Generic System for the Epidemiologic Surveillance of Dengue: Elaboration process

Presented by:Dr. Gamaliel Gutiérrez

Regional Dengue ProgramPAHO/WHO

Noviembre 2015

Dengue: First outbreaks in the Americas 1600-1900’s

1600 1650 1700 1750 1800 1850 1900

1635: The first dengue outbreaks occurred in Mar-tinique and Guadalupe.

1780: Benjamin Rush described a widespread out-break that occurred in Philadelphia, Pennsylvania, USA.

1827: First multi-country outbreak (US Virgin Islands, Cuba, Jamaica, Venezuela, and various cities within the USA).

1912: Dengue out-break in Panama, Puerto Rico, Chile, and the northern part of Ar-gentina..

Source: RUSH, A. B. 1780.. Medical Inquiries and Observations. Prichard & Hall, Philadelphia. GUBLER, D. 1997. Dengue and Dengue Haemorrhagic Fever. CAB International

IMS-Dengue:Epidemiology Objectives:

• Strengthen the capabilities for an integrated analysis, early detection and timely response to an outbreak.

• Establish diagnostic definitions and case classifications for dengue.

• Generate the necessary information for decision making for prevention and control.

• Define the strategies for vaccination and evaluate its impact.

IMS-Dengue: Advances in the Epidemiology component

• More countries are systematically reporting dengue

• Availability of weekly bulletins in more then 20 countries

• Epidemiological alert systems

• Advances and improvements in the regional epidemiological reports: PLISA

Peru

El Salvador

Mexico

Argentina

Colombia

Brazil

Costa Rica

Panama

8 countries

• The Technical Advisory Group (TAG) recognizes the work towards a harmonized surveillance system and recommends that all countries contribute and participate in these efforts.

• PAHO/WHO needs to support the national regulatory authorities in defining the harmonized regulatory paths.

• The TAG considers that it is important for the dengue vaccine to be accessible to the smallest countries, if they desire the vaccine.

Objectives of the Generic Epidemiologic Surveillance of dengue

1. Early detection of the incidence of cases and/or outbreaks.

2. Describe the tendencies and distribution of the cases in time, place, and person.

3. Describe the circulation of the different serotypes and its clinical correlation.

4. Detect fatalities and unusual cases.

Objectives of the Generic Epidemiologic Surveillance of dengue

5. Characterize the burden of clinical severity by viral serotype.

6. Monitor the effectiveness of clinical management.

7. Integrated analysis including environmental surveillance and entomology.

8. Detect and monitor new tools and instruments .

Generic System for the Epidemiologic Surveillance of Dengue

Standardization of the case reports

Two surveillance methods: National and Sentinel

Use of the environmental and entomological indicators

Estandarización en el reporte de casos de dengue

Probable case A person who has presented fever or history of fever of 2 to 7 days of duration plus two or more of the following manifestations:

1. Nauseas and/or vomiting,2. Exanthema, 3. Myalgia and/or arthralgia,4. Headache and/or retro-orbital pain,5. Petechia and/ or positive tourniquet test 6. Leucopenia7. Any warning signs, or8. Any severe manifestation

+• IgM positive or IgG ( ≥1,280), or• Epidemiological linkage

Confirmed caseEvery probably dengue case that has tested positive in at least one of the following laboratory tests:

1. RT- PCR conventional or in real time

2. NS1 positive3. Viral isolation4. Seroconversion of IgM or

IgG in paired serum samples or a four fold rise of IgG

5. Immunohistochemistry

NATIONAL

Methods in the Generic System for the Epidemiological Surveillance of dengue.

SENTINEL

• Early detection of the incidence of cases and/or outbreaks.

• Describe the tendencies and distribution of the cases in time, place, and person.

• Describe the circulation of the different serotypes.

• Detect fatalities and unusual cases.

• Characterize the burden of clinical severity by viral serotype.

• Monitor for effectiveness of clinical management

Surveillance system

Geographic location Collection and information flow

National Surveillance

The entire national territory – with operational definition and performance indicators that have been harmonized at a regional level.

Minimum data Weekly report

Sentinel Surveillance

Based on a sentinel area-One locality per country (countries with a greater extension have up to 2/3 localities) which is selected based on specific criteria and includes institutions within different levels.

Minimum data Supplemented with clinical

evolution and by laboratory confirmation

Integration with vectorial, and environmental surveillance and community conduct/

Monthly (or more) reports

Methodology of the Generic System for the Epidemiologic Surveillance of dengue

Use of environmental and entomological indicators VIGILANCIA CENTINELAV. CUADRO CLÍNICO

Fiebre: Cefalea: Mialgias: Artralgias: Dolor retroocular: Exantema:

Náusea: Vómito: Petequias: Torniquete positivo:

Otros:

Signos de alarma: Fecha de inicio de signo de alarma:Día Mes Año

Vómito persistente Dolor abdominal intenso y continuo: Acumulación de líquidos: Letargia:

Sangrado de mucosas: Letargo: Irritabilidad: Hipotensión postural

Hepatomegalia >2cm: Aumento hematocrito

Signos de dengue grave Fecha de inicio de signos de DG:Día Mes Año

Escape importante de plasma con:Pulso débil o indetectable Taquicardia Extremidades frías Llenado capilar >=3seg

Presión diferencial convergente Hipotensión arterial en fase tardía Insuficiencia respiratoria

<=20mmHg

Sangrado grave: Hematemesis Melena Metrorragia voluminosa Sangrado del Sistema Nervioso Central

Compromiso grave de órganos: Aspartato aminotransferasa (AST) Alteraciones de la Conciencia Miocarditis

o Alanina aminotransferasa (ALT)

Otros órganos Especifique

VI. ANTECEDENTES PATOLÓGICOS

Comorbilidad Embarazo: Trastornos hemorrágicos: Diabetes: Hipertensión: Enf. Úlcero-péptica:

Inmunosupresión: Cirrosis hepática: Otros: Especifique:

Datos de Egreso Fecha de egreso: Mejoría: Defunción: Fecha de defunción:

Diagnóstico final: Probable Confirmado

VIII. ANTECEDENTE DE VACUNACION

Fue vacunado Si No Dosis 1a 2a Esquema completo Si No

IX. ÍNDICES DE INFESTACIÓN EN ZONA DE RESIDENCIA DEL PACIENTE

Índice de vivienda positiva: Índice de Bretau

X.DETERMINANTES AMBIENTALES

¿Tiene acceso a agua potable permanente Si No ¿Tiene cobertura de eliminación de basura? Si No

(al menos una vez por semana)

XI. OBSERVACIONES

Nombre y firma de quien llenó el formato.

>=1.000 UI

VII. CLASIFICACION FINAL

AñoMesDía Mes Año Día

VIGILANCIA NACIONAL

I. DATOS DE LA UNIDAD NOTIFICANTE

Nombre de la Unidad código/Clave de unidad

II. DATOS DE IDENTIFICACIÓN DEL PACIENTE

Nombre:

Apellido paterno Apellido materno Nombre (s)

Edad: Años Fecha de nacimiento Sexo: M F

Calle y Núm. Barrio/Colonia/Localidad Municipio

Estado/Provincia/Departamento

III. DATOS EPIDEMIOLOGICOS

Fecha de inicio de síntomas: Fecha de solicitud de atención:Día

¿Fue hospitalizado? Si No Fecha de ingreso:Día

Clasificación Clínica: DSSA DCSA DG Criterios Probable Confirmado

IV. ESTUDIOS DE LABORATORIO

Se tomó muestra para laboratorio: Si No Fecha de toma de muestra:

Prueba Rápida

Fecha de resultado:

Mes

Serotipo Serotipo

Resultado: + - + - + - 1 2 3 4 1 2 3 4 + -

Día Mes Año Día Año

Neg. Neg.

Día Mes Año Día Mes AñoDía Mes Año Día Mes Año

NS1 ELISA IgM ELISA IgG Aislamiento PCR

Día Mes Año

Mes Año

Día Mes Año Mes Año

RESIDENCIA ACTUAL

Vigilancia Integrada de Dengue

Estudio de Caso de Dengue

Día Mes Año

• Access to improved water source

• Proper waste disposal

• Positive ovitraps

• Vaccines (date, dose, scheme)

Timeline for the implementation of the proyect

2013 2014 2015

Dec-Jan.

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan- Jul Jul Aug Sep Oct Nov Dec

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

2016

Preparation and elaboration of the generic protocol

Protocol sent to the countries

Pilot Phase

Meeting to evaluate the pilot project

Final adjustments to the document

End of pilot project

Protocolo modified for the Americas

Monitoring and evaluation of the analysis

Introduction of the protocol to the Americas

Summary;

• The Epidemiologic component of the IMS-Dengue is one of the most strengthened, with the most significant advances.

• The Generic System for the Epidemiological Surveillance of dengue includes:• Standard definitions for dengue cases• Two methods for surveillance: national and sentinel• Integrates other components (socio-economic and

entomologic)

• Countries have demonstrated great leadership in the implementation of this project, and soon it will be implemented in all of the Americas.

The Regional Working Group

Thank you very much for your attention