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<b>National Influenza Surveillance System in Vietnam (NISS) </b>

<b>Ngo Huy Tu, MD, MPM </b>

<b><small>Epidemiology Department </small></b>

<b><small>National Institute of Hygiene and Epidemiology </small></b>

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<b>Surveillance </b>

<i> Systematic collection, analysis, interpretation </i>

<i>and dissemination of information for use in </i>

<i>public health action </i>

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<b>Why sentinel surveillance? </b>

as an early warning, but:

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<b>What are the goals of the surveillance? </b>

matching?

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<b>Number of ILI cases in Vietnam, 2004 – 2015 </b>

<b><small>(Data from national communicable diseases surveillance system) </small></b>

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<b>Influenza surveillance in Vietnam </b>

surveillance and no laboratory-enhanced active sentinel surveillance

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<b><small>Severe Acute Respiratory Infection (SARI) </small></b>

<b>Influenza-Like Illness (ILI) </b>

<b>Venn diagram of respiratory illnesses </b>

<b><small>Viral </small></b>

<b><small>Influenza </small></b>

<b>Bacterial </b>

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<b>Pyramid of influenza virus infections </b>

<b><small>Asymptomatic </small></b>

<b><small>Mild symptoms, no medical care Mild symptoms, </small></b>

<b><small>outpatient care Severe symptoms, </small></b>

<b><small>inpatient care ICU </small></b>

<b><small>Death </small></b>

<b>Severity </b>

<b><small>Attempted to be detected by: </small></b>

<b><small>Pyramid within pyramid represents (re)emerging influenza virus with </small></b>

<b><small>pandemic potential SARI and SVP </small></b>

<b><small>surveillance </small></b>

<b><small>ILI surveillance </small></b>

<b><small>Household surveys </small></b>

<b><small>Serology studies </small></b>

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<b>Sentinel Influenza surveillance System in Vietnam </b>

<b>General Objective </b>

To collect the necessary epidemiological and virological

information to guide influenza prevention and control policies and activities. Gradually establish the nationwide influenza surveillance network in Vietnam.

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<b>Specific Objectives </b>

1. Describe epidemiological, virological characteristics and Monitor influenza virus strains circulating in Vietnam. Introduce influenza virus strains for vaccination.

2. To detect avian influenza viruses including emerging strain such as A/H5N1, A/H7N9 and outbreak potential re-assortment of influenza virus genomes and mutation.

3. Gradually establish the nationwide influenza surveillance

network in Vietnam to guide influenza prevention and control policies and activities

4. Contribute in FLunet (Global Influenza Surveillance and Response System) and WHO Collaborating Centers

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<b>Selecting sites </b>

<small>1. Is geographically representative </small>

<small>2. Has a high density of population, high level of commercial and cultural exchanges </small>

<small>3. Urban and rural coverage </small>

<small>4. Sentinel surveillance is based in health facilities that already have the necessary infrastructure, equipment, and trained staff. </small>

<small>5. Has close collaboration in specimens and data collection </small>

<small>6. Has the ability to preserve specimens at the proper temperature and easy transport specimens to the laboratory </small>

<small>7. Is a commitment and willingness to participate. </small>

<small>8. Ability to long term maintained surveillance activities </small>

<small>For ILI: Admits a large number of ILI patients (at least 50 patients/week) </small>

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<b>ILI Surveillance sites, 2006-2015 </b>

<b><small>16 sites: 7 in the northern; 3 in the central; 1 High plateau; 4 in the southern </small></b>

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<b>ILI Cases Definitions </b>

Influenza-like illness (ILI)

Criteria for sample collection

within 3 days

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<b>ILI TIME IMPLEMENTATION, 2006-2015 </b>

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<b>Selected ILI results (cumulative) </b>

Cumulative results in period 2006 to 2015

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<b>Rate of positive of Influenza A and B by month 2006-2015 </b>

<small>1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3 5 7 9 11 1 3</small>

<small>% dương tính% cúm B% cúm A</small>

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<b>Rate of positive ILI samples by influenza subtype by month 2006-2015 </b>

<small>1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4 7 10 1 4</small>

<small>KhácA/H1N1pdmA/H3N2BA/H1N1</small>

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<b><small>Rate of positive ILI samples by age group and by year 2006-2015 </small></b>

<small>Total2006200720082009201020112012201320142015</small>

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<b>Distribution of positive samples by gender and virus sub-type, 2013-2015 </b>

<small>50.7 49.3 </small>

<b><small>A/H1N1 </small></b>

<small>53.3 46.7 </small>

<b><small>B </small></b>

<small>51.4 48.6 </small>

<b><small>A/H3N2 </small></b>

<small>51.8 48.2 </small>

<b><small>Tổ g số + </small></b>

<small>50.5 49.5 </small>

<b><small>A/H1N1 pdm </small></b>

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• The Influenza infection rate in men and women almost equally.

• Influenza mainly influence on children under 15.

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<b>Selecting sites </b>

<small>1. Is geographically representative </small>

<small>2. Has a high density of population, high level of commercial and cultural exchanges </small>

<small>3. Urban and rural coverage </small>

<small>4. Sentinel surveillance is based in health facilities that already have the necessary infrastructure, equipment, and trained staff. </small>

<small>5. Has close collaboration in specimens and data collection </small>

<small>6. Has the ability to preserve specimens at the proper temperature and easy transport specimens to the laboratory </small>

<small>7. Is a commitment and willingness to participate. </small>

<small>8. Ability to long term maintained surveillance activities </small>

<small>For ILI: Admits a large number of ILI patients (at least 50 patients/week) </small>

<small>For SARI: Is a centre for diagnosis and treatment of severe acute respiratory diseases </small>

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<b>SARI Surveillance sites (2010 – 2015) </b>

<small>23 </small>

<b><small>BV Bạch Mai </small></b>

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<b>SARI Definitions </b>

Severe Acute Respiratory Infection (SARI)

For children < 5 years:

• Cough or difficult breathing AND • Any one of the following:

<small>– Breathing > 60/min for ages <2m </small>

<small>– Breathing > 50/min for ages 2m to < 1yr – Breathing > 40/min for ages 1 to < 5 years – Chest indrawing </small>

<small>– Stridor in a calm child </small>

<small>– Unable to drink or breast feed – Vomits everything </small>

<small>– Convulsions </small>

<small>– Lethargic or unconscious </small>

<small>– Oxygenation saturation < 90% </small>

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<b>SARI Definitions </b>

Severe Acute Respiratory Infection (SARI)

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<b>SARI SURVEILLANCE RESULTS, 2011-2015 </b>

• Total patients visit: 228.656

• Total SARI: 37.541 (16% in total admissions patients) • Total SARI sample collected for testing: 5.148

• Total SARI sample tested using RT-PCR: 5.148

• Total SARI samples positive with influenza 611 (11,9%)

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<b>PROPORTION SARI/TOTAL ADMISSION AND PROPORTION SARI SAMPLE POSITIVE WITH INFLUENZA ,2011-2015 </b>

<small>28 </small>

<small>0102030405060</small>

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<b>Distribution of SARI patients by region and aetiologies, 2011-2015 </b>

<b><small>Region Total samples No positive </small>^A/H1N1/09</b>

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<b><small>DISTRIBUTION OF POSITIVE RATE WITH FLUENZA BY MONTH AND YEAR 2011-2015 </small></b>

<small>20112012201320142015</small>

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<b>Distribution of influenza viruses by time, 2011-2014 </b>

<b><small>020406080100</small></b>

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<b>DISTRIBUTION OF SARI BY AGE GROUP </b>

<small>20.030.0</small>

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<small>• Proportion of SARI/Total Admission: 16.5% </small>

<small>• Influenza viruses account for 12% SARI patients. There were two picks in March and June. </small>

<small>• Age group 0 – 4 years old account more than 50% SARI patients. </small>

<b>CONCLUSION </b>

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<b>Case definitions for SARI Surveillance 2016 - 2017 </b>

– SARI (using WHO case definition 2014):

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<b>SARI Sentinel sites, 2016-2017 </b>

<b><small>2 Bệnh viện Nhi Trung 3 </small></b>

<b><small>4 5 6 B</small></b>

<b><small>7 Bệnh viện Trung 8 </small></b>

<b><small>9 </small></b>

<b><small>11 12 13 </small></b>

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<small>10 ới Tp HCM </small>

<small>11 </small>           

<small>12 </small>           

<small>13 </small>           

<small> </small> ^{CDC support}<small> </small> ^{WHO support}

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<b>Distribution of influenza on SARI </b>

<b><small>Region </small>^{Samples Influenza positive}^{A/ H1N1/pdm}^{A/ H3N2}^B</b>

<b><small>Other influenza </small></b>

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<b>Distribution of 7 non influenza viruses on SARI </b>

<b><small>No HMPV Adeno P1 P2 P3 RSV Rhino Co-infection </small></b>

<b><small># # % # % # % # % # % # % # % # % </small></b>

<small>Miền </small>

<small>Bắc </small> ⁹²⁶ ²³ <i>^2.5%</i> ⁴⁶ <i>^5.0%</i> ³² <i>^3.5%</i> ⁵ <i>^0.5%</i> ⁴² <i>^4.5%</i> ¹²⁷ <i>^13.7%</i> ¹⁰⁰ <i>^10.8%</i> ⁵³ <i>^5.7%</i><small>Miền </small>

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<b>SEVERE PNEUMONIA SURVEILLANCE (SVP SURVEILLANCE) </b>

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carbondioxide saturation level)

• Chest X-ray consistent with viral pneumonia

• No suspect diagnoses of other aetiology such as

bacterial pneumonia, tuberculosis etc. were made by specialist conference.

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<small>6/20/2017 43 </small>

Surveillance sites

– Passive surveillance system at all

<b>hospitals in 63 provinces. </b>

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<b>Methods </b>

– Sampled, epidemiological and clinical data collected on form for all SVP cases.

– Data and samples sent to regional lab

– All specimens will be tested in laboratories of 4 regional institutes using RT-PCR

– Standardized Laboratory Management in Lab network

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<b>Distribution of SVP cases by aetiologies, 2006-2015 </b>

<b><small>Lab results 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 </small>^Total<small>(%) </small></b>

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<b>Influenza A(H5N1) virus in Vietnam, 2003-2015 </b>

<small>64 deaths/127 cases in 41 provinces/cities </small>

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<small>• Influenza viruses account for 16.9% SVP patients. </small>

<small>• Early detect avian influenza A/H5N1. in the period 2006-2014 33/34 (97%) avian influenza A/H5N1 cases were detected through SVP surveillance system. </small>

<small>• In Vietnam, not yet found any cases of influenza A(H7N9) in humans. </small>

<b>CONCLUSION </b>

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<b>ACHIEVEMENTS OF NATIONAL INFLUENZA SURVEILLANCE SYSTEM </b>

<small> Establishment of the National Influenza Surveillance System </small>

<small> Provide epidemiological and virological information on all strains of human influenza in Vietnam through active surveillance </small>

<small> Detect outbreaks of Avian Influenza in Human by Passive surveillance for Viral Pneumonia (SVP) </small>

<small> Contribute to national influenza prevention and control, especially Strengthen Public Health Laboratory Networks </small>

<small> Sharing influenza isolates for Vaccine candidates of Northern Hemisphere </small>

<small> Serve as a background and basis for further researches on influenza viruses. </small>

<small> Reporting on weekly basis on the FluNet (Global Influenza Surveillance and Response System) </small>

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<b>ADVANTAGES </b>

 Advantage of support from MOH, GDPM, district and

provincial PMC, sentinel hospital, US.CDC representatives  Standardized Laboratory Networks, high quality performance

and stability in all 4 regions

 Enthusiastic staffs, dynamic, professional and technical mastery

 Effectiveness of the system to provide timely information to contribute to guide influenza prevention and control policies and activities.

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<b>CHALLENGES </b>

 System depends on outside funding, needs for long term with stable financial source to maintain and further strengthen the system.

 At provincial level, laboratory testing to confirm viruses

unavailable, test result is always late to be useful for on time intervention and treatment

 High costs of biological testing products, there is no

standardized estimating procedures and SOP for an effective management of biological products.

 Settlement and contract’s signatures was made late on scheduled activities.

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<b>Thank You </b>

<b>For Your Attention! </b>

</div>