Operational Guideline for ARI,ILI,SARI

39 Pages·2014·0.67 MB·English

Operational Guideline
for
Influenza-Like Illness
and
Severe Acute Respiratory Infection
Second Edition 2014
Public Health Laboratory
Department of Public Health
Ministry of Health
ILI & SARI
Surveillance
Second Edition 2014
Public Health Laboratory
Public Health Laboratory ILI & SARI Surveillance
Preface
ILI & SARI Surveillance
The influenza H1N1 pandemic of 2009 has demon-
Copyright © 2014 Public Health Laboratory strated a need for Bhutan to have a pandemic pre-
paredness plan in place. The establishment of an in-
Cover by: Tshering Dorji fluenza surveillance system in the country emerged
as one of the major requirements of the preparedness
plan. In 2012, Public Health Laboratory (PHL) came up
All rights reserved. No part of this book may be reproduced
with the first edition of the influenza surveillance guide-
in any form by any electronic or mechanical means including
line (Operational guideline for ARI/ILI/SARI Surveil-
photocopying, recording, or information storage and retrieval
lance). The guideline was operationalized in 2012 and
without prior permission in writing from Public Health Laora-
tory. the activities such as selection of surveillance sentinel
sites, training and retraining of the relevant stakehold-
ers, reporting of the cases on a timely basis, sample
shipment and testing, preparation and dissemination
ISBN-13: 978-1-451-51000-X
of reports were carried out as required.
ISBN-10: 1-451-51000-X
This Second Edition of the influenza surveillance
guideline is the revised edition of the first influenza
Give feedback on the book at: surveillance guideline.The revision of the second edi-
[email protected] tion of influenza surveillance guideline was carried out
with objective to enhance the efficiency of the exist-
www.phls.gov.bt ing surveillance system. The changes incorporated in
the second edition comprise of refinements of sur-
veillance objectives, segregation of Influenza-Like-
Illness(ILI) and Severe Acute Respiratory Infection
Printed in Bhutan
(SARI) sentinel surveillance sites, removal of Acute
Respiratory Infection (ARI) surveillance and redefin-
ing the roles and responsibilities of surveillance focal
points and Public Health Laboratory.
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Public Health Laboratory ILI & SARI Surveillance
Table of Contents Data security 46
Data Disposition 46
Guideline amendments 47
Training 47
Preface 5
References 48
Table of Contents 6
Annex 1 50
Background 8
Annex 2 51
Goal of this Document 10
Annex 3 52
Target Audience 10
Annex 4 53
Objectives of ILI & SARI Surveillance 11
Annex 5 54
Roles & Responsibilities 11
Annex 6 55
Selection and location of sentinel 17
Annex 7 58
sites 17
Annex 8 59
ILI Case Definition 21
Annex 9 64
Case selection and sampling strategy 21
Annex 10 65
Specimen processing at sentinel sites 22
Annex 11 66
Specimen Labeling 23
Annex 12 70
Onsite testing 23
Specimen Storage & Shipment 24
Specimen processing at NAIL, PHL 24
Data collection and Reporting 25
SARI Case Definition 29
Case selection and sampling strategy 29
Specimen processing at sentinel sites 30
Specimen labeling 31
Onsite testing 31
Specimen, Storage and Shipment 32
Specimen processting at NAIL, PHL 32
Data collection & Reporting 34
Data Management 36
Data Disposition 36
Analysis 36
Feedback 38
Indicators to assess the surveillance system 40
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Public Health Laboratory ILI & SARI Surveillance
Contributors Kunzang Dorji
Laboratory Officer
National Influenza Laboratory
Tshering Dorji Public Health Laboratory
Senior Laboratory Officer/Head Department of Public Health
National Disease Surveillance & Eoidemiology Unit Ministry of Health
Public Health Laboratory
Department of Public Health Sonam Gyeltshen
Ministry of Health Laboratory Officer
National Influenza Laboratory
Sonam Wangchuk Public Health Laboratory
Chief Laboratory Officer/Microbiologist Department of Public Health
Public Health Laboratory Ministry of Health
Department of Public Health
Ministry of Health Pema Chophel
Laboratory Officer
Chimmi Dorji Public Health Laboratory
Deputy Chief Laboratory Officer Department of Public Health
Public Health Laboratory Ministry of Health
Department of Public Health
Ministry of Health Thinley Jamtsho
ICT Officer
Binay Thapa Information, Communication & Technology Unit
Dy. Chief Laboratory Officer Public Health Laboratory
National Influenza Laboratory Department of Public Health
Public Health Laboratory Ministry of Health
Department of Public Health
Ministry of Health Tsheten
Laboratory Officer
Tsheten Enteric Disease Laboratory
Laboratory Officer Public Health Laboratory
Enteric Disease Laboratory Department of Public Health
Public Health Laboratory Ministry of Health
Department of Public Health
Ministry of Health
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Public Health Laboratory ILI & SARI Surveillance
population in the country.
The influenza A (H1N1 pdm2009) pandemic in 2009
Background
took many countries by surprise and most developing
countries were not prepared for a pandemic of such
scale. This pandemic has led to the establishment of
influenza surveillance and building of laboratory ca-
Influenza is a respiratory illness caused by influenza pacity to diagnose the virus in the country.
virus that can spread very easily from person to per- The Highly Pathogenic Avian Influenza (HPAI) H5N1
son. The virus is spread through the air by the ex- was first detected in Bhutan in poultry in 2011. Since
change of fluid droplets from the mouth or nose of one then it has caused periodic outbreaks in the poultry but
person to anotherperson due to sneezing and cough- no human cases have been detected so far. This epi-
ing. The manifestations of illness caused by the influ- zootic incidence poses a serious threat to public health
enza virus are usually mild to moderate but for some especially because of the severity and high mortality
it could be severe, leading to hospitalization and even in humans.
death. The influenza virus circulates around the world In February 2013, another novel influenza virus H7N9
and undergoes continuous evolution by antigenic drift was reported from China in humans. Compared to
which causes annual epidemics. In rare instances the 2009 H1N1, H7N9 cases have a higher percentage of
virus may change completely called ‘antigenic shift’, severe illness and deaths in humans, however its se-
and result in the emergence of novel influenza viruses. verity and mortality rate is lower than HPAI (H5N1).
Like HPAI (H5N1), H7N9 has limited human to human
World Health Organization (WHO) estimates 3 - 5 transmission. To date (March 2014), H7N9 has not
million cases of severe illness and about 250,000 – spread beyond China because of the global concerted
500,000 deaths every year around the world due to public health approach in containing the spread of the
a seasonal influenza epidemic. Additionally lower re- virus. However, this virus has the potential to cause
spiratory tract infections were found to be the leading another pandemic.
cause of death in low income countries and the third The ILI and SARIsurveillance system is aimed to moni-
leading cause of death globally. tor trends in respiratory illnesses and to understand
the burden and epidemiology of influenza viruses and
In Bhutan, respiratory illnesses are the major public other respiratory pathogens.Establishing a good sur-
health concern and affect a majority of the population veillance system will set the foundationto monitor other
irrespective of age. The annual Health Bulletin 2013 factors including the social and climatic factors that
reports that, for the past many years, acute respiratory influence community transmissionand help with plan-
infection is rated as the top disease affecting general ning for intervention and preventative measures.
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Public Health Laboratory ILI & SARI Surveillance
Objectives of ILI & SARI Surveillance
1. Describe the seasonality of influenza activity.
2. Establish baseline levels of influenza, ILI and
Goal of this Document
severe respiratory disease, which may be re-
lated to influenza and other respiratory patho-
This document proposes surveillance objectives and gens.
describes standards and a framework adopted from 3. Monitor unusual and unexpected events such
the WHO guidelines for a minimal basic surveillance as outbreaks of influenza during and outside
system for the monitoring of influenza virus. Use of the typical season.
standards will help us to understand the epidemiology, 4. Monitor which seasonal influenza viruses are
transmission, and impact of influenza in the country circulating and detect novel viruses (H5N1,
and compare with other countries. The existing SARI H7N9).
and ILI surveillance system is sentinel based for ef- 5. Contribute to WHO vaccine strain selection.
ficient data collection, laboratory transport, and other 6. Identify and monitor groups at high risk of se-
logistics. The data generated and analyzed from the vere disease and mortality, in order to target
surveillance system can help to make well-informed education and prevention measures.
policy decisions, and also reporting of data back to
those who are involved in surveillance will help im-
prove patient care and encourage continued reporting.
Roles & Responsibilities
Target Audience
Sentinel Sites
The sentinel sites must have a committed team com-
This document is intended to be a guidance tool for the
prising of: clinicians, laboratory technicians, nurses
medical and health professionals involved in ILI and
and the surveillance focal point. Each of these mem-
SARI surveillance.
bers of the team should be assigned a specific role
and responsibilities as follows:
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Public Health Laboratory ILI & SARI Surveillance
A. Influenza like Illness (ILI) Surveillance Site 4. Provide feedbacks from sentinel sites to
NAIL, PHL.
Clinicians
1. Identification of patients that meet the ILI Medical Laboratory Technologist/Technician
case definition in the guideline. 1. Ensure all ‘ILI Sample collection forms’ and
2. Daily recording of ILI cases at their respective ‘SARI patient sample collection form’ are
sentinel sites. filled out completely and accurately.
3. Proper completion of ILI sample collection 2. Ensure all respiratory specimens for ILI
form for patients to be sent for sample collec- and corresponding forms are assigned with
tion (Annex 4). unique ID number.
4. Refer the patient to laboratory for collection 3. Collect respiratory specimens appropriately
of respiratory specimens along with the ILI from patients meeting the case definitions.
sample collection form. 4. Properly label, pack, store, and transport
5. Provide the data collected to SFP on daily ba- specimen to NAIL, PHL according to the (An-
sis for compilation. nex 6).
5. Perform rapid flu test for ILI specimen and
Surveillance Focal Point (SFP) ensure test results are reported to the treat-
Each sentinel site should identify at least two focal ing clinician and simultaneously record on the
points responsible for the routine surveillance opera- form (Annex 4).
tion. Focal person should be appointed in consultation 6. Ensure there is adequate stock of test kits,
with the hospital administration. VTM, barcodes and relevant forms in the lab-
The SFP should: oratory.
1. Collect and collate data on total number of 7. Shipment of specimen along with cases in-
patients who meet the ILI case definition from vestigation forms to PHL as per the existing
OPD chambers and also count the total num- shipment schedule.
ber of OPD cases seen every day or on a
weekly basis (Annex 3). B. Severe Acute Respiratory Infection (SARI) Sur-
2. Report all ILI to PHL on weekly basis through veillance Site
online data system or by fax if internet facility
is not available. Surveillance Focal Point (SFP)
3. Disseminate the reports and feedbacks re- At least two designate Nurses from sentinel sites (na-
ceived from PHL to the relevant health per- tional, regional referral and district hospitals) will be
sonnel (Clinicians, laboratory, nurses etc.). appointed as Surveillance Focal Points for SARI sur-
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Public Health Laboratory ILI & SARI Surveillance
veillance. and when necessary for collection and rapid
1. Identification of patients that meet the SARI testing of SARI specimen.
case definition in the guideline. 5. Ensure adequate supply of rapid test kits and
2. Enrollment of SARI Cases. VTM in the wards.
3. Daily recording of all SARI cases.
4. Proper filling out of ‘SARI Patient Specimen C. Public Health Laboratory
Collection Form’ (Annex 2).
5. Data collection of the total number of SARI National Influenza Laboratory (NAIL)
and total number of admitted patients from 1. Serve as the technical and scientific focal
the wards every week to be sent to PHL on point for activities pertaining to ILI and SARI
weekly basis (Annex1). surveillance.
6. Collect respiratory specimen and other ap- 2. Perform following activities on specimens re-
propriate specimen for bacetriological inves- ceived from sentinel sites:
tigation and perform rapid test for influenza a. Enter data from SARI & ILI Specimen
virus. collection form.
7. Ensure all respiratory specimens and corre- b. Influenza virus typing and subtyping,
sponding forms are assigned with unique ID using molecular methods (Real time
number using the label provided by PHL. RT-PCR / conventional PCR)
8. Liaise with laboratory for specimen pick up c. Referral of any unsubtyped specimen
from wards, storage and shipment to PHL. to a designated WHO Collaborating
Center.
Medical Laboratory Technologist/Technician d. Receiving, archiving and storing origi-
nal clinical specimens at -70°C for ILI/
1. Pick up sputum specimen from patients en- SARI for ten years.
rolled for SARI surveillance and perform bac- e. upload results in the web-based data
teriological analysis. management system
2. Share bacteriological laboratory result for 3. Communicate the results of all individual con-
SARI cases with PHL every week using the firmatory tests for ILI and SARI cases back to
online system. the designated SFP weekly (Every Wednes-
3. Shipment of specimen along with cases in- day).
vestigation forms to PHL as per the existing 4. Share representative clinical specimen or vi-
shipment schedule. rus isolates of seasonal influenza specimens
4. Support nurse in respective sentinel sites as with a WHO Collaborating Center (WHO-CC)
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Public Health Laboratory ILI & SARI Surveillance
twice a year. Selection and location of sentinel
5. Immediate sharing of information on any un-
sites
subtypable or suspect novel influenza viruses
with a WHO Collaborating Center.
6. Participating in the WHO Global External The sentinel sites for ILI and SARI are selected based
Quality Assessment Project for the molecular on geographic, climatic and demographic representa-
detection of influenza virusesas well as in re- tiveness and also the feasibility such as capacity and
gional programs. accessibility of a hospital. Previously all the sentinel
7. Provide initial and refresher training to sen- sites (11 sites) were asked to conducted both ILI and
tinel sites on specimen collection,diagnosis, SARI surveillance. To improve efficiency of surveil-
storage and transport. lance, existing ILI sites will be down sized to 7.
8. Monitor sentinel sites to maintain quality of However all the sentinel sites will continue conducting
data and specimens sent to NAIL, PHL. SARI surveillance. ILI and SARI surveillance will now
consist of seven ILI sentinel sites and 11 SARI sentinel
sites (Table-1 & Figure 1).
National Disease Surveillance & Epidemiology
(NADSAE) Unit
1. Managing computer database of ILI/SARI
data.
2. Preparing and disseminating the weekly and
annual influenza surveillance reports to all
stakeholders.
3. Reporting weekly national surveillance data
to regional and global influenza surveillance
platforms.
4. Reporting to IHR focal point of any influenza
novel strains cases as per the IHR require-
ments.
5. Provide initial and refresher training to senti-
nel sites on surveillance guidelines.
Figure-1: SARI Surveillance Sites
6. Review and update influenza surveillance
guideline as needed.
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