1. Preamble: The recent outbreak of severe acute respiratory syndrome (SARS) worldwide made us aware that the concept of disease surveillance would be the key to cope with infectious disease outbreaks now and in future. Also the emergence during the recent two decades of pandemic infections of HIV, HCV along with several more localized new diseases such as mad cow diseases and hantaan pulmonary syndrome, has resulted in the growing importance of global surveillance for emerging and reemerging diseases. In response to this global need, a study group was set up in October 1997, which is funded by Ministry of Health and Welfare (MOH), Japan. The group initiated an operation since April 1998, which is intended to set up a sentinel surveillance system for selected infectious diseases mainly in South America, Africa, Middle East and Asia. Many of the institutions contacted by the study group have expressed interest in this study. By the end of second trial phase, March 2004, there are 61 sentinels in 28 countries. It is not envisaged that such system with limited number of sentinels will provide the global picture of target diseases, nevertheless it believed that it can certainly supplement the global information on Emerging and Reemerging Diseases (ERD) being collected by WHO and its collaborators, and furthermore that, once functional, it may well provide data unavailable elsewhere in a manner more timely than most more formal and elaborate surveillance systems. The plan described here aims at defining the research activities in the second trial phase (April 2004 - March 2006), based on the experiences and lessons learned during the last three years.
2. Study Advisory Group: This is formed to advise on technical and managerial aspects of the system. They are Japanese scientists who have specialized in epidemiology, microbiology and surveillance methodology. The advice is also sought ad hoc basis from WHO officials as well as some international researchers, who are concerned with global surveillance and responses.
3. Surveillance Sentinels: Responsible officers of sentinels are presently selected mainly from a group of foreign scientists or public health workers who joined international seminars or courses for epidemiology and control of infectious diseases conducted by ACIH (Agency for Cooperation in International Health) and in collaboration with JICA in recent years. They fall into three categories each of which provide different types of data:
Category 1: Scientists
dealing with clinical (or laboratory) diagnosis of patients, their treatment and
follow-up care and/or epidemic control in health institutions such as hospitals,
outpost clinics, pediatrics department, or infectious diseases control
department. Most of the data from this category are without laboratory
confirmation but are likely to provide a more realistic representation than only
laboratory-confirmed cases. Where feasible the number of laboratory confirmed
cases will be sought.
Category 2: Scientists mainly conducting laboratory work for
pathogen identification, drug resistance or any laboratory study on bacterial,
viral or parasitological agents obtained from specimens of infectious diseases.
This information will provide a check of the clinical information obtained from
category 1 participants.
Category 3: Scientists working in blood transfusion services who can provide information on certain blood borne diseases observed when blood is screened for such diseases. This includes HIV and HCV among others.
Collaborating sentinels are requested to identify themselves as either category 1, 2 or 3.
4. Principles in operating system
4.1 The participants were contacted initially during or after their training programme at ACIH in Japan. An important aim of the project is to develop collaborative research activities between sentinels and the study group represented by ACIH. Advice has also been received from WHO, Division of Emerging and other Communicable Diseases, Surveillance and Control (EMC). It is not intended that this surveillance system be just simple reporting and feedback. For that reason and for an optimal chance of a sustainable programme the ACIH felt it best to establish close personal contact between information providers and recipients. Thus, substantial efforts have been made over the last three years to develop this personal contact between ACIH and sentinel participants. For many sentinels this has been apparently achieved, but for others the communication has ceased despite substantial effort made by ACIH. The ACIH will continue to seek to develop the system through formation and maintenance of these personal contacts. It is recognized, however, that in order to fill certain important geographic areas, or information categories, contact through other means and people may well be required.
4.2 During the first trial phase, an attempt has been made to limit requested information in order not to overburden unduly the sentinel collaborators. This principle will continue. ACIH may explore collecting some further basic information on the situation of sentinel facilities, target diseases etc. when the relationships are strengthened and the programme is functioning smoothly. This information will enrich the database, and will provide a basis for further in depth exchanges between ACIH and the sentinel participants, with the view of continued strengthening the relationship.
4.3 ACIH has no interest in obtaining confidential information and would prefer not to receive data considered confidential by the sentinel collaborators or their institutions, unless the collaborator feels ACIH can be of help with the problem. In such a case, the information will remain confidential.
5. Surveillance Reporting
5.1 Whilst target diseases may be altered as the study develops in the future, it is thought that the following target diseases would be useful for global analysis of epidemiological situation at the trial phase of the study. The rationale for the selection of these surveillance targets is as follow:
WHO worldwide policy (e.g. diseases targeted for eradication) or WHO notifiable diseases according to the current International Health Regulations.
Mortality and morbidity from a worldwide perspective (disease burden)
Epidemic potential
Capacity of public health response to surveillance data
Likelihood of report occurrence during the trial phase
Thus, the following 12 diseases are identified for the activities in Category 1 and 2 sentinels.
Cholera
Meningococcal meningitis
Acute flaccid paralysis (polio like)
Measles
Acute jaundice syndrome*
Influenza
Drug resistant malaria (clinical)**
Antimicrobial resistant typhoid fever (chloramphenicol, quinolones)
Japanese encephalitis
Plague
Dengue
Pneumonia death***
*
aiming at hepatitis A, B and E, Yellow fever
* *P. falciparum or P. vivax
*** aiming at SARS
Parenthetically, tuberculosis and Hansenfs diseases are not targeted since they are being usually handled by independent programmes and this sentinel contribution would not be great.
5.2 For Category 3 sentinels (blood banks), target diseases will include:
Viral hepatitis B
Viral hepatitis C
HIV
Syphilis
It is requested to categorize the donors into two groups: first-time donors and other donors, and report separately.
5.3 Preparation and dispatch of information should not take unreasonably additional time and work for the sentinels. It is not needed for the sentinels to seek additional information from other department which is not under their jurisdiction.
6. Method of Communication
6.1 Method of communications will be by e-mail or by fax. Reporting forms are suggested in Annex 1. Where feasible e-mail will be encouraged, since it is much less expensive, and will promote more rapid and informal exchange between the participants and ACIH.
6.2 The sentinels reporting to ACIH consists of two kinds, namely, immediate reporting and routine quarterly reporting. Those, who have the difficulties to report quarterly, would report monthly, and ACIH would make quarterly report with monthly reports.
6.3 For the purpose of the pilot phase, the diseases proposed for immediate reporting are:
Cholera
Meningococcal meningitis
The routine report will cover all 12 target diseases for Category 1 and 2 sentinels and 4 target diseases for Category 3 sentinels, as mentioned in 5.1 and 5.2.
6.4 ACIH request that if no cases of a given disease are observed, it should be so mentioned, namely gnilh or g0h. Also, if the reports for a given disease are not available in your institutions at the time of reporting, gna (not available)h should be reported. These indications are important to the completeness of the system.
6.5 Routine quarterly report will be delivered ACIH as soon as possible, but within next month of the end of the concerned period. For example, the quarterly report for April to June 2004 will be delivered to ACIH, at latest, by the end of July 2004.
6.6 Most sentinels have already agreed to participate in this study with the concurrence of their health services. If necessary, however, ACIH will be pleased to explain this study plan to the relevant national surveillance department.
7. Feedback
7.1 An appropriate feedback to sentinels is essential and will include:
Acknowledge of receipt of sentinel reports by ACIH
Sharing of information with all sentinels (unless information is stated as confidential)
Pertinent surveillance information selected by ACIH, such as
Information on outbreaks from WHO, CDC, MOH Japan, etc.
Document, references, publication, as desirable
Attempt may be made for appropriate response, when and as needed, primarily through the provision of technical (e.g. consultants, training course) or logistic support (e.g. diagnostic reagents, medical supplies, communication equipment) in consultation with the public health authorities of the countries involved and WHO.
7.2 In order to provide as much information as possible to the participants of the sentinel programme, ACIH began in 1998 a contract with a certain media agency, which provides information on media reports of possible infectious diseases throughout the world. If such information is felt useful by the participants, it will be passed to the participating sentinels. Needless to say, media information is sometimes erroneous or scientifically unconfirmed. Hence, the information should be treated with caution, but will be useful to initiate epidemiological investigation, as required.
7.3 AGSnet:
7.3.1 An internet e-mail based mailing list called AGSnet (Alumni for Global Surveillance network) was introduced in July 1999, with the view to network the participating sentinels for regular exchanges of the ACIH alumni news, and sharing of ideas and opportunities on disease surveillance of public and private networks.
7.3.2 AGSnet is initially housed in WHOfs Majordomo server, which is a WHOfs experimental listserver for public health. Though physically housed in WHO, the list-owner operation of AGSnet will be conducted by ACIH.
7.3.3 The unique characteristics of the mailing list include: a closed list (ACIH alone can add members); membership kept strict confidential (disabled who command); a member can post message direct or via moderator; moderated only so that spam/junk mail will not get posted; a subject line starts with AGS> automatically; and only short messages in ascii text characters are posted
7.4 Joint research projects on surveillance-related topics will be planned and conducted with selected sentinels and members of Advisory group, in order to improve the surveillance quality. As of to-date, research topics include the disease occurrence investigation, subjected to influenza and rotavirus using the quick diagnostic kits in Asian area; the survey of MRSA and PRSP; and the investigation of blood borne diseases among blood donors in Africa area.
7.5 It will be possible to organize some international forum in the later stage of this study for exchange of information among individual sentinels. It can be also planned to organize special seminars for laboratory tests of drug resistance.
7.6 As mentioned previously, evaluation of the sentinel system is planned towards the end of this study, to assess its value as a complementary system for global surveillance of ERD. The evaluation will also assess the possibilities for continuing improvement of both the surveillance system and the response mechanism.
8. Financial implication: This study has been funded by MOH, as well as Japanese private donors who are interested in global health development. It would be possible for ACIH to cover the cost of communication depending upon the effectiveness of the system when it is developed. Cost associated with the response to a reported event will be discussed for necessary action, among ACIH, MOH, JICA and WHO on case basis as required.
9. Miscellaneous:
9.1 The system is meant to be part of a larger global effort, and as such will be developed and implemented in relation to other such efforts such as WHOfs global surveillance and control of ERD. Also, there are other international initiatives related to surveillance (e.g. CDC, U.S.A, Pro-MED, French Institut Pasteur, etc) with which this new system will collaborate. The feedback reports will be certainly shared with WHO and others as appropriate.
9.2 This system will rely on the personal interest and relationship of ACIH and individuals identified as sentinel collaborators. In the event of transfers, promotions, retirements, etc. we would request that an appropriate replacement be made in order to continue the programme with minimal disruption, and to report to ACIH to this effect.
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[Last updated at
2004.07.02
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