Surveillance for AI in Human Bureau of Epidemiology Health - PDF document

Surveillance for AI in Human Bureau of Epidemiology

Health services Ministry of Public Health Central Department of disease control: Bureau of epidemiology Department of Medical science: NIH Regional disease control office Regional 12 offices Province level University hospital Provincial health office Provincial hospital Private hospital 76 offices 76 District hospital District level District health office Health center Village

Pneumonia Diseases under Influenza notification

Annual cases report 1996-2002

Doing and Learning AI Surveillance in Human

Four waves of epidemic New reported 2 cases on 26 July, 5 Aug 2006 in Pichit, Uthai Confirmed case Third round Suspect case (Oct05-Nov05) Second round Area of outbreak (Aug-Oct 2004) in poultry First round (Jan-Mar 2004) Source: BOE, MOPH

Number of AI cases by date of onset, 2004 1-3 Jan 10 0 1 2 3 4 5 6 7 8 9 10-12 Jan Suspect (22) 19-21 Jan 28-30 Jan 6-8 Feb 15-17 Feb Probable (1) 24-26 Feb 4-6 Mar 29-31 Aug 7-9 Sept 16-18 Sept Confirm (17) 25-27 Sept 4-6 Oct

Enhancing surveillance for AI � Confirm AI in poultry and human � Determine extent of problem � Commitment of higher policy � Construct structure and system � Orientate the involving parties: physician, lab, epidemiologist, logistic, risk communicator, policy maker, � Training the teams

up to 10 March 2004 Announcement of the first confirm 23 Jan 2004 Capacity of confirmation in time

Number of cases notified by week, Jan-Aug 2005 Third wave of human epidemic August-September 2005 Maintenance the system Surge Capacity

Country AI control strategies Disease Surveillance Transparency Protection of high-risk groups in operation and information surveillance Outbreak control Man Prevent Infected in poultry Migratory exposure Risk communication Case management birds poultry and infection control for the public

1. New influenza Influenza pandemic phase virus in animals low risk for human WHO 2. High risk for human 3. Human infections, no or only inefficient man-to-man Tx 4. Increased man-to-man Tx, limited outbreak 5. Significant increase in man-to-man Tx, extended outbreak 6. Pandemic

Surveillance target (phase H3) � Detect the first generation of H-H transmission � Identify risk groups and trace all contacts � Limit the H-H transmission within 2 generation Possible dream?? Possible dream??

Structure � Health facility base reporting system � Hotline for case notification � Media check

Surveillance and Initiate and coordinate the Control: network, emergency commander, structure at province Mr monitoring and Bird Flu report Medical care & Medical care & network Network: Detect, Report, treat Health services SRRT: SRRTs rapid diagnosis, Health volunteers Investigation & community leaders Control Warning

Case detection and report

Clinical practice guideline Clinical practice guideline

Group1

Group 2

Cluster of ILI (5case in the same community in 1 wk) Group 3 • Confirm diagnosis • Active case finding • Describe the distribution by time, place, person • Control : increase social distance,

Web base report

Data management & analysis

Specimen collection � NP swab � NP aspiration Prepare • PPE and trained personnel � Tip of ET tube • Nasopharyngeal swab � Pair serum • Viral transport media • Sterile tube • Ice box with ice pack • Vehicle for transportation

Specimen testing � PCR for influenza A or B � PCR for Influenza A H1, H3, H5 � Viral isolation � Neutralization test

NP swab, T swab, NP aspirate RT - PCR Culture when NPA, or PCR + : Flu A + - 1. Detect CPE and IFA 2. If H5 + repeat PCR Flu B Flu A Flow of laboratory H3 H5 H1 RT-PCR Realtime-PCR RT-PCR confirm + + H 1 or All neg H 5 H 3 Real time PCR RT-PCR Report + + => Report H5 + - => wait for isolation/new specimen - N/D => Report non-H5

Lab facilities Report to Viral isolation Confirm Higher policy PCR for Influenza H1 H3 H5 National lab Positive for H5 BOE P 3 PCR for Influenza A and B Hospital Positive for H5 PCR for Influenza H1 H3 H5 Regional lab Negative 12 labs PCR for Influenza A and B Report to Hospital and NIH Specimen collection Discard Hospitals Clinical screening for notification criteria Screening: Dengue Leptospirosis Melioidosis Bacteria

Case monitoring � Exposure � Direct contact without protection +++ � Living in areas ++ � Contact to other pneumonia case + � Clinical � Severe pneumonia ++++ � Pneumonia +++ � ILI admitted ++ � ILI not admitted +

Case classification � Case under surveillance � Suspect case � Probable case � Confirm case � Excluded case Classification conduct when finish lab process, recover

Case definitions for surveillance (15 May 2006) Case definitions for surveillance (15 May 2006) � Suspect Suspect: : An individual whose body temperature is more � than 38 o C and who has at least one of the following symptoms: muscle pain, cough, breathing difficulty, shortness of breath, or physician suspects pneumonia or influenza, and � who has a history of direct contact with sick or dead poultry in the last 7 days or � there were reports of unusual poultry deaths in the village in the last 14 days or � has been looking after another pneumonia patient in the last 10 days before illness onset, but � who does not have a specimen which complies with the recommendation for laboratory testing for Influenza A/H5

Case definitions for surveillance (15 May 2006) Case definitions for surveillance (15 May 2006) � Probable case Probable case : a suspect who developed signs and � symptoms of, or died from, acute respiratory failure � Confirmed case Confirmed case : a suspect who has a final standard � laboratory confirmation of Influenza A/H5 through at least one of the following methods: � Single RT-PCR method using two primer/probe sets, or using specimens collected from at least two different locations (such as throat swab and nasopharyngeal aspirate, etc.), or using at least two specimens collected from a patient at different period of illness), � Viral culture � Neutralization test (four-fold antibody increase between acute and convalescent serum

Sharing information among epidemiology and lab � Daily lab result updated via e-mail report � Daily situation report via e-mail � Web base situation report for public: www.dld.go.th http://epid.moph.go.th

System evaluation

Weekly case report with zero report check Number of reported cases by week 2006 number week

Geographic distribution

Lessons learned � Pitfall of case detection � Surveillance is working with not only data BUT PEOPLE

Pitfall of case detection � Lack of history taking � Rely on laboratory � Time at collection � Quality of collection process � Quality of specimen transportation � Media � Quality of the test � Miss diagnosis to other diseases

Quick test result H1, H3, flu B PCR Rapid test positive negative Total Positive 265 100 365 BUT Negative 36 882 918 Rapid test for 2 confirm H5, all are negative Total 301 982 1283 � Sensitivity: 88%, PVP= 72% � Specificity: 89% NPV=96%

Working with people � Initiate and maintenance � Centralize VS De-centralize data � Warning VS threatening � Simplicity and flexibility � Trust and friendship

Thank you � Dr. Kumnuan Ungchusak � Dr. Rungnapa Prasarnthong � Dr. Supamitr Schunsuthiwat � Surveillance and Response unit, BOE � Epidemiologist at provincial health office, Thailand � Regional office of diseases control 1-12 � Department of Medical Science, NIH � Department of Medical Service � Department of Livestock, NIAH � FETP

ขอบคุณคะ ขอบคุณคะ Thank you Thank you