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Building Steps for Canada’s New Integrated Enteric Pathogen Surveillance Program

Building Steps for Canada’s New Integrated Enteric Pathogen Surveillance Program 12th Annual APHEO Conference October 4, 2004 Niagara Falls, Ontario Barbara J. Marshall Public Health Agency of Canada. Building Steps for Canada’s New Integrated Enteric Pathogen Surveillance Program.

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Building Steps for Canada’s New Integrated Enteric Pathogen Surveillance Program

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  1. Building Steps forCanada’s New Integrated Enteric Pathogen Surveillance Program12th Annual APHEO Conference October 4, 2004Niagara Falls, OntarioBarbara J. MarshallPublic Health Agency of Canada

  2. Building Steps forCanada’s New Integrated Enteric Pathogen Surveillance Program The aim of this presentation: To create awareness of the new national integrated pathogen surveillance system to be piloted in Ontario

  3. Enteric Pathogen Transmission Human / Animal / Food/Water Interface

  4. Current Situation of Enteric Disease Surveillance in Canada • Current surveillance systems only report a small fraction of the actual cases of enteric disease (limited to lab confirmed and reported and the most severe) 1 report for every 313 cases(Majowicz, S. et. al.,2004) 2. The etiologic agent remains unknown in a large proportion of the reported cases. (mainly outbreak-related)

  5. Current Situation of Enteric Disease Surveillance in Canada 3. Even if the etiologic agent is found, the source of the contamination remains unknown in a large proportion of the reported cases of enteric disease. 4. There is no link between pathogen exposure levels through food or water and human illness.

  6. Current Situation of Enteric Disease Surveillance in Canada 5. Under-reporting of the sources, etiologic agents and the pathways for transmission of human enteric diseases. 6. Consequently, information for public health, water treatment and delivery, and food safety management of enteric disease pathogens is limited.

  7. The Case for C-EnterNet Human Under-reporting Humans Unknown Microbes Humans Unknown Sources C-EnterNet Minimal Data on Exposure from: Retail Food Water Food/Animal

  8. Current Situation of Enteric Disease Surveillance in CanadaWhat information is needed? • More complete, accurate and comprehensive data about the occurrence of enteric disease in Canada • More comprehensive and timely information on exposure • More valid information about the link between exposure and disease

  9. Enteric Disease Surveillance in Canada Motivation to Change The need for enhanced, active, integrated surveillance of enteric pathogens has been acknowledged both in Canada and abroad. • Auditor General Reports (1999 & 2002) • Naylor Report (2003) • Haines Report (2004) • CIHR Risk Assessment Report (2004) • US Institute of Medicine’s 1992 Report

  10. C-EnterNet is a pilot sentinel surveillance project being developed as the national integrated enteric pathogen surveillance program • It was initiated to address the needs of the Public Health Agency of Canada, Agriculture and Agri-Food Canada and Canadians • C-EnterNet will provide information to integrate and strengthen the science, policy, and health promotion, protection & prevention activities related to food and water safety in Canada

  11. C S C C N P H I Strategic Collaborations with other National Initiatives C-EnterNet iPHIS NSAGI Public Health Units CIOSC NND Community Local Laboratories Physicians PulseNet Canada Reference Laboratories Outbreak Response ASAP NESP Information & isolate flow

  12. C-EnterNet : Objectives • Detect changes in pathogen exposure levels from food, animal and water sources as well as human enteric disease related to changes in policy or practices • Determine proportion of human cases due to water, food, animal contact • Provide information for early warning (pre-exposure) for problems in the agri-food chain 4. Enhancing analysis, interpreation and reporting of laboratory and epidemiological data for the public health and agri-food sectors at all levels

  13. Proposed FrameworkTargeted reservoirs and vehicles of transmission Wildlife Food vegetable production Food animal production Land by contact Water Food in process waterborne person to person foodborne Food Humans Companion animals

  14. Proposed Framework Data collection and integration Food sources: -Retail samples* Water sources: -Source water sampling* - Drinking water samples* -Recreational water sample Animal sources: -On-farm samples* -Slaughter samples* Human sources: -Stool /Laboratory samples * -Hospital data -Drug sales * Enhanced lab testing possible

  15. Food sources Water sources Animal sources Human sources Proposed Framework Challenge 2: Data Integration, Analysis, & Interpretation Information to local, regional, provincial and national level

  16. Proposed Framework for C-EnterNet: Continuous surveillance activities 1 positive reported to province 1.24 positives reported locally Enhanced, systematic epi investigation 1.56 stools positive 14 stools tested 15 submit the stool Enhanced, systematic lab testing Syndromic surveillance 19 have stool requested 73 cases visit physician 313 community cases of gastrointestinal illness Majowicz, S. et. al.,2004 (Submitted)

  17. C-EnterNet Analytical Methodology • Objective 1: • Monitoring of cases and • exposure • - Enhanced monitoring of gastrointestinal diseases in population • - On-going monitoring of enteric pathogen exposure

  18. C-EnterNet Analytical Methodology • Objective 2: Attribution • On-going assessment of attribution of gastrointestinal disease burden from various sources • Methods: • Case-control studies • Outbreak method • Pathogen distribution methods

  19. Attribution: Case-control studies • Compare cases to non cases over a range of possible risk factors • Specific design with controls and data on possible risk factors required • Valuable information • Difficult and costly to implement • Interesting as a research study

  20. Attribution: Outbreak Method • Uses available surveillance data: easy to implement at low cost • Limited to outbreak cases • Limited to pathogens and sources investigated • Problem of representativeness

  21. Attribution: Pathogen Distribution Methods • Assume high pathogen specificity to source • Such specificity can be achieved at various levels: species, types, subtypes (ARA, ribotyping, etc.) • Surveillance can be done at the right level: easy to implement at moderate cost

  22. C-EnterNet Initial Accomplishments to Date Step 1: • Scientific Team • Literature Review • Background Research • Stakeholder Consultations • Advisory Committee • Ideal surveillance system elaborated

  23. Initial Accomplishments • Cost evaluation with three options • Business Case • Business Plan • Ontario Ministry of Health & Long Term Care : Endorse proposal

  24. Next Steps… • Selection of pilot sentinel site* and agreement with all the local stakeholders (*Criteria) • Initiation of surveillance activities • Data analysis • Assessment of pilot • Implementation of national network of local sentinel sites

  25. C-EnterNet’s Network of Sentinel Sites Across Canada C-EnterNet Central Surveillance Activities Continuous _____________ Episodic Sentinel Sites Across Canada Surveillance components: Human Food On-farm Water

  26. Thank-you ! Contact: barbara_marshall@phac-aspc.gc.ca

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