the national plan in italy for the prevention of vector
TRANSCRIPT
LIFE CONOPS: Development & demonstration of management plans against -the climate change enhanced- invasive mosquitoes
in S. Europe
The national plan in Italy for the preventionof vector born diseases
Raffaella Angelini
Public Health Department – AUSL Romagna
Chikungunya in Emilia-Romagna 2007
G. Rezza et al., Lancet 2007, 370 1840-46
Index case lab confirmed: 1Lab confirmed: 217 Probable, drawing denied: 30Lab negative: 89
A total of 247 probable/confirmed cases, from four provinces (Ravenna, Forlì-Cesena, Rimini, Bologna)
Number of cases by lab results(July 4th, 2007 – September 28th, 2007)
Human national mandatory surveillance system - Italy (D.M. 15-12-1990): imported and authoctonous VBD
• “Classe I”: yellow fever, viral hemorrhagic fever, plague, esanthematic typhus Notification within 12 hours
• “Classe II”: rickettsial infections ≠ from esanthematic typhus, tularemia, cutaneous & visceral leishmaniasis Notification within 48 hours
• “Classe IV”: outbreaks (aggregated data) Notification within 24 hours
• “Classe V”: other infectious diseases, including vector borne diseases not included in previous classes No prescribed term
Special surveillance of WNND, Dengueand Chikungunya
• The increasing number of confirmed human cases from 2008 to 2009 and the occurrence of the WNV in a larger geographical area in 2009 prompted the Ministry of Health to publish, in spring 2010, a national program for WNND human surveillance, integrating information from veterinary and vector surveillances.
• Subsequently, in 2011, a new national plan on integrated human surveillance of imported and autochthonous vector-borne diseases (Chikungunya, Dengue and West Nile disease) was issued, with annual update in 2012.
Italian MoH directive: Surveillance of WNV
disease in Italy, 2010
• Between June 15 and November 15.
• Integrated human and veterinary surveillance.
• Defining the risk:
− “affected area”: province areas (secondary administrative unit) with positivity in the veterinary surveillance or autochthonous lab. confimed animal/human cases.
− “surveillance area”: regions (surrounding an affected area) with vector presence and with autochthonous animal/human cases within its Provinces.
Italian MoH directive: Surveillance of WNV
disease in Italy, 2011
• It includes surveillance of Chikungunya e Dengue
• Defining the risk:
− “affected area”: area (Provinces) with positivity in the veterinary and enthomological surveillances or autochthonous animal cases or lab. confimed human cases.
− “surveillance area”: subnational area (Regions) with vector presence and with autochthonous lab. confirmed animal/human cases within its Provinces.
• Between June 15 and November 15 for autochthonous cases and permanent for imported ones.
Italian MoH directives: adjustmentfrom 2012 to date
• 2014: Zika virus was included
• 2016: Split in two national preparedness Plans
− One for West Nile virus integrated with the veterinary and entomological surveillance for rapid risk assessment
− One for Arbovirosis transmitted through invasive mosquitoes, with particular focus on Chik, Den and Zika virus infections
• 2017: A National plan for TBE surveillance was published
How the system works
Public Health Response
Entomologicalinvestigations
Epidemiological investigations
Early detection of human cases
Vector control
Scientific Committee
Regional group + Municipalitiesto fight mosquitoes
Early detection of human cases
• Surveillance of imported cases throughout the year
• Strict cooperation of Local and regional Health Authorities with MoH and ISS
• Specific training of health professionals on early diagnosis and treatment
• During the vector activity period (June – October):
− Strengthened surveillance based on active case research
− Strengthened contacts with family doctors
Chikungunya case definition
• Probable case: a patient meeting the clinical and epidemiological criteria (staying in a Country endemic for the disease during the 15 days period before the disease onset) and IgM anti-Chik positive in serum.
• Confirmed case: a probable case and at least one of the following laboratory criteria:
− PCR - test positive in a clinical sample
− Viral isolation in a clinical sample
− Antigen identification in a clinical sample
− IgM positive confirmed by neutralization test
− Seroconversion or 4 fold increase in antibodies
Dengue case definition
• Probable case: a patient meeting the clinical and epidemiological criteria (staying in a Country endemic for the disease during the 15 days period before the disease onset) and IgM anti-Dengue positive in serum.
• Confirmed case: a probable case and at least one of the following laboratory criteria:
− PCR - test positive in a clinical sample
− Viral isolation in a clinical sample
− Antigen identification in a clinical sample
− IgM positive confirmed by neutralization test
− Seroconversion or 4 fold increase in antibodies
Zika case definition
• Probable case: a patient meeting the clinical, epidemiological criteria (staying in a Country endemic for the disease during the 15 days period before the disease onset, or sexual contacts with a confirmed or suspected cases) and IgM anti-Zika positive in serum.
• Confirmed case: a probable case and at least one of the following laboratory criteria:
− PCR - test positive in a clinical sample
− Viral isolation in a clinical sample
− Antigen identification in a clinical sample
− IgM positive confirmed by neutralization test
− Seroconversion or 4 fold increase in antibodies
Human surveillance data transmissionSurveillance period June 1st - October 31st
Clinician/Practitioner
detecting a possible / probable case
Ausl
Public Health Department
Regional Authority
Ministry of Health
ISS
Regional Reference Laboratory
National Arbovirosis Reference Laboratory
Dip. MIPI – ISS
ALERTBIOLOGICAL
SAMPLES
within 24 H
REPORTING
within 12 H
Municipalities
for mosquitoes disinfestation
Vector control
• Municipalities strengthened vector control both on larvae + adults (in case of imported cases and/or autochthonous outbreak)
• Regional group preparation of administrative acts, guidelines collaboration with entomologists
Vector control: routine measures
• Larvicide distribution in manholes on public roads
• Use of adulticides in sensitive sites hearing Local Health Unit
• Information and involvement of citizens on the management of their own gardens
Control measures: confirmed or suspected cases
• WHERE: Mosquitoes control activity are to be carried out − in a radius of 100 m around every single suspected case− in a radius of 300 m around a cluster of cases
• HOW: the protocol− Use of larvicide (Insect growth regulators or Bacillus
thuringiensis) in every manholes− Door-to door interventions for elimination of breeding sites− For 3 nights in succession use of fast acting insecticides
applied by truck mounted atomizer or backpack mist blower
Public Health Measures on blood, organand cells transplantation
Precautionary measures:
• Stop of blood donations from residents in affected areas
• Stop for 21 days from people staying in affected areas even for a very short time
• Coordination with Donors Associations to maintain blood supply
• Stop of organ and cells donation in affected areas
Disinsection
• All aircrafts landing at Italian
airports, regardless of their
origin, must present a residual
disinsection certification in
accordance with Annex 9 of the
Convention of the ICAO.
Chik/Dengue/Zika cases in Emilia-Romagna; 2008-2017
* Update 6/11/2017
In 2017 detected 4 cases of Chikungunya related to travel in Calabria e Lazio
Entomological surveillance
• Ovitraps located in the 10 largest Municipalities• Sampling every 14 days• Samples read in the lab of ARPAE (Environmental Agency)• Data published on website www.zanzaratigreonline.it• Maps to individuate area with higher infestation
Comune
N.
ovitrappole
2017
N.
substrati
10 turni
Parma 60 600
Piacenza 60 600
Reggio Emilia 60 600
Modena 60 600
Bologna 110 1100
Ferrara 90 900
Ravenna 100 1000
Cesena 75 750
Forlì 60 600
Rimini 80 800
Totale 755 7.550
Discussion
• Crucial for the system that the reference Lab maintains an high
standard in the timing of testing to allow a quickly
disinfestation.
• In recent years Municipalities have reduced the budget for
vector control due to economic crisis but also because the issue
of Vector borne disease is considered no more a real health risk
(too time passed from 2007 outbreak experience).
• It is important to gain more engagement of people in the
management of their gardens and backyards (in our towns
more than 60% of manholes is in private properties).
Conclusions
• The regional plan is effective: every year we face a number of
imported cases but we have never experienced autochthonous
transmission after the outbreak of 2007.
• In 2017 the system has proved its sensibility promptly detecting
suspected cases in citizens who had not traveled abroad but
coming from the Italian regions where chikungunya outbreak
was ongoing.
• It is crucial to maintain an high sensibility in clinicians and
General practitioners with continuous training and updating on
epidemic data and on the geographical areas where viral
circulation is ongoing.
Thank you for your attention and
thanks to all the Emilia-Romagna
working group.