Outbreak Investigation and Control

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Event based surveillance systems
Alicia Barrasa
EPIET Introductory course 2011 Lazareto, Menorca,
Spain
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Infectious diseases

• Arise from many different pathogens viruses,
  bacteria, parasites
• Spread in many different species humans,
  insects, domestic and wild animals, aquatic
  animals and sometimes breach barrier between
  animal and humans (70 of emerging infections
  arise from animal population)
• Take many different routes of transmission
  direct contact, vectors, food, environmental
• Affect all populations in all regions of the world

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Emerging and Re-emerging infectious diseases
EHEC
A(H1N1)v
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Accidental and deliberate release of infectious
agents

• Increased research, biotechnology is widely
  available
• Increased risk for accidental release (e.g. SARS
  2004 from laboratory)
• World tensions remain and the deliberate release
  of infectious agents is no longer a remote threat.

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International Health Regulation
1374 Venice Quarantine for Plague 1851 Paris 1s
t International Sanitary Conference 1947 Geneva WH
O Epidemiological Information Service 1951 Geneva
International Sanitary Regulations 1969 Geneva Int
ernational Health Regulations 2004 Regional
consultations Nov 2004 Geneva Intergovernmental
Working Group meeting Feb 2005 Geneva
Intergovernmental Working Group meeting May
2005 Geneva Revised IHR, World Health Assembly
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IHR Decision Instrument
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IHR Decision Instrument
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International Health Regulation - 2005
To decide on need for notification any public
health event can be assessed by the criteria

• Is the public health impact of the event serious?
• Is the event unusual or unexpected?
• Is there a significant risk of international
  spread?
• Is there a significant risk of international
  travel or travel restrictions ?

• Surveillance
• Response

Obligation to establish core capacities
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Preparedness and response - ECDC

• Detection of public health threats related to
  infectious disease, or of unknown origin
• Risk assessment, investigation and control
• Strengthening preparedness of EU member states
• Strengthening and building capacity through
  training
• Provision of technical advice and support to
  third countries upon request

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Epidemic Intelligence

• Definition
• The systematic collection and collation of
  information from a variety of sources, usually in
  real-time, which is then verified and analysed
  and, if necessary, activates response
• Objective
• to speed up detection of potential health threats
  and allow timely response

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Epidemic Intelligence
Event-based surveillance
Indicator-based surveillance
Event monitoring
Surveillance systems
Data
Events
CollectAnalyseInterpret
CaptureFilterVerify
Signal
Assess
Public health Alert
Disseminate
Investigate
Control measures
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Indicator based Surveillance

• Surveillance systems
• Ongoing and systematic
• Collection and analysis of data
• Interpretation and dissemination of results
  related to health events of interest
• Diagnosis-based or Syndromic surveillance
• For action
• Outbreak investigation
• Immunization programmes
• Programme planning and evaluation
• Operational research hypothesis
• Risk assessments

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Event based Surveillance

• Organized and rapid capture of information about
  events that are a potential risk to public
  health
• Events related to the occurrence to the disease
  in humans (clusters, unusual patterns, unexpected
  deaths)
• Events related to potential exposures (diseases
  in animals, contaminated food or water,
  environmental hazards)

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Epidemic Intelligence
Event-based surveillance
Indicator-based surveillance
Event monitoring
Surveillance systems
Data
Events
CollectAnalyseInterpret
CaptureFilterVerify
Risk assessment
Early warning
Signal
Assess
Public health Alert
Disseminate
Investigate
Risk Management
Response
Control measures
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Event based Surveillance

• Sources of information
• Hospitals/health care centres/emergency rooms
• Veterinary services, food agency
• West Nile Virus, Rift Valley Fever
• Foodborne outbreaks
• Meteorological data
• Pollution
• Heat
• Laboratories
• Identification of specific pathogens
• Increase in demand for hepatitis serology

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Event based Surveillance

• Sources of information
• Media
• systematic searching of news
• often in electronic format
• International networks

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Indicator vs event based
Indicator based Event based
Definitions - Clinical presentation Characteristics of people Laboratory criteria Specific - ...events that are a potential risk - ...unusual events in the community - Sensitive
Timeliness - Weekly / monthly (some may be immediate) - Possible delay between identification and notification - All events should be reported to the system immediately - Real time
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Indicator vs event based
Indicator based Event based
Actors Involved in the system Might not know
Reporting structure Clearly defined Reporting forms Reporting dates Teams to analyse data at regular intervals No predefined structure Reporting forms flexible for quali and quantitative data At any time Teams to confirm evens and prepare the response
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Indicator vs event based
Indicator based Event based
Trigger for action - a pre-defined thresholds - a confirmed event
Response - depends on the delay between identification, data collection and analysis - depends on the confirmation of the event, but ideally is immediate
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A small summary

• Indicator and event based systems are tools for
  PH Surveillance
• Event based systems have already been
  successfully used
• The challenge confirmation of the events

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Public Health Surveillance duringthe 2012
Olympic and Paralympic Games

• Helen Maguire
• acknowledgements
• Brian McCloskey, Director, HPS London region
• Ellen Heinsbroek, EPIET fellow, HPS Colindale

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London 2012 Olympic and Paralympic Games

• - 26 Olympic sports in 34 venues
• - 20 Paralympic sports in 17 venues
• - 10,500 Olympic and 4,200 Paralympic athletes
• - 21,000 media and broadcasters
• - Over 10.2 million tickets
• - 180,000 spectators per day in the Olympic Park
• - 17,000 people living in the Olympic Village

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What influences our preparations for London 2012?

• - Politics
• - Media
• - Scale

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Where do we start?

• Whats been learned before at other mass
  gatherings?
• What is the risk assessment?
• Whats proportionate in relation to the risk?
• What capability and capacity have we got?
• What aims /objectives for our surveillance ?

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Experience of mass gatherings

• In Atlanta 1996 and in Sydney 2000 infectious
  diseases accounted for less than 1 of healthcare
  visits
• In Beijing there were no problems ..?

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Experience of mass gatherings

• Winter Olympic Games, Torino Italy 2006
• 2 public and private microbiology laboratories
  provided test results data for
• Stool culture
• Hepatitis A serology
• ? No difference to non-Olympic period
• Data reported once a week

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Experience of mass gatherings

• Germany World Cup, 2006
• Burden of infectious disease did not increase
  during World Cup
• Maintenance of daily data transmission in all
  Federal States
• Additional free-text reporting for events through
  usual surveillance system
• -High sensitivity
• Syndromic surveillance was regarded as not
  necessary
• -as disease surveillance systems already in place

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London Olympics Surveillance

• Aim
• To provide information on selected indicators
  (including infection related, syndromes, and
  environmental) as well as on events or incidents
  that impact on Olympic venues/staff/athletes/visit
  ors
• -in order to rapidly identify any individual
  cases or outbreaks /incidents so that
  interventions can be implemented

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Objectives

• 1 review existing systems
• completeness, sensitivity to unusual events
  /outbreaks
• flexibility, timeliness, ability to detect new
  pathogens
• 2 identify gaps or limitations
• 3 enhance existing or establish new systems

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Enhance existing

• Enhance reportable disease by clinicians
• Enhance laboratory capacity and reporting
• Enhance environmental monitoring
• Create 24 on-call and rapid response teams

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Epidemic Intelligence (existing and new )

1. Syndromic Surveillance (NHS Direct, Q
   Surveillance, RCGP, EDSSS, OOH)
2. Notifications of Infectious Diseases
3. Surveillance at Olympic Village Polyclinics
4. Event-Based Surveillance
5. Laboratory Reporting

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Existing and new surveillance systems

• Surveillance of Undiagnosed Serious Infectious
  Illness (USII)
• Environmental monitoring at Centre for Radiation,
  Chemical (and Environmental Hazards Mortality
  Surveillance)

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1 Syndromic Surveillance

• Existing systems
• NHS Direct
• GP-based syndromic surveillance
• Q Surveillance
• Royal College General Practitioners
• New systems
• Out of Hours Providers
• Emergency Departments

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1 Syndromic Surveillance out of hours

• To provide enhanced surveillance during
  weekends/holidays/evenings

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1 Syndromic Surveillance emergency departments

• To establish a surveillance network of EDs across
  England

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2 Notifications of infectious diseases
Normal fax max. 3 days Emergency phone within
24 hrs
Max. 3 days (methods differ by LA/HPU)

• Extra requirements Olympics
• Olympic Venue Attendance
• Forms HPZone to be changed
• Speed up notifications
• Improve consistency reporting

Report published on internet
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3. Surveillance at Olympic Village

• Requirement to notify infectious diseases
  compulsory for overseas athletic team doctors
• Compulsory component of temporary registration
• Same forms as medical practitioners
• Notification System being set up
• HPA presence in Olympic Polyclinic
• Monitoring of staff absences

Olympics Surveillance Systems 3. Surveillance
at Olympic Village
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4. Event based surveillance

• What is a significant event?
• Standard factors e.g. severity,
• Olympic factors proximity to venue, affecting
  visitors
• The media!
• How do we identify significant events
• HPZone dashboard flagging events with an
  Olympic flag
• Regional reporting via teleconference or negative
  reporting
• Media screening

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NOIDS
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5 Lab reporting
- Weekly, by law (Oct10) - Automatic, with
manual checkingsending

• Extra requirements Olympics
• Daily reporting software change
• Automatic extraction software
• Exceedance Algorithms daily
• Adapt for changes in testing,
• e.g. multiplex PCR

- Weekly exceedance report published on
intranet - Departments access via software
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6. Surveillance of Undiagnosed Serious Infectious
Illness

• To ensure early detection and response to new and
  emerging infectious disease threats.

• Case definition
• Any person admitted to HDU/IDU
• with a serious illness suggestive of an
  infectious process where the clinical
  presentation does not fit with any recognisable
  clinical picture
• OR there is no clinical improvement in response
  to standard therapy
• AND initial laboratory investigations for
  infectious agents are negative

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• 7 Surveillance at Centre for Radiation, Chemical
  and Environmental Hazards
• -increase to daily reporting

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Olympic Surveillance Matrix Early Detection Olympic Surveillance Matrix Early Detection Olympic Surveillance Matrix Early Detection Olympic Surveillance Matrix Early Detection Olympic Surveillance Matrix Early Detection Olympic Surveillance Matrix Early Detection Olympic Surveillance Matrix Early Detection Olympic Surveillance Matrix Early Detection Olympic Surveillance Matrix Early Detection Olympic Surveillance Matrix Early Detection
Surveillance System   Scenario UK based surveillance UK based surveillance UK based surveillance UK based surveillance UK based surveillance UK based surveillance UK based surveillance UK based surveillance International Situational Analysis (horizon scanning)
Surveillance System   Scenario Syndromic Surv, (NHSD, Q, OOH) NOIDS Olympic Village Polyclinics CRCE Laboratory Reporting Syndromic Surveillance ED sentinel USII sentinel Mortality International Situational Analysis (horizon scanning)
Localized outbreak, small number of cases e.g. meningococcal
Localized outbreak, large number of cases e.g. measles
Widespread outbreak, small number of cases e.g. food poisoning
Widespread outbreak, large number of cases e.g. influenza
Increase in weather related disease, e.g. asthma
Chemical, Environmental or Radiation incident
Imported disease, e.g. plague
Newly emerging disease
Deliberate release, e.g. anthrax
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289 days to go!