Improved Surveillance and Diagnosis Capabilities in Mexico after the - PowerPoint PPT Presentation

Improved Surveillance and Diagnosis Capabilities in Mexico after the Influenza Pandemics Dra. Celia M. Alpuche Aranda Director MC Hiram Olivera Diaz Head of molecular Biology Department Institute for Epidemiological Diagnosis and Reference General Directorate of Epidemiology Under Secretariat for Health Prevention and Promotion Health Secretariat of Mexico

Agenda • Before A(H1N1)2009 pandemic, what did we have for influenza diagnosis in Mexico? • How did we change our capacities over the crisis? • How has the North America Partnership helped to develop the new laboratory capacity for influenza? • What is the current situation of the influenza laboratory network for epidemiological surveillance in Mexico? • Conclusions

Public Health Laboratory Network Secretariat (Ministry) of Health Under Under Under Secretariat Secretary of Secretary of of Health quality medical financial prevention and attention and administration promotion innovation CENAVECE CENAVECE CENAVECE InDRE and 31 Public Health State DGE Laboratories (one per Mexican State, InDRE excepting Mexico City) PROGRAMAS NOM017 Epidemiological Surveillance NOM017 Epidemiological Surveillance

Epidemiological Surveillance of Influenza in México before AH1N1 2009 pandemic What did we have? Surveillance since 2001. Organized sentinel epidemiology surveillance (SISVEFLU) since 2006, reinforced in 2008. On line report from epi jurisdictional offices (not from clinical units) . InDRE was already a National Center for GISN- WHO. CDC Influenza division was our collaborator Center in this system. Network of Influenza diagnosis (26/31) state PH lab, based on IF and WHO algorithms. EQA to Network by InDRE (Federal) to PHSL and CDC to InDRE. In addition to Hong Kong panels InDRE had end point PCR, Real Time PCR and virus isolation protocols. Only 6 PHSL in addition to InDRE end point PCR protocols Subtyping, viral isolation and further characterization only by InDRE Two years training program in biosecurity and biosafety by LRN and biosafety CDC in addition of CPHA personnel BIDs, EWIDs, IPIPI programs

Epidemiological Surveillance of Influenza in México before AH1N1 2009 pandemic Limitations Problematic Low adherence to SISVEFLU (less than 40%). FLU National Epidemiological Diagnosis network based on IF. Very low sampling. Surveillance of Influenza was Goals not reached. limited Report based on manual paper work (separate Lack of IT infrastructure questionnaire for lab and epi) and manually loaded to delayed report; only a limited the IT system at the epi jurisdictional office. number of samples reached laboratory Delay to report: 3-4 weeks. Delay to refer samples 1.5 months. Absence of protocols to characterize possible new Viral subtyping of Influenza virus. centralized in InDRE. No BSL3 facilities at InDRE, only at one PHSL (Veracruz) . No consistent daily or weekly direct inputs from hospitals to The National System of Epidemiological Surveillance (SINAVE)

Immediate changes in the Epidemiological Surveillance System in Mexico as a consequence of pandemic influenza response in 2009 ● Use of Pandemic Influenza Preparedness Response Plan as a baseline for all the areas within Public Health Sector. ● SISVEFLU change to mandatory active surveillance to every public clinic in the country and voluntary for private hospitals ● Daily zero reporting of hospitalization and deaths due to ILI/SARI ● Review, update, dissemination and implementation of new guidelines for epidemiological surveillance including laboratory case definition, sampling, diagnosis new algorithms, reports, etc. ● Implementation of a new epidemiological informatics system including laboratory results.

Changes in FLU Laboratory Network in response to AH1N1 pandemic 2009 ● Logistics to develop a TOTALLY NEW INFLUENZA LABORATORY NETWORK throughout the country: 1) defining protocols, 2) training, 3) purchasing equipment, supplies and reagents, 4) standard questionnaires to asses minimal requirements to include Laboratories in this network, 5) LIMS,6) EQA ● Challenge: handling laboratory data and deliver results to epidemiologist in less than 48 hrs/Testing 1600 samples per day only at InDRE ● Pandemic Influenza Preparedness Response Plan put into action. ● GREAT NORTH AMERICA PARTNERSHIP: NML AND CDC

FLU Diagnostic test for Influenza implementation in México during AH1N1 pandemic event in México CDC/WHO protocol for Real Time PCR A H1N1 pandemic 04/ 28 /2009 Revision 1 (04/30 /2009) ● WHO adopted (April 2009) CDC protocol as gold standard for A(H1N1) 2009 FLU diagnostic test ● April 26th NML and CDC personnel arrived to Mexico- InDRE ● Monday April 27th: they worked with us selection of personnel, equipment, logistic, full process, training etc. ● Same day a April 27th evening we started real time CDC protocol at InDRE ● Reagents supplies, primers and probes donated by CDC, NML ● 3-4 weeks later we were able to run 1200 samples per day at InDRE, decentralization of FLU diagnostic to 5 PHSL included in the network in addition to 3 National Institutes of Health.

What do we have now for FLU surveillance? � Back to Sentinel surveillance � Define new sentinel units to get information for ambulatory and hospitalized cases (650-700 units around the country) � Samples to all SARI hospitalized cases in USMIS sentinel clinics and 10% of the ambulatory ILI (now 100%) � New IT system: real time web based coming from sentinel clinical units � Weekly report and analysis � Epidemiology and Laboratory working together in one program � Working in ICS implementation with training and help of NML PHAC Octubre 13, 2009

What do we have now for FLU surveillance? Laboratory surveillance ● InDRE (14 equipments) 42 centers ● 28 PHSL (26/1, 1/2) ● Public Health Hospitals: 6 centers capable of running 5000 with a total of 8 equipments; 2 samples per day Lab/one equipment Federal Government ● National health Institutes (5) invested 40 million ● 4 PHSL doing end point PCR dollars in Epi ● InDRE and 2 PHSL for viral isolation surveillance and lab ● InDRE subtyping, molecular improvement characterization, antiviral • sequencing susceptibility analysis, • Antiviral susceptibility ● Other virus differential diagnosis testing PHSL, IF. InDRE, Luminex- Bioplex • Sero-prevalence platform.

InDRE coordinator of Influenza laboratory network ● Supervision and analysis of questionnaire to incorporate centers to the network ● Training of personnel, supervision of equipment installation and calibration ● EQA program: 1) Technical performance by proficiency panels; 2) personal visits and verification questionnaire. ● InDRE working very close to CDC influenza Division (Transfer of technology etc… ● Guidelines to request primer and probes, supervising accuracy of shipping companies ● Evaluation of other possible diagnostic platforms ● Evaluation of new primers and probes ● Evaluation and validation of other diagnostic test to use on the ABI7500 Applied platform: dengue subtyping and measles

Confirmed cases of AH1N1 pdm 2009 in México, Jan 1-March 31

Influenza virus identification in te first 10 epidemiological weeks 2009 in México % de virus identificados

DGAPI/InDRE Fuentes: Base de datos InDRE y CONAMED. Semana 19 2010

Geographic differences of AH1N1 epidemiology within México Base de datos InDRE

Laboratory indicators Promedio y mediana de días entre el inicio de síntomas y toma de muestras por laboratorio Semana 07 del 2010

Promedio y mediana de días entre toma llegada al laboratorio y emisión de resultados: TODOS BIEN

Conclusions ● Planning is essential for a correct response ● Surveillance needs epidemiological intelligence ● Early warning is essential for known and unknown defined diseases ● Detailed SOPs are essential for proper planning ● Flexible protocols to adapt to unexpected events ● International collaboration is a key component ● Working as a NETWORK ( Federal-State ) is a basic key element to succeed and to facilitate global communication ● EQA (International standards) for laboratories is basic ● Implementation of routine, global systematic communication and of the IHR(2005) ● Honest and transparent communication is essential

MUCHAS GRACIAS, Merci Thank you !!!!!!!! RED de 31 Laboratorios de Salud Pública de México DEPARTAMENTOS DE BIOLOGIA MOLECULAR Y DE VIROLOGIA DEL InDRE

CDC Deputy Secretariat Health Influenza Division: Prevention and Promotion Dr. Nancy Cox Dr. Mauricio Hernández Avila NML PHAC Dr. Alexander Klimov Dr. Frank Plummer Dr. Stephen Lindstrom Dirección General Adjunta de Dr. Ute Stroher Dr. Jaky Katz Epidemiología: Dr. Yan Li Dr. Hugo López Gatell Ramírez Dr. Michael Shaw Dr. Mathew Guilmore Dra. Ietza Bojórquez Dr. Rebeca Garten Dr. Ethel Palacios Dr. Ted Kuschak Dr. Marc Alain Dra. María Hoy Dr. Kristina Gordon And so on………. And so on Dr. Tammy Stuart and so on….. Dr. Jonas Michel InDRE: Agnes Warner Dra. Celia Alpuche Dr. Steve Waterman QFB: Lucía Hernández Dr. Alberto Díaz QFB. Irma Hernandez LRN/CDC Dr. Harvey Holmes Inluenza Laboratory Dr. David Blesser Ms Irma López, Dr. Cristina Vargas QFB Miguel Iguala Dwene Lansky MS Gisela Barrera and so on…… MS Rita Flores and so on MUCHAS GRACIAS, Molecular Biology Laboratory Merci Dr. Hiram Olivera Thank you !!!!!!!! DR. Ernesto Ramírez and so on