.g. pilgrims)

0 50 100 150 200 250

KosovoAlbaniaBosnia

Tunisia*Morocco

MaltaEgypt

LebanonRomania

TurkeySlovenia

ItalyAlgeria

secondary casesNb imported cases

Discussion / conclusion

Limits Different surveillance systems

Added value: First data and Regional overview (3 different WHO regions)

Reduced duplicationInformation / case definition, management, etc.Illustrated Different strategiesSpread of A/H1N1

Conclusion

Clear needs for enhanced international collaboration to:Optimise limited resources utilisation and minimise duplication Build on experiencesDevelop synergies and partnerships Improve dissemination of information

In case of major threats, pooling internationally available capacities will strengthen health security .A new challenge

Vast potential for synergy and collaboration with other networks

Key role for regional networks

Global crises = Global response

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Emilia Anis & Michal Bromberg Israel Raja’a Haddadin & S. Abdullah Saleh Jordan Naser Ramadani; Arijana Kalaveshi Kosovo Tanya Melillo, Jackie Maistre Melillo, Charmaine Gauci Malta Dragan Lausevic and Zoran Vratnica Montenegro Mohammed Youbi & Ahmed Rguig Morocco Bassam Saeed Madi and Basem Al-Rimawi Palestine Mondher Bejaoui & Mohamed Ben Ghorbel Tunisia Alex Leventhal & Sari Husseini MECIDS

Fatima Aït-Belghiti, Coralie Giese & Philippe Barboza France

Acknowledgements WP6 – Steering Group

Acknowledgements

The EpiSouth-Plus project is implemented by the Italian National Institute of Health and is co-funded by the European Union DG SANCO/EAHC and EuropeAid together with the participating national partner Institutions.

The financial support of the Italian Ministry of Health and ECDC is also acknowledged.

The contents of this presentation are the sole responsibility of the authors and can in no way be taken to reflect the views of the European Union.

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