‘113072020 ORIGINAL RESEARCH RH: Rural and Remote Health acl: 3784 - A rapid post-saster suvelance model enabiing outbreak detection and healthcare resp. Rural and Remote Heath horgau James Cook University ISN 1445-6354 A rapid post-disaster surveillance model enabling outbreak detection and healthcare response following earthquakes on Kefalonia island, Greece, February-May 2014 AUTHORS. ‘Crysovalats sites! MSc, EIT Fellow * Kassiani Mellou® Dr Christopher Williams? Dr, EPIET coordinator Eleni Tiantafylou' MSc George Rigakos* Dr, Medial doctor Eleni Papoutsidou® Dr, Medical doctor Katerina Tekou” RN, Registered nurse ‘Spyridon Likiardopoulos" Dr, Medical doctor GerasimosPantlos RN Registered suse Georgios Kou! Dr, Medial doctor Georgios Christodoulaki"” br, Medical doctor Theano Georgskopoulou”? Or Emmanouil Velonaks! Professor, Professor Christos Hadjichristodoulou" Professor, Professor Yiannis Tselentis"S Professor, Professor ‘CORRESPONDENCE + dhysovalantissvestros AFFILIATIONS: * European Programme for Intervention Epidemiology Training, European Centre for Disease Prevention and Control Stockholm, Swesden 25.672 Hellenic Center of Disease Control and Prevention, Marousi, Greece ‘sweden 4 Hellenic Center of Disease Contral and Prevention, Marousi, Greece 89 General Hospital of Argostoiou,Argostol, Kefalonia 19.11 General Hospital of tixouriou, Livousi Kefalonia “National School of Pubic Heath, Athens, Greece European Programme for Intervention Epidemiology Training (EPIET), European Centre for Disease Prevention and Contra, Stockholm, «Department of Hygiene and Epidemiology, Medical Faculty, Unversity of Thessaly, Larisa *S Faculty of Medicine, University of Crete, Heraklion, C PUBLISHED. hitpsshwww.rh.orgaullounalartl/3744 181113072020 RH: Rural and Remote Health arco: 3744 - A rapid post-dsaster survl 7 March 2017 Volume 17 Issue 1 3Nce madel enabling outbreak detection and healthcare resp, HISTORY RECEIVED: 13 October 2015 REVISED: 22 October 2016 ACCEPTED: 5 December 2016 CITATION Sivestos C Meliou , Wiliams C, WantafllouE,Rigakos G, PapoutsidouE, Tsckou K,Likiardopoulos S, Pantlios G, Kou G, CChristodoulakisG, Georgakopoulou T, Velonaks E Hacichristodoulow C,Teelentis¥, A rapid post-lsaster surveillance model enabling ‘outbreak detection an healthcare response flloting earthquakes on Kefalonia island, Greece, February-May 2014, Rural and Remote Health 2017; 17: 3744, hetps//do.org/10 22605/RRH3744 © chrysovalanti sivestros, Kasiani Mellou, Christopher Willams, Elen Trantafyllou, George Rigakos, Eleni Papoutsidou, Katerina Tsekou, Spyridon Likiardopoulos, Gerasimos Pantelios, Georgios Kours, Georgios Christodoulakis, Theano Georgakopoulou Emmanouil Velonaki, Christos Hadjichristodoulou, Yiannis Tselents 2017 A licence to publish this material has been given to James Cook Unversity, jewedau ABSTRACT: Intreduetion: In early 2014, earthquakes struck the island of Kefalonia in Greece, causing damage to facies and houses. An ‘onsite investigation concluded that existing suneilance systems might not have been able to identify events of public health interes Methods: A syndrome surveillance system was implemented and an additional system was designed for strengthening surveillance at the mest affected area, Paik The fist system was a dally reporting system of respiratory, gastrointestinal) including seven healthcare services ofthe island three clinical syndromes (fever, scribes the implementation of the two systems, presents their results, evaluates their performance and present the lessons leaned from this experience Results: The evaluation ofthe systems showed they performed well and fulfiled their objectives. One gastroenteritis out identified, enabling the timely implementation of control measures. Conclusions: Strengthening surveilance not only assured the timely Identification of possible events of public health interest but also reassured the authorities and the population of the absence of a isjor event. The second system involved the local mayors in reporting any ‘unusual health event in the villages of thee jurisdiction, The two. systems were in force from 7 Februay to 31 May 2014, This atile Key words: disease outbreak, earthquake, Greece, Kefalonia, natural isaster, public health surveillance, syndrome survellance, FULL ARTICLE: Introduction (On 26 January and 3 February 2014, two earthquakes of magnitude 6.1 struck Kefalonia island (35 801 permanent residents’ in westem Greece, The epicenter, Pale is located 9 km from the capital at the westem peninsula of Kefalonia, with a population of 6500 residents, There was severe damage at one of the two local hospitals, the health care center, approximately 1500 houses of Paki and the water supply system, Displaced residents were offered shelter at two cruise ships that arrived atthe island on 28 January and 8 February 2014 and stayed for 22 and #4 days, spectively, ‘On 3 February, the Hellenic Centre for Disease Control and Prevention (HCDCP) was informed through the mediat$ about the occurrence of gastroenter he ships. An onsite investigation conclided this was a fase alarm; however, it also revealed that existing surveillance systems might not have been able to identify similar evens in a timely manner. As a result, the implementation of a syndrome surveilance system (S55) was decided. It was also noted that the population living in alk! area had a limited access to local healthcare services due to the damaged read network and thus an addtional system was designed for strengthening survllance at this area, This antcle aims to describe the implementation of the two systems, present their results, evaluate their performance and present the lessons learned from this experience, Methods systems Syndrome surveillance system: The objective of the SSS vias to detect in a timely manner clusters or outbreaks requiking immediate action and to provide reliable epidemiolagical information to the municipality of Kefalonia and the lacal public health authorities. The authors identified seven healthcare services to use as reporting sites the two public hospitals, the local healthcare center, the two community centers and the medical centers of the two cruise ships). Reporting was case-based and a single-page form was created hitpsshwww.rh.orgaullounalartl/3744 261113072020 RH: Rural and Remote Health arco: 3744 - A rapid post-dsaster survl including demographic and symptoms data. A separate form was uted for zero reporting. Notifications were sent daily by midday (including weekends) via fax or email directly to HCDCP, HCDCP personnel actively sought reports not received on time by caling the assigned contact points, The population under surveillance was all residents and visitors on the island frorn 7 February to 31 May 2014 Based on the literature on communicable diseases that have been associated with similar natural disasters, and taking into account the pre-earthquake health stats ofthe population, vaccination coverage, the relatively good living coneitions and the capacity ofthe local laboratories to perform routine testing, the authors decided to include fever, respiratory and gastrointestinal syndromes in the SSS. The definitions were based on the US Centers for Disease Control and Prevention syndrome definitions? (Table 1). Also, data providers were asked to report any unusual health event/condition. ‘The authors provided one-day raining tothe identified contact points ofthe medical services on case defintions, filing inthe forms ete and allthe material was uploaded atthe web page ofthe local medical association. The contact points were informed that this was 2 lca provisional and time-imited system that cd not replace the existing reporting systems ‘A database was created with the use of EpiData and data analys's was performed with Stata v12 (StataCorp; httpiwwwmstata.com) The number of reports per day, by syndrome, reporting site place (nine municipalities) and type of residence (household or shelte) were recorded, 25 well asthe response rate (number of passively collected reports per reporting day) for each reporting sit [An alarm was defined as an increase in the observed numberof syndrome reports inthe same municipality exceeding the mean number ‘of reports for the three previous days plus two standard deviations Alarms due to single cases were excluded. Each alarm was investigated by epidemiologists of HCOCP in cooperation withthe lacal public health directorate (PHO), Table 1: Syndrome definitions, Kefalonia syndrome surveillance system, Kefalonia island, Greece, February - May 2014 as — coer [RBS tn gh mens sen thon a ah episy dcew in cidenaged sa mtaines0Umepermiie gees yes ofseereepratayaese nanan aieaby ‘sini nr bested oes oon waa ‘akc Te re Seay SHE HST TST RSA TOSTTAE 3 omit rth oue andere vent wit ‘snyoanan at oainoun eh Fa gee ESC ar US TT AT Pali enhanced surveillance system: The objective of the Palki enhanced surllance system (PSS) vas ta abtain health information ‘rom local authortes inorder to detect unmet healthcare needs including outbreaks and unusual events, which could then be addressed by directing healthcare resources to this remote area, The system was based on the network of mayors of the municipal authorities Residents were asked to report ay illness to mayors and contacted mayors daly (at 1000 am) by phone, asking if there was any Unusual health event inthe villages of their jurisdiction. Each report was followed up. Ths system was in force until 31 May 204 Evaluation of the systems In order to evaluate the SSS, timeliness (time interval between examination and reporting), sensitivity and completeness (percentage of passively collected reports by reporting site and percentage of missing information by field) wee addressed. For the evaluation ofthe PSS, acceptability (proportion of the lacal authorities that agreed to partcpate in the system) and sensithity (comparing the number of ‘outbreaks reported tothe system with reports fom other sources such as other survsllance systems, PHD and macla) were addressed, Ethics approvat Personal data were protected according to Greek Inw (2472/1997). HCDCP personnel are legally authorised to use personal dats for surveillance purposes (8204/23-12-2003), all the data were kept using personal information protection policy in compliance with the Helsink’ Declaration and were used only for surveillance purposes Results ‘Syndrome surveillance system From the 1423 notifications of the SS5, 54% were zero reports, of which the vast majority (88%) were actively collected by HCDCP personnel. The response rate varied among the reporting sites (495%), ‘Overall 646 syndromes were recorded: 397 (61%) fever, 158 (258) respiratory and 90 (74%) gastrointestinal cases. Most of the cases were ‘esider's living in ther own houses (95% and only 496 of the cases were residents staying ona crise ship, hitpsshwww.rh.orgaullounalartl/3744 Ince madel enabling outbreak detection and healthcare esp,1119072020 RH: Ruraland Remote Health ancl: 9744 - A rapid post disaster surveliance model enabling outbreak detection and heatheare resp. From the evaluation of the 61 alarms (7 gastrointestinal, 27 respiratory and 27 fever, only one alarm of gastrointestinal syndrome was \verfad as an outbreak The tru alarm was a cluster of 2 gastroenteritis cases among soldiers that had consumed a meal prepared by the same catering company. Soldiers developed diarrhea and abdominal pain 6-7 hours after consuming a meal on 14 February. The company had prepared 400 portions that day, which had been distibuted throughout the island, The ype of symptoms, the onset and duration {less than 24 hours) and the lack of secondary eases indicated this was probably a food poisoning caused by 2 toxin. No clinical sample was collected for laboratory t The PHD closed down the catering compary for 10 days 50 that the appropriate measures could bt ing, An inspection took place at the premises of the company and several hygiene failures wee identified taken. Recommendations to all possible consumers to dispose of any lunch boxes prepared that day by the company led to the disposal of 250 lunch boxes, possibly preventing the occurrence of more cases. No further eases were reported. Paliki enhanced surveillance system ‘The PSS system hal 20 reports (ever cases and inflenza-ike cases). No outbreak was identified after investigation and no public heath action was required. Evaluation of the systems For SSS, the time interval from examination to reporting was 1 day (ange 0-4 days). The percentage of the reports through SSS received ther passively or actively from the reporting sites was 100%. The proportion of passively received reports varied between diferent reporting sites. Completeness was above 90% forall variables, The authors were not informed by other sources for any other outbreak luring this perid, so the only known outbreak was identified by the SSS; however 60 cut ofthe 1 alarms were proved to be false ‘The PSS acceptabilty was very high - all mayors agreed to participate. According to the data available, no outbreak was identified in this area atthe same period Discussion Several different approaches have been used for post-lsaster surveillance based on the baseline surveillance systems, the surveillance needs, the population characteristics, and the geographical and political settings”. As with other similar systems used elsewhere, the 55 performed well and fullled its objectivs4™®"2" , and no unexpected or uncommon disease vas reported apart from one gastroenteritis outbreak, verifying thatthe rs fr infectious diseases ater natural disasters is low" "817, ‘The main limitations of the present system were the absence of comparable historical data, andthe low specificity of the system. Setting up a time-seres-based alarm proved helpful Keeping the balance between sensitivity and specificity is always an issue when implementing an S55 given the amount of effort required for investigating false alarms"*2 . Based on the results, setting the alarm ‘threshold from two cases to three or more would have probably been a more efficient choice {As the proportion of active-passive reports showed, telephone reports may have been 2 more suitable choice than fax or email reporting due to lack of means at reporting sites, The majariy of zero reports were obtained actively, suggesting that reporters prioritise case reports over zero reporting,» finding consistent with similar systems implemented elsewhere"™"™6 Finally, reporting by non-medical local municipality authontes can be considered for meeting the purposes of suvellance in remote ‘Overall, the authors conclude that even though the risk of major events after a natural disaster in 2 developed county is low, strengthening survsiliance is needed not only for assuring the timely identification of events of public heath interest but also for reassuring the authortes and the population ofthe absence of a major event!™"224 Acknowledgements The authors thank all local mayors, local public health authorities and hospital physicians who contributed to this work, The personnel from the HCDCP and especially Sissy Karadima Theodora Nikolopoulou and Anastasios Konstantopoulos contibuted to setting up the systems, ensured the quality ofthe data and provided administrative support inthe suvellance activities. The authors also thank the local medical association and ll the volunteers who participated in References 1. Hellenic Statistical Authority of the Hellenic Republic Announcement of results ofthe 2017 Census - Houses for permanent population Peraeus, Geece: Greek Statistical Service, 2011 2 Institute of Engineering Seismology and Earthquake Engineering Research and Technical Institue, (Internet) 2074, Preliminary report on the Mw6 1 Cephalonia earthquake of 26th Jan 2014. Avalabe: ttpy/www itsakgr/en/newsinews.offset=10 (Accessed 14 February 2014) 3. Institute of Engineering Seismology and Earthquake Engineering Research ané Technical Institute. Strang ground motion ofthe February +3 2014 (66.0) Cephalonia earthquake: effects on sol and built environment in combination with the January 26, 2074 (ME.1) event {lnteret) 2014. 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