The GHSA real-time surveillance action packageCheryl CohenCentre for Respiratory Disease and Meningitischerylc@nicd.ac.za

Portia MutevedziDivision of Public Health Surveillance and Responseportiam@nicd.ac.zaNational Institute for Communicable DiseasesSouth Africa

Overview

• The real-time surveillance package

• What is real-time surveillance?

• What is the status in South Africa?

• Notifiable Medical Conditions (NMC) surveillance in South Africa

• Discussion

Real-Time Surveillance Action Package

• The indicator refers to surveillance capacity for the country.

• The real-time surveillance system should include:

– ability to conduct surveillance for at least 3 core syndromes indicative of a public health emergency;

– ability to provide reports and data to high level public health decision makers in country;

– linkages to laboratory and other information systems to provide a complete surveillance picture.

What is Surveillance?

• From French sur (over), veiller (watch)

• Surveillance: Ongoing systematic collection, analysis and interpretation of outcome-specific data for use in the planning implementation and evaluation of public health practice. (Thacker 1988)

• Information for action

International Health Regulations (IHR) 2005

• 13 core capacities

• Core capacity 3: Surveillance

– The IHR require the rapid detection of public health risks, as well as the prompt risk assessment, notification, and response to these risks.

– Hence need a sensitive and flexible surveillance system with an early warning function

5

Syndromic surveillance

• Case definition is a clinical syndrome e.g.– Influenza-like illness

– Diarrhoea

• Advantages– Fast as do not need to wait for laboratory

– Identify outbreaks before aetiology known

• Disadvantages– Non-specific

– False alerts – cost and resources

Real-time surveillance

• Definitions vary

• Rapid transfer of information is critical

• Surveillance data transmitted in real-time to all levels

• Generally using electronic technology

• Real-time evaluation and action at all levels

Event-based surveillance

• Organized and rapid capture of information about events that are a potential risk to public health e.g.rumours and other ad-hoc reports

• transmitted through formal channels (i.e. established routine reporting systems) and informal channels (i.e. media, health workers and nongovernmental organizations reports)

• Often for specific event e.g. World cup

• can supplement traditional syndromic surveillance

Syndromic surveillance“The fundamental objective of syndromicsurveillance is to identify illness clusters early, before diagnoses are confirmed and reported to public health agencies, and to mobilize a rapid response, thereby reducing morbidity and mortality”

Syndromic surveillance in NYC, 2001-2 Diarrheal syndromes

Nowcasting...

Google flu trends

Real-time surveillance for travel

GHSA Real time surveillance action package

• Five-Year Target: –Efficient real-time indicator- and event-based surveillance systems in accordance with IHR and OIE standards for –Detection of significant events for public health, animal health and health security; –Improving communication and collaboration across sectors and between sub-national, national and international levels; –Improving country and regional capacity to analyse and link data from and between real-time electronic surveillance systems.

•Systems include– epidemiologic, clinical, laboratory, environmental testing,

product safety and quality, and bioinformatics data

Pilot assessment

Severe Acute Respiratory Illness (SARI) surveillance programme

• Data to guide policy

• Not primarily focused on outbreak detection

• 5 sentinel sites

• >24,000 patients enrolled 2009-2013

• >100 surveillance reports generated

• >20 peer-reviewed publications

Notifiable medical Conditions

(NMC) national surveillance in

South Africa: Current status

and future plans

Notifiable Disease Surveillance System in SA

What ?

Public health surveillance involving the • collection• collation• analysis and • dissemination of health data relevant to public health

Why ?• Promptly detect health risks and rapidly initiate required public

health response• identify disease patterns/ trends in different populations, • monitoring of zoonotic diseases to prompt appropriate inter-

sectorial responses (agriculture, health, trade and industry)• to develop prevention strategies, vigilance for vaccine preventable

illnesses; congenital acquired infections• resources for prevention , identification of epidemic-prone diseases

and treatment

Notifiable Disease Surveillance System in SA

The current notification system is referenced in the National

Health Act No 61, 2003.

Notifiable Disease Surveillance System in SA

• Who notifies?

– The first health care professional or facility to come into

contact with a patient presenting with at least one of the

NMC.

– Public and private medical practitioners

– Laboratories

– In an event of deaths (or cases) where the patient had no

contact with a health care professional , a member of the

community or mortician is obliged to notify the event

• How do they notify?

– GW 14 forms by

• Fax or telephone or other

The current notification process in SA

School of Health Systems and Public Health – University of PretoriaDr IB Weber 1, Professor MJ Matjila 1, Dr BN Harris 2

What is missing?

Is the current SA notification system functional and efficient?

South Africa

AuthorArea

Year Design Population Objectives Findings

Webber IG 37Pretoria

2007 Qualitative and Quantative analysis

3980 GPs 3 Stakeholders interviewed. 4695 Malaria cases

Evaluation of NDSS in Gauteng province

GPs 37% compliance with notifications. Incomplete and inaccurate data to inform outbreak response

Heidebrecht CL38Cape Town

2011 Qualitative Analysis

Exploration of perceptions and experiences of TB system users

Evaluate the tuberculosis surveillance system in the Cape Metro

Increased software flexibility needed

Auld SC39George, West. Cape

2013 Retrospective cohort records evaluation

TB-HIV co-infected patients

Assess completeness & concordance of dTB and HIV surveillance systems .

Completeness and concordance for clinical variables was somewhat lower than demographic data

Is the current SA notification system functional and efficient?

National evaluation (2015)

• Assessing – knowledge, attitudes and

practices of health workers

– Actual notifications (triangulation of lab and clinical data)

– Factors influencing compliance

– Lead by Dr Benson (national CDC chief director)

Challenges1. Legislative process delay 2. Case definitions 3. Training 4. Lack of integration5. Communicable vs. non-communicable

diseases 6. Tools 7. Triangulation and verification of data 8. Delayed reporting 9. Systems- decision tree 10. Process 11. Feedback 12. Consequences 13. Epidemiological capacity 14. Information for action

NMC national surveillance system NICD’s responsibility

• The DG for health has delegated the responsibility of managing and coordinating the NMC national surveillance system to the NICD

– Evaluating the current system to identify challenges and opportunities and inform on development of a new system

– Development and implementation of a re-engineered NMC surveillance system

– Providing scientific and epidemiological expert guidance

– Training

25

Revision of regulations relating to Notifiable

Medical Conditions

Proposed changes

• Category 1 Notifiable Medical Condition means a condition or a

disease that requires immediate reporting after the detection of the

clinical case (even before the case is laboratory confirmed) followed

by a written or electronic notification to the Department within 24

hours of detection;

• Category 2 Notifiable Medical Condition means a condition or a

disease that must be notified through a written or electronic

notification to the Department within 7 days of detection of the

clinical case;

• Category 3 Notifiable Medical Condition’ means a condition that

must be notified to the laboratory using the Laboratory Data Based

form on a monthly basis to the Department.

Conclusions• Real-time surveillance package focuses on syndromic and

event-based surveillance

• South Africa currently has a number of functional syndromicprogrammes

• Data are not sufficiently timeous

• Need for rapid, real-time programmes

• The NDOH has delegated the NICD to facilitate and coordinate the implementation of an efficient and reliable national surveillance system for NMCs

• Process of review underway

• Plan to have new system in place in 2016

29

Questions?

EXTRA SLIDES

GHSA Activities to date

• Review of surveillance programmes in South AfricaNICDDOH NHLS/ labOther partners

• Notifiable diseases system (under development)Real-time reportingLinks to laboratory

• Event-based surveillance – link to Outbreak Response Unit and EOC

Database development

National Health Act 61 of 2003, Section 90 (K)

(1) The Minister, after consultation with the National Health Council, may make regulations regarding-

(a) anything which may or must be prescribed in terms of this Act;

the fees to be paid to public health establishments for health services rendered;

the norms and standards for specified types of protective clothing and the use, 20

cleaning and disposal of such clothing;

(d) the development of an essential drugs list and medical and other assistive

devices list;

(e) human resource development;

co-operation and interaction between private health care providers and private 25 health establishments on the one hand and public health care providers and public health establishments on the other;

returns, registers, reports, records, documents and forms to be completed and kept by the national department, provincial departments, district health

councils, health care providers, private health establishments and public 30 health establishments;

the functions of persons who render voluntary, charitable or similar services in

connection with a public health establishment;

the rendering of forensic pathology, forensic medicine and related laboratory services, including the provision of medico-legal mortuaries and medico-legal 35 services;

(j) communicable diseases;

(k) notifiable medical conditions;

( l) rehabilitation;

(m) emergency medical services and emergency medical treatment, both within 40 and outside of health establishments;

Characteristics of Surveillance Systems

• Systematic data collection

• Continuous system – monitor trends

• Practical

• Uniform

• Rapid

• Analysis, interpretation and feedback

Is the current SA notification system functional, useful, efficient, timely?

Private practitioner survey in Gauteng

• 37% (n=26) - always reported cases of NMC seen at their practices to the department of health

• 28% (n=19) – had a notification book present in their practice.

• The commonest reasons cited for not consistently reporting

– assumption that someone else would report

• Sensitivity of malaria notifications compared to laboratory diagnosis was only 26%

Real-time and event-based surveillance for South Africa

• Do we need a system for monitoring non-specific signals in real-time?– Some capabilities in place

– Value of different programmes needs to be fully evaluated including resources needed and expected public health impact

• Event-based surveillance around high profile gatherings– Tools and database under development as part of

EOC

Other causes of death included in the bills over the years include being affrighted, bladder in the

throat, breakbone fever, canine madness, commotion, eel thing, frogg, gathering, grocer's itch, hectic

fever, kink, milk leg, screws, stranguary, stuffing, rag picker's disease, St. Anthony's fire, tympany,

worm fit, wolf, and being planet struck.

Abortive

Aged

Ague

Apoplexy

Asthma

Bloody Flux

Cancer

Childbed

Chrisoms [1]

Colick

Consumption

Convulsion

Dropsie

Evil

Fever

French-Pox

Gangrene

Gout

Griping in the Guts

Headmouldshot [2]

3

52

12

1

2

1

4

4

2

2

78

112

26

1

76

2

1

1

14

2

Jaundies

Imposthume [3]

Mortification

Plurisie

Rash

Rheumatism

Rickets

Rising of the Lights [4]

Rupture

Small-Pox

Stilborn

Stone

Stoppage in the

Stomach

Suddenly

Teeth

Thrush

Tissick [5]

Twisting of the Guts

Ulcers

1

2

7

2

1

1

1

1

1

54

9

2

2

1

39

1

5

6

1

London Bills of mortality since 1538“a somewhat poetical bent in the naming of lethal afflictions ”

Evaluation of current system to determine system requirements for the re-engineered system

ObjectivesAssess:

• Whether surveillance is–Effectively providing data that can be used for public health action.

– reflects national disease control priorities,

• resource requirements

Take advantage of new methods and techniques to strengthen surveillance

• Cognisance of advances in early detection and rapid diagnostic techniques

40