Robert Koch Institute, Berlin, Germany

Health in aviation: research work by the Robert Koch Institute, Berlin, Germany

Dr. Yanina Lenz

Department for Infectious Diseases Epidemiology

2nd CAPSCA Meeting, Frankfurt‐am‐Main July 3d, 2012

Robert Koch Institute

• Central German federal institute for disease control and prevention • Serves the Federal Ministry of Health as a central scientific institution in the field of biomedicine • > 700 employers • Headquarters: Berlin • www.rki.de

1 Department for Infectious Diseases Epidemiology

• Routine surveillance of infectious diseases • Analysis of reported data • Sentinel surveillance • Outbreak investigations • Early detection of epidemics • Represents the Institute in EU and WHO networks • Training of field epidemiologists • Research

Research initiatives

• RAGIDA: completed When to initiate contact tracing? • REACT: completed • KoNA: on‐going • AIRSAN: application submitted

2 RAGIDA

• Risk Assessment Guidelines for Infectious Diseases transmitted on Aircrafts • ECDC tender (2007): • Objective: to develop a tool aiding decisions for contact tracing of infectious diseases potentially transmitted on aircrafts

RAGIDA

• Tuberculosis • Diphtheria • Influenza • Ebola • SARS • Marburg Virus • Meningococcal disease • Lassa • Measles • Smallpox • Rubella • Anthrax

3 Transmission onboard: what is considered important?

Symptoms of Proximity: index patient Seating position during flight Pathogen-specific in relation to attributes: index patient transmission mode Quality and quantity of contacts Flight time to index patient incl. ground delays

Susceptibility Board techniques: of contact person HEPA system Functional ?

Slide by T. Eckmanns 7

ECDC Guidance. Risk assessment guidelines for diseases transmitted on aircraft. 2009 8

4 REACT

• Response to Emerging Infectious Diseases: Assessment and Development of Core Capacities and Tools • Funded by EU Health Programme • Project duration 2008‐2011 (30 months) • Scientific work packages • WP1: International contact tracing after exposure to infectious diseases in public ground conveyances (RKI, Germany) • WP2: Surveillance of infectious diseases during mass gatherings (PZH, Poland) • WP3: Surveillance of outbreaks in health care workers (HPA, UK) • WP4: Reporting of IHR relevant events from local to national level (NIHP, Norway)

REACT

• Development of a tool aiding decisions:

CT‐RAP Contact Tracing Risk Assessment Profile

• Tuberculosis • Meningococcal disease • Measles

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CT-RAP: Tuberculosis Low Indication for CT Neutral Position High Indication for CT

1. Symptoms of index case during exposure period (Sym) Please select the value representing the worst symptom during exposure

Sym (I) Cough Sym (II) Unspecific symptoms OR asymptomatic Sym (II) Sym ( I ) 2. Infectiousness of index case during exposure (Inf) Please select the most infectious value Inf (I) No t reatment OR inadequat e drug treatment OR < 2 weeks of adequate drug treat ment Inf (II) > 2 weeks of appropriat e drug treat ment and improvement of symptoms in the absence of Inf (II) Inf (I) any suspicion or proof of multidrug resistant tuberculosis 3. Drug resistance pattern of index case ( R) Please select the drug resistance pattern

R ( I ) Extensively drug-resistant R ( I ) CT‐RAP: Tuberculosis pulmonary TB OR multidrug resistant pulmonary TB R ( I I ) Pulmonary TB without drug resist ance R (II)

4. Transmission to other contact person(s) (T) Please select the value representing any evidence of t ransmission

T (I) Evi dence of transmission T (II ) No evi dence of transmission T (II) T (I) 5. Quality of contact between contact person(s) and index case (Q) Please select the value representing t he closest interaction

Q (I) Face-to-face conversation with index case Q (II) No social interaction Q (II) Q (I) 6. Proximity of contact person(s) to index case during exposure (Prox) Please select the closest distance of any passenger to the index case Prox (I) Prox ( I) Distance ≤ 1 m Prox ( II ) Distance > 1 m Prox(II) 7. Duration of exposure of contact person(s) to index case (Dur) Please select the longest duration of contact between any passenger and the index case

Dur (I) Duration ≥ 8 h Dur (II) Duration < 8 h Dur (II) Dur (I) 8. Susceptibility of contact person(s) (Sus) Please select the value representing the most susceptible individual among the passengers Sus ( I ) < 5 years of age, H IV infection, substance abuse, silicosis, diabetes mellitus, immunosuppressive t reat ment Sus ( I I ) Immunocompetent Sus ( I I ) Sus ( I ) 9. Environmental factors in means of transport (E) Please select the value representing t he environmental factors

E ( I ) No external vent ilation (wit h or E ( I ) without circulation) E ( I I ) External vent ilation (wit h air exchange) E (II)

Low Indication for CT Neutral Position High Indication for CT

6 CT-RAP: Tuberculosis Low Indication for CT Neutral Position High Indication for CT

1. Symptoms of index case during exposure period (Sym) Please select the value representing the worst symptom during exposure

Sym (I) Cough Sym (II) Unspecific symptoms OR asymptomatic Sym (II) Sym ( I ) 2. Infectiousness of index case during exposure (Inf) Please select the most infectious value Inf (I) No t reatment OR inadequat e drug treatment OR < 2 weeks of adequate drug treat ment Inf (II) > 2 weeks of appropriat e drug treat ment and improvement of symptoms in the absence of Inf (II) Inf (I) any suspicion or proof of multidrug resistant tuberculosis 3. Drug resistance pattern of index case ( R) Please select the drug resistance pattern no information R ( I ) Extensively drug-resistant R ( I ) CT‐RAP: Tuberculosis pulmonary TB OR multidrug resistant pulmonary TB R ( I I ) Pulmonary TB without drug resist ance R (II)

4. Transmission to other contact person(s) (T) Please select the value representing any evidence of t ransmission no information T (I) Evi dence of transmission T (II ) No evi dence of transmission T (II) T (I) 5. Quality of contact between contact person(s) and index case (Q) Please select the value representing t he closest interaction

Q (I) Face-to-face conversation with index case Q (II) No social interaction Q (II) Q (I) 6. Proximity of contact person(s) to index case during exposure (Prox) Please select the closest distance of any passenger to the index case Prox (I) Prox ( I) Distance ≤ 1 m Prox ( II ) Distance > 1 m  Prox(II) 7. Duration of exposure of contact person(s) to index case (Dur) Please select the longest duration of contact between any passenger and the index case

Dur (I) Duration ≥ 8 h Dur (II) Duration < 8 h Dur (II) Dur (I) 8. Susceptibility of contact person(s) (Sus) Please select the value representing the most susceptible individual among the passengers Sus ( I ) < 5 years of age, H IV infection, substance abuse, silicosis, diabetes mellitus, immunosuppressive t reat ment  Sus ( I I ) Immunocompetent Sus ( I I ) Sus ( I ) 9. Environmental factors in means of transport (E) Please select the value representing t he environmental factors

E ( I ) No external vent ilation (wit h or E ( I ) without circulation) E ( I I ) External vent ilation (wit h air  exchange) E (II)

Low Indication for CT Neutral Position High Indication for CT

CT-RAP: Tuberculosis Low Indication for CT Neutral Position High Indication for CT

1. Symptoms of index case during exposure period (Sym) Please select the value representing the worst symptom during exposure

E ( I ) No external vent ilation (wit h or E ( I ) without circulation) E ( I I ) External vent ilation (wit h air  exchange) E (II)

Low Indication for CT Neutral Position High Indication for CT

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Research initiatives

• RAGIDA: completed When to initiate contact tracing? • REACT: completed How does it happen in real life? • KoNA: on‐going • AIRSAN: application submitted

8 KoNa

• Kontaktpersonen‐Nachverfolgung bei möglicher Übertragung von Infektions‐Krankheiten in Verkehrsmitteln Contact tracing in international travel: air, ground, water • German national prospective study • Project duration: 01.03.2012 – 28.02.2013

• Tuberculosis • Measles • Meningococcal disease • Varicella • Hemorrhagic fevers • SARS

KoNa

• Aims: • Review of exisiting contact tracing guidelines and recommendations • Assessment of frequency and reasons for and against contact tracing • Assessment of existing obstacles while conducting contact tracing • Evaluation of succes rate of contact tracing • Evaluation of usage and usefullness of the REACT and RAGIDA tools as a decision aid

9 Research initiatives

• RAGIDA: completed When to initiate contact tracing? • REACT: completed How does it happen in real life? • KoNA: on‐going • AIRSAN: application submitted How to coordinate response internationally?

Coordinated action to control infectious diseases transmission on the aircrafts: AIRSAN

10 Framework of the Call

Background

• Rapid increase in number of people travelling by air • No formal arrangements exist at EU level to coordinate response to cross‐border public health threats • Existing mechanisms differ between the EU MS => possible delays in responses

11 Aim

• To support MS in IHR implementation by setting up the base for coordinated efficient information exchange in case of serious cross‐ border threats

General objectives

• To create across all EU Member States a functioning Network of: • national public health authorities • local public health authorities at location of airports • airport management responsible for public health events • airlines • SOPs and guidelines on control of infectious diseases transmission on the aircrafts: • to review existing • to develop new • to implement across the Network

12 Call requirements

• The Network should cover at least: • Main hub airports in the EU MS (min 8 MS and around 10 airports) • Involve major European airlines (min 8 airlines with a total No of 300 vectors)

Built on

• REACT • SHIPSAN • RAGIDA • CAPSCA

Coordinated by • Robert Koch Institute, Berlin, Germany • Department for Infectious Diseases Epidemiology, Surveillance Unit

13 Asssociated partners

1. National Institute for Public Health and the Environment (RIVM), Netherlands 2. University of Thessaly, Laboratory of Hygiene and Epidemiology, Greece 3. National Institute of Public Health, National Institute of Hygiene, Department of Epidemiology, Poland 4. Federal Public Service of Public Health, Food Chain Safety and Environment, SANIPORT, Belgium 5. KLM, Netherlands 6. ICAO, Department for Aviation Medicine, European Office 7. FRAPORT AG, Medical Services, Germany

Collaborating partners

• Swiss Federal Department of Home Affaires DHA, Swiss Federal Office of Public Health (Dr Jennifer Saurina) • Deutsche Lufthansa AG, Medical Services (Professor Jürgen Graf) • Air France, Medical Services (Dr Vincent Feuillie)

14 Scientific Advisory Board

• WHO Europe • ECDC • IATA • German Federal Ministry of Transport, Building and Urban Development • ACI‐Europe (expression of endorsement)

Work Packages

Work Title Co‐ordinator Package

WP 1‐3 Coordination, dissemination, evaluation RKI, Germany

WP 4 Creation of an AIRSAN Network and testing its RKI, Germany functionality

• Survey • Systematic review of exisiting SOPs in the field • Development of new SOPs • AIRSAN Network buidling • Field testing of new SOPs in real time or simulation events

15 Work Packages

Work Title Co‐ordinator Package

WP 5Development of an interactive communication e‐ UTH‐EL, Greece platform • E‐platform for national and local public health authorities, airlines and airports • Built on SHIPSAN platform • Public and password‐protected domains • Pilot at at least 5 competent authorities and airports

Work Packages

Work Title Co‐ordinator Package

WP 6Development of a training module RIVM, Netherlands

• Development of tabletop and simulation exercises • Piloting the exercises • Free‐internet access to training materials

16 • Planned time‐frame: January 2013 – December 2014 (24 months) • Decision: early September 2012

Yanina Lenz Department for Infectious Disease Epidemiology Robert Koch Institute E‐Mail: [email protected]