Public Health Laboratory Department of Public Health Ministry
Public Health Laboratory Department of Public Health Ministry of Health WELCOME Training on Influenza Sentinel Surveillance and Human Influenza study protocol, 11 -13 th January 2016, Paro www. phls. gov. bt
Training 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 www. phls. gov. bt
Anticipated 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 www. phls. gov. bt
Public Health Laboratory Department of Public Health Ministry of Health Background & Operational aspects of Influenza Sentinel Surveillance Binay Thapa Dy. Chief Laboratory Officer www. phls. gov. bt
Influenza 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 www. phls. gov. bt
Background • ILI surveillance, 2009 as preparedness against H 1 N 1 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 H 1 N 1 pandemic. (11 sentinel sites) • SARI surveillance was established in 2012. www. phls. gov. bt
Sentinel Sites for ILI & SARI JDW/NR H Punakh a Trongsa Paro ERRH Samts e Trashiga ng Tsirang Phuntsholing CRRH www. phls. gov. bt Samdrup Jongkhar
Background • Weekly reporting, 2010. • ILI/SARI guideline developed, 2012 and revised, 2014 • Quarterly Disease surveillance bulletin, 2015 • PHL embarked on NIC status, 2013 • Influenza laboratory capacity assessment, 2013 (WHO) • First International Influenza paper published, 2012 www. phls. gov. bt
Background • 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. www. phls. gov. bt
National 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) www. phls. gov. bt
National Influenza Laboratory diagnostic preparedness in Bhutan • Influenza virus testing capacity: - Influenza A & B - Seasonal A/H 1, A/H 3 Established in 2010 - A/H 12009 pandemic - Avian influenza (H 5 N 1) - H 7 N 9 Established in - MERS Co. V 2013 with help of AFRIMS • Use algorithm for testing. - www. phls. gov. bt
National Influenza Laboratory diagnostic preparedness in Bhutan • Participate in EQAP, Hongkong Centre for Health Protection. • Send samples to AFRIMS for crosschecking • 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) www. phls. gov. bt
Roles & Responsibilities (Sentinel sites) ILI sentinel surveillance www. phls. gov. bt
Objectives of ILI Surveillance 1. Describe the seasonality of influenza activity. 2. Monitor and investigate unusual influenza activities. 3. Monitor and detect circulating influenza viral strains and novel viruses. 4. Contribute to WHO vaccine strain selection through GISRS. 5. Identify and monitor high risk groups with severe disease and mortality, in order to target education and prevention measures. www. phls. gov. bt
Case definitions 1. 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) www. phls. gov. bt
Clinicians (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. www. phls. gov. bt
Surveillance 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. www. phls. gov. bt
Medical 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 www. phls. gov. bt
Cont. . • 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. www. phls. gov. bt
Case 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 www. phls. gov. bt
Roles & Responsibilities Public Health Laboratory www. phls. gov. bt
National 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 www. phls. gov. bt
National 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. www. phls. gov. bt
Cont. . • 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. www. phls. gov. bt
Data management and analysis www. phls. gov. bt
Data 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. www. phls. gov. bt
• Analysis – Weekly report – Quarterly report – Annual report www. phls. gov. bt
Monitoring & 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 www. phls. gov. bt
• Surveillance indicators – Timeliness – Completeness – Consistency – Number of specimen collected www. phls. gov. bt
Public Health Laboratory Department of Public Health Ministry of Health Updates on National Influenza Sentinel Surveillance (2015) Binay Thapa Dy. Chief Laboratory Officer www. phls. gov. bt
Objectives • 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. www. phls. gov. bt
Sentinel Sites for ILI & SARI JDW/NR H Punakh a Trongsa Paro ERRH Samts e Trashiga ng Tsirang Phuntsholing CRRH www. phls. gov. bt Samdrup Jongkhar
Trend of ILI cases (2015) www. phls. gov. bt
ILI visit by 1000 out patient 90 80 70 60 50 40 ILI visit by 1000 out patient 30 20 10 0 Paro P/kha Trongsa T/gang Tsirang Sentinel sites www. phls. gov. bt S/jonkhar Samtse
ILI 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 www. phls. gov. bt
www. phls. gov. bt
Trend of Influenza sub-types in Bhutan (2015) www. phls. gov. bt
• www. phls. gov. bt
Influenza positivity & No. of samples received 400 350 66 300 N=1457 30 250 53 Positivity 200 Sample 150 21 287 258 100 15 10 19 15 198 144 119 50 129 115 92 43 5 13 0 Paro Punakha Trongsa Trashigang 8 15 Tsirang S/Jongkhar Samtse P/ling www. phls. gov. bt Gelephu Mongar 59 Thimphu
% positivity by Influenza subtypes % positivity N=257 10 A/pdm 09 A/H 3 Flu B 23 67 www. phls. gov. bt
Influenza subtype distribution by age 40. 00 70 35. 00 60 30. 00 50 25. 00 40 20. 00 30 15. 00 20 10. 00 10 5. 00 Number of Influenza Positives 80 0 0. 00 0 -1 2 -4 5 -14 15 -29 30 -64 Age group A/pdm. H 1 A/H 3 Flu B www. phls. gov. bt Percentage 65+
Outbreak Status- Year 2015 Sl. No. 1 2 3 4 5 Outbreak site Outbreak date 04 - 06 Feb. Gaybekha, Wangdi 2015 Ramjar Midddle Secondary School, T/yangse 02 -Mar-2015 Yurung locality, P/Gatshel 04 -Mar-2015 Mukhung 05 -Mar-2015 community pry school, Mongar Phochu Dumra Lobdra, P/kha Sampl PCR result e Size 7 Flu A/pdm 09 - 7 20 Flu. A/H 3 - 18 9 Flu. A/pdm 09 - 4 8 Flu. A/pdm 09 - 7 12 -Mar-2015 7 Flu. A/pdm 09 - 7 www. phls. gov. bt
Outbreak Status- Year 2015 Sl. No. Outbreak site Outbreak date Samp PCR result le Size 6 Zhemgang Higher Secondary School, Zhemgang 21 -Mar-2015 10 Flu. A/pdm 09 - 1, Flu. A/H 3 -1 7 Langdurbi, Zhemgang 28 -Mar-2015 7 Flu. A/pdm 09 - 7 4 Flu A/pdm 09 - 3 4 Flu A/pdm 09 - 1 13 Flu. A/pdm 09 - 10 8 9 Subrang, Zhemgang Gomphu Lower Secondary School, S/Jongkhar 31 - March-2015 06 -Apr-2015 10 Riserboo Hospital, Trashigang 11 -May-2015 www. phls. gov. bt
Public Health Laboratory Department of Public Health Ministry of Health Key Inference/information from 2015 surveillance www. phls. gov. bt
Influenza activity • Globally, Influenza activity is low • SEARO experienced low activity • Bhutan status remains status quo based on ILI visit proportion compared to last year www. phls. gov. bt
Seasonality • 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 www. phls. gov. bt
Seasonality • Similar to SEARO region • Increasing trend seen during summer seasons only; especially from February to May and another wave from July to September. Øto medical-care seeking behavior of Bhutanese population Øcrowding in schools ØSustained transmission ØMonsoon, wet & relative humidity ØMore survival of virus www. phls. gov. bt
• ILI Age group most enrolled (ILI): 15 -29 years ØUsually mobile, captive in schools and monasteries ØMost turn up for medical care in the hospitals particularly during academic session. www. phls. gov. bt
Circulating 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/pdm 09 – Developed some level of immunity to this strain – 30 -64 most affected by this strain in 2015 www. phls. gov. bt
Public Health Laboratory Department of Public Health Ministry of Health LIMITATIONS www. phls. gov. bt
Possible 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 www. phls. gov. bt
Challenges/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 www. phls. gov. bt
• No 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 www. phls. gov. bt
Way forward • Laboratory supplies to be streamlined and explore RGo. B 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 www. phls. gov. bt
Acknowledgement • • AFRIMS Ministry of Health All sentinel sites WHO www. phls. gov. bt
- Slides: 55