Communicable Diseases Surveillance

in Estonia, 2005

Kuulo Kutsar MD, PhD

Health Protection Inspectorate, Estonia

MAIN OBJECTIVES OF THE NATIONAL COMMUNICABLE DISEASE SURVELLANCE SYSTEM

• Public health decision-making• Priority setting• Planning• Resource mobilization & allocation• Early detection of outbreaks/epidemics and

response• Implementation of immunization programme• Monitoring & evaluation of communicable

disease prevention & control programmes

CORE FUNCTIONS OF THE NATIONAL SURVEILLANCE SYSTEM

• Case detection• Case reporting• Case investigation & confirmation• Analyses & interpretation• Action

- response- control- feedback- decision/policy making

SUPPORT FUNCTIONS OF THE NATIONAL SURVEILLANCE SYSTEM

• Setting of standards/case definitions• Training• Supervision• Laboratory support• Communication• Resource management

SURVEILLANCE TASKS AT LOCAL LEVEL

• Case identification/diagnosis & case management• Case reporting to intermediate level

SURVEILLANCE TASKS AT REGIONAL LEVEL• Case management and reporting• Data analysis at local level for - epidemiological links and trends - achievement of control targets• Laboratory support/diagnosis• Outbreak investigation• Feedback to local level• Reporting to national level

SURVEILLANCE TASKS AT NATIONAL LEVEL

• Co-ordination of surveillance activities• verification of laboratory diagnosis• Data analysis at intermediate level for - epidemiological links and trends - achievement of control targets• Support to regional level for outbreaks control: case management, laboratory support,

epidemiological investigation, logistics, training• Feedback to regional & local levels• Collaboration with interested parties• Reporting to international organizations

PRIORITY DISEASES FOR SURVELLANCE

Commission Decision 2000/96/ECCriteria: high disease impact, high epidemic potential, target

of national/international programme, info leads to important public health activities

• Vaccine-preventable diseases• Viral hepatitis B & C• HIV- infection & AIDS• Other sexually transmitted diseases• Food & water-borne diseases• Diseases of environmental origin• Zoonoses• Air-borne diseases• Serious imported diseases• Nosocomial infections• Antimicrobial resistance

PRIORITIES IN SURVEILLANCE CAPACITY BUILDING

• A disease is frequent and has a high political priority:HIV/AIDS, tuberculosis

• A disease is of rare and of high public health importance:with bioterrorism potential (anthrax, malaria, a disease of unknown origin etc)

• A disease is moderate frequency and high public health importance: food-borne diseases and intoxications

• Diseases included into regional/global elimination/eradication programmes: poliomyelitis, measles, congenital rubella

STRATEGIC PRIORITIES IN CD SURVEILLANCE

• Keeping ministries and politicians informed on CD problems• Co-operation with neighbouring countries:

- exchange of CD surveillance info- operational early warning system- integrated outbreak/epidemic response- integration of prioritized diseases- implementation of common standards/case definitions

• Strengthening microbiological & other laboratories capacity- common standards for quality assessment

• Training in field epidemiology- co-operation with MS & neighbouring countries- training manuals

• Harmonization of epidemiological & microbiological investigation methods used by MS- integrated approach to CD surveillance

DISEASE SPECIFIC SURVEILLANCE SYSTEMS

• Case identification/diagnosis & case management• Case reporting to intermediate level

SURVEILLANCE TASKS AT REGIONAL LEVEL• Case management and reporting• Data analysis at local level for - epidemiological links and trends - achievement of control targets• Laboratory support/diagnosis• Inspected outbreak investigation• Feedback to local level• Reporting to national level

National legislation•Public Health Act (1995, 2004)•Communicable Diseases prevention and Control Act (2003) and regulations of the Minister of SA•Emergency Preparedness Act (2000, 2002)•Special Situation Act (2002)

EU legislation•2119/98/EC•2000/57/EC•2000/96/EC•2002/253/EC; 2003/534/EC•2003/542/EC• 1999/72/EC; 2003/72/EC•2003/99/EC

A dvis er ine nvironm e nta l he a lth

A dvis er inpubl ic re la tions

A dvis er ine pide m iology

D e p. o f E nviron .He a lth E x pe rt. (5 )

D e p. o f Pla n .a nd M onitor ing (5 )

D e p. o fE pide m iology (5 )

V ic e -D G

G e ne ra l D e p.(1 1 )

D e p. o fBook k e e ping (6 )

T a l l inn C e ntra lL a bora tory (33 )

T a rtu L a b (1 3 )

Pä rnu L a b (4 )

K -Jä rve L ab (6 )

V ic e -D G

Ha rjum a aC ounty D e pa rtm e nt

Ra pla m a aC ounty D e pa rtm e nt

Järvam a aC ounty D e pa rtm e nt

E s tonianS Q S

D ire c tor of theT a l l inn HPS (83 )

T a rtum a aC ounty D e pa rtm e nt

Jõge va m a aC ounty D e pa rtm e nt

Põlva m a aC ounty D e pa rtm e nt

V a lga m a aC ounty D e pa rtm e nt

V õrum a aC ounty D e pa rtm e nt

V i l ja ndim a aC ounty D e pa rtm e nt

D ire c tor of theT a rtu HPS (6 2 )

Pä rnum a aC ounty D e pa rtm e nt

L ä ä ne m a aC ounty D e pa rtm e nt

S a are m a aC ounty D e pa rtm e nt

L a bora toryunit

H i ium a aC ounty D e pa rtm e nt

D ire c tor of thePä rnu HPS (4 7 )

L ä ä ne -V irum a aC ounty D e pa rtm e nt

Ida -V irum a aC ounty D e pa rtm e nt

D ire c tor of theV irum aa HPS (3 6 )

D ire c tor G e ne ra l

Health Protection Inspectorate responsibilities

• surveillance of communicable diseases

(62 notifiable diseases, 88 etiological agents) • outbreak management• management and surveillance of immunization• EWRS

Health Protection Inspectorate responsibilities on CD surveillance

Surveillance of communicable diseases

(62 notifiable diseases, 88 agents) • data collection• analysis (epidemiological links, trends)• control • early warning & response• CD register established 1.07.2004, in action

1.01.2005

Health Protection Inspectorate

responsibilities on CD surveillance

• Outbreak investigation & management• Epidemiological investigation • Epidemiological risk assessment• Laboratory investigation• Communication

Health Protection Inspectorate responsibilities on immunization

Management of National Immunization Programme

• Data collection • Immunization analyses: coverage, timeliness• Vaccines procurement & logistics (storage &

distribution) • Cold chain management • Immunization safety• Supervision

Health Protection Inspectorate responsibilities on

epidemic/pandemic preparedness

• Planning and coordination• Situation monitoring and risk assessment• Prevention and control• Health system response a) health care, b) public health• Communication

NATIONAL COMMUNICABLE DISEASE SURVEILLANCE SYSTEM FLOWCHART

CASE DETECTION Local level

General practitioner, Laboratory TIME-LINE FEEDBACK Hospital ---------------- -------------------

Case report After final MonthlyHard copy diagnose Fax

Lab.results Hard copy---------------- -------------------

Intermediate levelCounty PublicHealth Office Monthly

Phone Monthly FaxFax E-mailE-mail

MonthlyInternational National level --------------- --------------------Institutions Health Protection

Inspectorate Monthly AnnuallyInf.dis. Annually Hard copyBulletin

E-mail

Ministry of Social ------------------ --------------------Affairs

Monthly AnnuallyAnnually Hard copy

E-mailState Statistics

Board ------------------ ---------------------

Exchange of information in the public health system

MSA

Public Health AuthorityHealth Protection Inspectorate

Regional Service County department

Municipalities

Rescue BoardEmergency

Centre

Sanitary QuarantineService 24h/7d

County Vet. &Food Board office

Microbiol/VirolLaboratories

GP

Internat. Port &AirportBorder Guard

Communication on CD surveillance

GP, HospitalsLaboratories

County HPI office

HPI

County Vet & FoodBoard office

Global SalmonellaNetwork

WHO

Ministry of SocialAffairs

EC Disease SpecificNetwork (ENTER-

NET, LISTER- NET,EUROCJD)

Individual data

Aggregated data

Communicable diseases notification under the Communicable Diseases Prevention and

Control Act & Gov. Regulation no. 297, 2003

• Physician notifies 62 CD diseases Record list: patient name, birth date, gender, address, date of onset, date of notification, diagnose (ICD-10), method of lab investigation, history of immunization, date of hospitalization

• Laboratory notifies 88 biological agents Record list: patient name, birth date, gender, diagnose (ICD-10), sample, method of lab investigation, identified biological agent

Reporting of CD surveillance data

• HPI website www.tervisekaitse.ee• Data provided to EU BSN & DSN and WHO• Monthly summary report to MoSA• Monthly bulletin EstEpiReport (in English)

to counterparts and interested countries• Annual report to MoSA• Annual report to the EpiNorth (Bulletin of

the Network for CD Control in Northern Europe & Baltic Sea Region)

Staffing of public health professionals/CD epidemiologists

(CA – Central Authority; HPO-Health Protection Office)

CA HPO ofHarjumaa

HPO ofTartumaa

HPO ofPärnuma

a

HPO ofVirumaa

Total

Senior Inspectorof Epidemiology

5 5,5 3,6 2 2,25 18,35

Junior Inspectorof Epidemiology

1 12,25 3,8 2,75 1,5 21,3

CO-OPERATION WITH INTERNATIONAL COMMUNICABLE DISEASE SURVEILLANCE

NETWORKS

• Global Salmonella Surveillance Network• EU DSN ( Influenzae, measles, pertussis, HIV-infection,

Haemophilus influenzae b, salmnellosis, Enterohaemorrhagic E. coli, meningococcal disease, diphtheria, TB, CJD, legionellosis)

• Inventory on resources on CD control (IRIDE)- Inventory of Communicable Disease Control Resources in the Baltic states. Project Report. Stockholm, 2001

• European Project on Surveillance of Vaccine-preventable Diseases (EUVAC-NET). EUSAFEVAC Project.

• International Tick-borne Encephalitis Working Group• Network for Communicable Disease Control in Northern Europe

(CD Surveillance in Baltic Sea Region)• CCEE-Baltics Communicable Disease Network (WHO/Euro)• European Food-borne Diseases and Intoxications Surveillance

System (WHO/Euro)

EARLY WARNING AND RESPONSE SYSTEM

KEYSTONES OF RAPID RESPONSE

• Simple decision taking• Minimum involved hierarchical structures• Coordinated response• Maximum complexity

- Ministry of Defense, Min of Justice, Min of Agriculture, Ministry of Inner Affairs, Ministry of Environment

• Funding• Risk assessment• Proposed prevention/control measures

NATIONAL EWRS CAPACITIES

1. Interventional epidemiology2. Clinical microbiology3. Research microbiology

• Epidemiological and clinical microbiology/virology capacities are integrated in Health Protection Inspectorate, some clinical microbiology - in hospital labs

• Research microbiology is provided by Tartu University Microbiology Institute

EWRS FLOWCHART

1. Case identification from surveillance activities2. Case/cluster confirmation3. Outbreak identification4. Early warning message 5. Assistance request

FOCAL POINT6. Assessment for collaboration investigation7. Epidemiological investigation team in the field

• media communication• logistic support• management/co-operation• epidemiological investigation• implementation of control measures

8. Outbreak controlled• epidemiological-analytical study

9. Outbreak report10. Feedback and ongoing surveillance

LIST OF PRIORITY COMMUNICABLE DISEASES FOR RESPONSE

A. Required special action for public health preparedness:smallpox, anthrax, plague, botulism, tularemia, viral

hemorrhagic fevers (Ebola, Marburg, Lassa, Junin etc)B. Required specific diagnostic capacity and enhanced surveillance response:brucellosis, Q-fever, glanders/malleus, meningococcal

infection, Clostridium perfringens epsilon toxin, Staphylococcus

enterotoxin BC. Food- and waterborne diseases:salmonellosis, shigellosis, enterohaemorrhagic E. coli O157:H7

infection; choleraD. Diseases having epidemic characteristics:HIV/AIDS, tuberculosis

GENERIC EPIDEMIOLOGICAL EXPERTISE IS OFFERED TO IMMIDIATE

PUBLIC HEALTH THREATS

• Food-borne diseases and intoxications• Food safety• Veterinary issues• Environmental disasters• Chemical disasters• Nuclear pollution• Military deployment• Bioterrorism

PERMANENT LINKS WITH OTHER NATIONAL ALERT SYSTEMS

• Food-borne diseases (Ministry of Agriculture)

• Zoonoses (Ministry of Agriculture)• Consumers protection (Ministry of

Economy)

PRE-EARLY WARNING BETWEEN MINISTERIES/INSTITUTES IS

OPERATIONAL

• Inquiry from involved partners may activate the system

• Technical capacity with skilled epidemiologists is available

• Verification of disseminated information• Consultation is essential part of the system• Disease specific surveillance systems and

reference labs are involved

STRENGTHENING OF NATIONAL EWRS

• Improvement of the quality of epidemiological surveillance• Increasing of public health information availability• Efficient and timely risk analysis• Standardization of epidemiological and microbiological investigation methods• Available high quality scientific expertise• Providing training• Networking• Promotion of research• Advise for public health policy• Strengthening communication• Co-operation with EC, WHO and other international

organisations• Identification of public health threats of cross-border nature

Current situation & perspectives

CDS system is well adopted to implement EU guidlines and priorities for data reporting, outbreak investigation, early warning & response

• Legislation covers not all aspects of CD surveillance & response1. List of CD for mandatory notification consists of 62 diseases & 88

biological agents, including EC covered diseases2. Case definitions have developed in May 2004 as guidelines 3. Data protection should be improved4. Preparedness for health threats: smallpox, bioterrorism, influenza

and SARS preparedness plans are developed, but not implemented• Several fields of activities are not legaly covered: EWRS is

operating only on initiative of HPI, Quarantine Act is not developed, epidemic preparedness & epidemic response are poorly funded, immunisation programme is poorly funded

Current situation & perspectives

• Improvement of institutional capacity 1. Administrative capacity, participation in EC committees,

working groups and DS Networks is problematic due to limited human resources and funding

2. Laboratory capacity: needs to be improved, reference lab system should be developed, standard test procedures for priority diseases should be implemented, national manuals for lab procedures, biosafety and quality control should be improved

• BSL-3 microbiology & virology labs should be established in public health system

• SARS diagnostic lab should be established

Current situation & perspectives

• Development of national guidelines on CD surveillance, epidemic response capacity, guarantine, control & prevention

• Development of computerized CD reporting system EU funded project in co-operation with SMI, Sweden (2005-2006)

• Strengthening of CD control capacity

• Development of national education and training system for public health professionals/epidemiologists

THANK YOU !