Présentation de Nissaf Ben Alaya Bouafif, directrice générale de l'observatoire national des maladies nouvelles et émergentes, durant le symposium organisé conjointement entre le Robert Koch Institute et l'Institut Pasteur de Tunis "Current challenges of Biological Risks and Heealth Security" (22-23 septembre 2016)

1. Pr ofessor Nissaf Bouafif ép Ben Alaya
General Director Observatory of New and Emerging Diseases
Early Warning System in Tunisia:
Evolution, Challenges and place of Environment and
Modeling

2. Timeline
1
• Presentation of Tunisian national surveillance system
2
• Examples of emerging diseases surveillance system implemented in Tunisia
3
• Challenges to improve Health surveillance in Tunisia
4
• Implementation of IHR capacities and health hazards in Tunisia
5
• Evaluation of Tunisian surveillance system 2013-2014 and priorities
6
• German partnership program in Tunisia
7
• Perspectives

3. Timeline
1
• Presentation of Tunisian national surveillance system
2
• Examples of emerging diseases surveillance system implemented in Tunisia
3
• Challenges to improve Health surveillance in Tunisia
4
• Implementation of IHR capacities and health hazards in Tunisia
5
• Evaluation of Tunisian surveillance system 2013-2014 and priorities
6
• German partnership program in Tunisia
7
• Perspectives

4. Local
level
Organization of national surveillance system of
Infectious Diseases in Tunisia
National
Level
Moh
DMSU DHMPE
Regional
level
Departement of
preventive medecine
Early Warning Unit
Rapid Response
Team
CSB ER Laboratories GP Hospitals Others
ShocRoom

5. National Public Health Surveillance System for Infectious
Diseases (IDs)
 Disease monitoring
 To guide intervention and control programs
 To give evidence for policy making
 To allow Appropriate allocation of resources
 Structured data
 Routinely produced
 Passively collected
 With established case definitions
 Sources of data
 Health-care facilities
 Laboratories
 Death registers
IBS: Indicator-based surveillance
DSSB

6. Objectives of National Public Health Surveillance
System for Infectious Diseases (IDs)
 Disease monitoring
 To guide intervention
and control programs
 To give evidence for
policy making
 To allow Appropriate
allocation of
resources
 Early detection of
acute public health
events
 To ensure rapid
detection and
investigation
 To implement
appropriate response
and control of events
DSSB ONMNE

7. Timeline
1
• Presentation of Tunisian national surveillance system
2
• Examples of emerging diseases surveillance system implemented in Tunisia
3
• Challenges to improve Health surveillance in Tunisia
4
• Implementation of IHR capacities and health hazards in Tunisia
5
• Evaluation of Tunisian surveillance system 2013-2014 and priorities
6
• German partnership program in Tunisia
7
• Perspectives

8. Human Geographic distribution
of 2012 outbreak
Predicted distribution according to
animal surveillance
West Nile surveillance
Multidisciplinary approach

9.  Risk assessment and
appropriate
management
 Prepare documents
 Preparation of the
national response to a
possible outbreak of
human infection with
the MERS-Cov
 Information for
travelers
 Technical data sheet
Prepardness plan for MERS-CoV
in Tunisia

10. Period of exposure of
the index case
Period of
exposure of
contacts
Confirmation of
MERS-Cov index cas
Investigation of the MERS- CoV cluster in Tunisia

11. Timeline
1
• Presentation of Tunisian national surveillance system
2
• Examples of emerging diseases surveillance system implemented in Tunisia
3
• Challenges to improve Health surveillance in Tunisia
4
• Implementation of IHR capacities and health hazards in Tunisia
5
• Evaluation of Tunisian surveillance system 2013-2014 and priorities
6
• German partnership program in Tunisia
7
• Perspectives

12. Advantages
 Highly valuable for
 Known diseases,
 Stable context
 Good access to
healthcare / laboratory
facilities
 Specificity
Disadvantages
 Scope
 Often communicable diseases
 Fixed list of diseases & syndromes
 Timeliness
 Delays for Reporting procedure /data
analysis & biological confirmation
 Reactivity
 Fixed case definitions, procedures….
 Emergency situation
 Coverage
 Uneven accessibility to healthcare
 Hard to reach areas &population

13. Timeline
1
• Presentation of Tunisian national surveillance system
2
• Examples of emerging diseases surveillance system implemented in Tunisia
3
• Challenges to improve Health surveillance in Tunisia
4
• Implementation of IHR capacities and health hazards in Tunisia
5
• Evaluation of Tunisian surveillance system 2013-2014 and priorities
6
• German partnership program in Tunisia
7
• Perspectives

14. ● Paradigm shift
 Disease-based surveillance  All hazards
 All sources of information
● Core surveillance capacities :
 Detection
 Assessment
 Notification/reporting
 Response
● IHR requirements
 Early detection based on health reporting is not enough
 Needs to develop access to other sources of information
International Context : IHR

15. WHO evaluation of IHR capacities and health hazards Implementation
Global Level - 2013
70
73
80 79
63
72
60
76
54
81
71
52 51
0
10
20
30
40
50
60
70
80
90
100
 EWAR and EBS are not well defined and
implemented
 Not all events (not only communicable diseases)
are detected timely and comprehensively
 Preparedness plan are limited to some diseases
 Laboratories capacities are to improve
 Risk Communication strategy is not available

16. Timeline
1
• Presentation of Tunisian national surveillance system
2
• Examples of emerging diseases surveillance system implemented in Tunisia
3
• Challenges to improve Health surveillance in Tunisia
4
• Implementation of IHR capacities and health hazards in Tunisia
5
• Evaluation of Tunisian surveillance system 2013-2014 and priorities
6
• German partnership program in Tunisia
7
• Perspectives

17.  IBS is implemented but is not
optimal because of
 lack of resources, Trained staff
and turn over
 Operating budget:
implementation and supervision
of activities
 Tools and equipment
 Electronic transmission of data
 EBS is not well defined
 Access to other sources of
information, multisectoral
collaboration and processes are
not systematized/formalized
National Evaluation of Tunisian surveillance system, 2013-2014
Priorities
 To improve surveillance with the
establishment of Epidemic
intelligence
 Integration of EBS and IBS
 Rapid reporting of events using
regular epidemiological conference
« EpiTec » tool
 To improve crisis communication
 To improve preparednessDelays in detection, reporting,
analysis, and response
Priorities

18. Epidemic intelligence
 Systematic collection, analysis, and
communication of information to:
 Detect
 Verify
 Assess
 Investigate
 Integrates IBS and EBS
Events and
health risks
with an EWAR
objective

19. • Outbreak
Investigation
• Field Research
• Support through
Communicating results of
Assessments
• Targeted
recommendations
• Surveillance
• EBS
• GP Networking
• ER Networking
• Diseases Specific
surveillance
• Field Research
• Program Evaluation
Evaluation
&
Monitoring
Event
Detection
Risk
Assessment
Prevention
& Control
Measures
Epidemic Intelligence for Risk Management Cycle
EpidemicIntelligence

20. Risk management cycle
Event Detection
risk assessment (formal
and rapid)
Control measures and
prevention
Monitoring and
evaluation
Communication
des risques Epidemiological
intelligence

21. Prevention Preparedness Response Resilience
Early Warning System

22. Assessment and management of
public health threats
Institutes and Public Health
Departments
other Partners
national experts
Ministry of Health
Other parteners
Assessment
Management

23. Timeline
1
• Presentation of Tunisian national surveillance system
2
• Examples of emerging diseases surveillance system implemented in Tunisia
3
• Challenges to improve Health surveillance in Tunisia
4
• Implementation of IHR capacities and health hazards in Tunisia
5
• Evaluation of Tunisian surveillance system 2013-2014 and priorities
6
• German partnership program in Tunisia
7
• Perspectives

24. 24
Goals of the project
19.10.2016
 Reduce biological security risks
 Enhance Tunisian health capacities
 Foster international scientific exchange and qualify scientific
personnel
 Contribute to the fight against dangerous diseases
 Support the safe and secure conduct with dangerous
pathogens and toxins

25. Crisis communication Strategy
development and media training
Joint training for epidemiologists and
laboratory EpiLab
Support the establishment of an
“Epidemic Intelligence Committee”
•EBS implementation
•EpiTec implementation
Support of the development
of a Tunisian epidemic
preparedness plan

26. Improvement of P3 capacities
Improvement of biosafety &
diagnostics of highly pathogenic
viruses
Training Biosafety and Biosecurity &
Biorisk Management

27. • EpiTec
• Networking
Tools
• IBS
• EBS
EWRS
• Procedures, SOPs
• Risk communication
strategy and media training
• Prepardness plan 2P2R
Preparedness and
response plan
Activities implemented by the project
Tab
simulation
exercice
Field Simulation
exercice

28. Activities implemented by the project

29. Timeline
1
• Presentation of Tunisian national surveillance system
2
• Examples of emerging diseases surveillance system implemented in Tunisia
3
• Challenges to improve Health surveillance in Tunisia
4
• Implementation of IHR capacities and health hazards in Tunisia
5
• Evaluation of Tunisian surveillance system 2013-2014 and priorities
6
• German partnership program in Tunisia
7
• Perspectives

30.  Elaboration of action plan
(national and regional)
 Development of
standardized protocols,
SOPs & guides
 Preparation of records of
data collection
 Computerized monitoring
system and electronic
transmission of
information
 Conduct more simulation
exercises
Next steps for strengthening of EWAR
 Establishment of an
environmental warning
system
 Climate warning system
 Animal and entomological
system
 Connection to other partners
(other administrative
database)
 Human resources capacity
development and training

31. Data collectionGeo-referencing Data entry
Common database for the EWRS

32. What are the challenges for the development
of health Surveillance EWRS
 Political vision for the organization of health systems in the
coming decades
 The legal framework and review of the different institutions
Missions
 Strengthening public health institutions
 Convergence of different epidemiological surveillance networks in
Tunisia
 The governance of epidemic warning tools
 Organization of health surveillance
 Operating the health alert system
 The development of health warning tools
 The strengthening of health surveillance systems
 Human resources
 Logistic
 Funding
 The development of international cooperation and networks (InVs,
ECDC, RKI,GIZ, ACDC, CDC)