Improved Surveillance and Diagnosis Capabilities in Mexico after the - - PowerPoint PPT Presentation

• Dra. Celia M. Alpuche Aranda

Director MC Hiram Olivera Diaz Head of molecular Biology Department Institute for Epidemiological Diagnosis and Reference General Directorate of Epidemiology Under Secretariat for Health Prevention and Promotion Health Secretariat of Mexico

Improved Surveillance and Diagnosis Capabilities in Mexico after the Influenza Pandemics

Agenda

• Before A(H1N1)2009 pandemic, what did we

have for influenza diagnosis in Mexico?

• How did we change our capacities over the

crisis?

• How has the North America Partnership

helped to develop the new laboratory capacity for influenza?

• What is the current situation of the influenza

laboratory network for epidemiological surveillance in Mexico?

• Conclusions

InDRE DGE

PROGRAMAS

CENAVECE CENAVECE CENAVECE

Public Health Laboratory Network

InDRE and 31 Public Health State Laboratories (one per Mexican State, excepting Mexico City) NOM017 Epidemiological Surveillance NOM017 Epidemiological Surveillance

Secretariat (Ministry) of Health

Under Secretariat

• f Health

prevention and promotion Under Secretary of quality medical attention and innovation Under Secretary of financial administration

Epidemiological Surveillance of Influenza in México before AH1N1 2009 pandemic

What did we have?

Surveillance since 2001. Organized sentinel epidemiology surveillance (SISVEFLU) since 2006, reinforced in 2008. On line report from epi jurisdictional offices (not from clinical units). InDRE was already a National Center for GISN- WHO. CDC Influenza division was our collaborator Center in this system. Network of Influenza diagnosis (26/31) state PH lab, based on IF and WHO

• algorithms. EQA to Network by InDRE (Federal) to PHSL and CDC to
• InDRE. In addition to Hong Kong panels

InDRE had end point PCR, Real Time PCR and virus isolation protocols. Only 6 PHSL in addition to InDRE end point PCR protocols Subtyping, viral isolation and further characterization only by InDRE Two years training program in biosecurity and biosafety by LRN and biosafety CDC in addition of CPHA personnel BIDs, EWIDs, IPIPI programs

Limitations Problematic

Low adherence to SISVEFLU (less than 40%). FLU Diagnosis network based on IF. Very low sampling. Goals not reached. National Epidemiological Surveillance of Influenza was limited Report based on manual paper work (separate questionnaire for lab and epi) and manually loaded to the IT system at the epi jurisdictional office. Delay to report: 3-4 weeks. Delay to refer samples 1.5 months. Lack of IT infrastructure delayed report; only a limited number of samples reached laboratory Absence of protocols to characterize possible new virus. Viral subtyping of Influenza centralized in InDRE. No BSL3 facilities at InDRE, only at one PHSL (Veracruz) . No consistent daily or weekly direct inputs from hospitals to The National System of Epidemiological Surveillance (SINAVE)

Epidemiological Surveillance of Influenza in México before AH1N1 2009 pandemic

• Use of Pandemic Influenza Preparedness Response Plan as a

baseline for all the areas within Public Health Sector.

• SISVEFLU change to mandatory active surveillance to every

public clinic in the country and voluntary for private hospitals

• Daily zero reporting of hospitalization and deaths due to ILI/SARI
• Review, update, dissemination and implementation of new

guidelines for epidemiological surveillance including laboratory case definition, sampling, diagnosis new algorithms, reports, etc.

• Implementation of a new epidemiological informatics system

including laboratory results.

Immediate changes in the Epidemiological Surveillance System in Mexico as a consequence of pandemic influenza response in 2009

• Logistics to develop a TOTALLY NEW INFLUENZA

LABORATORY NETWORK throughout the country: 1) defining protocols, 2) training, 3) purchasing equipment, supplies and reagents, 4) standard questionnaires to asses minimal requirements to include Laboratories in this network, 5) LIMS,6) EQA

• Challenge: handling laboratory data and deliver results to

epidemiologist in less than 48 hrs/Testing 1600 samples per day only at InDRE

• Pandemic Influenza Preparedness Response Plan put into

action.

• GREAT NORTH AMERICA PARTNERSHIP: NML AND CDC

Changes in FLU Laboratory Network in response to AH1N1 pandemic 2009

FLU Diagnostic test for Influenza implementation in México during AH1N1 pandemic event in México

CDC/WHO protocol for Real Time PCR A H1N1 pandemic 04/ 28 /2009 Revision 1 (04/30 /2009)

• WHO adopted (April 2009) CDC protocol as gold standard for A(H1N1) 2009 FLU

diagnostic test

• April 26th NML and CDC personnel arrived to Mexico- InDRE
• Monday April 27th: they worked with us selection of personnel, equipment, logistic,

full process, training etc.

• Same day a April 27th evening we started real time CDC protocol at InDRE
• Reagents supplies, primers and probes donated by CDC, NML
• 3-4 weeks later we were able to run 1200 samples per day at InDRE,

decentralization of FLU diagnostic to 5 PHSL included in the network in addition to 3 National Institutes of Health.

Octubre 13, 2009 Back to Sentinel surveillance Define new sentinel units to get information for ambulatory and hospitalized cases (650-700 units around the country) Samples to all SARI hospitalized cases in USMIS sentinel clinics and 10% of the ambulatory ILI (now 100%) New IT system: real time web based coming from sentinel clinical units Weekly report and analysis Epidemiology and Laboratory working together in one program

• Working in ICS implementation with training and help
• f NML PHAC

What do we have now for FLU surveillance?

Laboratory surveillance

• InDRE (14 equipments)
• 28 PHSL (26/1, 1/2)
• Public Health Hospitals: 6 centers

with a total of 8 equipments; 2 Lab/one equipment

• National health Institutes (5)
• 4 PHSL doing end point PCR
• InDRE and 2 PHSL for viral isolation
• InDRE subtyping, molecular

characterization, antiviral susceptibility analysis,

• Other virus differential diagnosis

PHSL, IF. InDRE, Luminex- Bioplex platform.

42 centers capable of running 5000 samples per day Federal Government invested 40 million dollars in Epi surveillance and lab improvement

• sequencing
• Antiviral susceptibility

testing

• Sero-prevalence

What do we have now for FLU surveillance?

• Supervision and analysis of questionnaire to incorporate centers

to the network

• Training of personnel, supervision of equipment installation and

calibration

• EQA program: 1) Technical performance by proficiency panels; 2)

personal visits and verification questionnaire.

• InDRE working very close to CDC influenza Division (Transfer of

technology etc…

• Guidelines to request primer and probes, supervising accuracy of

shipping companies

• Evaluation of other possible diagnostic platforms
• Evaluation of new primers and probes
• Evaluation and validation of other diagnostic test to use on the

ABI7500 Applied platform: dengue subtyping and measles

InDRE coordinator of Influenza laboratory network

Confirmed cases of AH1N1 pdm 2009 in México, Jan 1-March 31

% de virus identificados

Influenza virus identification in te first 10 epidemiological weeks 2009 in México

DGAPI/InDRE

Fuentes: Base de datos InDRE y CONAMED. Semana 19 2010

Geographic differences of AH1N1 epidemiology within México

Base de datos InDRE

Promedio y mediana de días entre el inicio de síntomas y toma de muestras por laboratorio Semana 07 del 2010

Laboratory indicators

Promedio y mediana de días entre toma llegada al laboratorio y emisión de resultados: TODOS BIEN

Conclusions

• Planning is essential for a correct response
• Surveillance needs epidemiological intelligence
• Early warning is essential for known and unknown

defined diseases

• Detailed SOPs are essential for proper planning
• Flexible protocols to adapt to unexpected events
• International collaboration is a key component
• Working as a NETWORK ( Federal-State ) is a basic key

element to succeed and to facilitate global communication

• EQA (International standards) for laboratories is basic
• Implementation of routine, global systematic

communication and of the IHR(2005)

• Honest and transparent communication is essential

MUCHAS GRACIAS, Merci Thank you !!!!!!!!

DEPARTAMENTOS DE BIOLOGIA MOLECULAR Y DE VIROLOGIA DEL InDRE

RED de 31 Laboratorios de Salud Pública de México

Deputy Secretariat Health Prevention and Promotion

• Dr. Mauricio Hernández Avila

Dirección General Adjunta de Epidemiología:

• Dr. Hugo López Gatell Ramírez
• Dra. Ietza Bojórquez
• Dr. Ethel Palacios
• Dra. María Hoy

And so on InDRE:

• Dra. Celia Alpuche

QFB: Lucía Hernández

• Dr. Alberto Díaz
• QFB. Irma Hernandez

Inluenza Laboratory Ms Irma López, QFB Miguel Iguala MS Gisela Barrera MS Rita Flores and so on Molecular Biology Laboratory

• Dr. Hiram Olivera
• DR. Ernesto Ramírez and so on

CDC Influenza Division:

• Dr. Nancy Cox
• Dr. Alexander Klimov
• Dr. Stephen Lindstrom
• Dr. Jaky Katz
• Dr. Michael Shaw
• Dr. Rebeca Garten
• Dr. Marc Alain

And so on……….

• Dr. Jonas Michel

Agnes Warner

• Dr. Steve Waterman

LRN/CDC

• Dr. Harvey Holmes
• Dr. David Blesser
• Dr. Cristina Vargas

Dwene Lansky and so on…… NML PHAC

• Dr. Frank Plummer
• Dr. Ute Stroher
• Dr. Yan Li
• Dr. Mathew Guilmore
• Dr. Ted Kuschak
• Dr. Kristina Gordon
• Dr. Tammy Stuart

and so on…..

MUCHAS GRACIAS, Merci Thank you !!!!!!!!