Caribbean Epidemiology Centre (CAREC/PAHO/WHO) Surveillance of FBD in the Caribbean and Pulse Net...

Caribbean Epidemiology Centre (CAREC/PAHO/WHO)

Surveillance of FBD in the Caribbean and Pulse Net

Pulse Net Latin America Meeting

Argentina, Oct 22-2, 2007

Lisa IndarCaribbean Epidemiology Centre

(CAREC/PAHO/WHO)


Outline• CAREC and its member countries (CMCs)• Surveillance and outbreak investigations (FBD)• Laboratory surveillance of FBD in CMCs- particularly

related to Salmonella, E coli 0157, Shigella and Campylobacter

• Proposal of CAREC being part of Pulse Net


CAREC and its member countries


Caribbean and CAREC Member Countries (CMCs)- 25 Countries linking North and South America

GUADELOUPE

FR. GUIANA


What is CAREC?• A public health information, service and consulting organization

• The Caribbean’s health monitoring and disease prevention agency – serving and acting on behalf of 21 member countries (CMCs)

• A PAHO/WHO Centre in the Americas, also governed by CARICOM

• Regional Epidemiological center- collation and analysis of data

• Regional reference and diagnostic Laboratory

• Regional training center

• An instrument of Caribbean Cooperation in Health (CCH)• Directing Council and Scientific Advisory Committee• Founded 1975 after outbreaks of polio, typhoid

• Multi Lateral & Bilateral Agreements;US$8M budget, 130 staff • >35 regional and international partners


VISION and MISSION

Vision: CAREC, a public health information, service and consulting organisation, dedicated to being the best at providing the information and specialised support services people need to promote health and prevent disease in the Caribbean

Mission : To improve the health status of Caribbean people by improving country capacity in epidemiology, laboratory and related public health disciplines, through programs of service, training and technical cooperation and through a well trained, motivated staff


CAREC Member Countries by Size

• Pop. >250,000– Bahamas, Barbados, Guyana, Jamaica, Suriname, Trinidad &

Tobago• Pop. 50,000-250,000

– Antigua & Barbuda, Aruba, Belize, Bermuda, Dominica, Grenada, Netherlands Antilles, St. Lucia, St. Vincent & the Grenadines

• Pop. <50,000– Anguilla, Br. Virgin Is., Cayman Is., Montserrat, St. Kitts &

Nevis, Turks & Caicos Is.

Total Pop: approx 7 millionNote: Haiti and Dom Rep are beneficiaries of several major projects, although not CMCs


Contextual issues: Challenges • Small populations ; Diverse economies, cultures, varying development

• Most tourism dependent region in the world

• Intense movement via Trade, Labor and Tourism

• Complex health situations:

– Health transition to NCDs, low mortality & fertility

– Various health conditions – CDs, NCDs, social pathologies• Susceptible to natural disasters

• Each CMC: own political governance; varying capacity, & priorities

Budgetary limitations; Bureaucracy, politics

• Lack of communication, collaboration, information dissemination• Deficiency in regional and national information systems on

surveillance, and harmonization of food safety and quality standards


Caribbean Travel & Tourism, 2002-most tourism dependant region in the world

• 20 million stay-over arrivals

• 14 million cruise ship arrivals

CAREC/PAHO/WHO


CAREC’s Programs

Surveillance and Response (Epidemiology Division) Laboratory diagnostic and reference service (Lab Division) Foodborne Disease prevention (FBD program) Vector borne diseases (VBD program) Immunization program coordination (EPI program) Special Program on Sexually Transmitted Infections (SPSTI) Travel & Health (Quality Tourism for Caribbean (QTC) NCD, Injury & Substance Abuse Prevention Information, Training, Research (IT Division)


Surveillance

and outbreak investigations


Health Situation ComplexCommunicable diseases

• Elimination of polio, measles, rubella

• AIDS continue increase-leading cause of death in 25-44 yrs

• EIDS: TB, Dengue & DHF, Malaria

• Tuberculosis (estimated 4,600 excess cases in last 12 years)

• Food borne disease increasing, outbreaks in tourism industry

• Potential EIDS: Chikungunya, pandemic flu

• Chronic Non-communicable diseases

– Leading causes of death– Heart disease, cancers, cerebrovascular diseases, diabetes, hypertension

– Huge cost: Morbidity, Treatment, Disability, Premature death• Injuries, violence & substance abuse: 4 CMCs 2nd yr of record homicides

• Behavioral risks underpin most preventable ill health & avoidable health costs


Surveillance of diseases in the Caribbean

• Syndromic surveillance – reported weekly– Acute flaccid paralysis - Fever & haemorrhagic symptoms– Fever and jaundice - Fever and neurological symptoms– Fever and rash - Undifferentiated fever <5 & ≥ 5 yrs– Fever and respiratory symptoms (ARI) < 5 yrs & ≥ 5 yrs– Gastroenteritis < 5 year olds and ≥ 5 yrs

• Laboratory Based /disease specific surveillance – Monthly– Salmonella, Shigella, Campylobacter, E coli, S aureus

• Outbreak surveillance- immediate reporting • Integrated FBD surveillance : Salmonella

– clinical, food and animal data for 6 CMCs


FBD in the Caribbean Major cause of economic burden, illness & death

1989-2005: FBD increased >500%

GE in < 5 years: 1981-’06: 24,000 to 52,385 cases

GE in > 5 years:’94-06: 7000 to 53,303 cases

1990-2006: >140 outbreaks: (40% viral, >50% bacteria)

48% were FBD due to Salmonella (mainly SE)

Multiple hotel based FBD outbreaks

2002: 4 hotels, 10 cruise ships FBD outbreaks

2006: 21 reported FBD outbreaks source: surveillance data at CAREC


Foodborne Diseases Surveillance Program

• Established in February 2003 (CCH & WHO/PAHO priority)

• Initiated by PAHO/FOS: Strategic Plan: by PAHO, CPC, CAREC

Goal: To decrease the incidence and impact of FBD among Caribbean people and visitors thereby enhancing food safety in Caribbean.

Purpose: To strengthen national and regional capacity to develop and sustain effective integrated FBD surveillance systems

Strategy: • Multidisciplinary, integrated farm to table approach to FBD surveill.• Integrating epidemiological, laboratory and environmental aspects of

FBD surveillance and response: coordinated approach• Inter-country, interagency, intersectoral, interdepartmental linkages


Integrated FBD surveillance

Clinical (human)

Veterinary (animal)

Environment

Linking pathogens to the source: Farm to Table

Epidemiological

•epidemiologists • surv. officers

Laboratory •clinical• food • veterinary•analytical

Environmental• EHOs• Vets

Food


Integrated FBD Activities

• Develop/enhance integrated national & regional FBD surveillance systems

• Strengthen laboratory infrastructure and technical capacity for FBD

• Training to enhance food safety and intersectoral, multidisciplinary FBD

surveillance

• Conduct applied research in collaboration with tertiary institutions to

provide information on FBD impact and prevention

• Provide science-based information to facilitate farm to table prevention and

control interventions

• Provide standards and training to upgrade food safety at public health and

industry (tourism) level

• Coordination , Communication and Networking


Laboratory surveillance of FBD in CMCs

particularly related to Salmonella, E coli 0157, Shigella and Campylobacter


LABORATORY SURVEILLANCE OF FBD

Regional (CAREC)• Reference lab (21 CMCs) , diagnostic (some CMCs)

– AMR and Serotyping of Salmonella and Shigella– Phage typing Typing of SE– Facilitate Outbreak investigations and further referral to other labs

• Central depository of data and FBD isolates (mainly Salmonella, Shigella and Campylobacter) from countries

• Databases (Salmonella, LABIS), analysis and reporting of data

In country• Diagnostic capacity varies widely between countries

– No lab diagnosis, only Salmonella, 1-3, >3 organisms• Only 6 CMCs has PH labs, most cases the hospital lab is PH lab• Through GSS and FBD: 6-8 countries now trained in isolation of

– Salmonella, Shigella, Campylobacter, Norovirus.– Sept 2007: E coli 0157:H7, Vibrio, pathogenic S aureus


Regional WHO-GSS Laboratory and Integrated FBD Training

Name Date Location

Course content Participants and countries

GSS-I Sept 2001

Tdad Laboratory: Salmonella and SerotypingEpidemiology: Outbreak Investigation

61 Participants; 21 countries 19 Epidemiologists,21 EHOs, 21 Lab. techs

GSS-II March 2004

Tdad Laboratory: Salmonella, Campylobacter, AMR testing & Serotyping

23 lab participants, 6 countries (clinical, PH, food, vet. labs)

GSS- III

May 2005

Tdad Integrated FBD surveillance, outbreak investigation, BOI, surveillance for mass gatherings refining country FBD protocols

52 participants, 10 countriesMultidisciplinary teams. (epidemiologists, microbiologists, environmental health officers, vets)

GSS IV Sept 2007

Tdad Laboratory: E.coli 0157:H7, Vibrio, pathogenic S. Aureus, NorovirusIntegrated FBD surveillance and BOI

28 lab participants, 8 countries (clinical, PH, food, vet. labs


Countries and Labs with Enhanced Laboratory Capacity

9 Countries > 60 LABS >150 persons

Number and Type of laboratories trained Country Clinical (public)

Clinical (private)

Veterinary Food /water

University

Total

Barbados 1 2 1 2 6 Belize 3 1 1 1 6 St Lucia 3 2 1 3 9 Jamaica 2 4 1 1 1 9 Suriname 2 1 3 Trinidad 6 4 3 4 1 17 Bahamas 3 3 4 10 SVG 1 2 1 4 SKN 1 1 Total 21(32%) 16(25%) 10(15%) 16 (25%) 2 (3%) 65


Reported cases of GE & specific FBD pathogensSymptom # cases in 2005 # cases 2006 Gastroenteritis (GE) <5 25, 819 (17 CMCs) 52,385 (17 CMCs)

Gastroenteritis (GE) >5 34,658 ( 16 CMCs) 53,303 ( 16 CMCs)

GE/FBD outbreaks 21 21

FBD Etiologic agent Salmonella 1078 ( 17 CMCs) 728 (15 CMCs)

Shigella 183 (13 CMCs) 156 ( 10 CMCs)

Campylobacter 37 (3 CMCs) 43 (4 CMCs)

Listeria - 13 ( 1 CMC)

Vibrio 1 (1 CMC) - Ciguatera poisoning 453 (9 CMCs) 358 ( 6 CMCs)

Hepatitis 41 ( 7 CMCs) 11 ( 2 CMCs)

Norwalk * 3 outbreaks ( 7 CMCs) 7* (1 outbreak) ( 1 CMC) *Only outbreak related data. Source: Surveys: Lab. confirmed cases CMC; outbreaks, specific pathogens, FBD–

related data from CAREC’s Epidemiology and Laboratory division (2007)


Food & water borne illnesses in the Caribbean

• FBD continued to be a major cause of human illnesses, economic burden and public health concern

• High & increased reported cases of GE (doubling in < 5 years and 1.5 times in >5 years) – high burden & marked increase in FBD

• Salmonella and Shigella :most common, Ciguatera fish poisoning: 6 CMCs

• Etiologic determination: reflection of laboratory capacity-

• Continued occurrence of FBD: only some reported

Hence: Urgent need:

-determine the proportion of GE that is FBD;

-enhanced laboratory testing for wider range of key pathogens commonly transmitted by food of pathogens

- Implement PFGE for further discrimination, esp for Salmonella


Current Laboratory capacity for FBD

• Improved capacity:

– isolation of Salmonella, Shigella, Campylobacter (9-15 CMCs) – Serotyping of Salmonella and AMR (8 CMCs)– Isolation of E coli0157;H7, path S. Aureus, vibrio, Norovirus (6 CMCs)

• Standard methods for FBD isolation being used by clinical, food, veterinary, public health labs: in country, between countries

• Improved linkages bet. clinical, food & vet labs: enhanced integrated laboratory surveillance (human, animal food data): 80% reported improved communication

• Phage typing of Salmonella Enteritidis

• Early detection of outbreaks

• Improved and timely outbreak investigation

• Laboratories part of WHO GSS network


Proposal of how CAREC could being part of Pulse Net


How can CAREC be part of PN • Because of costs and skills needed, CAREC proposes to join

PN as a one regional lab- representing 21 English countries

• PFGE at CAREC will be a regional reference service

• What CAREC currently has to facilitate PFGE:

– Laboratory space- new molecular lab

– One person qualified in PFGE

– Regional database and depository of isolates

• What CAREC Needs

– PFGE equipment - determines when we can start ???

– 1 new staff and Training of staff

– Mechanism for data sharing to be worked out


Discussion

-Obtaining donation/funds for PFGE equipment and personnel- Data sharing issues


Thank You

Caribbean Epidemiology Centre (CAREC/PAHO/WHO) Surveillance of FBD in the Caribbean and Pulse Net...

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