National Influenza Surveillance CDC Kenya

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National Influenza Surveillance CDC - Kenya

• Nila Dharan
• Georgetown University
• Research Noon Conference
• 11/17/2006

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Kenya Facts

• 540,000 sq miles
• Population 32 million
• Fertility rate 3.47 children/woman
• Literacy Rate 85
• HIV prevalence around 15
• Tribal groups over 70

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CDC Abroad

• Many International Programs
• Global AIDS Program (GAP) throughout the world
  including Africa
  
• International Emerging Infections Program (IEIP)
  population-based disease surveillance. First
  office established in Thailand in 2000, in Kenya
  in 2004. Plan eventually for 16 sites throughout
  the world.
• In Kenya
• 1978 in Kisumu, on Lake Victoria, initially for
  malaria research, now with many projects and
  programs including GAP and IEIP
  
• 2000 in Nairobi, capital of Kenya, includes GAP
  and IEIP

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My Projects

• National Influenza Sentinel Surveillance Project
• Disease Surveillance in Kibera, Africas largest
  contiguous slum

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National Influenza Sentinel Surveillance Project

• Influenza background - Seasonal, Avian, and
  Pandemic
  
• Risk in Kenya
• Project design
• Implementing the first surveillance site at
  Kakuma Refugee Camp

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Influenza Basics

• Influenza A
• Causes more significant disease, epidemics, and
  pandemics,
  
• Affects humans and other species
• Subtypes are determined by two surface
  glycoproteins
  
• Hemagglutinin (HA) - 16
• Neuraminidase (NA) - 9
• Influenza B
• Causes milder disease
• Affects humans only

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Influenza Basics

• Seasonal A and B
• Avian Influenza A, H5N1
• Pandemic Flu
• Though it is highly contagious amongst birds,
  Avian Influenza has not proven to be highly
  transmissible from human to human.
  
• A pandemic strain could emerge if the virus mixes
  and re-assorts to create a new strain that would
  be as fatal as Avian Flu, and highly
  transmissible.

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Prior Pandemics

• 1918-19 Spanish Flu (H1N1)
• 40 million deaths worldwide
• 1957-58 Asian Flu (H2N2)
• 1 - 2 million deaths worldwide
• 1968-69 Hong Kong Flu (H3N2)
• 700,000 deaths worldwide

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Current Worldwide Outbreak

• Currently, there have been ten countries with
  confirmed cases of H5N1 in humans.
  
• Asia Vietnam (93), Indonesia (60), Thailand
  (24), China (21), Cambodia (6)
  
• Middle East Turkey (12), Azerbaijan (6,) Iraq
  (2)
  
• Africa Egypt (14) and Djibouti (1).
• Transmission Primarily avian ? human, there is
  no sustained human ? human. There is possible
  environmental? human

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Current Worldwide Outbreak Map
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Risk Areas in Kenya for Avian Influenza

• It is not entirely clear how Avian Influenza
  spreads
  
• Wild bird migration
• Illegal bird trade
• Risk profile based on
• Migratory pathways
• Poultry population
• Water masses, wetlands
• Border districts with active trade in poultry and
  poultry products

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National Influenza Sentinel Surveillance Project

• Purpose
• Case Definitions
• Personnel and Study Design
• Data Collection and Laboratory Sampling
• Our first surveillance site Kakuma refugee camp

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National Influenza Sentinel Surveillance Project

• Purpose
• Establish a surveillance system in place to
  record cases of influenza in Kenya.
  
• Collect data on each case to characterize these
  illnesses.
  
• Collect laboratory samples to determine the cause
  of these illnesses and the strains of influenza
  that are present.
  
• Detect new influenza strains capable of causing a
  pandemic
  
• To characterize the epidemiology of seasonal
  human influenza in Kenya to establish prevention
  strategies

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National Influenza Sentinel Surveillance Project

• Team Members Kenya MoH, KEMRI, WHO, CDC
• Duration one year with option for another year
• Sites
• 8 provincial Hospitals Kakamenga, Nyeri,
  Kenyatta, Mombasa CGH, Embu, Garissa, Nakuru,
  New Nyanza
  
• 2 Refugee hospitals IRC in Kakuma, GTZ in
  Dadaab
  
• 1 Private Hospital Aga Khan Hospital, Nairobi

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Case Definitions

• Influenza Like Illness (ILI) out-patients
• Fever (/ 38.0)
• AND EITHER cough OR sore throat
• Severe Acute Respiratory Illness (SARI)
  in-patients
  
• Adult age 5 and up
• Fever (/ 38.0)
• AND EITHER cough OR shortness of
  breath/difficulty breathing
  
• Pediatric 2 mo 4 years
• EITHER Cough OR shortness of breath/difficulty
  breathing
  
• AND one of unable to drink or breastfeed at all,
  lethargic or unconscious, vomits everything,
  convulsions, nasal flaring, grunting, oxygen
  saturation
  under the ribcage on inspiration), stridor in a
  calm child, tachypnea (2mo-50/min
  1yr-4yrs - RR40)

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Case Definitions continued

• Suspect Avian Influenza (SAI) ILI or SARI AND
  one of the following within 7 days of symptom
  onset
  
• Close contact (within 1m) with a person who is a
  suspected, probable, or confirmed H5N1 case
  
• Exposure (within 1m in any setting including
  handling, slaughtering, defeathering, butchering,
  preparing for consumption) to poultry or wild
  birds or their remains, or to environments
  contaminated by their feces in an area where H5N1
  infection in animals or humans has been suspected
  or confirmed
• Consumption of raw or undercooked poultry in an
  area where H5N1 infection in animals or humans
  has been suspected or confirmed
  
• Close contact (within 1m) with a confirmed H5N1
  animal other than poultry or wild birds.
  
• Handling samples (animal or human) suspected of
  containing H5N1 virus in a laboratory or other
  setting

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Study Design and Personnel

• At each of the eleven sites one Surveillance
  Officer
  
• Assess patients chief complaint in triage area
• Identify patients seeking care for ILI/SARI/SAI
• Fill out data collection forms for all cases
• Collect NP and OP swab for all cases
• Photocopy data collection forms and package all
  samples to be sent bi-weekly to the MoH in
  Nairobi.

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Study Design and Personnel

• At the national level
• One Surveillance Coordinator at the Ministry of
  Health in Nairobi
  
• Supervision of the project at the national level
  at the Ministry of Health
  
• A point of contact for the 11 surveillance
  officers
  
• 2 Laboratory personnel at the National Influenza
  Center at Kenya Medical Research Institute in
  Nairobi.

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Data and Sample Collection

• Data collection forms
• Demographics age, sex, location, nationality
• Symptoms date of onset, fever, wt loss,
  lethargy, LOC, HA, sore throat, cough, SOB,
  n/v/d, myalgias
  
• Risk factors smoking, alcohol, exposure to
  children, occupation (health care field or animal
  exposure), sick contacts, contact with someone
  who died form an illness with breathing problems
• Physical Exam vital signs, lab tests
• Laboratory Sampling NP and OP swabs
• The first three cases of ILI and all cases of
  SARI and SAI

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NP swabs

• Insert swab into nostril parallel to the palate
  (upper jaw) and straight back to nasopharynx
  
• If resistance is met, try the other nostril
• Rotate and leave in place for a 3-5 seconds
• Slowly remove swab while slightly rotating it
• Put tip of swab into vial containing VTM, cut the
  swab tip with flame-sterilized scissors.

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Avian Influenza outbreak in birds in Juba, South
Sudan, September 2006

• Sick and dead poultry in backyard flocks were
  reported to the Ministry of Animal Resources and
  Fisheries (MARF).
  
• These households were visited and remaining
  poultry were euthanized for laboratory testing.
  Several household flocks were H5N1 by PCR. 
  
• The public health response
• Household survey evaluating sick poultry and sick
  humans
  
• Veterinarians training
• Human health readiness - Juba Teaching Hospital
• Communication with the public

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Our first surveillance site Kakuma Refuge Camp,
Turkana District

• Kakuma is about 1 hour by car from the border
  with South Sudan.
  
• There is one main road from Juba to Kenya which
  passes right through Kakuma.
  
• There is a lot of human traffic back and forth
  between Juba and Kakuma.
  
• Kakuma Refugee Camp est in 1992 by UNHCR
• Health, Sanitation, Nutrition are run by the
  International Rescue Committee

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Establishing the First Surveillance Site in Kakuma

• Working with IRC, we implemented the surveillance
  project
  
• Our surveillance officers are two refugees who
  have finished a nurses aid training program.
  
• One is stationed at the hospital, the other at
  Clinic four which is the busiest clinic in the
  camp.
  
• We trained them on influenza, seasonal and avian,
  the project, case definitions, data
  questionnaires, and logistics.
  
• We trained laboratory personnel on obtaining NP
  and OP swabs and storing and packaging the
  specimens.
  
• We worked with IRC to establish a way to ship the
  questionnaires and samples bi-weekly to the lab
  in Nairobi.
  

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Preliminary Results

• We have been getting approximately 8-10 samples
  each week.
  
• Most of these samples are SARI from the pediatric
  unit at the hospital
  
• These are tested for Influenza A and B, and if
  positive will be tested for subtype.
  
• Preliminary results have all been negative for
  Influenza.
  
• Challenges
• Communication and translation
• Sample storage
• LogisticsPeds Ward outsideWindstorm insideClinic
  4 outside

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