Introduction of the Infectious Disease Surveillance System in China

Feng Zijian, MD, DirectorOffice of Disease Control and Emergency Response, Chinese Center for Disease Prevention and Control

June 5, 2007 , Jacksonville, FL, U.S.A

Health System in China

MOH

Provincial Health Department

PrefectureHealth Bureau

County/DistrictHealth Bureau

China CDC

Provincial CDC

Prefecture CDC

County CDC

Township Disease Control Group

Provincial Hospital

Prefecture Hospital

County Hospital

Community hospitalTownship Hospital

Leading role Guiding role

Coordination Office for environmental &Occupational health and Food safety

Coordination Office for environmental &Occupational health and Food safety Organization Structure of

China CDC National Institute forNutrition and Food SafetyNational Institute forNutrition and Food SafetyOffice of Disease

Control &Emergency Response

Office of Disease Control &Emergency Response

National Institute for Environmental Health &Related Product Safety

National Institute for Environmental Health &Related Product Safety

National Immunization Program (NIP)

National Immunization Program (NIP)

National Institute for Communicable Disease Control & Prevention

National Institute for Communicable Disease Control & Prevention

Office of NCD Prevention & Community HealthOffice of NCD Prevention & Community Health

National Institute for Occupational Health &Poison Control

National Institute for Occupational Health &Poison Control

National Institute for Viral Disease Control & Prevention

National Institute for Viral Disease Control & Prevention

National Center for Chronic and NCD Control & Prevention

National Center for Chronic and NCD Control & Prevention

National Institute for Radiological Protection &Nuclear Safety

National Institute for Radiological Protection &Nuclear Safety

National Center for TB Control & PreventionNational Center for TB Control & Prevention

Office for Public HealthPolicy research

Office for Public HealthPolicy research

National Center for Public Health Information ServicesNational Center for Public Health Information Services

National Institute for Parasitic DiseaseNational Institute for Parasitic Disease

National Center for Maternal and Child HealthNational Center for Maternal and Child Health

Office of Epidemiology ProgramOffice of Epidemiology Program

National Center for AIDS/STD Control & Prevention

National Center for AIDS/STD Control & Prevention

National Institute for Health EducationNational Institute for Health Education

Office of DirectorsOffice of Directors

Office of HRDOffice of HRD

Office of FinanceOffice of Finance

Office of Int’ CooperationOffice of Int’ Cooperation

National Center for Rural Water Supply Technical Guidance

National Center for Rural Water Supply Technical Guidance

Chinese Internet based reporting began on Jan

1, 2004 and covers 37 infectious diseases

Notifiable Infectious Diseases

• plague, cholera

• SARS, AIDS, hepatitis, poliomyelitis, human infection of HPAI, measles, EHF, rabies, encephalitis, dengue, anthrax, bacillary & amebic dysentery, TB, typhoid fever, meningitis, pertussis, diphtheria, neonatal tetanus, scarlet fever, brucellosis, gonorrhea, syphilis, leptospirosis, schistosomiasis, malaria

• influenza, mumps, rubella, conjunctivitis, leprosy, typhus, kala-azar, echinococcosis, filariasis, infectious diarrhea.

Internet-based Reporting System of NotifiableInfectious Diseases

DisseminationReporting Management Application

Data Center of China CDC

Information Application and Dissemination

Data Collection

Application ServiceData

Center

Hospitals

Township Hospitals

County CDC

Others

MOH

Health Bureau

CDCs

Others

Internet, B/S, VPN

Real-time Reviewing

Analysis Report

Monitoring and

Analysis

Data Mining

Percent of hospitals covered by internet-based system by province,2007

县级以上医院网络报告率（%）

90 至 10080 至 9070 至 8060 至 70

????

海南省

香港澳门

内蒙古自治区

甘肃省 天津市河北省北京市

山西省

辽宁省

吉林省

上海市

黑龙江省

江苏省

贵州省 湖南省

宁夏回族自治区

陕西省

广东省广西壮族自治区

青海省

江西省

安徽省

浙江省

河南省

山东省

西藏自治区 湖北省

云南省

新疆维吾尔自治区

重庆市四川省

福建省

台湾台湾

94.9%

Percent of Township hospitals covered by internet-based system by province,2007

乡镇卫生院网络报告率（%）

90 至 100 (5)80 至 90 (9)70 至 80 (6)60 至 70 (1)50 至 60 (2)10 至 50 (8)

???? 香港澳门

天津市

安徽省

江西省

海南省

内蒙古自治区

甘肃省 河北省

北京市

山西省

辽宁省

吉林省

上海市

黑龙江省

江苏省

贵州省 湖南省

宁夏回族自治区陕西省

广东省广西壮族自治区

青海省

浙江省

河南省

山东省

西藏自治区 湖北省

云南省

新疆维吾尔自治区

重庆市四川省

福建省

台湾

70.3%

Percent of cases reported by hospital/clinic type

Hospi t al s66. 97%

Townshi pHospi t al s

12. 89%

CDCs11. 98%

Ot her s8. 16%

Total No. of Internet-based Reporting Units : 67232

Cases of brucellosis by week,2004-2007

0

200

400

600

800

1000

1 5 9 13 17 21 25 29 33 37 41 45 49 1 5 9 13 17 21 25 29 33 37 41 45 49 1 5 9 13 17 21 25 29 33 37 41 45 49 1 5 9 13 17 周

报告病例数

2004 2005 2006 2007

Cases of brucellosis by county through January 1 to May 31,2007

0

20

40

60

80

100

120

140

160

180

200

1-1

1-6

1-11

1-16

1-21

1-26

1-31 2-

52-

102-

152-

202-

25 3-2

3-7

3-12

3-17

3-22

3-27 4-

14-

64-

114-

164-

214-

26 5-1

5-6

5-11

5-16

5-21

5-26

5-31 月-日

例审核日期

Health protection officer (HPO) collects new cases from doctors and enters data

• Clinical reports– Doctors fill card to give to HPO

– Doctors call HPO to get case data

– HPO goes to collect cases from doctors

• Laboratory input– Some HPOs go to laboratory to confirm clinical cases

– Some HPOs go to laboratory to identify cases

– Doctor can update reports with HPO

Do doctors and HPOs use case definitions?

• They apply them to high priority diseases.– Measles, polio, HIV/AIDS, pulmonary TB, SARS,

Human HPAI

• MOH published simplified diagnostic criteria for case reporting in 1989– These are not generally used

– Doctors use “experience” to diagnose for reporting

Capacity for laboratory confirmation depends on province and hospital

• High level hospital– Viral isolation– Special serologic tests

• Average hospital– Culture and identification of common bacteria– Smears for microscopy– Hepatitis B surface– HIV screening – Widal tests

• Township level– No Lab test at township level

Hospitals may request local or regional CDC for diagnostic assistance

• Hemorrhagic fever (hantavirus)

• Plague F-1 antibody

• Japanese B encephalitis IgM

• Streptococcus suis identification

• Influenza isolation and identification

• Brucellosis (Rose Bengal and agglutination)

• And many more

Some infectious diseases are always confirmed at the CDC (county to province)

• Province

– HIV– Polio– SARS– HPAI

• Lower level

– Measles IgM– Malaria– TB– Cholera– Diptheria

Diseases of Unknown Cause

• Many infections not tested

• Negative laboratory specimens are not

retested for other organisms

• Special training of doctors and HPO to

identify unusual cases is needed

• No service for diagnosis of unusual cases

• No funds for testing of unknowns

What are the most important next steps for the laboratory in surveillance?

• Laboratory network• Quality management• Clarify the role of the public health laboratory

– Basic Research?– Applied research?– Service?– Generate revenue?

• Advocate to national and provincial governments• Increase laboratory activity• Select syndromes of high priority for increased

sampling

The enhanced system covers 17 of the 37 notifiable diseases

• 31 provinces (all)• 762 sentinel sites• Laboratory confirmation• Epidemiologic Case investigation• Pathogen characterization• Antibiotic resistance• Vector surveillance• Reservoir surveillance• Serosurveys• Environmental surveillance

Three High Priority Infectious diseases are included

• Hepatitis B– Cross-sectional survey every 10 years

• Tuberculosis– Registry– Follow-up for case management

• HIV/AIDS– Registry– Follow-up for case management

The 14 other included diseases are:

• Plague• Cholera• Typhoid• Dysentery (Shigella)• Meningococcal disease• Hemorrhagic fever

– (hantavirus)

• Measles• AFP (polio)• Neonatal tetanus

• Malaria• Rabies • Brucellosis• Leptospirosis• Anthrax• Japanese B

Encephalitis• Schistosomiasis

China-US Collaborative Programs on Emerging and Re-emerging Infectious Disease

• Sub-project1: Strengthening Surveillance Rapid Response and

Containment of H2H Transmission of AI Virus

Sub-Project 2: Field Epidemiology Training Program-AI

Sub-Project 3: Field Epidemiology Training Program

Sub-Project 4: Knowledge Center Development

Sub-Project 5: Development of Laboratory Management System

• Sub-Project 6: Building Capacity for Laboratory-base Surveillance

for Emerging Food-related Diseases

• Sub-Project 7: International Emerging Infectious Diseases Program

• Sub-Project 8: Laboratory Safety

•Thank you!