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��4 June 2020��1 &#x/MCI; 0 ;&#x/MCI; 0 ;Guidance on Integration of COVID19 in Existing Acute Febrile Illness (AFI) Surveillance SystemsBackgroundey actions to reducetransmission of COVIDinclude active case finding, care and isolation, contact tracing, and quarantine. Acute Febrile Illness (surveillance systems are typically used to better understand common causes of feverhey may alsobeeffectively leveraged Global Influenza Surveillance and Response System (GISRS) The integration of COVID19 in xisting urveillance ystems is intended to:Complement, not replace, ongoing ILI and SARI or COVID19 surveillance activitiesLeverage existingsurveillance systems for efficient and costeffective implementation of COVID19 surveillance.Support emergency and high websitesfor further information about COVID19 and SARSCoV2. As the COVIDpandemic is evolving, and WHO updates COVID andguidance for GISRS partnersCDC guidance will reflect those revisions in its guidelines. Surveillance Objectiveswhen everaging AFI urveillanSystemsfor COVIDThe overall aim is to use existing surveillance systems for epidemiological and virologic surveillance for COVID19. Depending on the existing systems, one or more of the following objectives can be addressed ��4 June 2020��2 &#x/MCI; 4 ;&#x/MCI; 4 ; What is the ratio of outpatient to inpatient cases of COVID19 illness? To understand risk factors for severe disease and transmissionWhat age groups are most affected? What fraction of COVID19 cases have underlying illness or other highrisk conditions? What risk factors are associated with risk of exposure (for example,health care practitioners)?To monitor for changes in viruspropertiesAre SARSCoVgenetic sequences or virologic characteristics changing in ways that might affect transmission, severity, immune correlates of protection, or vaccine development? Secondary ObjectivesTo assessthe proportion of febrile patients without respiratory symptomswho test positive for SA

RSCoVvirusTo conduct future studies of patients with AFI,including serologic investigations to assess immune response to SARSCoV2 infection To evaluate new SARSCoVdiagnosticor serologic testsApproachesting of specimens for SARSCoV2 collected through existingsurveillance will help monitor the progression and impact of COVID19 illnessThis activity is separate from, but complementary to, efforts to identify COVID19 cases using the person underinvestigation or suspect case definitions used by CDC and WHOrespectively. Surveillance systems may be employed for situational awareness, public health actionand to understand the impact of disease, as well as for characterizing COVID19 illnessin the inpatient and outpatient settings.Relationship to ongoing AFIsurveillanceactivitiesCountries that conduct AFI surveillance should continue to do sowithoutinterruption oralteration to the case definition being used to trigger enrollment in surveillance and sample collectionRegardless of whether the system enrolls and tests patients using a broad AFI case definition or a more specific UF case definitio, CDC suggests the integration of SARSCoV2 RTPCR testing into existing aboratory testing algorithmused for AFI surveillance.The SARSCoV2 RTPCR diagnostic approach should follow the same biosafety, specimen management and testing guidelines as described in the CDC Guidance on integration of COVID19 in existing influenzalike illness (ILI) or severe acute respiratory infection (SARI) sentinel surveillance andthe WHO’s Operational considerations for COVID19 surveillance using GISRS Considerations for the Interplay betweenExisting AFI Surveillance & SARI/ILI SurveillanceAspreviously mentioned, this guidance is intended to complement ongoing efforts to leverage existing ILI/SARI surveillance systems for COVID19 surveillance. The complementary role of AFI surveillance systems in this regard may vary among countriesIn countries with deficientor no ILI/SARI surveillance, AFI surveillance platforms mayprovide opportunity for

establishing COVID19 surveillanceIn countries with existing ILI/SARI surveillancethat can effectively be leveraged for COVID19 surveillance, AFI surveillance systems may be similarly leveragedin a complementary fashion in order to: ��4 June 2020��3 &#x/MCI; 3 ;&#x/MCI; 3 ;o Expand the coverage of surveillance to geographical areasor populations not covered by ILI/SARI surveillanceAnswer different surveillance questions of national or international importanceProvide access to additional testing equipment and resourcesAdaptation of Specimen Collection Procedures in AFI SurveillanceDepending on the specifics of AFI enrollment and existing sample collection, the adaptation of AFI surveillance systems for this purpose may take onof three forms:If NPand oropharyngeal(OP)swabs are already being collected from enrolled AFI cases, then this activity should continueand these samples can form the basis of SARSCoV2 RTPCR testing.If NP/OPswabs are not already being collected and the surveillance system currently enrolls and tests AFI cases on the basis of a broad AFI case definition, then NP/OPswabsshould be collected from the subset of enrolled AFI cases meeting the ILI or SARI case definitions, depending on whether they are outpatients or inpatients(see Appendix 1)If NP/OPswabs are not already being collected and the surveillance system currently enrolls and tests AFI cases on the basis of a UF case definition that excludes persons with respiratory symptoms, then appropriate patients meetingthe ILI or SARI case definitionsshould be identified upstream during screening procedures.At that point, NP/OPswabs should be collected from individuals meeting the ILI or SARI case definitions Generally reported or measured fever of a certain duration with certain exclusions to rule out specific, noninfectious causes of fever ��4 June 2020��4 &#x/MCI; 0 ;&#x/MCI; 0 ; &#x/MCI; 1 ;&#x/MCI; 1 ;AFI surveillance also allows forthe possibility of detec

ting SARSCoV2 among patients who do not present with respiratory symptom. In all scenariolaid out above, the collection of NP/OP swabs for SARSCoV2 RTPCR testing from asample of AFI or UF cases with norespiratory symptommayalso be considered in order to assess the proportion of febrile patients without respiratory symptoms who test positive for SARSCoVSuggested Sampling ProceduresTesting capacitymay vary depending upon local resources,but countries shouldconsider testing a minimum of 50 samples per weekor up to 100 samples per week, as test kits permitsituationwhere testing resourcesare limited, there should ideallybe an a prioriallocationof test kitsand other laboratory suppliesfor surveillance activities during a certain time periodIn this scenario, the number of eligible samples during the givetime periodcan be divided by the number of available testsin order to calculate a sampling interval which can be used to make a systematic selection of samples to test.If SARSCoV2 is detected during initial phase of testing, expandingtesting to a larger sample or to all specimensmay be consideredas resources allow, to further evaluate the frequency of detection.Specimenollectiackaging andTransportAll procedures outlined in the CDC Guidance on integration of COVID19 in existing influenzalike illness (ILI) or severe acute respiratory infection (SARI) sentinel surveillanceor the WHO’s Operational considerations for COVID19 surveillance using GISRSshould be followed for the safe collection, packaging and transportof NP/OP swabs collected through AFI surveillance systems. ��4 June 2020��5 &#x/MCI; 0 ;&#x/MCI; 0 ;LaboratoryestingWHO recommends using reverse transcriptionpolymerase chain reaction (RTPCR) for laboratory confirmation of SARSCoV2 in respiratory specimens. All procedures outlined in the CDC Guidance on integration of COVID19 in existing influenzalike illness (ILI) or severe acute respiratory infection (SARI) sentinel surveillanceor the WHOOperational consideration

s for COVID19 surveillance using GISRSshould be followed for SARSCoVRTPCR testing. Epidemiological ata ollectionCase investigation forms used in existing AFIsurveillance should be modified to include COVIDspecific questions. Much of the information included on the WHO COVID19 case investigation form is similar to that collected in existing AFIsurveillance.The minimum data variables are outlined in the CDC Guidance on integration of COVID19 in existing influenzalike illness (ILI) or severe acute respiratory infection (SARI) sentinel surveillanceand WHO’s Operational considerations for COVID19 surveillance using GISRS At a minimum, data should include the date of symptom onsetdate of health care visitsand date of laboratory confirmation. These data will help countries characterize and monitor COVID19 activity over time. Critical demographic information to understand the populations at greatest risk include age and gender, comorbidities, pregnancy status, and other factors that may impact severity of disease. Health status at the time of reporting and clinical course should include information about admission to the intensive care unit (ICU) and the need for and ventilation.When possible, outcomes e.g., recovered, died) should be collected as well. All case report forms should include a unique case identifierand the laboratory specimen should include the same unique identifier, as is standard practice in surveillance.Additional variables specific to COVID19 may be added to existing country case report forms. Where possible, CDC does not recommend creating different forms for COVID19 surveillance where appropriate forms for AFI surveillance exist.However, additional COVIDspecific questions may need to be administered to AFI patients enrolled for COVID19 testing. In addition, there may be a need to have a full COVID19 specific questionnaire used for patientswhere UF cases are being enrolled and no data is currently being collected fromthe patients with respiratory symptoms.Weekly ggregate eporting Regula

r aggregate reportingnational, regional (e.g.,Africa CDC) and international (.g.,WHO) should occuraccording to established mechanisms. One option for countries with SARI/ILI surveillance systems, as outlined in the CDC Guidance on integration of COVID19 in existing influenzalike illness (ILI) or severe acute respiratory infection (SARI) sentinel surveillance, is to submitweekly aggregate report to WHO FluMart, as recommended by WHO. WHO has incorporated reporting for COVID19 into the FluMart platform, and requests that GISRS partners share data on testing for SARSCoV2. Questions regarding reporting in FluNet or FluID may be directed to flumart@who.int Other reporting channels may vary depending on the countryand the reporting systems available Weekly aggregate reports shouldat minimumincludethe number of AFI pecimens tested for COVID19 and the number of those that test positive by the week of samplecollectionthe numberof specimens with negative and conclusiveresultcan also be reported if available). Each weekis important to trackwhich specimensare being testede.g., specimens from casesmeeting the ILI/SARI case definitions, specimensfrom cases without respiratory symptoms, only influenzanegative samples, or a subset of either. The number of specimenstested and theassociated results can also be broken down by case definition (e.g., ILI, SARI, others, disease severity or outcome. ��4 June 2020��6 &#x/MCI; 0 ;&#x/MCI; 0 ;Opportunities for Future Testing in AFI Surveillanceore is learned about COVID19 and new diagnostic technologies are developed, future opportunities for additional testing of samples collected through AFI surveillance systems should be considered.The preexisting procedures to collect blood and/or serum through AFI surveillance systems present an opportunity for srologicaltestingwhich can help to evaluate the proportion ofthe population that has been exposed to SARSCoVand answer other basic surveillance questionsSerological tests can look for the presence

of specific antibodies, typically IgM or IgG, made in response to infection. The antibodies detected by the serological test can indicate whether PCR positiveatienthad an immune response to SARSCoVor if asymptomaticpatients have antibodies indicating a past or recent infectionf procedures are not already in place to do so, AFI surveillance programs interested in conducting serological studies in the future may consider biobanking blood and/or serum specimens for future use.As necessary, existing AFI protocols and patient consentformsshould be amended to include simple, flexible language that would allow for the storage and future testing of specimens.AFI surveillance systemmight also be used to evaluate noveldiagnosticsThese could includserological assays, additional molecular assaysand pointofcare rapid testsMonitoring the Implementation of these GuidelinesThese guidelines will continue to be refined as more is learned about COVIDand SARSCoV2. Monitoring their implementation and incorporating lessons learned will also be important in this effortAll countries implementing these guidelines are asked to consult with CDC’s Epidemiology, Informatics, Surveillance, and Laboratory Branch in the Division of Global Health Protectionof the Center for Global Health (POC:Olga Henao, dot8@cdc.gov for coordinationof technical assistance requests and collection of relevant information for monitoring implementation of activities Other ResourcesWHO Coronavirus hub WHO Technical Guidance CDC Coronavirus hub CDC Situation Updates Johns Hopkins University update map ��4 June 2020��7 &#x/MCI; 0 ;&#x/MCI; 0 ;Appendix 1Case Definitions for SARI and IL Inpatient Surveillance Outpatient Surveillance SARI Acute respiratory infection with:history of fever or measured fever of 38C or more, ANDcoughwith acute onset within past 10 days AND - requires hospitalization ILI Acute respiratory infection with:measured fever of 38C or more, ANDcoughwith onset within past 10