RIGHT-SIZING INFLUENZA
VIROLOGIC SURVEILLANCE:
LESSONS LEARNED FROM
A TABLETOP EXERCISE
by Stephanie Chester, MS, senior specialist, influenza programs
Participants taking part in one of the tabletop exercises
APHL and CDC’s Influenza Division launched a multi-year project in 2010 to define the core capabilities and the optimal “right size” for influenza virologic surveillance. A key deliverable of the Right Size Influenza Virologic Surveillance Project is a
roadmap document describing surveillance system requirements
and providing tools to determine appropriate, statistically-based
sample sizes to support surveillance objectives. Implementation of
the roadmap guidelines, beginning in the 2013-14 influenza season,
will help CDC, public health laboratories (PHLs) and surveillance
programs maximize the use of available resources, redirect resources
and build new capacity for effective surveillance.
In December 2012, a tabletop exercise helped evaluate the utility, feasibility and clarity of the requirements outlined in the draft
roadmap document; participants included public health laboratory
(PHL) representatives and epidemiologists or influenza surveillance coordinators from 15 states and one local jurisdiction. Lessons
learned from the exercise underscored the importance of the Right
Size project and the receptiveness of states to statistically “
right-sizing” their surveillance systems to improve both effectiveness and
efficiency. Participants provided valuable feedback on the benefits of
the roadmap document, potential barriers to implementation, and
the utility of sample size calculation tools. Additionally, they helped
identify critical components for an effective surveillance system,
such as staffing and CDC-provided reagent support.
Highlighting the benefits of the roadmap document, participants
stated that the requirements, resources and statistical calculators
provided will aid in planning and justifying budget and resource
requests, and potentially increase understanding and support of
political leaders and the public. The document will help epidemiologists and PHLs establish virologic sample-sizes more systematically
for different surveillance objectives and scenarios based on acceptable confidence levels and error. For many, this reflects a shift away
from a sampling strategy that has relied on convenience and laboratory capacity. The roadmap and sample size calculation tools will
help quantify system resource needs and improve interpretation of
the surveillance data generated.
Implementation barriers will vary state-to-state, but there were
common concerns expressed by the exercise participants. The most
difficult roadmap elements to address were associated with the challenges in acquiring specimens from providers, collecting the necessary demographic and clinical information with specimens, and
establishing effective communications with external partners such
as clinicians. Current and anticipated funding constraints also create
difficulties for achieving an optimal virologic surveillance system.
Best practices and potential models will be provided to address some
of these concerns as part of the implementation guidance in the
roadmap document.
Participants identified staffing and reagent support as absolutely
essential to maintaining an effective surveillance system that meets
the roadmap requirements. Also prioritized was the capability to
maintain a minimum level of readiness or capacity (“warm base”)
for influenza surveillance, specifically retaining staff for epidemiology and laboratory testing. Many participants noted the difficulty of
maintaining an effective surveillance system without a sufficient
PHL testing staff or influenza coordinator. The availability of influenza testing reagents through CDC’s Influenza Reagent Resource (IRR)
allows PHLs to provide rapid, sensitive and accurate detection and
identification of influenza viruses for routine influenza surveillance,
outbreak detection, and pandemic response; this work supports national influenza surveillance goals and is essential to maintain PHLs’
influenza testing capacity.
The December 2012 Right Size Tabletop Exercise exceeded the
project stakeholders’ expectations and the feedback garnered will
impact the success of the project greatly. This is likely to be an ongoing process since there are many challenges to right-sizing a
system that serves diverse populations and strives to meet varying
national, state and local public health objectives. CDC and APHL look
forward to providing the basic requirements and implementation
tools to the PHLs and health departments for the next influenza
season. u
