Arden, N

Haaheim, L

Hampson, AW

Hannoun, C

Monto, AS

Nerome, K

Regnery, H

Ruben, FL

Shortridge, KF

Zimmerman, H

The Journal of Infectious Diseases

HKU Scholars Hub

Title Workshop 1: Surveillance issues of pandemic influenzaAuthor(s)Hannoun, C; Arden, N; Haaheim, L; Hampson, AW; Monto, AS;Nerome, K; Regnery, H; Ruben, FL; Shortridge, KF; Zimmerman,HCitationPandemic Influenza: Confronting a Re-emergent Threat,Bethesda, Maryland, 11-13 December 1995. In Journal ofInfectious Diseases, 1997, v. 176 n. Supp 1, p. S73-S75Issued Date 1997URL http://hdl.handle.net/10722/53435Rights Journal of Infectious Diseases. Copyright © University ofChicago Press.S73Workshop 1: Surveillance Issues of Pandemic InfluenzaThe purpose of this workshop was to review the status of regions so that if a pandemic strain arises in these vast areas, itmay be detected. Various models may be adopted for this pur-surveillance activities and to recommend new approaches nec-essary to detect and control pandemics. The specific questions pose; one that has proven successful would be to create ‘‘twin-ning’’ or sister laboratories. The developed country laboratorythat the panel addressed were as follows:• Is the current global surveillance network equipped to rap- would adopt the facility in the less-developed country and provideadvice for and assistance in improving capabilities. These effortsidly detect a new pandemic strain of influenza, to monitor theimpact as the virus spreads, and to disseminate surveillance are not without costs in time, travel, and equipment.The World Health Organization (WHO), through its collabo-information in a timely manner?• How can surveillance data be used to control a pandemic? rating centers in London, Atlanta, and now Melbourne, hastaken the lead in working with a network of national labora-• What are the ways by which increased research efforts canimprove virologic and disease surveillance? tories. Alan Hampson described the history of WHO and thedevelopment of the concept of the networks of National Influ-The panel agreed that adequate surveillance is critical forthe prompt detection of influenza variants, including strains of enza Centres. However, at present, only 60 countries havenational centers, and these function at various levels of activity.pandemic potential. Both the detection of the viruses and thediseases they cause are components of this effort, which, by While surveillance activity has increased in some countries, inparticular China, it is important to realize that similar condi-its very nature, must be international in scope. Surveillancequestions were examined formally by the group, which in- tions for transmission exist in many areas of South and South-east Asia and that it is impossible to obtain either specimenscluded participants from France, Norway, Australia, Japan,Hong Kong, and the United States. or data from these areas.Another issue that needs to be considered in improving thecollection of potential pandemic viruses is the substrate to beCurrent Global Surveillance Networksused. If eggs are not available, is there a cell line that can beused? Also, is that cell line going to be acceptable if the virusClaude Hannoun, chair of the session, reported on two issues:the methods used over many years in France and now in other isolate turns out to be one that should be a candidate for thenew vaccine and there is insufficient time available to isolatecountries in Western Europe for surveillance and the absenceof laboratories in certain parts of the world. In Europe, a system another representative virus in a suitable substrate? These is-sues need to be considered as laboratories with capabilities toof sentinel physicians collects samples for virus isolation frompractices covering large geographic areas. Specimens are trans- collect and process specimens and to identify and characterizenew isolates are recruited.ported to central laboratories, and recovery of viruses has beengood. As a result, it has been possible to recognize quickly the China remains a focus both in terms of dense population,which in the past had little sampling of influenza viruses, andoccurrence of influenza outbreaks and to let physicians and thepublic know about the timing and virus strains involved in the the well-known likelihood that new pandemic strains arise fromthis region. Helen Regnery reviewed the existing virologic sur-outbreaks. Studies are underway, sponsored by the EuropeanScientific Working Group on Influenza, to better define the veillance program in China, which has been organized andsupported by the WHO collaborating center at the Centers forimpact of influenza in the European region. Hanspeter Zimmer-man reported on the Swiss system of sentinel physician surveil- Disease Control and Prevention (CDC) in Atlanta since 1989.Currently, eight surveillance sites have been established in dif-lance, which was developed so that attack rates could be gener-ated for various regions of the country. ferent geographic locations. Each site collects specimens frompersons with acute respiratory disease and performs the initialOther parts of the world are less well covered by laboratories,and in some extensive regions, especially in Africa, laboratories isolation. After isolation, influenza viruses are transported tothe Institute of Virology in Beijing, where samples are lyophi-with the capability of identifying viruses simply do not exist.Contacts have been made to help develop laboratories in these lized and forwarded to the CDC for further characterization.Information provided with submitted specimens includes col-lection date, the patient’s age and geographic location, and theextent of influenza activity in the area at the time of specimenChair: Claude Hannoun; rapporteur: Nancy H. Arden; participants: Lars collection.Haaheim, Alan W. Hampson, Arnold S. Monto, Kuniaki Nerome, HelenRegnery, Frederick L. Ruben, Kennedy F. Shortridge, and Hanspeter Zimmer-man.Held at: Pandemic Influenza: Confronting a Re-emergent Threat, Bethesda,Use of Surveillance Data to Control PandemicsMaryland, 11–13 December 1995.The Journal of Infectious Diseases 1997;176(Suppl 1):S73–5 Other studies sponsored by various agencies have examinedq 1997 by The University of Chicago. All rights reserved.0022–1899/97/76S1–0016$02.00 the occurrence of influenza viruses in domestic and other ani-/ 9d2e$$au13 06-30-97 17:21:17 jinfa UC: J InfectS74 Workshop 1 JID 1997;176 (Suppl 1)mals in contact with human populations, particularly pigs and Surveillance has been accomplished using different methodsin areas of the industrialized world. Lars Haaheim reported onducks. Kennedy F. Shortridge, of the University of Hong Kong,systematically reviewed the status of theory and fact sur- studies in Bergen, Norway, in which serologic methods wereused before and after outbreaks of infection over a period of tworounding the observation that influenza pandemics originate inChina. This observation is based on the theory that pandemic decades. The purpose was an attempt to predict susceptibility tonew strains and then to evaluate the impact of those strains oninfluenza strains may arise through genetic reassortment whenhuman and avian influenza type A strains infect a common the population. The method has been valuable for the latteroutcome but not for the former. That limitation should be kepthost. Because the domestic pig is susceptible to infection withboth human and avian strains, it is a likely host for such an in mind when planning surveillance activities.Nancy Arden and Arnold Monto discussed surveillance activi-event. Living conditions in South China, with animals andhumans in close association, facilitate this possibility. With ties in the United States. That surveillance has been based onvirologic data from specimens received from health departmentsthis background, it is important to design an ‘‘early-warningsystem’’ for the emergence of a novel virus, involving surveil- and clinical and research laboratories, morbidity data from senti-nel practice sites, outbreak reports from schools and nursinglance of animals as the likely source of pandemic virus andsurveillance of human populations as recipients. homes, and mortality data characterized by pneumonia- and in-fluenza-related deaths. It was emphasized that efforts are neededDr. Shortridge reviewed the rationale for these recommendedsurveillance programs. Poultry, especially ducks, do not experi- to enhance systematic surveillance of influenza-related morbidityin terms of attack rates in defined population groups, clinicalence illness with infection but are documented to have anabundance of viruses of diverse hemagglutinin subtypes. Espe- characteristics of the illnesses, and frequency of complications,including outpatient visits and hospitalization. One mechanismcially in view of the large numbers of poultry (7000 millionin 1993), a general surveillance program would not be likely for achieving this goal would be to take advantage of informationcollected by managed care organizations, which could also pro-to result in development of any useful information about trans-mittal of viruses to human populations. Data suggest that the vide the opportunity for regular follow-up data. Collection ofpneumonia- and influenza-related mortality data from death cer-presence of avian influenza viruses in pigs in southern China,while well-documented, is uncommon. The large size of the tificates has proven to be a satisfactory mechanism for studyinginfluenza. Recent studies suggest that a greater effort should bepig population, like that of poultry, presents a significant diffi-culty in any attempt to identify a prepandemic strain. An excep- made to examine total respiratory and ‘‘all cause’’ mortality aswell. In addition, a more systematic approach should be devel-tion would be special studies of selected farming communities.In contrast, outbreaks of equine influenza occurring in China oped to assess the impact of changes in the distribution and usesof vaccines and antivirals. Antivirals play a special role in controlshould be monitored. In this way, existing anecdotal informa-tion from Mongolia on transmission of influenza from horses of pandemics; however, more information is needed on the effec-tiveness of and adverse reactions caused by antivirals and onto nomadic children could be confirmed or refuted.the occurrence of resistant strains.Charles Hoke discussed the role of the US military in influ-enza surveillance. The Air Force participates in global influenzaEfforts to Improve Virologic and Disease Surveillancesurveillance by enlisting US and overseas bases that routinelycollect and test throat-swab specimens from active-duty person-As a result of these observations, Dr. Shortridge recom-mended concentration of efforts in China on human surveil- nel and their dependents with acute respiratory illnesses; othermilitary bases submit specimens when they detect an increaselance, with creation of an international pandemic influenza taskforce to be sited in China but administered though the WHO. in respiratory illness. This system can augment the WHO inter-national virologic surveillance by providing additional sites,For this effort to have full Chinese participation, a change inthe way influenza is viewed in China will be required. Influenza especially in geographic areas where there is no WHO labora-tory. Because a large proportion of military personnel receiveis generally considered a relatively low priority cause of diseasein humans. Until this changes, especially in the North, where influenza vaccine every year, rates of influenza infection arelow when there is a good antigenic match between the vaccineseasonal influenza outbreaks are recognized, it will be difficultto mount the targeted surveillance of human infections neces- and circulating strains. This provides an opportunity to quicklyrecognize antigenic changes in circulating strains, since out-sary for early detection of potential pandemic viruses. It shouldalso be remembered that China has changed enormously since breaks of influenza can be detected and investigated quickly.Several participants talked about the need for better commu-the last pandemic, and any new pandemic virus will certainlymove differently and probably more rapidly than in the past. nications, and this area was summarized by Fred Ruben. Thekey here is a quick turn-around and the ability to inform andIn terms of the situation in Asia, Kuniaki Nerome describedJapanese surveillance activities and proposed the development to reassure the public that appropriate measures are being taken.In addition, in the interpandemic period, it is vital to educateof special kits that include avian hemagglutinin reagents foridentification of new pandemic strains. the public as to the importance of the threat of influenza so/ 9d2e$$au13 06-30-97 17:21:17 jinfa UC: J InfectS75JID 1997;176 (Suppl 1) Surveillance Issues of Pandemic Influenzathat all education does not have to be undertaken when the • Since large gaps in global surveillance of influenza exist,efforts should be made to strengthen both virologic and dis-pandemic is imminent.ease surveillance, possibly through the development of ‘‘sis-ter’’ laboratories. This would include a more detailed systemreporting such items as attack rates, clinical characteristicsRecommendationsof illness, nature and severity of complications, and hospital-On the basis of this discussion, the panel made the following izations.recommendations for consideration by the National Institute of • The system of coordination with the US military surveillanceAllergy and Infectious Diseases, National Institutes of Health: system should be improved.• The number of sites conducting human surveillance should • Existing collaborations among agencies and internationalbe increased, and the capacity of current sites conducting organizations, as well as local and country resources, needanimal and human surveillance in East Asia, particularly in to be strengthened, especially to prepare for epidemiologicinvestigations of influenza outbreaks.China and possibly in Russia, should be improved./ 9d2e$$au13 06-30-97 17:21:17 jinfa UC: J Infect

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