th January 2016 Paro Training Objective General Objective To strengthen Influenza sentinel surveillance system Specific Objectives To update the participants on global regional and local influenza surveillance status ID: 811637
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Slide1
WELCOME
Training on Influenza Sentinel Surveillance and Human Influenza study protocol, 11 -13
th
January 2016,
Paro
Slide2Training Objective
General Objective
To strengthen Influenza sentinel surveillance system
Specific Objectives
To update the participants on global, regional and local influenza surveillance status
To sensitize operational aspects of influenza surveillance protocol
To update on renewed human influenza study conducted in collaboration
To discuss on operational and logistic challenges both in sentinel sites and RCDC
Slide3Anticipated Outcome
Participants aware of general functionality of the surveillance system and understand individual roles and responsibilities associated with surveillance
Generate recommendations to address the current operational and logistic challenges associated with Influenza sentinel surveillance
Attain consensus on operational aspects of Human Influenza study protocol
Slide4Background & Operational
aspects of
Influenza Sentinel Surveillance
Binay
Thapa
Dy. Chief Laboratory Officer
Slide5Influenza Surveillance System in Bhutan
Event-based surveillance (NEWARS
)
Web based & SMS
Indicator based surveillance (NEWARS
)
Web based & SMS
Sentinel surveillance
7 hospital based
sites
Web based, SMS yet to be trained
Slide6Background
ILI
surveillance, 2009
as preparedness against H1N1 pandemic.
Burden of influenza
Dominant circulating strains
Risk groups
First
case, June
2009
Sample sent to AFRIMS for viral detection
National Influenza Laboratory, 2010 following 2009 H1N1 pandemic. (11 sentinel sites)SARI surveillance was established in 2012.
Slide7Sentinel Sites for ILI & SARI
JDW/NRH
Punakha
Paro
Samtse
Phuntsholing
CRRH
Trongsa
Tsirang
ERRH
Samdrup Jongkhar
Trashigang
Slide8Background
Weekly reporting,
2010.
ILI/SARI guideline
developed,
2012 and
revised, 2014
Quarterly
Disease
surveillance
bulletin, 2015PHL embarked on NIC status, 2013Influenza
laboratory capacity assessment, 2013 (WHO)First International Influenza paper published, 2012
Slide9Background
Cooperative Agreement with US CDC awarded
in September 2013 and started implementation from Jan 2014.
External review of existing influenza surveillance system and laboratory capacity by CDC.
Technical Working Group was formed following the external review.
Slide10National Influenza Laboratory diagnostic preparedness in Bhutan
Existing staff working in NIL 5.
Two Real Time PCR machine
(World Bank).
One ABI 7500 Fast
Dx
RT-PCR (CDC)
Slide11National Influenza Laboratory diagnostic preparedness in Bhutan
Influenza virus testing capacity:
- Influenza A & B
- Seasonal A/H1, A/H3
- A/H12009 pandemic
- Avian influenza (H5N1)
- H7N9
- MERS
CoV
Use algorithm for testing.
-
Established in 2010
Established in 2013 with help of AFRIMS
Slide12National Influenza Laboratory diagnostic preparedness in Bhutan
Participate in
EQAP,
Hongkong
Centre for Health Protection.
Send samples to AFRIMS for cross-checking
Laboratory supplies and reagents supported by AFRIMS and majority by US CDC project
Inaugural consecration of New PHL structure in 2015 November with new name as Royal Centre for Disease Control (RCDC)
Slide13Roles & Responsibilities (Sentinel sites)
ILI sentinel surveillance
Slide14Objectives of ILI Surveillance
Describe
the seasonality of influenza activity.
Monitor and investigate unusual influenza activities.
Monitor and detect circulating
influenza
viral strains and
novel
viruses.
Contribute
to WHO vaccine strain
selection through GISRS. Identify and monitor high risk groups with severe disease and mortality, in order to target education and prevention measures.
Slide15Case definitions-
ILI Case Definition
Any person with acute respiratory infection with;
1. Fever ≥ 38 ºC; AND
2. Cough or sore throat; AND
3. Onset within the last 10 days.
(Note: Consider sample collection from ILI patients
only if onset of fever is within the past five days)
Slide16Clinicians (HA/ACO/Dr)
Identification
of patients that meet the ILI case definition in the guideline.
Daily
recording of ILI cases at their respective sentinel sites.
Proper completion of ILI sample collection
form and send to lab for
sample
collection.
Provide
the data collected to SFP on
daily or weekly basis for compilation.
Slide17Surveillance Focal Point (SFP)
Collect and collate data on total number
of ILI patients from OPD
chambers and
count
the total
number
of OPD cases seen every day or on a weekly basis (
Annex 3
).
Report all ILI to PHL on weekly basis through online data system or by fax if internet facility is not available
. Disseminate the reports and feedbacks received from PHL to the relevant health personnel (Clinicians, laboratory, nurses etc.)Provide feedbacks from sentinel sites to NAIL, PHL.
Slide18Medical Laboratory Technologist/Technician
Ensure all ‘ILI Sample collection forms’ and ‘SARI patient sample collection form’ are filled out completely and accurately.
Ensure
all respiratory specimens for ILI and corresponding forms are assigned with unique ID number.
Collect
respiratory specimens appropriately from
patients based on
Annex 6
.
Properly
label, pack, store, and
transport specimen to NAIL, PHL according to the SOP in the guideline
Slide19Cont..
Perform rapid test for ILI specimen and ensure test results are reported to the treating clinician.
Ensure there is adequate stock of test kits, VTM, barcodes and relevant forms in the laboratory.
Shipment of specimen along with cases investigation forms to PHL as per the existing
shipment schedule
.
Slide20Case selection
and
Sampling strategy
Each identified sentinel site for ILI should enroll at least 6-8 ILI cases every week (i.e. 24-32 specimen per month) for specimen collection.
Equal distribution between child and adult
Enroll case from Monday to Wednesday
Specimen processing at sentinel sites
Onsite testing
Specimen Storage & Shipment
Specimen processing at NAIL, PHL
Slide21Roles & Responsibilities
Public Health Laboratory
Slide22National Influenza Laboratory (NAIL)
Serve as the technical and scientific focal point for activities pertaining to ILI and SARI surveillance.
Perform
following activities on specimens
received
from sentinel sites:
Enter
data from SARI & ILI Specimen collection form.
Influenza
virus typing and subtyping, using molecular methods (Real time RT-PCR / conventional PCR
)
Referral of any unsubtypable specimen to a designated WHO Collaborating Center. Receiving, archiving and storing original clinical specimens at -70°C for ILI/ SARI for ten years. upload results in the web-based data management system
Slide23National Influenza Laboratory (NAIL)
Share
representative clinical specimen or virus isolates of seasonal influenza specimens with a WHO Collaborating Center (WHO-CC) twice a year.
Immediate sharing of information on any
unsubtypable
or suspect novel influenza viruses with a WHO Collaborating Center.
Slide24Cont..
Participating in the WHO Global External Quality Assessment Project for the molecular detection of influenza viruses as well as in regional programs.
Provide initial and refresher training to sentinel sites on specimen collection, diagnosis, storage and transport.
Monitor sentinel sites to maintain quality of data and specimens sent to NAIL, PHL.
Slide25Data management and analysis
Slide26Data Management
Both ILI and SARI data from the form (
Annex 2&3
) should be maintained using online surveillance
system
. NADSAE should manage the data for both the surveillances. NAIL should provide laboratory data to NADSAE.
Data Disposition
Data will be maintained using online database system for at least 10 years after which it will be disposed
according
to standard procedure.
Slide27Analysis
Weekly report
Quarterly report
Annual report
Slide28Monitoring & Evaluation(M&E)
A surveillance system should undergo regular monitoring to routinely assess whether it is functioning efficiently and providing quality data to meet its stated objectives.
Monitoring sites
NAIL
NADSAE
Sentinel sites
Slide29Surveillance indicators
Timeliness
Completeness
Consistency
Number of specimen collected
Slide30Updates on National Influenza Sentinel Surveillance (2015)
Binay
Thapa
Dy. Chief Laboratory Officer
Slide31Objectives
To determine the burden of respiratory diseases in the country
To monitor epidemiology and severity of influenza and other respiratory pathogens
To provide information on groups at high risk to institute prevention and control measures
Provide feedbacks to field people and policy makers for planning and action.
Slide32Sentinel Sites for ILI & SARI
JDW/NRH
Punakha
Paro
Samtse
Phuntsholing
CRRH
Trongsa
Tsirang
ERRH
Samdrup Jongkhar
Trashigang
Slide33Trend of ILI cases (2015)
Slide34Slide35ILI OPD visit by Age distribution
Age group
Frequency
%
0-1
848
9
2-4
1331
13
5-14
2596
26
15-29
3201
32
30-64
1698
17
65+
320
3
Slide36Slide37Trend of Influenza sub-types in Bhutan (2015)
Slide38
Slide39Influenza positivity & No. of samples received
N=1457
Slide40% positivity by Influenza subtypes
N=257
Slide41Slide42Outbreak Status- Year
2015
Sl. No.
Outbreak site
Outbreak
date
Sample Size
PCR result
1
Gaybekha
,
Wangdi
04- 06 Feb-2015
7
Flu
A/pdm09- 7
2
Ramjar
Midddle
Secondary School, T/
yangse
02-Mar-2015
20FluA
/H3- 183Yurung
locality, P/Gatshel04-Mar-2015
9
FluA
/pdm09- 4
4
Mukhung
community pry school,
Mongar
05-Mar-2015
8
FluA
/pdm09- 7
5
Phochu
Dumra
Lobdra
, P/
kha
12-Mar-2015
7
FluA
/pdm09- 7
Slide43Outbreak Status- Year
2015
Sl. No.
Outbreak site
Outbreak
date
Sample Size
PCR result
6
Zhemgang
Higher Secondary School,
Zhemgang
21-Mar-2015
10
FluA
/pdm09- 1
,
FluA
/H3-1
7
Langdurbi
, Zhemgang
28-Mar-20157
FluA/pdm09- 78
Subrang, Zhemgang
31- March-20154
Flu
A/pdm09- 3
9
Gomphu
Lower Secondary School, S/
Jongkhar
06-Apr-2015
4
Flu
A/pdm09- 1
10
Riserboo
Hospital,
Trashigang
11-May-2015
13
FluA
/pdm09- 10
Slide44Key Inference/information from 2015 surveillance
Slide45Influenza activity
Globally, Influenza activity is low
SEARO experienced low activity
Bhutan status remains status quo based on ILI visit proportion compared to last year
Slide46Seasonality
Northern & Southern Hemisphere
Highly synchronized annual influenza epidemics (WINTER MONTHS) in temperate zone
Complex & diverse annual Influenza epidemics
in tropical and sub-tropical
region
Coincide with rainy season
Year round influenza activity without well- defined seasonality
Slide47Seasonality
Similar to SEARO region
Increasing trend seen during summer seasons only; especially from February to May and another wave from July to September.
to medical-care seeking behavior of Bhutanese population
crowding in schools
Sustained transmission
Monsoon, wet & relative humidity
More survival of virus
Slide48ILI Age group most enrolled (ILI): 15-29 years
Usually mobile, captive in schools and monasteries
Most turn up for medical care in the hospitals particularly during academic session.
Slide49Circulating Influenza strains
Unpredictable subtype circulation
One strain dominating other at the given time
Cross protecting immunity to already exposed strain
Antigenic drift
2014, 15-29 most affected by A/pdm09
Developed some level of immunity to this strain
30-64 most affected by this strain in 2015
Slide50LIMITATIONS
Slide51Possible challenges in sentinel sites
Inconsistency in reporting & case identification
Lack of awareness among
clinicians and other relevant health workers
Inadequate number of sample referrals from sites
Frequent transfer/long term training of health staff
Inadequate data verification
Slide52Challenges/Gaps in RCDC
Lack of human resources in Influenza Laboratory
Additional testing of other emerging diseases; other respiratory pathogens, dengue, malaria
Other program specific activities
National focal points
No sustained laboratory supplies
No RGOB committed budget for the supplies
Supplies through collaboration limited (CDC & AFRIMS)
No quotation from local suppliers
Slide53No virus culture
Capacity building in process for the new structure
Equipment procured
No expertise to set up
Reagents and other supplies yet to procure
Difficulty in Ex-country shipment of samples
No local agent (E.g. World courier)
Hindrance in supply of reagents and other consumables from Reference laboratory
No staff in surveillance unit
Slide54Way forward
Laboratory supplies to be streamlined and explore
RGoB
support
Seek Technical assistance /expertise for virus culture set up
Increase frequency of data
verification
Technical assistance for burden study
Establish
sustainable shipment to US CDC & WHO CCs
Slide55Acknowledgement
AFRIMS
Ministry of Health
All sentinel sites
WHO