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Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010 Council of State and Territorial Epidemiologists United States Centers for Disease Control and Prevention

Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

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Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010. Council of State and Territorial Epidemiologists. United States Centers for Disease Control and Prevention. Part 1: Background and Objectives. Outline. Background Purpose of the Training Guiding Principles - PowerPoint PPT Presentation

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Page 1: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Influenza Sentinel Site Surveillance TrainingAddis Ababa, Ethiopia: February, 2010

Council of State and Territorial Epidemiologists

United States Centers for Disease Control and Prevention

Page 2: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Part 1: Background and Objectives

Page 3: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Outline

BackgroundPurpose of the TrainingGuiding PrinciplesObjectives of sentinel surveillanceTopics covered in the guidance

Page 4: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Global Burden of Respiratory Infections

Influenza: 3 – 5 million cases of severe illness 250,000 – 500,000 deaths

Lower Respiratory Infections: Leading cause of death in low-income countries 3rd leading cause worldwide

Page 5: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Need for Improved Surveillance

Historically, influenza surveillance data collection: Virologic data for vaccine selection Limited epidemiologic data Lacked international standards

Remaining gaps in understanding: Epidemiology, burden of disease Social factors, clinical risk factors Climatic factors

Page 6: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Global Surveillance for Influenza

WHO Global Influenza Surveillance Network (GISN) International, laboratory-based (NICs) surveillance

network Provides virus strain information to select seasonal

vaccine• National Influenza Centres (NICs)

Laboratories designated by national Ministries of Health and recognized by WHO to participate in GISN

131 NICs, in 102 countries (as of Feb. 4, 2010)

Page 7: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Pandemic H1N1 (2009)

Timely virologic and epidemiologic monitoring at national level:o Track progression of pandemico Track impact of pandemico Convey an accurate perspective on severity and risk to

populationo Prioritize country-specific risk groups for intervention

resources

Page 8: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Seasonal Influenza Preparedness

Pandemic Monitoring

Relatedness of Seasonal and Influenza Pandemic Preparedness

Page 9: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Surveillance Needs During a Pandemic

Is the situation changing?o Total amount of ILI, proportion of outpatient ILI due to influenzao Laboratory data to look at proportion of subtypes circulating in the

communityo Systematic sampling of viruses by age

How severe is the disease and is it changing?o SARI hospitalizationso Deaths (and ICU admissions) from sentinel hospitalso Clinical picture of hospitalized cases

Is the virus changing?o Drug resistance, drift and shift from laboratorieso Comparison of viruses from less and more severe cases

Page 10: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Why is Monitoring the Severity/Virulence of a Pandemic Important?

Inform how aggressively we think about interventions, for example: School closures Stopping public gatherings Vaccination priorities Antivirals priorities

Mitigation, gain time to procure vaccine  

Page 11: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Role of Sentinel Surveillance in Broader Monitoring Systems

Reporting of qualitative indicators

Aggregate reporting of laboratory-confirmed cases

Aggregate reporting of syndromes ILI/SARI/Mortality

Embedded sentinel sites to efficiently monitor oVirus characteristicsoSeverity and change in severityoRisk factors for severe illnessoHospital impact

Page 12: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Routine Value of Sentinel Surveillance

Routinely produce useful epidemiologic and virologic datao Identify priority groups for intervention (severe outcomes)oAccurately characterize circulating virusesoMonitor seasonality to prepare for influenza seasonoCompare provinces, countries and regionsoEstimate burden of disease

Establish standards for surveillance reporting, collection and analysis

Provide a platform for the study of influenza and other respiratory pathogens

Page 13: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Guiding Principles: Short and Long Term Value

Integration into national systemsStandard case definitions for comparisons (ILI,

SARI)Efficiently monitor pandemic severity, high risk

groups, and impact Ongoing surveillance of influenza and other

pathogensHigh quality data in limited amounts

Page 14: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Seasonal Surveillance Pandemic Monitoring

Virologic Objectives

• Monitoring changes in virus• Monitor antiviral susceptibility• Monitor known markers of virulence• Strain surveillance, by age, for the

development of new vaccines• Strain surveillance, by severity, to

assess virologic risk factors for severe disease

• Detect novel viruses

• Monitoring changes in virus• Monitor antiviral susceptibility• Monitor known markers of

virulence• Strain surveillance, by age, for the

development of new vaccines• Strain surveillance, by severity, to

assess virologic risk factors for severe disease

• Detect novel viruses

Epidemiologic Objectives

• Identify priority groups for intervention--risk factors for severe outcomes.

• Monitor the intensity of influenza season in relation to baselines

• Estimate burden of disease• Monitor the timing/ seasonality of

influenza to inform seasonal planning

• Provide a platform for surveillance that includes additional pathogens

• Identify priority groups for intervention--risk factors for severe outcomes.

• Monitor the intensity of influenza season in relation to baselines

• Estimate burden of disease • Inform timely public risk

communication messages• Monitor treatment practices• Support rapid investigations• Be useful in the long term

Page 15: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Topics Covered in Training

Toolkit to establish a few high quality sentinel IP/OP sites

Criteria for selecting sentinel SARI and ILI sitesMethods to avoid bias in the selection of cases for

testingEpidemiologic data collection formsProcedures for laboratory specimensReport templates for weekly and annual data

summariesTechniques for routine monitoring of the surveillance

systemPandemic support functions

Page 16: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Part 2: Case Definitions

Page 17: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Goal of Pathogen-based Surveillance: Global Burden of Influenza

DeathsDeaths

HospitalizedSARI CasesHospitalizedSARI Cases

Mild Disease, Not Medically-Attended Mild Disease, Not Medically-Attended

Medically-Attended Outpatient Cases

Medically-Attended Outpatient Cases

ILI Surveillance

SARI Surveillance

Pathogen-based surveillance

Household Surveys/ Serum

Surveys

Page 18: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

SARI Surveillance

Should be priority/minimum basic influenza surveillance for countries with limited resources

Recommend adding this measure in countries with existing outpatient surveillance

Page 19: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

SARI Case Definition > 5 Years Old

Any person requiring hospitalization* and presenting with manifestations of acute lower respiratory infection with: sudden onset of fever (> 38 ºC) and cough or sore throat and shortness of breath, or difficulty breathing with or without

clinical or radiographic findings of pneumonia, or any person who died of an unexplained respiratory illness.

* hospitalization may not be a required in some sites (i.e. remote from hospitals). Time requirement for onset of illness may vary.

Page 20: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

SARI Case Definition < 5 Years Old

IMCI case definition for pneumonia:Any child aged 2 months to 5 years with cough or

difficulty breathing and: Breathing faster than 40 breaths / minute (ages 1 – 5 years) Breathing faster than 50 breaths / minute (ages 2 – 12

months)

*Note that infants less than 2 months of age with fast breathing of 60 breaths or more per minute should be referred for serious bacterial infection.

Page 21: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

SARI Case Definition < 5 Years Old

IMCI case definition for severe pneumonia:

Any child aged 2 months to 5 years with cough or difficulty breathing and any of the following: Unable to drink or breastfeed, or Vomits everything, or Convulsions, or Lethargic or unconscious, or Chest indrawing or stridor in a calm child

Page 22: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

ILI Case Definition

A person with:osudden onset of fever >38°C, and ocough or sore throat in the absence of other

diagnosis

Page 23: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

ILI SARI

Strengths • Less resource intensive as a case definition than SARI.

•Captures hospitalized component of influenza.

•Will capture cases with exacerbations of chronic conditions, not just those with pneumonia.

Weaknesses •Fever requirement may overlook persons without fever, such as elderly and immune-compromised.

• Not ideal if being used to monitor viral respiratory pathogens other than influenza.

•Will overlook those that do not present with fever.

•Will overlook those that do not seek care at a hospital.

•Fever requirement makes it more specific, less sensitive

Page 24: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Considerations When Using the SARI Case Definition

Fever requirement: may exclude elderly and immunocompromised

Option: do not include fever, or require a measured fever May detect non-influenza viral pathogens Will increase resource demands Should record presence or absence of measured fever on the

swab form for comparison to other countries Ensure consistent application of case definitions across all

sites

Page 25: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Experiences with SARI Surveillance

Early data from Member States in 5 WHO regions suggests routine surveillance for SARI will….

…achieve virologic objectives of seasonal influenza surveillance (pct. positive similar to ILI during influenza season)

…provide epidemiologic and virologic data on severe influenza infections

…provide a basis for monitoring severe respiratory disease during a pandemic

…serve as a platform for assessing burden of multiple viral respiratory pathogens

Page 26: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Prioritizing the Focus of the Surveillance System

Simple ModelBudget: Low, no existing surveillanceSurveillance for: SARI as a minimum standard

Epidemiologic data collection (i.e., denominator data = total number of SARI or ILI seen)

Virologic testing Small number of well-run sentinel sites preferred to large

number of poorly-run sites.

Page 27: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Prioritizing the Focus of the Surveillance System

Intermediate ModelBudget: MediumSurveillance for: SARI and outpatient ILI

Virologic testing Epidemiologic data collection (i.e. denominator data)

Page 28: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Prioritizing the Focus of the Surveillance System

Advanced ModelBudget: HighSurveillance for: SARI and ILI surveillance

Virologic testing Epidemiologic data collection (i.e. denominator data) Multiple pathogens, possibly reduce fever requirement in

inpatient setting as well

Page 29: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Part 3: Mechanics of Sentinel Surveillance

Page 30: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Outline

Sentinel site selectionCase sampling strategiesEpidemiologic data collection and forms

Page 31: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Selection of Sentinel Sites

Page 32: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

What is sentinel surveillance?

One or more designated health care facilities that routinely collect epidemiologic information and laboratory specimens from patients presenting an illness consistent with a specified case definition

The system provides an efficient way to obtain high-quality data on relatively common conditions from a manageable number of locations

Page 33: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Why Sentinel Surveillance?

For monitoring/ identification of: Identify target groups:

For antiviral use and timing That might have greatest impact on transmission

Strains to include in vaccine Appropriate management practices Hospital staffing and procurement needs

Page 34: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Key Attributes of Sentinel Sites

Efficient data collectionHigh quality data Limited number of well-chosen sites

“A few high quality data are better than a lot of bad data”

Page 35: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

The Efficiency of Sentinel Sites

Systematic testing of inpatient and outpatient (SARI and ILI) cases

Representation of viruses by age and severity Efficient collection of demographic and epidemiologic data

that is linked to virologic data Can yield measures of disease burden Valuable seasonally as well as in a pandemic Can support efforts to monitor surge on hospitals

Page 36: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

ILI Sentinel Surveillance

SARI Sentinel Surveillance

Strengths • Not a “new” system that must be created in a pandemic.

• Can be used to monitor progression of pandemic when other testing shifts to focus on only severe cases.

• Can be compared to meaningful baselines in many places to provide a measure of the relative magnitude of ILI consultations as compared to previous seasons.

• Efficient way to monitor severity and clinical characteristics of severe cases, and their change over time

• Monitor the progression and impact of a pandemic by focusing on an important outcome with a standard case definition.

• Will inform understanding of viruses that cause severe disease

• Timely feedback of results to clinicians can inform treatment practices.

• Sentinel hospitals can be used to estimate burden of severe disease.

• Sentinel hospitals can be used to monitor the impact of a pandemic on health care resources.

Weaknesses • Does not capture severe illness, which is needed to inform priority groups for intervention

• Not an easy or highest priority entity to collect epidemiologic data on

• No viruses from severe cases• Not ideal for monitoring if a

pandemic is becoming worse.

• Baselines are less well established at this point in time.

• It is a change from traditional practices to initiate systematic testing in hospitalized setting

• Sentinel sites are limited in their ability to characterize geographic spread.

Page 37: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Ideal Characteristics of Sentinel Sites

Feasibility People that are motivated to run the system Political willingness for a site to participate Sufficient staffing and laboratory capacity to maintain sampling

and testing during healthcare surge Efficient data management and transmission capability

Page 38: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Ideal Characteristics of Sentinel Sites

Patient representativeness All ages Wide range of medical conditions

For SARI surveillance, general or community hospitals are preferable to specialty care hospitals

For ILI surveillance, general outpatient clinics are often appropriate

Page 39: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Ideal Characteristics of Sentinel Sites

Quantifiable population denominatoro Facilitates estimates of burden of diseaseo Requires understanding of population served by the

sentinel site

Large referral hospitals may underestimate community incidence and require extra staff Difficult to test a large proportion of all SARI cases

identified If calculating rates, may be difficult to assess the total

population served by the surveillance site

Page 40: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Placement of Sentinel Sites

Population representativeness Ethnicity Socioeconomics

Climatic representativeness Climate affects virus activity (transmission and viability in

environment)

Page 41: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Example: Influenza Sentinel Site Selection in Cote d’Ivoire

Selection originally based on locations with confirmed AI and high poultry density/activity

Other considerations: Health centers/hospitals that

provide care to both adults and children  

Availability of staff Availability of a cold chain Status of the health

center/hospital; public, private, religious

Availability of financial and material resources for setting-up & monitoring

Page 42: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Example: SARI sentinel sites in South Africa, 2009

Chris Hani Baragwanath

Agincort

Edendale

Example: SARI Sentinel Surveillance in South Africa, 2009

Page 43: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Example: Sentinel Site Selection in Ukraine

Page 44: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Integration into National Clinical Reporting Systems

Ideally, sentinel sites could be integrated: Adopt standard case definitions Establish smaller number of sentinel sites within

the broader universal reporting system Assure high-quality data at these sites through more

intensive training and oversight Systematic laboratory testing only at sentinels Broader clinical reporting provides valuable indicator

of geographic spread within a country

Page 45: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Integration into National Clinical Reporting Systems

ILI/SARICase-based epi data collection, laboratory testing

ILI/SARI Syndrome Reporting

ILI/SARI Syndrome Reporting

ILI/SARI Syndrome Reporting

ILI/SARI Syndrome Reporting

ILI/SARI Syndrome Reporting

ILI/SARI Syndrome Reporting

ILI/SARICase-based epi data collection, laboratory testing

ILI/SARICase-based epi data collection, laboratory testing

Page 46: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Selection of SARI Cases

It is preferable to collect data and specimens from all or most SARI cases from a few facilities rather

than a small sample of SARI cases from multiple facilities

Logistically feasible Less bias If not possible, an unbiased sampling protocol should be

established

Page 47: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Selection of ILI Cases

Large number of cases at outpatient sentinel sites is likely

Total number of ILI cases seen is very important to collect

Collect specimens and case-based epidemiologic data from only a sample of ILI cases

Select cases for laboratory testing in as unbiased a manner as logistically possible

Page 48: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Sampling Methods for Respiratory Specimen and Case-based Epidemiologic Data Collection

Select all cases for testing

Select every xth case for testing

Select all cases on certain days of the week for testing

Select the first x cases on a certain day of the week

Page 49: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Selecting All Cases For Testing

Minimizes bias

Requires the most resources

May not be feasible in many settings

More feasible for sentinel surveillance focused on hospitalized cases (SARI)

Page 50: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Selecting Every Xth Case For Testing

Less likely to be biased than methods that only select cases on the same day or at the same time

Fewer resources than sampling all cases

Frequently used for hospital-based (SARI) surveillance

Page 51: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Selecting All Cases On Certain Days Of The Week For Testing

Does introduces biaso Patient volume and mix is not the same every day of the weeko Day(s) of the week should be alternated

Reduces logistical challenges of transport to laboratory

Page 52: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Selecting the First X Cases On a Certain Day of the Week

Can introduce bias by day-of-week or time-of-day

Commonly used for ILI surveillance where General Practitioners (GP’s) require convenience sampling models

Consider local health seeking behaviors

Not desirable for burden estimation of for SARI surveillance

Page 53: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

SARI ILI

Feasibility Desirability Feasibility Desirability

Selecting all cases 2 3 1 3

Selecting every xth case 3 3 2 3

Selecting all cases on certain days of the week

3 1-2 2 2

Selecting the first x cases on certain days of the week

3 1 3 2

1 = least feasible/desirable; 3 = most feasible/desirable

Page 54: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Epidemiologic Data Collection

Page 55: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Data Collection Tools

Forms filled out by designated sentinel site staff

At a minimum, collect data 4 weeks before and after typical peak months

Assign each patient a unique identification number to link epidemiologic and laboratory data Recorded on data collection form,

swab forms, and laboratory specimen

Page 56: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Minimal Data Elements

Unique identification numberPatient demographicsMinimal clinical information including relevant dates

of onset and clinical symptomsPre-existing medical conditions (for SARI only)Vaccine and antiviral use

Page 57: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Case-Based Data Collection Forms: SARI Swab Form

For all SARI cases tested for influenzao Should be completed as soon as possible after identification

Send one copy to laboratory with the specimen, one to the national surveillance centre, keep original at the sentinel site

Page 58: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010
Page 59: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Case-Based Data Collection Forms: Outpatient Swab Form

For all ILI cases tested for influenza

Complete as soon as possible after selection for laboratory testing

Send one copy to laboratory with the specimen, one to the national surveillance centre, keep original at the sentinel site

Page 60: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010
Page 61: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

SARI Weekly Aggregate Data Form

ID number of sentinel site, and focal pointNew SARI cases during weekNew inpatients during weekNumber of SARI cases selected for influenza

testingNumber of SARI deaths during the week

Ages: 0-4, 5-14, 15-29, 30-64, 65+, Total

Page 62: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

SARI Weekly Aggregate Data Form

Page 63: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

ILI Weekly Aggregate Data Form

ID number of sentinel site, and focal pointDay(s) of week surveillance was undertakenNew ILI cases during weekNew outpatients during weekNumber of ILI cases selected for influenza

testing

Ages: 0-4, 5-14, 15-29, 30-64, 65+, Total

Page 64: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Unique Identification Numbers

Important for linkage between laboratory and epidemiologic information

Numbers should be standardized throughout the country

Assigned when SARI or Outpatient Swab forms are filled out

Same number used on any forms or specimens for each patient

Page 65: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Identification Number Example

001 / 09 / 1 / 0001Sentinel

SiteYear SARI or

ILICase

Number

Example: 1 = SARI 2 = ILI

Page 66: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Part 4: Roles and Responsibilities Within the Sentinel Surveillance

System

Page 67: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Sentinel Surveillance Structure

Countries implementing a sentinel surveillance system should have:

•Sentinel sites with a designated focal point

•National surveillance centre that coordinates the epidemiologic data collection and analyses

•National Influenza Centre / laboratory that oversees virologic aspects of the surveillance system and laboratory quality

WHO / Regional Offices

Regional Surveillance Platform

CountriesData

Summary Reports

WHO Global Platforms (FluNet and FLU-ID)

Page 68: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Sentinel Site Focal Point

Adhere to case definitionsAdhere to unbiased

systematic sampling strategies

Collect respiratory specimens

Package, store, and transport specimens

Assign unique ID number to specimens and forms

All data forms are filled out completely and accurately

Manage and transmit epidemiologic data

Track daily number of SARI and ILI cases, and number selected for laboratory testing

Assure timeliness of data reporting and specimen collection and transport

Report SARI laboratory test results to the clinician

Ensures that staff at the site carry out the following:

Page 69: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

National Surveillance Centre

Organizational entity assigned to coordinate influenza surveillance in a country

Should have a national surveillance focal point who is responsible for implementation and coordination of the national influenza sentinel site surveillance system

May be located in different agencies or institutes in different countries

Page 70: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

National Surveillance Centre Focal Point

Assist MOH with selection of sentinel sitesAssist with decisions about ILI and SARI sampling

and epidemiologic data collectionAssure that sites have data collection forms and

reporting mechanismsAssure that the data is analyzed correctlyDisseminate the weekly and annual flu reportReport data into the regional and global platformsRoutinely monitor the sentinel surveillance system

Responsibilities:

Page 71: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

National Influenza Centre (NIC)

Recognized by WHO

Participates in regional influenza network and GISN

An up-to-date list of NICS can be found at: http://www.who.int/csr/disease/influenza/centres/en/index.html

Page 72: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

NIC Routine Responsibilities

Provide technical support and guidance to sentinel sitesReceive, register, and store specimens from SARI and ILI

casesPerform analyses on seasonal virusesPerform subtyping of non-seasonal viruses, minimally

Influenza A(H5N1) Pandemic influenza A(H1N1) 2009

Archive and store original specimens at least one yearShare samples with WHO CCsConduct antiviral susceptibility testing (where possible)Maintain linkage between site and laboratory ID numbers

Page 73: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

NIC Responsibilities: Data Analysis and Reporting

Communicate results of confirmatory testsConsolidate and analyze national laboratory dataReport weekly national surveillance data into

regional and global surveillance platformsDevelop national diagnostic standards and assays,

provide training, and organize quality assurance programs (where possible)

Page 74: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

SentinelSites

INHP ( Epi Surv, MoH)

DGS (Gen. Dir, MoH)

IPCI (NIC)

Partners: WHO, CDC, UNICEF…

SentinelSite

SentinelSite

Example: Surveillance System Organization in Cote D’Ivoire

CABINET (Minister)

Page 75: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

UkraineUkraine GeorgiaGeorgia

Sentinel site focal point submits data forms

Regional surveillance coordinator enters data and verifies accuracy and completeness

Regional laboratories test specimens

NIC provides confirmatory testing and ensures functioning of the system

Smaller population and geographic area

Sentinel sites send samples and data forms to NIC within national public health agency

National Center for Disease Control and Public Health monitors operation of the system

Examples of Surveillance System Organization

Page 76: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Notification of Novel Influenza Viruses through the IHR Mechanism

Immediate notification to WHO through the IHR mechanism: Human infection with influenza A other than seasonal subtypes

Any combination of H2, or H4-H16 with any of the N1-N9 subtypes

Includes avian influenza subtypes A(H5N1), A(H9N2), and A(H7N7)

Human infections of Influenza A viruses that grow poorly in cell culture or react poorly with standard WHO reagents in HAI assays

May have same subtype as seasonal viruses, but be of animal origin (such as pandemic (H1N1) 2009)

Page 77: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Participating in WHO External Quality Assessment Project for the Detection of Influenza A Viruses by PCR

To improve global laboratory capacity for influenza diagnosis

To monitor quality and standards of performance of NICs around the world

Requirements: Laboratories test a panel of simulated H1, H3, H5 specimens

twice per year Each laboratory receives performance report

Page 78: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Part 5: Data Reports and Analysis

Page 79: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Outline

Measures of BurdenWeekly ReportsAnnual ReportsReporting Outside the Country/Publications

Page 80: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Measures of Burden

Incidence rate o Number of influenza cases per 100,000 population per time unito Allows for estimate of age-specific burden of disease o International standard for reportingo Incidence of influenza consultations also valuable to monitor

seasonal intensity over time

Proportion of SARI and ILI at sentinel sites that is caused by laboratory-confirmed influenzao Minimal standard

Page 81: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Example: The Netherlands

General practitioners Collect specimens and data from a random sample of persons

meeting ILI case definition Each maintains list of 2,500 patients, which can be used for

denominator data

Incidence rate Calculated per 100,000 per week

Page 82: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Minimal Analyses and Reports

Generate weekly, at least 4 weeks prior and following typical peak months

Disseminate to all relevant governmental partners, sentinel sites, and the public

Virologic surveillance conducted outside flu season may be reported less frequently

Page 83: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Weekly SARI Data

During the previous week:Number of new cases at each sentinel siteNumber of total new hospital admissions at each

sentinel siteNumber of SARI cases selected for influenza

testing % testing positive By influenza type and subtype

Number of inpatient deaths due to SARINumber of sentinel SARI sites reporting

Results for all sites stratified by the age groups: 0-4, 5-14, 15-29, 30-64, 65+

Page 84: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Example: SARI Surveillance Weekly Report (South Africa)

Report comes out weeklyPosted on website:

http://www.nicd.ac.za/Includes graph and table

portraying virological data By epidemiological week By sentinel site

Page 85: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Weekly Outpatient Data

During the previous week:Number of new ILI cases reported Number of total outpatients seen at ILI sentinel siteNumber of ILI cases selected for influenza testing

Percent of tested ILI positive for influenza By influenza type and subtype

Page 86: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Additional Data to Report

If available, report: Weekly consultation rates for ILI, or

SARI Antiviral resistance testing results

http://www.cdc.gov/flu/weekly/

• Data on geographical spread (map)

• Level of detail will depend on number and location of sentinel sites

Page 87: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Annual Analyses and Reports

Page 88: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Annual Analyses

SARI, ILI, and confirmed influenza cases by age and month

Underlying medical conditions of SARI patientsNumber and percent of positive influenza

cases who received vaccination in the current season.

Number and percent of positive influenza cases exposed to antivirals 14 days before onset of symptoms

Incidence rates

Page 89: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

All AnalysesAll Analyses Optional StratificationsOptional Stratifications

0-4 years5-14 years15-64 years>65 years

0-12 months15-2930-64>75 yearsAdditional age

categories that inform vaccination policy

Standard Age Stratification

Page 90: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Assessment of Seasonality

Establish the baseline rate of influenza in a region/ country

Inform the timing of vaccination and treatment

Page 91: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Example: Using Data in the UK

Yearly guidance issued to doctors about when antiviral agents should be prescribed

Recommendations are based off of surveillance data and are triggered when:o GP consultation rates rise above 30 consultations per 100,000

populationo Community-based influenza surveillance is above baseline

Page 92: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Reporting and Publication

Page 93: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Regional and Global Reporting for Seasonal Influenza

Flu Season (4 weeks before and after typical peak influenza months): epidemiologic and virologic data should be reported regionally

Non-flu season: only virologic data

Can be used for a regularly published bulletin

Page 94: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Example: EuroFlu Weekly Electronic Bulletin

Detailed epidemiologic and virologic data for each country and Europe as a whole. Presented with: Maps Tables Graphs Pie charts

National level reporting mechanism is important

Page 95: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Example: EuroFlu as a Basis for Synthesizing Regional Information

Page 96: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Reports for Posting/Publication

Public posting of routine analysis and data should be national surveillance system goal.

Peer-reviewed publication is also important. May include: Routine analyses Special studies

Informs international influenza control effortsCreates advocates for influenza interventions

Page 97: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Part 6: System Monitoring

Page 98: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Outline

Suggested Quality IndicatorsTimelinessCompletenessValidity

Page 99: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Timeliness Indicators

Expected dates of data reporting from sentinel site to next administrative level compared to actual dates

Some examples are time elapsed from: Specimen collection to arrival at the laboratory Laboratory receipt of specimens to laboratory

processing and testing Laboratory confirmation results to inclusion of results in

Weekly Influenza Reports Laboratory confirmation results for individual SARI

cases to notification of the sentinel site focal point Laboratory results for individual SARI cases by the

sentinel site focal point to notification of the patient’s doctor

Page 100: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Quantification of Timeliness Indicators

Percent of time site achieves targets for specific time intervals

e.g. 90% of specimens received at the laboratory within 48 hours of specimen collection

Percent of samples tested within a target time framee.g. 90% of tested specimens have results within 1 week

Percent of sites achieving time targets or time lag averagese.g. 90% of sentinel sites package and transport 90% of specimens within 48 hours of collection

Percent of time that doctors receive laboratory results for SARI cases within 48 hours of confirmatory test completion

Page 101: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Completeness

Percentage of swab forms received from each site with complete data

Percentage of total expected swab forms that are received

Percentage of total expected cases that have specimens submitted to the laboratory

Page 102: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Validity: Data Audits

Ensures Validity by determining the following:oCase definitions are understood and adhered tooCases are counted appropriately (no duplicates)oReported cases meet the case definitionoUniform sampling procedures are being followedo Laboratory equipment and staff are sufficientoData values are being recorded correctly (can be

compared to gold-standard of chart-review)o Sentinel sites and doctors are receiving timely feedback

and SARI test results

Page 103: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Validity: Compare to Expected Results

Number of cases reported each month at siteNumber of specimens submitted each month at each

sitePercent of specimens positive for influenza each

month at each siteNumber and percent of SARI and ILI cases tested

Does something look out of the ordinary?

Page 104: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Comprehensive System Evaluations

Conduct in addition to routine monitoringWhen to conduct

At start-up At regular intervals If aberrations in expected results are observed

Page 105: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Part 7: Additional Uses of the System and

Surveillance Data

Page 106: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Outline

Estimating disease burden

Establishing baselines and thresholds

Pandemic detection, planning, and monitoring

Page 107: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Overview

Make decisions about health resource allocation

Identification of risk groups for targeted intervention

Monitoring of the impact of intervention programs, including vaccination

Page 108: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Estimating Disease Burden

Page 109: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Estimates of Disease Burden

Disease burden = amount and impact of influenza in the population represented by a sentinel site(s)Basic measures

o Incidence rates of hospitalized SARI caused by laboratory-confirmed influenza

o Estimates of excess mortalityo Direct costs of medical care and treatmento Indirect costs due to lost time from employment or costs

incurred by family members of a sick person

Page 110: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Importance of Disease Burden

Assist policy makers Decisions about allocation of

resources by putting influenza in perspective relative to other diseases

Judge cost-benefit ratio of interventions

Stimulate or target future surveillance activities

Page 111: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Estimating Catchment Area

Sources of population denominator data:Patient lists from sentinel physiciansWell circumscribed municipalities of medium

size where sentinel sites capture a large portion of admissions/outpatients

Health Utilization Survey can be used if: Well-defined community Site does not receive a large proportion of cases

from distant areas See guidance document for more details

Page 112: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Establishing Baselines and Thresholds

Page 113: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Baseline Incidence

Baseline = level of influenza activity typically seen outside the seasonal epidemic

Rise above baseline indicates start of seasonal epidemic

Serves as an objective threshold for public health action

Occasionally influenza activity does not exceed the baseline threshold

Page 114: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Pandemic Detection, Planning, and Monitoring

Page 115: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Sentinel Surveillance Supports Public Health Response

Establishes infrastructure for: Prioritizing investigation of severe respiratory illness cases Creating clinical specimen collection and transport network Building expertise in confirmatory testing for human and novel

influenza viruses Strengthening relationships between laboratory, epidemiologic,

and clinical personnel

Page 116: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Sentinel Systems and Early Warning

Sentinel systems are generally not adequate for detection of unusual events or outbreaks early in their

course

Page 117: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

The Role of the Sentinel System in Monitoring a Pandemic

Monitoring the course of a pandemic will use existing routine influenza surveillance data describing: Location of the virus Trend in cases Severity of pandemic Changes in virulence

Page 118: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Part 8:Laboratory Specimen Processing

Page 119: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Outline

Specimen collectionSpecimen storage and packagingSpecimen testingShipment of specimens

Page 120: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Specimen Collection

Page 121: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Collecting Respiratory Specimens

For direct detection of antigens or nucleic acids, and for virus isolation (culture)o Take no more than 7 days after onset of symptomso Ideally take within 3 dayso Preferably before antiviral therapy

Record time from illness onset to specimen collection

Give patient verbal explanation of reason for specimen collection and how it will be collected

Page 122: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Specimen Tube Labeling

Patient unique identifier

Specimen date

Type of specimen in the tube

Hazard label

Page 123: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Upper Respiratory Specimens

Best for virus isolation and PCR Nasopharyngeal (NP) swab Nasopharyngeal aspirates or washes Nasal wash

Alternatively, collect both Nasal swab Throat swab Combine in single vial of VTM

Page 124: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Materials Required

Personal protective equipmentSwabsTongue depressorsPlastic vials, such as cryovials, containing 2-3

ml of virus transport medium (VTM) stored at 4°C (supplied by the NIC)

Serum collection: collection tubes, alcohol, gauze, non-heparin treated needles

Alcohol and/or bleachPackaging materials for transport in country

Page 125: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Specimen Storage and Packaging

Page 126: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Specimen Storage

Place in VTM immediatelyStore at 4°C, up to 24 hoursFor immunoflourescence:

Refrigerate and process within 1-2 hours

For virus isolation: Refrigerate and inoculate into cell cultures as soon as

possible

If not processed within 48-72 hours, freeze at or below -70°C

Page 127: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Specimen Storage

Specimens may be divided into aliquotsFreeze-thaw cycles should be minimizedDo not store in a household freezer (-20°C)

with a “defrost” cycle Keeping sample on ice up to a week is better than

allowing freeze-thaw cyclesBlood may be stored at room temperature

overnight or incubated at 56°C for 30 minutes Remove serum and store at 4°C up to a week or

put into long term storage at -20°C

Page 128: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Preparation of VTM

Add 10g veal infusion broth and 2g bovine albumin fraction V to 400 ml sterile distilled water

Add 0.8 ml gentamicin sulfate solution (50 mg/ml) and 3.2 ml amphotericin B (250 μg/ml)

Sterilize by filtration

Store unopened for up to one year

Page 129: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Packaging

3 layers of packagingCompliance with P650

requirements for infectious substances in UN 3373 category B

1st layer Watertight specimen tube

(no more than 500mL) Absorbent material

2nd layer Watertight container (zip-

loc or hard plastic)3rd layer

Rigid outer packaging

Page 130: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Packaging

May need to include ice packs or dry ice

Example: P650 packaging system in combination with Safetybag

Page 131: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Specimen Testing

Page 132: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Specimen Processing

BSL-2 laboratoryClass II microbiological safety cabinet for

procedures that may give rise to infectious aerosols

Seasonal influenza: disposable gloves and gownSuspect avian influenza / severe respiratory

pathogens: BSL-2 laboratory with BSL-3 practices, or BSL-3 laboratory

Page 133: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Non-molecular Influenza Detection and Subtyping

Viral isolation Eggs Cell culture Followed by HAI assay using WHO reagent kit

Immunofluorescence assay Initial screen to select specimens for viral

isolation Low sensitivity Requires living cells

ELISA Low sensitivity

1918 influenza virions.CDC/ Dr. Terrence Tumpey

Page 134: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Influenza Detection and Subtyping by RT-PCR

Higher sensitivityIncreased biosafety

Uses low amounts of virus Viral isolation can be performed on known subtypes

Cost effectiveRapid

Can provide results in 24 hours

Page 135: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

RT-PCR is Recommended for Confirmatory Testing and to Select Specimens for Virus Isolation

Real-time RT-PCR preferred

Assays can be developed locally or obtained commercially Primers and probes must be validated at least once a year

Can be performed in BSL-2 laboratory o Reduces chances that isolation of a novel virus (a BSL-3

practice) will be attempted in BSL-2 conditions

Page 136: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Virus Isolation

Performed after confirmation of type and subtype

Cell or egg culture Cell line: Madin-Darby canine

kidney

Results in 2-10 daysFollowed by HAI, RT-PCR,

or IFAMing Wang, et al. Food Markets with Birds as a Source of Avian Influenza. Emerg Inf Dis Vol. 12, No. 11. Nov 2006

Page 137: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Principles for Viral Isolation

BSL-2 laboratories test for: Seasonal influenza A(H1N1) Seasonal influenza A(H3N2) Influenza B Other respiratory viruses (RSV, adenovirus)

BSL-3 laboratories test for: Influenza A, subtype not identified Influenza A, subtype identified as not being

Human seasonal A(H1N1) or Human seasonal A(H3N2)

Page 138: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Testing Algorithm for SARI and ILI

Test one of duplicate specimens by (real time) RT-PCR: type A/B

Isolate virus on cell culture or eggs

Perform lineage identification or influenza A subtyping

Ship an aliquot of to a WHO CC for further virus identification and strain characterisation

Subtyping for H1, H1v, and H3 by RT-

PCR

A+

BSL2: Ship aliquot of specimen to a WHO CC

BSL 3: isolate virus on cell culture of eggs from early specimens, and a sample of future specimens

Test for other respiratory viral pathogens

B +Influenza -

H1+ or H3+

H1v

Page 139: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Seasonal Influenza Serology

TestingUse reagents from WHO

CDC test kitConduct HAI assay on

paired sera (if available) Positive: 4-fold rise in

antibody titerCollect convalescent serum

14 days – 4 weeks after symptom onset

Other considerationsImportant for

retrospective analysis of outbreaks

Page 140: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Avian influenza A(H5N1) Serology

TestingVirus neutralization

assayBSL-3 laboratory with

BSL-3 standardsPositive: 4-fold or greater

rise in neutralization antibody titer

Paired serum samples

Other considerationsSingle serum samples can

be useful for detecting antibodies

Used for: Confirmation when

respiratory specimen testing and virus isolation are inconclusive

Retrospective analysis of outbreaks

Page 141: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

WHO kits and protocols for real time RT-PCR detection of pandemic (H1N1) 2009

In response to the pandemic, WHO CC at CDC has developed and distributed kits for real-time RT-PCR detection of pandemic (H1N1) 2009.

Page 142: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Shipment of Specimens

Page 143: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Shipment of Specimens to WHO Collaborating Center

Logistical support: WHO Global Shipment Project Covers 2-3 shipments of seasonal viruses per season Covers novel viruses as necessary Uses World Courier Shipment initiated by completing booking form Requires export permit (standing permit recommended)

Page 144: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Shipment Regulations

International regulations for air shipment Technical Instructions for the Safe Transport of Dangerous

Goods by Air Dangerous Goods Regulations (DGR) may add further

restrictions

Shipping personnel IATA-certified training available to NIC staff Certificate valid for 12 months Encouraged, but not required for personnel shipping

seasonal influenza pathogens

Page 145: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Shipping Specimens on Ice

For fresh isolates Use ice packs Use insulated vials Delivery within 48 hours or refrigerate at 4°C

For frozen isolates Ship on dry ice

Include swab form and itemized list of contents between secondary and outer packaging

Page 146: Influenza Sentinel Site Surveillance Training Addis Ababa, Ethiopia: February, 2010

Specimens for WHO CC or WHO H5 Reference Laboratories

Forward to WHO CC for virus strain characterization and vaccine strain selection:

Representative seasonal viruses from SARI and ILI cases

A(H3N2) A(H1N1) Influenza B

At beginning, peak and near end of season

Dispatch immediately to WHO CC and/or WHO H5 Reference Laboratory: The first specimens found to be positive for H1N1vLow-reacting virusesSpecimens with influenza A viruses for which subtype was not identifiedSpecimens with avian influenza or other novel virusesInclude swab form and list of contents