Maria Grazia Dente, Flavia Riccardo and Silvia Declich

Istituto Superiore di Sanità, Rome- Italy

on behalf of MediLabSecure Network

Zika virus and other mosquito-borne viruses. Science for preparedness and response in the Mediterranean region Barcelona, 23 -24 May 2017

Strengthening preparedness to arbovirus infections in

Mediterranean and Black Sea Countries: the experience

of integrated surveillance. Challenges and opportunities.

Public Health Group Aim

Public health activities reinforce the preparedness of MediLabSecure Network by investigating and improving the standard methods of surveillance towards: integrated surveillance, integrated risk assessment and early case detection in the framework of One Health.

Public Health Group Activities

Criteria to define integrated surveillance (IS) and to assess and compare different systems still need to be identified and tested. MediLabSecure addressed this lack of common criteria for IS for arboviral diseases with:

• A Scoping Review • A Survey with Medilabsecure members • A Situation analysis in the Mediterranean and Black

Sea Regions

The Scoping Review: Materials and Methods • The study question: what is known from the

existing literature on integrated surveillance of arboviral diseases and relevant criteria to identify and describe it?

• Two specific objectives: 1.To analyse publications describing existing surveillance systems for WNV, CHK, DEN, and RVF (mosquito transmitted arbovirus priorities for MediLabSecure) integrating human and/or animal and/or medical entomology and/or environmental surveillance.

2. To identify levels and criteria, in the publications, which can define a surveillance system as “integrated”.

The Scoping Review: Proposed Conceptual Framework to assess existing levels of integration between human/animal/entomological/environmental surveillance for a specific pathogen

Level of integration Sublevels of integration Criteria

Policy and institutional Policy 1. Existence of a national policy addressing

integrated surveillance for a specific

pathogen

2. Existence of a policy addressing integrated

surveillance for a specific pathogen at

subnational level

Institutional 1. Existence of agreements among the

institutions involved in

human/animal/entomological surveillance

for the specific pathogen

2. Existence of a coordination mechanisms

among the institutions involved

3. Existence of identified focal points for each

human/animal/entomological surveillance

for the specific pathogen

Data collection and analysis Interoperability mechanisms at data collection 1. Existence of integrated data collection tools

2. Existence of activation mechanisms of

human surveillance based on signals from

animal/entomological surveillance

3. Other interoperability mechanisms at data

collection level

Interoperability mechanisms at data analysis 1. Presence of database

exchange/merging/other mechanisms to

facilitate joint analysis among sectors.

2. Performance of joint/integrated data

analysis among the different surveillance

sectors

3. Other interoperability mechanisms at data

analysis level

Dissemination - 1. Existence of joint results dissemination

mechanisms (e.g. bulletins, reports, papers,

media reports, websites …)

The Scoping Review: Search Strategy and data extraction

for articles

• Search strategy defined on the working priorities for the MediLabSecure Network: mosquito transmitted arboviruses with autochthonous cases of disease (endemic/sporadic) in the EU, Mediterranean and Black Sea regions. For this reason, the review focused on WNV, CHK, DEN and RVF.

• We defined three search axes and searched articles in PubMED using Medical Subject Headings (MeSH) terms.

Search Axes Description

Intervention Surveillance of a viral VBD that integrates human virology, animal virology and/or

medical entomology components

Outcome models of integrated surveillance for this viral VBD

Exposure West Nile Virus (WNV)

Chikungunya (CHK)

Dengue (DEN)

Rift Valley Fever (RVF)

The Scoping Review: inclusion criteria

• Studies published in scientific peer-reviewed journals and grey literature for the period 2000-2014 in English/French/Italian that focused on:

• Descriptive/analytical epidemiology and surveillance evaluation studies/reports analysing the functioning of public health surveillance systems for WNV, CHK, DEN and RVF and

• Reporting integration between sectors.

• Studies were included regardless of the country of publication.

The Scoping Review: Results (1)

The Scoping Review: Results (2)

• The articles reported experiences of integrated surveillance in: • the United States (10/36, 28%),

• Italy (5/36, 14%),

• France/Réunion Island (4/36, 11%),

• Canada (2/36, 6%),

• Cuba, Greece, Hungary, Mexico, Pacific Islands, Romania, Singapore, Spain, Trinidad and Tobago, Turkey (1 article per country).

• Four articles described more than one country (4/36, 11%) while one article did not mention a specific country.

The Scoping Review: Results (3) Number of articles reporting on number and type of sectors integrated in arboviral surveillance, by pathogen

Sectors Pathogen

CHK DEN Multi RVF WNV Total

human and entomological 5 4 2 1 12

human and animal 1 1 4 6

human and animal and

entomological 12 12

human and entomological and

environmental

2 2

human and animal and

entomological and

environmental 3 3

Total 5 6 3 1 20 35

The Scoping Review: Results (4) Number of articles reporting on level of arboviral surveillance integration, by pathogen

Sectors Pathogen

CHK DEN Multi RVF WNV Total

data collection and analysis and dissemination

levels 2 1 3 6

data collection and analysis level 3 3

policy and institutional and data collection and

analysis and dissemination levels 2 1 1 11 15

policy and institutional and data collection and

analysis levels 1 1

policy and institutional level 1 1 2

Total 5 7 3 1 20 27

Survey with MediLabSecure members: materials and

methods

Policy and Institutional level

• Existence of a National policy addressing integrated surveillance for arbovirosis

• Existence of a coordination mechanisms among the institutions involved

Data collection and analysis level

• Existence of integrated data collection tools

• Presence of DB exchange/merging/other mechanisms to facilitate joint analysis among sectors.

• Performance of joint/integrated data analysis among the different surveillance sectors

Dissemination level

• Existence of joint result dissemination mechanisms (e.g. bulletins, reports, papers, media reports, websites …)

On line questionnaire to explore criteria describing existing levels of integrated surveillance

Survey with MediLabSecure members: Results (1)

• 19 countries (Albania, Algeria, Armenia, Bosnia Herzegovina, Egypt, Former Yugoslavic Republic of Macedonia, Georgia, Jordan, Kosovo, Lebanon, Libya, Moldova, Montenegro, Morocco, Palestine, Serbia, Tunisia, Turkey, Ukraine) invited to participate in the survey between December 2014 and July 2015

• 56 contact points from laboratories (animal virology, human virology and medical entomology)

• 19 contact points from Public Health Institutes (PHI)/Ministries of Health (MoH) (human

epidemiology)

• Responses from 51 laboratories (51/56; 91%) and 10 PHI/MoH (10/19; 53%): Black

Sea 14, North Africa& Middle East 25 and Balkans 22.

Survey with MediLabSecure members: Results (2)

Levels of integration reported

Level of

integration

Sublevels of

integration

Number of countries

reporting

integration

(N 19)

Number of

respondents

reporting

integration

(N 61)

N Respondents reporting integration

Balkans

(N 22)

Black Sea

( N 14)

NA & ME

( N 25)

Policy and

institutional level

Policy level 17 52% (32) 41% (9) 57% (8) 60% (15)

Institutional level 16 48% (29) 36% (8) 57% (8) 52% (13)

Data collection

and analysis level - 10 26% (16) 27% (6) 29% (4) 24% (6)

Dissemination

level - 16 54% (33) 45% (10) 43% (6) 68% (17)

The MeSA Study: materials and methods MediLabSecure Situation Analysis on integrated surveillance of arboviruses in the Mediterranean and Black Sea Region

• qualitative situational analysis study

• involving human, animal and entomology sectors of vector borne disease surveillance

• in three countries of the Mediterranean and Black sea region participating in the MediLabSecure Project: Serbia (WNV), Tunisia (WNV) and Georgia (CCHF).

General Objective

• Contribute to the integration of laboratory/clinical human, animal and entomological surveillance of arboviruses in the Mediterranean and Black Sea region and encourage inter-sectoral collaboration.

Specific objectives

• Describe how the collection, analysis and dissemination/exchange of information is organized within and between human, animal and entomological surveillance of arboviruses in three countries of the MediLabSecure network,

• Identify formal procedures, informal practices and legal constraints for integrated surveillance and inter-sectoral collaboration in these three countries,

• Discuss main challenges and success stories in establishing a functional inter-sectoral collaboration and integration of surveillance between the human, animal and entomological sectors in these three countries.

The MeSA Study

Preliminary results

In the period July-December 2016 we collected background

information on the IS of the three countries, visited the countries’

institutions and conducted interviews with the relevant

stakeholders.

Surveillance processes (intra/inter sectorial) with flows of

information, samples, feedback and responsibilities were analized

in the three countries.

The results highlight that the added value of IS and its aim/s

(early warning, mitigation, response, etc.) may vary in accordance

with the context, the available resources, and the pathogens.

Points for Discussion (1)

• Results of the scoping review on integration type confirm that integration between sectors is pathogen-driven (i.e. human, animal and entomological for WNV, human and entomological for DEN, etc.).

• The occasional involvement of the environmental sector reported in the surveillance of some pathogens, is a point to consider also in the view of environmental and climate changes with potential impact on arboviral diseases.

• the majority of the articles, 22(81%), describes the levels of integration, with criteria comparable to those reported in the conceptual framework we proposed: • for example, almost all the papers that reported integration

at policy and institutional level, also mentioned the existence of specific national policy/plan.

Points for Discussion (2)

• Integrated data collection and analysis are reported, however, the systems are not described in detail in the articles and, in the survey, the % of respondents reporting integration is very low (26%). It seems that each sector collects and analyses its own data, generating results that are then shared with the other sectors.

• The analysis of IS in Tunisia, Serbia and Georgia shows that an integrated data system is the cornerstone on which the whole system should be built up.

• More than 80% of the articles and the majority of the stakeholders interviewed with the MeSA Study, recognized the early warning as the main added value of the integrated surveillance, however, integration between sectors is being described predominantly for response activities and control measures. It seems that prevention and mitigation of impact through early warning with the intersectoral integration approach still need attention and consolidation.

The first challenge for integration… …….the desired impact of the One Health approach expected through intersectoral integration can only be achieved if also the capacities of each involved sector are sufficiently strong and developed. Häsler B, Gilbert W, Jones BA, Pfeiffer DU, Rushton J, Otte MJ. The economic value of One Health in relation to the mitigation of zoonotic disease risks. Curr Top Microbiol Immunol. 2012;365:127–51.

MedilabSecure is working with a comprehensive strategy addressing both the capacity of the single sectors and the intersectoral integration.

Challenges

Opportunities

Integrated/One Health Surveillance

The MediLabSecure Project is supported by the European Commission (DEVCO: IFS/21010/23/_194)

@medilabsecure @medilabsecure @medilabsecure

Thanks for your attention!

NCDC Tbilisi, 15 December 2016

Batut PHI- Belgrade, 7 July 2016

DSSB MoH – Tunis, 13 October 2016