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Disease Prevention and Control / Communicable Diseases / Emerging/Reemerging Diseases

VIth Meeting of the Southern Cone Surveillance Network for Emerging Infectious Diseases

(Florianópolis, Santa Catarina, Brazil, 4–5 March 2005)

VIa Reunión Red Cono Sur EIE
Final Report (Spanish, 75 pp, PDF, 2178 Kb)

Compliance with recommendations from last meeting
1. General Activities of the Network
2. Evaluation of Laboratory Performance
3. Antimicrobial Resistance (AMR)
4. Hemolytic Uremic Syndrome
5. Hantavirus
6. Influenza
7. Dengue and Yellow Fever
8. Syndromic Surveillance

Recommendations
I. General Activities of the Network
II. Evaluation of Activities
III. Communication and Information-Sharing on EID Outbreaks and the Steps Taken to Contain Them
IV. Evaluation of Laboratory Performance
V. Hantavirus
VI. Influenza
VII. Dengue and Yellow Fever

PAHO Links
- EID Networks
- PAHO EID Page
- PAHO AMR Page
- PAHO Hantavirus Page
- PAHO Influenza Page
- PAHO Dengue Page
- PAHO Yellow Fever Page

WHO Links
- WHO EID Page
- WHO Influenza Page
- WHO Drug Resistance Page
- WHO Dengue Page
- WHO Yellow Fever Page

Meeting sponsored by PAHO and three US government agencies:
- Centers for Disease Control and Prevention (CDC)
- Department of Health and Human Services (HHS)
- Agency for International Development (USAID)

Participants were from all Southern Cone countries. For the first time, part of delegation from each country, with the exception of Brazil, were infectious diseases physicians. Dr. Expedito Luna from Brazil was elected Chairman, and Dr. Vilma Savy, Argentina as rapporteur.

Discussions at the meeting focused on the new approach for implementation of the International Health Regulations; planning for epidemic emergencies using as scenario an eventual influenza pandemic; experiences of the National Technical Group approach for dengue control in the Southern Cone; EID outbreaks with potential for dissemination, and containment measures implemented in the Southern Cone; future challenges for the role of clinicians and hospitals in surveillance; and assessment of health services capacities for implementing of EID surveillance (serology for diagnosis of EID and for monitoring antimicrobial resistance).

Since the joint meeting of the Amazon and Southern Cone networks held in Atlanta in March 2002, it was decided that recommendations issued in the annual meeting one year would be analyzed to determine their fulfillment during the following annual meeting. Therefore, below is a summary of country compliance with recommendations made in the Atlanta meeting held in 2004*.

Compliance with the Recommendations to Southern Cone Countries Made at the IIIrd Joint Meeting of the Regional EID Surveillance Networks, Atlanta, February 2004

1. General Activities of the Network

To Countries

  • Recommendation: Countries should report on the main events related to these diseases at the next EID meeting.
    Compliance:In this meeting, the countries reported the main events related to EIDs.
  • Recommendation: Gradually integrate issues common to MERCOSUR and the Southern Cone EID networks, beginning in the initial stage with information exchange, as mandated by the MERCOSUR Subcommittee on Epidemiological Surveillance-SGT11.
    Compliance:The countries agreed on integrating the issues common to the EID and MERCOSUR networks. However, the issues to be addressed in MERCOSUR must be on the agenda 6 months in advance; this was not possible at this time.
  • Recommendation: Hold the next EID meeting immediately after the MERCOSUR meeting.
    Compliance:Although PAHO asked Paraguay to yield the secretariat pro tempore to Brazil for the period J anuary-June 2005 so that the EID meeting could be convened immediately after the meetings of MERCOSUR, this could not be done due to a lack of political precedent to justify this action.

To PAHO

  • Recommendation: Continue periodic dissemination of information on important international public health events through the ListServ and the PAHO website.
    Compliance:Information on important EID events continued to be disseminated through the ListServ and the PAHO website.
  • Recommendation: Distribute the next meeting's agenda to the countries through the ListServ so they can review it and make suggestions before the final version is prepared.
    Compliance:The Meeting's agenda was distributed to the countries by the PAHO/WHO Representative Offices and the ListServ.
  • Recommendation: Distribute country reports submitted for that meeting through the ListServ.
    Compliance:This was not done.
  • Recommendation: Make Make biosafety training in all relevant areas part of the cooperation with EID network institutions.
    Compliance:The pertinent provisions of the 13th edition of the United Nations Model Regulation on the transport of infectious substances were distributed to the countries, with explanatory notes. (WHO/CDS/CSR/LYO/2004- 9).

To CDC

  • Recommendation:Continue supporting network activities to ensure resources for reagents and supplies.
    Compliance:The CDC continued its support for network activities.
  • Recommendation:Increase support for epidemiology, clinical practices, and the investigation of outbreaks.
    Compliance:This support from CDC was targeted to vector-borne EIDs (dengue and West Nile virus).

2. Evaluation of Laboratory Performance

To Countries

  • Recommendation:Report on the types and frequency of activities.
    Compliance:Argentina, Bolivia, Brazil, Chile, Paraguay, and Uruguay participated in the IV annual evaluation of serodiagnosis of EID, conducted by CENETROP, Bolivia. Epidemiologists, clinicians, and laboratory personnel participated in the evaluation.
  • Recommendation:Ensure cooperation among the different members of the network to equalize diagnostic capacity.
    Compliance:In Argentina, the National Institute of Infectious Diseases (INEI), evaluated the quality of the laboratories and provided reagents to other Southern Cone countries participating in influenza, antimicrobial resistance, hantavirus, and HUS surveillance. They also provided reagents and training to Central American laboratories for diagnosis of HUS. The Institute for Hemorrhagic Viral Diseases (ISP) serves as the reference laboratory for West Nile virus.
    In Chile, the Institute of Public Health (ISP) provided training to the other Andean countries on influenza and to the Region as a whole on the surveillance of antimicrobial resistance in gonococci.
    The Evandro Chagas Institute in Brazil is the reference laboratory for dengue and yellow fever, and FIOCRUZ for bordetella. Peru's National Institute of Health provided support to Chile's ISP in the diagnosis of dengue.
  • Recommendation:Ensure that the instructions for the next performance evaluation exercise in serodiagnosis of infectious diseases explicitly call for the participation of clinical and epidemiological personnel.
    Compliance:In all countries, laboratory and clinical personnel, jointly with epidemiologists, participated in the performance evaluation (see section 3 of this report).

To PAHO

  • Recommendation:Continue support for intercountry activities through a TCC.
    Compliance:Support was provided through TCC for joint projects on hantavirus (between Argentina and Chile) and HUS (between Argentina and Paraguay); and for the monitoring of antimicrobial resistance (between Argentina and Venezuela).
  • Recommendation:In the next evaluation exercise, disseminate information on this activity to the countries' epidemiology institutions through the ListServ.
    Compliance:The PAHO Representative Office notifies the countries' epidemiology institutions in advance about the annual evaluation of serodiagnosis of EID organized by CENETROP, Bolivia.

3. Antimicrobial Resistance

To Countries

  • Recommendation:Compliance with quality assurance standards must be a sine qua non for participation in the network.
    Compliance:All the Southern Cone countries are participating in the performance evaluation exercise in microbiological diagnosis and determination of susceptibility to antibiotics that the National Laboratory for Enteric Pathogens of Canada is conducting as organizing laboratory, in collaboration with INEI, Argentina, and SALM-SURV/WHO.
  • Recommendation:Each country should evaluate its strategy for local dissemination of resistance profiles, based on its specific situation.
    Compliance:The strategies for locally disseminating the results of antimicrobial resistance surveillance varies from country to country. For example, in Chile the ISP has a website called Vigilancia (Surveillance) that publishes information on this topic. Similar websites can be found in Argentina and Brazil. In all countries, the findings are also disseminated through presentations in congresses and articles in domestic and foreign journals.
    In spite of progress made, there is still a need to improve dissemination of information in hospitals on the prevalence of the species isolated and the resistance profiles of the bacteria responsible for hospital-acquired infections.
  • Recommendation:Surveillance of antimicrobial resistance should be an effective part of epidemiological surveillance activities, using the methodology most suited to the organizational capacity of the health services.
    Compliance:Surveillance of antimicrobial resistance through sentinel sites is carried out in all Southern Cone countries.

4. Hemolytic Uremic Syndrome

To Countries

  • Recommendation:Ensure that intervention strategies to prevent HUS cases are effectively implemented in each endemic country.
    Compliance:In Argentina, 14 HUS Sentinel Units (HUSSU) commenced operations to detect cases and study foci of patients with the object of preventing new cases. The HUSSU were set up in provinces that have cases and in health personnel interested in conducting active surveillance.
    In Chile, the ISP received a total of 218 isolates, 89% of them clinical samples. Out of the 146 patients studied, 41 (28%) tested positive for STEC and 9 of them presented HUS. E. coli O157:H7 was found in 23 cases (7 of the HUS cases). Health authorities conduct slaughterhouse inspections to ensure good sanitary practices. The Food Hygiene Program monitors places were food is sold and, at the regional level, is responsible for alerting the population about potential risks. Paraguay made HUS case reporting compulsory.

5. Hantavirus

To Countries

  • Recommendation:Explore an effective media strategy for prevention.
    Compliance:Although media campaigns targeting the general public have been conducted in the endemic areas of Argentina (including Buenos Aires Province), Chile, and the Chaco region of Paraguay, results on studies evaluating their effectiveness are still not available.
  • Recommendation:The activities should be multidisciplinary in nature, integrating environmental research, clinical practice, epidemiology, and laboratory practices.

  • Compliance:All the countries are attempting the use of a multidisciplinary approach. However, integration is most advanced between epidemiologists and laboratory personnel.
  • Recommendation:Continue studies on the rodent population dynamic in both urban and peri-urban areas.
    Compliance:Studies of the rodent population dynamic and seroprevalence in humans and rodents continue in Argentina (Río Negro and Chubut), in urban and peri-urban areas of Brazil (Brasilia), and in the Paraguayan Chaco.
  • Recommendation:Continue research to obtain a better understanding of human-to-human transmission.
    Compliance:Further evidence of human-to-human transmission was provided in Buenos Aires Province, Argentina; while in Chile the analysis of the information in this area continues.

6. Influenza

To Countries

  • Recommendation:Bolivia and Paraguay should begin preparation of a national pandemic preparedness plan.
    Compliance:In Paraguay, a preliminary draft of the general part of the national plan was prepared and presented to the Minister of Health in July 2004. In October 2004, this document was sent to all the bureaus of the Ministry of Health, so that the plans corresponding to each area could be drawn up. There is no information on Bolivia.
  • Recommendation:All the countries should work to produce a more finished draft and a checklist to finalize the preparedness plan for an influenza pandemic, which should be disseminated through the ListServ by June 2004.
    Compliance:Although the preliminary national pandemic preparedness plans were improved in Argentina, Brazil, and Chile, there is no evidence that the countries have drawn up common checklist or that they have used the ListServ for disseminating information.
  • Recommendation:The regional strategy for vaccine production should be studied.
    Compliance:Brazil is the only country in a position to manufacture a vaccine by 2007.
  • Recommendation:Countries should arrive at a regional consensus on the use of antivirals, using the conclusions of the WHO meeting in February 2004 as a precedent.
    Compliance:The countries have agreed on the use of oseltamivir as the drug of the treatment of choice for prophylaxis and treatment.
  • Recommendation:Strengthen the national influenza centers and their respective network to improve epidemiological surveillance systems for human and animal influenza.

  • Compliance:In Argentina, Brazil, and Chile, influenza diagnosis in the national influenza centers (NIC) improved with the use of molecular techniques for detecting avian and human influenza strains.
  • Recommendation:Promote avian flu surveillance as an essential part of the epidemiological surveillance system.
    Compliance: In Argentina, Brazil, and Chile, coordination with the Ministry of Agriculture authorities in charge of avian flu surveillance was promoted. In Paraguay, avian surveillance is being conducted only as a research project (National University of Asunción and Memphis, Tennessee, USA). An outbreak in hens was investigated in January 2004, along with an outbreak of human influenza in an indigenous community in Bajo Chaco in June 2004.
  • Recommendation:Increase the number of samples to be sent to the WHO Collaborating Center.
    Compliance:Southern Cone countries sent 319 samples to the WHO Collaborating Center. The samples were characterized before making the decision about the 2005 vaccine formula for the Southern Hemisphere. Meetings continued in all the countries (except in Bolivia) to improve national contingency plans for emergencies, which include a pandemic preparedness plan.

To PAHO

  • Recommendation:Once the regional strategy is defined, consider mass procurement of antivirals.
    Compliance:The procurement of antivirals depends on the countries' economic situation, which leaves much to be desired. No country's public health network has oseltamivir in stock.
  • Recommendation:Draft recommendations on methods for analyzing morbidity and mortality to gauge the impact of the services (including laboratory services) in a pandemic.
    Compliance:This recommendation was not complied with.
  • Recommendation:Continue assistance for the procurement of reagents and the shipment of strains to the WHO Collaborating Center.
    Compliance:This assistance continues. The Southern Cone countries sent 319 samples to the WHO Collaborating Center in Atlanta in 2004.
  • Recommendation:Continue support for the preparation of national contingency plans, promoting dissemination of the guidelines developed by the PAHO advisory group to all the countries, and for the sharing of experiences in the preparation of national plans.
    Compliance:The Regional Office and the PAHO/WHO Representative Offices in countries assist the Ministries of Health in the development of contingency plans. In addition, the guidelines developed by PAHO for this purpose were distributed (Doc. OPS/DPC/CD/232/03).

7. Dengue and Yellow Fever

To CDC and PAHO

  • Recommendation:Continue support with reagents and training.
    Compliance:Reagents continue to be provided on request. The training is unnecessary, since staff have already been trained.

8. Syndromic Surveillance

To PAHO

  • Recommendation:Disseminate information on new activities in syndromic surveillance.
    Compliance:The report of the IIIrd Joint Meeting of Regional EID Surveillance Networks, OPS/DPC/CD/319/04, was distributed. This report summarized the activities for implementation of the syndromic approach in Brazil, Colombia, Ecuador, Peru, and Venezuela (also in Rev. Patol. Trop. 34 (Supl.1): Jan–Jul, 2005.

Recommendations

I. General Activities of the Network

To Countries

  • At the next EID meeting, countries should report on the main events in connection with these diseases.
  • Recognize and encourage the involvement of clinicians in surveillance activities targeting priority infectious diseases of the Southern Cone. This will require: i. developing an EID training program for clinicians and a permanent feedback system; ii. publishing surveillance results in journals or publications of interest to clinicians; iii. promoting improvements in physicians' epidemiological understanding from the undergraduate level on in (and with) scientific and academic societies.
  • At least two countries should prepare a project for the qualitative study of opportunities and obstacles to motivating clinicians to detect and report events of epidemiological interest.

To CDC

  • Continue support for network activities, guaranteeing the resources for reagents and supplies and expanding support for epidemiology, clinical practice, and the investigation of outbreaks.

To PAHO/WHO

  • Clinicians from each country should continue to participate in the upcoming meetings of the network.

II. Evaluation of Activities

To CDC

  • Support the evaluation of epidemiological surveillance systems for EIDs.

III. Communication and Information-Sharing on EID Outbreaks and the Steps Taken to Contain Them

To Countries

  • Report outbreaks to the other countries in the subregion through the existing formal and informal mechanisms, so that they can prepare for the eventual spread of outbreaks and mobilize the country's capacity.
  • Publish a calendar of training activities through the ListServ; share experiences with national training programs in field epidemiology (FTP) and study the possibility of offering FTP in countries that do not have them.
  • Improve forecasting models and see to it that they are shared; and periodically report the results of antimicrobial resistance surveillance and progress in IIH surveillance.

To PAHO/WHO

  • Use the ListServ to announce events of international interest, based on the IHR, as well as events of national import. Hold moderated virtual meetings on specific topics, beginning with the plan for an influenza pandemic.
  • Continue the periodic dissemination of information on events of interest in international public health (Alerts) through the ListServ and the PAHO website.
  • Disseminate the next meeting's agenda to the countries through the ListServ so that they can review it and make suggestions before the definitive agenda takes shape. Also, distribute the country reports submitted for that meeting through the ListServ.

IV. Evaluation of Laboratory Performance

To Countries

  • All should participate in the CENETROP evaluation of performance in the serodiagnosis of EID and continue national evaluations to establish how quality assurance is implemented in public health laboratories.
  • At the next meeting of the Network, report on the measures implemented on the basis of the performance evaluation.
  • Laboratory staff, epidemiologists, and clinicians should participate in the National Reference Laboratory performance evaluation.

To CDC

  • Continue supporting the activities.

To PAHO/WHO

  • Develop a protocol for analyzing the performance evaluation data;
  • The next evaluation of EID serodiagnosis should be announced to the epidemiology institutions in the countries through the Listserv.
  • Indicate in the instructions clinical and epidemiology staff will participate in the evaluation.
  • The organizing laboratory should increase the number of samples in the panels and the laboratories will continue to have 7 days to return the results for the evaluation.

V. Hantavirus

To Countries

  • Explore an effective mass media strategy for prevention.
  • Continue studies on the population dynamic of rodents (which should include urban and peri-urban areas) and also on person-to-person transmission of the infection.

To PAHO/WHO

  • Support Brazil to boost the production of reagents for use in serology and promote the development of new rapid diagnostic techniques in Chile.

VI. Influenza

To Countries

  • Finish developing the lines of action for the plan, based on the checklist proposed by WHO. This includes: i. identifying training needs to implement the plan (Thus, Uruguay, Bolivia, and Paraguay should strengthen field epidemiology); ii. strengthening surveillance of animal influenza and opening lines of collaboration with the responsible agencies; iii. sharing existing protocols and experience in the use of antivirals with the other countries; iv. ensuring that reference laboratories have the capacity and supplies for the identification of influenza strains, as well as the necessary biosafety conditions; and v. ensuring that they start implementing the plan through simulations or during outbreaks of acute respiratory disease and share their experience with other countries.

To CDC

  • Continue support to the reference laboratories to ensure that they have the capacity to diagnose pandemic strains.

To PAHO/WHO

  • Distribute all the necessary documents to the countries for the preparation of contingency plans for an eventual influenza pandemic.

VII. Dengue and Yellow Fever

To Countries

  • Characterize risk areas in order to carry out prevention activities; engage in joint activities and cooperation with other countries, especially in border areas; maintain the continuity of surveillance and warning systems; implement quality control in dengue laboratories; and facilitate and promote the development of noncommercial diagnostic kits.

To CDC and PAHO/WHO

  • Continue support by providing reagents and training, including the shipment of samples for proficiency testing for dengue.

* IInd Joint Meeting of the Network for the Surveillance of Emerging Diseases in the Amazon and Southern Cone Regions. Atlanta, Georgia, USA, March 2002. Revista de Patología Tropical, Vol. 32, Suppl.1, Jan–Jun 2003.


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