Communicable Diseases Surveillance in Estonia, 2005

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Communicable Diseases Surveillance in Estonia,
2005

• Kuulo Kutsar MD, PhD
• Health Protection Inspectorate, Estonia

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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

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CORE FUNCTIONS OF THE NATIONAL SURVEILLANCE SYSTEM

• Case detection
• Case reporting
• Case investigation confirmation
• Analyses interpretation
• Action
• - response
• - control
• - feedback
• - decision/policy making

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SUPPORT FUNCTIONS OF THE NATIONAL SURVEILLANCE
SYSTEM

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

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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

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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

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PRIORITY DISEASES FOR SURVELLANCE

• Commission Decision 2000/96/EC
• Criteria 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

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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

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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

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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

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• 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

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Health Protection Inspectorate responsibilities

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

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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

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Health Protection Inspectorate
responsibilities on CD surveillance

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

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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

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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

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Exchange of information in the public health
system
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Communication on CD surveillance
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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

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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)

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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)

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EARLY WARNING AND RESPONSE SYSTEM
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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

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NATIONAL EWRS CAPACITIES

• 1. Interventional epidemiology
• 2. Clinical microbiology
• 3. 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

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EWRS FLOWCHART

• 1. Case identification from surveillance
  activities
• 2. Case/cluster confirmation
• 3. Outbreak identification
• 4. Early warning message
• 5. Assistance request
• FOCAL
  POINT
• 6. Assessment for collaboration investigation
• 7. 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 report
• 10. Feedback and ongoing surveillance

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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 B
• C. Food- and waterborne diseases
• salmonellosis, shigellosis, enterohaemorrhagic
  E. coli O157H7
• infection cholera
• D. Diseases having epidemic characteristics
• HIV/AIDS, tuberculosis

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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

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PERMANENT LINKS WITH OTHER NATIONAL ALERT SYSTEMS

• Food-borne diseases (Ministry of Agriculture)
• Zoonoses (Ministry of Agriculture)
• Consumers protection (Ministry of Economy)

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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

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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

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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 response
• List of CD for mandatory notification consists of
  62 diseases 88 biological agents, including EC
  covered diseases
• Case definitions have developed in May 2004 as
  guidelines
• Data protection should be improved
• 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

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Current situation perspectives

• Improvement of institutional capacity
• Administrative capacity, participation in EC
  committees, working groups and DS Networks is
  problematic due to limited human resources and
  funding
• 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

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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/epidemiolog
  ists

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THANK YOU !