French Pacific territories workshop. Conclusions and recommendations

Transcription

1 French Pacific territories workshop Conclusions and recommendations 1. Overall conclusions: A workshop for the French Pacific Territories organized by SPC s Public Health Division was held in collaboration with the InVS (French Health Surveillance Agency) and WHO at SPC Headquarters in Noumea from 22 to 25 February. It brought together health professionals from the three French Pacific territories. The purpose of the workshop was to allow the three French territories to discuss common issues and plan the responses and solutions that could be applied to each one, share their experiences and, in this way, enhance the public health work carried out by each territory. The themes discussed made it possible to get updates on the Influenza A (H1N1) and DEN 4 epidemics that affected the French Pacific territories in 2009 and on control strategies for tuberculosis, leptospirosis and rheumatic fever, share information and experiences and identify areas for upcoming joint efforts. The exchanges between health professionals, both in plenary session and in work groups, allowed the formulation of a certain number of recommendations, given in detail below, designed to improve and harmonise the territories approaches to the surveillance, diagnosis and prevention of the workshop s target diseases. In addition, a series of more general recommendations designed to improve surveillance and diagnosis and strengthen collaboration between the territories were formulated: Surveillance It is important to clearly differentiate the objectives of individual diagnosis and population surveillance; Surveillance efforts should produce data that are comparable in space and time; The territorial network needs to be organised and administered with information and training for staff, active follow up in the event there is no response, and coordination (role of the DASS NC [New Caledonia Health and Social Affairs Department] or the BVS [French Polynesia Health Surveillance Office]). This should include systematic communication of surveillance information between agencies and offices; o A guide to facilitating a national surveillance network would be useful and should be part of the syndromic surveillance proposed to the region o The geographic coverage of the surveillance network must take into account potential entry points for epidemic diseases It would be advisable to hold consultations, outside crisis periods, focussed on the surveillance system and how to structure it better during periods of crisis. Laboratory The various rapid diagnostic tests on the market need to be evaluated on a regular basis, with recommendations and standardisation for the region ; Standardisation or harmonisation of laboratory diagnostic algorithms between the different territories is recommended. This should lead to differentiating between dengue fever, influenza and leptospirosis, as well as between results for individual diagnoses and those for public health purposes, and to defining cases ; Response from French national reference centres (CNR), particularly CNR tuberculosis and leptospirosis, should be improved with the assistance of the InVS. 1

2 Collaboration Set up a monthly systematic tele or video conferences between the surveillance units and programs in the three territories, via Internet if possible, with the secretariat based at SPC; Hold an annual workshop to exchange experiences and harmonise practices. SPC was also asked to hold a training session in 2010 on strategic communication in health for health professionals from the three territories as preparation for both the recommended KAP surveys on tuberculosis and dengue fever and formulating a Combi plan for rheumatic fever. 2. Tuberculosis : Tuberculosis is still a significant public health problem in the French Pacific territories. After a rapid drop in incidence beginning in the late 1990s, for the past several years a levelling off has been noted and recently even trends toward increases in incidence in New Caledonia and Wallis and Futuna, which need to be confirmed. Incidence rates are normally between 20 and 30 cases of tuberculosis per 100,000 inhabitants in New Caledonia and in French Polynesia, i.e. rates that are much higher than those in metropolitan France, in particular. In 2009, the incidence rates for all types of tuberculosis were, respectively, 18 per 100,000 inhabitants in French Polynesia, 26 per 100,000 in New Caledonia and 66 per 100,000 in Wallis and Futuna. Improving adherence to treatment and reducing mortality The persistence of a high number of deaths from tuberculosis in New Caledonia (9 deaths in 2008) and in French Polynesia (2 deaths in 2008), along with the high number of relapses are causes for concern. TB monitoring treatment, which is sometimes difficult to arrange, and screening, which often comes too late, would appear to be the main causes. Explore the causes of deaths during TB treatment through a systematic study of case files ; Improve early diagnosis through awareness raising and on going training for health professionals ; Improve the availability of diagnostic tools in cases with complex clinical pictures ; use the PCR technique on disease materials in certain cases ; Get a better understanding of the population, hindrances to using the health care system and obstacles to treatment ; carry out a KAP survey and identify the role of traditional medicine ; Strengthen therapeutic education for patients and psycho social care for both patients and their wider circle of family and friends; Maintain and strengthen the network between health professionals: meetings, communication with reference physicians. Improve the external quality control system for TB microscopy tests In French Polynesia, two laboratories (Hospital and Malardé Institute) do microscopy tests and cultures but use different techniques; another private lab (Paofai Clinic) only does microscopy tests. Antibiograms are not done locally but by the CNR in metropolitan France. There is no reference lab for mycobacteria. In New Caledonia, the New Caledonia Pasteur Institute (IPNC) is the reference laboratory for mycobacteria and does microscopy tests, cultures and antibiograms for New Caledonia and Wallis and Futuna. Two private labs also do TB microscopy tests in New Caledonia. 2

3 Up to now, external quality control, particularly for microscopy, has been carried out by the reference lab in Brisbane, Australia but in a very spotty and infrequent manner. Implement regular external quality control for all the labs that do AFB testing in the French territories, in conjunction with the InVS and the CNR in metropolitan France; Facilitate double blind readings between the different labs, at least in the same territory ; Give scheduling and management to a third party that has the authority to require that all the parties submit to its controls ; Identify a single reference laboratory in French Polynesia. Biosecurity International and national (metropolitan France) recommendations require that Class 3 agents be handled in an enclosed Level 3 bio security lab. However, these regulations are not enforced in the territories. This does not keep labs from complying with the recommendations as far as possible while taking local capacities into consideration. So, for the moment, none of the French Pacific territories has an enclosed Level 3 laboratory. The IPNC A is preparing a proposal for a Level 2+ bio security lab and the future medical complex will have a Level 3 lab. In the same way, the French Polynesia Hospital in Tahiti is supposed to be equipped with this kind of facility when the new hospital is built. In addition, a French Government/French Polynesia/Malardé Institute project contract is designed to equip the Malardé Institute (ILM) with such a facility. There will, then, have to be some kind of coordination and cooperation between the various partners of these two territories in order to centralise culture/antibiogram activities if, by chance, the decision were to be made to implement the national and international recommendations. Improve TB detection rates According to WHO estimates, TB detection rates are high in New Caledonia (87%) and in French Polynesia. However, they could be improved, particularly by setting up an active screening strategy for certain high risk populations. Carry out active TB screening in the wider circle of people around high risk families, among people with weak immune systems and in high risk communities (the homeless and prisons) Continue the screening strategy for close contacts of infectious cases, as previously recommended at the TB workshop in November 2008, using both the TST test and x rays, in line with local capacities. Update recommendations on the indications for gamma interferon release assays During the workshop on TM case contact investigation strategies for the French territories SPC held in Noumea in November 2008, recommendations were made about the use of interferon assays. Since then, these tests have been used on a wide scale in French Polynesia, mainly by FP Hospital doctors as an aid for diagnosing active tuberculosis. A private laboratory in New Caledonia also offers the test but the test is not reimbursed by the health insurance programs. So, the recommendation on using these tests, particularly as part of public health programs needed to be updated. These tests can be worthwhile for individual patients: o as an aid in diagnosing extra pulmonary forms of TB, but with oversight of prescriptions 3

4 o before beginning anti TNF treatment o to diagnosis LTBI in adults at risk, e.g. close contacts, certain people with impaired immunity In terms of using these tests for other reasons, particularly for diagnosing LTBI in children aged 5 to 15, it would be better to wait for HAS recommendations and their inclusion in the health insurance program s lists ; In terms of public health investigations, these tests cannot be recommended for systematic LTBI screenings for adults as long as the hindrances to accepting preventative treatment or the extension of DOTS have not been eliminated. 3. Dengue fever Dengue fever is a major public health concern in the French Pacific territories, where it is endemo epidemic. The most recent DEN 4 outbreak began in New Caledonia in 2008 and spread to Wallis and French Polynesia in early While of moderate severity, it led to five deaths in New Caledonia, including three of unidentified DEN 1 and 2 serotypes; it caused 100 hospitalisations in French Polynesia and mobilised public health and vector control teams in all three territories. Surveillance and prevention and control plan Adapt the territorial plan by using WHO s regional plan; Appoint a territorial program manager to guide and monitor implementation of the territorial plan; Ensure that dengue fever is included in the territorial planning efforts carried out as part of implementation of the IHR (2005), e.g. setting up systems for early detection and reporting outbreaks to WHO as part of the IHR; The three territories should try to standardise and harmonise case definitions : o by using the new WHO recommendations on categorising severity levels, o suspected/confirmed case classification can be used for surveillance purposes, o suspected/positive/confirmed case classification can continue to be used by laboratories and to guide public health measures (perifocal vector control efforts) Compiling and summarising surveillance data from the three territories on a regular basis as a coordinated effort by SPC and the InVS ; Develop a standardised common approach to estimating the total number of cases during an outbreak ; Carry out prospective seroprevalence surveys, e.g. pregnant women, hospitalised children, in order to gather data needed for estimating the percentage of asymptomatic cases, the level of immunity and the total number of cases during an outbreak; The three territories should also formulate and share with clinical and health staff common dengue fever diagnostic algorithms, if possible with the support of WHO/SPC, to allow surveillance, public health measures, and patient care; Identify, on the basis of New Caledonia s experience, a minimum entomological surveillance network feasible in the three territories (already in place in Wallis and Futuna). Vector control efforts Vector control is the key pin of dengue fever prevention. In New Caledonia, the emergence of resistance changed the vector control strategies the townships were using. In French Polynesia, vector control efforts are the responsibility of the Health Department, which does not have any effective focal points in the townships. Vector control strategies to be adopted in the event of resistance to pyrethrinoids : 4

5 o Localised spraying alternating pyrethrinoids and organophosphates ; o Assess the use of lethal nesting traps (bifenthrine) together with well targeted Malathion spraying; o Strengthen larval control efforts, which have a lower impact on the environment ; o Communication with civil society: change communication methods by seeking out contacts with associations, informing them, promoting them and making them information focal points to pass on messages ; A lot of interest in how the disease is seen and the various stages of the chain of transmission for dengue fever. Formulate messages adapted to different target groups. Carry out a KAP survey so as to adapt communications strategies ; Develop public/private partnerships to decrease the weight of vector control efforts. o Raise awareness in the private sector about the usefulness of control efforts given the economic consequences of outbreaks 4. Leptospirosis Leptospirosis, a zoonotic disease that is widespread in the Pacific and has a variety of animal hosts such as rats, pig and deer, is an important public health problem, particularly in the French Pacific territories. Not only does it represent a high cost in terms of both care for severe cases and mortality, its incidence in the French territories is among the highest in the world. Futuna is aptly known as a paradise for leptospirosis. The annual incidence per inhabitants is, respectively, 100 ( 500 in certain zones) in New Caledonia, 35 (150 in certain zones) in French Polynesia and > 1000 on Futuna, with a specific mortality of nearly 5 % in New Caledonia and about 3% in French Polynesia, but only a single death on Futuna since The incidence of leptospirosis increases during the rainy season and also under the influence of an ENSO climate (El Nino). Reduce the incidence and mortality of leptospirosis Improve knowledge about leptospirosis epidemiology and risk factors in order to effectively target public health actions; Improve early diagnosis of the disease by raising awareness among and providing on going training for health professionals: all suspected cases of leptospirosis must be given immediate antibiotic treatment in appropriate doses even before lab results are received; Better inform and educate the population using simple messages, e.g. If you have a fever for more than half a day, go and see your doctor!; With the French territories, SPC, the InVS and WHO are going to explore the possibilities for funding and support to allow better understanding and long term epidemiological monitoring so as to decrease the public health aspect of this problem. Information on the costs generated by the disease and on leptospirosis incidence and mortality rates will be used to do this. Improve activities designed to confirm cases of leptospirosis The value here is, above all, epidemiological since suspected cases should receive immediate treatment. Continue discussions with the IPNC in order to identify the conditions that would allow PCR typing from the 1st sample for the other territories ; 5

6 The availability of a reliable rapid test is vital for the region; Given the low practical value of taking samples in order to diagnose patients, feedback to general practitioners is vital so as to encourage them to take samples for epidemiological surveillance. Strengthen collaboration between human and animal health Leptospirosis is an infection of animal origin and, as such, requires a joint animal human health approach for both epidemiological identification of the problem and prevention activities. This is within a wider context of collaboration between human health and animal health as part of efforts to control zoonotic diseases that affect human health. Create a human health/animal health working group with a set calendar and objectives, focussed particularly, but not exclusively, on leptospirosis ; Develop a joint animal health/human health project for zoonotic disease prevention and control, taking a multi factoral and multi disciplinary approach; Harmonise lab techniques and share information on results between the two sectors; Begin or continue joint animal health/human health messages about zoonotic diseases for the general public. 5. Influenza The first wave of pandemic flu reached the French Pacific territories early in the second half of It gave rise to a rapidly spreading outbreak that affected about 16 to 18% of the population in New Caledonia, 17% in French Polynesia and 31% in Wallis and Futuna (symptomatic cases only). It also led to 10 deaths (including 7 confirmed) in New Caledonia, 7 confirmed deaths in French Polynesia and no deaths in Wallis and Futuna (respective mortality of 4, 3, and 0 per 100,000 inhabitants), and it pushed health services to the very limits of their capacities. A second wave, whose size is difficult to predict, is possible in the fairly near future. Vaccination is the best public health protection measure for this disease and is currently available. Due to the moderate severity of the pandemic and the controversy it generated in the media, immunization coverage is very low in the territories. There are differences in how French Polynesia and New Caledonia approach influenza surveillance. Surveillance At the international level, PacNet and the surveillance implemented by WHO worked well. The territories surveillance systems successfully detected the beginning of the local outbreaks and monitored their evolution. Certain aspects could, however, be improved. Discussions need to be held in regards to syndromic and virological surveillance of flu pandemics : fairly comprehensive and wide (sensitive) surveillance before the virus enters the territory so as to be able to rapidly detect the first cases and limit the scope of transmission ; surveillance through sentinel networks for monitoring the pandemic ; The objectives of flu and dengue fever surveillance may differ and call on two different networks or else on the same network. However, the costs generated by increasing the number of networks must be taken into account; 6

7 In the event that combined dengue fever influenza surveillance is adopted, during periods of a double outbreak, it must be carried out on all suspected cases of dengue fever or the flu from whom samples have been taken ; This surveillance must not lose sight of leptospirosis and can easily be combined for leptospirosis and dengue fever by carrying out two lab tests. Leptospirosis could, in this way, benefit from the dengue fever (flu) network for occasional studies or as a secondary surveillance objective ; French Polynesia should hold discussions with New Caledonia and Wallis and Futuna to try to agree on combined surveillance. At the international level: PacNet worked well but the countries would like to have a summary of the messages and adaptation to the local level ; The weekly surveillance of pandemic flu set up by the WHO could be used for other syndromes/diseases, e.g. dengue fever. Laboratory It is important to thoroughly train health staff in how to use the sampling and transport kits; Existing kits are useful for surveillance and diagnosis of clustered cases and it would be worthwhile having a standardised use protocol for that purpose. They could be used as a diagnostic tool for isolated cases if an algorithm was developed. Communication between the French Government and territories during crisis situations and among French Pacific territories In a view towards better management of international crises and improved communication with the French Government during such crises, the following is needed: o Validate the status and responsibilities of the deputies to national IHR focal points; o Identify, in metropolitan France, ONE health decision maker correspondent to work with the territories on needs and the means for response during crises ; o The InVS DIT could help facilitate the process; o Collaboration and coordination between the three territories on issues of relations with the French Government so as to respond in the most consistent way possible ; o Improve, with the InVS s assistance, the response of the CNRs in France. In order to maintain systematic communication between the three territories in terms of public health issues and public health measures that are appropriate for the Pacific, it is recommended that the following be established : o A monthly tele or video conference bringing together the surveillance units and programs of the three territories, via Internet is possible, with the secretariat component provided by SPC ; o Sharing surveillance bulletins between the three territories, with the information sent out whenever there are updates to the website ; o annual workshops to be held on a rotating basis with sustainable funding. Communication and behavioural change Recommendation: In 2010 SPC should hold a francophone workshop for the Pacific territories on communications strategies and behavioural change. 7

8 6. Rheumatic fever (RF) RF is a major public health problem in developing countries, affecting more than 15 million people throughout the world, of whom die each year while thousands of others remain handicapped. Some new cases are diagnosed each year. Rheumatic fever and rheumatic heart disease are under diagnosed and under reported and, for that reason, these figures are probably underestimated. In the Pacific region, in the French territories and beyond, RF remains a major public health problem due to its morbidity and mortality (mortality that is probably underestimated given the way death certificates are filled out. These certificates could be improved in terms of this disease) and its economic cost. In New Caledonia and French Polynesia, more than 100 initial stages of RF are diagnosed each year and nearly 2000 patients are receiving on going prophylactic antibiotic treatment as part of secondary prevention. French Polynesia s RF program, which is coordinated by the FP Hospital s cardiology department, is experiencing some difficulties and is supposed to go back to the Health Department in New Caledonia s RF program has very satisfactory results and could serve as a model for the other territories. A certain number of improvements could still be made, however, particularly to overall ultrasound screenings of post rheumatic valve disease, currently done in school year 4 (age group: 9 10 years old); to secondary prevention (frequency, dose of injections and length of treatment and treatment monitoring in the private sector) and, finally, to primary prevention (type of message, target group and message vector). In general: The epidemiology of this disease in the three territories shows that RF mainly affects Pacific islanders. The proposal was made to clearly identify this issue during formulation of RF strategies. New Caledonia s strategy should be cleaned up and Wallis and Futuna s strategy needs to be formalised and French Polynesia s rewritten: The proposal was made to hold a workshop reserved exclusively for sharing experiences and formulating a common strategy that takes into account the Pacific island aspect of this disease and could facilitate its political acceptability. A common approach will allow these problems to be better identified by political authorities and lead to the allocation of resources that better match the human and financial costs of this disease in the territories. Primary prevention It would not be wise to forgo an assessment of its impact even though this is a bit complicated to do. It would be worthwhile clearly identifying the target group, i.e. Pacific island parents and children, along with health professionals who, for the most part come from countries where there are almost no more cases of RF and so, need continuing education and training in how to screen and care for this disease. The messages must be clear and adapted to the target: Educate parents about the need to visit a doctor as so as an ENT or skin infection appears ; 8

9 Carry out a survey of treating physicians to identify the difficulties in using injectable antibiotics to treat sore throats, given that this is the best solution for high risk populations, and compiling their proposals/solutions; Encourage children to pay attention to their bodies and to share their problems with those around them. Educate them about daily hygiene, e.g. blowing their noses, washing their hands ; Make doctor s visits more accessible (free RF visits?) Formulate a Combi plan in collaboration with the three territories, which can then adapt it to their own specific circumstances. Ensuring better compliance with treatment Some kind of therapeutic education program, to be formulated and approved, seems to be a prerequisite to ensuring better compliance with this long, difficult and painful treatment. It needs to be adapted to Pacific island families and to the age of the child. It must be done systematically when the treatment begins and when treatment is recommenced after it had been stopped. In NC s strategy, the proposal was made to follow New Zealand s recommendations and, in order to reduce the painfulness of the injection, to: Decrease the dose to 1.2 million units while keeping a rhythm of 21 days (every three weeks), instead of 2.4 Million for weights higher than 30 kg. Maintain the dose at 2.4 units for all cases where the 21 day rhythm is not feasible and extend the rhythm to 28 days (every four weeks). According to studies, and in countries with high levels of endemism, the best thing is to use the longest course of prophylactic treatment possible. However, while this recommendation does seem unfeasible as an overall strategy, it can be proposed on an individual basis to compliant patients who want to continue their prophylactic treatment. Discuss, with all those involved, a specific protocol for young patients who have difficulty following their treatments on a regular basis by giving the shots at school, taking into account the specific circumstances of the various geographic areas. Managing the pain of this injection should be part of training for health professionals. The pain network that is currently being set up in NC will be asked to propose a protocol for professionals. Organised screenings for rheumatic heart disease; Given the low number of studies available, it is difficult to give specific arguments for or against the strategies to be adopted. Here again the predominant proportion of Pacific islanders in people found to have anomalies during the three years of organised screenings in NC favours more targeted screening of Pacific island children. In NC, keep the year 4 age group (peak at 10 years old) for school screenings. The inclusion of an older age group, about 16 years old, should be discussed ; Ultrasound screening could be recommended as soon as pregnancy is reported. A preliminary study could confirm or invalidate information suggesting that at the time of their first pregnancy, young women may be more likely to relapse during the first trimester of the pregnancy ; 9

10 The proposal was made to have cardiologists record ultrasound loops and ask another cardiologist to read them in cases where the RF diagnosis is difficult to reach ; Develop the cardiologist and screening staff network in the public and private sectors so as to improve screening conditions (reduce the wait between screening and confirmation). 10