Surveillance for Severe Acute Respiratory Infection as one approach to enhance Global Health Security in Indonesia

Background: The existing national surveillance system for severe acute respiratory infection (SARI) provides critical information on influenza virus circulation, provides a system to control influenza outbreaks that threaten the safety and security of the population and feeds data into the global influenza surveillance and response system (GISRS). Indonesia’s ability to detect and control communicable diseases is critical for global health security. The aim of this study was to assess the SARI surveillance system and utility for monitoring other priority pathogens as an effort to enhance global health security. Methods: Surveillance attributes were assessed by reviewing records, data analysis and through interviewed with staffs involved in the surveillance system. All patients at six sentinel hospitals who meet the SARI case definition during May 2013 – April 2015 were enrolled. Epidemiological and virological data were analyzed. The surveillance system utility for its influenza surveillance objectives and flexibility to support surveillance of emerging infectious diseases were assessed. Resuts: A total of 1,806 SARI cases were reported of which 1,697 (94%) had specimens tested for influenza viruses. Of those tested, 200 (12%) were positive, of which 46% were influenza A(H3N2), 18% A(H1N1)pdm09 and 37% influenza B viruses. The system exceeded the targets of >80% adherence for most attributes: 95% for completeness of online reporting, 100% for cases adhering to the case definition, 94% for cases with specimens collected and 100% of laboratory results uploaded to the online database. A surveillance system for dengue and other arbovirus infections was established in the outpatient/emergency units at the SARI surveillance sentinel. Conclusion: SIBI was adjusted to incorporate surveillance for other priority diseases indicating its utility and flexibility to support global health security. (Health Science Journal of Indonesia 2018;9(1):8-13)

2][3] The existing national surveillance system for severe acute respiratory infection (SARI) provides critical information on influenza virus circulation, provides a system to control influenza outbreaks that threaten the safety and security of the population and feeds data into the global influenza surveillance and response system (GISRS). 4 learn how Indonesia's SARI surveillance system might serve additional surveillance functions such as monitoring for emerging infectious diseases, its utility and flexibility was evaluated.Indonesia's SARI surveillance system, Surveilans Infeksi Saluran Pernapasan Akut Berat Indonesia (SIBI) was established in May 2013 in accordance with the World Health Organization's (WHO) influenza surveillance standards. 5Sites were established at inpatient wards in four district and two provincial hospitals that were geographically dispersed (Figure 1). 6The aim of this study is to enhance global health security, countries might consider adjusting existing surveillance systems to detect other priority pathogens.

METHODS
Nasal and throat swabs were collected and a questionnaire for clinical and demographic variables was administered from all patients that meeting the SARI case definition according to WHO influenza surveillance guideline. 5e SIBI's utility for its influenza surveillance objectives and flexibility to support surveillance of emerging infectious diseases were assessed in May 2015, 2 years after the system was established (Table 1). 7Utility was assessed by determining if (1) the system outputs were fulfilling the system's stated objectives and (2) the system processes were meeting surveillance attribute targets (Table 1).Flexibility was assessed by determining whether the system's data collection and analyses could be modified for surveillance of emerging infectious diseases including MERS CoV and dengue.SIBI's guideline, monthly bulletins, quarterly site-monitoring visit reports, and surveillance data for May 2013 -April 2015 were reviewed for supporting evidence. 8is

Surveilans Infeksi Saluran Pernapasan Akut Berat
Indonesia addressed all of its stated objectives (Table 1).In May 2013 -April 2015, a total of 1,806 SARI cases were reported of which 1,697 (94%) had specimens tested for influenza viruses.Of those tested, 200 (12%) were positive, of which 46% were influenza A(H3N2), 18% A(H1N1)pdm09 and 37% influenza B viruses.Detailed clinical and epidemiological findings for both SARI and influenza cases were reported in the SIBI monthly bulletin (Table 2). 8Data on underlying medical conditions and patient outcomes can be used to identify risk groups for future preventive measures including vaccination. 9e system exceeded the targets of >80% adherence for most attributes: 95% for completeness of online reporting, 100% for cases adhering to the case definition, 94% for cases with specimens collected and 100% of laboratory results uploaded to the online database.The timeliness of each site's online reporting of cases increased over time but only 14-52% of cases were reported by the targeted Monday midnight deadline.The key challenges for prompt online reporting of cases include the availability of internet connection in rural areas and the availability of administrative staff for data upload.

Flexibility
Even though SIBI was established with the objective of conducting routine influenza surveillance, it demonstrated flexibility to incorporate surveillance of emerging infectious diseases including MERS CoV and novel influenza A(H7N9) virus.This flexibility was a result of adjusting two aspects of the system in December 2013: (1) updating variables collected to include travel history, and (2) adjusting the laboratory testing algorithm so that SARI cases with travel history to affected countries could be tested for MERS CoV or A(H7N9) virus infection.SIBI's capacity to test for emerging infectious diseases especially for MERS CoV was critical because approximately 1.2 million Indonesians undertake pilgrimage to Saudi Arabia each year and the risk of virus introduction was deemed high. 10,11ithin 3 weeks of adjusting SIBI, the first suspect case of MERS CoV was detected and tested negative.guidelines to the sentinel sites to ensure that case enrolment, questionnaire administration, specimen collection, and reporting were correct. 12 2014, as a result of improved performance on surveillance system attributes, a further innovation was introduced at each hospital site.A surveillance system for dengue and other arbovirus infections was established in the outpatient/emergency units.This system, known as Sistem Surveilans Sentinel Dengue, was established in September 2014 and provides data on regional dengue serotype trends and patient clinical presentation.SIBI and Sistem Surveilans Sentinel Dengue enable cost efficiency as specimens are shipped together (from sites up to 1500 miles away) to the Ministry of Health laboratory and the administrative resources are shared. 13This innovation was based on the WHO influenza standards that recommended introduction of surveillance for other priority syndromes at SARI hospital sites. 4

DISCUSSION
The SIBI has operated for over three years in Indonesia and yields high quality data from geographically dispersed hospitals.However, as the system is relatively new and timeliness of online case reporting is still below target, there is a need to continually strengthen its operation.With only six sites, SIBI cannot replace nationwide indicator or event-based surveillance systems for the detection of emerging infectious diseases such as MERS CoV.However, SIBI serves as a second line of defense for the detection of newly emerging diseases as sites are actively searching for patients meeting the case definition.As SIBI operates year-round, it helps maintain the continuous operation of surveillance capacities such as laboratory diagnostic skills, specimen collection supplies, supply management and specimen shipment chains.This enhances Indonesia's readiness for emerging infectious diseases and other disease threats.
This evaluation, in context of the system's utility and flexibility to address global health security needs, found that SIBI is highly valuable in addressing the current objectives for influenza surveillance as well as flexible for incorporating surveillance for other emerging infectious diseases.Future SIBI enhancements envisioned include work on other vaccine-preventable illnesses, including pneumococcal disease and respiratory syncytial virus infection, to provide baseline data for programmatic and policy decision-making.
For global health security, it is important for countries to increase disease surveillance capacities, including surveillance for emerging infectious diseases.Indonesia's success is critical as it is the world's fourth most populous country that spans over 3000 miles (5000 km) with increasing international travel and trade.Indonesia's severe acute respiratory infection surveillance system (SIBI), which focuses on influenza surveillance, was evaluated to assess its broader surveillance flexibility. 12,14BI successfully addressed the current influenza surveillance objectives, by exceeding 4 of 5.By adding additional variables and testing algorithms, it was sufficiently flexible to incorporate surveillance for other emerging infectious diseases such as Middle East Respiratory Syndrome Coronavirus. 15The inpatient system for influenza was also augmented by an outpatient surveillance system for dengue to increase cost efficiency.
In conclusion, The existing surveillance systems can be adjust to detect other priority pathogens and enhance global health security.Indonesia is investing in geographically-dispersed surveillance sites to generate high quality data that can inform various disease control programs.

Table 1 .
Evaluation methods and findings for SIBI assessment, May 2013 -April 2015 May 2015, 21 cases of suspected MERS CoV were detected by SIBI and all tested negative.At each adjustment of SIBI, the Ministry of Health provided refresher training, monitoring, and updated Abbreviations: SARI=Severe acute respiratory infection; GISAID=Global Initiative on Sharing Avian Influenza Data, MERS CoV=Middle East Respiratory Syndrome Coronavirus.By