Strengthening PH Surveillance & Control

1. Strengthening PH Surveillance & Control WHO European Region Dr Robert Hartley Stevens WHO Country Office, Turkey

2. InternationalPolicy Context

3. The UN Family Specialised Agencies UNO WHO FAO UNESCO ILO Implementing bodies Self-Governing Agencies • UNICEF • UNDP • UNHCR • Etc. • IMF • WB • WTO • Etc.

4. Health For All Individuals fulfill their health potential Nutrition Education Housing Income Health Services Public Health Secure and Supportive Society

5. The Health For All approach • Improve Health and Reduce Health Inequalities through: • Multi-Sectoral Working • Evidence Based Practice • Partnership and Participation • Health Systems Development

6. The Health Gap in WHO Euro Disability Adjusted Life Years (DALYs) 55y 57y 59y 61y 63y 65y 67y 69y 71y 73y 75y EU 15 before May 2004 EU 10 joining May 2004 Republic of Turkey Commonwealth of Independent States

7. Health versus Wealth Turkey Reported Turkey Actual Deaths / 100,000 live births GDP per cap PPP USD 000s Maternal Mortality Rate versus Gross Domestic Product42 / 52 Euro states, 2002, HFA Database 2005

8. Health Spending as a National Priority Turkey Health Exp as a % of GDP GDP per cap PPP USD 000s Health Expenditure as a % of GDP versus log GDP 42 / 52 Euro states, 2002, HFA Database 2005

9. Health Systems Development • Turkey is spending an above average %GDP on health • But MMR is still average to high because of organisational factors

10. Old Int Health Reg 1969 • Limited scope (Cholera, Yellow fever, Plague) • Only official reports and information considered • Notification by MS only after confirmation • WHO involved only after official notification • Border controls

11. New IHR 2005 • All PH Emergencies of International Concern • Containment in-country • WHO acts on all information sources • Adapted responses according to risks • WHO / ECDC / GOARN support from the start

12. EC CD Legislation • List of 46 diseases brought progressively under surveillance • Contribution to Community networks • Comparable and compatible data • Early warning and response

13. EC CD Legislation LegalFramework ECDC Norms + Systems = NPoA WHO GuidelinesSoPs Performance Audit

14. Technical Issues:Surveillance

15. Public Health Emergency of International Concern (PHEIC) ‘an extraordinary event which constitutes a public health risk to other States through the international spread of disease and potentially require a coordinated international response’ Any two of: • Serious public health impact of the event • Event is unusual or unexpected • Significant risk of international spread • Significant risk of international travel or trade restrictions

16. Examples of PHEICs • Sudden increase in IMD in pilgrims returning from the Haj • Cholera with high risk of international spread • Cases of a novel strain of influenza • Natural disasters with potential impact on other countries • Serious chemical contamination of rivers crossing international boundaries • Serious chemical or radioactive air pollution following an industrial accident

17. CD Surveillance and Control • Event detection, warning and early response • Estimating burden and trend in disease • Changes in severity, clinical picture • Monitoring disease control incl. VPI • Generating research hypotheses

18. Event Detection Action threshold Alert threshold Baseline

19. Signals and Noise Reporting Variation Noise Typo Outbreak Seasonality Year-on-yeartrend

20. Turkey Meningitis • Source: MoH routine notifications 1996 to 2006 • Includes all causes of probable cases of meningitis • 30-fold variation due to reporting bias

21. Turkey Meningitis EU 25 average • Source: MoH routine notifications 1996 to 2006 • Rapid decrease in baseline

22. Turkey Meningitis EU Median 2005 • Source: MoH routine notifications 1996 to 2006 • Reports are 1/5 of EU average, lower than any of EU 25

23. Surveillance System Strengthening

24. Main Achievements to Date • EPIET-like 3 week epidemiology course (30 Fellows) • 4 / 5 x 1-week modules in more specialized public health topics (30 Fellows) • Adult education • Preparatory of study protocols • Data analysis of study results • Health Mapping • 6 / 6 x 2-week ToTs (180 CD Department staff). • 30 / 81 Provinces x 2-day Basic Training (3000 GPs) • Strategic management training to a national planning group (20 core Working Group members) • Laboratory management training • 2-week ToT (40) 3-day (450 microbiologists) • SoPs for PH microbiology • Launching a pilot laboratory sentinel surveillance network

25. IHR: Planning and Management Cycle Assessing risks; prioritising public health threats; assessing existing systems Evaluating outcomes and impact Strategic 5 year plan Monitoring progress Yearly action plans

26. Integrated Surveillance - 1 Vital Registration MoH NRL NRL MoH NRL Nosocomial Infections TB Dispens. Group D PHDs Food and Water Safety Animal Health Primary Health Medical Universities and Sate Hospitals Other systems…?

27. Integrated Surveillance - 2 National Focal Point MoH NRL Reporting Feedback Intermediate level Provincial Health Directorates Primary Health Care and Hospitals

28. CDS&C System Development Model • Evidence Based Policy / • Critical Appraisal of Literature • Operational Research (OR) • Surveillance & Lab Guidelines • Monitoring & Evaluation (M&E) • Management & Organisational Development (M&OD)

29. Next Steps • Building on the broad base of ESCCDS I: • ESCCDS II • Development of National Electronic Surveillance • Bench laboratory training • 20 Cohort II surveillance and control Fellows • National Conference • EC 2008 funding • IHR integrated surveillance strengthening • ? Turkish Field Epidemiology Training Programme

30. Thank you Robert Hartley Stevens Project Manager RST@.euro.who.int