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Technical and policy guidance for setting up, implementing and assessing surveillance systems of water-related disease. Minsk 5-6 April 2011 Enzo Funari. Italian Higher Institute of Health.

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Technical and policy guidance for setting up, implementing and assessing surveillance systems of water-related disease

Minsk 5-6 April 2011

Enzo Funari. ItalianHigherInstituteofHealth


Technical guidance document on water related disease surveillance origin story of their preparation
TECHNICAL GUIDANCE DOCUMENT ON and assessing surveillance systems of water-related diseaseWATER-RELATED DISEASE SURVEILLANCEorigin, story oftheirpreparation

  • Inspired by a WHO public health initiative in Asia, organized by the WHO Collaborating Centre for Health-promoting Water Management and Risk Assessment at the University of Bonn, Germany.

  • Multilateral co-operation programme between the WHO Regional Office and the central Asian countries.

  • Later on, further developed by this TF.


Approach contents aims
Approach, contents , aims and assessing surveillance systems of water-related disease

  • Holistic approach;

  • The document reviews the main threats to health related to water services, recalls basic concepts of epidemiology and disease surveillance, and provides guidance on data management and analysis.

  • It is in line with the International Health Regulations (2005) which entered into force on 15 June 2007.

  • A sort of synthesis of scientific knowledge in the area (basis) but then practical tools to face the possible problems in the area.


Approach contents aims1
Approach, contents , aims and assessing surveillance systems of water-related disease

  • Aimed specifically at the needs of local laboratories in central Asian countries;

  • Also aimed at strengthening cross sectoral activities (water, environment managers and health sector workers).

  • In conclusion, the Guidance document is aimed at supporting national efforts towards national and international health security


Scientists experts involved
Scientists, experts involved and assessing surveillance systems of water-related disease

Editors:

  • Enzo Funari, chair of Task Force on Water-related Disease Surveillance

  • Thomas Kistemann, Institute for Hygiene, Rheinische Friedrich Wilhelms Universitat, Bonn, Germany

  • Dr Suzanne Herbst, Executive Director, WHO Collaborating Centre for Health Promoting Water Management and Risk Communication

  • R Aertgeerts, WHO Regional Office for Europe

    Main contributors:

  • Akgaev, D (Turkmenistan); Blasi, M (Italy); Classen, T (Germany); Cronin, A A (UK); Dangendorf , F (Germany) ; Davlyatov, S K (Tajikistan); Exner, M (Germany); Funari, E (Italy); Herbst, S (Germany); Kadar, M (Hungary); Kaitbaev, N (Tajikistan); Kistemann, T (Germany); Loock, A (Germany); Ishankuliev, Y (Turkmenistan); Mishina, O (Uzbekistan); Moe, C (USA); Pond, K (UK); Queste, A A (Germany); Schoenen, D (Germany); Sharipova, N V (Uzbekistan); Wienand, I (Germany); Vashneva, N (Kyrgyzstan)


Technical guidelines
Technical and assessing surveillance systems of water-related diseaseguidelines

2. HEALTH RISKS FROM MICROBIAL PATHOGENS

3. HEALTH RISKS FROM CHEMICALS

4 HEALTH RISKS IN THE WATER SYSTEM

5. ESSENTIAL EPIDEMIOLOGY

6. ESSENTIAL SURVEILLANCE.

7. DATA MANAGEMENT AND ANALYSIS USING GEOGRAPHICAL INFORMATION SYSTEM


Technical guidelines1
Technical and assessing surveillance systems of water-related diseaseguidelines

The publication is available at http://www.unece.org/env/documents/2010/wat/MP_WH/wh/ece_mp_wh_2010_L3_E.pdf

157 pages, 18 tables, 22 figures


Policy guidelines
Policy guidelines and assessing surveillance systems of water-related disease

  • Short guidance for the organization or improvement of health systems, with particular attention to water-related diseases (WRDs).

  • Where safe access to water is not ensured, political authorities should be aware of the consequences, not limited to the disease (sustainable development is hampered and economic costs are prohibitive).


Co authors
Co-authors and assessing surveillance systems of water-related disease

  • Roger Aertgeerts, WHO Regional Office for Europe

  • Enzo Funari, Italy

  • Nana Gabriadze, Georgia

  • Paul Hunter, United Kingdom of Great Britain and Northern Ireland

  • Frantisek Kozisek, Czech Republic

  • Arben Luzati, Albania

  • Aida Petikyan, Armenia

  • Andrea Rechenburg, Germany


Contents
Contents and assessing surveillance systems of water-related disease

II. Water safety plans

III. Legal obligations with regard to disease surveillance

IV. Surveillance system for water-related diseases

V. How to set up an essential surveillance system for water-related diseases (OMT)

VI. How a water-related disease surveillance system should work in practice

VII. How to evaluate a surveillance system for water-related diseases

VIII. National examples

I. The problem (Introduction)


The problem
The Problem and assessing surveillance systems of water-related disease


The problem1
The Problem and assessing surveillance systems of water-related disease


Figure 1‑2 SDR diarrhoeal disease and assessing surveillance systems of water-related disease

below 5 y of age (Source: WHO Health for All)

EUR B+C

EUR-A

While mortality data are surely the most striking, morbidity figures show that water-related diseases continues to be a serious problem in the European region, are hampering sustainable development and imposing prohibitive economic costs.


Controlling and reducing the burden of wrds
Controlling and assessing surveillance systems of water-related disease and reducing the burdenofWRDs

Surveying the health status of communities

Controlling and reducing the burden of WRDs has two main tools

Promoting adequate preventive measures in order to ensure safe access to water (adequate quality and quantity)


Examples where the system failed included an outbreak of giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.


Who water safety plans one of the most important tools in ensuring safe water
WHO Water safety plans giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks. one of the most important tools in ensuring safe water.

  • WSPs: management multi step approach aimed at ensuring safe access to water.

  • WSPs should be developed for each individual drinking-water system, whether large- or small-scale.

  • Beyond drinking water


Who wsps
WHO WSPs giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

Raw waters should be protected against pollution in the catchment area

Surface and shallow waters must always be treated before being used as a source of drinking-water;

the higher the level of contamination of raw water, the greater the efficiency of the water treatment process required;


Who wsps1

Figure 8‑1 Sources of failures in the WSP approach giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

WHO WSPs

Drinking-water: subject to surveillance for the main risk factors (special attention to microbial quality)

Adequate education and training for the personnel


Surveillance systems for wrds
Surveillance systems for WRDs giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

Surveillance systems implemented in several countries in the EURO Region but often do not include specific surveillance for WRDs.


Wrds surveillance systems
WRDs Surveillance systems giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

Specific WRDs surveillance systems would provide relevant added value, as they can:

  •  identify the diseases transmitted by water

  • define/estimate the burden of WRDs;

  • use data and information to identify communities where there are problems with water related diseases;


Wrds surveillance systems1
WRDs giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.Surveillancesystems

Mapping of pollution hazards and identifying risks;

promote intervention measures to control and prevent WRDs;

target resources towards areas with priority needs;

assess the effectiveness of the implemented water and sanitation interventions in reducing diseases.


Wrd surveillance systems
WRD giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.Surveillancesystems

In countries with limited resources:

High incidence of typhoid fever→ need for targeted vaccine campaigns;

epidemic and endemic giardiasis and cryptosporidiosis → need for water filtration (chlorination is not very effective against these pathogens)

need of household water treatment of water in high-risk areas;

outbreaks in adequately treated piped water supplies ( intrusion problems in the water distribution system) → need to keep water pressure stable or accept additional measures like booster chlorination

high prevalence of helminth infections → need for improvements in sanitation and increased water availability for general hygiene;

High incidence of blue-baby syndrome → need to control and reduce nitrate concentrations in drinking water.


How to set up an essential surveillance system for wrds
How to set up an essential surveillance system for WRDs giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

  •  Public health surveillance systems represent the ongoing and systematic collection, analysis and interpretation of health data to describe and monitor a health event.

  • The surveillance of WRDs should be included within the context of more general surveillance systems for communicable diseases.

  • A specific surveillance system for waterborne disease outbreaks should include a method for evaluating the evidence that an outbreak is indeed attributable to contaminated water.


How to set up an essential surveillance system for wrds1
How to set up an essential surveillance system for WRDs giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

  • WRDs:

  • Priority diseases (characterised by a high epidemic potential): cholera, diseases caused by enterohaemorrhagicE. coli, viral hepatitis A, bacillary dysentery and typhoid fever.

  • Emerging diseases (showing a rapid increase in the affected population, or are being observed in countries where they were previously absent): campylobacteriosis, cryptosporidiosis, giardiasis, and legionellosis.


How to set up an essential surveillance system for wrds2
How to set up an essential surveillance system for WRDs giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

Local diseases (diseases that are not present throughout the country concerned but may potentially have a severe local impact) : methemoglobinaemia, arsenicosis, viral infections (particularly those attributable to Norovirus) and parasitic diseases.


Essential surveillance system for wrds
Essential giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.surveillance system for WRDs

  • Local level

  • An outbreak management team (OMT) should be set up at the local health unit.

    OMT composition: representatives of waterworks and sanitation system, water department of the regional environmental agency, expert in hygiene and environmental medicine.


Essential surveillance system for wrds1
Essential surveillance system for WRDs giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

  • In case of a WRD outbreak, the local OMT should:

  • Review the evidence for an outbreak

  • Identify the population at risk

  • Decide on control measures

  • Provide quick and adequate information to the public

  • Make arrangements for the commitment of personnel and resources

  • Health surveillance data should be linked with data on the quality and distribution of water supplies in the same area.


Essential surveillance system for wrds2
Essential surveillance system for WRDs giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

  • Regional level

  • An OMT with similar features should be established at regional level, with the following tasks after WRD outbreaks:

  • Prepare a notification to be sent to the national agencies

  • Prepare a report to be sent to the regional authorities responsible for management measures

  • Promote further epidemiological and environmental studies, as necessary;

  • Provide adequate information to the public; and

  • Provide feedback on surveillance results and analyses to the local OMT in order to sustain the interest and co-operation of the data collectors and data providers


Essential surveillance system for wrds3
Essential surveillance system for WRDs giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

  • National level

  • With representatives from the sectors of health, environment, waterworks and sanitation, and agriculture (including animal husbandry and aquaculture).

  • Tasks

  • Draft the notifications on WRDs and provide information to the public;

  • Map the WRDs on a national scale (possibly using geographic information systems);

  • Identify most critical areas / situations;

  • Assess the burden of WRDs;

  • Transmit the information on WRDs at the international level;

  • Provide training and educational initiatives;

  • Promote specific surveys;

  • Provide feedback on surveillance results and analyses to the regional OMT in order to sustain interest and cooperation;

  • Assess the functionality of the whole surveillance systems;

  • Prepare a report to be sent to the national authorities responsible for management measures; and

  • Coordinate activities in the case of transboundarywaterbodies.


How a wrd surveillance system should work in practice
How a WRD surveillance system should work in practice giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

  • Preparedness

  • First and foremost, the local OMT should be well-prepared to (i) detect water-related outbreaks; and (ii) react adequately if a water-related outbreak occurs.

  • In setting up a surveillance system, it is crucial to take into account the local situation and focus on critical areas / situations


How a wrd surveillance system should work in practice1
How a WRD surveillance system should work in practice giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

  • Response

  • Trigger event: outbreak detection and confirmation

  • Acute reaction: outbreak declaration, quick and preliminary descriptive hazard investigation, initial and immediate control measures

  • Analysis: in-depth analytical hazard investigation, continuous re-evaluation of control measures

  • Normalization: conclusion of outbreak and declaration of normalization

  • End: evaluation, formal report, lessons learned for the future


National examples
National giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.examples

  • The experience of Croatia, Germany, Hungary, Norway and Slovak Republic in the water qualitymonitoring and diseaseoutbreak detection


Policy guidelines1
Policy guidelines giardiasis in Hordaland (Bergen) in 2004 – 2005 where the surveillance system proved to be “late” in detecting outbreaks.

The publication is available at http://www.unece.org/env/documents/2010/wat/MP_WH/wh/ece_mp_wh_2010_L2_E.pdf

22 pages, 2 figures


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