SARInet Meeting Proceedings

The Severe Acute Respiratory Infection Network (SARInet) is a network of Member States of the Americas that conduct SARI surveillance and was established in 2013 to facilitate sharing of ideas, access to resources, and to strategically address SARI surveillance. Since 2013 an annual regional network meeting has taken place in order to strengthen the collaboration and quality of work performed by the network members. The most recent meeting was held in Punta Cana, Dominican Republic in May 2017, uniting over 100 participants from 28 countries, 20 national influenza centers (NICs), nine national laboratories, and several collaborating institutions.

During the three day meeting, a variety of topics was addressed through oral presentations, posters, and workshops, including updates on SARI surveillance guidance and policies, integrating human and animal influenza surveillance, influenza vaccination, application of surveillance tools and data uses, and emerging issues in influenza and surveillance. Country and regional surveillance staff and technical influenza experts shared their experiences, challenges, updates, and recommendations for strengthening influenza surveillance.

The objectives of the meeting were to: Identify regional gaps in influenza surveillance, and Share advances in regional influenza and other respiratory virus surveillance

Meeting Presentation Summaries

Block 1: Integrating human and animal influenza surveillance

The increasing interactions between populations of poultry, pigs, and people worldwide have led to an increasing threat of the emergence of novel influenza viruses. While much has been learned about controlling avian influenza in animals and people over the past decades, significant gaps remain in the knowledge of modes of transmission, occupational risks, baseline exposure rates, and the sustainable implementation of control measures. The need for animal and human health sectors to coordinate and collaborate in the areas of disease control, prevention, and research in a more formal manner was highlighted by presenters during this block.

Global updates on avian influenza and tools to assess pandemic potential, Dr Julia Fitzner, WHO Advance planning and preparedness are critical to help mitigate the impact of a pandemic.

Pandemic influenza risk management (PIRM) takes an emergency risk management for health approach which aligns more closely with the disaster risk management structures already in place in many countries.

Various guidance documents exist to assist in the tracking and management of influenza; these include the TIPRA guidance to assess the pandemic potential of non-seasonal influenza viruses, PISA guidance to support the assessment of influenza severity, and a protocol to investigate non-seasonal influenza and other emerging acute respiratory diseases (in clearance).

Virus information for all human infections with a non-seasonal influenza virus is reportable under the IHR.

Within the Americas, Canada, Mexico, and the USA have recorded 295 original viruses via the influenza virus traceability mechanism (IVTM). This included the documentation of Influenza A/Mexico/7218/2012 (H7N3) isolated from a human and detected in Mexico in 2012 which was recorded in IVTM by CDC Atlanta.

Global updates of avian and other novel influenza sub-types: From 2003 through 12 May 2017, 859 laboratory-confirmed human cases of avian

influenza A(H5N1) virus infection have been officially reported to WHO from 16 countries; of these cases, 453 have died. Since May 2016 there has been a dramatic decline of reported human cases worldwide

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From 2014 through 12 May 2017, 16 lab-confirmed human cases of avian influenza A(H5N6) virus infection have been reported to WHO from China; most cases had exposure to live poultry or live poultry markets; 6 cases were fatal

From 2013 through 16 May 2017, 1486 lab-confirmed human cases of avian influenza A(H7N9) virus infection have been reported to WHO from 3 countries; of these cases, at least 373 have died

Only by sharing data and viruses can the global situation be understood.

Emergence and changes in swine and avian influenza viruses globally, Dr Stephen Lindstrom, CDC

Avian H5Nx continues to spread to many countries although numbers of human infections are low.  Updated CDC H5 assays detect recently circulating viruses.

Avian H7N9 continues to spread more widely in poultry populations in China and causes high numbers of human infection and death.  Detection has spread throughout China including provinces near the country’s border.  CDC EuH7 assay detects recently circulating H7N9 viruses from China.

Other viruses causing human infection include, by origin: swine H3N2v, H1N1v, and H1N2v; Asian avian H9N2; and Feline (N. Am. avian origin) H7N2.

H1N2v notes from the field, BRA A novel human influenza A(H1N2) variant virus was identified by genomic characterization in a

specimen from a pig farmer in the southern Brazilian region who presented with influenza-like illness.

The virus was a triple reassortant virus containing gene segments from subtypes H1N2 (hemagglutinin), H3N2 (neuraminidase), and pandemic H1N1 (remaining genes), closely resembling a swine virus detected in Brazil in 2011.

The patient did not have antibodies against the virus circulating in the swine population. Lessons learned include the need to improve the integration of the animal and human health

sectors and the need to fortify human and animal influenza surveillance networks in Brazil.

H7N6 notes from the field, CHIExperience in the investigation of the avian influenza outbreak H7N6, December 2016-January 2017, Valparaíso region, Chile

12/30/2016: The Agricultural and Livestock Service (SAG) reported to the Ministry of Health the finding of avian influenza in turkeys in two poultry farms in Comuna Quilpué. Influenza A virus(H7) was detected by ELISA technique.

Immediate activation of control methods according to SAG protocol were implemented, including the slaughter and destruction of affected birds, isolation of the affected area, restriction of access to the affected site, virologic study of the poultry, increasing biosecurity measures to prevent the spread of the virus to other levels, and reporting of the event to the World Organization for Animal Health (OIE).

Avian influenza research was conducted to detect in a timely manner the presence of respiratory symptoms in exposed persons and establish control measures to prevent illness propagation. A retrospective study of direct or indirect exposures in those working from December 11, 2016 through January 3, 2017 (14 days before the initial detection of infected poultry) was conducted.

Results: Two affected foci were found in fattening turkeys, with 7 of 10 sectors affected 132 (of 136) exposed workers interviewed, 99% male No positive cases in exposed workers, however, influenza vaccination is below 70% in

the at-risk population Most cases experienced mild respiratory symptoms, and tested negative for avian

influenza (H7) Diverse use of biosecurity measures reported among workers

It is hypothesized that the influenza outbreaks in poultry were caused by: (a) indirect transmission from migratory birds found near to the tanks located on both farms, (b) indirect

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transmission through fomites, as both outbreaks had the same causal agent, or (c) increased risk due to using the same vehicles to transport birds.

Country experience with integrated surveillance, USA Variant influenza A virus infections are defined as human infection with influenza A virus subtypes

different from currently circulating human subtypes (A/H1 and A/H3). Influenza viruses that are known to circulate in pigs are called “influenza viruses—swine” when isolated from pigs, but are called “variant viruses” when isolated from humans.

Prevention of variant influenza includes: getting seasonal influenza vaccination, avoiding contact with sick animals, minimizing unnecessary contact with animals at fairs, staying away from animals when sick, and washing hands after contact with animals, contaminated equipment, or surfaces, etc.

CDC and APHIS developed a monitoring plan for responders involved in outbreaks of HPAI H5 avian influenza in the United States. This plan supports increased engagement of state and local health departments in the monitoring of responders for illness consistent with influenza.

CDC recommends that all persons exposed to infected birds or virus-contaminated environments be monitored for illness for 10 days after their last exposure. State health departments should notify CDC immediately when testing any patient under investigation for HPAI H5 virus infection.

Country experience with integrated surveillance, MEX 60% of human pathogens are of animal origin, 75% of emerging animal diseases can be

transmitted to humans. Mexico utilizes active and passive surveillance for tracking of animal diseases. Strengthening of the intersectoral response is achieved through the continuous exchange of

information, the sharing of protocols and advances in diagnosis, routinely holding meetings, and carrying out collaborative projects between the animal and health sectors.

Country experience with integrated surveillance, COL On 12/09/2016, the National Institute of Health received a report of the death of a 49-year-old

female resident from a rural community. The patient presented with symptoms of headache, fever, and general malaise following the handling of a diseased hen which quickly evolved to clinical and neurological deterioration and death.

Biological samples from the poultry farm and nearby areas were collected. The biological samples tested negative for New Castle and avian influenza infection. Samples tested negative for influenza and positive for Streptococcus pneumonia by hemoculture assays.

In Colombia, all cases complying with the case definition of antecedent exposure to sick birds or travelers from areas with avian influenza circulation should be reported and investigated in a timely manner.

Field research and laboratory results must be obtained for all reported cases. The sensitivity of the early warning system depends on the proper integration and joint work of all

levels and actors involved in both human and animal surveillance.

Animal influenza surveillance strengthening activities in Latin America, Dr Shultz-Cherry, St Judes/WHO CC

Surveillance was conducted in South America to determine the prevalence and diversity of influenza viruses in Colombia and Chile. The study was initiated in 2010 and 2015, respectively, with four sites in Colombia (Santa Marta, Medellin, Bogota, Los Llanos) and 15 sites in Chile around Santiago.

Wild birds (environmental samples), swine, and domestic birds (live animal markets, backyard, industry, and captive) were examined, using a risk assessment algorithm (CDC IRAT) to determine the risk of influenza viruses to humans, poultry, and swine.

Results: Avian influenza virus and swine influenza virus are present in South America Limited avian influenza found in Colombia, however swine influenza is prevalent; virus

prevalence by species is determined by RT-qPCR. In Chile, diverse strains of avian influenza and swine influenza viruses were detected, influenza is prevalent

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Studies linking avian influenza viruses in the Americas continue and need to be done in more countries

Latitudinal segment diversity is found between South American and North American avian influenza viruses

What’s next in the animal-human interface? Serosurvey studies of disease surveillance in Colombia Investigation of high-risk influenza virus subtypes and occurrence of spill-over events Lots of opportunities for collaboration Expand within South America Training Capacity building

Human-animal interface survey results in the Americas, Dr Rakhee Palekar, PAHO PAHO administered a 41-question survey to n=17 Ministries of Health (MoH) and n=12 Ministries

of Agriculture (MoAg) in the Americas to assess inter-sectoral influenza surveillance and response.

Survey results suggest the following: most MoH have limited influenza surveillance of farmers/farm inhabitants and are not collecting information about exposure to animals from SARI and ILI cases; most MoAg have active avian influenza surveillance and have a national laboratory to test for influenza; and MoH and MoAg agree that it would be feasible to establish inter-sectoral information sharing.

Recommendations for the strengthening of inter-sectoral influenza surveillance and response include: improve ascertainment of high-risk exposures among SARI and ILI cases, increase information sharing between MoH and MoAg, and provide inter-sectoral preparation/training of clinicians and workers to recognize and respond to high-risk events.

Reporting unusual and unexpected events to PAHO/WHO, Dr Angel Rodriguez, PAHO Unusual events include findings of: novel influenza viruses not circulating widely in the human

population, unsubtypeable influenza viruses, and exposure history to unusual pathogens combined with respiratory disease (e.g. respiratory disease plus travel to the Middle East (MERS-CoV) or exposure to sick animals).

Human infection caused by a confirmed or suspected novel influenza virus with pandemic potential, including a variant virus, should be reported immediately to the WHO IHR Regional Contact Point (via the IHR National Focal Point) and the Global Influenza Surveillance and Response System (GISRS) (via flu@paho.org). 

Block 2: Influenza seasonality and virus sharing

Twice per year, the World Health Organization (WHO) convenes a group of experts to determine the seasonal influenza vaccine composition for the Northern and Southern Hemispheres. The group analyzes global surveillance and vaccine effectiveness data to make an informed decision. Effective surveillance is necessary for understanding influenza seasonality and for determining the best strategies for influenza control, which include an optimal choice of influenza vaccine formulation and timing of vaccination campaigns.

During this block presenters’ highlighted approaches to determining the seasonality of influenza and the importance of shipping samples to the WHO Collaborating Centers for antigentic and genetic characterization as part of routine surveillance.

How to establish influenza seasonality, Dr Paula Couto, PAHO Analysis of seasonality allows for an understanding of what is usual and preparation for increased

influenza activity periods. A variety of statistical methods are available to estimate influenza seasonality (based on the

weekly proportion of influenza positive samples, % of SARI or ILI cases): Averaging methodology: aligns all annual curves into a single average epidemic curve

based on the median epidemiologic week

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Binomial negative method: a logistic regression model which assumes a negative binomial distribution to predict monthly influenza activity

Moving epidemic methodology (MEM): calculated with the R package, determines the arithmetic mean of pre- and post-epidemic rates for historical seasons, with defined intensity thresholds

A combination of methods is required to ascertain influenza seasonality, particularly in tropical countries, as there is no gold standard.

Using the MEM method for influenza seasonality determination, Dr Tomas Vega, MoH Spain Objectives: To detect the start of epidemics and to compare the intensity (transmissibility,

seriousness and impact) of seasonal epidemic waves in a territory over time and between different territories.

Method: The Moving Epidemic Method identifies and locates the epidemics, aligns the epidemic waves, establishes a baseline and estimates the intensity thresholds.

The MEM can be used with any influenza surveillance parameter, with different performances, usefulness, and limits.

A Web application is being developed to facilitate the use of the MEM modeling process at the local/country level. A version can be downloaded from https://github.com/lozalojo/memapp. Modelling guidelines and a technical manual complete the MEM documents.

New approaches for modelling influenza data in tropical countries are under investigation. An international collaborative project is being designed.

Importance of viral genetic and antigenic characterization and human serology for influenza vaccine strain selection, Dr Xiyan Xu, CDC/WHO CC

Information regarding the WHO vaccine strain selection for the Northern Hemisphere 2017-18 season was reviewed.

Next generation sequencing (NGS) has improved throughput of genomic sequencing. However, the complexity, cost factors, and need for NGS must be considered before

implementing NGS.

Block 3: Influenza vaccination

Knowledge of influenza-seasonality is important to determine the appropriate timing for influenza vaccine campaigns. Trivalent influenza vaccines contain three influenza viruses: two influenza A viruses and an influenza B virus; while quadrivalent vaccines contain four influenza viruses-the same viruses as the trivalent vaccine plus an additional influenza B virus.

During this block, experts discussed the use of trivalent versus quadrivalent influenza vaccines, measures of influenza vaccine effectiveness, and ways to improve influenza vaccine coverage.

Updates on REVELAC-i network and current vaccine recommendations, Ms Alba Maria Ropero, PAHO

The presenter discussed advances in influenza vaccination in the Americas, the progress made in generating evidence for vaccination programs in Latin America and the Caribbean, the status of Revelac in Chile, and opportunities for intra- and inter-institutional collaboration.

SAGE/TAG recommendations for seasonal influenza vaccination 2004-2015 were reviewed: All countries should strengthen their surveillance system to determine:

o disease burden due to influenzao cost-effectiveness of introducing the vaccine, ando seasonality in order to identify the best vaccination strategy, formulation and

vaccination period in tropical countries All countries should establish a vaccination policy against seasonal influenza in:

o Pregnant womeno children <5 years (6-23 months)o older adults, ando health workers and people with risk conditions

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Evidence needed by influenza vaccination programs in LAC Epidemiological information to guide influenza vaccination programs

o know the burden of disease by influenzao seasonality, when to vaccinate in countries of the tropico what formulation of the vaccine to use

Evidence of vaccine performance (effectiveness)o support investment in the vaccine (free vaccine to target groups)o keep or extend to high-risk groupso guide complementary measures in seasons of low concordance between vaccine

and circulating virus Evidence of Impact

o insert disease burden, effectiveness, and coverage data to assess the impact of the vaccine

Evidence of program performanceo coverage, maternal immunization, health workerso economic studies

Requirements for participation in the multicenter evaluation of REVELAC-i are presented Opportunities:

Strengthening of IRAG surveillance and the efficient use of these platforms by countries Strengthening of multidisciplinary teams Evidence of vaccine effectiveness, impact, and good practices for decision makers Responding to specific needs by subregions, for example, risk communication and

vaccination of health workers Continuing the development of a dynamic research agenda Identifying new collaborating centers and projects (mobilization of technical and financial

resources)

Roll-out of influenza vaccination campaign 2017, BRA The 2017 influenza vaccination campaign in Brazil included teachers and had a target population

of 60 million individuals, with a target coverage rate of 90% (based on an estimated country population of 210 million people).

As of 18 May, approximately 28 million people in Brazil have been vaccinated. H3N2 virus predominated during the 2017 influenza season, in contrast to the 2016 season when

the H1N1 pdm09 strain prevailed. Anecdotally, the low demand for influenza vaccine in 2017 is due to the focus of healthcare

workers and the population on concurrent yellow fever outbreaks in parts of Brazil and lack of concern to influenza infection with virus strains other than H1N1 pdm09.

Using surveillance data to make decisions about vaccine use, GUT

U.S. estimates for vaccine effectiveness, Dr Sofia Arriola, CDC Preliminary end-of-season results for the 2016–17 flu season indicate a vaccine effectiveness of

43% against medically attended influenza. Interim and preliminary end-of-season estimates are similar to previous seasons when the

vaccine was well matched to circulating influenza viruses. There was significant protection against circulating influenza A(H3N2) and B viruses

(predominantly B/Yamagata).

REVELAC-i – The way forward, Ms Nathalie El Omeiri, PAHO Presented reasons to measure influenza vaccine effectiveness (VE) in LAC

40 countries in the Americas have policies in place for influenza vaccination; over 250 million doses distributed annually

Despite the substantial increase in influenza vaccine use in LAC, there is no routine monitoring of influenza vaccine effectiveness

Need for regional evidence to support current policies and guide public health measures

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VE varies between seasons and depends on the match between the vaccine and circulating strains, host factors (age, underlying conditions), prior exposure to influenza virus, different products (TIV/LAIV, adjuvant/non-adjuvant), and field conditions.

REVELAC-i - What We’ve Learned: Feasibility of using SARI platforms and the Expanded Programme on Immunization (EPI) Demographics, clinical, lab data completeness Vaccination status ascertainment Timeliness - active surveillance, information systems, vaccination registries Sample size Target groups

o IVE per type/subtypeo subregion

Virological information – antigenic and genetic data

Modeling vaccine impact in LAC, Ms Nathalie El Omeiri, PAHO The modeling exercise aims to provide health authorities with usable data to justify investments in

the influenza vaccine and guide decision-making for influenza prevention programs in Latin America and the Caribbean.

The model requires analysis of secondary data using estimates of disease burden, data from departments of health statistics, PAIs and vaccine effectiveness (REVELAC-i estimates).

Age groups will be based on the vaccination groups in each country. During the pilot phase, available data sources will be identified and will guide selection of the best sources for the implementation phase.

The model will allow for calculation of the number of deaths, hospitalizations, medical visits and cases of illness avoided by vaccination in children under 6 months to 2 years, 2 to 5 years and adults over 60 years in selected countries of the region using a mathematical model.

Trivalent versus quadrivalent vaccine use, Dr. Sergio Loayza SCost-utility of the introduction of the inactivated quadrivalent influenza vaccine to the Chilean immunization program: analysis in groups of 6 months to 5 years and ≥ 65 years

Trivalent vaccine: two subtypes of influenza A and one lineage of influenza B; mismatch in lineage of influenza B up to 50%.

Quadrivalent vaccine: includes two lineages of influenza B; higher cost. Cost-effectiveness studies in high-income countries indicate cost effectiveness of quadrivalent

vaccine. In LAC there are health and economic impact studies from Colombia, Brazil, and Panama. Discussed

Consistency: methodological differences, cost effectiveness thresholds Interpretation of results: base year = average, a specific year will not be cost effective if

there is perfect matching It is important to analyze with probable costs of quadrivalent vaccine, to evaluate

variability associated with viruses Other target groups of the program Feasibility of incorporating quadrivalent vaccine into specific groups

Experience vaccinating pregnant women in Nicaragua, NIC

Vaccination among healthcare workers–a KAP study in Guatemala, Dr Rafael Chacon, Univ de Guatemala

Improving vaccine coverage in healthcare workers in Guatemala, Dr Jorge Jara, Univ de Guatemala

Block 4: Surveillance tools and data uses

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Surveillance data should be collected and analyzed on a routine basis and tools that facilitate this process can improve the quality of the surveillance systems.

During this session, presenters discussed the benefits of using tools such as an automated monitoring dashboard to efficiently display and assess the performance of an influenza surveillance system. Additionally, assessment tools and severity tools were discussed.

PAHO Monitoring dashboard, Dr Myrna Charles, PAHO Dashboards simplify data into manageable pieces of visual information that show what is being

done right and where improvement is needed. An effective data dashboard should fit on a single computer screen, display the most important

performance indicators, be easy to understand, and be routinely updated by a responsible party. Monitoring indicators are used to measure a project or system, to clarify the relationships

between a system's impacts, outcomes, outputs, and inputs. Monitoring indicators proposed by OPS/OMS assess the performance of SARI surveillance

systems through the various steps of SARI surveillance: case identification, data collection and entry into an information technology system, clinical sample collection, sample transport and testing, data analysis, reporting, and management.

Benefits of using a monitoring dashboard, ELS ILI and SARI influenza sentinel surveillance was implemented in 2007 in El Salvador. Monitoring and evaluation systems allow for weekly analysis of data at different levels; annual

evaluation of surveillance results and performance by establishment; weekly generation and dissemination of epidemiological and laboratory reports to the Ministry of Health, to the region, intersectoral, and to PAHO.

Benefits: View the surveillance processes Identify quickly and systematically the performance of establishments over time Identify opportunities for improvement by site Prioritize support needs (e.g. resource management, training, visits) Integrated epidemiology and laboratory approach Implement local process adjustments

Challenges: Compliance with case definitions High turnover of human resources Continuous improvement of the information system Transport and shipment of samples to LNR Sustainability of resources for laboratory monitoring Monitoring of surveillance processes Development of information analysis methodologies

Implementation of different tools for the monitoring and evaluation of data generated by the sentinel sites allows for strengthening of surveillance quality and generation of useful data for decision making.

PAHO sentinel site evaluation tool, Dr Paula Couto, PAHO Monitoring and evaluation are complementary processes that ensure that the best quality and

consistent surveillance data are collected. Evaluation is a more complete process where all parts of the surveillance system are thoroughly examined. During 2016, WHO/PAHO updated the sentinel sites assessment tool.

The new PAHO/WHO tool includes a SARI and an ILI sentinel assessment and is organized in terms of processes following the standard surveillance cycle: 1) case detection and data collection, 2) respiratory specimen collection, packaging and shipment, 3) personal protective equipment and respiratory sampling techniques, 4) data reporting, management and analysis, and 5) quality monitoring.

The balance between evaluation and monitoring is achieved by implementing the assessment tool at the sentinel sites once or twice a year, and intensified monitoring of the reported data

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through SARI sentinel indicators monthly or every two weeks (with monitoring dashboards). This allows for the improvement of surveillance in terms of opportunity, regularity and data quality.

Implementation of an information system, STL Limitations of the previous information system include data is in summary form and missing

important variables; double entry of data by infection control nurses, there is no standard operating procedure for data management; and the time lag in data entry of confirmatory lab results.

Implementation of SARI data analysis with the online PAHOFlu system and dashboard allows for multi user data entry in real time and immediate lab updates.

With the PAHOFlu system, challenges arise when: not every case of SARI has a sample taken, nasopharyngeal swabs are not available at one sentinel site; data entry is not timely, there is non- closure of case encounters, and the turn over time for results is delayed.

The way forward: Continue to work with physicians to ensure that every case has a sample taken Advocate for a public health budget Advocate for 100% closure of all entries in the database Undertake more in-depth SARI analyses for presentation at meetings Publish an article about Saint Lucia SARI Online Surveillance System, Year One

PISA tool, Dr Julia Fitzner, WHO By applying, evaluating, and refining tools to measure severity every year, WHO and the

Ministries of Health will be better prepared to assess severity during the next pandemic. An early assessment followed by ongoing re-assessment as the pandemic evolves and new

information becomes available, is recommended as severity will likely vary by site and over time. Severity indicators used in the PISA tool include transmission, seriousness of disease, and

impact (on society and health care systems). Absolute values are not comparable between countries; when put into context with historical data, it is possible to assign a category and compare parameters within and between countries.

In the Northern Hemisphere, during the 2016/2017, PISA measures showed: Transmission

o Generally low to moderateo Comments: Higher transmissibility in elderly

Seriousnesso Half of countries reported moderate to high; mainly in European countrieso Comments: High especially in elderly

Impacto Moderate to high in all countries reportingo Comments: Elderly possibly at risk for high impacto Spain: high impact but low seriousness

PISA country experience, CAN Canada has participated in the PISA project and pilot data collection since 2014. Current indicators for Canada

1. Transmission: Number of laboratory specimens positive for influenza (respiratory virus detections surveillance); percentage of primary care visits for ILI (sentinel physician ILI reporting)

2. Seriousness of disease: Number of pediatric hospitalizations (IMPACT) 3. Impact: (none)

PISA measures for the 2015/2016 flu season displayed an extraordinary level triggered by high numbers of paediatric hospitalizations. Exploratory analysis revealed it to be a true surveillance signal, validated by other systems. This finding was corroborated by some other countries (although not reflected in PISA levels).

Next steps for Canada:

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Application and comparison of MEM for Canada Assess denominators for current indicators Evaluate additional indicators to include in PISA assessment Explore capacity for age-specific thresholds Establish complementary threshold measures for other national purposes

Canada recommendations PISA provides a meaningful global interpretation of national indicators A common understanding and clear communications are important Needs stable historical data (which can be maintained during a pandemic)

Assessing severity during influenza seasons, MEX During the 2016/2017 flu season, a mosaic of influenza virus subtypes show predominance of

A(H1N1)-48%, A(H3N2)-23%, influenza B-23%, and Influenza A-6%. The Infectious Diseases Reference Laboratory (InDRE) did not identify any antigenic mutations

impacting the virulence or pathogenicity of the influenza viruses. During the 2016/2017 season, 5691cases were reported with onset of symptoms between

epidemiologic weeks 40 through 20, with 489 deaths. The influenza positivity index for the 2016/2017 season is 28.5%. In 2016 the burden of influenza disease was 175,854 total estimated positive cases, with 734

deaths (case-fatality rate: 0.42%)

Block 5: Surveillance capacity in the region and data reporting

One critical component of surveillance is the analysis and global dissemination of data. Since 2009, the capacity for surveillance, that includes the timely collection and analysis of data, has improved tremendously in the Americas. During this block, regional and global platforms for data reporting were presented as was a landscape analysis of the influenza and non-influenza respiratory virus surveillance capacity that exists in the region today.

Regional surveillance inventory, Ms Paulina Sosa, PAHO The newly updated and published 2017 PAHO Influenza Surveillance Inventory is presented with

new subregional and country-by-country analyses. Discussed how data and content were gathered from countries and utilized to prepare summary

maps and country factsheets. Discussed the visualization of data in the new factsheets and how maps and graphs were

generated with raw data provided from countries. Comparison of the amount of data we were able to utilize and analyze now compared to the 2014

publication. Congratulations for the amount of teamwork that has been done in a matter of three years for

epidemiologic and virologic surveillance system development and establishment, as the data that has been provided from system strengthening is now showcased in the 2017 publication of the surveillance inventory.

NIC survey, Dr Juliana Leite, PAHO The survey collects data from the NIC or National Reference Laboratory regarding: sample

collection and handling protocols, laboratory network information, and process for sending of samples to the WHO Collaborating Centers.

Compared to the previous year, the number of laboratories and countries who returned the survey increased from 19 to 29 laboratories and from 15 to 24 countries, respectively.

Over 50% of the laboratories are using the CDC protocol for ORV and most of the laboratories are using the PAHO and WHO sample selection criteria for shipping to CDC.

The laboratory survey is a tool for obtaining NIC and National Laboratories data, for knowing the response capacity of the lab and provides an opportunity to identify areas for improvement and strengthening.

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NIC ToRs and GISRS, Dr Sandra Jackson, WHO Global influenza virus surveillance has been conducted through the WHO Global Influenza

Surveillance and Response System (GISRS) for over half a century. Established in 1952 GISRS celebrates 75 years of surveillance in 2017.

GISRS diagnostics and timely surveillance systems are essential for the early detection of evolving influenza viruses and non-seasonal influenza viruses with pandemic potential.

Global surveillance has strengthened over recent years. Revised NIC terms of reference will facilitate standardization and continued improvements in the quality and function of GISRS.

The revised NIC terms of reference includes descriptions on: General requirements for NIC’s General work conditions for NIC’s

o work with human seasonal influenza viruses (Category 1)o work with influenza viruses that are “PIP biological materials” (Category 2)o work with other influenza viruses from animal or environmental specimens that are not

classified as “human seasonal influenza viruses” or PIP BM. (Category 3) NIC core terms of reference

o General conditions and activitieso Laboratory and related activitieso Information and communicationo Research, scientific presentations and publications

Next steps: review and redesignation of National Influenza Centres.

FluID updated platform and data reporting to PAHO/WHO, Dr Angel Rodriguez and Ms Paulina Sosa, PAHO

The newly updated and published 2017 PAHO Influenza Surveillance Inventory is displayed. New sub regional and country-by-country analyses are presented and published in the 2017 publication.

Unveiling and launch of the new PAHO/WHO FluID platform, with a detailed description and demonstration of the new variables in the Home page and the SARI pages.

A comparative analysis between 2016 and 2017 shows new countries providing data for the FluID platform.

PAHO/WHO recommends and urges countries not included in the platform, to begin the process of FluID reporting via flu@paho.org . FluID can be viewed at: http://ais.paho.org/phip/viz/flumart2015.asp

PAHO/WHO recommends that virological and clinical epidemiological data be sent on a weekly basis to flu@paho.org

PAHO/WHO recommends that samples be sent four times a year for additional characterization to the WHO Collaborating Center (US CDC Atlanta).          

Block 6: ILI and SARI Surveillance

The recommended global strategy for influenza surveillance relies upon two key clinical syndromes—Severe Acute Respiratory Infection (SARI) and influenza-like illness (ILI). During this session, countries presented the advances and lessons learned related to SARI and ILI surveillance.

ILI surveillance using sentinel sites, PAR MODALITIES for ILI surveillance:

Universal weekly data: Consolidated numerical notification by Health Region of Influenza in minors and over 5 years

Sentinel Sites: Individual notification through case-by-case notification form: ILI activity; seasonality and geographical distribution; virological surveillance: distribution and prevalence of viruses and strains

An ILI case is defined as a person of any age presenting with: sudden onset of axillary temperature equal to or exceeding 37.5 ° C, and cough or sore throat

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in the absence of other diagnoses During EW 1 to 17, 2017, 215 positive samples of influenza virus and other respiratory viruses. The proportion of ILI consultations in sentinel sites during 2017 by epidemiological week was

compared to epidemic thresholds for ILI consultations during 2014-2016.

ILI surveillance using a sentinel provider, SUR The objectives and case definition used for ILI surveillance in Suriname were highlighted. The characteristics of the ILI surveillance system as it complements the routine surveillance

systems for influenza and other respiratory viruses were discussed. The use and dissemination of data as produced by the surveillance activities were presented; this

included some discussion regarding challenges at all levels of the ILI surveillance system. ILI surveillance data and challenges provide topics to work on for planning in-country actions.

Surveillance strengthening, DOR Objectives of the influenza and other respiratory virus sentinel surveillance are presented. Operation of the sentinel surveillance system of influenza and other respiratory viruses. Location of sentinel sites. Distribution of circulating viruses during 2016. Progress in sentinel surveillance of influenza and other respiratory viruses. Next steps.

National assessment to reduce sentinel sites, CRI Presenters discussed the evaluation of the IRAG case definition in sentinel units (CDC-CAP

instrument). Evaluation of the sentinel surveillance process. Evaluation of laboratory sampling during the years 2013 to 2015. Based on the findings of the 2015 and 2016 evaluations presented in this report, it is

recommended to decrease sentinel hospitals from seven to four.

National SARI surveillance, BRAThe Universal SARI surveillance

Benefits: Provides the opportunity to improve influenza virus prevention and control strategies:

(medications, training courses, seminars, etc.) Seasonality studies (mathematic models, REVELAC-i) Epidemiological patterns of morbidity and mortality aim to discuss treatment protocols, clinical

management, and vaccination priority groups Is a valuable tool to identify influenza virus circulation in Brazilian counties that still need

support to maintain the sentinel surveillance follow-up Challenges:

Lack of denominator High cost requirement Impact on the laboratory routine Death counts reported by the media (panic scenarios)

Universal SARI surveillance aims to achieve a balance between the benefits and the challenges.

Crowd-sourcing ILI surveillance with SMS, Dr Neely Kaydos-Daniel, CDC Participatory surveillance based on text messages using mobile telephones can be used for

rapid, anonymous, syndromic surveillance. We pilot-tested a mobile-phone based system for ILI surveillance in San Marcos, Guatemala from

August 2016 to March 2017. Respondents were enrolled face-to-face and responded to simple questions about household

members’ symptoms weekly via mobile phone. 189 households made 469 weekly reports in which 27% indicated at least one person with ILI. Participatory surveillance using mobile phones was rapid and inexpensive, but further studies

should be conducted to increase participation.

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Block 7: Burden of disease

Estimations of burden of influenza and RSV are lacking in the Americas, especially in Latin America. Tremendous advances have been made in this area, however, during the last two years. During this block, global, regional, and country-specific estimates of influenza morbidity and mortality were presented.

Global influenza mortality estimates, Dr Julia Fitzner, WHO Disease mortality and morbidity are measured to support development of public health policy for

influenza prevention and control, to communicate disease severity, and to conduct research and expand knowledge.

Development of a methodology to estimate the global influenza burden involves producing credible global burden estimates of influenza mortality, and hospitalization, including information on high risk groups. Work is ongoing in five areas: Literature review for mortality and incidence Literature review on risk factors Under 5 years burden estimate with comparison to RSV Global mortality estimates for seasonal influenza Global morbidity estimates for seasonal influenza

Current global burden of disease estimates show an annual attack rate estimated at 5%–10% in adults and 20%–30% in children. Worldwide, annual epidemics estimated to result in 3 to 5 million cases of severe illness, and 250 000 to 500 000 deaths.

The CDC and GLAMOR II methods for producing national disease estimates are discussed. The aims of the influenza burden of disease activities are to:

Lay out a strategy to further close the gap in burden estimate o update the 250,000 - 500,000 death/year estimate and give global morbidity estimates

Help countries make decision if they should introduce vaccination or other control measures and for who based on evidence

Prepare countries to estimate the burden of seasonal epidemics and future pandemics and build a baseline to measure impact of interventions

Regional influenza hospitalizations estimates, Dr Rakhee Palekar, PAHO This is the first analysis to estimate the total number of influenza-associated respiratory

hospitalizations in the Americas, using primary data that represented 92% of the population of the Americas

This analysis estimated there to be ~750,000 influenza-associated respiratory hospitalizations annually in the Americas; estimates are comparable to the estimates published to date

These estimates of influenza-associated respiratory hospitalizations will be important for countries to use when making decisions about public health policy and the use and impact of the influenza vaccine

Country medical burden of disease estimates, CHI Annually between 4,000 and 6,500 hospitalizations associated with influenza occur at the national

level, with a higher risk in people 65 years and older and children under five years of age. Between 400 and 500 influenza-related deaths occur annually, with mortality rates being higher in

people aged 65 years and over. The importance of maintaining prevention and control strategies in these at-risk groups is

stressed. Specific data contributes to impact assessments and economic burden disease estimates. These estimates were used to calculate cases averted at the start of the 2017 influenza season. Challenges, limitations, and next steps were discussed.

Country medical burden of disease estimates, HON The incidence of influenza-associated SARI hospitalized patients (J09-J18) during the 2011-2015

study period was 19.4 per 100,000 population, with children under 1 year of age being the most affected with 107.5 per 100,000 population.

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Our estimate of overall incidence is six times lower than that reported in the study by Rowlinson, Dueger, Mansour, Azzazy, Mansour, et al. during 2009-2013 in the region of the Nile Delta, Egypt, where the estimated incidence was 123.4 per 100 000 inhabitants.

Estimates show that the highest number of influenza-associated SARI deaths occur during the months of October to December.

The results obtained allow us to conclude that the burden of influenza illness is high in Honduras, affecting children under five years of age, especially those under one-year old, and adults aged 60 years and over.

We recommend continuing influenza vaccination campaigns in the appropriate season, with the composition of circulating strains in the country, emphasizing the most vulnerable groups of the population.

Conduct analyzes with respect to the seasonality of influenza virus and estimates of medical burden.

Country medical burden of disease estimates, ECU Surveillance system data in 2011 are not sound or reliable. Since 2012 the SARI sentinel surveillance system has provided robust data. From the data used for morbidity and mortality:

Proxy J00 - J99: the rate of severe morbidity is concentrated in patients over 65 years of age, and a direct relationship with the mortality rate is observed. Whereas in the years 2012 to 2015, except for 2014, there is a significant burden of disease due to morbidity in children less than 5 years of age

Proxy J09 - J18, as in the previous analysis, in 2011 morbidity and mortality rates are higher in those 65 years of age or older, whereas in the years 2012 to 2015 a significant burden of disease in relation to morbidity is found in children under 5 years of age.

Next steps: Sustainability of the SARI sentinel surveillance monitoring system Maintain up-to-date estimates of influenza disease burden Communicate the burden of disease information to the National Authorities for timely

decision-making

Block 8: Non-influenza respiratory virus surveillance

The surveillance of non-influenza respiratory viruses has tremendous public health importance in the Americas and is often built upon the existing influenza surveillance platforms. These platforms benefit from the continued investments in influenza surveillance strengthening.

During this session, ways to expand surveillance using the influenza surveillance platform were discussed, as were updates in the global surveillance of pathogens such as MERS-CoV and RSV.

MERS CoV update, Dr Maria Van Kerkhove, WHO

Global pilot for RSV, Dr Sandra Jackson, WHO Respiratory syncytial virus (RSV) is recognized as a leading cause of respiratory morbidity and

hospitalization in the young and the elderly. The RSV Pilot was launched in 2016 in 14 countries representing the six WHO regions. To date

14 pilot laboratories have implemented the RSV Pilot with the support of three RSV reference laboratories which include; the CDC Atlanta, PHE UK and NICD in South Africa.

RSV surveillance ≠ RSV results from influenza surveillance. Through continuous monitoring and surveillance, the Pilot aims to integrate epidemiologic

and virological surveillance to better understand features of RSV circulation globally and to provide evidence for the introduction of RSV vaccines, including seasonality, risk groups and burden of disease

Participating pilot countries within AMRO include: Argentina, Brazil, Canada and Chile. Additional information on the WHO Global RSV Pilot, is available at:

http://www.who.int/influenza/rsv/en/

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Country experience with RSV global pilot, CAN In Canada, approximately ½ of acute respiratory illness hospitalizations are due to RSV (among

kids <2 years); Palivizumab treatment is available for high risk children. Currently, there is no population-based or sentinel surveillance for RSV in Canada. Canada

confirmed its participation in the Global RSV Surveillance Pilot in fall 2016. Nationally, RSV data are available from two sources: hospital administrative data (discharge

abstract database) and laboratory-based surveillance (respiratory virus disease surveillance system).

An RSV surveillance gap exists in Canada – in the context of vaccine development and anticipated vaccination program implementation.

Canada will leverage a core component of its influenza surveillance infrastructure to pilot RSV surveillance in the pediatric hospitalized population in 2017/18.

Data and information gathered during the pilot year will inform future system modifications.

Country experience RSV surveillance, USA

Expanding surveillance using influenza platform, Drs Teresa Peret and Julia Fitzner, CDC, WHO Implementation of molecular diagnostic testing for respiratory viruses other than influenza (ORV). Benefits of expanded laboratory surveillance:

Complements influenza surveillance, establish seasonality (inform clinical practice and lab testing), disease burden and risk data in anticipation of vaccines, broaden capacity for outbreak investigations, help pinpoint outbreaks of unknown etiology, reference site for confirmatory testing and training, respiratory outbreak investigations (understanding of the disease, risk groups and transmission), and improve threat response (e.g. SARS-CoV and MERS-CoV)

Methods for the laboratory implementation of rRT-PCR assays for ORV are presented. Components for the laboratory Implementation of RSV rRT-PCR assay as part of the WHO RSV

Initiative (GISRS) are discussed. Many challenges remain and questions must be addressed in the implementation of expanded

molecular testing.

Laboratory TrackBlock 1: Testing algorithms, PCR kits, and ensuring diagnostic proficiency

Influenza and non-influenza respiratory virus testing algorithm recommendations and discussion Dr. Juliana Leite, PAHO

Need for a virological testing and diagnostic algorithm for influenza and other respiratory viruses (ORV) to provide guidance to national influenza centers (NICs), national, and decentralized laboratories.

The PAHO sample detection and flow algorithm proposed for virological surveillance of influenza and ORV presented.

Presentation of the criteria for sending samples to the WHO Collaborating Center. National Influenza Centers are national institutions designated by the Ministries of Health and

recognized by the World Health Organization (WHO) to participate in the WHO Global Influenza Surveillance Network.

Information given about the terms of reference and the process to become a National Influenza Center. Recognition as a NIC continues until the WHO or national authorities propose to terminate the collaboration of the institution.

Influenza real-time RT-PCR updates, Dr Stephen Lindstrom, CDC/WHO CC Reagent kits available by ordering from IRR website and technical support (protocols, instructions

for use, guidance) are available from the CLSIS Sharepoint site. Reminder that the updated FluA subtyping kit includes updated pdmH1 reagents to detect most

recently circulating A(H1N1)pdm09 viruses of clade 6B.1.

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Additional nucleic acid extraction and real-time RT-PCR equipment under evaluation – protocols for Qiagen EZ1 Advanced XL and Roche Magnapure 96 will be posted on CLSIS.

Navigating the Influenza Reagents Resource (IRR), ECU General information and review of the International Reagents Resource (IRR) website, detailed

description of the support provided by the CDC and the ATCC, as well as a brief review of each of the tabs and hyperlinks associated with the home page of the tool are presented.

Registration procedures as a user to the IRR: reviewed the documents necessary for the submission process and where this information should be sent for further reception, revision, approval, and assignment of the IRR user according to the appropriate level of biosafety.

Selection of reagents, confirmation of information, and receipt of requested inputs: Familiarized the audience with the methods for choosing reagents and viewing additional product information, as well as how to communicate the reception status to the IRR focal point.

WHO EQAP for influenza, Dr Sandra Jackson, WHO Globally, continued improvements have been observed in the participation of GISRS and non-

GISRS laboratories in the WHO Influenza EQAP with 100% correct results recorded by 87% of laboratories in EQA Panel 15, (N= 151) compared with 67% in EQA Panel 1 (N=54)

Within the PAHO region, similar improvements in performance continue to be observed with 35 of 37 invited laboratories participating in EQAP 15. Among participating laboratories, 87% (27/31) returned results on time and 88.9% (24/27) reported 100% correct results.

Globally 34% (52/151) of laboratories participated in subtyping of influenza A(H9) in panel 15 compared with 88.9% (136/153) of laboratories for the subtyping of influenza A(H7) in panel 14. Five (5) PAHO countries participated in influenza A(H9) subtyping and three (3) countries participated in NAI susceptibility testing.

Continued capacity strengthening in the PAHO region for the sub-typing of influenza A(H9, H7 and H5) viruses and NAI susceptibility testing is encouraged .

Summaries of the performance of participating laboratories have been reported in the Weekly Epidemiological Record.

CDC proficiency panel for influenza, Dr Stephen Lindstrom, CDC/WHO CC Performance evaluation exercises conducted with selected PAHO countries in 2013, 2014/15 and

2016. Performance of participating countries improved from 45% correctly identifying at least 9/10

samples, to 91% in 2016. Main challenges identified include misinterpretation of results for A(H3)v, as well as possible

mislabeling or processing of samples.

Antiviral susceptibility testing for influenza and discussion, BRA Examined the antivirals available against influenza viruses (M2 proton channel blockers and

neuraminidase inhibitors) and the possibility of conformational changes in their viral targets leading to antiviral resistance.

Discussed methods used to measure antiviral drug susceptibility and compared advantages and disadvantages of phenotypic (fluorescence and chemiluminescent protocols) and genotypic assays (sequencing, SNP detection by pyrosequencing or real time RT-PCR protocols).

Described the Brazilian experience with influenza antiviral resistance surveillance, the implementation of antiviral surveillance, the detection of resistant viruses, and the possibility of the circulation of resistant strains within communities.

Challenges of viral isolation and discussion, MEXFactors that contributed to an increase in the percentage of isolation:

Training of personnel, adequate preservation of samples, reduced time of delivery to the laboratory, supervision of activities, implementation of a Quality System and Biological Risk.

Surveillance of isolation conditions such as mycoplasma monitoring in cell culture, preservation of incubation temperature, verification of the pH of the medium, and concentration of CO2.

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CDC / WHO recommends DMEM and Trypsin / 0.05% EDTA. Cells in the NIC are handled with MEM and Trypsin / EDTA at 0.25%. Cells have been tried to the recommended conditions and the desired results have not been achieved.

Block 2: Improving vaccine strain selection

Characterization of seasonal influenza viruses from the Americas during October 2016-May 2017, Dr Xiyan Xu, CDC/WHO CC

High levels of influenza A(H3N2) activity was detected in Northern American countries during the 2016-17 season, while influenza activities in central and southern American countries remained low.  

The vast majority of viruses characterized by WHO-CC CDC were antigenically similar to 2016-17 vaccine strains.

A small number of variant influenza B/Vic lineage viruses with 2 amino acid deletions in the HA were detected mainly in the US.

Shipments to WHO CC from Latin America and Caribbean (LAC), Dr Rakhee Palekar, PAHO

Countries are recommended to ship samples at least twice annually to a WHO Collaborating Center (CC) for influenza surveillance for additional characterization

Among LAC countries, n=16 made two or more shipments to the WHO CC at the U.S. CDC during 2016 as compared to only n=8 during 2014

Sample quality and timeliness are of paramount importance among the samples shipped to the WHO CC; recently collected samples (<6 weeks old) should be shipped under proper shipping conditions

Block 3: Unusual event detection and reporting

Identifying unusual cases and information sharing, Dr Angel Rodriguez, PAHO Unusual events include novel influenza viruses not circulating widely in the human population,

unsubtypeable influenza virus, and unusual exposure history accompanied by respiratory disease (e.g. respiratory disease plus travel to Middle East (MERS-CoV or exposure to sick animals).

Human infection caused by a confirmed or suspected novel influenza virus with pandemic potential, including a variant virus, should be reported immediately via two channels —the WHO IHR Regional Contact Point (via the IHR National Focal Point) and the Global Influenza Surveillance and Response System (GISRS) (via flu@paho.org). 

Human and animal virologic influenza data sharing: challenges and discussion, MEX For epidemiological surveillance of influenza in humans, Mexico has the SISVEFLU, a sentinel

system with 554 influenza health units (USMI) distributed throughout the country. For virological surveillance, 36 laboratories are used for the diagnosis of human samples.

The surveillance of influenza in animals is carried out by the National Service of Health, Safety, and Agro-Food Quality (SENASICA), which belongs to the Secretariat of Agriculture, Livestock, Rural Development, Fisheries and Food (SAGARPA), has 24 laboratories for diagnosis in animals.

On April 20, the National Service of Health, Safety and Agro-Food Quality (SENASICA) detected the presence of an H7N3 virus in the birds of a commercial egg-producing flock. The flock had no clinical symptoms and was vaccinated against influenza, after performing the corresponding confirmatory tests on 04 May 2017. SENASICA notified the World Organization for Animal Health (OIE) of the presence of an H7N3 avian influenza virus.

On May 10, 2017, an initial meeting was held to coordinate activities of the operation involving DGAE staff, InDRE IMSS Delegation, and the State Influenza Coordinator. In total, 39 participants were sampled from the involved farm and trail; pharyngeal and conjunctival exudates and blood samples were collected. These samples are being processed at the InDRE laboratory. It is proposed that a risk assessment using TIPRA be carried out to strengthen the information exchange between the DGE and SENASICA.

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Influenza Virus Traceability Mechanism for viruses with pandemic potential, Dr Sandra Jackson, WHO

The Influenza virus traceability mechanism (IVTM) is a database system for the recording of transfer and movement of PIP biological materials (PIP BM) within and to parties outside the WHO GISRS. It is an important function of GISRS with a primary goal to increase the transparency of GISRS activities of PIP biological materials.

It is a requirement under the PIP Framework and the GISRS labs terms of reference that the WHO IVTM be used to record the receipt and transfer of PIP biological materials (Guiding Principle 8, Annex 5). This allows users and all stakeholders to trace the movement and use of all PIP materials.

As of 25 May 2017, IVTM records show 2059 shipments of materials, of which 1972 PIP BM are recorded as being shared.

Within the Americas, Canada, Mexico, and the USA have recorded 295 original viruses in IVTM. This includes the documentation of influenza A/Mexico/7218/2012 (H7N3) isolated from a human and detected in Mexico in 2012 which was recorded in IVTM by CDC Atlanta. These 295 viruses have been shared among GISRS and non-GISRS laboratories 707 times.

The development of operational guidance on IVPP virus sharing is under process by the GIP. Regional offices are encouraged to communicate with countries the importance of virus sharing and documentation in IVTM of PIP viruses.

Block 4: Strengthening non-influenza respiratory virus surveillance

Non-influenza respiratory viruses diagnostics and discussion, Dr Teresa Peret, CDCContrasting MERS & RSV Laboratory Capacity Surveillance

MERS -CoV surveillance objective is to identify any MERS cases; classified as requires emergency public health response. Country-wide testing of any person that meets the MERS case definition should be done.

Laboratory features: high sensitivity/specificity tests are essential requires multiple rRT-PCR signatures for MERS-CoV detection and confirmation and

confirmation by reference laboratory; should include testing for other respiratory pathogens to “rule in” other etiologies; wide network of qualified laboratories needed to minimize test result turn-around time; EQA programs essential, but restricted availability

RSV surveillance objective is to conduct research to determine seasonality, risk groups, disease burden, etc.

RSV surveillance targets children <5 years (or elderly ≥65 yrs.) who meet the RSV case definition; usually limited to networks of representative pediatric hospitals (or long-term care facilities); surveillance duration determined by study.

Laboratory features: high sensitivity/specificity tests ideal single rRT-PCR signature for RSV sufficient rapid tests may be effective multiple commercial FDA or CE-marked molecular assays available EQA programs ideal and more readily available

Decentralization of IFA, NICUpdate of the Surveillance Regulations for Acute and Severe Respiratory Infections and Influenza-like Diseases

Updates to the regulations are based on interpandemic periods, evidence from scientific literature, the updated PAHO guide, and the need to define the most appropriate technical procedures.

The fundamental changes were: a new structure to the National Surveillance Regulations, redefining the objectives of each component of the surveillance system, updating the algorithms

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of the ARI and SARI sentinel surveillance systems, modifying of indicators for the SARI surveillance system, and addition of standard operating procedures.

In patients younger than 5 years, respiratory samples will be taken by oropharyngeal swabs and in those older than 5 years samples will be taken by nasopharyngeal and oropharyngeal swabs.

All patients who are admitted to the integrated SARI surveillance system will have respiratory secretions sampled (100%) and PCR testing.

A sentinel unit has been created in the department of Estelí in the north of the country, with an immunofluorescence laboratory. In Managua’s sentinel unit, the decentralized PCR laboratory has started to operate, which has led to a great advance in the quality of the SARI surveillance data.

Challenges in the region and discussion, Dr Juliana Leite, PAHO

Epidemiology Track

Block 1: Introduction to R

Monitoring seasonal and pandemic influenza patterns with MEM, Dr Tomas Vega, MoH Spain Objectives: To detect the start of the epidemics and to compare the intensity (transmissibility,

seriousness and impact) of seasonal epidemic waves in a territory over time and between different territories.

Method: The Moving Epidemic Method identifies and locates the epidemics, aligns the epidemic waves, establishes a baseline and estimates the intensity thresholds.

The MEM can be used with any influenza surveillance parameter, with different performances, usefulness and limits.

A Web application is being developed to facilitate the use of the MEM modeling process at the local/country level. A version can be downloaded from https://github.com/lozalojo/memapp. A technical manual and modelling guidelines complete the MEM documents.

Novel approaches for modelling influenza data in tropical countries is under research. An international collaborative project is being designed.

Working with data by country in groups, Drs Tomas Vega and Sofia Arriola, MoH Spain, CDC

Block 2: Data analysis and presentations

Countries presented the results of their analyses using the MEM package to assess influenza seasonality

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