The implementation of Integrated Disease Surveillance and Response in Uganda: a review of progress and challenges between 2001 and 2007

Assessing the performance of the integrated disease surveillance and response systems: a systematic review of global evidence

OBJECTIVES

Public health surveillance systems are critical for detecting and responding to health threats. This review aims to analyze international literature on the performance of these systems in terms of core, support, and attributes of surveillance system.

STUDY DESIGN

Systematic review.

METHODS

Following the preregistered protocol (PROSPERO: CRD42022366051), a systematic search was conducted on PubMed/MEDLINE, CINHAL, CABI, Web of Science, and Google Scholar for articles evaluating Public Health Surveillance System performance from inception to July 21, 2023. Various study designs were included, and quality assessment was performed. Thematic analysis categorized findings into key surveillance system functions.

RESULTS

Nine studies from different countries assessed core and supportive functions, as well as surveillance attributes. Performance varied among countries, with some excelling overall and others showing poor performance in specific areas. Many countries' surveillance systems had inadequate performance in key measures in terms of the core and supportive functions, as well as the attributes of the surveillance system.

CONCLUSION

This review shows significant variations in the performance of public health surveillance systems across countries. Further research is needed to understand underperformance reasons and inform global policymaking for strengthening surveillance systems.

Perceptions of yellow fever emergency mass vaccinations among vulnerable groups in Uganda: A qualitative study

BACKGROUND

Yellow fever (YF), a mosquito-borne viral hemorrhagic fever, is endemic in Uganda and causes frequent outbreaks. A total of 1.6 million people were vaccinated during emergency mass immunization campaigns in 2011 and 2016. This study explored local perceptions of YF emergency mass immunization among vulnerable groups to inform future vaccination campaigns.

METHODOLOGY

In this qualitative study, we conducted 43 semi-structured interviews, 4 focus group discussions, and 10 expert interviews with 76 participants. Data were collected in six affected districts with emergency mass vaccination. We included vulnerable groups (people ≥ 65 years and pregnant women) who are typically excluded from YF vaccination except during mass immunization. Data analysis was conducted using grounded theory. Inductive coding was utilized, progressing through open, axial, and selective coding.

PRINCIPAL FINDINGS

Participants relied on community sources for information about the YF mass vaccination. Information was disseminated door-to-door, in community spaces, during religious gatherings, and on the radio. However, most respondents had no knowledge of the vaccine, and it was unclear to them whether a booster dose was required. In addition, the simultaneous presidential election during the mass vaccination campaign led to suspicion and resistance to vaccination. The lack of reliable and trustworthy information and the politicization of vaccination campaigns reinforced mistrust of YF vaccines.

CONCLUSIONS/SIGNIFICANCE

People in remote areas affected by YF outbreaks rely on community sources of information. We therefore recommend improving health education, communication, and engagement through respected and trusted community members. Vaccination campaigns can never be seen as detached from political systems and power relations.

Influences of community engagement and health system strengthening for cholera control in cholera reporting countries

The 2030 Global Task Force on Cholera Control Roadmap hinges on strengthening the implementation of multistranded cholera interventions, including community engagement and health system strengthening. However, a composite picture of specific facilitators and barriers for these interventions and any overlapping factors existing between the two, is lacking. Therefore, this study aims to address this shortcoming, focusing on cholera-reporting countries, which are disproportionately affected by cholera and may be cholera endemic. A scoping methodology was chosen to allow for iterative mapping, synthesis of the available research and to pinpoint research activity for global and local cholera policy-makers and shareholders. Using the Arksey and O'Malley framework for scoping reviews, we searched PubMed, Web of Science and CINAHL. Inclusion criteria included publication in English between 1990 and 2021 and cholera as the primary document focus in an epidemic or endemic setting. Data charting was completed through narrative descriptive and thematic analysis. Forty-four documents were included, with half relating to sub-Saharan African countries, 68% (30/44) to cholera endemic settings and 21% (9/44) to insecure settings. We identified four themes of facilitators and barriers to health systems strengthening: health system cooperation and agreement with external actors; maintaining functional capacity in the face of change; good governance, focused political will and sociopolitical influences on the cholera response and insecurity and targeted destruction. Community engagement had two themes: trust building in the health system and growing social cohesion. Insecurity and the community; cooperation and agreement; and sociopolitical influences on trust building were themes of factors acting at the interface between community engagement and health system. Given the decisive role of the community-health system interface for both sustained health system strengthening and community engagement, there is a need to advocate for conflict resolution, trust building and good governance for long-term cholera prevention and control in cholera reporting countries.

Progress and experiences of implementing an integrated disease surveillance and response system in Somalia; 2016-2023

Introduction

In 2021, a regional strategy for integrated disease surveillance was adopted by member states of the World Health Organization Eastern Mediterranean Region. But before then, member states including Somalia had made progress in integration of their disease surveillance systems. We report on the progress and experiences of implementing an integrated disease surveillance and response system in Somalia between 2016 and 2023.

Methods

We reviewed 20 operational documents and identified key integrated disease surveillance and response system (IDSRS) actions/processes implemented between 2016 and 2023. We verified these through an anonymized online survey. The survey respondents also assessed Somalia's IDSRS implementation progress using a standard IDS monitoring framework Finally, we interviewed 8 key informants to explore factors to which the current IDSRS implementation progress is attributed.

Results

Between 2016 and 2023, 7 key IDSRS actions/processes were implemented including: establishment of high-level commitment; development of a 3-year operational plan; development of a coordination mechanism; configuring the District Health Information Software to support implementation among others. IDSRS implementation progress ranged from 15% for financing to 78% for tools. Reasons for the progress were summarized under 6 thematic areas; understanding frustrations with the current surveillance system; the opportunity occasioned by COVID-19; mainstreaming IDSRS in strategic documents; establishment of an oversight mechanism; staggering implementation of key activities over a reasonable length of time and being flexible about pre-determined timelines.

Discussion

From 2016 to 2023, Somalia registered significant progress towards implementation of IDSRS. The 15 years of EWARN implementation in Somalia (since 2008) provided a strong foundation for IDSRS implementation. If implemented comprehensively, IDSRS will accelerate country progress toward establishment of IHR core capacities. Sustainable funding is the major challenge towards IDSRS implementation in Somalia. Government and its partners need to exploit feasible options for sustainable investment in integrated disease surveillance and response.

Timeliness and completeness of monthly disease surveillance data reporting, Uganda, 2020-2021

Introduction

timely and complete reporting of routine public health information about diseases and public health events are important aspects of a robust surveillance system. Although data on the completeness and timeliness of monthly surveillance data are collected in the District Health Information System-2 (DHIS2), they have not been routinely analyzed. We assessed completeness and timeliness of monthly outpatient department (OPD) data, January 2020-December 2021.

Methods

we analyzed secondary data from all the 15 regions and 146 districts of Uganda. Completeness was defined as the number of submitted reports divided by the number of expected reports. Timeliness was defined as the number of reports submitted by the deadline (15th day of the following month) divided by reports received. Completeness or timeliness score of <80% was regarded incomplete or untimely.

Results

overall, there was good general performance with the median completeness being high in 2020 (99.5%; IQR 97.8-100%) and 2021 (100%; IQR 98.7-100%), as was the median timeliness (2020; 82.8%, IQR 74.6-91.8%; 2021, 94.9%, IQR 86.5-99.1%). Kampala Region was the only region that consistently failed to reach ≥ 80% OPD timeliness (2020: 44%; 2021: 65%). Nakasongola was the only district that consistently performed poorly in the submission of timely reports in both years (2020: 54.4%, 2021: 58.3%).

Conclusion

there was an overall good performance in the submission of complete and timely monthly OPD reports in most districts and regions in Uganda. There is a need to strengthen the good reporting practices exhibited and offer support to regions, districts, and health facilities with timeliness challenges.

Timeliness and completeness of weekly surveillance data reporting on epidemic prone diseases in Uganda, 2020-2021

INTRODUCTION

Disease surveillance provides vital data for disease prevention and control programs. Incomplete and untimely data are common challenges in planning, monitoring, and evaluation of health sector performance, and health service delivery. Weekly surveillance data are sent from health facilities using mobile tracking (mTRAC) program, and synchronized into the District Health Information Software version 2 (DHIS2). The data are then merged into district, regional, and national level datasets. We described the completeness and timeliness of weekly surveillance data reporting on epidemic prone diseases in Uganda, 2020-2021.

METHODS

We abstracted data on completeness and timeliness of weekly reporting of epidemic-prone diseases from 146 districts of Uganda from the DHIS2.Timeliness is the proportion of all expected weekly reports that were submitted to DHIS2 by 12:00pm Monday of the following week. Completeness is the proportion of all expected weekly reports that were completely filled and submitted to DHIS2 by 12:00pm Wednesday of the following week. We determined the proportions and trends of completeness and timeliness of reporting at national level by year, health region, district, health facility level, and facility ownership.

RESULTS

National average reporting timeliness and completeness was 44% and 70% in 2020, and 49% and 75% in 2021. Eight of the 15 health regions achieved the target for completeness of ≥ 80%; Lango attained the highest (93%) in 2020, and Karamoja attained 96% in 2021. None of the regions achieved the timeliness target of ≥ 80% in either 2020 or 2021. Kampala District had the lowest completeness (38% and 32% in 2020 and 2021, respectively) and the lowest timeliness (19% in both 2020 and 2021). Referral hospitals and private owned health facilities did not attain any of the targets, and had the poorest reporting rates throughout 2020 and 2021.

CONCLUSION

Weekly surveillance reporting on epidemic prone diseases improved modestly over time, but timeliness of reporting was poor. Further investigations to identify barriers to reporting timeliness for surveillance data are needed to address the variations in reporting.

Uganda's experience in establishing an electronic compendium for public health emergencies

Uganda has implemented several interventions that have contributed to prevention, early detection, and effective response to Public Health Emergencies (PHEs). However, there are gaps in collecting and documenting data on the overall response to these PHEs. We set out to establish a comprehensive electronic database of PHEs that occurred in Uganda since 2000. We constituted a core development team, developed a data dictionary, and worked with Health Information Systems Program (HISP)-Uganda to develop and customize a compendium of PHEs using the electronic Integrated Disease Surveillance and Response (eIDSR) module on the District Health Information Software version 2 (DHIS2) platform. We reviewed literature for retrospective data on PHEs for the compendium. Working with the Uganda Public Health Emergency Operations Center (PHEOC), we prospectively updated the compendium with real-time data on reported PHEs. We developed a user's guide to support future data entry teams. An operational compendium was developed within the eIDSR module of the DHIS2 platform. The variables for PHEs data collection include those that identify the type, location, nature and time to response of each PHE. The compendium has been updated with retrospective PHE data and real-time prospective data collection is ongoing. Data within this compendium is being used to generate information that can guide future outbreak response and management. The compendium development highlights the importance of documenting outbreak detection and response data in a central location for future reference. This data provides an opportunity to evaluate and inform improvements in PHEs response.

Private Sector Engagement for Infectious Disease Surveillance in Mixed Health Systems: Lessons from a Model Dengue Reporting Network in India

Disease estimates from surveillance in mixed health systems is affected by lack of data from the private sector. We aimed to characterize private sector engagement and reporting to a disease surveillance network, and determine the implications on dengue case detection. We developed and set up a public–private network (CODREN—Community Disease Detection and Response Network) with recruitment of eligible health resources ( n = 462) in a municipal ward of Pune city, India (population 209,331). Dengue cases reported through CODREN were compared with reports of the local dengue surveillance (LDS) over 1 year. Private clinics constituted the majority of eligible providers (60%, 276). Retention of participants was 81.7% with 13.9% reporting dengue cases. Phone call was the preferred reporting method (85.5%, 564 reports). CODREN captured a higher number of cases than LDS (78.9%, 251 vs 50.6%, 161), increasing case detection by 18% due to increased private reporting points. A twofold lower number of cases was reported by LDS from shared reporting points with CODREN, due to discrepancies in case definitions and diagnostic test preferences among private providers. We conclude that private sector engagement can improve dengue case detection with the selective inclusion of providers, sustained contact, feedback and simple reporting methods. Testing guidelines and case definitions adopted by the LDS need to address heterogeneity of private practice in mixed health systems, in order to improve dengue estimates in India.

Comparative Assessment of the Implementation of Integrated Disease Surveillance and Response in Public and Private Health Facilities in Jos North Local Government Area of Plateau State, Nigeria

Background

Due to the continuous increase in the spread of epidemic-prone diseases and the associated morbidity and mortality, integrated disease surveillance and response (IDSR) was introduced as the main strategy in resource-poor settings for the detection and notification of these diseases. Integrated disease surveillance is a combination of active and passive systems using a single infrastructure that gathers information about multiple diseases or behaviors of interest.

Methods

: A comparative cross-sectional study was conducted between March and July 2018 among selected public and private health facilities in Jos North Local Government Area (LGA), Plateau State. Quantitative data were collected with the aid of a semi-structured interviewer-administered questionnaire and facility-based checklist. Data were analyzed using SPSS version 23. Statistical significance level was set at P ≤ 0.05 at a 95% confidence level.

Results

A.

total of 126 health workers were studied. IDSR-trained health personnel was found in 52.7% of the public health facilities compared with only 16.7% of the private health facilities studied (P < 0.001). Awareness of IDSR was higher in the public health facilities than in the private ones (P < 0.001). IDSR implementation was poorer in the private health facilities 40.7% compared with 76.4% in public health facilities (P < 0.001). Evidence of previous disease notification and reporting was seen only in 33.3% and 16.7% of public and private health facilities, respectively (P < 0.001).

Conclusion

This study revealed that awareness and attitude of health workers in public health facilities in Jos North were higher than that of those in private health facilities and there is the sub-optimal implementation of IDSR among the health workers in Jos North LGA, especially among the private health facilities.

Delayed outbreak detection: a wake-up call to evaluate a surveillance system

During May, 83 of the 120 districts in Uganda had reported malaria cases above the upper limit of the normal channel. Across all districts, cases had exceeded malaria normal channel upper limits for an average of six months. Yet no alarms had been raised! Starting in 2000, Uganda adopted the World Health Organization (WHO) Integrated Disease Surveillance and Response (IDSR) strategy for disease reporting, including for malaria. Even early on, however, it was unclear how effectively IDSR and DHIS2 were being used in Uganda. Outbreaks were consistently detected late, but the underlying cause of the late detection was unclear. Suspecting there might be gaps in the surveillance system that were not immediately obvious, the Uganda FETP was asked to evaluate the malaria surveillance system in Uganda. This case study teaches trainees in Field Epidemiology and Laboratory Training Programs, public health students, public health workers who may participate in evaluation of public health surveillance systems, and others who are interested in this topic on reasons, steps, and attributes and uses the surveillance evaluation approach to identify gaps and facilitates discussion of practical solutions for improving a public health surveillance system.

Twenty years of integrated disease surveillance and response in Sub-Saharan Africa: challenges and opportunities for effective management of infectious disease epidemics

INTRODUCTION

This systematic review aimed to analyse the performance of the Integrated Disease Surveillance and Response (IDSR) strategy in Sub-Saharan Africa (SSA) and how its implementation has embraced advancement in information technology, big data analytics techniques and wealth of data sources.

METHODS

HINARI, PubMed, and advanced Google Scholar databases were searched for eligible articles. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols.

RESULTS

A total of 1,809 articles were identified and screened at two stages. Forty-five studies met the inclusion criteria, of which 35 were country-specific, seven covered the SSA region, and three covered 3-4 countries. Twenty-six studies assessed the IDSR core functions, 43 the support functions, while 24 addressed both functions. Most of the studies involved Tanzania (9), Ghana (6) and Uganda (5). The routine Health Management Information System (HMIS), which collects data from health care facilities, has remained the primary source of IDSR data. However, the system is characterised by inadequate data completeness, timeliness, quality, analysis and utilisation, and lack of integration of data from other sources. Under-use of advanced and big data analytical technologies in performing disease surveillance and relating multiple indicators minimises the optimisation of clinical and practice evidence-based decision-making.

CONCLUSIONS

This review indicates that most countries in SSA rely mainly on traditional indicator-based disease surveillance utilising data from healthcare facilities with limited use of data from other sources. It is high time that SSA countries consider and adopt multi-sectoral, multi-disease and multi-indicator platforms that integrate other sources of health information to provide support to effective detection and prompt response to public health threats.

Assessment of the core and support functions of the integrated disease surveillance and response system in Zanzibar, Tanzania

Background

Disease surveillance is a cornerstone of outbreak detection and control. Evaluation of a disease surveillance system is important to ensure its performance over time. The aim of this study was to assess the performance of the core and support functions of the Zanzibar integrated disease surveillance and response (IDSR) system to determine its capacity for early detection of and response to infectious disease outbreaks.

Methods

This cross-sectional descriptive study involved 10 districts of Zanzibar and 45 public and private health facilities. A mixed-methods approach was used to collect data. This included document review, observations and interviews with surveillance personnel using a modified World Health Organization generic questionnaire for assessing national disease surveillance systems.

Results

The performance of the IDSR system in Zanzibar was suboptimal particularly with respect to early detection of epidemics. Weak laboratory capacity at all levels greatly hampered detection and confirmation of cases and outbreaks. None of the health facilities or laboratories could confirm all priority infectious diseases outlined in the Zanzibar IDSR guidelines. Data reporting was weakest at facility level, while data analysis was inadequate at all levels (facility, district and national). The performance of epidemic preparedness and response was generally unsatisfactory despite availability of rapid response teams and budget lines for epidemics in each district. The support functions (supervision, training, laboratory, communication and coordination, human resources, logistic support) were inadequate particularly at the facility level.

Conclusions

The IDSR system in Zanzibar is weak and inadequate for early detection and response to infectious disease epidemics. The performance of both core and support functions are hampered by several factors including inadequate human and material resources as well as lack of motivation for IDSR implementation within the healthcare delivery system. In the face of emerging epidemics, strengthening of the IDSR system, including allocation of adequate resources, should be a priority in order to safeguard human health and economic stability across the archipelago of Zanzibar.

A systematic review on improving implementation of the revitalised integrated disease surveillance and response system in the African region: A health workers' perspective

Background

The revised integrated disease surveillance and response (IDSR) guidelines adopted by African member states in 2010 aimed at strengthening surveillance systems critical capacities. Milestones achieved through IDSR strategy implementation prior to adopting the revised guidelines are well documented; however, there is a dearth of knowledge on the progress made post-adoption. This study aimed to review key recommendations resulting from surveillance assessment studies to improve implementation of the revitalised IDSR system in the African region based on health workers’ perspectives. The review focused on literature published between 2010 and 2019 post-adopting the revised IDSR guidelines in the African region.

Methods

A systematic literature search in PubMed, Web of Science and Cumulative Index for Nursing and Allied Health Literature was conducted. In addition, manual reference searches and grey literature searches using World Health Organisation Library and Information Networks for Knowledge databases were undertaken. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement checklist for systematic reviews was utilised for the review process.

Results

Thirty assessment studies met the inclusion criteria. IDSR implementation under the revised guidelines could be improved considerably bearing in mind critical findings and recommendations emanating from the reviewed surveillance assessment studies. Key recommendations alluded to provision of laboratory facilities and improved specimen handling, provision of reporting forms and improved reporting quality, surveillance data accuracy and quality, improved knowledge and surveillance system performance, utilisation of up-to-date information and surveillance system strengthening, provision of resources, enhanced reporting timeliness and completeness, adopting alternative surveillance strategies and conducting further research to improve surveillance functions.

Conclusion

Recommendations on strengthening IDSR implementation in the African region post-adopting the revised guidelines mainly identify surveillance functions focused on reporting, feedback, training, supervision, timeliness and completeness of the surveillance system as aspects requiring policy refinement.

Systematic review registration

PROSPERO registration number CRD42019124108.

Systematic review of Integrated Disease Surveillance and Response (IDSR) implementation in the African region

Background

The WHO African region frequently experiences outbreaks and epidemics of infectious diseases often exacerbated by weak health systems and infrastructure, late detection, and ineffective outbreak response. To address this, the WHO Regional Office for Africa developed and began implementing the Integrated Disease Surveillance and Response strategy in 1998.

Objectives

This systematic review aims to document the identified successes and challenges surrounding the implementation of IDSR in the region available in published literature to highlight areas for prioritization, further research, and to inform further strengthening of IDSR implementation.

Methods

A systematic review of peer-reviewed literature published in English and French from 1 July 2012 to 13 November 2019 was conducted using PubMed and Web of Science. Included articles focused on the WHO African region and discussed the use of IDSR strategies and implementation, assessment of IDSR strategies, or surveillance of diseases covered in the IDSR framework. Data were analyzed descriptively using Microsoft Excel and Tableau Desktop 2019.

Results

The number of peer-reviewed articles discussing IDSR remained low, with 47 included articles focused on 17 countries and regional level systems. Most commonly discussed topics were data reporting (n = 39) and challenges with IDSR implementation (n = 38). Barriers to effective implementation were identified across all IDSR core and support functions assessed in this review: priority disease detection; data reporting, management, and analysis; information dissemination; laboratory functionality; and staff training. Successful implementation was noted where existing surveillance systems and infrastructure were utilized and streamlined with efforts to increase access to healthcare.

Conclusions and implications of findings

These findings highlighted areas where IDSR is performing well and where implementation remains weak. While challenges related to IDSR implementation since the first edition of the technical guidelines were released are not novel, adequately addressing them requires sustained investments in stronger national public health capabilities, infrastructure, and surveillance processes.

Evaluation of health surveillance system attributes: the case of neglected tropical diseases in Kenya

Background

Control of preventive chemotherapy-targeted neglected tropical diseases (PC-NTDs) relies on strengthened health systems. Efficient health information systems provide an impetus to achieving the sustainable development goal aimed at ending PC-NTD epidemics. However, there is limited assessment of surveillance system functions linked to PC-NTDs and hinged on optimum performance of surveillance system attributes. The study aimed to evaluate surveillance system attributes based on healthcare workers’ perceptions in relation to PC-NTDs endemic in Kenya.

Methods

A cross-sectional health facility survey was used to purposively sample respondents involved in disease surveillance activities. Consenting respondents completed a self-administered questionnaire that assessed their perceptions on surveillance system attributes on a five-point likert scale. Frequency distributions for each point in the likert scale were analysed to determine health workers’ overall perceptions. Data was analysed using descriptive statistics and estimated median values with corresponding interquartile ranges used to summarise reporting rates. Factor analysis identified variables measuring specific latent attributes. Pearson’s chi-square and Fisher’s exact tests examined associations between categorical variables. Thematic analysis was performed for questionnaire open-ended responses.

Results

Most (88%) respondents worked in public health facilities with 71% stationed in second-tier facilities. Regarding PC-NTDs, respondents perceived the surveillance system to be simple (55%), acceptable (50%), stable (41%), flexible (41%), useful (51%) and to provide quality data (25%). Facility locality, facility type, respondents’ education level and years of work experience were associated with perceived opinion on acceptability (p = 0.046; p = 0.049; p = 0.032 and p = 0.032) and stability (p = 0.030; p = 0.022; p = 0.015 and p = 0.024) respectively. Median monthly reporting timeliness and completeness rates for facilities were 75 (58.3, 83.3) and 83.3 (58.3, 100) respectively. Higher-level facilities met reporting timeliness (p < 0.001) and completeness (p < 0.001) thresholds compared to lower-level facilities.

Conclusion

Health personnel had lower perceptions on the stability, flexibility and data quality of the surveillance system considering PC-NTDs. Reporting timeliness and completeness rates decreased in 2017 compared to previous surveillance periods. Strengthening all surveillance functions would influence health workers’ perceptions and improve surveillance system overall performance with regard to PC-NTDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10443-2.

Evaluation of the Ebola Virus Disease (EVD) preparedness and readiness program in Uganda: 2018 to 2019

Introduction

the Democratic Republic of Congo (DRC) declared its 10^thoutbreak of Ebola virus disease (EVD) in 42 years on August 1^st 2018. The rapid rise and spread of the EVD outbreak threatened health security in neighboring countries and global health security. The United Nations developed an EVD preparedness and readiness (EVD-PR) plan to assist the nine neighboring countries to advance their critical preparedness measures. In Uganda, EVD-PR was implemented between 2018 and 2019. The World Health Organization commissioned an independent evaluation to assess the impact of the investment in EVD-PR in Uganda. Objectives: i) to document the program achievements; ii) to determine if the capacities developed represented good value for the funds and resources invested; iii) to assess if more cost-effective or sustainable alternative approaches were available; iv) to explore if the investments were aligned with country public health priorities; and v) to document the factors that contributed to the program success or failure.

Methods

during the EVD preparedness phase, Uganda's government conducted a risk assessment and divided the districts into three categories, based on the potential risk of EVD. Category I included districts that shared a border with the DRC provinces where EVD was ongoing or any other district with a direct transport route to the DRC. Category II were districts that shared a border with the DRC but not bordering the DRC provinces affected by the EVD outbreak. Category III was the remaining districts in Uganda. EVD-PR was implemented at the national level and in 22 category I districts. We interviewed key informants involved in program design, planning and implementation or monitoring at the national level and in five purposively selected category I districts.

Results

Ebola virus disease preparedness and readiness was a success and this was attributed mainly to donor support, the ministry of health's technical capacity, good coordination, government support and community involvement. The resources invested in EVD-PR represented good value for the funds and the activities were well aligned to the public health priorities for Uganda.

Conclusion

Ebola virus disease preparedness and readiness program in Uganda developed capacities that played an essential role in preventing cross border spread of EVD from the affected provinces in the DRC and enabled rapid containment of the two importation events. These capacities are now being used to detect and respond to the COVID-19 pandemic.

Preparedness of health care systems for Ebola outbreak response in Kasese and Rubirizi districts, Western Uganda

BACKGROUND

The level of preparedness of the health care workers, the health facility and the entire health system determines the magnitude of the impact of an Ebola Virus Disease (EVD) outbreak as demonstrated by the West African Ebola outbreak. The objective of the study was to assess preparedness of the health care facilities and identify appropriate preparedness measures for Ebola outbreak response in Kasese and Rubirizi districts in western Uganda.

METHODS

A cross sectional descriptive study was conducted by interviewing 189 health care workers using a structured questionnaire and visits to 22 health facilities to determine the level of health care system preparedness to EVD outbreak. District level infrastructure capabilities, existence of health facility logistics and supplies, and health care workers' knowledge of EVD was assessed. EVD Preparedness was assessed on infrastructure and logistical capabilities and the level of knowledge of an individual health work about the etiology, control and prevention of EVD.

RESULTS

Twelve out of the 22 of the health facilities, especially health center III's and IV's, did not have a line budget to respond to EVD when there was a threat of EVD in a nearby country. The majority (n = 13) of the facilities did not have the following: case definition books, rapid response teams and/or committees, burial teams, and simulation drills. There were no personal protective equipment that could be used within 8 h in case of an EVD outbreak in fourteen of the 22 health facilities. All facilities did not have Viral Hemorrhagic Fever (VHF) incident management centers, isolation units, guidelines for burial, and one-meter distance between a health care worker and a patient during triage. Overall, 54% (n = 102) of health care workers (HCWs) did not know the incubation period of EVD. HCWs who had tertiary education (aOR = 5.79; CI = 1.79-18.70; p = 0.003), and were Christian (aOR = 10.47; CI = 1.94-56.4; p = 0.006) were more likely to know about the biology, incubation period, causes and prevention of EVD.

CONCLUSIONS

Feedback on the level of preparedness for the rural districts helps inform strategies for building capacity of these health centers in terms of infrastructure, logistics and improving knowledge of health care workers.

Assessment of surveillance core and support functions regarding neglected tropical diseases in Kenya

BACKGROUND

Effective surveillance and response systems are vital to achievement of disease control and elimination goals. Kenya adopted the revised guidelines of the integrated disease surveillance and response system in 2012. Previous assessments of surveillance system core and support functions in Africa are limited to notifiable diseases with minimal attention given to neglected tropical diseases amenable to preventive chemotherapy (PC-NTDs). The study aimed to assess surveillance system core and support functions relating to PC-NTDs in Kenya.

METHODS

A mixed method cross-sectional survey was adapted involving 192 health facility workers, 50 community-level health workers and 44 sub-national level health personnel. Data was collected using modified World Health Organization generic questionnaires, observation checklists and interview schedules. Descriptive summaries, tests of associations using Pearson's Chi-square or Fisher's exact tests and mixed effects regression models were used to analyse quantitative data. Qualitative data derived from interviews with study participants were coded and analysed thematically.

RESULTS

Surveillance core and support functions in relation to PC-NTDs were assessed in comparison to an indicator performance target of 80%. Optimal performance reported on specimen handling (84%; 100%), reports submission (100%; 100%) and data analysis (84%; 80%) at the sub-county and county levels respectively. Facilities achieved the threshold on reports submission (84%), reporting deadlines (88%) and feedback (80%). However, low performance reported on case definitions availability (60%), case registers (19%), functional laboratories (52%) and data analysis (58%). Having well-equipped laboratories (3.07, 95% CI: 1.36, 6.94), PC-NTDs provision in reporting forms (3.20, 95% CI: 1.44, 7.10) and surveillance training (4.15, 95% CI: 2.30, 7.48) were associated with higher odds of functional surveillance systems. Challenges facing surveillance activities implementation revealed through qualitative data were in relation to surveillance guidelines and reporting tools, data analysis, feedback, supervisory activities, training and resource provision.

CONCLUSION

There was evidence of low-performing surveillance functions regarding PC-NTDs especially at the peripheral surveillance levels. Case detection, registration and confirmation, reporting, data analysis and feedback performed sub-optimally at the facility and community levels. Additionally, support functions including standards and guidelines, supervision, training and resources were particularly weak at the sub-national level. Improved PC-NTDs surveillance performance sub-nationally requires strengthened capacities.

Institutionalized data quality assessments: a critical pathway to improving the accuracy of integrated disease surveillance data in Sierra Leone

Background

Public health agencies require valid, timely and complete health information for early detection of outbreaks. Towards the end of the Ebola Virus Disease (EVD) outbreak in 2015, the Ministry of Health and Sanitation (MoHS), Sierra Leone revitalized the Integrated Disease Surveillance and Response System (IDSR). Data quality assessments were conducted to monitor accuracy of IDSR data.

Methods

Starting 2016, data quality assessments (DQA) were conducted in randomly selected health facilities. Structured electronic checklist was used to interview district health management teams (DHMT) and health facility staff. We used malaria data, to assess data accuracy, as malaria was endemic in Sierra Leone. Verification factors (VF) calculated as the ratio of confirmed malaria cases recorded in health facility registers to the number of malaria cases in the national health information database, were used to assess data accuracy. Allowing a 5% margin of error, VF < 95% were considered over reporting while VF > 105 was underreporting. Differences in the proportion of accurate reports at baseline and subsequent assessments were compared using Z-test for two proportions.

Results

Between 2016 and 2018, four DQA were conducted in 444 health facilities where 1729 IDSR reports were reviewed. Registers and IDSR technical guidelines were available in health facilities and health care workers were conversant with reporting requirements. Overall data accuracy improved from over- reporting of 4.7% (VF 95.3%) in 2016 to under-reporting of 0.2% (VF 100.2%) in 2018. Compared to 2016, proportion of accurate IDSR reports increased by 14.8% (95% CI 7.2, 22.3%) in May 2017 and 19.5% (95% CI 12.5–26.5%) by 2018. Over reporting was more common in private clinics and not- for profit facilities while under-reporting was more common in lower level government health facilities. Leading reasons for data discrepancies included counting errors in 358 (80.6%) health facilities and missing source documents in 47 (10.6%) health facilities.

Conclusion

This is the first attempt to institutionalize routine monitoring of IDSR data quality in Sierra Leone. Regular data quality assessments may have contributed to improved data accuracy over time. Data compilation errors accounted for most discrepancies and should be minimized to improve accuracy of IDSR data.

A rapid assessment of the implementation of integrated disease surveillance and response system in Northeast Nigeria, 2017

Background

Integrated disease surveillance and response (IDSR) is the strategy adopted for public health surveillance in Nigeria. IDSR has been operational in Nigeria since 2001 but the functionality varies from state to state. The outbreaks of cerebrospinal meningitis and cholera in 2017 indicated weakness in the functionality of the system. A rapid assessment of the IDSR was conducted in three northeastern states to identify and address gaps to strengthen the system.

Method

The survey was conducted at the state and local government areas using standard IDSR assessment tools which were adapted to the Nigerian context. Checklists were used to extract data from reports and records on resources and tools for implementation of IDSR. Questionnaires were used to interview respondents on their capacities to implement IDSR. Quantitative data were entered into an MS Excel spreadsheet, analysed and presented in proportions. Qualitative data were summarised and reported by thematic area.

Results

A total of 34 respondents participated in the rapid survey from six health facilities and six local government areas (LGAs). Of the 2598 health facilities in the three states, only 606 (23%) were involved in reporting IDSR. The standard case definitions were available in all state and LGA offices and health facilities visited. Only 41 (63%) and 31 (47.7%) of the LGAs in the three states had rapid response teams and epidemic preparedness and response committees respectively. The Disease Surveillance and Notification Officers (DSNOs) and clinicians’ knowledge were limited to only timeliness and completeness among over 10 core indicators for IDSR. Review of the facility registers revealed many missing variables; the commonly missed variables were patients’ age, sex, diagnosis and laboratory results.

Conclusions

The major gaps were poor documentation of patients’ data in the facility registers, inadequate reporting tools, limited participation of health facilities in IDSR and limited capacities of personnel to identify, report IDSR priority diseases, analyze and interpret IDSR data for decision making. Training of surveillance focal persons, provision of IDSR reporting tools and effective supportive supervisions will strengthen the system in the country.

Investigation of a Cluster of Severe Respiratory Disease Referred from Uganda to Kenya, February 2017

On February 22, 2017, Hospital X-Kampala and US CDC-Kenya reported to the Uganda Ministry of Health a respiratory illness in a 46-year-old expatriate of Company A. The patient, Mr. A, was evacuated from Uganda to Kenya and died. He had recently been exposed to dromedary camels (MERS-CoV) and wild birds with influenza A (H5N6). We investigated the cause of illness, transmission, and recommended control. We defined a suspected case of severe acute respiratory illness (SARI) as acute onset of fever (≥38°C) with sore throat or cough and at least one of the following: headache, lethargy, or difficulty in breathing. In addition, we looked at cases with onset between February 1 and March 31 in a person with a history of contact with Mr. A, his family, or other Company A employees. A confirmed case was defined as a suspected case with laboratory confirmation of the same pathogen detected in Mr. A. Influenza-like illness was defined as onset of fever (≥38°C) and cough or sore throat in a Uganda contact, and as fever (≥38°C) and cough lasting less than 10 days in a Kenya contact. We collected Mr. A's exposure and clinical history, searched for cases, and traced contacts. Specimens from the index case were tested for complete blood count, liver function tests, plasma chemistry, Influenza A(H1N1)pdm09, and MERS-CoV. Robust field epidemiology, laboratory capacity, and cross-border communication enabled investigation.

A systematic review on integration mechanisms in human and animal health surveillance systems with a view to addressing global health security threats

BACKGROUND

Health surveillance is an important element of disease prevention, control, and management. During the past two decades, there have been several initiatives to integrate health surveillance systems using various mechanisms ranging from the integration of data sources to changing organizational structures and responses. The need for integration is caused by an increasing demand for joint data collection, use and preparedness for emerging infectious diseases.

OBJECTIVE

To review the integration mechanisms in human and animal health surveillance systems and identify their contributions in strengthening surveillance systems attributes.

METHOD

The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) 2015 checklist. Peer-reviewed articles were searched from PubMed, HINARI, Web of Science, Science Direct and advanced Google search engines. The review included articles published in English from 1900 to 2018. The study selection considered all articles that used quantitative, qualitative or mixed research methods. Eligible articles were assessed independently for quality by two authors using the QualSyst Tool and relevant information including year of publication, field, continent, addressed attributes and integration mechanism were extracted.

RESULTS

A total of 102 publications were identified and categorized into four pre-set integration mechanisms: interoperability (35), convergent integration (27), semantic consistency (21) and interconnectivity (19). Most integration mechanisms focused on sensitivity (44.1%), timeliness (41.2%), data quality (23.5%) and acceptability (17.6%) of the surveillance systems. Generally, the majority of the surveillance system integrations were centered on addressing infectious diseases and all hazards. The sensitivity of the integrated systems reported in these studies ranged from 63.9 to 100% (median = 79.6%, n = 16) and the rate of data quality improvement ranged from 73 to 95.4% (median = 87%, n = 4). The integrated systems were also shown improve timeliness where the recorded changes were reported to be ranging from 10 to 91% (median = 67.3%, n = 8).

CONCLUSION

Interoperability and semantic consistency are the common integration mechanisms in human and animal health surveillance systems. Surveillance system integration is a relatively new concept but has already been shown to enhance surveillance performance. More studies are needed to gain information on further surveillance attributes.

Conducting the Joint External Evaluation in Uganda: The Process and Lessons Learned

Uganda is currently implementing the Global Health Security Agenda (GHSA), aiming at accelerating compliance to the International Health Regulations (IHR) (2005). To assess progress toward compliance, a Joint External Evaluation (JEE) was conducted by the World Health Organization (WHO). Based on this evaluation, we present the process and lessons learned. Uganda's methodological approach to the JEE followed the WHO recommendations, including conducting a whole-of-government in-country self-assessment prior to the final assessment, using the same tool at both assessments, and generating consensus scores during the final assessment. The in-country self-assessment process began on March 24, 2017, with a multisectoral representation of 203 subject matter experts from 81 institutions. The final assessment was conducted between June 26 and 30, 2017, by 15 external evaluators. Discrepancies between the in-country and final scores occurred in 27 of 50 indicators. Prioritized gaps from the JEE formed the basis of the National Action Plan for Health Security. We learned 4 major lessons from this process: subject matter experts should be adequately oriented on the scoring requirements of the JEE tool; whole-of-government representation should be ensured during the entire JEE process; equitable multisectoral implementation of IHR activities must be ensured; and over-reliance on external support is a threat to sustainability of GHSA gains.

Cholera surveillance and estimation of burden of cholera

Cholera continues to be poorly controlled in multiple epidemic and endemic areas across the globe, with estimated annual incidence of 1.3-4.0 million cases, resulting in 21,000 to 143,000 deaths worldwide in 2015. The usual approach for patient diagnosis and cholera surveillance is clinical examination of cases of acute watery diarrhea (AWD), confirmed by positive culture or polymerase chain reaction tests. Rapid diagnostic tests (RDTs) are used in regions with limited laboratory capacities but have been found to demonstrate large variations in performance, ranging in sensitivity from 58% to 100% and in specificity from 60% to 100%. Most countries rely on hospital-based surveillance of diarrheal disease to compute the cholera burden. The World Health Organization (WHO) recommends that countries assess public health events involving cholera against the International Health Regulations 2005 criteria and determine need for official notification using the standard case definition. Cholera is an often under-recognized and under reported problem because of differences in case definitions, reluctance by authorities to acknowledge and report cholera, inadequacies in hospital surveillance systems, lack of effective diagnostic tests and commonalities in clinical presentation of cholera with other AWD etiologies. The resulting gap in burden data impairs economic analysis of disease impact and identification of areas for targeted control interventions. There is an urgent need to strengthen surveillance data by supplementing reported numbers with estimates from literature reviews and data from modelling studies, developing better-performing RDTs, enhancing monitoring and evaluation processes of in-country surveillance systems, and encouraging countries to report cholera cases by "rewarding" better reporting with technical support and improved access to vaccines. It is imperative that immediate steps are taken towards strengthening surveillance and reporting systems globally, especially in cholera-prone and resource-limited areas, where it will enable countries to articulate their demand for resources more accurately.

Integrated Disease Surveillance and Response (IDSR) strategy: current status, challenges and perspectives for the future in Africa

In 1998, the WHO African region adopted a strategy called Integrated Disease Surveillance and Response (IDSR). Here, we present the current status of IDSR implementation; and provide some future perspectives for enhancing the IDSR strategy in Africa. In 2017, we used two data sources to compile information on the status of IDSR implementation: a pretested rapid assessment questionnaire sent out biannually to all countries and quarterly compilation of data for two IDSR key performance indicators (KPI). The first KPI measures country IDSR performance and the second KPI tracks the number of countries that the WHO secretariat supports to scale up IDSR. The KPI data for 2017 were compared with a retrospective baseline for 2014. By December 2017, 44 of 47 African countries (94%) were implementing IDSR. Of the 44 countries implementing IDSR, 40 (85%) had initiated IDSR training at subnational level; 32 (68%) had commenced community-based surveillance; 35 (74%) had event-based surveillance; 33 (70%) had electronic IDSR; and 32 (68%) had a weekly/monthly bulletin for sharing IDSR data. Thirty-two countries (68%) had achieved the timeliness and completeness threshold of at least 80% of the reporting units. However, only 12 countries (26%) had the desired target of at least 90% IDSR implementation coverage at the peripheral level. After 20 years of implementing IDSR, there are major achievements in the indicator-based surveillance systems. However, major gaps were identified in event-based surveillance. All African countries should enhance IDSR everywhere.

A systematic review of vaccine preventable disease surveillance cost studies

BACKGROUND

Planning and monitoring vaccine introduction and effectiveness relies on strong vaccine-preventable disease (VPD) surveillance. In low and middle-income countries (LMICs) especially, cost is a commonly reported barrier to VPD surveillance system maintenance and performance; however, it is rarely calculated or assessed. This review describes and compares studies on the availability of cost information for VPD surveillance systems in LMICs to facilitate the design of future cost studies of VPD surveillance.

METHODS

PubMed, Web of Science, and EconLit were used to identify peer-reviewed articles and Google was searched for relevant grey literature. Studies selected described characteristics and results of VPD surveillance systems cost studies performed in LMICs. Studies were categorized according to the type of VPD surveillance system, study aim, the annual cost of the system, and per capita costs.

RESULTS

Eleven studies were identified that assessed the cost of VPD surveillance systems. The studies assessed systems from six low-income countries, two low-middle-income countries, and three middle-income countries. The majority of the studies (n = 7) were conducted in sub-Saharan Africa and fifteen distinct VPD surveillance systems were assessed across the studies. Most studies aimed to estimate incremental costs of additional surveillance components and presented VPD surveillance system costs as mean annual costs per resource category, health structure level, and by VPD surveillance activity. Staff time/personnel cost represents the largest cost driver, ranging from 21% to 61% of total VPD surveillance system costs across nine studies identifying a cost driver.

CONCLUSIONS

This review provides a starting point to guide LMICs to invest and advocate for more robust VPD surveillance systems. Critical gaps were identified including limited information on the cost of laboratory surveillance, challenges with costing shared resources, and missing data on capital costs. Appropriate guidance is needed to guide LMICs conducting studies on VPD surveillance system costs.

Healthcare workers' experiences regarding scaling up of training on integrated disease surveillance and response (IDSR) in Uganda, 2016: cross sectional qualitative study

Background

The Integrated Disease Surveillance and Response (IDSR) strategy was adopted as the framework for implementation of International Health Regulation (2005) in the African region of World Health Organisation (WHO AFRO). While earlier studies documented gains in performance of core IDSR functions, Uganda still faces challenges due to infectious diseases. IDSR revitalisation programme aimed to improve prevention, early detection, and prompt response to disease outbreaks. However, little is known about health worker’s perception of the revitalised IDSR training.

Methods

We conducted focus group discussions of health workers who were trained between 2015 and 2016. Discussions on benefits, challenges and possible solutions for improvement of IDSR training were recorded, transcribed, translated and coded using grounded theory.

Results

In total, 22/26 FGDs were conducted. Participants cited improved completeness and timeliness of reporting, case detection and data analysis and better response to disease outbreaks as key achievements after the training. Programme challenges included an inadequate number of trained staff, funding, irregular supervision, high turnover of trained health workers, and lack of key logistics. Suggestions to improve IDSR included pre-service and community training, mentorship, regular supervision and improving funding at the district level.

Conclusion

Health workers perceived that scaling up revitalized IDSR training in Uganda improved public health surveillance. However, they acknowledge encountering challenges that hinder their performance after the training. Ministry of Health should have a mentorship plan, integrate IDSR training in pre-service curricula and advocate for funding IDSR activities to address some of the gaps highlighted in this study.

Evaluation of integrated disease surveillance and response (IDSR) core and support functions after the revitalisation of IDSR in Uganda from 2012 to 2016

BACKGROUND

Uganda is a low income country that continues to experience disease outbreaks caused by emerging and re-emerging diseases such as cholera, meningococcal meningitis, typhoid and viral haemorrhagic fevers. The Integrated Disease Surveillance and Response (IDSR) strategy was adopted by WHO-AFRO in 1998 as a comprehensive strategy to improve disease surveillance and response in WHO Member States in Africa and was adopted in Uganda in 2000. To address persistent inconsistencies and inadequacies in the core and support functions of IDSR, Uganda initiated an IDSR revitalisation programme in 2012. The objective of this evaluation was to assess IDSR core and support functions after implementation of the revitalised IDSR programme.

METHODS

The evaluation was a cross-sectional survey that employed mixed quantitative and qualitative methods. We assessed IDSR performance indicators, knowledge acquisition, knowledge retention and level of confidence in performing IDSR tasks among health workers who underwent IDSR training. Qualitative data was collected to guide the interpretation of quantitative findings and to establish a range of views related to IDSR implementation.

RESULTS

Between 2012 and 2016, there was an improvement in completeness of monthly reporting (69 to 100%) and weekly reporting (56 to 78%) and an improvement in timeliness of monthly reporting (59 to 93%) and weekly reporting (40 to 68%) at the national level. The annualised non-polio AFP rate increased from 2.8 in 2012 to 3.7 cases per 100,000 population < 15 years in 2016. The case fatality rate for cholera decreased from 3.2% in 2012 to 2.1% in 2016. All districts received IDSR feedback from the national level. Key IDSR programme challenges included inadequate numbers of trained staff, inadequate funding, irregular supervision and high turnover of trained staff. Recommendations to improve IDSR performance included: improving funding, incorporating IDSR training into pre-service curricula for health workers and strengthening support supervision.

CONCLUSION

The revitalised IDSR programme in Uganda was associated with improvements in performance. However in 2016, the programme still faced significant challenges and some performance indicators were still below the target. It is important that the documented gains are consolidated and challenges are continuously identified and addressed as they emerge.

Consent for mobile phone surveys of non-communicable disease risk factors in low-resource settings: an exploratory qualitative study in Uganda

BACKGROUND

Lack of data for timely decision-making around the prevention and control of non-communicable diseases (NCDs) presents special challenges for policy makers, especially in resource-limited settings. New data collection methods, including pre-recorded Interactive Voice Response (IVR) phone surveys, are being developed to support rapid compilation of population-level disease risk factor information in such settings. We aimed to identify information that could be used to optimize consent approaches for future mobile phone surveys (MPS) employed in Uganda and, possibly, similar contexts.

METHODS

We conducted an in-depth qualitative study with key stakeholders in Uganda about consent approaches, and potential challenges, for pre-recorded IVR NCD risk factor surveys. Semi-structured interviews were conducted with 14 key informants. A contextualized thematic approach was used to interpret the results supported by representative quotes.

RESULTS

Several potential challenges in designing consent approaches for MPS were identified, including low literacy and the lack of appropriate ways of assessing comprehension and documenting consent. Communication with potential respondents prior to the MPS and providing options for callbacks were suggested as possible strategies for improving comprehension within the consent process. "Opt-in" forms of authorization were preferred over "opt-out". There was particular concern about data security and confidentiality and how matters relating to this would be communicated to MPS respondents.

CONCLUSIONS

These local insights provide important information to support optimization of consent for MPS, whose use is increasing globally to advance public health surveillance and research in constructive ways.

Integrated Disease Surveillance and Response (IDSR) in Malawi: Implementation gaps and challenges for timely alert

Objective

The recent 2014 Ebola Virus Disease (EVD) outbreaks rang the bell to call upon global efforts to assist resource-constrained countries to strengthen public health surveillance system for early response. Malawi adopted the Integrated Disease Surveillance and Response (IDSR) strategy to develop its national surveillance system since 2002 and revised its guideline to fulfill the International Health Regulation (IHR) requirements in 2014. This study aimed to understand the state of IDSR implementation and differences between guideline and practice for future disease surveillance system strengthening.

Methods

This was a mixed-method research study. Quantitative data were to analyze completeness and timeliness of surveillance system performance from national District Health Information System 2 (DHIS2) during October 2014 to September 2016. Qualitative data were collected through interviews with 29 frontline health service providers from the selected district and 7 key informants of the IDSR system implementation and administration at district and national levels.

Findings

The current IDSR system showed relatively good completeness (73.1%) but poor timeliness (40.2%) of total expected monthly reports nationwide and zero weekly reports during the study period. Major implementation gaps were lack of weekly report and trainings. The challenges of IDSR implementation revealed through qualitative data included case identification, compiling reports for timely submission and inadequate resources.

Conclusions

The differences between IDSR technical guideline and actual practice were huge. The developing information technology infrastructure in Malawi and emerging mobile health (mHealth) technology can be opportunities for the country to overcome these challenges and improve surveillance system to have better timeliness for the outbreaks and unusual events detection.

Outbreak of yellow fever in central and southwestern Uganda, February-may 2016

BACKGROUND

On 28 March, 2016, the Ministry of Health received a report on three deaths from an unknown disease characterized by fever, jaundice, and hemorrhage which occurred within a one-month period in the same family in central Uganda. We started an investigation to determine its nature and scope, identify risk factors, and to recommend eventually control measures for future prevention.

METHODS

We defined a probable case as onset of unexplained fever plus ≥1 of the following unexplained symptoms: jaundice, unexplained bleeding, or liver function abnormalities. A confirmed case was a probable case with IgM or PCR positivity for yellow fever. We reviewed medical records and conducted active community case-finding. In a case-control study, we compared risk factors between case-patients and asymptomatic control-persons, frequency-matched by age, sex, and village. We used multivariate conditional logistic regression to evaluate risk factors. We also conducted entomological studies and environmental assessments.

RESULTS

From February to May, we identified 42 case-persons (35 probable and seven confirmed), of whom 14 (33%) died. The attack rate (AR) was 2.6/100,000 for all affected districts, and highest in Masaka District (AR = 6.0/100,000). Men (AR = 4.0/100,000) were more affected than women (AR = 1.1/100,000) (p = 0.00016). Persons aged 30-39 years (AR = 14/100,000) were the most affected. Only 32 case-patients and 128 controls were used in the case control study. Twenty three case-persons (72%) and 32 control-persons (25%) farmed in swampy areas (OR_adj = 7.5; 95%CI = 2.3-24); 20 case-patients (63%) and 32 control-persons (25%) who farmed reported presence of monkeys in agriculture fields (OR_adj = 3.1, 95%CI = 1.1-8.6); and 20 case-patients (63%) and 35 control-persons (27%) farmed in forest areas (OR_adj = 3.2; 95%CI = 0.93-11). No study participants reported yellow fever vaccination. Sylvatic monkeys and Aedes mosquitoes were identified in the nearby forest areas.

CONCLUSION

This yellow fever outbreak was likely sylvatic and transmitted to a susceptible population probably by mosquito bites during farming in forest and swampy areas. A reactive vaccination campaign was conducted in the affected districts after the outbreak. We recommended introduction of yellow fever vaccine into the routine Uganda National Expanded Program on Immunization and enhanced yellow fever surveillance.

Expenditures on vaccine-preventable disease surveillance: Analysis and evaluation of comprehensive multi-year plans (cMYPs) for immunization

Despite the importance of vaccine-preventable disease (VPD) surveillance, little is known about the costs of monitoring disease. We used Comprehensive Multi-Year Plans for Immunization (cMYPs) - developed by countries following guidelines from the World Health Organization and United Nations Children's Fund - to estimate expenditures on VPD surveillance at the country level in 2015 US Dollars (USD) in 63 low- and middle-income countries. To evaluate the reliability of cMYP estimates, we also compared cMYP data with findings from previous research studies and assessed whether countries explicitly budgeted for major categories of surveillance activities in their plans for immunization. According to our analysis of cMYPs, countries spent an annual median of $406,108 on VPD surveillance ($0.04 per capita and $1.47 per infant), with reported expenditures ranging from $1,098 (Kiribati) to $21,644,770 (Nigeria). However, the majority of countries failed to explicitly mention several key categories of surveillance activities in their plans, especially laboratory-related surveillance activities. Our results show a large amount of variation in surveillance expenditures (total, per capita, and per infant) between countries and provide insights to improve costing guidelines and practices.

The design and implementation of the re-vitalised integrated disease surveillance and response (IDSR) in Uganda, 2013-2016

BACKGROUND

Uganda adopted and has been implementing the Integrated Disease Surveillance (IDSR) strategy since 2000. The goal was to build the country's capacity to detect, report promptly, and effectively respond to public health emergencies and priorities. The considerable investment into the program startup realised significant IDSR core performance. However, due to un-sustained funding from the mid-2000s onwards, these achievements were undermined. Following the adoption of the revised World Health Organization guidelines on IDSR, the Uganda Ministry of Health (MoH) in collaboration with key partners decided to revitalise IDSR and operationalise the updated IDSR guidelines in 2012.

METHODS

Through the review of both published and unpublished national guidelines, reports and other IDSR program records in addition to an interview of key informants, we describe the design and process of IDSR revitalisation in Uganda, 2013-2016. The program aimed to enhance the districts' capacity to promptly detect, assess and effectively respond to public health emergencies.

RESULTS

Through a cascaded, targeted skill-development training model, 7785 participants were trained in IDSR between 2015 and 2016. Of these, 5489(71%) were facility-based multi-disciplinary health workers, 1107 (14%) comprised the district rapid response teams and 1188 (15%) constituted the district task forces. This training was complemented by other courses for regional teams in addition to the provision of logistics to support IDSR activities. Centrally, IDSR implementation was coordinated and monitored by the MoH's national task force (NTF) on epidemics and emergencies. The NTF and in close collaboration with the WHO Country Office, mobilised resources from various partners and development initiatives. At regional and district levels, the technical and political leadership were mobilised and engaged in monitoring and overseeing program implementation.

CONCLUSION

The IDSR re-vitalization in Uganda highlights unique features that can be considered by other countries that would wish to strengthen their IDSR programs. Through a coordinated partner response, the program harnessed resources which primarily were not earmarked for IDSR to strengthen the program nation-wide. Engagement of the local district leadership helped promote ownership, foster accountability and sustainability of the program.

Systems, supplies, and staff: a mixed-methods study of health care workers' experiences and health facility preparedness during a large national cholera outbreak, Kenya 2015

Background

From December 2014 to September 2016, a cholera outbreak in Kenya, the largest since 2010, caused 16,840 reported cases and 256 deaths. The outbreak affected 30 of Kenya’s 47 counties and occurred shortly after the decentralization of many healthcare services to the county level. This mixed-methods study, conducted June–July 2015, assessed cholera preparedness in Homa Bay, Nairobi, and Mombasa counties and explored clinic- and community-based health care workers’ (HCW) experiences during outbreak response.

Methods

Counties were selected based on cumulative cholera burden and geographic characteristics. We conducted 44 health facility cholera preparedness checklists (according to national guidelines) and 8 focus group discussions (FGDs). Frequencies from preparedness checklists were generated. To determine key themes from FGDs, inductive and deductive codes were applied; MAX software for qualitative data analysis (MAXQDA) was used to identify patterns.

Results

Some facilities lacked key materials for treating cholera patients, diagnosing cases, and maintaining infection control. Overall, 82% (36/44) of health facilities had oral rehydration salts, 65% (28/43) had IV fluids, 27% (12/44) had rectal swabs, 11% (5/44) had Cary-Blair transport media, and 86% (38/44) had gloves. A considerable number of facilities lacked disease reporting forms (34%, 14/41) and cholera treatment guidelines (37%, 16/43). In FDGs, HCWs described confusion regarding roles and reporting during the outbreak, which highlighted issues in coordination and management structures within the health system. Similar to checklist findings, FGD participants described supply challenges affecting laboratory preparedness and infection prevention and control. Perceived successes included community engagement, health education, strong collaboration between clinic and community HCWs, and HCWs’ personal passion to help others.

Conclusions

The confusion over roles, reporting, and management found in this evaluation highlights a need to adapt, implement, and communicate health strategies at the county level, in order to inform and train HCWs during health system transformations. International, national, and county stakeholders could strengthen preparedness and response for cholera and other public health emergencies in Kenya, and thereby strengthen global health security, through further investment in the existing Integrated Disease Surveillance and Response structure and national cholera prevention and control plan, and the adoption of county-specific cholera control plans.

Investigation of an isolated case of human Crimean-Congo hemorrhagic fever in Central Uganda, 2015

BACKGROUND

Crimean-Congo hemorrhagic fever (CCHF) is the most geographically widespread tick-borne viral infection. Outbreaks of CCHF in sub-Saharan Africa are largely undetected and thus under-reported. On November 9, 2015, the National Viral Hemorrhagic Fever Laboratory at the Uganda Virus Research Institute received an alert for a suspect VHF case in a 33-year-old male who presented with VHF compatible signs and symptoms at Mengo Hospital in Kampala.

METHODS

A blood sample from the suspect patient was tested by RT-PCR for CCHF and found positive. Serological testing on sequential blood specimens collected from this patient showed increasing anti-CCHFV IgM antibody titers, confirming recent infection. Repeat sampling of the confirmed case post recovery showed high titers for anti-CCHFV-specific IgG. An epidemiological outbreak investigation was initiated following the initial RT-PCR positive detection to identify any additional suspect cases.

RESULTS

Only a single acute case of CCHF was detected from this outbreak. No additional acute CCHF cases were identified following field investigations. Environmental investigations collected 53 tick samples, with only 1, a Boophilus decoloratus, having detectable CCHFV RNA by RT-PCR. Full-length genomic sequencing on a viral isolate from the index human case showed the virus to be related to the DRC (Africa 2) lineage.

CONCLUSIONS

This is the fourth confirmed CCHF outbreak in Uganda within 2 years after more than 50 years of no reported human CCHF cases in this country. Our investigations reaffirm the endemicity of CCHFV in Uganda, and show that exposure to ticks poses a significant risk for human infection. These findings also reflect the importance of having an established national VHF surveillance system and diagnostic capacity in a developing country like Uganda, in order to identify the first cases of VHF outbreaks and rapidly respond to reduce secondary cases. Additional efforts should focus on implementing effective tick control methods and investigating the circulation of CCHFV throughout the country.

Health worker knowledge of Integrated Disease Surveillance and Response standard case definitions: a cross-sectional survey at rural health facilities in Kenya

BACKGROUND

The correct knowledge of standard case definition is necessary for frontline health workers to diagnose suspected diseases across Africa. However, surveillance evaluations commonly assume this prerequisite. This study assessed the knowledge of case definitions for health workers and their supervisors for disease surveillance activities in rural Kenya.

METHODS

A cross-sectional survey including 131 health workers and their 11 supervisors was undertaken in two counties in Kenya. Descriptive analysis was conducted to classify the correctness of knowledge into four categories for three tracer diseases (dysentery, measles, and dengue). We conducted a univariate and multivariable logistic regression analyses to explore factors influencing knowledge of the case definition for dysentery.

RESULTS

Among supervisors, 81.8% knew the correct definition for dysentery, 27.3% for measles, and no correct responses were provided for dengue. Correct knowledge was observed for 50.4% of the health workers for dysentery, only 12.2% for measles, and none for dengue. Of 10 examined factors, the following were significantly associated with health workers' correct knowledge of the case definition for dysentery: health workers' cadre (aOR 2.71; 95% CI 1.20-6.12; p = 0.017), and display of case definition poster (aOR 2.24; 95% CI 1.01-4.98; p = 0.048). Health workers' exposure to the surveillance refresher training, supportive supervision and guidelines were not significantly associated with the knowledge.

CONCLUSION

The correct knowledge of standard case definitions was sub-optimal among health workers and their supervisors, which is likely to impact the reliability of routine surveillance reports generated from health facilities.

Challenges of implementing the integrated disease surveillance and response strategy in Zambia: a health worker perspective

Background

Despite advances in medical technology and public health practice at the global level over the past millennia, infectious diseases are still the leading causes of death in most resource limited countries. Stronger infectious disease surveillance and response systems in developed countries facilitated the near elimination of infectious disease related deaths in those countries. Today, low-income countries are following this path by strengthening disease surveillance and response strategies that would help reverse the trend in infectious disease associated morbidity and mortality cases. In 2000, Zambia adopted the World Health Organisation Regional Office for Africa’s (WHO-AFRO) Integrated Disease Surveillance and Response Strategy (IDSR) to monitor, prevent and control priority notifiable infectious diseases in the country. Through this strategy, activities pertaining to disease surveillance are coordinated and streamlined to take advantage of similar surveillance functions, skills, resources and targeted populations. The purpose of the study was to investigate and report on the existing challenges in the implementation of the IDSR strategy in a resource limited country from a health worker perspective.

Methods

A qualitative study approach was used to achieve the study aim. Data was collected through key informant interviews with selected persons at the Lusaka Province Health Office (LPHO); Lusaka and Chongwe District Health Management Team Offices; and four selected health facilities in the two districts (two from each). Thematic analysis approach was used to analyse the qualitative data.

Results

The major successes included operationalised response and epidemic preparedness at all levels (National to district); full-time staff and budget dedicated to disease surveillance at all levels and adoption of the 2010 World Health Organisations’ Integrated Disease Surveillance and Response Strategy technical guidelines to the Zambian context. Several challenges hampered effective implementation. These include inadequate trained human resources, poor infrastructure and coordination challenges.

Conclusion

The implementation of IDSR strategy in Zambia has recorded some successes. However, several gaps hinder effective implementation. It is imperative that these gaps are addressed for Zambia to have a robust surveillance system that could inform policy in a comprehensive and timely manner.

Positive predictive value and effectiveness of measles case-based surveillance in Uganda, 2012-2015

INTRODUCTION

Disease surveillance is a critical component in the control and elimination of vaccine preventable diseases. The Uganda National Expanded Program on Immunization strives to have a sensitive surveillance system within the Integrated Disease Surveillance and Response (IDSR) framework. We analyzed measles surveillance data to determine the effectiveness of the measles case-based surveillance system and estimate its positive predictive value in order to inform policy and practice.

METHODS

An IDSR alert was defined as ≥1 suspected measles case reported by a district in a week, through the electronic Health Management Information System. We defined an alert in the measles case-based surveillance system (CBS) as ≥1 suspected measles case with a blood sample collected for confirmation during the corresponding week in a particular district. Effectiveness of CBS was defined as having ≥80% of IDSR alerts with a blood sample collected for laboratory confirmation. Positive predictive value was defined as the proportion of measles case-patients who also had a positive measles serological result (IgM +). We reviewed case-based surveillance data with laboratory confirmation and measles surveillance data from the electronic Health Management Information System from 2012-2015.

RESULTS

A total of 6,974 suspected measles case-persons were investigated by the measles case-based surveillance between 2012 and 2015. Of these, 943 (14%) were measles specific IgM positive. The median age of measles case-persons between 2013 and 2015 was 4.0 years. Between 2013 and 2015, 72% of the IDSR alerts reported in the electronic Health Management Information System, had blood samples collected for laboratory confirmation. This was however less than the WHO recommended standard of ≥80%. The PPV of CBS between 2013 and 2015 was 8.6%.

CONCLUSION

In conclusion, the effectiveness of measles case-based surveillance was sub-optimal, while the PPV showed that true measles cases have significantly reduced in Uganda. We recommended strengthening of case-based surveillance to ensure that all suspected measles cases have blood samples collected for laboratory confirmation to improve detection and ensure elimination by 2020.

Understanding mSOS: A qualitative study examining the implementation of a text-messaging outbreak alert system in rural Kenya

Outbreaks of epidemic diseases pose serious public health risks. To overcome the hurdles of sub-optimal disease surveillance reporting from the health facilities to relevant authorities, the Ministry of Health in Kenya piloted mSOS (mobile SMS-based disease outbreak alert system) in 2013-2014. In this paper, we report the results of the qualitative study, which examined factors that influence the performances of mSOS implementation. In-depth interviews were conducted with 11 disease surveillance coordinators and 32 in-charges of rural health facilities that took part in the mSOS intervention. Drawing from the framework analysis, dominant themes that emerged from the interviews are presented. All participants voiced their excitement in using mSOS. The results showed that the technology was well accepted, easy to use, and both health workers and managers unanimously recommended the scale-up of the system despite challenges encountered in the implementation processes. The most challenging components were the context in which mSOS was implemented, including the lack of strong existing structure for continuous support supervision, feedback and response action related to disease surveillance. The study revealed broader health systems issues that should be addressed prior to and during the intervention scale-up.

Status of surveillance and routine immunization performances in Amhara Region, Ethiopia: findings from in-depth peer review

Introduction

Trend analyses of non-polio AFP and stool adequacy rates in Amhara Region showed optimal performance over the years. However, sub regional gaps continue to persist in certain zones where the reasons for low performance were not well documented. The objective of this study was to assess the performance of the disease surveillance and immunization system in Amhara Region, Ethiopia with emphasis on low performing woredas and zones.

Methods

A descriptive cross-sectional study was conducted from July 2-10, 2015 to assess the structure, core and support surveillance functions in five zones and two town administrations that were purposively sampled based on differing performances, geographic location, and history of vaccine preventable disease outbreaks among others.

Results

Of the 82 sites reviewed, 71 (87%) have a designated surveillance focal person. Less than half 36(44%) of these focal persons have written terms of reference. Twenty-six (93%) of the health offices had a written surveillance work plan for the fiscal year. Only 17 (81%) of woreda health offices and town administrations had prioritized active surveillance sites into high, medium and low during the last 12 months. Only 4(17%) had independent active case search visits to these sites as per the priority. Seventy-eight (95%) and seventy-seven (94%) sites have a designated immunization focal person and updated EPI performance monitoring charts, respectively. There had been vaccine stock out in the 3 months before assessment in 28 (34%) of the sites.

Conclusion

Though there is an existence of well-organized surveillance network with adoption of the integrated disease surveillance and response, gaps exist in following the standard guidelines and operation procedures. Improvements needed in reporting site priority setting and regular visiting for active case search, outbreak investigation and management, vaccine supply and overall documentations.

Comparing laboratory surveillance with the notifiable diseases surveillance system in South Africa

OBJECTIVE

The aim of this study was to compare laboratory surveillance with the notifiable diseases surveillance system (NDSS) in South Africa.

METHODS

Data on three tracer notifiable diseases - measles, meningococcal meningitis, and typhoid - were compared to assess data quality, stability, representativeness, sensitivity and positive predictive value (PPV), using the Wilcoxon and Chi-square tests, at the 5% significance level.

RESULTS

For all three diseases, fewer cases were notified than confirmed in the laboratory. Completeness for the laboratory system was higher for measles (63% vs. 47%, p<0.001) and meningococcal meningitis (63% vs. 57%, p<0.001), but not for typhoid (60% vs. 63%, p=0.082). Stability was higher for the laboratory (all 100%) compared to notified measles (24%, p<0.001), meningococcal meningitis (74%, p<0.001), and typhoid (36%, p<0.001). Representativeness was also higher for the laboratory (all 100%) than for notified measles (67%, p=0.058), meningococcal meningitis (56%, p=0.023), and typhoid (44%, p=0.009). The sensitivity of the NDSS was 50%, 98%, and 93%, and the PPV was 20%, 57%, and 81% for measles, meningococcal meningitis, and typhoid, respectively.

CONCLUSIONS

Compared to laboratory surveillance, the NDSS performed poorly on most system attributes. Revitalization of the NDSS in South Africa is recommended to address the completeness, stability, and representativeness of the system.

Mobile Phone Surveys for Collecting Population-Level Estimates in Low- and Middle-Income Countries: A Literature Review

Background

National and subnational level surveys are important for monitoring disease burden, prioritizing resource allocation, and evaluating public health policies. As mobile phone access and ownership become more common globally, mobile phone surveys (MPSs) offer an opportunity to supplement traditional public health household surveys.

Objective

The objective of this study was to systematically review the current landscape of MPSs to collect population-level estimates in low- and middle-income countries (LMICs).

Methods

Primary and gray literature from 7 online databases were systematically searched for studies that deployed MPSs to collect population-level estimates. Titles and abstracts were screened on primary inclusion and exclusion criteria by two research assistants. Articles that met primary screening requirements were read in full and screened for secondary eligibility criteria. Articles included in review were grouped into the following three categories by their survey modality: (1) interactive voice response (IVR), (2) short message service (SMS), and (3) human operator or computer-assisted telephone interviews (CATI). Data were abstracted by two research assistants. The conduct and reporting of the review conformed to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Results

A total of 6625 articles were identified through the literature review. Overall, 11 articles were identified that contained 19 MPS (CATI, IVR, or SMS) surveys to collect population-level estimates across a range of topics. MPSs were used in Latin America (n=8), the Middle East (n=1), South Asia (n=2), and sub-Saharan Africa (n=8). Nine articles presented results for 10 CATI surveys (10/19, 53%). Two articles discussed the findings of 6 IVR surveys (6/19, 32%). Three SMS surveys were identified from 2 articles (3/19, 16%). Approximately 63% (12/19) of MPS were delivered to mobile phone numbers collected from previously administered household surveys. The majority of MPS (11/19, 58%) were panel surveys where a cohort of participants, who often were provided a mobile phone upon a face-to-face enrollment, were surveyed multiple times.

Conclusions

Very few reports of population-level MPS were identified. Of the MPS that were identified, the majority of surveys were conducted using CATI. Due to the limited number of identified IVR and SMS surveys, the relative advantages and disadvantages among the three survey modalities cannot be adequately assessed. The majority of MPS were sent to mobile phone numbers that were collected from a previously administered household survey. There is limited evidence on whether a random digit dialing (RDD) approach or a simple random sample of mobile network provided list of numbers can produce a population representative survey.

Evaluation of the reporting completeness and timeliness of the integrated disease surveillance and response system in northern Ghana

OBJECTIVES

The integrated disease surveillance and response (IDSR) and district health information management system II (DHIMS2) strategies were implemented in 2002 and 2012 respectively to improve surveillance data reporting and quality. The objective of this study was to evaluate the reporting completeness and timeliness of the IDSR system at the sub-national level in northern Ghana.

METHODS

This was an observational study in Upper East Region (UER). Weekly and monthly disease surveillance reports on completeness and timeliness were downloaded and analysed for 2012 and 2013 from the DHIMS2 in UER, the two Kassena-Nankana districts and their nine health facilities representing public, private and mission providers. Comparison of paper-based and DHIMS2 reporting from the periphery health facilities were assessed.

RESULTS

IDSR monthly reporting completeness and timeliness in UER increased by 9% and 37% respectively in 2013 compared to 2012 and weekly completeness and timeliness improved by 79% and 24% respectively in 2013. Similar reporting increases were seen in the districts and health facilities over the same period, except the Kassena-Nankana Municipal which showed decrease of 2% in monthly completeness for 2013. At the health facilities, the paper-based reporting completeness was 96% and timeliness 45% while DHIMS2 completeness was 83% and timeliness 18% in 2012. However, DHIMS2 reporting completeness and timeliness improved in 2013 reaching 100% and 61% respectively.

CONCLUSIONS

Disease surveillance reporting through DHIMS2 became more complete over time, but there remain problems with timeliness. Surveillance data need to be timely to enable rapid responses to disease outbreaks.

Epidemiology of cholera outbreaks and socio-economic characteristics of the communities in the fishing villages of Uganda: 2011-2015

Background

The communities in fishing villages in the Great Lakes Region of Africa and particularly in Uganda experience recurrent cholera outbreaks that lead to considerable mortality and morbidity. We evaluated cholera epidemiology and population characteristics in the fishing villages of Uganda to better target prevention and control interventions of cholera and contribute to its elimination from those communities.

Methodology/Principal findings

We conducted a prospective study between 2011–15 in fishing villages in Uganda. We collected, reviewed and documented epidemiological and socioeconomic data for 10 cholera outbreaks that occurred in fishing communities located along the African Great Lakes and River Nile in Uganda. These outbreaks caused 1,827 suspected cholera cases and 43 deaths, with a Case-Fatality Ratio (CFR) of 2.4%. Though the communities in the fishing villages make up only 5–10% of the Ugandan population, they bear the biggest burden of cholera contributing 58% and 55% of all reported cases and deaths in Uganda during the study period. The CFR was significantly higher among males than females (3.2% vs. 1.3%, p = 0.02). The outbreaks were seasonal with most cases occurring during the months of April-May. Male children under age of 5 years, and 5–9 years had increased risk. Cholera was endemic in some villages with well-defined “hotspots”. Practices predisposing communities to cholera outbreaks included: the use of contaminated lake water, poor sanitation and hygiene. Additional factors were: ignorance, illiteracy, and poverty.

Conclusions/Significance

Cholera outbreaks were a major cause of morbidity and mortality among the fishing communities in Uganda. In addition to improvements in water, sanitation, and hygiene, oral cholera vaccines could play an important role in the prevention and control of these outbreaks, particularly when targeted to high-risk areas and populations. Promotion and facilitation of access to social services including education and reduction in poverty should contribute to cholera prevention, control and elimination in these communities.

Cholera, though a preventable and treatable disease, remains a major cause of morbidity and mortality in the Great Lakes Region of Africa, including Uganda. The communities in the fishing villages constitute 5–10% of the total Ugandan population. Most fishing villages are located along Lakes Victoria, Albert and Edward and the River Nile. During the study period, 2011–2015 these villages were responsible for over 50% of the reported annual cholera cases and deaths in Uganda. The CFR was significantly higher among males than females (3.2% vs. 1.3%, p = 0.02). Our study is the first to systematically describe the epidemiology of these outbreaks and socioeconomic characteristics of communities in the fishing villages in Uganda. Our study found that persons in the fishing villages were at increased risk of cholera outbreaks due to poor access to safe water, sanitation, and hygiene. Furthermore, the villages had similar population characteristics such as illiteracy, ignorance regarding cholera transmission, poverty and constant population migration. In addition to improvements in water, sanitation, and hygiene, complementary use of oral cholera vaccines could play an important role, particularly when targeted to high-risk areas and populations. As a long term strategy, improvements in education and reduction in poverty should contribute to cholera prevention, control and elimination in the fishing villages and Uganda as whole.

Cholera public health surveillance in the Republic of Cameroon-opportunities and challenges

INTRODUCTION

In Cameroon, cholera has periodically resurfaced since it was first reported in 1971. In 2003, Cameroon adapted the Integrated Disease Surveillance and Response (IDSR) strategy to strengthen surveillance in the country. This study was an in-depth description and assessment of the structure, core and support functions, and attributes of the current cholera surveillance system in Cameroon. It also discussed its strengths and challenges with hope that lessons learned could improve the system in Cameroon and in other countries in Africa implementing the IDSR strategy.

METHODS

Semi-structured key informant interviews, peer reviewed articles, and government record review were conducted in the Far North and Centre Regions of Cameroon. We used the matrix and conceptual framework from the World Health Organization (WHO) and Centers for Disease Control and Prevention, WHO Regional Office for Africa Technical Guidelines to frame the study. Site visits included the WHO country office, the ministry of public health (MoPH), two Regional Public Health Delegations (RPHDs), eight health districts (HDs) and health facilities (HFs) including two labs.

RESULTS

Cholera surveillance is passive but turns active during outbreaks and follows a hierarchical structure. Cholera data are collected at HFs and sent to HDs where data are compiled and sent to the RPHD in paper format. RPHDs de-identify, digitalize, and send the data to the MoPH via internet and from there to the WHO. The case definition was officially changed in 2010 but the outdated definition was still in use in 2013. Nationally, there are 3 laboratories that have the ability to confirm cholera cases; the lack of laboratory capacity at HFs hampers case and outbreak confirmation. The absence of structured data analysis at the RPHD, HD, and HF further compounds the situation, making the goal of IDSR of data analysis and rapid response at the HD very challenging. Feedback is strongest at the central level (MoPH) and non-existent at the levels below it, with only minimal training and supervision of staff. In 2012, mobile phone coverage expanded to all 183 HDs and to HFs in 2014 in the Far North and North Regions. The phones improved immediate reporting and outbreak control. Further, the creation of cholera command and control centers, and introduction of laptops at all RPHDs are major strengths in the surveillance system. Completeness and timeliness of reporting varied considerably among levels.

CONCLUSION

Significant milestones in the hierarchical structure towards integration and achieving early detection and rapid response in cholera surveillance are in effective use; however, some challenges exist. The surveillance system lack labs at HFs and there is no data analysis at HD level. Thus, the goal of IDSR-strategy of early detection, data analysis, and rapid response at the HD level is a challenge. Both human and material resources are needed at the HD level to achieve this goal.

The Ebola Virus Disease Outbreak in West Africa: A Wake-up Call to Revitalize Implementation of the International Health Regulations

The 2014/15 Ebola virus disease (EVD) outbreak in West Africa has highlighted the inherent weaknesses associated with the implementation of the International Health Regulations (IHR). In this perspective article, the lessons learnt from the outbreak are used to review the challenges impeding effective implementation of the IHR and to propose policy and strategic options for enhancing its application. While some progress has been achieved in implementing the IHR in several countries, numerous challenges continue to impede its effectiveness, especially in developing countries, such as those affected by the West Africa EVD outbreak. Political and economic sensitivities associated with reporting public health emergencies of international concern (PHEIC), inadequate resources (human and financial), and lack of technical know-how required for implementation of the IHR are weaknesses that continue to constrain the implementation of the regulations. In view of the complex sociopolitical, cultural, and public health dimensions of PHEICs, frameworks, such as the IHR, which have legal backing, seem to be the most effective and sustainable option for assuring timely detection, notification, and response to such events. Renewed efforts to strengthen national and global institutional frameworks for implementation of the IHR are therefore required. Improvements in transparency, commitment, and accountability of parties to the IHR, mainstreaming of the IHR into national public health governance structures, use of multidisciplinary approaches, and mobilization of the required resources for the implementation of the IHR are imperative.

Factors associated with adequate weekly reporting for disease surveillance data among health facilities in Nairobi County, Kenya, 2013

Introduction

Kenya adopted the Integrated Disease Surveillance and Response (IDSR) strategy in 1998 to strengthen disease surveillance and epidemic response. However, the goal of weekly surveillance reporting among health facilities has not been achieved. We conducted a cross-sectional study to determine the prevalence of adequate reporting and factors associated with IDSR reporting among health facilities in one Kenyan County.

Methods

Health facilities (public and private) were enrolled using stratified random sampling from 348 facilities prioritized for routine surveillance reporting. Adequately-reporting facilities were defined as those which submitted >10 weekly reports during a twelve-week period and a poor reporting facilities were those which submitted <10 weekly reports. Multivariate logistic regression with backward selection was used to identify risk factors associated with adequate reporting.

Results

From September 2 through November 30, 2013, we enrolled 175 health facilities; 130(74%) were private and 45(26%) were public. Of the 175 health facilities, 77 (44%) facilities classified as adequate reporting and 98 (56%) were reporting poorly. Multivariate analysis identified three factors to be independently associated with weekly adequate reporting: having weekly reporting forms at visit (AOR19, 95% CI: 6-65], having posters showing IDSR functions (AOR8, 95% CI: 2-12) and having a designated surveillance focal person (AOR7, 95% CI: 2-20).

Conclusion

The majority of health facilities in Nairobi County were reporting poorly to IDSR and we recommend that the Ministry of Health provide all health facilities in Nairobi County with weekly reporting tools and offer specific trainings on IDSR which will help designate a focal surveillance person.

Pertussis Across the Globe: Recent Epidemiologic Trends From 2000 to 2013

Pertussis has reemerged as a problem across the world. To better understand the nature of the resurgence, we reviewed recent epidemiologic data and we report disease trends from across the world. Published epidemiologic data from January 2000 to July 2013 were obtained via PubMed searches and open-access websites. Data on vaccine coverage and reported pertussis cases from 2000 through 2012 from the 6 World Health Organization regions were also reviewed. Findings are confounded not only by the lack of systematic and comparable observations in many areas of the world but also by the cyclic nature of pertussis with peaks occurring every 3-5 years. It appears that pertussis incidence has increased in school-age children in North America and western Europe, where acellular pertussis vaccines are used, but an increase has also occurred in some countries that use whole-cell vaccines. Worldwide, pertussis remains a serious health concern, especially for infants, who bear the greatest disease burden. Factors that may contribute to the resurgence include lack of booster immunizations, low vaccine coverage, improved diagnostic methods, and genetic changes in the organism. To better understand the epidemiology of pertussis and optimize disease control, it is important to improve surveillance worldwide, irrespective of pertussis vaccine types and schedules used in each country.

The integrated disease surveillance and response system in northern Ghana: challenges to the core and support functions

Background

The integrated disease surveillance and response (IDSR) strategy was adopted in Ghana over a decade ago, yet gaps still remain in its proper functioning. The objective of this study was to assess the core and support functions of the IDSR system at the periphery level of the health system in northern Ghana.

Methods

A qualitative study has been conducted among 18 key informants in two districts of Upper East Region. The respondents were from 9 health facilities considered representative of the health system (public, private and mission). A semi-structured questionnaire with focus on core and support functions (e.g. case detection, confirmation, reporting, analysis, investigation, response, training, supervision and resources) of the IDSR system was administered to the respondents. The responses were recorded according to specific themes.

Results

The majority (7/9) of health facilities had designated disease surveillance officers. Some informants were of the opinion that the core and support functions of the IDSR system had improved over time. In particular, mobile phone reporting was mentioned to have made IDSR report submission easier. However, none of the health facilities had copies of the IDSR Technical Guidelines for standard case definitions, laboratories were ill-equipped, supervision was largely absent and feedback occurred rather irregular. Informants also reported, that the community perceived diagnostic testing at the health facilities to be unreliable (e.g. tuberculosis, Human Immunodeficiency Virus). In addition, disease surveillance activities were of low priority for nurses, doctors, administrators and laboratory workers.

Conclusions

Although the IDSR system was associated with some benefits to the system such as reporting and accessibility of surveillance reports, there remain major challenges to the functioning and the quality of IDSR in Ghana. Disease surveillance needs to be much strengthened in West Africa to cope with outbreaks such as the recent Ebola epidemic.