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The Canadian Pandemic Influenza Plan for the Health Sector

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Annex N Pandemic Influenza Surveillance Guidelines (PDF document - 625 KB - 70 pages)

Annex N
Pandemic Influenza Surveillance Guidelines

Date of Latest Version: October 2006, updated February 2010

Note: This is a new annex being released with the 2006 version of the Canadian Pandemic Influenza Plan.

Summary of Significant Changes:

  • Updated to include recommendations for the production of operational-level surveillance guidance in every pandemic situation
  • Updated to include an example of an operational surveillance guidance document

Table of Contents


1. Preamble

Since 2004, Canadian public health surveillance stakeholders, through national working groups, have been defining the roles and responsibilities as well as the minimum standards associated with the collection of national surveillance data during interpandemic and pandemic periods.

The ability to adapt to rapidly evolving situations must be emphasized in all surveillance guidelines. It follows that this annex is part of an ongoing and evolving preparedness plan. It is recognized that while the current published version outlines high-level surveillance guidelines, further detail is required in order to provide comprehensive national guidelines, in particular, a more detailed description of streamlined surveillance activities for phase 6. Therefore, the annex should be considered with the following list of next steps:

  • Review the sustainability of routine surveillance activities and consider options for streamlined surveillance, which may include either greater focus on more reliable indicators or modification/simplification of routine activities during a pandemic.
  • Prioritize surveillance activities by phase.
  • Explore the options for and feasibility of developing new surveillance activities as part of preparedness, e.g. timely mortality surveillance.
  • Produce detailed guidance for surveillance that will operationalize the general surveillance framework outlined in this document. Specific surveillance guidance will vary in each pandemic. It is therefore recommended that a surveillance guidance document be produced in each pandemic, in partnership with the provinces and territories, that will build on and operationalize the recommendations outlined in this document. An example of an operationalized guidance document is provided in Appendix II.

2. Introduction

The overall goals of influenza pandemic preparedness and response are First, to minimize serious illness and overall deaths, and second to minimize societal disruption among Canadians as a result of an influenza pandemic.

The strategies used to achieve these goals will depend on a number of factors, including the epidemiology of the pandemic. Determination of epidemiologic parameters and indicators is critical for informing the public health response and policy decisions, defining research priorities and meeting international reporting obligations. As the pandemic progresses through each phase, the surveillance activities needed to guide public health actions will change from enhanced activities in the pandemic alert phases to streamlined activities at the height of the pandemic.

In this document, influenza surveillance guidelines, including data collection, collation, analysis and dissemination/communication issues for both disease and virologic surveillance, are outlined for each phase of the pandemic. In addition, detailed protocols for virologic surveillance and other laboratory procedures can be found in the laboratory annex of the Canadian Pandemic Influenza Plan (Annex C).

This document has been prepared for pandemic planning purposes as well as to facilitate a standardized approach to national influenza surveillance during the interpandemic period. Although the characteristics of a novel influenza virus are not known, the experiences learned from SARS (severe acute respiratory syndrome), outbreaks of human infection with influenza A (H5N1) and pandemic H1N1 2009 have underscored the importance of planning and establishing a surveillance infrastructure capacity for the detection and monitoring of emerging respiratory infections. The following framework addresses planning for surveillance in general terms; however, it should be understood that while some of the recommended actions can be prepared for in advance, other situation-specific recommendations and alerts will need to be developed on the basis of information that will only be available as the pandemic evolves. It should also be noted that specific surveillance strategies may be required for remote and isolated communities, including many First Nations and Inuit communities, to appropriately describe an outbreak in these regions.

Guidelines are necessary to ensure that data are collected in a standardized manner across jurisdictions in order to enable national level analysis and cross-jurisdictional comparison. The guidelines represent the minimum recommended activities required for national monitoring of the evolving pandemic. Provincial and territorial jurisdictions may choose, on the basis of their on own risk assessment and experience, to increase the sensitivity of surveillance activities (e.g. increased timeliness of data collection and reporting or use of more sensitive case definitions for monitoring) while respecting national health reporting standards. Further, as additional information becomes available during the course of the pandemic, monitoring and reporting activities may be refined as necessary. It is recognized that specific data needs, desired reporting frequency and availability of data may differ across pandemic influenza situations. It is also recognized that as a given pandemic evolves, the capacity to collect and report data may change. It is therefore recommended that a surveillance guidance document be produced in each pandemic situation that will build on and operationalize the recommendations given in this annex. Such a document will outline the data to be collected and reported under various levels of capacity (for example, shifts in capacity that may lead to a change from case-based, to line-listed, to aggregate data reporting), including a description of the minimum surveillance activities required to continue national monitoring of the pandemic. An example of an operationalized surveillance guidance document is provided in Appendix II.

The objectives of these guidelines are to assist federal, provincial and territorial (F/P/T) partners in the development or enhancement of surveillance activities; they are intended to facilitate the following:

  • ongoing risk assessment for pandemic influenza based on national and international sources
  • rapid detection and monitoring of the arrival of a novel/pandemic influenza virus anywhere in Canada
  • timely description of the epidemiologic and virologic characteristics of the pandemic
  • detection and characterization of unusual/unexpected disease patterns or manifestations
  • timely monitoring of disease severity indicators, i.e. through surveillance of hospitalizations or deaths
  • implementation and discontinuation of public health measuresFootnote 1
  • ongoing evaluation of disease and virologic surveillance activities for each pandemic phase (e.g. timeliness, appropriate sensitivity and specificity, effectiveness in guiding public health measures)
  • comparison of novel influenza strains to match pandemic vaccine composition
  • identification of areas of need for special studies and further research.

2.1 Assumptions

  • The Respiratory Illness Outbreak Response Protocol (RIORP)Footnote 2 will be approved and implemented in order to facilitate data sharing and communication in Canada during the pandemic. This document outlines local and F/P/T reporting processes.
  • Information on the current risk assessment and epidemiologic, virologic and clinical descriptions (based on the global situation) will be available and shared in a timely manner through our international partners (e.g. World Health Organization).
  • The majority of, if not the entire, population will be susceptible to the pandemic strain.
  • During the pandemic alert period (the early phases of the arrival of a novel virus with pandemic potential in Canada) detailed reporting of epidemiologic data and contact tracing for initial cases by public health will be possible.
  • As the efficiency of human-to-human transmission increases, resulting in widespread activity of the novel virus in Canada, surveillance resources are expected to be strained. This may affect participation and reporting rates for routine surveillance activities such as sentinel influenza-like illness (ILI) reporting. While in some areas participation may be maintained at sufficient levels for accurate monitoring of population-based trends on a local or even P/T level, participation rates may fall off elsewhere, thus limiting the representativeness of the data in certain areas or nationally. At the height of the pandemic, if population-based ILI rates become unreliable for monitoring disease spread or population impact, particularly at the regional or national level, surveillance may be limited to tallying outbreaks in residential institutions and/or assessment of regional influenza activity levels (i.e. streamlined surveillance). Furthermore, if capacity to collect and report surveillance data declines as the pandemic progresses, there may be a need to switch from detailed to aggregate reporting. The operationalized surveillance guidance document should outline the data reporting recommended in each of these situations.
  • The novel virus strain (pandemic strain) will eventually supplant other circulating influenza strains.
  • The pandemic will last 12 to 18 months; more than one wave may occur within a 12 month period and could have a similar or more severe impact than the initial wave.
  • The Public Health Agency of Canada (PHAC) will follow guidelines as per the international health regulations.

2.2 Special Studies

Protocols for special studies that may be conducted during the pandemic should be developed and pre-tested in the interpandemic/pandemic alert periods, recognizing that refinements may be necessary at the time of a pandemic. It is recognized that these studies will most likely be conducted in parallel with other surveillance activities.

Special studies may include, but are not limited to, serological surveys of early cases/clusters of human infection with a novel influenza virus, the role of bacterial pathogens in the development of secondary complications and serious outcomes, and modes of transmission studies (e.g. in community or hospital-based settings).

In addition, targeted studies may be useful in supplementing routine surveillance data to assess the impact of the pandemic on the health care system as well as the social and economic impact. Even if conducted at the end of the pandemic wave, special studies may serve as a means of evaluating and refining various attempted interventions to lessen the impact of successive waves of the pandemic. Efforts should be made to ensure that special studies are planned and implemented in such a way as to complement and supplement existing surveillance data. Conducting a gap analysis of surveillance activities to determine the key questions that can and cannot be answered through established or planned surveillance activities can help to identify the areas of inquiry that may benefit from targeted study. Where possible, data should be collected through surveillance and research activities that will allow for analysis by social determinants, including sex, disability, income or other measure of socio-economic status, age and race/ethnicity.

2.3 Surveillance Activities by Canadian Pandemic Phases

Surveillance for pandemic influenza is expected to be founded on timely, representative and comprehensive surveillance activities that are the cornerstones of ongoing routine annual influenza surveillance:

  • disease/epidemiologic surveillance
  • laboratory/virologic surveillance, including antiviral resistance monitoring
  • ongoing information sharing through established communication networks (e.g. CIOSC [Canadian Integrated Outbreak Surveillance Centre], FluWatch, provincial and territorial networks).

Several additional activities are recommended for pandemic influenza surveillance, for both enhanced detection of early warning signals and monitoring during a pandemic:

  • build on existing enhanced surveillance systems to collect supplementary surveillance data and/or to ensure that there is timely analysis of variables important in understanding the pandemic;
  • conduct animal health surveillance (early detection of animal outbreaks and/or animal-to-human transmission in interpandemic and pandemic alert periods).

The following tables describe the surveillance objectives, roles and responsibilities for public health stakeholders at each level of government (F/P/T and local). The tables are organized by successive phases of a pandemic according to the Canadian pandemic phases, reflecting both the global situation (phases 1.0, 2.0, 3.0, etc.) and the highest level of novel virus activity in Canada (sub-phases 3.1, 4.1, 5.1, etc.). See the Background Section of the Canadian Pandemic Influenza Plan for more details.

Note: In the description of the phases the term "animal" is used to cover both avian and mammalian species.

3. Interpandemic Period

Table 1 Interpandemic period

Canadian Pandemic Phase

1.0 No new virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals located outside Canada. If the virus is present in animals, the risk of human infection/disease is considered to be low.

1.1 No new virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection is present in animals in Canada, but the risk of human infection/disease is considered to be low.

2.0 No new virus subtypes have been detected in humans. However, an animal influenza virus subtype that poses substantial risk to humans is circulating in animals located outside Canada.

2.1 No new virus subtypes have been detected in humans. However, an animal influenza virus subtype that poses substantial risk to humans is circulating in animals in Canada.

Surveillance Objectives/Roles and Responsibilities

Objectives

  • to assess the seasonal burden of influenza and to detect and describe unusual events, including emergence of new strains and unexpected outcomes, such as changes in distribution or increases in severity
  • to establish baseline influenza activity levels

Federal

  • Provide ongoing leadership through organization of teleconferences/meetings, providing guidance and surveillance recommendations as needed
  • Align national pandemic surveillance plans with WHO global pandemic influenza surveillance plans
  • Participate in the WHO Global Influenza Surveillance Network
  • Conduct regular information scanning and seek verification of international disease activity of potential public health significance, e.g. from international ministries of health and/or other international surveillance networks
  • Coordinate national level routine annual influenza surveillance activities through FluWatch, including hosting national influenza surveillance meetings and leading the development of recommendations for ongoing improvements of the FluWatch system
  • Develop national recommendations/surveillance protocols for enhanced surveillance of severe emerging respiratory infections (SRI) for early detection and response
  • Provide regular dissemination and knowledge transfer of surveillance information and analysis (for example, weekly Fluwatch, annual influenza reports)
  • Provide information, risk assessment and surveillance recommendations on an as-needed basis in relation to identified events with pandemic potential (e.g. avian influenza) and specific alerts/signals to F/P/T public health surveillance stakeholdersFootnote 3
  • Lead the development of national standards for case definitions, minimum datasets and mechanisms for data collection and reporting during the pandemic phases
  • Enhance linkages among federal departments, including linkages among human and animal health surveillance partners (e.g. Canadian Food Inspection Agency, National Centre for Foreign Animal Diseases, Canadian Cooperative Wildlife Health Centre)
  • Develop business continuity plans, and increase capacity and training and/or set priorities to meet surveillance requirements during each phase of a pandemic. This includes identifying which routine activities can be suspended or reduced during a pandemic
  • Develop a human resources plan to ensure that surveillance activities are sustainable during a pandemic
  • Work with F/P/T and local partners to agree on phase-specific minimum surveillance activities for monitoring at each phase of the pandemic. In particular, work to establish priorities for critical common surveillance activities that can be maintained as streamlined surveillance during the height of a pandemic when resources are strained
  • Coordinate the establishment of surveillance systems and/or special studies to estimate severity

P/T/local

  • Determine key surveillance stakeholders within P/T jurisdiction
  • Ensure P/T pandemic plan is in place and align P/T/local surveillance plans with national surveillance plans
  • Participate in routine annual influenza surveillance activities (e.g. FluWatch)
  • Participate in national influenza surveillance meetings
  • Maintain intra-P/T surveillance networks to enable early detection of influenza activity
  • Ensure that there is sufficient capacity (surveillance infrastructure, technical/human resources) to meet national minimum standards for case detection, minimum datasets and mechanisms for data collection and reporting during the pandemic period
  • Establish and maintain mechanisms for the timely sharing of surveillance data from the local to the P/T and on to the federal jurisdictions
  • Provide regular dissemination and knowledge transfer of surveillance information and specific alerts/recommendations to national and jurisdictional stakeholders
  • Develop business continuity plans, and increase capacity and training and/or set priorities to meet surveillance requirements during each phase of a pandemic. This includes identifying which routine activities can be suspended or reduced during a pandemic
  • Develop a human resources plan to ensure that surveillance activities are sustainable during a pandemic
  • Identify potential sentinel surveillance sites (regions, settings) that may be used to assist in focusing limited resources or answer specific questions (i.e. special studies) during a pandemic
  • Work with F/P/T and local partners to agree on phase-specific minimum surveillance activities for monitoring at each phase of the pandemic. In particular, work to establish priorities for critical common surveillance activities that can be maintained as streamlined surveillance during the height of a pandemic when resources are stretched
  • Confirm that public health laboratories within the province/territory have the capacity and materials needed to isolate and subtype influenza viruses. If they do not, linkages to laboratories having this capacity should be established and coordination agreements put in place

Table 1.1 National surveillance data during the interpandemic periodFootnote 4

Canadian Pandemic Phase

1.0 No new virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection may be present in animals located outside Canada. If the virus is present in animals, the risk of human infection/disease is considered to be low.

1.1 No new virus subtypes have been detected in humans. An influenza virus subtype that has caused human infection is present in animals in Canada, but the risk of human infection/disease is considered to be low.

2.0 No new virus subtypes have been detected in humans. However, an animal influenza virus subtype that poses substantial risk to humans is circulating in animals located outside Canada.

2.1 No new virus subtypes have been detected in humans. However, an animal influenza virus subtype that poses substantial risk to humans is circulating in animals in Canada.

National Surveillance Data

Disease surveillance

  • (a) influenza activity level by P/T region (based on FluWatch definitions)
  • (b) influenza-like illness (ILI) consultation rate (number of ILI sentinel physician visits/1000 consults)
  • (c) number of laboratory-confirmed outbreaks in long-term care facilities
  • (d) number of influenza-associated hospitalizations and influenza-associated deaths in children 0-18 years through sentinel paediatric hospitals (IMPACTFootnote 5)

Laboratory surveillance

  • (e) percent positive influenza tests (total number of laboratory tests for influenza and number of positive results, by virus type, A or B)
  • (f) strain characterization, number identified for each strain and subtype, and percentage of total for approximately 10% of isolates from the Sentinel Laboratory Respiratory Virus Detection System
  • (g) increased targeted strain characterization based on risk assessment in areas where animal strains are circulating
  • (h) antiviral resistance testing for influenza isolates

Risk assessment

  • (i) summary of national/international areas where animal virus activity has been confirmed

Appendix II provides a pictorial representation of the national FluWatch influenza surveillance system.

4. Pandemic Alert Period

Table 2 describes the surveillance objectives for the pandemic alert period. The objectives are general, given the unknown epidemiology of a novel influenza virus infection and uncertainties as to how the virus might behave in terms of efficiency of human-to-human transmission, impact on the population/population sub-groups and capacity to spread rapidly. Recommended surveillance tools and protocols, including surveillance case definitions, will need to be developed and revised according to information received as the situation evolves. The triggers that will signal the move to a new phase are generally based on relative ability to infect humans and spread efficiently among humans, as determined by observed activity and a comprehensive risk assessment. This risk assessment will include analyzing the interplay of these and other factors (e.g. infectiousness, rate of transmission, incubation period and period of communicability, severity of illness, impact of initial control measures). These factors should be viewed as general parameters that are useful for describing the critical points in the evolution and escalation of a pandemic and can only be assumed prior to strain identification and circulation of the novel virus. Furthermore, initial predictions are subject to change as the novel virus becomes adapted to human populations, and flexibility will be important to respond with rapid adjustment of surveillance and related activities.

The following tables provide a basic framework for establishing and maintaining the recommended surveillance infrastructure and for clarifying the basic roles and responsibilities for managing these activities at the various levels of government. As mentioned above, specific surveillance recommendations will vary by pandemic situation, thus it is recommended that a surveillance guidance document be developed in each pandemic situation to build on and operationalize these recommendations (see Appendix II for an example of an operational surveillance guidance document).

4.1 Supplementary Surveillance Recommendations: Ongoing Risk Assessment and Emerging Respiratory Illness Updates (Alerts/FYIs)

The ongoing maintenance and adjustment of routine surveillance activities and the timely sharing of surveillance and risk assessment information is an important supplement to the basic surveillance framework laid out in this annex. On the basis of ongoing risk assessment derived from the interpretation of local, regional, national and international influenza/emerging respiratory illness activity, recommendations may be made on an as-needed basis. These will guide increased vigilance and direct surveillance and investigation of severe and/or unexpected respiratory illnesses in relation to exposures of concern (high-risk travel locations, exposure settings or types of contact). Furthermore, monitoring and investigation activities may be adjusted in terms of sensitivity and specificity as dictated by the evolving situation. Factors that may influence the opportunity for initial containment of cases/isolated clusters, such as the length of the incubation period and efficiency of transmission, will contribute to the decision as to whether or not to continue case and cluster investigation with a view to controlling spread, if only temporarily, to buy additional time at the outset of a pandemic.Footnote 6 The following framework should be considered with these factors in mind, underscoring the need for flexible, simple and proven activities/systems founded on good routine surveillance practices, clarified roles and responsibilities, and efficient use of resources.

Table 2 Pandemic alert period

Canadian Pandemic Phase

3.0 Outside Canada human infection(s) with a new subtype are occurring, but no human-to-human spread or, at most, rare instances of spread to a close contact have been observed. No cases identified in Canada.

Surveillance Objectives/Roles and Responsibilities

Objectives

  • to detect and describe the first introduction of the novel virus in Canada and communicate this information to appropriate partners in a timely manner
  • to create awareness and ensure that surveillance systems meet standards and that pandemic plans are updated, tested and ready for possible implementation

Federal

  • Provide ongoing leadership through organization of teleconferences/meetings, providing guidance and surveillance recommendations as needed in a timely manner
  • Conduct regular information scanning and seek verification of international disease activity of potential public health significance, e.g. from international ministries of health and/or other international surveillance networks

Additional roles/responsibilities for phase 3

  • Confirm with WHO any reports of novel virus detection
  • Establish current risk assessment with international surveillance partners
  • Assess and convey current risk assessment to national surveillance partners
  • Inform the Council of Chief Medical Officers of Health (CCMOH), the Canadian Public Health Laboratory Network (CPHLN), FluWatch representatives and other appropriate officials of the situation and advise all to remain on alert for further updates (e.g. for updates of current avian influenza H5N1 affected areas refer to http://www.phac-aspc.gc.ca/h5n1/index.html)
  • Review the surveillance annex of pandemic plans and ensure that systems and resources are ready/tested/available for rapid ramp-up
  • Review and confirm that all pandemic alert period surveillance activities conducted through FluWatch and SRI surveillance are operating optimally
  • Coordinate with P/T partners the review and modification of national case definitions. Ensure that a process is in place to document changes in the case definition and that the definitions for reporting purposes are consistent with the international definitions
  • Review/revise standard reports and pandemic reporting tools for dissemination and knowledge transfer of epidemiologic and virologic information within Canada (for example, FluWatch weekly reports for the public and CIOSC weekly updates for public health professionals)
  • Define reporting parameters to the national level (process, frequency)
  • Coordinate the implementation of surveillance systems and/or special studies to estimate the severity of a novel virus outbreak (e.g. hospitalizations, mortality surveillance)

P/T/local

Additional roles/responsibilities for phase 3

  • Ensure that key stakeholders are aware and carry out appropriate actions, and confirm that enhanced surveillance is implemented
  • Review and confirm that all normal interpandemic influenza surveillance activities conducted through FluWatch and SRI surveillance are operating optimally
  • Review the surveillance annex of pandemic plans and ensure that systems and resources are ready/available for rapid ramp-up if this becomes necessary
  • Participate in regular information sharing with F/P/T/local stakeholder partners through teleconferences and electronic reporting
  • Define reporting parameters (process, frequency, content)
  • Review/revise standard reporting forms, data collection tools and surveillance reports
  • Regularly share information nationally as well as from local to provincial jurisdictions
  • Implement surveillance systems to estimate the severity of the pandemic (e.g. mortality surveillance) if not already established during the interpandemic period

Canadian Pandemic Phase

3.1 Single human case(s) with a new subtype detected in Canada. Virus is not known to be spreading from human to human or, at most, rare instances of spread to a close contact have been observed

Surveillance Objectives/Roles and Responsibilities

Objectives

  • to capture epidemiologic data on the first case(s) of the novel virus infection in Canada
  • to further heighten awareness and ensure that surveillance systems meet standards and that pandemic plans are updated, tested and ready for implementation. In addition to phase 3.0 roles and responsibilities the following apply.

Federal

  • Convene a meeting of the national surveillance working group in order to develop recommendations to review risk and implement enhanced surveillance, e.g. awareness/heightened vigilance, surveillance/advisory at points of entry, increasing proportion of isolates subtyped and isolate referral
  • Send Public Health Alert using CIOSC, which includes an analysis of the epidemiologic information on the first case(s) detected in Canada (Alert to be approved by appropriate officials)
  • Follow-up potential imported/exported cases (e.g. linking with relevant international counterparts to share/obtain exposure/contact history)
  • Report non-nominal case information to the WHO (for list of data elements refer to Appendix II)
  • Coordinate the enhancement of antiviral resistance monitoring

P/T/local

  • The public health and other viral diagnostic laboratories will be on high alert and will focus on enhanced laboratory-based surveillance for the emerging new subtype; viral isolation by culture if appropriately equipped; implementation or augmentation of real-time PCR (polymerase chain reaction) assays or other nucleic acid tests (NATs) for identification and subtyping of influenza viruses. Case-by-case risk assessments will be used at this phase to determine the extent of enhanced surveillanceFootnote 7
  • Immediately report and refer to the National Microbiology Laboratory (NML) any positive influenza laboratory findings or situations in which the strain type cannot be identified at the P/T laboratory level from a case with ILI symptoms and epidemiologic links with the novel influenza strain; report and ship to the NML immediately to obtain rapid confirmation characterization. Refer to the laboratory annex of the CPIP for details
  • Convene a meeting of P/T surveillance groups to review national recommendations, review P/T/local recommendations and implement enhanced surveillance
  • Investigate sporadic cases, including contact tracing, public health monitoring and collection of detailed epidemiologic data using the SRI or other available report form (www.phac-aspc.gc.ca). The recommended variables to report and reporting frequency will be outlined in the surveillance guidance document (see Appendix II for an example).

Canadian Pandemic Phase

4.0 Outside Canada small cluster(s) with limited human-to-human transmission are occurring, but spread is highly localized, suggesting that the virus is not well adapted to humans. No cases identified with such cluster(s) have been detected in Canada.

Surveillance Objectives/Roles and Responsibilities

Objectives

  • to detect and describe the first introduction of the novel virus in Canada
  • to provide the information to heighten awareness and increase vigilance while safeguarding system capacity and resource availability

Federal

  • Provide ongoing leadership through organization of teleconferences/meetings, providing guidance and advice as needed
  • Conduct regular scanning and verification of national and international surveillance information, e.g. from ministries of health and other international surveillance networks
  • Assess and convey current risk assessment to national surveillance partners
  • Convene a meeting of the national surveillance working group to develop recommendations to review risk and implement enhanced surveillance, e.g. awareness/heightened vigilance, surveillance/advisory at points of entry, increasing proportion of isolates subtypes and isolate referral
  • Review surveillance annex of pandemic plans and ensure that systems and resources are ready/available for rapid ramp-up if this becomes necessary
  • Review and confirm that all normal interpandemic surveillance activities conducted through FluWatch and SRI surveillance are operating optimally
  • Coordinate with P/T partners the review and modification of national case definitions. Ensure that a process is in place to document changes in the case definition and that the definitions are consistent with the international definitions
  • Review/revise standard reports for dissemination and knowledge transfer of epidemiologic information within Canada
  • Review/revise reporting parameters (process, frequency)

Additional roles/responsibilities for phase 4

  • Confirm with the WHO reports of clusters of 2 or more cases
  • Confirm case definitions with the WHO
  • Review/revise Public Health Alert to increase awareness for informed public health and clinical decision-making as necessaryFootnote 8 (revisions to Alert to be approved by appropriate officials)

P/T/local

  • Ensure that there is regular contact with key pandemic decision-makers and stakeholders within the P/T jurisdiction
  • Ensure that key stakeholders are aware and take appropriate action, and confirm that enhanced surveillance is implemented
  • Review the surveillance annex of pandemic plans and ensure that systems and resources are ready/available for rapid ramp-up if this becomes necessary

Additional roles/responsibilities for phase 4

  • Review and confirm that all normal interpandemic influenza surveillance activities conducted through FluWatch and SRI surveillance are operating optimally
  • Disseminate change in pandemic phase to health care providers

Canadian Pandemic Phase

4.1 Single human case(s) with virus that has demonstrated limited human-to-human transmission detected in Canada. No cluster(s) identified in Canada.

4.2 Small localized clusters with limited human-to-human transmission are occurring in Canada, but spread is highly localized, suggesting that the virus is not well adapted to humans.

Surveillance Objectives/Roles and Responsibilities

Objectives

  • to identify and capture epidemiologic data and to describe the epidemiologic characteristics of the first cases and clusters of the novel virus infection in Canada
  • to provide data to monitor the containment of the outbreak
  • to provide the information to heighten awareness and increase vigilance while safeguarding system capacity and resource availability

Federal

  • Provide ongoing leadership through organization of teleconferences/meetings, providing guidance and advice as needed
  • Conduct regular scanning and verification of national and international surveillance information, e.g. from ministries of health and other international surveillance networks
  • Assess and convey current risk assessment to national surveillance partners
  • Convene a meeting of the national surveillance working group in order to develop recommendations to review risk and implement enhanced surveillance, e.g. awareness/heightened vigilance, surveillance/advisory at points of entry, increasing proportion of isolates subtyped and isolate referral
  • Review the surveillance annex of pandemic plans and ensure that systems and resources are ready/available for rapid ramp-up if this becomes necessary
  • Review and confirm that all routine interpandemic surveillance activities conducted through FluWatch and SRI surveillance are operating optimally
  • Coordinate with P/T partners the review and modification of national case definitions. Ensure that a process is in place to document changes in the case definition and that the definitions are consistent with the international definitions
  • Review/revise standard reports for dissemination and knowledge transfer of epidemiologic information within Canada
  • Provide Alerts to increase awareness for informed public health and clinical decision-making as necessary

Additional roles/responsibilities for phase 4.1, 4.2

  • Implement international border-based surveillance (depending on origin of cases) coordinated by the Centre for Emergency Preparedness and Response (PHAC)Footnote 5 Footnote 9
  • Collect/compile/distribute epidemiologic data for cases reported in Canada
  • Establish current level of risk to guide public health actions (e.g. transmission characteristics associated with secondary cases)
  • Review the key questions for the pandemic that are not being addressed by existing/planned surveillance activities and attempt to address these through special studies. Review existing protocols for special studies, summarize the main outcomes and timelines for special studies already under way and prepare dedicated teams as necessary to establish prompt activation of the new studies when appropriate
  • Revise case definitions according to observed clinical presentation of cases
  • Report non-nominal case/cluster information to the WHO (for list of data elements refer to Appendix III)

P/T/local

  • Ensure that key stakeholders are aware and take appropriate action, and confirm that enhanced surveillance is implemented immediately in affected areas in order to identify any human-to-human transmission in Canada
  • Review the surveillance annex of pandemic plans and ensure that systems and resources are ready/available for rapid ramp-up if this becomes necessary

Additional roles/responsibilities for phase 4.1, 4.2

  • Review and confirm that all normal interpandemic influenza surveillance activities conducted through FluWatch and SRI surveillance are operating optimally
  • Conduct case/cluster investigation and report to PHAC (for list of data elements refer to Appendix III)

Canadian Pandemic Phase

5.0 Outside Canada larger cluster(s) are occurring, but human-to-human spread is still localized, suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk). No cases identified with such clusters have been detected in Canada.

Surveillance Objectives/Roles and Responsibilities

Objectives

  • to detect and describe the first introduction of the novel virus in Canada
  • to heighten awareness and increase vigilance while safeguarding system capacity and resource availability

Federal

  • Provide ongoing leadership
  • Confirm with the WHO sustained person-to-person transmission and determine whether there are outbreaks in one or more countries
  • Conduct regular scanning and verification of national and international surveillance information, e.g. from ministries of health and other international surveillance networks
  • Assess and convey current risk assessment to national surveillance partners
  • Convene the national surveillance working group to determine situation-specific information needs and appropriate enhanced surveillance activities (increased laboratory testing and referral, collection of epidemiologically relevant information, e.g. travel history, immunization status, other information needed to guide the control measures based on global experience)
  • Notify CCMOH, CPHLN, FluWatch representatives and other appropriate officials of the situation and recommended action, including situation-specific enhanced surveillance activities
  • Initiate ramp-up of enhanced surveillance if deemed necessary (based on efficiency of human-to-human spread and assessment of pandemic potential) or increase frequency of analysis of key variables already collected through enhanced surveillance to ensure that there is timely use of existing data
  • Ensure that any additional systems and resources are ready/available for rapid ramp-up if this becomes necessary

P/T/local

  • Ensure that key pandemic stakeholders have heightened awareness and carry out appropriate action, including enhanced surveillance activities
  • Ramp up to enhanced surveillance as required
  • Ensure that additional systems and resources are ready/available for rapid ramp-up if this becomes necessary
  • Share information with F/P/T/local partners

Canadian Pandemic Phase

5.1 Single human case(s), detected in Canada, with virus that is better adapted to humans. No cluster(s) identified in Canada.

Surveillance Objectives/Roles and Responsibilities

Objectives

  • to identify and capture epidemiologic data and describe the epidemiologic characteristics of the first cases and clusters of the novel virus infection in Canada
  • to provide data to monitor the containment of the outbreak
  • to provide the information to heighten awareness and increase vigilance while safeguarding system capacity and resource availability. In addition to phase 5.0 roles and responsibilities the following apply.

Federal

  • Report non-nominal case/cluster information to the WHO (for list of data elements refer to Appendix III)

P/T/local

  • Conduct case investigation and report to the PHAC (for list of data elements refer to Appendix III)

Canadian Pandemic Phase

5.2 Larger localized cluster(s) with limited human-to-human transmission are occurring in Canada, but human-to-human spread is still localized, suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk).

Surveillance Objectives/Roles and Responsibilities

Objectives

  • to identify and capture epidemiologic data and describe the epidemiologic characteristics of the first cases and clusters of the novel virus infection in Canada
  • to provide data to monitor the containment of the outbreak
  • to provide the information to heighten awareness and increase vigilance while safeguarding system capacity and resource availability. In addition to phase 5.1 roles and responsibilities the following apply.

Federal

  • Cluster within one P/T: assist with the coordination and implementation of the outbreak investigation as led by the P/T, act as the liaison with international organizations
  • Clusters in more than one P/T: coordinate outbreak investigation and act as the liaison between provinces/territories as well as international organizations
  • Revise case definitions according to observed clinical presentation of cases

P/T/local

  • Cluster within one P/T: lead the outbreak investigation and report to the PHAC (for list of data elements refer to Appendix III)

Table 2.1 National surveillance data for the pandemic alert period

Canadian Pandemic Phase

3.0 Outside Canada human infection(s) with a new subtype are occurring, but no human-to-human spread or, at most, rare instances of spread to a close contact have been observed. No cases identified in Canada.

National Surveillance Data

Disease surveillance

  • (a) influenza activity level by P/T region (based on FluWatch definitions)
  • (b) ILI consultation rate (number of ILI sentinel physician visits/1,000 consults)
  • (c) number of laboratory-confirmed outbreaks in long-term care facilities
  • (d) number of influenza-associated hospitalizations and influenza-associated deaths in children 0-18 years through sentinel paediatric hospitals (IMPACT)

Laboratory surveillance

  • (e) percent positive influenza tests (total number of laboratory tests for influenza and number of positive results, by virus type, A or B)
  • (f) strain characterization, number identified for each strain and subtype, and percentage of total for approximately 10% of isolates from the Sentinel Laboratory Respiratory Virus Detection System
  • (g) increased targeted strain characterization based on risk assessment in areas where animal strains are circulating
  • (h) antiviral resistance testing for influenza isolates

Risk assessment

  • (i) summary of national/international areas where animal virus activity has been confirmed
  • (j) summary of international activity in humans

Canadian Pandemic Phase

3.1 Single human case(s) with a new subtype detected in Canada. Virus is not known to be spreading from human-to-human or, at most, rare instances of spread to a close contact have been observed.

National Surveillance Data

Disease surveillance

  • (a) influenza activity level by P/T region (based on FluWatch definitions)
  • (b) ILI consultation rate (number of ILI sentinel physician visits/1,000 consults)
  • (c) number of laboratory-confirmed outbreaks in long-term care facilities
  • (d) number of influenza-associated hospitalizations and influenza-associated deaths in children 0-18 years through sentinel paediatric hospitals (IMPACT)

Laboratory surveillance

  • (e) percent positive influenza tests (total number of laboratory tests for influenza and number of positive results, by virus type, A or B)
  • (f) strain characterization, number identified for each strain and subtype, and percentage of total for approximately 10% of isolates from the Sentinel Laboratory Respiratory Virus Detection System
  • (g) increased targeted strain characterization based on risk assessment in areas where animal strains are circulating
  • (h) antiviral resistance testing for influenza isolates

Risk assessment

  • (i) summary of national/international areas where animal virus activity has been confirmed
  • (j) summary of international activity in humans

In addition to indicators for 3.0

  • (k) detailed epidemiologic description and estimation of incubation and communicability periods (e.g. number of secondary cases) (may require special studies to address)
  • (l) enhanced laboratory surveillance (increased strain characterizations) targeted to areas where the first case(s) are identified. Includes subtyping samples from contacts with known exposure who report ILI symptoms (based on case-by-case risk assessment)
  • (m) monitoring for unusual outbreaks and cluster activity

Canadian Pandemic Phase

4.0 Outside Canada small cluster(s) with limited human-to-human transmission are occurring, but spread is highly localized, suggesting that the virus is not well adapted to humans. No cases identified with such cluster(s) have been detected in Canada.

5.0 Outside Canada larger cluster(s) are occurring, but human-to-human spread is still localized, suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk). No cases identified with these clusters have been detected in Canada.

National Surveillance Data

Same data as 3.0
Disease surveillance

  • (a) influenza activity level by P/T region (based on FluWatch definitions)
  • (b) influenza-like illness (ILI) consultation rate (number of ILI sentinel physician visits/1,000 consults)
  • (c) number of laboratory-confirmed outbreaks in long-term care facilities
  • (d) number of influenza-associated hospitalizations and influenza-associated deaths in children 0-18 years through sentinel paediatric hospitals (IMPACT)

Laboratory surveillance

  • (e) percent positive influenza tests (total number of laboratory tests for influenza and number of positive results, by virus type, A or B)
  • (f) strain characterization, number identified for each strain and subtype, and percentage of total for approximately 10% of isolates from the Sentinel Laboratory Respiratory Virus Detection System
  • (g) increased targeted strain characterization based on risk assessment in areas where animal strains are circulating
  • (h) antiviral resistance testing for influenza isolates

Risk assessment

  • (i) summary of national/international areas where animal virus activity has been confirmed
  • (j) summary of international activity in humans

Canadian Pandemic Phase

4.1 Single human case(s) with virus that has demonstrated limited human-to-human transmission detected in Canada. No cluster(s) identified in Canada.

4.2 Small localized clusters with limited human-to-human transmission are occurring in Canada, but spread is highly localized, suggesting that the virus is not well adapted to humans.

5.1 Single human case(s) with virus that is better adapted to humans detected in Canada. No cluster(s) identified in Canada.

5.2 Larger localized cluster(s) with limited human-to-human transmission are occurring in Canada, but human-to-human spread is still localized, suggesting that the virus is becoming increasingly better adapted to humans but may not yet be fully transmissible (substantial pandemic risk).

National Surveillance Data

Same data as 3.1
Disease surveillance

  • (a) influenza activity level by P/T region (based on FluWatch definitions)
  • (b) influenza-like illness (ILI) consultation rate (number of ILI sentinel physician visits/1,000 consults)
  • (c) number of laboratory-confirmed outbreaks in long-term care facilities
  • (d) number of influenza-associated hospitalizations and influenza-associated deaths in children 0-18 years through sentinel paediatric hospitals (IMPACT)

Laboratory surveillance

  • (e) percent positive influenza tests (total number of laboratory tests for influenza and number of positive results, by virus type, A or B)
  • (f) strain characterization, number identified for each strain and subtype, and percentage of total for approximately 10% of isolates from the Sentinel Laboratory Respiratory Virus Detection System
  • (g) increased targeted strain characterization based on risk assessment in areas where animal strains are circulating
  • (h) antiviral resistance testing for influenza isolates

Risk assessment

  • (i) summary of national/international areas where animal virus activity has been confirmed
  • (j) summary of international activity in humans
  • (k) detailed epidemiologic description and estimation of incubation and communicability periods (e.g. number of secondary cases)
  • (l) enhanced laboratory surveillance (increased strain characterizations) targeted to areas where the first case(s) are identified. Includes subtyping samples from contacts with known exposure who report ILI symptoms (based on case-by-case risk assessment)
  • (m) monitoring for unusual outbreaks and cluster activity

In addition to data for 3.1

  • (n) number and epidemiologic description of settings involved

5. Pandemic Period

Table 3 Pandemic period

Canadian Pandemic Phase

6.0 Outside Canada increased and sustained transmission in general population has been observed. No cases have been detected in Canada.

Surveillance Objectives/Roles and Responsibilities

Objectives

  • to describe the first cases in Canada
  • to inform the response by tracking the occurrence and progression of the pandemic through the population

Federal

  • Provide ongoing leadership
  • Confirm with the WHO reports of multiple widespread outbreaks with high rates of morbidity/mortality in multiples countries
  • Conduct regular scanning and verification of national and international surveillance information, e.g. from ministries of health and other international surveillance networks
  • Evaluate current epidemiology to facilitate prioritization (if necessary) of scarce resources to high-risk groups
  • Convene meeting with the national surveillance working group to evaluate the situation and determine information needs and frequency of reporting, e.g. geographic regions/specific urban centres or selected population groups/health care settings for ramping up of surveillance activities (e.g. sentinel/non-sentinel surveillance ramp-up to increase coverage, specimen collection, collection of mortality data)
  • Scale up surveillance activities as required (frequency of data collection, additional information needs, dissemination to and knowledge transfer with partners)
  • Coordinate with P/Ts the review and revision of the case definition based on current evidence of the clinical spectrum of the disease
  • Distribute revised surveillance guidance document, including data collection forms and database transmission instructions/protocols if not done previously
  • Prepare to implement the human resources plan developed during phase 1

P/T/local

  • Have regular contact with key stakeholders within jurisdictions
  • Ensure that surveillance activities are scaled up, resources are in place as necessary and appropriate action is carried out
  • Prepare to implement the human resources plan developed during phase 1

Canadian Pandemic Phase

6.1 Single human case(s) with the pandemic virus detected in Canada. No cluster(s) identified in Canada. Note: It is likely that this phase will have a very short duration and may not occur at all in Canada (i.e. novel virus activity may not be detected prior to the occurrence of a cluster of cases).

Surveillance Objectives/Roles and Responsibilities

Objectives

  • to describe the first cases in Canada
  • to inform the response by tracking occurrence and progression of the pandemic through the population. In addition to phase 6.0 roles and responsibilities the following apply.

Federal

  • Collect, collate and analyze national impact and trends and provide epidemiologic summaries to characterize outbreaks and impact using mortality and enhanced surveillance data (age-specific mortality rates, high-risk groups)
  • Provide epidemiologic summaries to characterize outbreaks and impact (mortality, high-risk groups, clinical presentation)
  • Implement the human resources plan developed during phase 1

P/T/local

  • Collect, collate and analyze P/T impact and trends, and provide epidemiologic summaries to PHAC to characterize outbreaks and impact using mortality and enhanced surveillance data (age-specific mortality rates, high-risk groups, clinical spectrum of the disease)
  • Implement the human resources plan developed during phase 1

Canadian Pandemic Phase

6.2 Localized or widespread pandemic activity observed in Canadian population.

Surveillance Objectives/Roles and Responsibilities

Objectives

  • to identify and describe the affected population thereby facilitating identification of high-risk groups and comparisons between other populations or other influenza seasons in order to guide public health actions
  • to inform the response by tracking the occurrence and progression of the pandemic through the population
  • to determine triggers based on decreasing activity levels for implementation of post-pandemic activities in preparation for second and later waves. In addition to phase 6.0 roles and responsibilities the following apply.

Federal

  • Scale back to streamlined surveillance (to be further defined in the specific surveillance guidance document for a given pandemic)
  • Coordinate activities for evaluation and resource planning for subsequent waves

P/T/local

  • Scale back to streamlined surveillance (to be further defined)
  • Evaluate performance, and plan resources for subsequent waves

Table 3.1 National surveillance data for the pandemic period

Canadian Pandemic Phase

6.0 Outside Canada increased and sustained transmission in the general population has been observed. No cases have been detected in Canada.

National Surveillance Data

Disease surveillance

  • (a) influenza activity level by P/T region (based on FluWatch definitions)
  • (b) ILI consultation rate (number of ILI sentinel physician visits/1,000 consults)
  • (c) number of laboratory-confirmed outbreaks in long-term care facilities
  • (d) number of influenza-associated hospitalizations and influenza-associated deaths in children 0-18 years through sentinel paediatric hospitals (IMPACT)

Laboratory surveillance

  • (e) percent positive influenza tests (total number of laboratory tests for influenza and number of positive results, by virus type, A or B)
  • (f) strain characterization, number identified for each strain and subtype, and percentage of total for approximately 10% of isolates from the Sentinel Laboratory Respiratory Virus Detection System
  • (g) increased targeted strain characterization based on risk assessment
  • (h) antiviral resistance testing for influenza isolates

Risk assessment

  • (i) summary of international activity in humans

Canadian Pandemic Phase

6.1 Single human case(s) with the pandemic virus detected in Canada. No cluster(s) identified in Canada.

Note: It is likely that this phase will have a very short duration and may not occur at all in Canada (i.e. novel virus activity may not be detected prior to the occurrence of a cluster of cases).

National Surveillance Data

Same data as 5.1, 5.2
Disease surveillance

  • (a) influenza activity level by P/T region (based on FluWatch definitions)
  • (b) ILI consultation rate (number of ILI sentinel physician visits/1,000 consults)
  • (c) number of laboratory-confirmed outbreaks in long-term care facilities
  • (d) number of influenza-associated hospitalizations and influenza-associated deaths in children 0-18 years through sentinel paediatric hospitals (IMPACT)

Laboratory surveillance

  • (e) percent positive influenza tests (total number of laboratory tests for influenza and number of positive results, by virus type, A or B)
  • (f) strain characterization, number identified for each strain and subtype, and percentage of total for approximately 10% of isolates from the Sentinel Laboratory Respiratory Virus Detection System
  • (g) increased targeted strain characterization based on risk assessment
  • (h) antiviral resistance testing for influenza isolates

Risk assessment

  • (i) summary of international activity in humans
  • (j) detailed epidemiologic description and estimation of incubation and communicability periods (e.g. number of secondary cases)
  • (k) enhanced laboratory surveillance (increased strain characterizations) targeted to areas where the first case(s) are identified. Includes subtyping samples from contacts with known exposure who report ILI symptoms (based on case-by-case risk assessment)
  • (l) monitoring for unusual outbreaks and cluster activity
  • (m) number and epidemiologic description of settings involved

In addition to data for 5.1, 5.2

  • (n) number of surveillance regions with widespread activity, based on FluWatch definitions

NOTE: Currently, there is no mechanism for collecting mortality data on a real-time basis. This is a recognized gap in information for monitoring the severity of the pandemic. Mortality data are required during interpandemic phases to monitor the severity of annual influenza epidemics, to establish baseline expected seasonal mortality trends and to detect potential signals. The collection of real-time, or at minimum timely, mortality data is recommended at the height of a pandemic to describe the severity of the pandemic, identify high-risk age groups and provide crude indications of intervention effectiveness. As well, during this heightened phase of the pandemic, resources are expected to be scarce and, because of low participation/reporting rates, existing surveillance activities may no longer provide accurate or complete data. While routine surveillance activities are not expected to stop entirely, participation rates may be very low and therefore data quality and representativeness may be poor. Thus, simple and flexible systems for surveillance are key. In addition to routine activities that are established and maintained, new and recommended activities, such as real-time/timely mortality surveillance, should be simple and flexible.

6. Post-Pandemic Period

While the post-pandemic period suggests that the pandemic waves have ended and that the virus is no longer causing significant outbreaks in the population, it is acknowledged that the virus will continue to circulate. Table 4 outlines ways to evaluate the surveillance activities conducted during the pandemic; however, surveillance and laboratory activities in the post-pandemic period should continue to monitor changes in the pandemic virus.

Table 4 Post-pandemic period

Canadian Pandemic Phase

Post-pandemic reports of case counts and other broad indicators of pandemic activity in Canada suggest that the pandemic virus is no longer causing significant illness in the population.

Surveillance Objectives/Roles and Responsibilities

Objectives

  • to assess the seasonal burden of influenza and to detect unusual events, including unusual or new strains, unusual outcomes/syndromes, or unusual distribution or severity of influenza within the population
  • to evaluate and assess the system's ability to provide information useful for reducing morbidity and mortality during a pandemic
  • to summarize the epidemiologic characteristics of the pandemic waves in Canada
  • to continue to monitor changes in the pandemic virus

Federal

  • Provide ongoing leadership
  • Confirm with WHO the end of global widespread novel virus activity
  • Resume regular scanning and verification of national and international surveillance information, e.g. from ministries of health and other international surveillance networks
  • Evaluate current epidemiology and the end of pandemic activity
  • Convene a meeting with the national surveillance working group to determine any special information needs for the evaluation of surveillance system performance during the pandemic waves
  • Provide epidemiologic summaries to characterize the impact of the pandemic waves in Canada (spread, age-specific morbidity and mortality rates, high-risk groups)
  • Coordinate activities for evaluation and resource planning, including special studies for surveillance of delayed effects of the pandemic virus (e.g. neurological)
  • Resume interpandemic influenza surveillance via FluWatch (except in case of additional information needs for evaluation)
  • Scale back frequency and change focus of regular updates by e-mail, fax, teleconferencing and web postings to meet the needs of evaluation and planning activities
  • Evaluate surveillance system performance and plan improvements as required

P/T/local

  • Resume interpandemic FluWatch and jurisdiction-specific activities
  • Evaluate surveillance system performance and plan improvements as required; share the information with F/P/T/local stakeholders

Appendix I: Example of Detailed Case Report Form for Avian Influenza Outbreak

BC Outbreak Reporting Questionnaire - April 2004

The questionnaire that follows was developed by the BC Centre for Disease Control (BCCDC) for use during the 2004 avian influenza H7N3 outbreak in British Columbia with input from scientists who were previously involved in the response to an avian influenza H7N7 outbreak in the Netherlands in 2003.

Avian Influenza in British Columbia Initial Report

PDF Version PDF
(6 Pages, 80 KB)


Appendix II: Example of Operational Surveillance Guidance Document for Pandemic Influenza Surveillance

Pandemic (H1N1) 2009 Surveillance Guidance Document for Provincial and Territorial Surveillance Partners

Last revision: February 2010

Contact:

Influenza Surveillance and Epidemiology Section
Centre for Immunization and Respiratory Infectious Diseases
Public Health Agency of Canada
130 Colonnade Road Ottawa, Ontario
K1A 0K9
Email: HSFLUEPI@phac-aspc.gc.ca

Disclaimer: The reporting guidelines are valid as of the last update and are subject to revision.  Provinces, territories and other surveillance partners will be notified accordingly.

A.1 Introduction

The influenza surveillance strategy in place this year (2009) differs substantially from previous seasons as Canada is currently in a phase 6 pandemic period. National guidance and reporting recommendations for the surveillance of Pandemic (H1N1) 2009 will help to ensure that data submitted to the Public Health Agency of Canada (PHAC) are standardized across the country in order to allow for comparison among jurisdictions and also allow Canada to meet World Health Organization (WHO) international reporting requirements.

A.1.1 Purpose

This document aims to provide reporting guidance to our provincial and territorial surveillance partners in order to support standardized submission of data. It also includes reference information regarding other reporting sources that participate in the PHAC influenza surveillance program, and influenza protocols and data collection tools used by other participating partners.

A.1.2 Objectives

The objectives of surveillance during a pandemic are to continually monitor and assess the progression of influenza virus so that effective public health measures can be adopted and evaluated in order to best reduce the burden of illness and societal disruption attributed to the disease. These objectives are based on the WHO Global Pandemic Influenza Surveillance Strategy and meet objectives developed in the Canadian Pandemic Influenza Plan.

Specifically, the surveillance objectives are as follows:

  1. Monitor the geographic spread of the virus across Canada
  2. Monitor the trend of disease occurrence as it rises and falls within each province/territory and Canada
  3. Monitor the intensity, severity and impact of the pandemic (e.g. clinical cases, hospitalizations and deaths; severe clinical syndromes and their associated risk groups; and demands on the health system)
  4. Monitor for changes in the antigenicity and antiviral sensitivity of the virus
A.1.3 Surveillance Partners

National influenza surveillance is achieved by integrating information received from an extensive network of surveillance partners who provide PHAC with different pieces of the influenza picture and allow us to make a comprehensive assessment of influenza activity in Canada. Table 1 identifies these partners and provides a short description of the role they play in influenza surveillance.

The surveillance data provided by the provincial and territorial partners are crucial to the overall surveillance of Pandemic (H1N1) 2009 and FluWatch. It is recommended that provincial and territorial partners report the recommended surveillance data in a timely manner as much as possible, although it is understood that the information is not always available in all provincial and territorial surveillance systems.

A.1.4 Protection of Identifiable Information

Any collection, use and disclosure of identifiable information by PHAC will be conducted in accordance with PHAC’s Policy for the Collection, Use and Dissemination of Public Health Data, dated June 2009.




Table 1. Data sources, indicators and objectives
Sources of information Indicators Description Objectives
Provinces & territories FluWatch
Influenza activity,
outbreaksH1N1-specific
Hospitalizations, deathsSevere respiratory illness (SRI)Unusual events
Provinces and territories report on influenza activity levels, number of outbreaks occurring in health care facilities and schools, and unusual activity.Provinces and territories report on all hospitalized cases and deaths on a weekly basis. Monitor the geographic spread of the virus across Canada and trend over time.Monitor the trend of severe disease (hospitals, intensive care units [ICU] and deaths) occurrence in the community as it rises and falls within each province/territory and Canada.Estimate population-based hospitalization and mortality rates.Identify major groups at risk and provide information on the impact on the health care system.Monitor other severe clinical syndromes and how they differ from H1N1 cases.The objective of the real-time reporting of unusual events is to rapidly assess this signal and to determine whether further public health actions are warranted.
Immunization Monitoring Program-Active (IMPACT) Paediatric hospital-based surveillance
(clinical and interventions information)
Twelve tertiary care paediatric hospitals across Canada cover 90% of paediatric hospital beds.
Report aggregate information about laboratory-confirmed influenza-related hospitalizations (by age group, type of influenza, date of admission) and deaths in children aged <16 years.  Starting in the fall of 2009 they are to provide bi-weekly detailed case reports.
IMPACT provides a detailed clinical description of the paediatric population affected by pandemic influenza (clinical presentation, bacterial complications, level of care needed).
Evaluate the effectiveness of some interventions (vaccine, and to a lesser degree antivirals).
Assess the impact that pandemic H1N1 in the paediatric population is having on the health care system.
Canadian Nosocomial Infections Surveillance Program (CNISP) Adult hospital-based surveillance (clinical and interventions information) A network of 45 acute-care hospitals located across Canada reports on a weekly basis the number of all laboratory-confirmed influenza hospitalizations and summarizes data from detailed case report forms on a monthly basis.
Start date for all 45 hospitals is Sep 1, 2009.
CNISP provides a detailed clinical description of the adult population affected by pandemic influenza (clinical presentation, bacterial complications, level of care needed).
Evaluate the effectiveness of some interventions (vaccine, and to a lesser degree antivirals).
Assess the impact that pandemic H1N1 in the adult population is having on the health care system.
National Research System (NaReS)- The College of Family Physicians of Canada Provincial/territorial networks Community influenza-like illness (ILI) surveillance A network of approximately 300 physicians or community health centres from across the country report weekly on ILI activity in their practice. Monitor the trend of ILI occurrence in the community as it rises and falls within each province/territory and Canada.
Respiratory Virus Detection Surveillance System (RVDSS) Virologic surveillance (circulating type/subtype of influenza, and other respiratory viruses) A network of 32 laboratories across the country, including provincial public health and hospital laboratories. They report on a weekly basis the number of specimens tested and the proportion positive for influenza (by subtype) and other respiratory viruses (e.g. para-influenza, adenovirus and respiratory syncytial virus).
*Some of the 32 reporting RDVSS laboratories report for more than one laboratory.
Monitor the trend of H1N1 laboratory detection as it rises and falls within each province/territory and Canada.Monitor other concomitant circulating viruses.
National Microbiology Laboratory (NML) Virologic surveillance (antigenic characterization and antiviral resistance) Provide information on antigenic characterization and antiviral resistance based on samples received from public health and private laboratories. Monitor changes in the antigenicity and antiviral sensitivity of the virus.

Figure 1. Flow chart of FluWatch and Pandemic (H1N1) 2009 surveillance system

Flow chart of FluWatch and Pandemic (H1N1) 2009 surveillance system

Text Equivalent

A.2 Reporting Guidelines and Recommendations

A.2.1 Provinces & Territories

A.2.1.i Influenza Surveillance and Respiratory Virus Detection

a. FluWatch indicators

This includes information to create the national ILI activity level maps, number of regions reporting localized or widespread activity, and number of ILI outbreaks in Canada.

All provinces and territories (P/Ts) are asked to report on a weekly basis by Thursday 13:00 EDT their assessment of influenza activity level by surveillance regions within their jurisdiction, the number of regions reporting localized or widespread activity and the number of outbreaks in health facilities (long-term care facilities and hospitals) and schools.  This information will cover all influenza, as P/Ts may not have the ability to stratify by the type/subtype of influenza that is circulating.  As per the previously established reporting process all P/Ts are to collect this information on the FluWatch: Preliminary Feedback & Activity Level Reporting Form and email the form to Fluwatch@phac-aspc.gc.ca.  P/Ts using the Canadian Network of Public Health Intelligence (CNPHI) platform may continue to do so. Please refer to Appendix A for a list of case definitions.

A.2.1.ii Pandemic (H1N1) 2009 Surveillance

a. Pandemic (H1N1) 2009 hospitalizations (case-based reporting)
New for the 2009-10 influenza season is that P/Ts are asked to report on a weekly basis by Monday 17:00 EDT a core set of data elements, as per the line list variables outlined in Appendix C.1, for all hospitalized cases and deaths (see below for additional information regarding reporting deaths) with Pandemic (H1N1) 2009 in their jurisdiction. The weekly line list should be emailed to HSFLUEPI@phac-aspc.gc.ca. Reporting of case-based Pandemic (H1N1) 2009 hospitalizations is to be kept in place as long as possible.

While not mandatory, completion of the Pandemic (H1N1) 2009 Influenza Case Report Form (Appendix C.3) by P/Ts is encouraged for Pandemic (H1N1) hospitalized cases. However, if completed, this information should also be included in the weekly line list.

b. Pandemic (H1N1) 2009 deaths (case-based reporting)
Until further directives are provided, P/Ts are to continue to notify PHAC at HSFLUEPI@phac-aspc.gc.ca in real time of all new deaths.

Additionally, these cases should be updated in the weekly national Pandemic (H1N1) 2009 line list report that is forwarded to PHAC as described above. Reporting of case-by-case deaths with Pandemic (H1N1) 2009 hospitalizations is tobe kept in place as long as possible.

While not mandatory, completion of the Pandemic (H1N1) 2009 Influenza Case Report Form (Appendix C.3) is encouraged for Pandemic (H1N1) deaths. This information should also be included in the weekly line list.

c. Aggregate reporting of hospitalizations and deaths with laboratory-confirmed influenza

If, during the peak periods of the pandemic, P/Ts are no longer able to continue with individual case-based reporting, they may choose to shift from case-based reporting to weekly aggregate reporting. It is at the discretion of the P/Ts as to when they will need to switch from case-by-case reporting to aggregate reporting. If a P/T switches to aggregate reporting, it is recommended that the aggregate report be submitted by email on a weekly basis by Monday 17:00 EDT to HSFLUEPI@phac-aspc.gc.ca. See Appendix C.2: Weekly Aggregate Reporting of Hospitalizations and Deaths.

In this situation, PHAC requests that the P/Ts submit the following information on a weekly basis

Hospitalizations:

  • Aggregate count of hospitalizations (including count of ICU admissions, if known) with Pandemic (H1N1) 2009 (please refer to Appendix C.2, section H1). If age and sex breakdown is available, please provide as per Appendix C.2, section H2.
  • Aggregate report of all laboratory-confirmed influenza hospitalizations, excluding Pandemic (H1N1) 2009. See Appendix C.2, section H3. It is expected that not all P/Ts will be able to provide this information.

Deaths:

  • Aggregate count of deaths with Pandemic (H1N1) 2009 (please refer to Appendix C.2, section D1). If age and sex breakdown is available, please provide as per Appendix C.2, section D2. It is assumed that this information will only be available in a timely manner for deaths that occur in hospital.
  • Aggregate report of all laboratory-confirmed influenza deaths, excluding Pandemic (H1N1) 2009. See Appendix C.2, section D3. It is expected that not all P/Ts will be able to provide this information.

d. Severe respiratory illness
When the P/T is notified of any severe respiratory illness that meets the case definition (as per Appendix B), a detailed SRI case report form should be completed and emailed to HSFLUEPI@phac-aspc.gc.ca or faxed to 613-946-8808 as soon as possible. The case report form is provided in Appendix C.4.

e. Unusual respiratory events
A report of an unusual event should be made to PHAC as soon as the P/T becomes aware of it and has made an assessment. An email should be sent to HSFLUEPI@phac-aspc.gc.ca. Lines of communication with non-traditional surveillance partners (e.g. emergency departments, network of ICU physicians, tele-health leads, or media) is necessary to ensure that rapid identification and reporting of these events will occur (see case definition in Appendix A for examples of unusual events).  Reporting of unusual activity is subjective: there may not be an established threshold by which to judge current activity, and so it may require a certain level of public health professional discretion.

f. Reporting of out-of province or territory casesFootnote 10
If a hospitalization or death occurs in a P/T that is different from the patient’s P/T of residence, the P/T where the patient was hospitalized or died is responsible for reporting the information as soon as possible to the P/T where the case resides. The P/T where the case resides will be the jurisdiction responsible for reporting patient information to PHAC. If the P/T of residence is blank, PHAC will consider the reporting P/T to be the P/T of residence. For a P/T that has an agreement already in place that differs from the above recommendation, please continue as per the existing agreement.

g. Notifications of out-of country cases
If a hospitalization or death occurs in an individual who is not normally a resident of Canada, the P/T where the individual dies will be responsible for reporting this information to PHAC. PHAC will then report information on fatal cases through the international health reporting (IHR) channel, which subsequently forwards the information to the relevant country. Until further notification we request that P/Ts continue to forward this information to PHAC. It can be faxed to 613-946-8808 or emailed to HSFLUEPI@phac-aspc.gc.ca

A.2.2 Other Influenza Surveillance Systems

A.2.2.i Immunization Monitoring Program Active (IMPACT)

As per established agreements, IMPACT is to continue to submit a weekly aggregate count by hospital site on the number of paediatric patients admitted with influenza.  Information about sex, age group and whether or not a child died is also to be reported.

IMPACT is to submit detailed case reports every two weeks on patients admitted to hospital with laboratory-confirmed Pandemic (H1N1) 2009. These reports provide detailed clinical information about the patient, such as the presence of underlying medical conditions, occurrence of secondary bacterial infections, and information on vaccination history and antiviral treatment. Please refer to Appendix E for more information on the IMPACT program.

A.2.2.ii Canadian Nosocomial Infections Surveillance Program (CNISP)

The 2009-10 influenza season will be the first time that CNISP will participate in routine influenza surveillance carried out by FluWatch. It is to provide information on the adult hospitalized population. Each week, CNISP submits by email a count of influenza-associated admissions (see protocol in Appendix D for list of conditions), all laboratory-confirmed influenza hospitalizations and deaths. Once per month they are to submit detailed case reports of patients admitted with laboratory-confirmed influenza.

A.2.2.iii Difference Between Hospitalization Reports Provided by P/Ts and IMPACT and CNISP

The hospital and mortality information provided by the P/T partners differs from that reported through CNISP and IMPACT. While the data reported from P/Ts cover the whole population, the level of information provided is relatively limited (e.g. no clinical information, no vaccine or treatment information). It is used mainly to estimate population-based hospitalization and mortality rates, identify major groups at risk and provide information on the impact on the health care system.

The information provided by CNISP and IMPACT will be used to provide a more detailed clinical description of the population affected by pandemic influenza (clinical presentation, bacterial complications, level of care needed), allow us to evaluate the effectiveness of some interventions (vaccine and to a lesser degree antivirals) and to assess the impact that Pandemic (H1N1) 2009 is having on the health care system, since information on bed-counts will be received.

It should be noted that the IMPACT and CNISP databases will not be integrated into the national line-list database. Those databases will be analyzed separately, and the reports generated will clearly mention the source of the information. Therefore P/Ts are asked to submit both national line list and IMPACT/CNISP data; there will not be a risk of double counting.

A.2.2.iv FluWatch Sentinel Physician Network

Each week participating sentinel physicians and community health centres submit aggregate counts of patients with ILI by age group. Physicians submit their information by fax, or it is uploaded by some P/Ts into the Canadian Network of Public Health Intelligence (CNPHI). Data are usually received by Tuesday at 17:00 EDT.

A.2.2.v Respiratory Virus Detection Surveillance System (RVDSS)

The network of 32 public and private laboratories (some reporting laboratories may represent a group) submit to PHAC the number of respiratory specimens tested, the number and percent positive for influenza by subtype, and the number and percent positive for other respiratory viruses. Reports are received by Tuesday 17:00 EDT, and a national final report is posted on the PHAC FluWatch website on Wednesdays.

A.2.3 Public Health Agency of Canada

While PHAC-CIRID (Centre for Immunization and Respiratory Infectious Diseases)
is leading the national Influenza surveillance, a number of other Centres within PHAC contribute to influenza surveillance.

A.2.3.i National Microbiology Laboratory (NML)

Each week the NML submits to PHAC FluWatch the number of specimens tested for strain characterization and antiviral sensitivity. This information is included in the FluWatch report.

A.2.3.ii Centre for Communicable Diseases and Infection Control (CCDIC)

CCDIC is overseeing the CNISP surveillance network. When influenza surveillance through CNISP is fully operational, CCDIC will be reporting on a weekly basis for aggregate reporting and monthly for case-based reporting through HSFLUEPI@phac-aspc.gc.ca.

A.2.3.iii Centre for Immunization and Respiratory Infectious Diseases (CIRID)
CIRID is responsible for collating, cleaning, analyzing and interpreting surveillance data coming from the different sources mentioned above (such as P/T partners, IMPACT, CNISP, RDVSS) and monitoring international official and informal sources of information.

Surveillance outputs are produced on a regular basis:

  • A weekly FluWatch report is produced and available on the PHAC website by 16h00 EDT on Fridays. A French version is also available.
  • The Pandemic (H1N1) 2009 Epidemiological Summary is produced generally on a weekly basis and is sent internally to P/T partners (Chief Medical Officer of Health [CMOH], influenza surveillance partners). Discussions are under way with Communications to make this report accessible to a wider audience. 
  • An International Pandemic (H1N1) 2009 Situation Update is provided to the CMOH and F/P/T partners on a weekly basis.
  • There is weekly reporting of qualitative indicators to PAHO (Pan American Health Organization)/WHO.
  • Ongoing ad-hoc requests from F/P/T decision-makers are addressed.

CIRID reports hospitalizations and deaths of non-Canadian residents to relevant countries through the IHR channel.

CIRID notifies the IHR focal point for Canada, WHO/PAHO, of unusual influenza events (cases with antiviral-resistant Pandemic (H1N1) 2009 virus, cluster of SRI, novel influenza strains, etc.) as per IHR requirements.

Other roles of PHAC-CIRID include chairing and organizing weekly (or bi-weekly) F/P/T conference calls to discuss technical and operational surveillance issues. CIRID also oversees the IMPACT and the FluWatch sentinel physician networks.

A.3 Special Topics

A.3.1 Obesity

An attempt should be made to collect obesity information from all Pandemic (H1N1) 2009 hospitalized and fatal cases. When weight in kilograms and height in centimetres are available on patient charts both can be documented on the case report form or line list.  PHAC will convert this information and calculate the body mass index (BMI). If only weight is available, please indicate this. When “obesity“is mentioned on the chart, please report it, irrespective of the severity of the obesity (whether obesity, morbid or severe obesity).

A.3.2 Remote or Isolated Community

An attempt should be made to collect this information from all Pandemic (H1N1) 2009 hospitalized and fatal cases if the community or Regional Health Authority where the patient resides is considered isolated and/or remote by the specific P/T.

Remote Community:
A remote community is located ≥200 km or ≥4 hours away from a community with an acute care hospital but where year-round road access is available. 

Isolated Community:
An isolated community has no year-round road access. There may be air access, and ground access may be seasonal.

Appendix A:  Case Definitions

Laboratory-Confirmed Pandemic (H1N1) 2009 case
Person with (or without) clinical symptoms confirmed by one of the following tests:

  • Reverse-transcriptase polymerase chain reaction (RT-PCR)
  • Viral culture
  • 4-fold rise in Pandemic (H1N1) 2009-specific neutralizing antibodies.Footnote 11

Influenza-Like Illness
Acute onset of respiratory illness with fever and cough and with one or more of the following: sore throat, arthralgia, myalgia or prostration, which could be due to influenza virus.
N.B. In children under 5 years, gastrointestinal symptoms may also be present. In patients under 5 or older than 65 years, fever may not be prominent.

Hospitalizations with Pandemic (H1N1) 2009
Any person admitted to hospital with laboratory-confirmed Pandemic (H1N1) 2009 influenza.Footnote 12

Deaths with Pandemic (H1N1) 2009
A death occurring in any person with laboratory-confirmed Pandemic (H1N1) 2009 influenza with no period of complete recovery between illness and death.

Influenza and Pandemic (H1N1) 2009 Influenza Outbreaks in Health Care Facilities and Residential Institutions (e.g. hospitals, long-term care facilities, correctional facilities, supportive living facilities)
Two or more cases of ILI within a seven-day period, including at least one laboratory-confirmed Pandemic (H1N1) 2009 case.

Influenza and Pandemic (H1N1) 2009 Influenza School OutbreakFootnote 13
Greater than 10% absenteeism OR absenteeism that is higher than baseline levels, determined by schools or the surveillance region, that is likely due to ILI.

Other Community Outbreaks of Influenza and Pandemic (H1N1) 2009 Influenza (e.g. small communities or workplacesFootnote 14)
Two or more cases of ILI within a seven-day period, including at least one laboratory-confirmed Pandemic (H1N1) 2009 case.

Unusual Respiratory Event
Reporting of unusual events may require collaboration with non-official influenza surveillance partners or groups in your area. Some examples of unusual activity include the following:

  • A large Pandemic (H1N1) 2009 outbreak in a closed or semi-closed setting.
  • Cluster of epi-linked SRI cases or epi-linked Pandemic (H1N1) 2009 cases admitted to ICU or deaths.

Appendix B: Severe Respiratory Illness Case Definition

The case definition for reporting SRI is applicable to any person meeting all of the following four criteria (I, II, III and IV):

SRI case (A)

A person admitted to hospitalwith the following:

I. Respiratory symptoms, i.e.

  • FeverFootnote 15 (over 38 degrees Celsius) AND new onset of (or exacerbation of chronic) cough or breathing difficulty

AND

II. Evidence of severe illness progression, i.e.

  • Either radiographic evidence of infiltrates consistent with pneumonia, or a diagnosis of acute respiratory distress syndrome (ARDS) orsevere ILIFootnote 16, which may also include complications such as encephalitis, myocarditis or other severe and life-threatening complications

AND

  • Either admission to the ICU/other area of the hospital where critically ill patients are cared for OR mechanical ventilation

AND

III. No alternative diagnosis within the first 72 hours of hospitalization, i.e.

  • Results of preliminary clinical and/or laboratory investigations, within the first 72 hours of hospitalization, cannot ascertain a diagnosis that reasonably explains the illness.

AND

IV. One or more of the following exposures/conditions, i.e.

  • Residence, recent travel or visit to an affected area where a novel influenza virus or other emerging or re-emerging respiratory virus has been identified (including pandemic (H1N1) 2009) (refer to table of currently affected areas/sites: http://www.phac-aspc.gc.ca/h5n1/index-eng.php).
  • Close contact (including health care providers) of an ill person who has been to an affected area/site within the 10 days prior to onset of symptoms.
  • Exposure to settings in which there had been mass die-offs or illness in domestic poultry or swine in the previous six weeks.
  • Occupational exposure involving direct health care, laboratory or animal exposure, i.e.
  • Health care exposure involving primary care providers exposed to patients linked to an ongoing outbreak investigation or sick/dying animals;

OR

  • Laboratory exposure in a person who works directly with emerging or re-emerging pathogens;

OR

  • Animal exposure in a person employed as one of the following:
    • domestic poultry/swine farm worker
    • domestic poultry/swine processing plant worker
    • domestic poultry/swine culler (catching, bagging, transporting
      or disposing of dead birds/swine)
    • worker in live animal market
    • dealer or trader of pet birds, pigs or other potentially affected
      animals
    • chef working with live or recently killed domestic poultry, swine or
      other potentially affected animals

OR

SRI death (B)

A deceased person with the following:

I. A history of respiratory symptoms, i.e.

  • History of unexplained acute respiratory illness (including fever and new onset of [or exacerbation of chronic] cough or breathing difficulty) resulting in death

AND

II. Autopsy performed with findings consistent with SRI, i.e.

  • Autopsy findings consistent with the pathology of ARDS without an identifiable cause

AND

III. No alternative diagnosis that reasonably explains the illness AND

IV. One or more of the exposures/conditions listed above.

Appendix C: Reporting Templates and Forms

C1. National Pandemic (H1N1) 2009 Line List

Core data elements to be completed for all hospitalized Pandemic (H1N1) 2009 cases and Pandemic (H1N1) 2009 deaths.

Variables

Definition

Reporting date

Date that data are reported to PHAC.

P/T unique ID

Provincial or territorial unique ID.

P/T where case was identified

Reporting province or territory.

P/T where case resides

Province or territory of residence where case resides.

Age in years

Case's age in years as of symptom onset date/specimen collection date/report date

Age in months if <2 years

If case is under 2 years of age, specify age in months

Gender

Specify gender as M=male, F=female or U=unknown

Aboriginal

If case is Aboriginal , specify as Y=yes, N=no or U=unknown

Aboriginal ethnicity

Specify aboriginal ethnicity as 0=Unknown, 1=First Nations, 2=Inuit or 3=Metis

Reserve status

If case has First-Nations ethnicity, specify the reserve status as 1=Primarily On reserve, 2=Primarily Off reserve, 3=Unknown

Registered Indian

If case is First-Nations, specify if they are a registered Indian as Y=yes, N=no, U=unknown

Isolated Community

A case from an isolated community. An isolated community has no year round road access. There may be air access, and ground access may be seasonal.

Remote Community

A case from a remote community. A remote community is located ≥ 200 km or ≥ 4 hours away from a community with an acute care hospital but where year round access is available.

Presence of underlying  medical condition(s)

Presence of any underlying conditions, specify as Y=yes, N=no or U=unknown – Excluding pregnancy, obesity, current smoking

Chronic pulmonary  disease

Case's underlying medical condition (chronic pulmonary disease including: COPD, bronchiectasis, cystic fibrosis, bronchopulmonary dysplasia, etc), specify as Y=yes, N=no or U=Unknown

Asthma

Case’s underlying medical condition (asthma that requires continuous or repeated use of inhaled or systemic corticosteroids or with previous exacerbation, which required hospital admission), specify as Y=yes, N=no, or U=unknown

Chronic heart disease

Case's underlying medical condition (chronic heart disease including congenital heart disease, hypertension with cardiac complications, chronic heart failure and ischemic heart disease), specify as Y=yes, N=no or U=unknown

Diabetes

Case's underlying medical condition (diabetes type 2 requiring insulin or hypoglycaemic drugs or diabetes type 1), specify as Y=yes, N=no or U=unknown

Chronic liver disease

Case's underlying medical condition (liver disease including cirrhosis, chronic hepatitis, biliary atresia), specify as Y=yes, N=no or U=unknown

Kidney disease

Case's underlying medical condition (kidney disease including chronic renal failure, nephritic syndrome or renal transplantation), specify as Y=yes, N=no or U=unknown

Immunodeficiency

Case's underlying medical condition (immunodeficiency related to use of immunosuppressive drugs (e.g. chemotherapy) or systemic steroids, AIDS/HIV infection, asplenia or immune dysfunction), specify as Y=yes, N=no or U=unknown

Anemia  or hemoglobinopathy

Case's underlying medical condition ( including Sickle cell anemia and chronic anemia), specify as Y=yes, N=no or U=unknown

Chronic neurological disease

Case's underlying medical condition (stroke and neuromuscular disease that lead to impaired respiratory function or aspiration such as cerebral palsy or myasthenia gravis), specify as Y=yes, N=no or U=unknown

Other conditions

Other underlying medical conditions, please specify._____________________________

Pregnancy or within first 6 weeks postpartum

Case who is/was pregnant (Pregnancy), specify as Y=yes, N=no or U=unknown

Pregnancy trimester

If case is pregnant, specify the trimester at time of illness as 0=post partum, 1=first trimester, 2=second trimester, 3=third trimester, U=unknown

Patient weight (in kilograms or pounds) if available

Patient weight indicated in kilograms or pounds

Patient height (in centimetres or inches) if available

Patient height indicated in  centimetres or inches

Obesity

As noted in case’s chart, irrespective of severity, specify as Y=yes, N=no or U=unknown

Current smoking

As noted in case’s chart, irrespective of type of smoker, specify as Y=yes, N=no or U=unknown  

Symptom onset date

Date of symptom onset (dd/mm/yyyy)

Specimen collection date

Date of specimen collection (dd/mm/yyyy)

Hospitalization

Was case hospitalized? Specify as Y=yes, N=no or U=unknown

Date of hospitalization

Date on which the case was hospitalized (dd/mm/yyyy)

Discharge

Was case discharged from the hospital? Specify as Y=yes, N=no or U=unknown

ICU

If case has been hospitalized, specify if case admitted to ICU (Intensive care unit) as Y=yes, N=no or U=unknown

Ventilation

If case has been hospitalized, specify if case has been intubated as Y=yes, N=no or U=unknown

Death

If the case has died, specify as Y=yes, N=no or U=unknown

Date of death

Date of death (dd/mm/yyyy)

C2. Weekly Aggregate Reporting of Hospitalizations and Deaths

PDF Version PDF
(1 Page, 35 KB)

C3: Pandemic (H1N1) 2009 Influenza Case Report Form

PDF Version PDF
(3 Pages, 90KB)

C4: Severe Respiratory Illness Case Definition and Report Form

PDF Version PDF
(5 Pages, 90KB)


Appendix D.1: Canadian Nosocomial Infection Surveillance Program (CNISP)

The Canadian Nosocomial Infection Surveillance Program (CNISP) is a collaborative effort of the Canadian Hospital Epidemiology Committee (CHEC), a subcommittee of the Association of Medical Microbiology and Infectious Disease Canada and the Centre for Communicable Diseases and Infection Control (CCDIC) of PHAC. Data belong to CHEC-participating hospitals, which have a role in how the data are analyzed. The data are analyzed at CCDIC.

Since its establishment in 1994, CNISP's objectives have been the following:

  • provide rates and trends of health care-associated infections at Canadian health care facilities
  • provide data that can be used in the development of national guidelines on clinical issues related to health care-associated infections

There are 52 sentinel hospitals in the CNISP network from nine provinces across Canada. In the last three seasonal 'flu seasons (from 2005-2006 to 2008-2009), 15 CNISP hospitals have been involved in conducting laboratory-confirmed influenza surveillance in hospitalized patients >16 years of age.  Eligible patients were those with episodes of influenza that were laboratory-confirmed by a positive rapid antigen test, positive PCR result or a positive culture for influenza A or B.

Changes to CNISP in Response to Pandemic (H1N1) 2009

In order to focus on community monitoring of adult in addition to paediatric disease, a comprehensive hospital-based surveillance system for patients admitted with influenza or acquiring influenza during hospitalization was formulated.  All provincial and territorial authorities were supportive of having this done through CNISP.  As a result, CNISP seasonal laboratory-confirmed influenza surveillance was extended to year-round reporting of both confirmed cases of 'flu and hospitalizations with a possible influenza-associated admitting diagnosis. The number of hospitals in the CNISP influenza network was expanded from 15 to 40 out of 52 CNISP hospitals. The surveillance period is June 1, 2009, to May 31, 2010.  In practice, data collection began July 1, 2009. All CNSIP hospitals will be given the choice of doing surveillance for 1) laboratory-confirmed influenza, 2) influenza-associated admitting diagnosis or 3) both.

Strategically, these real-time hospital data are designed to fulfill two goals:

  1. Monitoring (a new function for CNISP)
    • CNISP will provide an alert system to detect increasing numbers of admissions that are potentially related to influenza and to monitor influenza-related admissions during the epidemic/pandemic period (increasing, peak and decreasing trend).
  2. Identification of high-risk groups, outcomes and effectiveness of treatment or interventions
    • This will inform decision-makers on a numbers of issues, such as which should be the priority groups for vaccine and antiviral treatment, hospital bed management, etc.

Data Collection

Weekly, participating hospitals submit the following data to PHAC:

  • Aggregate laboratory-confirmed case counts
  • Daily line lists of influenza-associated admitting diagnosis (with date of admission, admitting diagnosis, date of birth and sex)
  • Aggregate count of total weekly admissions for influenza-associated admitting diagnosis

Monthly, participating hospitals submit the following:

  • Case report forms, based on retrospective chart review (Annex D2)
  • outcome data (follows when available)

Quarterly, participating hospitals submit the following denominator data to PHAC:

  • number of adult admissions (if not submitted with the weekly reporting)
  • number of adult patient days
  • number of influenza tests performed on inpatients.

Descriptive Data Analysis

  • Rate of admitted influenza cases per 1,000 admissions
  • Rate of health care-associated cases per 10,000 patient days
  • Variability between geographic regions (Western, Central and Eastern Canada) and/or provinces and territories in rates of testing and in rates of disease
  • In the event of a re-activation of HP-EOC (Health Portfolio - Emergency Operation Centre to Level 3 or 4, rates may be calculated by Canadian city
  • Burden of illness will be estimated as mortality (influenza as primary or contributing cause) and acute length of stay (truncated at day 30)
  • Analysis of antibiotic and antiviral management
  • Bacteremia

Additionally, all the following denominators of each participating facility must be submitted:

  • Number of adult admissions
  • Number of adult patients days
  • Number of influenza tests performed on inpatients

Potential changes to CNISP in Response to Pandemic (H1N1) 2009

Primary analysis of CNISP data will be descriptive. In addition to the indicators mentioned above, CIRID has been asked to specify analyses of greatest interest. The Task Force may wish to consider the highest priorities, including most useful indicators and comparisons, the frequency with which they should be conducted, and with whom and in what formats they should be shared.




Appendix D.2: Surveillance for Laboratory-Confirmed Influenza in Hospitalized Adults 2009- 2010, Patient Questionnaire

PDF Version PDF
(3 Pages, 98KB)

Appendix D.3: Surveillance for Laboratory-Confirmed Influenza in Hospitalized Adults

PDF Version PDF
(1 Page, 33KB)

Appendix D.4: Denominator Information Form for Surveillance for Laboratory-Confirmed Influenza in Hospitalized Adults 2009-2010

PDF Version PDF
(1 Page, 60KB)

Appendix D.5: Case Definitions for Surveillance for Laboratory-Confirmed Influenza in Hospitalized Adults 2009-2010

Laboratory-confirmed
Any test the laboratory reports as confirmed positive for influenza A or B.
Note: if, in the best judgement of a CHEC member, a positive rapid antigen test or PCR test was a false positive, then the case should NOT be included.

Health care-associated
Must meet one of the following criteria:

  1. onset of symptoms is >96 hours after hospital admission
  2. onset of symptoms is 24-96 hours after hospital admission, and, in the best judgement of the infection control professional, illness was acquired in hospital
  3. re-admitted with a positive test <96 hours after discharge from hospital

Appendix D.6: CNISP Hospitals Participating in the 2009-10 Influenza Surveillance Program

Province

City

Hospital

Participating

OptionTable 1 - Footnote 1 *

Table 1 - Footnote 1 *
  • Option 1 - Laboratory-based influenza surveillance
  • Option 2 - Admissions with influenza-related diagnosis
  • Option 3 - Both
Table 1 - Footnote 2
Paediatric febrile respiratory illness

British Columbia

Vancouver

Vancouver General Hospital

Yes

3


Vancouver

Richmond General Hospital

Yes

3


Vancouver

Lion’s Gate

Yes

3


Vancouver

Powell River

Yes

3


Vancouver

St. Mary’s Hospital

Yes

3


Vancouver

Squamish Hospital


3


Vancouver

Victoria General


3


Vancouver

Royal Jubilee




Vancouver

Children’s and Women’s Health Center



Alberta      

Calgary

Peter Lougheed




Calgary

Rockyview General




Calgary

Foothills Hospital




Calgary

Alberta Children’s Hospital

Yes

Peds FRITable 1 - Footnote 2


Calgary

Rockyview Hospital




Edmonton

University of Alberta Hospital

Yes

3


Edmonton

Stollery Children’s Hospital

Yes

Peds FRITable 1 - Footnote 2

Saskatchewan

Saskatoon

Royal University Hospital

Yes

3

Manitoba

Winnipeg

Health Sciences Centre

Yes

3


Winnipeg

University of Manitoba, Paediatric Infectious Diseases

Yes

Peds FRITable 1 - Footnote 2

Ontario

London

St. Joseph’s Health care




London

Children’s Hospital of Western Ontario




London

Victoria Hospital




London

University Hospital




Toronto

Toronto Western Hospital

Yes

3


Toronto

Toronto General Hospital




Toronto

Princess Margaret Hospital




Toronto

Mount Sinai Hospital

Yes

3


Toronto

Sunnybrook Health science Centre

Yes

1


Toronto

The Hospital for Sick Children

yes

Peds FRITable 1 - Footnote 2


Kingston

Kingston General Hospital




Hamilton

Hamilton Health Sciences Centre

Yes

3


Hamilton

McMaster Site

No



Hamilton

Chedoke

No



Hamilton

Henderson & General Sites

No



Hamilton

St. Joseph’s Healthcare

Yes

1


Ottawa

The Ottawa Hospital

Yes

(Sept)


Ottawa

Civic Site

Yes



Ottawa

General and Heart Institute

Yes



Ottawa

Children’s Hospital of Eastern Ontario

Yes

Peds FRITable 1 - Footnote 2

Quebec

Montreal

SMBD-Jewish General Hospital

Yes

3


Montreal

Montreal Children’s Hospital

Yes

Peds FRITable 1 - Footnote 2


Montreal

Maisonneuve-Rosemont Hospital




Montreal

Montreal General Hospital

Yes

3


Montreal

Royal Victoria Hospital

Yes

3


Montreal

Montreal Neurological Hospital

Yes

3


Montreal

Montreal Chest Institute

Yes

3


Sherbrooke

CHUS Hopital Fleurimont

No



Quebec City

Hotel-Dieu de Quebec du CHUQ

no


New Brunswick

Moncton

The Moncton Hospital

Yes

3

Nova Scotia

Halifax

QEII Health Sciences Centre

Yes

3


Halifax

IWK Health Centre

Yes

Peds FRITable 1 - Footnote 2

Newfoundland

St John’s

Health care Corp. of St. John’s General & Miller Sites




St John’s

Janeway Site




St John’s

St. Clare Site



Appendix E: Immunization Monitoring Program Active (IMPACT)

The Immunization Monitoring Program Active, also known as IMPACT, is a paediatric hospital-based national active surveillance network for adverse events following immunization (AEFI), vaccine failures and selected infectious diseases (that are or are soon to be vaccine preventable). The core surveillance targets funded by PHAC include AEFI, pertussis, varicella, invasive pneumococcal disease, Haemophilus influenzae all types, acute flaccid paralysis and influenza. IMPACT is also involved in other surveillance activities financed by the private sector for targets such as invasive meningococcal disease and rotavirus.

IMPACT is administered by the Canadian Paediatric Society with funding from the Centre for Immunization and Respiratory Infections Division of PHAC. IMPACT was started in December 1990 as a pilot project in five paediatric referral centres across Canada.  It now involves 12 tertiary care level paediatric centres across the country, representing 90% of all tertiary care paediatric beds in Canada. The 12 IMPACT centres consist of the following:

  • Alberta Children's Hospital, Calgary, AB
  • BC Children’s Hospital, Vancouver, BC
  • Centre Mère-Enfant de Québec (CHUQ), Québec City, QC 
  • Children’s Hospital of Eastern Ontario, Ottawa, ON
  • CHU-Sainte-Justine, Montreal, QC
  • IWK Health Centre, Halifax, NS
  • Eastern Health Janeway Child Health and Rehabilitation Centre, St. John’s, NL
  • Montreal Children’s Hospital, Montreal, QC
  • Royal University Hospital, Saskatoon, SK
  • Stollery Children's Hospital, Edmonton, AB
  • The Hospital for Sick Children, Toronto, ON
  • Winnipeg Children’s Hospital, Winnipeg, MB

Influenza became a surveillance target in 2004 when the Influenza Pilot Study was first instituted. At that time, the IMPACT surveillance objectives for influenza were as follows:

  • surveillance of influenza hospitalizations in children
  • ascertainment of the clinical presentation and outcomes of the cases and their immunization status
  • Data analysis, to be done on overall data and by centre, by size of reporting centre and by geographic representation

Each centre has a designated nurse monitor. The nurse monitor is responsible for identifying all influenza-related hospital admissions and deaths by review of daily admission lists, laboratory results and discharge lists, based on selected ICD-9/10 coding. Aggregate data and information from case report forms are sent to PHAC electronically, and the relevant information is re-distributed to provincial and territorial health authorities, Canadian health care practitioners and the general public.

On a weekly basis aggregate data are collected to report influenza activity in the paediatric population. These include the following:

  • IMPACT centre
  • Sex
  • Age group
  • 'Flu type
  • Number of deaths

Annually, an analysis is made from the information gathered in case report forms.  Here are the main categories of the information collected:

Demographic
  • Date of birth
  • Sex
  • Date of admission
General Health
  • Conditions for which influenza immunization is recommended
Immunization History
  • Immunization status
  • Immunization history
Laboratory Diagnosis
  • Test performed
  • Influenza type
Treatment
  • Antiviral treatment given
  • Antibiotic treatment given
Clinical Manifestations
  • Date of onset
  • Symptoms
  • Laboratory-confirmed 2° bacterial infections
Level of Care Required
  • Duration of hospital stay
  • Care in ICU
  • If ventilator used
Outcome
  • Survived
  • Died
Travel History
  • Traveled to Asia, Europe or Africa in 10 d prior to onset
  • Household contacts have similar symptoms and traveled to Asia, Europe or Africa

Changes to IMPACT in Response to Pandemic (H1N1) 2009

In response to the emerging pandemic in Canada, the weekly electronic aggregate data reporting has continued. However, as indicated above, since week 17 (April 26-May 2, 2009) the number and proportion of laboratory-confirmed influenza-associated paediatric hospitalizations and deaths attributable to Pandemic (H1N1) 2009 virus have been posted on FluWatch on a weekly basis. In terms of case reporting, the IMPACT-specific case report form is completed.

As for case report form analyses, because of the scope and seriousness of this pandemic it has been recommended that as of July 23, 2009, an analysis be performed twice a month to better follow the trend of serious cases and pinpoint other identifying factors that could assist in the understanding and clinical management of patients infected with Pandemic (H1N1) 2009 influenza virus. This analysis will be specified and conducted by CIRID.

With the discontinuation of detailed case reporting as part of the enhanced FluWatch system, detailed information on hospitalized influenza cases will now be available only through the IMPACT and CNISP sentinel networks. Therefore, the objectives and deliverables associated with IMPACT data have been modified, and contract negotiations are currently under way. Data will be available for preliminary analysis in a more real-time way than in the past. Changes to the Case Report Form may need to be implemented to assist in the clinical description of hospitalized cases, including potential addition of the following (or other) fields:

  • Health status: underlying conditions such as obesity
  • Treatment: when antivirals and antibiotics were given (start and end dates)
  • Complications: more description on complications during hospitalization (e.g. multiorgan system failure, ARDS, pulmonary embolism)

Special surveillance studies will need to be specified on the basis of nationally determined priority questions.




Appendix III. Example of Detailed Case Report Form from Pandemic (H1N1) 2009

Pandemic (H1N1) 2009 Flu Virus Case Report Form
Only Confirmed Cases to be Reported to Public Health Agency of Canada (PHAC)
Please fax completed form to Public Health Agency of Canada (613) 946-880

PDF Version PDF
(2 Pages, 47KB)


Footnote 1
Refer to the Public Health Measures, Annex M of the Canadian Pandemic Influenza Plan.
Footnote 2
RIORP is an agreement between federal/provincial/territorial governments to guide the operating procedures to assist in coordinating the investigation and control of severe respiratory outbreaks in Canada.
Footnote 3
At the federal level, regular environmental scanning for the detection of potentially significant influenza-like illness is conducted using official information sources for influenza surveillance (e.g. WHO and international government influenza surveillance programs) as well as unconfirmed reports from early warning systems (e.g. ProMed and other media scanning software such as the Global Public Health Intelligence Network). Provinces and territories receive regular summaries of the international situation through the Canadian Integrated Outbreak Surveillance Centre (CIOSC).
Footnote 4
During the interpandemic phases, these data(FluWatch) will be reported on a weekly (during the influenza season) and bi-weekly (during the summer months) basis
Footnote 5
The Immunization Monitoring Program ACTive (IMPACT) is a paediatric hospital-based national active surveillance network for adverse events following immunization, vaccine failures and selected infectious diseases in children that are, or are soon to be, vaccine preventable.
Footnote 6
Refer to the Public Health Measures, Annex M, of the Canadian Pandemic Influenza Plan.
Footnote 7
The level of enhanced surveillance will depend on the location of the first case(s) in Canada as well as the risk assessment and whether the cases arise in Canada or are imported cases and novel viruses arising in Canada.
Footnote 8
Although it is considered unlikely that a pandemic strain will first emerge in Canada, the public health system needs to be prepared to deal with this possibility. Public Health Alerts need to address the situation for both imported and domestic cases.
Footnote 9
Refer to the Public Health Measures, Annex M, of the Canadian Pandemic Influenza Plan.
Footnote 10
Please note that the recommendation differs slightly from that for other notifiable diseases, for which the "Protocol for Interprovincial/territorial Notification of Disease” states: The jurisdiction where the disease is diagnosed normally notifies the federal level or has the responsibility to make sure that the disease is notified by some jurisdiction.
Footnote 11
At this time serology is not recommended as a front line testing procedure because of concerns pertaining to sensitivity and specificity as well as the intensity of labour associated with hemagglutination inhibition (HI) assays.
Footnote 12
Provinces/territories may decide whether this case definition of hospitalization applies to someone who is admitted for a short period for observation. In this instance a “short period” is defined as <24 hours. Patients admitted to hospital for other reasons in whom Pandemic (H1N1) is an incidental finding (e.g. some obstetric or psychiatric patients) are still considered hospitalized cases with Pandemic (H1N1) 2009.
Footnote 13
Newfoundland/Labrador regularly reports workplace outbreaks according to the definition used for school outbreaks in a separate reporting field on the CNPHI report form. All other provinces and territories sporadically report workplace outbreaks using the definition of “other” community outbreaks.
Footnote 14
Newfoundland/Labrador regularly reports workplace outbreaks according to the definition used for school outbreaks. All other provinces and territories may sporadically report workplace outbreaks using the definition of “other” community outbreaks.
Footnote 15
As per the influenza-like illness (ILI) definition, fever may not be prominent in patients under 5 years or 65 years and older as well as in immunosuppressed individuals. Failure to take temperature should not rule out a history of self-reported fever.
Footnote 16
Severe ILI: In addition to the symptoms of ILI, severe ILI may include complications such as encephalitis, myocarditis or other severe and life-threatening complications

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