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  • Surveillance and Surveillance and SubtypingSubtyping of of SalmonellaSalmonella sppspp. in Malaysia.. in Malaysia.

    KwaiKwai Lin Thong, PhDLin Thong, PhD University of MalayaUniversity of Malaya

    Kuala Lumpur, MalaysiaKuala Lumpur, Malaysia

  • OutlineOutline

    Overview of Surveillance system in Overview of Surveillance system in MalaysiaMalaysia

    Incidence of Incidence of SalmonellosisSalmonellosis in Malaysiain Malaysia

    SubtypingSubtyping by PFGE of predominant by PFGE of predominant Salmonella Salmonella entericaenterica serovarsserovars

  • FoodborneFoodborne Disease SurveillanceDisease Surveillance

    Carried out by different units, sections, departments and Carried out by different units, sections, departments and institutions within the Ministry of Healthinstitutions within the Ministry of Health

    Passive surveillancePassive surveillance Data collected through physician based surveillance and Data collected through physician based surveillance and outbreak investigationoutbreak investigation

    Notification is received from government health facilities Notification is received from government health facilities & private hospitals & GP& private hospitals & GP

    FoodborneFoodborne diseases monitored: cholera, typhoid & diseases monitored: cholera, typhoid & paratyphoid, hepatitis A, dysentery, food poisoning paratyphoid, hepatitis A, dysentery, food poisoning ((nontyphoidalnontyphoidal SalmonellaSalmonella & other etiologic agents)& other etiologic agents) Acute gastroenteritis (AGE) also reported but not Acute gastroenteritis (AGE) also reported but not mandatorymandatory

  • Laboratory surveillance

    Mandatory Notification Dis. Surv.

    Clinical Based (sentinel/national

    Syndromic

    Community based surveillance

    Other agencies

    Microbiology Labs

    Public: Health Ctr Hospitals Private: GP clinics Hospitals

    Sentinel selected Clinics National (hospitals) Syndromic A/E wards

    Community/Media International sources

    District Heath Office

    State Health Dept

    National : Div. Disease Control, Ministry of Health

    Veterinary Dept (Zoonoses)IMR/

    PHLs

    Overview of Surveillance Food Borne diseases in Malaysia

  • Incidence rates in Malaysia (1995-2003) DISEASESDISEASES 19951995 19961996 19971997 19981998 19991999 20002000 20012001 20022002 20032003

    Food poisoningFood poisoning 7.087.08 15.2915.29 31.0831.08 31.4531.45 38.0438.04 36.6136.61 29.9929.99 28.6328.63 14.7214.72

    Typhoid/Typhoid/ paratyphoidparatyphoid

    4.464.46 4.504.50 3.243.24 3.533.53 3.573.57 3.453.45 2.922.92 3.483.48 1.741.74

    Source: Disease Control Div, Ministry of Health, Malaysia 2005 per 100.000 population

    Salmonella infection -major foodborne disease in Malaysia

  • Burden of Burden of FoodborneFoodborne diseasesdiseases True incidence True incidence ––difficult to determinedifficult to determine Passive surveillance: reported casesPassive surveillance: reported cases

    *67% of reported outbreaks occurred in public scho*67% of reported outbreaks occurred in public schools, residential ols, residential colleges,factoriescolleges,factories *any outbreak cases or sporadic cases involved an*any outbreak cases or sporadic cases involved any food outlets y food outlets –– difficult to detectdifficult to detect

    Grossly underestimatedGrossly underestimated A local study done in the State of A local study done in the State of KelantanKelantan (2001) showed a higher ( 2x) estimated (2001) showed a higher ( 2x) estimated annual IR of typhoid cases (annual IR of typhoid cases (Wan Wan MansorMansor, unpublished , unpublished data)data)

  • Laboratory Based Surveillance for Laboratory Based Surveillance for Infectious DiseasesInfectious Diseases

    Introduced in 2002Introduced in 2002

    an initiative between Surveillance Section & Institute for Medical Research (IMR), Ministry of Health

    Complements the mandatory Complements the mandatory notifiablenotifiable disease surveillance system.disease surveillance system. This system requires participating hospitals to submit isolaThis system requires participating hospitals to submit isolates to IMR tes to IMR for refor re--culture and culture and subtypingsubtyping..

    Database may not be 100% representative as it involves only Database may not be 100% representative as it involves only government hospital laboratoriesgovernment hospital laboratories

    Currently 6 types of bacteria being monitored:Currently 6 types of bacteria being monitored: VibrioVibrio choleraecholerae, , HaemophillusHaemophillus influenzaeinfluenzae, , Salmonella Salmonella entericaenterica S. S. Typhi/ParatyphiTyphi/Paratyphi, , NeisseriaNeisseria meningitidismeningitidis

  • Laboratory based surveillance flowchartLaboratory based surveillance flowchart

    Microbiology labs of public/private hospitals & private labs

    IMR/NPHL and other Reference Labs ( confirmation, typing, etc

    District Health Officer

    State Health Office

    Communicable Disease Surveillance Section, Ministry of Health

    Data notification Information feedback

    Notification form

    Isolates with laboratory

    notification

    results

    notification

    results

  • http://dph.gov.my

    Infectious Disease Bulletin

    Based on the labBased on the lab-- surveillance system, the surveillance system, the Disease SurveillanceDisease Surveillance Section, Disease Control Section, Disease Control Division, MOH, Division, MOH, publishes a Bulletinpublishes a Bulletin

    Aims:Aims: ••To To diseminatediseminate/share /share information on information on communicable disease communicable disease and to stimulate and to stimulate exchanges of ideasexchanges of ideas ••To update and inform To update and inform health professionalshealth professionals

  • 2003 2004 2005

    Serotypes total % Serotypes total % Serotypes total % Enteritidis 244244 26.726.7 Enteritidis 206206 25.025.0 Enteritidis 155155 28.128.1 Weltevreden 200200 21.921.9 Weltevreden 165165 20.020.0 Weltevreden 142142 25.725.7 Corvallis 115115 12.612.6 Corvallis 117117 14.214.2 Corvallis 5757 10.310.3 Typhimurium 4949 5.45.4 Typhimurium 4343 5.25.2 Typhimurium 3737 6.76.7 Stanley 3232 3.23.2 AlbanyAlbany 3737 4.54.5 LimeteLimete 99 3.33.3 Tshongwe 2929 3.23.2 LimeteLimete 1818 2.22.2 StanleyStanley 88 1.41.4 Biegdam 1919 2.12.1 Braenderup 1515 1.81.8 AgonaAgona 77 1.31.3

    Albany 1717 1.91.9 Tshongwe 1515 1.81.8 AlbanyAlbany 55 0.90.9

    Braenderup 1212 1.31.3 StanleyStanley 1111 1.31.3 RissenRissen 55 0.90.9

    Newport 1010 1.11.1 BovismorfibicBovismorfibic ansans

    1010 1.21.2 VirchowVirchow 55 0.90.9

    Top 10 Nontyphoidal Salmonella Serotypes identified and reported to the Laboratory Based Surveillance database, 2003-5

    Source: Lab Surv. Bulletin, Disease Control Division, Ministry of Health Malaysia (October 2005 )

    Total 915 682 460

  • Application of PFGE as a Application of PFGE as a SubtypingSubtyping tooltool

    Still not fully implemented in all Still not fully implemented in all PHLsPHLs Designated 4 Designated 4 PHLsPHLs

    -- availability of infrastructure: PFGE availability of infrastructure: PFGE equipmentequipment --lack of technical expertiselack of technical expertise --no dedicated staff to perform no dedicated staff to perform PFGEPFGE Institute of Medical Research (IMR) : Institute of Medical Research (IMR) :

    National Reference CentreNational Reference Centre: : routinely does routinely does serotypingserotyping, AST, and perform PFGE on a case to case , AST, and perform PFGE on a case to case basisbasis

  • Salmonella Salmonella TyphiTyphi most common serotypemost common serotype

    Typhoid fever A public health problem & endemic in Malaysia Annual incidence of 10.2 to 17.9 per 100,000 population but can be as high as 50.3 /100,000 in certain hyper-endemic state ( eg Kelantan)

  • Example of application of PFGE in a Example of application of PFGE in a recent outbreak of typhoid fever in recent outbreak of typhoid fever in

    MalaysiaMalaysia In 2005, an outbreak of typhoid fever in

    Kelantan As of 8 May, 2005As of 8 May, 2005-- State Health Dept of State Health Dept of KelantanKelantan reported 517 confirmed typhoid reported 517 confirmed typhoid cases. Included 2 deathscases. Included 2 deaths 19 (2.14%) food samples, 19 (2.14%) food samples, 12 ( 2.9%) drinking water samples12 ( 2.9%) drinking water samples 2 (0.2%) food handlers 2 (0.2%) food handlers

    ––tested positive for tested positive for SalmonellaSalmonella sppspp

  • Week No cases ( no death)

    Cumulative cases ( death) (throughout the country)

    2005 2004 Wk 18 ( 1-7 May 2005 397 1408 (0) 146 (0) Wk 19 (8-14 May,2005 120 (2) 1533 (2) 152 Wk 20 (15-21 May,2005) 156 1718 (2) 158 Wk 21 (22- 28.5.2005) 99 1822 (2) 160 (0) Wk 22( 29.5 - 4.6.2005 84 1919 (2) 164 (0) Wk 23 (5 -11.6.2005) 61 1985 (2) 170 Wk 24 (12 -18.6.2005) 48 2013(2) 183 Wk 25(19- 25.6.2005) 23 2045 185 Source: Infect Dis Bull. Disease Control Div, Min Health, Malaysia

    988

    Number of notified cases of Typhoid Fever in Kelantan, Malaysia (May-June 2005)

  • ActionAction (Ministry of Health)(Ministry of Health)

    State Response TeamState Response Team Rapid Response Team

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