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Outbreak Alert and Response Systems: a review
February 2004
Ayana Yeneabat, MD, MPHEpidemiologist, WHO
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What is an outbreak?
• A public health emergency!• A political emergency!• An economic emergency!• An unusual event!• An event requiring rapid action!• Surveillance failure!• Control failure!• An opportunity !
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Influenza pandemics 20th century
A(H1N1) A(H2N2) A(H3N2)
1918: “Spanish Flu” 1957: “Asian Flu” 1968: “Hong Kong Flu”
20-40 million deaths 1-4 million deaths 1-4million deaths
Credit: US National Museum of Health and Medicine
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Total population of the SEA Region = 1.5 billion
Total population at risk = 1.3 billion (87%)
DF/DHF re-emerging infectious diseases
No report
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Sou
rce:
FA
O
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Ebola (Viral Haemorrhagic Fever) in Africa
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What is outbreak management?
The process of anticipating, preventing, preparing for, detecting, responding and controlling disease outbreaks in order that health and economic impacts are minimised
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Surveillance: Information for Action
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Components of Effective Outbreak Management
• Anticipation/Prediction• Preparedness• Early warning/Surveillance• Effective and co-ordinated response• Evaluation
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Components of Effective Outbreak Management
• Anticipation/Prediction• Preparedness• Early warning/Surveillance• Effective and co-ordinated
response• Evaluation
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Reported cases of encephalitis in Nepal, 1997-1998: Prediction/trends
0
50
100
150
200
250
300
350
1 5 9 13 17 21 25 29 33 37 41 45 49
Week No
Cas
es
1997
1998
Source: EWARS
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re) RVF EPIZOOTICS
Davies et al. 1985. Bull. WHO. 63:941-3.
Effect of rainfall in producing RVF Epizootics in Kenya 1950-1982:
Forecast/Metrological Data
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Components of Effective Outbreak Management
• Anticipation/Prediction• Preparedness• Early warning/Surveillance• Effective and co-ordinated
response• Evaluation
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• What should be done ?
• Who should do it ?
• What resources or supplies will be required ?
Epidemic Preparedness and Response
Plan
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Components of Epidemic Preparedness
1 Established planning and co-ordination mechanism
2. Agreed priorities
3. Implemented epidemic preparedness plan (surveillance, response etc)
4. Functional early warning system
5. Capacity for rapid implementation of plans
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Components of Effective Outbreak Management
• Anticipation/Prediction• Preparedness• Early warning/Surveillance• Effective and co-ordinated
response• Evaluation
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What is the Early Warning/surveillance objective for outbreaks?
• To predict, detect and confirm outbreaks of public health importance in a timely fashion and to disseminate that information to those who need to know so that effective public heath action can be taken
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What are the components of an effective early warning system ?
• Small number of priority diseases• Syndromic reporting • Simple case definitions• Processes for dealing with rumours• Rapid case investigation and sampling• Rapid laboratory confirmation• Standard procedures for information sharing
and initiation of response• Preparedness plans in place
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Outbreak Alerts: Thresholds
Absolute numbers 1 case of AFP or rabies
Relative values compared to similar periodNeed to establish trend
Absolute rate over a period Population at risk and index cases (2/100,000)
Statistical cut-offs Time series modeling (deviations)
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0
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20
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DAY
CASES
Labconfirmation
Outbreak Detection and Response: no functional EWS
Response
Opportunity for control
Detection/Reporting
First Case
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0
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CASES
Outbreak Detection and Response: functional EWS
First Case
Detection/Reporting
Confirmation
Response
Opportunity for control
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How can early warning systems contribute to outbreak management ?
• Establish the expected
• Predict the future
• Detect the unexpected (early warning)
• Verify/Confirm the existence of an outbreak
• Monitor the evolution of an outbreak
• Tell you the when outbreak is over
• Monitor control programme!
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Early warning: tracking of unusual events; Orissa, India, 2003
Number of outbreaks reported under the drought management information system available form the SRC's office, Orissa
0
2
4
6
8
10
12
14
16
1/3
1
2/1
5
2/2
8
3/1
5
3/3
1
4/1
5
4/3
0
5/1
5
5/3
1
6/1
5
6/3
0
7/1
5
7/3
1
8/1
5
8/3
1
9/1
5
9/3
0
10/1
5
10/3
1
11/1
5
11/3
0
12/1
5
12/3
1
Fortnight end date
Nu
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Mapping of Reported Disease Outbreaks, Orissa, MIS/OMDSS, 2003
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Components of Effective Outbreak Management
• Anticipation/Prediction• Preparedness• Early warning/Surveillance• Effective and co-ordinated
response• Evaluation
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Confirm outbreak and diagnosis
Diagnosis verified ? clinical + laboratory
Link between cases?Expected numbers?
DetectionRoutine surveillanceClinical / LaboratoryGeneral publicMedia
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Outbreak confirmed
Further investigation?
Immediate control measures?
Control can happen at any time during the outbreak! But you still
may need to investigate
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0
5
10
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1 3 5 7 9 11 13 15 17 19
0
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1 5 9 13 170
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Examples of epidemic curves
Point source
Continuing common source Multiple waves -person to person or further outbreak
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Post outbreak Tasks
• Prepare written report
• Communicate public health messages
• Convince public health policy
• Evaluate performance
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PREPAREDNESS OUTBREAK CONTROL
Detect & Confirm
Investigate
Analyse
Respond
Evaluate
Predict & Prevent
TreatControl
CommitteePriorities
PlanCo-ordination
ResponsibilitiesResourcesSuppliesTraining
SurveillanceRapid Response
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Attributes: detection, alert, response • EWARN, Sudan• DEWS, Pakistan• KO-SURV, Kosovo• EWORS, Indonesia • EAST TIMOR• EWARS, Nepal• Global outbreak alert and response network (GOARN)• Global Public Health Intervention Network (GPHIN)
• Orissa-MDSS/MIS/Early Warning• Gujarat/Kachchh District Early Warning System• NSPCD/IDSP In India: focus on early epidemics
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Hallmark: information for prompt action
Timely Information Real time transfer of information Sound Analysis Instant and meaningful Interpretation Prompt and effective response Feedback Simple and flexible to context
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Partnership: Key for EWS