EUR/03/5042861/1 ORIGINAL: ENGLISH UNEDITED E78908 Meeting of Countries of the Dubrovnik Pledge on Infectious Disease Surveillance Report on a WHO Meeting Vlora, Albania 28–30 August 2002 2003 ABSTRACT The meeting of countries of the Dubrovnik Pledge on infectious disease control was held from 28–20 August 2002 in Vlora, Albania. The objectives of the meeting were to review the recent trends in the capacity of national public health surveillance systems, to respond to health needs or inform about the control of infectious diseases in the population, including the early warning systems for the timely detection of the occurrence of epidemics, including HIV/AIDS; to review the current surveillance systems, including training opportunities; to identify the needs and agree on the mechanisms to strengthen the capacity of national surveillance systems; and to identify and agree on the ways national systems might be better linked to regional and global alert and response networks. All participating countries made a presentation on their current epidemiological situation as well as social economical, geographical and demographical characteristics. The participants were then divided into two working groups on strengthening national surveillance systems and the training needs for surveillance systems. In a plenary session results and recommendations were presented and a summary table of proposed activities was adopted Keywords COMMUNICABLE DISEASE CONTROL COMMUNICABLE DISEASES – epidemiology HIV INFECTIONS – prevention and control EPIDEMIOLOGIC SURVEILLANCE LABORATORIES QUALITY CONTROL INFORMATION SYSTEMS HEALTH PLANNING EUROPE © World Health Organization – 2003 All rights in this document are reserved by the WHO Regional Office for Europe. The document may nevertheless be freely reviewed, abstracted, reproduced or translated into any other language (but not for sale or for use in conjunction with commercial purposes) provided that full acknowledgement is given to the source. For the use of the WHO emblem, permission must be sought from the WHO Regional Office. Any translation should include the words: The translator of this document is responsible for the accuracy of the translation. The Regional Office would appreciate receiving three copies of any translation. Any views expressed by named authors are solely the responsibility of those authors. This document was text processed in Health Documentation Services WHO Regional Office for Europe, Copenhagen
CONTENTS Page Preface............................................................................................................................................................i Introduction ...................................................................................................................................................3 Epidemiological surveillance and control of communicable diseases in the countries of the Dubrovnik Pledge........................................................................................................................................3 Presentations..................................................................................................................................................4 UNICEF ...................................................................................................................................................4 Second-generation HIV and sexual health surveillance...........................................................................5 Role of laboratories in national surveillance systems ..............................................................................7 Early warning systems .............................................................................................................................9 Conclusions, recommendations and plans of work developed by the working groups...............................11 Working group on early warning and strengthening laboratory capacity ..............................................11 Conclusions of the working group on early warning and strengthening laboratory capacity ................11 Conclusions of the working group on strengthening national capacity for infectious disease surveillance and second-generation HIV/AIDS surveillance...............................................................12 Plan of work prepared by the working group on early warning and strengthening laboratory capacity ...............................................................................................................................14 Plans of work for the working group on strengthening national capacity for infectious disease surveillance and second-generation HIV/AIDS surveillance...............................................................15 Annex 1. Programme of the meeting...........................................................................................................17 Annex 2. Provisional list of participants .....................................................................................................19
EUR/03/5042861/1 page i Preface Communicable diseases continue to be a major source of illness and death globally. This is especially true in countries and populations in less favourable socioeconomic circumstances. This issue was discussed during the Health Ministers’ Forum for Regional Health Development Action in South East Europe from 31 August to 2 September 2001 in Dubrovnik. The health ministers of Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Romania, The former Yugoslav Republic of Macedonia and Yugoslavia signed the Dubrovnik Pledge: Meeting the Health Needs of the Vulnerable Populations in South-East Europe, including seven projects on health needs for vulnerable groups, one being to strengthen the surveillance and control of communicable diseases. In 1995, the World Health Assembly adopted resolution WHA48.13 on new, emerging and re- emerging infectious diseases and resolution WHA48.7 on the revision and updating of the International Health Regulations. The World Health Assembly was fully aware that strengthening epidemiological and laboratory surveillance and of disease control activities at the national level is the main defence against the international spread of communicable diseases. In 2001, the Fifty-fourth World Health Assembly adopted resolution WHA54.14 on global security – epidemic alert and response. Ways need to be identified to strengthen national and international capacity to detect and respond early to the health threats that have emerged in this new context in the whole European Region. The objectives of the Meeting of Countries of the Dubrovnik Pledge on Infectious Disease Surveillance were: to review the recent trends in the capacity of national public health surveillance systems to respond to health needs or inform about the control of infectious diseases in the population, including the early warning systems for the timely detection of the occurrence of epidemics, including HIV/AIDS; to review the current surveillance systems, including training opportunities; to identify the needs and agree on the mechanisms to strengthen the capacity of national surveillance systems; to identify and agree on the ways national systems might be better linked to regional and global alert and response networks. The technical experts responsible for communicable disease surveillance at the national level from the countries of the Dubrovnik Pledge and nominated by their governments to represent their country in this project were invited to the meeting. We would like to thank the Government of Albania for kindly hosting the meeting and the National Institute of Public Health of Tirana, especially Dr Silva Bino, for excellent organization and technical support. We would also like to take the opportunity to thank the Government of France, whose continuing financial and technical support has been crucial for the successful implementation of this EUR/03/5042861/1 page ii meeting, which is part of a WHO plan to strengthen the international surveillance of infectious diseases in Europe. Special thanks go to Professor Christopher L.R. Bartlett, who acted as the Rapporteur of this meeting, as well as the temporary advisers who facilitated the discussions on different technical subjects. EUR/03/5042861/1 page 3 Introduction Minister of Health, Albania Professor Mustafa Xhani, Minister of Health, welcomed participants to Albania and to the meeting. The Government of Albania approves and supports the important project of controlling infectious disease under the Dubrovnik Pledge. Although good results have been achieved, more needs to be done in prevention and control in the European Region. Improvements are required for public security, not just at the country level, but across the whole Region and globally. New as well as existing diseases must be addressed. Participant countries are implementing health care reforms, but surveillance systems must be maintained and strengthened. The services must reach out to the vulnerable groups who are most affected by infectious diseases. The national surveillance systems must be linked to international networks so that they are part of the global system. In closing his address, Professor Xhani acknowledged support for the project by the Government of France and other governments. Mayor of Vlora Dr N. Veizi welcomed participants to the city of Vlora. As a physician as well as Mayor, he appreciated the significance of the meeting and how important it is that infectious diseases be controlled. Changes in microorganisms, in labour and in high internal and external migration are affecting infectious diseases. Old diseases are re-emerging and new infections are appearing. As Mayor of Vlora, he is very conscious of the need to care for the health of the community and the health care system and to improve living conditions. Malaria was eradicated from Vlora fifty years ago, but there remains the risk that this disease and other vector-borne infections may re-emerge, so it is vital that vector control be maintained. Dr Veizi wished the meeting every success in its deliberations. WHO Regional Office for Europe Dr Bernardus Ganter thanked the Minister of Health and Institute of Public Health of Albania for hosting the meeting. He presented an overview of the situation in the WHO European Region and outlined the priorities of the Communicable Disease Surveillance and Response Unit of the WHO Regional Office for Europe. He reminded participants that this meeting was being held under the Initiative for Social Cohesion of the Stability Pact for South Eastern Europe. Infectious diseases are linked to poverty, and experience in other WHO regions has shown that controlling major problems such as malaria and HIV/AIDS can promote development. Timely surveillance and control can help to minimize economic loss. Dr Ganter added his thanks to all the sponsors of the meeting, especially the Government of France. Epidemiological surveillance and control of communicable diseases in the countries of the Dubrovnik Pledge Representatives from Albania, Bulgaria, Croatia, Romania, The former Yugoslav Republic of Macedonia and Yugoslavia presented an overview of the vital statistics, health service structure and system for communicable disease surveillance in each country. Several common themes emerged from the speakers’ assessments of the strengths and weaknesses of the current national arrangements for preventing communicable disease. All countries have established surveillance and control systems for infectious diseases and share a similar list of EUR/03/5042861/1 page 4 diseases. They include immediate notification (within 24 hours) of a number of infectious diseases, as well monthly reporting for a large number of infectious diseases included in statuary reporting. At the national levels Public Health Laboratory provide some support for diagnosis of infectious diseases. However, laboratories are often under funded and not equipped for a modern diagnostic role. Most countries appear to have too many peripheral-level laboratories to be economically sustainable. It was agreed in the discussion that care would be needed in reducing the number of laboratories, but to ascertain national capacity for specific public health laboratory functions in support of infectious disease control. Concern was expressed over pressures to merge hospital and public health laboratories in some countries. Experience elsewhere has shown that the public health function risks harm if all public health laboratories are incorporated in this way. Resources for public health work in merged laboratories tend to be lost to the acute pressures of diagnostic clinical work. Microbiologists in such laboratories often focus their interests on the challenges of the clinical work because of the immediacy of diagnosis and clinical management problems. It was suggested that significant numbers of laboratories would need to be upgraded to meet current international standards. Quality control and quality assurance systems need to be implemented, together with specified standards. Laboratory data management systems may warrant strengthening. Reference laboratories need to be clearly identified, officially recognized and properly funded. In epidemiology, systems for data collection, data analysis and distribution of information need to be modernized, especially through computerization. In view of the dynamics of infectious diseases, legislation on controlling communicable disease may need to be updated and drafted to ensure sufficient flexibility to allow timely changes in methods of surveillance or control. This applies especially to statutory notification, which needs to be revised. Clinicians should be required to provide information for public health purposes, and efforts should be made to encourage their collaboration. Links with government departments and other agencies with responsibility for the surveillance and control of food, water and the environment need to be strengthened. In particular, sharing of timely information should be increased. Administrative and financial obstacles to acute public health investigations, including population- based surveys, need to be addressed to improve response capability. Presentations Several formal presentations were made to inform discussions within the working groups. UNICEF The representative from the United Nations Children’s Fund (UNICEF) gave an overview of HIV/AIDS in the Balkans and Albania and the role that UNICEF plays in its amelioration and prevention. HIV/AIDS is a global priority for UNICEF, as the impact of the infection is unravelling decades of progress for children and young people. The key approaches used are: advocacy and analysis with governments, community leaders, nongovernmental organizations and young people to promote sustainable country responses; preventing HIV/AIDS by informing, mobilizing and protecting young people; supporting research to better understand the factors influencing HIV transmission; improving access to health and social services and education; and supporting youth-led initiatives. EUR/03/5042861/1 page 5 The countries and territories of South Eastern Europe are considered to have low prevalence of HIV/AIDS, but caution needs to be exercised in accepting this classification in view of the recent economic, social and political transition, accompanied by conflict, poverty and unemployment. Changing societal and cultural norms have resulted in the increased presence of factors enabling the transmission of HIV. Although there are some indications of patterns and trends, there are few reliable data. This situation allows an “ostrich syndrome” to develop. Given that the prevalence is low, low priority may be given to HIV/AIDS and a view held that there is no significant risk behaviour. This could result in a lack of ability or desire to set priorities, leading to a lack of direction in preventive action. Other consequences may include stigmatization, denial and lack of treatment. The availability of testing varies considerably in the countries and territories of South Eastern Europe. Confidentiality may be an issue, and there is only limited anonymous testing and counselling. Laboratory quality and capacity vary, and there is no comprehensive systematic surveillance. Few nongovernmental organizations are active, and they are limited in scope and capacity. Traditional health services are not usually consultative or youth-friendly. Peer education and life skills teaching are not implemented systematically, and schools or parents are minimally involved in teaching life skills to young people. Given all these factors, UNICEF has four main objectives for the countries and territories of South Eastern Europe: to support governments, civil society and key actors in efforts to strengthen, coordinate and expand national and regional responses to HIV/AIDS; to support the development and implementation of national plans of action through multisectoral national commissions; to help build the capacity of existing initiatives and mechanisms and to establish new ones to increase impact; and to support the strengthening of surveillance and related research. The strategic priorities are young people, injecting drug users, sexually transmitted infections and mobile populations (including peacekeepers and humanitarian workers). In the area of legislation and social policy development, UNICEF will promote the protection of human rights and the participation of vulnerable groups in decision-making processes. It will encourage the review of existing legislation related to all vulnerable groups to eliminate legal barriers to effective HIV/AIDS prevention, awareness and treatment. It will also work to ensure high-level, multisectoral collaboration and coordination in the national response. In summary, UNICEF’s commitments in relation to HIV/AIDS in the countries and territories of South Eastern Europe are for advocacy, youth-friendly services and participation of young people. There will be a human rights focus to tackle stigmas combined with political and social mobilization and a commitment to resource mobilization. Second-generation HIV and sexual health surveillance Second-generation HIV surveillance is being implemented to fully capture the diversity of the epidemic, to explain changes over time and to build a more informative picture in Europe. The general concepts of this new approach are: 1) concentrating data collection in the populations most at risk; 2) comparing information on HIV prevalence and on the types of behaviour that spread it; EUR/03/5042861/1 page 6 3) making better use of other sources of information such as reproductive health surveys; and 4) adapting the surveillance system to the pattern of the epidemic in each country. For this last concept, the Joint United Nations Programme on HIV/AIDS (UNAIDS) and WHO classify countries as having either low level, concentrated or generalized epidemic status. In low-level countries, HIV infection may have existed for many years but has never increased to significant levels in any subpopulation. The infection is largely concentrated in individuals with higher-risk behaviour, suggesting that networks of risk are rather diffuse or that the virus was introduced very recently. In countries with concentrated epidemic status, HIV has spread rapidly in a defined subpopulation but is not well established in the general population. This pattern of infection suggests active networks of risk within the subpopulation. The future course of the epidemic will be determined by the frequency and nature of the links between the highly infected subpopulation and the general public. Where the epidemic is classified as generalized, HIV is firmly established in the general population. Although subpopulations at high risk may continue to contribute disproportionately to the spread of HIV, sexual networking in the general population is sufficient to sustain an epidemic independent of the subpopulations at higher risk of infection. Quantitatively, UNAIDS and WHO classify low- level epidemic status as HIV prevalence consistently not exceeding 5% in any defined subpopulation. Concentrated epidemic status is accepted when HIV prevalence is consistently 5% or more in at least one defined subpopulation but 1% or less among pregnant women in urban areas. A generalized epidemic is considered to occur when the HIV prevalence is greater than 1% in pregnant women. The countries of the Dubrovnik Pledge are currently classified as having low- level epidemic status. The key questions for countries with a low-level epidemic include the following. Is there any risk behaviour that might lead to an HIV epidemic? In which subpopulations is that behaviour concentrated? What are the size of these subpopulations? What is the prevalence of HIV infection in these subpopulations? Which types of behaviour expose people to HIV infection in these subpopulations and how common are they? What are the links between the subpopulations at risk and the general population? Behavioural surveillance is beginning to be developed in several countries, but many have yet to address this approach. The method being used in behavioural surveillance, where it exists, currently comprises repeated cross-sectional surveys in the general population or in defined subpopulations. This contrasts with bio-epidemiological surveillance, in which a variety of methods are used, including HIV prevalence surveys, assessment of HIV incidence and HIV and AIDS case reporting. Each of these methods has limitations, so that a multiplicity of approaches is required to provide the fullest picture of the epidemic. Bio-epidemiological and behavioural surveillance give different types of information about the epidemic and provide the opportunity to validate one another. The challenge for the future would be to put the pieces of the puzzle together to provide a more complete picture of the epidemic and its possible evolution. EUR/03/5042861/1 page 7 The second edition of Guidelines for second generation HIV surveillance is available on compact disc from UNAIDS/WHO (http://www.unaids.org/publications/documents/epidemiology/ surveillance/2nd_GENERATION_FINAL.PDF, accessed 15 November 2002). Summary pages are included in Annex 5. Role of laboratories in national surveillance systems The principles of establishing and maintaining national public health laboratory systems were considered under the following topics: minimum requirements for diagnostic tests training needs evaluation of operational capacity quality control and quality assurance sampling in the field information systems use of laboratory data for surveillance experience to date. Minimum requirements for diagnostic tests Nationally the laboratory service should provide diagnostic tests in parasitology, mycology, bacteriology, virology, serology, molecular biology and antimicrobial resistance. Although a wide range of tests is required to cover these areas adequately, there are several common guiding principles. Each test should be scientifically valid, provide answers that can be understood and used for action, have known specificity and sensitivity and provide answers rapidly. Further, testing methods should be sustainable, affordable, technologically appropriate and be readily upgraded. When laboratory services are being developed, it is advisable to plan for the next 5–10 years. Training needs Training is a constant requirement for all levels of staff. The cost of such training of laboratory staff is estimated to be as high as 15% of salary in some countries. The greatest demand usually results from turnover of lower-level staff. Training may be organized within countries or through international programmes, such as the courses provided by the WHO Communicable Disease Surveillance and Response Office in Lyon or other international agencies. Evaluation of operational capacity Operational capacity and performance of public health laboratories should be reviewed at regular intervals, perhaps every five years. Two documents can help in planning this activity: Protocol for the evaluation of epidemiological surveillance systems (http://whqlibdoc. who.int/hq/1997/WHO_EMC_DIS_97.2.pdf). Geneva, World Health Organization, 1997 (document WHO/EMC/DIS/97.2; accessed 15 November 2002). Protocol for the assessment of national communicable disease surveillance and response systems: guidelines for assessment teams (http://whqlibdoc.who.int/hq/2001/ WHO_ CDS_CSR_ISR_2001.2_text_annexes1-11.pdf and http://whqlibdoc.who.int/hq/2001/WHO_ EUR/03/5042861/1 page 8 CDS_CSR_ISR_2001.2_annexes12-14.pdf). Geneva, World Health Organization, 2001 (document WHO/CDS/CSR/ISR/2001.2; accessed 15 November 2002). Techniques and methods may be developed and improved through collaborative activity within each country or through international networks. Quality control and quality assurance Quality is an essential component of laboratory practice and not an optional extra. There should be full documentation of methods with standard operational procedures and routine quality control systems. Several sources of guidance are available, including: El-Nageh, M.M. et al. Basics of quality assurance for intermediate and peripheral laboratories. Alexandria, WHO Regional Office for the Eastern Mediterranean, 1992 (WHO Regional Publications, Eastern Mediterranean Series, No. 2). El-Nageh, M.M. et al. Quality systems for medical laboratories. Guidelines for implementation and monitoring. Alexandria, WHO Regional Office for the Eastern Mediterranean, 1995 (WHO Regional Publications, Eastern Mediterranean Series, No. 14). There are also international accreditation schemes such as the International Organization for Standardization and the Australian Quarantine and Inspection Service (AQIS) and various guidelines on national and regional accreditation. Sampling in the field Public health laboratories must work in the principle of taking “the right sample at the right time”. Again, guidelines are available: • Guidelines for the collection of clinical specimens during field investigation of outbreaks (http://whqlibdoc.who.int/hq/2000/WHO_CDS_CSR_EDC_2000.4.pdf). Geneva, World Health Organization, 2000 (document WHO/CDS/CSR/EDC/2000.4; accessed 15 November 2002). Several national institutes, such as the United States Centers for Disease Control and Prevention in Atlanta and the Public Health Laboratory Service in London, also produce guidance on this aspect of laboratory practice. Many disease-specific guidelines have been developed. Safety in the collection and transport of samples requires high priority; in this respect, the following guidelines are recommended: • Guidelines for the safe transport of infectious substances and diagnostic specimens (http://whqlibdoc.who.int/hq/1997/WHO_EMC_97.3.pdf). Geneva, World Health Organization, 1997 (document WHO/EMC/97.3; accessed 15 November 2002). Expertise may be available through WHO to develop appropriate national guidelines. Information systems Laboratory diagnostics must be integrated with epidemiological surveillance systems to provide timely information for action. The relevant guidance documents are: Information for action: developing a computer-based information system for the surveillance of EPI and other diseases (http://whqlibdoc.who.int/hq/1998/ WHO_EPI_GEN_98.15.pdf). Geneva, World Health Organization, 2000 (document WHO/EPI/GEN/98.15; accessed 15 November 2002). EUR/03/5042861/1 page 9 Making surveillance work. Module 3: Logistics management (http://whqlibdoc. who.int/hq/2001/WHO_V&B_01.10.pdf). Geneva, World Health Organization, 2000 (document WHO/V&B/00.10; accessed 15 November 2002). WHO recommended surveillance standards (http://whqlibdoc.who.int/hq/1999/ WHO_CDS_CSR_ISR_99.2.pdf). 2nd ed. Geneva, World Health Organization, 2000 (document WHO/CDS/CSR/ISR/99.2; accessed 15 November 2002). Any new system adopted should be internationally compatible. In this respect, WHO recommended surveillance standards is particularly useful. Use of laboratory data for surveillance Public health laboratories should be integral parts of disease surveillance systems and not just an add-on service. Laboratory data, including reference typing results, are essential for a modern communicable disease surveillance and control system. When a laboratory reporting system is developed, care should be taken in determining the most appropriate reporting structures, including lines of responsibility, what variables should be reported, the frequency of reporting and the arrangements for timely feedback of information. Participation in scientific or surveillance networks is now considered essential to help maintain standards, promote further development, distribute the workload and exchange information. Many successful public health laboratory networks already exist, such as the WHO collaborating centres, the WHO polio and measles laboratory networks and FluNet for influenza surveillance. Experience to date Experience has shown that hierarchical systems work best, with specialized, less frequent or reference tests undertaken at a higher level. In some larger countries, peripheral, regional and national laboratories have been put in place, whereas in others, two levels suffice. Making a precise recommendation for the number of public health laboratories is difficult, but in general a peripheral laboratory may cover a population of one million and a regional laboratory 8–10 million (depending on geography and/or logistics), and there is normally one national laboratory. In summary, laboratories are an integral part of infectious disease surveillance, and planning activities must include laboratory personnel from the outset. New systems do not need to be invented, as good guidelines and advice are already available. WHO can assist in planning the next steps, determine what is already available and can be modified, developed or extended, establish plans for an integrated infectious disease surveillance system and use these to advocate for funding and technical support. Early warning systems The WHO representative gave an overview of current thinking on early warning systems. Public health surveillance is an essential component of the health sector to influence good practice and inform policy development. Within public health surveillance, different objectives, methods and data are used in epidemic intelligence compared with health status monitoring. Early warning of communicable disease events may be defined as the timely dissemination of outbreak information, leading to effective intervention measures, including investigative and containment activities. The essential features are technical expertise support, clear terms of reference, dedicated staff for coordination and generation of information for public health action. It requires regular meetings of participants, common data standards, scientific rigour and sharing of EUR/03/5042861/1 page 10 problems and solutions. The critical components are careful monitoring of trends in the incidence and distribution of infectious agents, the ability to detect routine and unusual events and the means to respond. The characteristics of early warning systems are timeliness, sensitivity, flexibility and simplicity. This contrasts with programme monitoring, which requires representativity, completeness and a positive predictive value. Early detection relies on alert networks at the national and international levels that can address the unexpected risks. Early warning systems are a subset of surveillance systems and address the known risks. Identification and confirmation of an event require effective laboratory services and a functional collaborative link between sensitized primary care providers, laboratories, epidemiologists and health managers. The nature of the health event to be detected depends on the source, the vehicle and the mode of transmission of the agent. The event may be massive and sudden, such as a common source outbreak of salmonellosis; diffuse and progressive through person-to-person spread, as in shigellosis; or sporadic and widespread where there is a persistent common source, such as in legionellosis. The early warning system must be able to detect all such events in a timely manner. Alert systems need to be developed at the national and international levels, primarily based on the electronic transmission of information. A timely response requires a plan for epidemic preparedness, with agent-specific guidelines and protocols. Emergency services and primary care providers may need to be involved, and there should be stockpiles of relevant drugs and arrangements for communication with the mass media and health care professionals. In the implementation of a plan for communicable disease surveillance, it is advisable to start with an epidemic response capacity followed by diseases in priority order. Common flaws in national communicable surveillance include inadequate response mechanisms from poor analysis of data at all levels and insufficient feedback. There may be limited capacity for rapid field investigation and insufficient preparedness for epidemics. In other words, there is often information but no action! Addressing the core functions of case detection, reporting, investigation and confirmation, analysis and interpretation and control activities is important. The critical support functions are the setting of standards, training and supervision, laboratory support, establishing communications and resource management. The aims of assessing a national surveillance system are to bring together everyone in the country responsible for surveillance, leading to an agreed plan of action to improve system performance. Opportunities for an integrated approach should be explored, areas to be strengthened should be identified and the required resources should be specified in the plan. The assessment should address structures, processes and outputs. The capacity for core functions and support functions, including laboratory capacity, should be addressed and opportunities for integration and coordination identified. The national disease surveillance plan should be developed in such a way to ensure national ownership. The total burden of communicable diseases and potential threats should be reviewed so that surveillance priorities may be set. Ongoing surveillance activities should be inventoried, and gaps between priorities and activities should be analysed. Focusing on functions and building on existing activities are important. Gaps should be filled and areas for synergy identified. The WHO Regional Office for Europe may be able to advise and assist in this process. EUR/03/5042861/1 page 11 Conclusions, recommendations and plans of work developed by the working groups Working group on early warning and strengthening laboratory capacity The objectives of this working group were to strengthen national surveillance systems and early warning and to strengthen laboratory capacity for surveillance. Conclusions of the working group on early warning and strengthening laboratory capacity Seven countries need to establish a consensus on surveillance priorities, case definitions, data exchange format, laboratory methods and standards. A workshop meeting is proposed for November 2002. The participants should include four from each country – an epidemiologist, a microbiologist, a data manager and a senior health manager. A priority-setting exercise took place last year, and all seven countries were part of it. If data are going to be exchanged, this should be done similarly to how the countries of central and eastern Europe did this. We need to review how much is spent on such systems within the health budget and how the budget decreases during health care reforms. This was not clear from each presentation, although it was mentioned that budgets are decreasing. Thereafter, recommendations can be made or other changes can be suggested to countries. Laboratory capacity needs to be assessed in each country. WHO will establish a standard protocol for the rapid assessment of the capacity of laboratory systems to meet the priorities and standards already agreed upon. Each assessment should take 2–3 days, using a small team of assessors (two or three), and will start in December 2002 and be completed by June 2003. Before assessment takes place, background information on the laboratory system and capacity needs to be acquired from countries. A consensus protocol on common responses to outbreaks and public health events needs to be established. The Regional Office will coordinate the process and build a consensus in early 2003. Coordination with the CCEE–Baltic States Communicable Disease Network needs to be ensured. Assessment should be conducted parallel with the training activities. Each country should have its own working group, which will revise the legislation and amendments about all infectious diseases and outbreak response. The working group will prepare a report, which will be discussed with an international expert and make recommendations to the health ministry. The Working Group discussed the objectives and the time frame within which planned activities could be implemented. There was agreement about principles for collaboration; based on the plenary presentations and discussions, the Working Group participants agreed that early warning systems are tools that allow timely and accurate dissemination of public health event information, leading to effective intervention measures, including investigative and containment activities. Timely recognition of outbreaks requires early warning systems to detect these events before they EUR/03/5042861/1 page 12 develop into public health crises. Prompt detection requires careful monitoring by modern surveillance systems and thorough understanding of trends in the incidence and distribution of known infectious agents. The ability to detect what is new, emerging or re-emerging depends on the capacity to identify and track the routine as well as the unusual. Good national surveillance systems supported by an efficient laboratory network are needed to develop and implement rapid, effective prevention and control measures for epidemics, detecting infectious diseases before they become widespread. Three major components of surveillance were considered by the group for developing a plan of action: the priority diseases to be monitored strengthened capacity for epidemiological and laboratory confirmation of the outbreaks measures to respond to and contain outbreaks. Priorities need to be set for the events and the diseases a country or group of countries should consider to be under surveillance. There should be a consensus on the list of diseases or events under surveillance, but the objectives for national surveillance are different from those that guide international collaboration. To be effective, some actions need to be planned. Each country should review the list of diseases under immediate reporting, compare with similar lists from the other countries, define national and international priorities and develop workable case definitions and laboratory procedures as well as data exchange standards. Based on the defined priorities, the capacity of national reference laboratories should be rapidly assessed. The outcome of such assessments should provide clear guidance to national laboratories on action to undertake to meet international standards for surveillance. The participants also agreed that protocols for outbreak response should be developed; these should include guidelines for rapid laboratory tests, minimum supply requirements and guidance on stockpiling for drugs, vaccines and diagnostics. A plan of action was developed by the group with activity descriptions, a calendar of implementation and expected outcomes. Conclusions of the working group on strengthening national capacity for infectious disease surveillance and second-generation HIV/AIDS surveillance The discussion centred on the needs for training in several technical areas of the surveillance system or systems. It was thought important to strengthen the national capacities for surveillance both in human and animal populations and to strengthen laboratory diagnoses of reported, priority infectious cases both at the national and subnational levels, especially for diseases prone to epidemics. Cost-effective early warning systems should be strengthened as part of the national surveillance systems. In addition, the capacity of each country in field investigation and response needs to be reviewed. Romania’s Ministry of Health had evaluated its surveillance system through a WHO international assessment team. The results of the assessment were used to prepare a national plan of action and to identify additional resources for implementation. A project funded by the European Union Phare Programme is being tendered and will be implemented shortly, focusing on national capacity-building in laboratory capability as well as training. This example illustrates well the usefulness of this process and could be used as a model for similar projects in other countries of the European Region. EUR/03/5042861/1 page 13 A proposal was made to train national surveillance managers using the methods of the Epiet (European Programme for Intervention Epidemiology Training). Such a course could take place in early 2003. This course would include all the heads of communicable disease surveillance from each country. Dr Ira Gjenero-Margan agreed to work as a focal point for this activity, and the most likely place to hold the meeting would be in Zagreb or elsewhere in Croatia. In addition, it was discussed that training in some specific areas is needed, notably on information management as well as geographical information systems. A work plan, including dates, places and estimated cost, was prepared. At the same time a five day training course on 2nd Generation Surveillance will be organized by the HIV/AIDS programme from WHO for participants from all countries mostly likely during the first week of November. This workshop will be organized in coordination with UNICEF and the Canadian Public Health Association and should be seen as a first step to actually implement HIV surveillance activities at country level. EUR/03/5042861/1 page 14 Plan of work prepared by the working group on early warning and strengthening laboratory capacity 2002 2003 Activity Description 4 1 2 3 4 Places Expected outcomes Priority-setting exercise A team for each country should participate in a two-day workshop to review a national priority list of events under surveillance and, through a Delphi modified approach, reach consensus on priorities for collaboration. A national team from each country will participate including: • a manager with political responsibilities; • an epidemiologist; • a microbiologist; and • a data manager. X Bucharest, Romania Priority list of diseases or events Case definitions Laboratory procedures and requirements Data exchange format Estimated cost: US $40 000 Assessment of national laboratory capacity A group of 2–3 experts will be recruited: • to set up a standard protocol for assessment; and • to visit countries and assess laboratory capacity (maximum three days per country) X X X All countries A list of requirements for each country to meet standards as defined in the priority-setting exercise Estimated cost: US $40 000 Developing a protocol for investigation and response A workshop will be organized with working groups (including an epidemiologist, a microbiologist and a data manager from each country) to develop: • a protocol for investigating and containing outbreaks; and • a manual of procedures, such as a list of supplies, logistics required and rapid laboratory tests. X Romania? Definition of the contribution for each country to build up a pool of experts and supplies Estimated cost: US $15 000 Adopting priority lists, case definitions, laboratory procedures and outbreak management protocols at the national level National health ministry committee to adapt and adopt tools developed by working groups X All countries Legislation modified to adhere to international requirements for surveillance EUR/03/5042861/1 page 15 Plans of work for the working group on strengthening national capacity for infectious disease surveillance and second- generation HIV/AIDS surveillance A. Strengthening national capacity for infectious disease surveillance 2002 2003 Activity Description 4 1 2 3 4 Places Expected outcome Assessment missions to 2–3 countries in the Region Evaluate the current status of surveillance of a number of priority diseases, including early warning mechanisms and laboratory capacity. Multinational teams with participation of at least three neighbouring countries. X X X Bulgaria, Albania, Bosnia and Herzegovina (?) Better understanding of the strengths and weakness of national surveillance systems. WHO method will be proposed. Estimated cost: US $90 000 Training of national surveillance managers Epiet adapted course for two-week period, focal point Ira Gjenero-Margan from Croatia. Total participants 20. Objective: to strengthen and implement surveillance tools at the country level and strengthen future national training modules. X Croatia Improved capacities and training models for epidemiological surveillance. Estimated cost: US $85 000 Short course on data management and statistical analysis One week of training, one person per country to improve the management of large databases at the national level. Workshop with examples of databases and software. In coordination with the WHO Communicable Disease Surveillance and Response Office in Lyon. X Romania (to be confirmed) Improved capacity at the country level to maintain timely and accurate databases. Improved national capacities to use applicable software both for analysis and for early warning mechanisms. Estimated cost: US $18 000 Training course on geographical information systems (WHO HealthMapper) Training by WHO on HealthMapper to map morbidity and mortality as well as risk factors for 1–2 participants from each country. X The former Yugoslav Republic of Macedonia Improved geographical presentation and analysis of infectious disease morbidity and mortality. Estimated cost: US $18 000 EUR/03/5042861/1 page 16 B. Strengthening national capacity for second-generation HIV/AIDS surveillance 2002 2003 Activity Description 4 1 2 3 4 Places Expected outcome Training of national experts on second- generation surveillance From each country, three national focal points will be trained in second-generation surveillance. This activity is to be developed further by WHO, UNICEF, UNAIDS and the Canadian Public Health Association. X Zagreb Improved capacity for second-generation surveillance, especially in high-risk groups, and improved information on trends in transmission characteristics. Implementation of surveillance of risk populations. Estimated cost: US $75 000 Promotion of behavioural surveillance methods Distribution and, if required, translation of guidelines for repeated behavioural surveys in population at risk (Family Health International guidelines) X Countries in South Eastern Europe Broad use of standardized methods of sentinel surveillance in risk groups. Estimated cost: US $70 000 Evaluation of ongoing surveys from reproductive health and others at the country level Liaison with demographic surveys of reproductive health and international counterparts such as the US Centers for Disease Control and Prevention and the Harvard School of Public Health. X X More standardized survey methods. Improved and synergy among specific health surveys. EUR/03/5042861/1 page 17 Annex 1 PROGRAMME OF THE MEETING Wednesday, 28 August 2002 08.30 Registration 09.00 Opening ceremony Minister of Health Coordinator of Stability Pact WHO – Spokesman /Spokeswoman Selection of Chairman/Rapporteur 09.45–10.15 Background on Stability Pact (EU) 10.15–10.30 Regional Overview 10.30–11.00 Coffee break 11.00–11.30 Bosnia 11.30–12.00 Bulgaria 12.00–12.30 Croatia 12.30–14.00 Lunch break 14.00–14.30 The former Yugoslav Republic of Macedonia 14.30–15.00 Romania 14.50–15.30 Yugoslavia 15.30–16.00 Coffee Break 16.00–16.30 Albania 16.30–17.30 Presentations by partners EUR/03/5042861/1 page 18 Thursday, 29 August 2002 09.00–09.45 Overview current TB and HIV/AIDS/STI situation 09.45–10.30 Second Generation HIV/SH Surveillance, especially in vulnerable groups 10.30–11.00 Coffee break 11.00–11.45 Role of laboratories in National Surveillance Systems 12.00–12.30 Early Warning Systems 12.30–14:00 Lunch break 14.00–17.30 Group 1: National Surveillance, laboratory and Early Warning systems Group 2: Training for epidemiology and Second Generation Surveillance in vulnerable groups Friday, 30 August 2002 09.00–10.30 Continuation of work plans 10.30–12.00 Presentation of work plans 12.00 Closure EUR/03/5042861/1 page 19 Annex 2 PROVISIONAL LIST OF PARTICIPANTS Albania Dr Silva Bino Tel. No.: +355 43 70058/59 Director Fax No.: +355 43 700 58 Institute of Public Health E-mail: silvi@sanx.net Rruga Alexander Moisiu No. 80 Tirana Professor Eduard Kakarriqi Tel.No.: +355 4 363553 Head Fax No.: +355 4 363553/370059 Department of Epidemiology E-mail: ekakarriqi@ishp.gov.al Institute of Public Health E-mail: edikakarriqi@hotmail.com Rruga Alexander Moisiu 80 Tirana Dr Alban Ylli1 Tel. No.: +355 4 263664 Deputy Director Fax No.: +355 4 370058 Institute of Public Health E-mail: albanylli@ishp.gov.al Rruga Aleksander Moisiu 80 Tirana Bulgaria Dr Mira Kojuharova Tel. No.: +359 2 46 55 17 National Consultant Fax No.: +359 2 4555 17 National Centre of Infectious and E-mail: j.levi@techno-link.com Parasitic Diseases E-mail: mkojouharova@ncipd.netbg.com Department of Epidemiology Yanko Sakazov Blvd. 26 BG-1504 Sofia Dr Angel Kunchev Tel. No.: +359 2 93 01 251 Head Fax No.: +359 2 93 01 183 Ministry of Health E-mail: epimngr@aster.net Direction Head Promotion and Stated Sanitary Control 5, Sveta Nedelya Square Sofia 1000 Croatia Dr Ira Gjenero-Margan Tel. No.: +385 1 46 83 005 Head Fax No.: +385 1 46 83 004 Croatian Public Health Institute E-mail: ira.gjenero-margan@hzjz.hr Department of Epidemiology of Infectious Diseases Rockefellerova Str. 7 HR-10000 Zagreb 1 Note. People whose names are written in italics were invited by unable to attend. EUR/03/5042861/1 page 20 Dr Zeljko Slemensek Tel. No.: +385 14 60 75 28 Head Fax No.: +385 14 60 76 31 Ministry of Health Sanitary Inspection Ksaver 200a 10000 Zagreb The former Yugoslav Republic Of Macedonia Professor Rozalinda Isjanovska Tel. No.: +389 2 114 825 University St. Kiril and Metodij Fax No.: +389 2 111 828 Medical Faculty – Skopje E-mail: isjanovska@yahoo.com Institute of Epidemiology, Biostatistic and Medical Informatics Vodnjanska no. 17 1000 Skopje Dr Kristin Vasilevska Tel. No.: +389 2 147 020 Medical Faculty Skopje Fax No.: +389 2 121 169 University Sv. Kiril i Metodij E-mail: skopje7@yahoo.com Institute of Epidemiology, Biostatistics and Medical Informatics 'Vodnjanska' 31 1000 Skopje Romania Dr Irina Codita Tel. No.: +40 1 4114200 Deputy Director Fax No.: +40 1 4115672 Cantacuzino Institute, Bucharest E-mail: stphylo@cantacuzino.ro Spaiul Independentei No.103, CP 1-525 70 100 Bucharest Dr Adriana Pistol Tel. No.: +40 1 310 39 19 Chief Epidemiologist Fax No.: +40 1 313 66 60 Communicable Diseases E-mail: adip@ms.ro Ministry of Health and Family General Department of Public Health Service of Prevention and Control of Communicable Diseases 1–3 Ministerului Str., Sector 1 70109 Bucharest Yugoslavia Dr Darko Djurkovic Tel. No.: +381 11 311 73 40 Head Fax No.: +381 11 311 20 80 Federal Institute of Public Health E-mail: daredj@Eunet.yu Epidemiology Department Omladinskih Brigada 1 11070 Novi Beograd EUR/03/5042861/1 page 21 Dr Verica Ilic Tel No.: +381 11 3028666 Epidemiologist Fax No.: 381113227828 Gradski Zavod za zastitu zdravllja E-mail: epid@yugc.net Ul. 29 Novembra 54/a Beograd Temporary Advisers Professor Christopher L R Bartlett Tel. No.: +44 77 14 33 72 88 University College London Fax No.: +44 2073884179 Third Floor E-mail: clr.bartlett@talk21.com Centre for Infectious Disease Epidemiology Mortimer Market Centre, off Capper Str London WC1 6AU United Kingdom Dr Raymond Sanders Tel. No.: +44 1905 42 67 32 Scientist Fax No.: +44 1905 42 71 32 72 Henwick Road E-mail: RaySanders@geek.com Communicable Diseases Laboratory System St John's Worcester WR2 5NT United Kingdom Dr Caroline Semaille Tel. No.: +33 1 41 79 68 03 Epidemiologist Fax No.: +33 1 41 79 68 02 EuroHIV E-mail: c.semaille@invs.sante.fr Institut de Veille Sanitaire 12, rue du Val D'Osne 94 415 Saint Maurice Cedex France Governmental, nongovernmental and other organizations Ministry of Health, Albania Dr Mustafa Xhani Tel. No.: +355 42 362937 Minister of Health Fax No.: +355 42 364221 Ministry of Health Fax/Phone +355 42 362554 Tirana World Wide Web www.tirana.al/minjash Albania Dr Petrit Vasili Tel. No.: +355 436 4 622 Vice Minister of Health Fax No.: +355 436 2554 Ministry of Health E-mail: petritvasili@moh.gov.al Blv. Bajram Curri Tirana - Shqiperi Albania EUR/03/5042861/1 page 22 Ms Ruki Kondaj Tel. No.: +355 4 376 194 Secretary General Mobile: +355 68 20 50089 Ministry of Health E-mail: rukikondaj@yahoo.com Bil. “Bajram Cum” Tirana Albania Embassy of Greece Dr Dimitris N. Iliopoulos Tel. No.: +355 42 34 290/1 Ambassador Fax. No.: +355 42 32102/5 223 Greek Embassy Frederik Shiroka Stre., No.2 Tirana Albania Ministry of Health – France Dr Anne Pinteaux Tel. No.: +33 1 40567372 Ministère de la santé (DAEI) E-mail: anne.pinteaux@sante.gouv.fr 8, avenue de Ségur F-75350 Paris France UNICEF Ms Helena Eversole Tel. No.: +387 33 230 118 Special Representative and Chief of Mission Fax No.: +387 33 642 970 UNICEF E-mail: Sarajevo@unicef.org Office for BIH Kolodvorska 6 71000 Sarajevo Bosnia and Herzegovina Observers Dr Agim Shehi Fax/Phone No.: +355 43 761 77 Director Fax/Phone No.: +355 43 646 71 Primary Health Care Department Fax No.: +355 42 271 40 Ministry of Health E-mail: ashehi@hotmail.com Tirana E-mail: agimsheli@hotmail.com Albania E-mail: maritas@albnet.net Dr Dritan Ulqinaku Medical Epidemiologist c/o WHO Office for Humanitarian Assistance in Albania Rr. Lek Dukagjini, no.5 Tirana Albania EUR/03/5042861/1 page 23 World Health Organization WHO Office for Humanitarian Assistance in Albania Dr Santino Severoni Fax/Phone No.: +355 4 223841 Head of the WHO Office for Humanitarian Assistance Fax/Phone No.: +355 4 266162 in Albania Mobile: +355 38 20 23306 Mobile: +355 38 20 33734 Mobile: +355 38 20 38651 E-mail: office@who-albania.org World Wide Web: par.who.dk Dr Stefania Pace-Shanklin Tel No.: +355 4 223841 Public Health Officer Fax No.: +355 4 266 162 Email: space@who-albania.org WHO Liaison Office in Albania Dr Vasil Miho, WHO Liaison Officer Tel. No.: +355 4 364270 WHO Liaison Office Fax No.: +355 4 364270 c/o Ministry of Health E-mail: vmiho@albaniaonline.net Tirana, Albania Regional Office for Europe Dr Massimo Ciotti Tel. No.: +45 39 17 1449 Medical Officer Fax No.: +45 39 17 1851 E-mail: mci@who.dk Dr Bernardus Ganter Tel. No.: +45 39 17 1398 Regional Adviser Fax No.: +45 39 17 1851 E-mail: bga@who.dk Dr Maria Haralanova Tel. No.: +45 39 171513 Project Manager Fax No.: +45 39 17 15 13 E-mail: mahr@who.dk Dr Ulrich Laukamm-Josten Tel. No.: +45 39 17 1561 Coordinator, Task Force on STD Epidemics Fax No.: +45 39 17 15 61 E-mail: ulj@who.dk Ms Doris Sørensen Tel. No.: +45 39 171490 Administrative Assistant Fax No.: +45 39 17 18 51 E-mail: dso@who.dk Ms Gladiola Kashari Tel. No.: +355 4364270 Administrative Assistant Fax No.: +355 4364270 E-mail: vmiho@albaniaonline.net EUR/03/5042861/1 ORIGINAL: ENGLISH UNEDITED E78908 Meeting of Countries of the Dubrovnik Pledge on Infectious Disease Surveillance Report on a WHO Meeting Vlora, Albania 28–30 August 2002 2003