????? ?? ???? ????? ???? ?????? ???????? ???????? A(H1N1) Detecting first cases of swine-origin influenza A(H1N1) infection

1
????? ?? ???? ????? ???? ?????? ????????
???????? A(H1N1)Detecting first cases of
swine-origin influenza A(H1N1) infection

• Republic of Lebanon
• Ministry of Public Health
• Epidemiological Surveillance Program
• Presented by Dr Nada Ghosn
• 02 May 2009

2
Outlines /??????

• Objectives
• Case definition
• Notification detection
• Investigation
• Specimen collection
• Contact tracing

• ????? ??????
• ????? ??????
• ??????? ??????
• ??????
• ??? ?????
• ?????????

3
????? ?????? / Surveillance objectives

• ????? ???????
• ????? ?????? ????? ?????? ?????? ????????
  ???????? A(H1N1) ?? ?????
• ??????? ???????
• ?????? ???? ?????? ??????? ??? ?????? ???????
• ??? ??????? ?? ????? ?????

• Main objective
• Detect and confirm first cases in Lebanon
• Secondary objectives
• Monitor the spread of the virus by time and place
• Collect data on disease severity

4
????? ??????Case definition

• ????? ????? ????? ?????? ??? 62
• (29 ????? 2009)

5
Confirmed case?????? ???????/

• A confirmed case of swine-origin influenza
  A(H1N1) virus infection is
• An individual with acute febrile respiratory
  illness (gt38C)
• AND who is laboratory confirmed, in a national or
  WHO reference laboratory, by
• Real time RT-PCR
• OR viral culture

• ?????? ??????? ????? ????? ???????? ????????
  A(H1N1)
• ????? ????? ?? ????? ?????? ???? ?????? ??????
  ?????? (gt38C)
• ????? ??? ??? ????? ?????? (?? ????? ????? ????
  ?? ?????)
• PCR RT
• ??? ???????

6
Probable case?????? ???????? /

• A probable case of swine-origin influenza A(H1N1)
  virus infection is
• An individual with acute febrile respiratory
  illness (gt38C)
• With positive influenza A test
• AND with unsubtypable virus as tested by reagents
  used for seasonal influenza virus

• ?????? ???????? ????? ????? ????????
  ????????A(H1N1) ?
• ?? ????? ????? ?? ????? ?????? ???? ?????? ??????
  ?????? (gt38C)
• ???? ??????? ????? ?????? ?????? ?????????? ??
  ??? A
• ????? ??? ???? ?????? ??????? ?????? ???????????
  ????????.

7
Suspected case?????? ???????? /

• ?????? ???????? ????? ????? ????????
  ????????A(H1N1)
• ????? ????? ?? ????? ?????? ???? ?????? ??????
  ??????
• ????? ???? ?????? ???????
• ??? ?????? ??? ????? ??? ???? ????? ????? ? ???
  ???? ?????? ?????? ??? ???? ???????
• ?? ??? ?? ???? ????? ?? ???? ?????
• ?? ???? ?? ????? ??? ???? ????? ?????

• A suspected case of swine-origin influenza
  A(H1N1) virus infection is
• ???A person with acute febrile respiratory
  illness
• With one of the following exposures
• Who had recent travel to an area where there are
  confirmed cases within 7 days of illness onset,
• OR who is a close contact to a confirmed case
• OR Who resides in a community in which one or
  more confirmed cases have occurred.

8
Case under investigation???? ??? ?????/

• A person who is investigated for possible
  swine-origin influenza A (H1N1) infection.
• Examples
• The person is a contact of a person who traveled
  to affected countries
• The person is a contact of a deceased person from
  unexplained respiratory illness
• The person is a health care provider with severe
  respiratory infection

• ??? ??? ???? ?????? ?????? ?????? ????????
  ???????? A(H1N1).
• ?????
• ????? ??????? ?? ???? ??? ???? ??????? ???????
• ????? ?????? ?? ??? ????? ??? ?????
• ?? ???? ???? ?? ???? ?? ??????????? ??????? ??
  ?????? ??? ????? ?? ?????

9
Infectious period???? ??????? ?? ??????/

• ???? ??????
• ??? ??? ???? ???????
• ??? 7 ???? ?? ????? ???? ???????

• Infectious period
• From one day before onset
• To 7 days after onset

onset
                       
-1 0 1 2 3 4 5 6 7
days days days days days days days days days days days days
10
Patient B
nb  
nb  
nb  
nb 5  
nb 4  
nb 3  
nb 2  
nb 1                      
25 26 27 28 29 30 31 1 2 3 4
March March March March March March March April April April April
Confirmed case
Suspected case
Patient B girl, 9 years, Imperial county
(USA), fever cough, outpatient clinic Lab
virus isolation ()
The Brother 13 years, Imperial county (USA),
Influenza like illness. Lab non test
Source Swine Influenza A(H1N1) Infection in two
children Southern California, March-Apri 2009.
MMWR, 2009 58(15)400-402
11
??????? ?? ???????Case notification
12
Reporting??????? /

• All health settings
• Immediate reporting
• In hospital settings
• Weekly zero reporting
• Active surveillance
• ICU admissions surveillance
• Hospital causes of deaths
• Rumor surveillance

• ???? ??????? ??????
• ????? ????
• ?? ??????????
• ??????? ??????
• ?????? ?????
• ????? ??????? ???????
• ????? ??????? ?? ??????????
• ???? ????????

13
??????? ??????Immediate reporting/notification
14
Immediate notification ??????? ?????? /

• ???????? ????? ?? ???? ????
• ???????? ???????? A(H1N1)
• ???????? ?????? A(H5N1)
• ???? ????? ?????? ?? ???? ??????
• ?? ???? ????? ?? ?????? ????????
• ?????? ???? ???? ?? ????
• ?? ???? ?????? ?? ???? ??????? ????? ??? ?

• Influenza new virus subtypes
• Swine-origin A(H1N1)
• Avian A(H5N1)
• Presence of similar cases around the case
• Is there any time/place cluster ?
• Health care provider
• Is the case related to patient care?

15
Immediate notification ??????? ?????? /
16
Immediate notification ??????? ?????? /
????? ???? ????? ????? ..................................... ????? ????? ????? ............................................ ?? ??? ?????? ???????? ??? ?? ??? ???????? ..................................................... ????? ???? ????????............................................ ?? ?? ????? ????? ??? ?? ??? ???? ??? ........................................................ ............................................................................ ???? ????? ?????? ?? ???? ?????? ??? ?? ????? ?????? ???? ????/???? ??? ??
17
Immediate notification ??????? ?????? /
Central
Mohafaza
Caza
Data Flow
Telephone / Fax
18
??????? ??????Zero-Reporting
19
Zero-reporting??????? ?????? /

• ??????
• ????? ????? ????? ?????? ??? 65 (30 ????? 2009)
• ???? ????? ????? ?????? ??? 550/2 (15 ??????
  2006)
• ???? ????? ????? ?????? ??? 1162/2 (5 ????? ?????
  2001)
• ???? ???????
• ?? ???? ????????
• ???? ?????? ?? ??????? ????????
• ?? ??? ???? ?????
• ????? ????
• ????? ??????? ??????? ??????
• ?? ??? ??? ???? ?????
• ????? ??????? ??????? ??????
• ???? ?????????? ??? ??? ????? ?? ?????? ???????
  ??????

• Regulations
• MOPH circular 65 (30 April 2009)
• MOPH decision 550/2 )15 June 2006)
• MOPH decision 1162/2 )5 December 2001(
• Hospital focal point
• From hospital staff
• Searches for suspected cases
• If case
• Immediate notification to MOPH
• Fill zero form
• If no case
• Fill Zero Form
• Sent Zero form to caza level, on weekly basis

20
Zero-reporting??????? ?????? /

• Informatic system
• Data entry at mohafaza level
• Sent to central level on weekly basis
• Monitoring
• Number of cases
• Completeness Number of received forms / number
  of expected forms
• Timeliness number of forms received on time /
  number of received forms
• On time 1 week after the end of concerned week.

• ???? ?????????
• ????? ????????? ??? ???? ????????
• ???? ??? ?????? ?????? ??????
• ????????
• ??? ???????
• ???? ??????? ?????????? ??? ?????????? ????????
  / ??? ?????????? ????????? ????????
• ???? ?????? ?????????? ?? ????? ??? ??????????
  ???????? ?? ????? / ??? ?????????? ????????
• ???? ????????? ?? ????? ?? ???? ????? ?? ???
  ?????? ??????? ??????

21
Zero-reporting??????? ?????? /
Zero-Reporting form
???????? ???????? A(H1N1) ??? ????? ??????
???? ???? ??? ?????? ??????? - ??? ?????? ???
????? ??? ???? ????? ?????? ???? ???? ??????
?????? ??? ???? ??????? - ?? ??? ?? ???? ????? ??
???? ????? - ?? ???? ?? ????? ??? ???? ??????
?????
22
Zero-reporting??????? ?????? /
Central
Mohafaza
Caza
Data Flow
Fax
23
Zero-reporting??????? ?????? /
Routine zero-reporting from public and private hospitals, Lebanon, 2008 Routine zero-reporting from public and private hospitals, Lebanon, 2008 Routine zero-reporting from public and private hospitals, Lebanon, 2008 Routine zero-reporting from public and private hospitals, Lebanon, 2008 Routine zero-reporting from public and private hospitals, Lebanon, 2008 Routine zero-reporting from public and private hospitals, Lebanon, 2008 Routine zero-reporting from public and private hospitals, Lebanon, 2008
Provinces Number of hospital sites Nb of expected zero forms Number of received zero forms Completeness of zero-reporting Number of zero forms received on time Timeliness of zero-reporting
Nabatieh province 9 468 468 100 438 94
North province 27 1404 1393 99 287 21
South province 16 832 771 93 502 65
Bekaa province 21 1092 1089 100 919 84
Beirut province 19 988 815 82 450 55
Mount Lebanon province 44 2288 2010 88 1182 59
Lebanon 136 7072 6546 93 3778 58
Source Lebanese Ministry of Public Health - Epidemiological Surveillance Program Source Lebanese Ministry of Public Health - Epidemiological Surveillance Program Source Lebanese Ministry of Public Health - Epidemiological Surveillance Program Source Lebanese Ministry of Public Health - Epidemiological Surveillance Program Source Lebanese Ministry of Public Health - Epidemiological Surveillance Program Source Lebanese Ministry of Public Health - Epidemiological Surveillance Program Source Lebanese Ministry of Public Health - Epidemiological Surveillance Program
24
?????? ?????Active Surveillance
25
Active surveillance?????? ????? /

• Regulations
• MOPH decision 549/2 (15 June 2006)
• Target diseases
• MOPH circular 66 (30 April 2009)
• MOPH circular 79 (26 June 2006)
• MOPH Medical officer
• On weekly basis
• Conducts hospital visits
• Contacts hospital staff
• Search for cases
• Notification guidance
• Checks admission registries
• Search for cases
• Fills visit form

• ??????
• ???? ????? ????? ?????? ??? 549/2 (15 ??????
  2006)
• ??????? ?????????
• ????? ????? ????? ?????? ??? 66 (30 ????? 2009)
• ????? ????? ????? ?????? ??? 79(26 ?????? 2006)
• ???? ????? ????? ??????
• ?????? ??????
• ???? ????? ????????
• ?????? ?????? ????? / ?????
• ?????????
• ????? ???????
• ?????? ????? ??????
• ????? ?? ?????
• ????? ??????? ????

26
Active surveillance?????? ????? /
Active surveillance form
???????? ????????
27
Active surveillance?????? ????? /

• Informatic system
• Data entry at mohafaza level
• Sent to central level on weekly basis
• Monitoring
• Number of cases
• Completeness Number of conducted visits / number
  of expected visits

• ???? ?????????
• ????? ????????? ??? ???? ????????
• ???? ??? ?????? ?????? ??????
• ????????
• ??? ???????
• ???? ??????? ???????? ??? ???????? ?????????
  ???? ???? / ??? ???????? ????????? ????????

28
Active surveillance?????? ????? /
Active surveillance, Lebanon, 2008 Active surveillance, Lebanon, 2008 Active surveillance, Lebanon, 2008 Active surveillance, Lebanon, 2008 Active surveillance, Lebanon, 2008
Provinces Number of hospital sites Nb of expected visits Number of conducted visits Completeness of active surveillance visits
Nabatieh province 6 252 224 89
North province 16 832 724 87
South province 4 208 190 91
Bekaa province 7 364 326 90
Beirut province 2 46 22 48
Mount Lebanon province 13 676 562 83
Lebanon 48 2378 2048 86
Source Lebanese Ministry of Public Health - Epidemiological Surveillance Program Source Lebanese Ministry of Public Health - Epidemiological Surveillance Program Source Lebanese Ministry of Public Health - Epidemiological Surveillance Program Source Lebanese Ministry of Public Health - Epidemiological Surveillance Program Source Lebanese Ministry of Public Health - Epidemiological Surveillance Program
29
??????? ?? ????? ??????? ???????ICU Surveillance
30
ICU surveillance???? ???? ????? ??????? ??????? /

• Regulations
• MOPH decision 617/1 (29 October 2005)
• MOPH circular 67 (30 April 2009)
• At ICU
• Acute Respiratory Distress
• Number of new admissions
• Search for
• Travel history to affected countries
• Swine-origin influenza
• Avian influenza
• Occupation exposure
• Health care worker
• Laboratory worker
• Animal-related
• Close contact with confirmed cases
• Swine-origin influenza
• Avian influenza
• On weekly basis

• ??????
• ???? ????? ????? ?????? 617/1 (29 ????? ?????
  2005)
• ????? ????? ????? ?????? ??? 67 (30 ????? 2009)
• ?? ????? ??????? ???????
• ????? acute respiratory distress
• ??? ??????? ???????
• ????? ?? ????
• ??? ????? ??? ????? ??? ???? ?????
• ?????? ???????? ????????
• ?????? ???????? ??????
• ??? ??????
• ?? ????? ?????? / ??????
• ?? ?????
• ?? ???? ?????? ?????????
• ??? ?????????
• ???? ???? ????? ???????? ????????
• ???? ???? ???? ???????? ??????
• ?????? ??????

31
ICU surveillance???? ???? ????? ??????? ??????? /
ICU form
Close contact with confirmed case of swine /
avian influenza
swine influenza affected countries
32
??????? ?? ????? ??????? ?? ??????????Hospital
Causes of Deaths Surveillance
33
Hospital causes of deaths ????? ??????? ??
?????????? /

• ??????
• ???? ????? ????? ?????? ??? 206/1 (4 ????? 2006)
• ???? ??? 228/1 (11 ????? 2006)
• ?? ????????
• ??? ??? ?????? ??????? ???? ???? ???? ?????????
  ??? ????
• ????? ???? ???? ??? ????? ???????
• ????? ????? ?????? ????? ?????? ?????? ??? ??????
  ??? ??? ???????
• ????? ???????
• ????? ???????
• ???? ??
• ???? ??
• ???? ??
• ??????? ??????? ????????
• ???? ?? ????? ??????? ???? ???? ????? ???
  ??????.

• Regulations
• MOPH decision 206/1 (4 April 2006)
• MOPH decision 228/1 (11 April 2006)
• At hospital level
• Causes of death registry
• Appointment of medical doctor in charge of the
  registry
• The registry is nominative
• Weekly notification to MOPH, with anonymous data.
  No mention of names
• Collected data
• Immediate cause of death
• Due to
• Due to
• Due to
• Comorbidities
• Cardiac respiratory arrest state of death and
  not a cause of death

34
Hospital causes of deaths ????? ??????? ??
?????????? /
35
???? ????????Rumor Surveillance
36
Rumor surveillance???? ???????? /

• ??????
• ???? ????? ????? ?????? ??? 52/1 (25 ????? ??????
  2006)
• ?? ????? ????? ?????? ?? ???????? ??????????
  ??????
• ????? ????? ?? ?????? ??? ???? ????
• ??? ???? ????? ?? ????????
• ?? ????? ??????
• ??? ??????? ????? ???? ?????
• ?? ????? ???? / ???? ? ????
• ?? ????? ?????? ???? ?? ????
• ???? ????????
• ??????? ?? ??????? ?????? ?????? ? ??????
  ????????? ???????
• ????? ????? ??????? ???? ????????

• Regulations
• MOPH decision 52/1 (25 January 2006)
• At MOPH caza, mohafaza and central level
• Objective detect outbreaks not reported
• First step search rumors sources
• Variety of sources
• Official and not official
• Medical/Health sources or other
• Written, Visual, Oral
• Rumor investigation
• Disease
• Time, Place, Person
• Laboratory
• Document rumor investigation
• Rumor form

37
Rumor surveillance???? ???????? /
38
???? ???????Case Investigation
39
Investigation?????? /

• Infection control and personal protective
  equipment
• Data collection
• Specimen collection
• Contact search and monitoring

• ?????? ?????? ?????? ??????? ???????
• ??? ???????
• ??? ?????
• ????? ?? ????????? ?????????

40
????? ??????? ???????Personal Protective
Equipment
41
Personal Protective Equipment / ????? ???????
???????

• Sequence of using PPE
• Wash hands
• Put on boots or cover shoes
• First pair of gloves
• Gown and plastic Apron
• Second pair of gloves
• Mask, N95 Particulate respirator (Perform seal
  check (
• Hair cover
• Goggles or eye protective ware

• ????? ?????????
• ??? ??????
• ??? ???? ??????
• ??? ???? ???? ?? ???????
• ??? ???????
• ??? ???? ????? ?? ???????
• ??? ????? ?? ??? N95
• ??? ???? ?????
• ??? ???? ?? ????? ??????? ???????

42
Personal Protective Equipment / ????? ???????
???????
1. Wash hands
2. Put cover shoes
3. Put First pair of gloves
4. Put Gown
5. Put Second pair of gloves
6. Put Mask
7. Put Cap
8. Put Goggles
43
Personal Protective Equipment / ????? ???????
???????
44
Personal Protective Equipment / ????? ???????
???????

• Sequence to remove PPE
• Disinfect outer pair of gloves
• Remove outer gloves
• Remove apron gown
• Disinfect gloved hands
• Remove goggles
• Remove head cover
• Remove mask
• Remove boots
• Remove inner gloves
• Wash hands

• ????? ??? ??????? ??????? ???????
• ????? ???????
• ??? ??????? (?????? ???????)
• ???? ???????
• ????? ??????? (?????? ??????)
• ???? ???????? ????????
• ??? ???? ?????
• ??? ??????? (?? ?????)
• ??? ???? ??????
• ??? ??????? (?????? ??????)
• ??? ??????

45
??? ?????????Data collection
46
Data collection / ??? ?????????

• ?? ?????? ?????? ?? ????? ?????? ?
• ??? ???? ??????
• ??? ???? ?? ???? ????? ???? ??? ???? ???????
  ????????
• ??? ???? ??? ????? / ??????
• ??? ???? ?? ???? ????? ???? ???? ??? ????? ???
  ??? ??????
• ??? ???? ??? ??????
• ??? ???? ?? ???? ?? ???? ????? ?????? ????? ???
  ?????
• ??? ???? ??? ??????

• Does the case fit the case definition?
• Yes suspected case
• If no, are there any contacts who traveled to
  affected countries?
• Yes case under investigation
• If no, is there a close death with unexplained
  acute respiratory illness?
• Yes case under investigation
• If no, is the case a health care provider with
  severe disease?
• Yes case under investigation

47
Data collection / ??? ?????????

• For suspected cases and cases under
  investigation
• Verify the completeness of the reporting form
• Start fill investigation form
• Initiate specimen collection

• ??????? ???????? ?? ??? ??????
• ?????? ?? ????? ??????? ???????
• ????? ?????? ??????? ??????
• ?????? ??? ???????

48
Data collection / ??? ?????????
??????
??????
???????
????? ????? ?????
?????
??? ??????
49
Data collection / ??? ?????????
???? ????????
????? ??? ??????
?????? ?? ?????
???? ??????
???? ???? ???
50
Data collection / ??? ?????????
???? ?????
??? ?????
????? ????????
??????
???? ??????
????? ??????
51
??? ??????Specimen collection
52
Specimen collection / ??? ???????
53
Specimen collection / ??? ???????

• Nasopharyngeal swab
• Swab the posterior oropharynx near tonsillar
  area, avoiding tongue
• Place swab in sterile vial containing 2 ml viral
  transport media
• Cut off or break off the applicator and close
  vial tightly
• Label vial with patient name, number and date
• Conserve vial at 4C and within 48 hours should
  be in reference lab. Store specimens at -70 C
  beyond 48 hours
• Contact the MOPH for referral to reference
  laboratory

54
Specimen collection / ??? ???????

• Specimen collection kit
• Swab dracon, rayon, or polyester fiber-tipped
  applicators (Do not use calcium alginated or
  cotton swabs)
• Sterile vial
• Viral Transport Media (VTM)
• Personal Protective Equipment
• Solution for desinfection
• Tongue depressors
• Sealed bag
• Label
• Specimen form

55
Specimen collection / ??? ???????

• Specimen transport
• Three packaging layers for transportation
• Primary container leak proof, labeled, capped,
  and sealed with parafilm absorbent material.
• Secondary container watertight list of
  contents in a sealed plastic bag
• Third container protects against physical damage
  while in transit.

56
????????? Contact tracing
57
Contact finding /????? ?? ?????????

• Rationale
• Close contacts may be infected and may spread the
  virus
• Ascertain person-to-person transmission
• Objectives
• Identify contacts
• Categorize contacts
• High risk groups
• Gathering
• Monitor contacts
• If symptoms onset
• Specimen collection

• ??????
• ????????? ?????? ?????? ? ?????? ??? ???? ?????
• ???? ?????? ??????? ?? ????? ??? ?????
• ???????
• ????? ?????????
• ????? ????????
• ?????? ????
• ??????
• ?????? ?????????
• ?? ??? ??????? ??? ?????

58
?? ?????What next?
59
Enhance case detection / ????? ?????? ??? ???
???????

• ???? ???????? ????????
• ???????? ?????? ????
• ???? ??????? ???????? ??????
• ?????? ?? ???????
• ???? ???? ?????? ?? ???????
• ????????? ????????...

• Outpatient system
• Dispensaries / medical centers
• Private clinics sentinel
• Community-based
• School absenteeism
• Municipalities, civil officer, mokhtars

60
Enhance case detection / ????? ?????? ??? ???
???????

• ?????????
• ????? ??? ???????
• ????? ?????
• ???????
• ??? ???? ??????
• ??? ?????? ?? ?????????
• ??? ???? ????????
• ??????????
• ???? ??????? ???????? ??????
• ??? ???? ??????
• ?????????? ??????? ??????
• ???????? ?????????...

• Logistics
• Laboratory
• Transportation
• Sessions
• At national level
• For mohafaza rapid response team
• At mohafaza level
• For hospitals
• For sentinel system
• At caza level
• For dispensaries/medical centers
• For municipalities

61
????Thank you