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INTERNET‐BASED INTELLIGENCE FOR PUBLIC HEALTH EMERGENCIES AND DISEASE OUTBREAK NATO SCIENCE FOR PEACE AND SECURITY PROGRAMME ADVANCED RESEARCH WORKSHOP NATO Public Diplomacy Division, Bd. Leopold III, B‐1110 Brussels, Belgium fax +32 2 707 4232 : e‐mail [email protected] MARCH 13‐15, 2011 DAN PANORAMA HOTEL HAIFA HAIFA, ISRAEL 2 INTERNET‐BASED INTELLIGENCE FOR PUBLIC HEALTH EMERGENCIES AND DISEASE OUTBREAK ORGANIZING COMMITTEE Co‐Directors Emilio Mordini Manfred Green Centre for Science, Society and Citizenship, Rome, Italy School of Public Health at Haifa University, Haifa, Israel Committee Members François M.H. Géré Toby Merlin Institut Français d'Analyse Stratégique, Paris, France Influenza Coordination Unit Centers for Disease Control and Prevention, Atlanta, USA Secreteriat: Centre for Science, Society and Citizenship Piazza Capo di Ferro 23, 00186 Rome, Italy Phone: +39 0645551042/3 ‐ Fax: +39 0645551044 Email: [email protected] 3 INTERNET‐BASED INTELLIGENCE FOR PUBLIC HEALTH EMERGENCIES AND DISEASE OUTBREAK Need A number of initiatives aimed at identifying health crises earlier than existing official monitoring systems are in progress. Web crawlers – automated software programs that scour the web for information – are increasingly used to find patterns that may signify an emerging threat. “Over the past 15 years, Internet technology has become integral to public health surveillance. Systems using informal electronic information have been credited with reducing the time to recognition of an outbreak, preventing governments from suppressing outbreak information, and facilitating public health responses to outbreaks and emerging diseases” 1. Yet Internet‐based systems for outbreak detection still lack a calm and reflective evaluation, which includes not only an assessment of their technical reliability but also a careful analysis of their policy and regulatory implications. The main issues include; 1) Whether web‐crawler systems are truly able to extract reliable data on emerging crises from the Internet; 2) How it is possible to deal with information overload, false reports, lack of specificity of signals; 3) How it is possible to exploit new mobile technologies to engage directly with citizens to report illness; 4) How it is possible to minimize the risk that affected groups might deliberately provoke false alarms; 5) Whether it is possible to also apply this technology to the early detection of other kinds of crisis (e.g., conflicts, environmental disasters, financial crisis, etc). 6) How it is possible to improve the coverage of developing countries, where news sources are fewer; 7) Political impact given that Internet based systems bypass state based epidemiological surveillance. 8) How it is possible to implement public verification and follow‐up procedures; 9) Privacy concerns for strategies that have the potential to identify individual internet activity. Importance The potential threat of infectious diseases to the security of human life and global stability is very real. In a closely interconnected and interdependent world, new infectious diseases may adversely affect economic growth, trade, tourism, business and industry, and social stability as well as public health2. Severe high‐
mortality rate pandemics due to highly‐transmissible viruses are a real threat for the world in the 21st century. Over the past three decades, scientists have identified more than 30 "new" infectious diseases, including HIV/AIDS, SARS, Ebola, and the West Nile Virus. In addition, the risk of infectious diseases crossing species boundaries may be more frequent, as in the case of “mad cow disease” and the threat of “swine flu.” Public health measures to control and fight emerging infectious diseases are still limited3. Governments have to weigh the benefits and harms of exposing people, communities and whole countries to possible discrimination and economic insult through epidemic controls. A range of negative outcomes are possible including a population's refusal to accept preventive measures or treatment regimens such as isolation and quarantine. Inappropriate public health responses may cause social disruption and civil disobedience. Beyond the immediate human health toll of epidemic crises, there may be damage inflicted by stereotyping, stigmatization and staggering economic losses. Another aspect of epidemics in our age is that it is hard to distinguish a natural disease outbreak from an intentionally caused biological threat. The combined danger arising from the bioterrorist threats to public order and the emergence of naturally‐occurring new infections demand novel solutions and particular attention. 1
Brownstein JS, Freifeld CC, Madoff LC. (2009) Digital disease detection‐‐harnessing the Web for public health surveillance. N Engl J Med. 21;360(21):2153‐5, 2157
2
Klaucke D. (2002) Globalization and Health: A Framework for Analysis and Action. Presentation at the Institute of Medicine Workshop on the Impact of Globalization on Infectious Disease Emergence and Control: Exploring the consequences and the Opportunities, Washington, D.C. Institute of Medicine Forum on Emerging Infections.
3
Smolinski, M, Hamburg, MA, Lederberg, J (2001) Microbial Threats to Health; Emergence, Detection, and Response. Institute of Medicine of the National Academies: Washington DC.
4 INTERNET‐BASED INTELLIGENCE FOR PUBLIC HEALTH EMERGENCIES AND DISEASE OUTBREAK If fighting new epidemics is not easy, predicting them is still more difficult4. The spread of infections depends on several factors, related to the nature of the microbiological agent, peoples’ behaviour, socio‐economic conditions and the like. Despite established links between microbiological, ecological, geographical, socio‐
economic variables and epidemics, surveillance systems to forecast epidemics are far from being accurate. False alarms can have huge economic costs and can seriously undermine public confidence. As a consequence, our ability to deal effectively with new and emerging epidemics chiefly relies on early detection. Early detection of disease activity, when followed by a rapid response, can reduce the impact of outbreaks and allow essential medical, social and economic countermeasures to be taken. Timeliness Early detection of disease outbreak has traditionally relied on microbiological and clinical data. Yet since 1990s new surveillance systems have been created to monitor indirect signals of disease activity. Among these indirect methods some rely on obvious indicators, such as the volume of over‐the‐counter drug sales5 or the number of calls to telephone triage advice lines6; other more innovative methods are based on electronic communication monitoring . The aim of these innovative methods is to detect health crises earlier than official monitoring systems. The Program for Monitoring Emerging Diseases (PROMed‐mail) was founded in 1994 by the International Society for Infectious Diseases, and it is likely to be the most ancient online, publicly available, reporting system. ProMED uses the Internet to disseminate information on outbreaks by e‐mailing and posting case reports, including many gleaned from readers, along with expert commentary. Founded in 1997, GPHIN, Global Public Health Intelligence Network, is an Internet‐based 'early warning' system for potential public health threats including chemical, biological, radiological and nuclear (CBRN). GPHIN has been developed by the Canada's Centre for Emergency Preparedness and Response (CEPR). GPHIN retrieves relevant articles from news aggregators every 15 minutes, using extensive search queries. The system monitors on a worldwide, 24/7 basis, with media sources in six languages (Arabic, Chinese, English, French, Russian and Spanish) and provides relevant information on disease outbreaks and other public health events. The automatic system filters and categorizes information, which is further processed by human analysis. More recently a new generation of web application hybrids (mushups), which combine information from multiple sources into a single representation, have been used to mine, categorize, filter, and visualize online intelligence about epidemics in real time. Current systems include Healthmap, Google Flu Trends, MediSys, Argus, EpiSPIDER, BioCaster, and the Wildlife Disease Information Node. Text‐processing algorithms are used to determine the relevance of the information, which is then sorted by disease and location, with duplicate articles filtered out. The mining power of these systems is constantly increasing, for instance, Healthmap searches 20,000 websites every hour, tracking about 75 infectious diseases, including malaria, cholera, Ebola, and recently also swine flu. An average of 300 reports are collected each day, about 90% of which come from news media sources. Current systems combine similar types of media, yet the introduction of new automated analysis of online video materials and radio broadcasts, and the possibility to aggregate different types of media, will soon provide still more robust and sophisticated systems. ProMED and GPHIN played critical roles in informing public health officials of the outbreak of SARS, or severe acute respiratory syndrome, in Guangdong, China, as early as November 2002, by identifying informal reports on the Web through news media and chat‐room discussions. Yet the use of using electronic tools to monitor for infection outbreaks went to the limelight only with the recent outbreak of swine flu in Mexico when Google Flu Trends, which aggregates and analyzes search queries to detect online early sign of flu epidemics, found a peak in telltale flu‐related search terms about two weeks in advance of the actual outbreak. In other words, 4
Tait, J., Meagher, L., Lyall, C., Suk, J. (2006) Foresight. Infectious Diseases: preparing for the future. Risk Analysis. Office of Science and Innovation, London
5
Magruder, S., (2003) Evaluation of over‐the‐counter pharmaceutical sales as a possible early warning indicator of public health. Johns Hopkins University APL Technical Digest 24, 349–353 6
Espino, J., Hogan, W. & Wagner, M. (2003) Telephone triage: A timely data source for surveillance of influenza‐like diseases. Proc AMIA Symp 215–219
5 INTERNET‐BASED INTELLIGENCE FOR PUBLIC HEALTH EMERGENCIES AND DISEASE OUTBREAK Google data may have been able to provide an early warning of the swine flu outbreak, if the system were adopted as a reference system. When on April 25, 2009 the World Health Organisation (WHO) declared a "public health emergency of international concern", it was too late to contain the disease and stop its spread. Could the spread of the virus have been stopped if public health groups had paid better attention online earlier? The answer is likely to be “yes”. John Brownstein, an assistant professor of pediatrics at Harvard University and co‐creator of the Health Map service (one of the new digital detection devices for infectious diseases), believes the swine flu outbreak represents a "different era" in the world of information flow and communication. "The speed at which we are receiving data of this outbreak and new reports in different countries, different provinces is just astonishing" he said7. Early detection of an infectious disease outbreak is an important element of security policies. Infectious disease outbreak are not only medical events, but complex socio‐economic incidents which affect the whole of society in several ways, not to mention the possibility of the occurrence of bioterrorist attacks. Rapid disease identification allows to implement public health intervention and to establish the necessary social, economical and political countermeasures, which improve public resilience and reduce the risk of disruptive societal reactions. Yet many countries, often in the same world regions in which new infectious diseases are emerging, lack capacity for early detection and sometimes tend to not fully disclose the nature and extent of an outbreak in order to avoid a negative economic impact. The Internet offers solutions to some of these challenges. Freely available Web‐based sources of information may allow us to detect disease outbreaks earlier with reduced cost and increased reporting transparency. A vast amount of real‐time information about infectious disease outbreaks is found in various forms of Web‐based data streams. These range from official public health reporting to informal news coverage to individual accounts in chat rooms and blogs. However infectious disease intelligence, like any other kind of intelligence, should never be considered a trivial issue. On the contrary it always requires a careful, technical and political, critical assessment. This ARW aims to initiate such a critical assessment by gathering a multidisciplinary pool of experts and launching a high level conversation on the main technical, regulatory and political issues raised by this new technology. General Approach The workshop will provide a flexible framework within which to assess emerging systems of global epidemiological surveillance based on monitoring online communications and the World Wide Web. We aim to gather information from different perspectives and provide a pluralistic picture of the issue. The workshop will allow a full exchange of opinions to take place and promote open debate among participants. These participants will be both men and women from academia, international organisations, civil society organizations, national and international regulatory bodies and security agencies. During the three‐day workshop, the main speakers will present a full picture of the situation from their own perspectives to a selected audience, including other speakers, chairs, and participants, up to max 40 persons in total. This should allow ample opportunity for each participant to ask questions, debate points or refute one or more of the statements made by the speakers. Papers will be collected, edited, and published in a book. 7
CBC News, May 1, 2009 , http://www.cbc.ca/technology/story/2009/05/01/tech‐090501‐online‐tools‐pandemic.html
6 INTERNET‐BASED INTELLIGENCE FOR PUBLIC HEALTH EMERGENCIES AND DISEASE OUTBREAK SUNDAY, MARCH 13 15:00 ‐ 17:00 SESSION 1 17:00 – 17:20 17:20 – 17:40 17:40– 18:10 Registration and Coffee OPENING Chair: Manfred Green, Israeli Co‐Director Welcome by Manfred Green, Israeli Co‐Director Welcome and scope of the workshop by Emilio Mordini, NATO country Co‐Director Key notes delivered by Marjorie P. Pollack, Deputy Editor Epidemiology & Surveillance, Moderator ProMED‐mail Digital Detection of Diseases: where we are, where we go 18:10 ‐ 18:40 18:40 – 19:00 19.00 General Discussion Chair’s conclusive remarks and adjourn Get together Reception MONDAY, MARCH 14 SESSION 2 EARLY DETECTION OF DISEASE OUTBREAKS BY USING THE INTERNET, THE CONTEXT
Chair: Toby L. Merlin Deputy Director, Influenza Coordination Unit, US Centers for Disease Control and Prevention 09:00 ‐09:10 Chair’s general introduction 09:10 – 09:30 Tamar Shohat, Director, Israel Center for Disease Control The use of multi sources digital data bases for influenza surveillance Discussion 09:30 – 09:50 09:50 ‐ 10:10 10:10 – 10:30 Predrag Kon, Head of the Department for immunization at Institute of Public Health Internet based intelligence service during pandemic influenza season 2009/2010 in Serbia Discussion 10:30 – 11:00 Break 11:00 – 11:20 Marc Gastellu Etchegorry, Director of the International Department, French Institute for Public Health Surveillance, EpiSouth project Sources of Information in Epidemic Intelligence Discussion Massimo Ciotti, Preparedness and Response Unit, European Centre for Disease Prevention and Control Epidemic intelligence in the European Union: the role of Internet Discussion 11:20 – 11:40 11:40 – 12:00 12:00 – 12:20 7 INTERNET‐BASED INTELLIGENCE FOR PUBLIC HEALTH EMERGENCIES AND DISEASE OUTBREAK 12:20‐12:40 12:40 ‐ 13:00 13:00 – 13:10 Laetitia Vaillant Global Health Security Action Group, Institute for Public Health Surveillance Epidemic intelligence in France and within the GHSAG community Discussion 13:10 – 14:30 Chair’s conclusive remarks and adjourn Lunch SESSION 3 INTERNET, PUBLIC HEALTH AND COMMUNICATION Chair: Emilio Mordini, Centre for Science, Society and Citizenship Chair’s general introduction Donato Greco, Italian National Institute of Health New Communication Strategies in Epidemics Discussion Ben Reis, Assistant Professor, Harvard Medical School, Affiliated Faculty, Harvard‐MIT Division of Health Sciences and Technology Social networks and health Discussion Break Anat Gesser‐Edelsburg Health Promotion‐School of Public Health, University of Haifa Strategies of persuasion on the Internet
Discussion Yair Amikan, Head, Department of Information, Ministry of Health Transparency in Public Health Communication Discussion Goran Belojevic, Institute of Hygiene and Medical Ecology, School of Medicine, University of Belgrade Internet Based Health Communication – Analysis of Messages on the Websites of Serbian Public Health Institutes Discussion Chair’s conclusive remarks and adjourn Conference dinner 14.30 – 14:40 14:40 – 15:00 15:30 – 15:20 15:20 – 15:40 15:40 – 16:00 16:00 – 16:20 16:20 – 16:40 16:40 – 17:00 17:00 – 17:20 17:20 – 17:40 17:40 – 18:00 18:00 ‐ 18:20 18:20 – 18:30 20:30 8 INTERNET‐BASED INTELLIGENCE FOR PUBLIC HEALTH EMERGENCIES AND DISEASE OUTBREAK TUESDAY, MARCH 15
SESSION 3 THE COMPLEX RELATION BETWEEN SECURITY AND PUBLIC HEALTH Chair: François M.H. Géré, Institut Français d'Analyse Stratégique Chair’s general introduction Deborah Cohen, British Medical Journal
WHO and the “pandemic flu conspiracies” Discussion Michael Hopmeier, Director, Unconventional Concepts Public Health, Intelligence and National Security: an approach for the 21st Century Discussion Break Iris Hunger Research Group for Biological Arms Control, University of Hamburg Internet Based Intelligence and Bioterrorism
Discussion Richard B. Schwartz, Chairman Emergency Medicine Georgia Health Sciences University, Vice Chairman National Disaster Life Support Foundation (NDLSF) A Health Security Card (HSC) for Disasters and Public Health Emergencies Discussion FINAL ROUND TABLE: LESSON LEARNED AND FUTURE DIRECTIONS Manfred Green, Emilio Mordini, Toby l. Merlin, François M.H. Géré Adjourn & Lunch 09:00‐09:10 09:10 – 09:40 09:40 – 10:00 10:00 ‐ 10:20 10:20 – 10:40 10:40 – 11:00 11:00 – 11:20 11:20 – 11:40 11:40 – 12:00 12:00 – 12:20 12:20 ‐ 13:00 13: 00 9 INTERNET‐BASED INTELLIGENCE FOR PUBLIC HEALTH EMERGENCIES AND DISEASE OUTBREAK Participants Valeria Balestrieri Centre for Science, Society and Citizenship
ITALY Yair Amikan Department of Information, Ministry of Health
ISRAEL Artak Barseghyan Academy of Armenia Engineering ARMENIA
Goran Belojevic Institute of Hygiene and Medical Ecology, School of Medicine, University of Belgrade SERBIA Massimo Ciotti Preparedness and Response Unit, European Centre for Disease Prevention and Control EUROPEAN UNION
Daniel Cohen Dept of Epidemiology, Tel Aviv University
ISRAEL Deborah Cohen British Medical Journal
UNITED KINGDOM
Marc Gastellu Etchegorry French Institute for Public Health Surveillance, EpiSouth project FRANCE François M.H. Géré Institut Français d'Analyse Stratégique
FRANCE Anat Gesser‐Edelsburg Health Promotion‐School of Public Health, University of Haifa
ISRAEL Donato Greco Italian National Institute of Health
ITALY Manfred Green School of Public Health at Haifa University
ISRAEL Michael Hopmeier Unconventional Concepts
UNITED STATES Iris Hunger Research Group for Biological Arms Control, University of Hamburg GERMANY
Predrag Kon Department for immunization at Institute of Public Health
SERBIA Toby Merlin Influenza Coordination Unit Centers for Disease Control and Prevention UNITED STATES Emilio Mordini Centre for Science, Society and Citizenship
ITALY Adkham Paiziev Uzbek Academy of Science and Ministry of Public Health
Epidemiology & Surveillance, and ProMED‐mail
UZBEKISTAN
Ben Reis Harvard Medical School, Children's Hospital Informatics Program, Harvard‐MIT Division of Health Sciences and Technology UNITED STATES
Tamar Shohat Israel Center for Disease Control
ISRAEL Richard B. Schwartz Emergency Medicine Georgia Health Sciences University, National Disaster Life Support Foundation (NDLSF) UNITED STATES
Laetitia Vaillant Global Health Security Action Group, French Institute for Public Health Surveillance FRANCE Marjorie P. Pollack 10 UNITED STATES
EpiSouth
Mediterranean Early
Warning and alert System
M. GASTELLU ETCHEGORRY, F. AÏT-BELGHITI, C. GIESE
and P. BARBOZA
for the WP 6 Steering Group
International Department
Institut de Veille Sanitaire (InVS),
France
1
Globalisation of health crisis
International threats
Access to information
Mediterranean countries share common history,
populations, ecosystem… and threats
Existing EWS (WHO, ECDC, OIE, FAO…) do not
fulfil totally Mediterranean needs
Participating countries
EpiSouth
1st Phase
Dec 2006-June 2010
Objective “Create a framework of collaboration on
epidemiological issues and communicable diseases
control in the Mediterranean region”.
Funding
DG-Sanco (EU countries only) + EU- RELEX (TAIEX)
Italian Ministry of Health
Participating countries
EpiSouth
2nd Phase
Start: 15 October 2010 -- Duration: 2 ½ years
Focus :
Increase health security in in the Mediterranean Area
Preparedness to common health threats
Funding:
EU : DG-SANCO (EAHC) & DEVC, ECDC
Italian Ministry of Health
All participating countries
EpiSouth 1st Phase
8 WP managed by EU Public Health Institutes
Cross-border-epidemic intelligence (InVS, France).
Vaccine preventable diseases in migrants
(NICPD, Bulgaria).
Emerging zoonoses (HCDCP, Greece)
Training (ISCIII, Spain)
Networking (Venetia, Italia)
Coordination (ISS, Italy)
Communication (ISS, Italy)
Evaluation (Venetia, Italy)
Episouth Network Added Values
1st phase
Trust and cohesion among focal points and leaders
Awareness on regional and cross-border issues
Proved feasibility
Majors challenges remain
Governance
Sustainability
Formalisation
 To be addressed during the 2nd phase : EpiSouth Plus
EpiSouth +
2nd Phase
9
Governance
Coordination
Work packages (PHI)
Leaders, co-leaders, steering committees
2 focal points per countries
Crossroad of reception and dissemination
Technical WPs
WP 4
Laboratory network
WP Leaders :
Institut Pasteur (France) &
Refik Saydam National Hygiene Center, MoH Turkey
WP 5
Generic Preparedness & Risk management
WP Leaders :
Instituto de Salud Carlos III (Spain) &
Institut National de Santé Publique of Algeria.
WP6
Early warning system
WP Leaders :
InVS (France) & Middle East Consortium on Infectious Disease Surveillance
(MECIDS) [Israel + Jordan + Palestine
WP 7
Data collection & assessments for IHR
Preparedness & Risk management
WP Leaders :
Istituto Superiore di Sanità (ISS) Italy &
WHO-LYON
Horizontal WPs
WP 1
Coordination
WP Leaders :
Istituto Superiore di Sanità (ISS) Italy &
Ministry of health of Tunisia
WP 2
Dissemination
WP Leaders :
Istituto Superiore di Sanità (ISS) Italy) &
Institute of Public Health of Montenegro
WP3
Evaluation
WP Leaders :
Azienda Sanitaria Locale Torino 1 (ASLTO1) Italy
EpiSouth
Epidemic intelligence and
Early warning
13
EpiSouth E.I. Global Concept
International threats
EpiSouth E.I.
Consists in 5 mains steps (# InVS)
Detection
Selection
Validation
Analysis & interpretation
Information dissemination
But tailored to EpiSouth needs (geographical
criteria +++)
Not exhaustive but aims at covering most countries needs
Only verified information shared
Reduces duplication
Communication
Two main communication supports
In English
Only new & verified events
Available online in the EpiSouth site
http://www.episouth.org
e-Web
EpiSouth Weekly epidemiological Bulletin
Thematic notes
ad hoc basis
Complex, not well known or multiple countries
issues (CCHF, WNV, A/H1N1, Alkhurma virus…)
Cross border EW
Mediterranean Alert Early
warning system
Secured web site (confidential)
To share national alerts
Operational since November 09
Accessible to
EpiSouth FP
 NPHI
 MoH
Majors Stakeholders
 WHO
 ECDC
 EU commission
Complements existing systems
WHO
E.U. / ECDC
Focus of the 2nd phase / Lessons
Maintain EI and Cross-border activities
Synergies / interoperability /other network institutions
WHO, OIE, ECDC, EU (EWRS and alert systems…)
Regional Network MECIDS, SEEHN, etc.
Develop articulation with
Diseases surveillance
Thematic networks
Work packages
Involvement of non EU countries
Collaboration with partners: WHO, ECDC…
West Nile virus
circulation in the
EpiSouth countries
as of 7th October 2010
19
Mediterranean WN Context
Since 1st documented outbreak in 1951 in Israel,
circulation documented almost worldwide
Large human outbreaks EpiSouth & neighboring areas
Romania (1996-1997) Tunisia (1997); Israel (2000) Russia (1999)
Up to 2010, restricted to limited geographical settings
Surveillance biases
Number of reported neurological cases grossly underestimate
circulation in human
Not all countries have specific surveillance system
West Nile 2010
Mid August 2010
 signals of WNV (cases and deaths)
 circulation ?
2nd September  EpiSouth survey on
WN surveillance systems, availability of national WNV laboratory
Epidemiological context; cases definition and recent cases…
24 countries participated
1st July and 7th Oct.  8 countries reported WN
outbreaks
Distribution of WNV cases and deaths.
EpiSouh countries 1st July / 7 October 2010
Human cases and deaths
Equine cases
Countries
Cases
Deaths
Greece(*)
257
31
Israel
65
3
Italy
1
0
41
4
Spain
2
0
Turkey(*)
7
3
Romania
Countries
Greece
Italy
Spain (**)
Morocco
Bulgaria (**)
Total
(*) First outbreak ever reported
373
41
140
(**) First equine cases reported to OIE
Surveillance (23 responding countries)
WN Reference Laboratory
15 operational
4 non functional
1 external reference laboratory
4 no reference laboratory
14 specific Human Surveillance of which:
9 permanent (year long) passive surveillance
2 seasonal only
3 permanent surveillance + enhanced seasonal system in at-risk
areas.
Veterinary surveillance
11 equine permanent
3 seasonal equine
6 countries have also implemented a bird sentinel surveillance system
Limits/discussion
Objective : Rapid information for decision (e.g. blood donors)
Limits : Information collected in a very short time
Number of items wilfully limited
Does not allow in-depth analysis.
Issues :
In 2010, unprecedented reported viral circulation in the area
Contributed to raise awareness
 Exchange of information and description of WN circulation
 Heterogeneity of strategies and resources available for WN surveillance
Among 11 EpiSouth countries with specific WNV (humans and horses)
surveillance and operational lab : 7 diagnosed human or horses cases
No countries without specific WNV surveillance system reported case
Origin of high viral circulation not clearly understood.
Lack of virological data (lineage, phylogenetic…)
The progressive expansion of the Novel
A(H1N1)v epidemic in the EpiSouth region
(Mediterranean and Balkans)
27
Focus on EpiSouth region
Source of data: EpiSouth countries
Data collected:
Confirmed cases
Case definition and case management strategies
Deaths / severe cases
Community transmission: circulation intensity
Imported VS local cases
Descriptive analysis on a weekly basis
Information shared with the network:
Daily bulletin (since 06 May to 26 June);
Twice a week (in June)
Weekly bulletin (from July)
Chronological A(H1N1) evolution
(detected cases reported)
11 May 2009
31 May 2009
08 June 2009
13 July 2009
Evolution by « sub-region »
Cumulative A(H1N1)2009 confirmed cases, EpiSouth sub-regions,
as of 28 July (week 31).
Exportation of cases:
Imported cases and countries of origin
Countries of origin
Imported VS local cases
(imported cases)
(for 12/13 countries providing data)
Algeria
Italy
Slovenia
Turkey
Romania
Lebanon
Egypt
Malta
Morocco
Tunisia*
Bosnia
Albania
Kosovo
secondary cases
Nb imported cases
0
50
100
150
200
250
Main trends:
 Canada and USA exported in Egypt, Lebanon, Saudi Arabia, Morocco (Students and expatriate
population back for summer)
 Europe exported in Tunisia and Algeria
 Saudi Arabia in the Middle East neighbouring countries (e.g. pilgrims)
Discussion / conclusion
Limits
Different surveillance systems
Added value:
First data and Regional overview (3 different WHO
regions)
Reduced duplication
Information / case definition, management, etc.
Illustrated
Different strategies
Spread of A/H1N1
Conclusion
Global crises = Global response
Clear needs for enhanced international collaboration to:
Optimise limited resources utilisation and minimise duplication
Build on experiences
Develop synergies and partnerships
Improve dissemination of information
In case of major threats, pooling internationally available capacities
will strengthen health security
.
A new challenge
Vast potential for synergy and collaboration with other networks

Key role for regional networks
Acknowledgements
WP6 – Steering Group
 Emilia Anis & Michal Bromberg
 Raja’a Haddadin & S. Abdullah Saleh
 Naser Ramadani; Arijana Kalaveshi
 Tanya Melillo, Jackie Maistre Melillo, Charmaine Gauci
 Dragan Lausevic and Zoran Vratnica
 Mohammed Youbi & Ahmed Rguig
 Bassam Saeed Madi and Basem Al-Rimawi
 Mondher Bejaoui & Mohamed Ben Ghorbel
 Alex Leventhal & Sari Husseini
 Fatima Aït-Belghiti, Coralie Giese & Philippe Barboza
Israel
Jordan
Kosovo
Malta
Montenegro
Morocco
Palestine
Tunisia
MECIDS
France
34
Acknowledgements
The EpiSouth-Plus project is implemented by the Italian
National Institute of Health and is co-funded by the
European Union DG SANCO/EAHC and EuropeAid
together with the participating national partner
Institutions.
The financial support of the Italian Ministry of Health and
ECDC is also acknowledged.
The contents of this presentation are the sole responsibility of the authors and can in no
way be taken to reflect the views of the European Union.