Communicable Diseases
Surveillance
in Estonia, 2005
Kuulo Kutsar MD, PhD
Health Protection Inspectorate, Estonia
MAIN OBJECTIVES OF THE NATIONAL
COMMUNICABLE DISEASE SURVELLANCE
SYSTEM
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Public health decision-making
Priority setting
Planning
Resource mobilization & allocation
Early detection of outbreaks/epidemics and response
Implementation of immunization programme
Monitoring & evaluation of communicable disease
prevention & control programmes
CORE FUNCTIONS OF THE NATIONAL
SURVEILLANCE SYSTEM
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Case detection
Case reporting
Case investigation & confirmation
Analyses & interpretation
Action
- response
- control
- feedback
- decision/policy making
SUPPORT FUNCTIONS OF THE NATIONAL
SURVEILLANCE SYSTEM
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Setting of standards/case definitions
Training
Supervision
Laboratory support
Communication
Resource management
SURVEILLANCE TASKS AT LOCAL LEVEL
• Case identification/diagnosis & case management
• Case reporting to intermediate level
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SURVEILLANCE TASKS AT REGIONAL LEVEL
Case management and reporting
Data analysis at local level for
- epidemiological links and trends
- achievement of control targets
Laboratory support/diagnosis
Outbreak investigation
Feedback to local level
Reporting to national level
SURVEILLANCE TASKS AT NATIONAL
LEVEL
• Co-ordination of surveillance activities
• verification of laboratory diagnosis
• Data analysis at intermediate level for
- epidemiological links and trends
- achievement of control targets
• Support to regional level for outbreaks control:
case management, laboratory support, epidemiological
investigation, logistics, training
• Feedback to regional & local levels
• Collaboration with interested parties
• Reporting to international organizations
PRIORITY DISEASES FOR SURVELLANCE
Commission Decision 2000/96/EC
Criteria: high disease impact, high epidemic potential,
target of national/international programme, info leads to
important public health activities
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Vaccine-preventable diseases
Viral hepatitis B & C
HIV- infection & AIDS
Other sexually transmitted diseases
Food & water-borne diseases
Diseases of environmental origin
Zoonoses
Air-borne diseases
Serious imported diseases
Nosocomial infections
Antimicrobial resistance
PRIORITIES IN SURVEILLANCE CAPACITY
BUILDING
• A disease is frequent and has a high political priority:
HIV/AIDS, tuberculosis
• A disease is of rare and of high public health importance:
with bioterrorism potential (anthrax, malaria, a disease of
unknown origin etc)
• A disease is moderate frequency and high public health
importance: food-borne diseases and intoxications
• Diseases included into regional/global
elimination/eradication programmes: poliomyelitis,
measles, congenital rubella
STRATEGIC PRIORITIES IN CD
SURVEILLANCE
• Keeping ministries and politicians informed on CD problems
• Co-operation with neighbouring countries:
- exchange of CD surveillance info
- operational early warning system
- integrated outbreak/epidemic response
- integration of prioritized diseases
- implementation of common standards/case definitions
• Strengthening microbiological & other laboratories capacity
- common standards for quality assessment
• Training in field epidemiology
- co-operation with MS & neighbouring countries
- training manuals
• Harmonization of epidemiological & microbiological investigation
methods used by MS
- integrated approach to CD surveillance
DISEASE SPECIFIC SURVEILLANCE
SYSTEMS
• Case identification/diagnosis & case management
• Case reporting to intermediate level
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SURVEILLANCE TASKS AT REGIONAL LEVEL
Case management and reporting
Data analysis at local level for
- epidemiological links and trends
- achievement of control targets
Laboratory support/diagnosis
Inspected outbreak investigation
Feedback to local level
Reporting to national level
National legislation
•Public Health Act (1995, 2004)
•Communicable Diseases prevention and Control
Act (2003) and regulations of the Minister of SA
•Emergency Preparedness Act (2000, 2002)
•Special Situation Act (2002)
EU legislation
•2119/98/EC
•2000/57/EC
•2000/96/EC
•2002/253/EC; 2003/534/EC
•2003/542/EC
• 1999/72/EC; 2003/72/EC
•2003/99/EC
Director General
Adviser in
environmental health
Adviser in
public relations
Adviser in
epidemiology
Vice-DG
Vice-DG
Director of the
Tallinn HPS (83)
Director of the
Tartu HPS (62)
Director of the
Pärnu HPS (47)
Director of the
Virumaa HPS (36)
Dep. of Environ.
Health Expert. (5)
General Dep.
(11)
Harjumaa
County Department
Tartumaa
County Department
Pärnumaa
County Department
Lääne-Virumaa
County Department
Dep. of Plan.
and Monitoring (5)
Dep. of
Bookkeeping (6)
Raplamaa
County Department
Jõgevamaa
County Department
Läänemaa
County Department
Ida-Virumaa
County Department
Dep. of
Epidemiology (5)
Tallinn Central
Laboratory (33)
Järvamaa
County Department
Põlvamaa
County Department
Saaremaa
County Department
Tartu Lab (13)
Estonian
SQS
Valgamaa
County Department
Hiiumaa
County Department
Pärnu Lab (4)
K-Järve Lab (6)
Võrumaa
County Department
Viljandimaa
County Department
Laboratory
unit
Health Protection Inspectorate
responsibilities
• surveillance of communicable diseases
(62 notifiable diseases, 88 etiological agents)
• outbreak management
• management and surveillance of immunization
• EWRS
Health Protection Inspectorate
responsibilities on CD surveillance
Surveillance of communicable diseases
(62 notifiable diseases, 88 agents)
• data collection
• analysis (epidemiological links, trends)
• control
• early warning & response
• CD register established 1.07.2004, in action
1.01.2005
Health Protection Inspectorate
responsibilities on CD surveillance
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Outbreak investigation & management
Epidemiological investigation
Epidemiological risk assessment
Laboratory investigation
Communication
Health Protection Inspectorate
responsibilities on immunization
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Management of National Immunization
Programme
Data collection
Immunization analyses: coverage, timeliness
Vaccines procurement & logistics (storage &
distribution)
Cold chain management
Immunization safety
Supervision
Health Protection Inspectorate
responsibilities on epidemic/pandemic
preparedness
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Planning and coordination
Situation monitoring and risk assessment
Prevention and control
Health system response
a) health care, b) public health
• Communication
NATIONAL COMMUNICABLE DISEASE SURVEILLANCE SYSTEM FLOWCHART
CASE DETECTION
Local level
General practitioner,
Hospital
Case report
Hard copy
Intermediate level
County Public
Health Office
Phone
Fax
E-mail
Laboratory
TIME-LINE
---------------After final
diagnose
Lab.results
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FEEDBACK
------------------Monthly
Fax
Hard copy
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Monthly
Monthly
Fax
E-mail
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Monthly
Annually
Annually
Hard copy
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Monthly
Annually
Annually
Hard copy
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Monthly
International
Institutions
National level
Health Protection
Inspectorate
Inf.dis.
Bulletin
E-mail
Ministry of Social
Affairs
E-mail
State Statistics
Board
Exchange of information in the public
health system
MSA
Public Health Authority
Municipalities
Health Protection Inspectorate
Regional Service County department
Rescue Board
Emergency
Centre
Microbiol/Virol
Laboratories
County Vet. &
Food Board office
Sanitary Quarantine
Service 24h/7d
GP
Internat. Port &
Airport
Border Guard
Communication on CD surveillance
GP, Hospitals
Laboratories
Individual data
County Vet & Food
Board office
County HPI office
Aggregated data
Global Salmonella
Network
WHO
EC Disease Specific
Network (ENTERNET, LISTER- NET,
EUROCJD)
HPI
Ministry of Social
Affairs
Communicable diseases notification under the Communicable
Diseases Prevention and
Control Act & Gov. Regulation no. 297, 2003
• Physician notifies 62 CD diseases
Record list: patient name, birth date, gender,
address, date of onset, date of notification, diagnose
(ICD-10), method of lab investigation, history of
immunization, date of hospitalization
• Laboratory notifies 88 biological agents
Record list: patient name, birth date, gender,
diagnose (ICD-10), sample, method of lab
investigation, identified biological agent
Reporting of CD surveillance data
HPI website www.tervisekaitse.ee
Data provided to EU BSN & DSN and WHO
Monthly summary report to MoSA
Monthly bulletin EstEpiReport (in English)
to counterparts and interested countries
• Annual report to MoSA
• Annual report to the EpiNorth (Bulletin of the
Network for CD Control in Northern Europe &
Baltic Sea Region)
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Staffing of public health professionals/
CD epidemiologists
(CA – Central Authority; HPO-Health Protection Office)
CA
Senior Inspector
of Epidemiology
Junior Inspector
of Epidemiology
HPO of
HPO of
HPO of
Harjumaa Tartumaa Pärnuma
a
HPO of
Virumaa
Total
5
5,5
3,6
2
2,25
18,35
1
12,25
3,8
2,75
1,5
21,3
CO-OPERATION WITH INTERNATIONAL
COMMUNICABLE DISEASE SURVEILLANCE
NETWORKS
• Global Salmonella Surveillance Network
• EU DSN ( Influenzae, measles, pertussis, HIV-infection, Haemophilus
influenzae b, salmnellosis, Enterohaemorrhagic E. coli,
meningococcal disease, diphtheria, TB, CJD, legionellosis)
• Inventory on resources on CD control (IRIDE)
- Inventory of Communicable Disease Control Resources in the Baltic
states. Project Report. Stockholm, 2001
• European Project on Surveillance of Vaccine-preventable Diseases
(EUVAC-NET). EUSAFEVAC Project.
• International Tick-borne Encephalitis Working Group
• Network for Communicable Disease Control in Northern Europe (CD
Surveillance in Baltic Sea Region)
• CCEE-Baltics Communicable Disease Network (WHO/Euro)
• European Food-borne Diseases and Intoxications Surveillance
System (WHO/Euro)
EARLY WARNING AND
RESPONSE SYSTEM
KEYSTONES OF RAPID RESPONSE
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Simple decision taking
Minimum involved hierarchical structures
Coordinated response
Maximum complexity
- Ministry of Defense, Min of Justice, Min of Agriculture,
Ministry of Inner Affairs, Ministry of Environment
• Funding
• Risk assessment
• Proposed prevention/control measures
NATIONAL EWRS CAPACITIES
1. Interventional epidemiology
2. Clinical microbiology
3. Research microbiology
• Epidemiological and clinical microbiology/virology
capacities are integrated in Health Protection
Inspectorate, some clinical microbiology - in hospital
labs
• Research microbiology is provided by Tartu
University Microbiology Institute
EWRS FLOWCHART
1. Case identification from surveillance activities
2. Case/cluster confirmation
3. Outbreak identification
4. Early warning message
5. Assistance request
FOCAL POINT
6. Assessment for collaboration investigation
7. Epidemiological investigation team in the field
• media communication
• logistic support
• management/co-operation
• epidemiological investigation
• implementation of control measures
8. Outbreak controlled
• epidemiological-analytical study
9. Outbreak report
10. Feedback and ongoing surveillance
LIST OF PRIORITY COMMUNICABLE
DISEASES FOR RESPONSE
A. Required special action for public health preparedness:
smallpox, anthrax, plague, botulism, tularemia, viral
hemorrhagic fevers (Ebola, Marburg, Lassa, Junin etc)
B. Required specific diagnostic capacity and enhanced surveillance
response:
brucellosis, Q-fever, glanders/malleus, meningococcal
infection, Clostridium perfringens epsilon toxin, Staphylococcus
enterotoxin B
C. Food- and waterborne diseases:
salmonellosis, shigellosis, enterohaemorrhagic E. coli O157:H7
infection; cholera
D. Diseases having epidemic characteristics:
HIV/AIDS, tuberculosis
GENERIC EPIDEMIOLOGICAL EXPERTISE
IS OFFERED TO IMMIDIATE PUBLIC
HEALTH THREATS
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Food-borne diseases and intoxications
Food safety
Veterinary issues
Environmental disasters
Chemical disasters
Nuclear pollution
Military deployment
Bioterrorism
PERMANENT LINKS WITH OTHER
NATIONAL ALERT SYSTEMS
• Food-borne diseases (Ministry of Agriculture)
• Zoonoses (Ministry of Agriculture)
• Consumers protection (Ministry of Economy)
PRE-EARLY WARNING BETWEEN
MINISTERIES/INSTITUTES IS
OPERATIONAL
• Inquiry from involved partners may activate the system
• Technical capacity with skilled epidemiologists is
available
• Verification of disseminated information
• Consultation is essential part of the system
• Disease specific surveillance systems and reference labs
are involved
STRENGTHENING OF NATIONAL EWRS
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Improvement of the quality of epidemiological surveillance
Increasing of public health information availability
Efficient and timely risk analysis
Standardization of epidemiological and microbiological
investigation methods
Available high quality scientific expertise
Providing training
Networking
Promotion of research
Advise for public health policy
Strengthening communication
Co-operation with EC, WHO and other international organisations
Identification of public health threats of cross-border nature
Current situation & perspectives
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CDS system is well adopted to implement EU guidlines and priorities for
data reporting, outbreak investigation, early warning & response
Legislation covers not all aspects of CD surveillance & response
List of CD for mandatory notification consists of 62 diseases & 88
biological agents, including EC covered diseases
Case definitions have developed in May 2004 as guidelines
Data protection should be improved
Preparedness for health threats: smallpox, bioterrorism, influenza and
SARS preparedness plans are developed, but not implemented
Several fields of activities are not legaly covered: EWRS is operating only
on initiative of HPI, Quarantine Act is not developed, epidemic
preparedness & epidemic response are poorly funded,
immunisation programme is poorly funded
Current situation & perspectives
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Improvement of institutional capacity
Administrative capacity, participation in EC committees, working
groups and DS Networks is problematic due to limited human
resources and funding
Laboratory capacity: needs to be improved, reference lab system
should be developed, standard test procedures for priority
diseases should be implemented, national manuals for lab
procedures, biosafety and quality control should be improved
BSL-3 microbiology & virology labs should be established in public
health system
SARS diagnostic lab should be established
Current situation & perspectives
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Development of national guidelines on CD surveillance,
epidemic response capacity, guarantine, control &
prevention
Development of computerized CD reporting system
EU funded project in co-operation with SMI, Sweden
(2005-2006)
Strengthening of CD control capacity
Development of national education and training system
for public health professionals/epidemiologists
THANK YOU !