Intercountry Meeting on Avian Influenza and Preparedness for Human Pandemic Influenza Scaling up Nat

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Inter-country Meeting on Avian Influenza and
Preparedness for Human Pandemic
InfluenzaScaling up National Epidemiological
and Laboratory Surveillance for Pandemic
Influenza

• Cairo, Egypt28-30 November 2005

Prepared by Drs Stella Chungong and Philippe
Dubois
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Scaling up Surveillance Guiding principles
Background

• Scaling up to meet priorities such as Avian
  Influenza should as much as possible
• Be based on surveillance principles of
• Improving performance
• Enhancing cost-effectiveness
• Sustainability
• Building influenza surveillance on existing
  systems
• National systems
• Integrated surveillance
• Surveillance of respiratory infections/influenza-l
  ike illnesses

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Phases of an Influenza Pandemic
Background
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National Surveillance Systems Challenges in
pre-pandemic phase
Background

• Although capacities for surveillance exist in all
  countries there is still
• Public health infrastructure in some countries
  weak
• Limited alliances/collaboration with other
  sectors and partners
• Limited national resources for surveillance and
  response
• Further need to strengthen
• structured epidemic intelligence and flexible
  early warning systems
• investigation and response capacity
• field epidemiology and laboratory capacity
• capacity to limit cross border/international
  spread of disease
• Limited capacity to cope with current public
  health priorities
• Process of building core capacities for IHR

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Challenges forsurveillance during pandemic Alert
Background

• Detection of cases
• Outbreak investigation
• Identifying source of infection
• Assessing efficiency of human-to-human
  transmission
• Timeline from sampling to full characterization
• Workload, resources consuming
• Sustainability

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Challenges for Pandemic Influenza Surveillance
Background

• Detecting of start of the pandemic in time
• The role of surveillance at pandemic phase
• New organization, new partners
• Sustainability and impact on other surveillance
  activities

Limited Capacity to cope with the effect of a
Pandemic on health and essential services
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Considerations in Scaling up Influenza
Surveillance
CONTROL
MINIMUM DATA
OBJECTIVES
Outbreak investigation
TARGET POPULATION
DATA SOURCES
Case management/ Infection Control
DATA ANALYSIS REPORTING
INDICATORS
Risk Communication
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Scaling up surveillance for Pandemic Influenza
Epi capacity

• Preparation
• Plan for easy and fast activities up-scaling
• Survey of existing resources and network
• Draft protocol for surveillance, investigations,
  monitoring, research
• Build human capacity, increase awareness,
  sensitize
• Coordination mechanisms in place for
  investigation and surveillance
• Key factors to take into account
• Sustainability of enhanced surveillance -
  resources consuming
• Laboratory confirmation takes time

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Scaling up Surveillance for pandemic influenza
Preparedness plans
Epi Capacity

• Assess capacities and resources
• Develop Preparedness plans
• Public Awareness
• Lab supplies and reagents,
• Infection control in health settings
• Antiviral drugs, vaccines
• Technical support
• Guidelines and tools
• Simulations exercises

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Scaling up Surveillance for pandemic influenza
Structure and organization
Epi capacity

• Co-ordination mechanisms
• National Structures
• Multi-Sectoral National Task Force to co-ordinate
• National Steering Committees
• Technical Committees
• National focal persons
• Existing Structures at all levels of the system
• Community, peripheral, intermediary, national
• Surveillance networks
• Inter-country collaborative structures and
  mechanisms

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Scaling up Surveillance for pandemic influenza
tools and processes
Epi Capacity

• Appropriate surveillance policies and legislation
• Surveillance tools and formats
• Cluster detection
• Event (rumours) monitoring and verification
• Early Warning system
• Fit into routine surveillance framework
• Surveillance, lab and virology protocols
  (including SCDs), guides, and norms

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Scaling up epidemiological Surveillance for
pandemic influenza Some national level actions
Epi Summary

• Commitment
• Transparency/Information sharing with partners
• Inter-sectoral Coordination and Communication
• Inter-country collaboration and cross-border
  surveillance
• National Pandemic Preparedness Plan

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Scaling up epidemiological Surveillance for
pandemic influenza Key national level actions
Epi Summary

• Capacity building including training
• Strengthening lab capacity and networks,
• Risk communication and Health Education
• Research and vaccine development

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Scaling up Surveillance during pandemic
influenza Detection of H5 virus
Lab Surveillance
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Available diagnostic tests

• Method Advantages Disadvantages
• Culture Whole virus Requires infectious
  virus
• Low cost Skill
• Time
• Lab
• IF Speed Requires intact cells
• Skill
• Lack of virus/sensitvity
• Specialised equipment
• Antigen No specialised facility Cost
• Speed Lack of virus
• Low skill Sensitivity/specificity?
• PCR Sensitivity Cost
• Molecular analysis Skill
• Specialised equipment
• Lack of virus
• Time
• Serology Low cost Retrospective
• Sensitive Paired samples

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Scaling up for pandemic influenza National Level
Lab capacities

• High level identification and typing/sub-typing
• Define capabilities including available biosafety
  levels
• Consider the establishment of an NIC designated
  by WHO, or ensure that the existing NIC meets the
  terms of reference for these laboratories
• http//www.who.int/csr/disease/influenza/en/TORNI
  Cs.pdf
• Transmission to International Reference
  Laboratories (WHO collaborating Centers Network)

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Scaling up for pandemic influenzaNational level
Lab capacities

• Definition and training on sampling and transport
  protocols
• http//www.who.int/csr/disease/avian_influenza/gui
  delines/en/
• Permanent contacts with PHC, clinicians,
  veterinarians, etc
• When the pandemic is established, it is unlikely
  that testing of all cases will be possible. A
  strategy will be needed for rationing laboratory
  testing during an established pandemic.
  Facilities for storing clinical specimens
  (respiratory secretions, serum and animal faeces)
  from suspected and confirmed cases need to be
  explored. These specimens could be tested as part
  of opportunistic research projects once the
  pandemic is over.

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Scaling up for pandemic influenza National
Diagnostic Preparedness
Lab capacities

• Validated tests (serology molecular)
• Reference laboratory capability
• Regional laboratory proficiency
• Quality Assurance programme

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Scaling up for pandemic influenza Specimen
collection and transport
Lab priorities

• Preposition (national influenza centre)
• Equipment for collection
• Media for transport
• Equipment for transport
• Organization
• Local transporters International Transporters
• Means of transportation
• Staff
• Training for specimen collection
• Training for specimen transport
• Standard Operating Procedures-Biosafety rules

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Scaling up for pandemic influenza Analysis of
capacities
Lab priorities

• Central Laboratories to decide on their capacity
  and bio-safety conditions to perform High tech
  Diagnostic tests needed
• A national inventory of laboratories with
  bio-safety security levels (BSL) 3 and 4 should
  be available.
• If a country has no such laboratories,
  arrangements may be made with BSL3 and BSL4
  laboratories in other countries.
• Decision tree for communication of samples to
  International Level or testing in Central level

Definition of capacities may be found in
http//www.who.int/csr/disease/influenza/en/TORNI
Cs.pdf
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Scaling up for pandemic influenza Maintenance
of the National Laboratory Network
Lab priorities

• Management of Central level of National
  Laboratory Network
• Maintenance of laboratory capabilities
• Facilities, Equipment, Reagents, Staff
• Quality control of diagnostic capabilities
• Regulations for bio-safety and containment of
  pathogens
• Transport, Facilities, Handling
• Quality control and maintenance of capacity to
  produce data and oversee flow of data
• Connection with WHO focal point, International
  networks, participation in National Surveillance
  System

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Scaling up for pandemic influenza Lab Early
Warning Alert and Response Network
Lab priorities

• Organized contact and collaboration between
• Peripheral points of alert and District
  Laboratories to
• Obtain specimen collection
• Send specimen to reference or High containment
  Laboratory
• Send data to reference Laboratory
• Perform First Line presumptive diagnostic tests
• Send information to National Surveillance System
•  countries may occasionally use commercial rapid
  antigen detection kits for outbreak investigation
  only, when there is no other option, however
  they are not recommended for patient diagnosis .

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Summary
Lab summary

• All countries (whether they have local
  laboratory capacity or not) should ensure access
  to a designated reference laboratory and regional
  networks.
• Local laboratories should be aware of packing
  and transportation requirements for diagnostic
  specimens and infectious agents in accordance
  with the International Air Transport Association
  (IATA) regulations and WHO principles for sharing
  live viruses.

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Summary Scaling up Epidemiological and
Laboratory Surveillance

• Core surveillance functions for effective
  surveillance
• Detection and Reporting
• Analysis and interpretation of data
• Investigation and confirmation
• Epidemic preparedness EPR plans, committees,
  RRT, stockpiles, budget, logistics
• Outbreak investigation, case management and
  control

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Summary Scaling up Epidemiological and
Laboratory Surveillance

• Laboratory capacity/networks specimen flow, lab
  data/reports, protocols, SOPs, which lab does
  what
• Support functions
• Trained staff, appropriate guidelines, SoP, norms
  and Standards
• Communication, risk management,
• Feedback and supervision

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Conclusion

• Influenza will be a primary health problem for
  all
• Surveillance will impact on timeliness of
  detection of pandemic virus and implementation of
  control measures
• Preparing for, and implementing surveillance and
  control should benefits the overall surveillance
  system
• Another opportunity to strengthen national
  surveillance and build core capacities for the
  IHR
• Unique Opportunity to be ready

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Influenza pandemics in the 20th century
Credit US National Museum of Health and Medicine
1968 Hong Kong Flu
1957 Asian Flu
1918 Spanish Flu
1-4 million deaths
1-4 million deaths
21st Century??
A(H3N2)
Thank You