TechnoHealth Surveillance

Newsletter

Volume1, Number5 July 2016

Editorial address TechnoHealth Surveillance From the Editor’s Desk Newsletter Southern African Centre for Dear reader, Infectious Disease Surveillance, Sokoine University of Agriculture P.O. Box 3297 We are delighted to welcome you to the 5th issue of Chuo Kikuu, Morogoro, TechnoHealth surveillance. Kindly find in this issue how SACIDS E-mail: [email protected] researchers addressed the challenges that community health reporters experienced while using digital disease surveillance Editorial Committee tool s. It is interesting to learn our achievements and Dr. Calvin Sindato Prof. Esron Karimuribo upcoming activities to enhance early detection, timely reporting Dr. Leonard Mboera and prompt response to cholera outbreak. June 2016 Prof. Kariuki Njenga Dr. Chubwa Choby In this issue, we also report how unsafe burial practices resulted Dr. Florence Kabinga in the spread of cholera in the community. We are pleased to Mr. Yunus Karsan share with you a simulation on how One Health Knowledge

Repository could support presumptive diagnosis of the recently unidentified mysterious disease outbreak in the central Tanzania.

Looking back, we have been impressed by feedback from our

esteemed readers, and we are now much more confident that

we have been keen to respond to their interests. We look

forward to your feedback and comments on this 5th edition.

Kindly do not hesitate to share with us stories on health related

events occurring in humans, animals and environment for the

sustainability of our newsletter.

We wish you an informative read!

Enjoy your reading!

SACIDS researchers and CHRs jointly address the challenges of using mobile phones for digital disease surveillance

From April 24 to May 1, 2016, a team of or with poor internet connection, the CHRs researchers (Eric Beda, Mpoki Mwabukusi, record the health events together with Moses Ole Neselle and Calvin Sindato) from geographical coordinates, save data in the the Southern African Centre for Infectious mobile phones and finally submit data after Disease Surveillance (SACIDS) visited the having accessed locations with reliable community health reporters (CHRs) in their internet connection. Some CHRs had, respective villages in Ngorongoro and however, assumed that given poor or no Kibaha districts. The aim was to discuss and internet connectivity, it was not possible to address the challenges that CHRs have being record the geographical coordinates of the facing while using digital disease surveillance data source-location. As a result, the technology, an initiative being implemented recorded location was the reporting location by SACIDS using mobile phones to enhance that they had accessed to submit recorded early detection, reporting and response to data rather than the incident location. health events. Another challenge was when the CHRs were The frequently reported challenges included: called by community members to attend health events at household level, and upon Concept of finalized and un-finalized form in arrival, the CHRs found that the clients had open data kit (ODK) left for health care facility. Then the CHRs Some CHRs were not certain when to mark followed up the clients to the health facility, the data collection form finalized or un- recorded the health event and geographical finalized. In this case the reports were kept coordinates at health facility. This under “edit” section in the open data kit contributed to many health events (ODK) instead of being under “send”, and incorrectly been aggregated around health were therefore not synchronized with the facilities, and not reflecting the actual SACIDS server at the Sokoine University of location of their occurrence. The CHRs were Agriculture in Morogoro. The CHRs were refreshed on how to record health events at educated further on how to manage ODK. the location the illness began and geographical coordinates using mobile Accessing and using the Geographical phones. Information System (GIS) in the mobile phones The ODK lost from mobile phones

During the quality control exercise, health Some CHRs had unintentionally deleted ODK events data from CHRs were projected onto from their phones and were therefore not maps and some mismatch was observed able to record health events. The forms were between the location of events and re-installed, and the SACIDS ICT geographical coordinates. The outputs were programmers are working to configure the shared with the CHRs. phones such that once installed, the user will It is known that the internet is not evenly not be able to delete the important distributed throughout the study villages. software. Customarily, while in the locations without

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SACIDS conducts planning meeting with stakeholders to support control of cholera outbreaks in Tanzania

Cholera has been a menace to society in Authorities in (Morogoro- different parts of Tanzania since August Urban, and Mvomero districts) and 2015; it disappears for a while and comes Dar es Salaam region (Kinondoni and back, affecting the most vulnerable of Temeke districts). populations in high risky areas. The disease is caused by Vibiro cholerae bacterium. The A planning meeting was held at NIMR affected individuals develop severe headquarters in Dar es Salaam on June 14, dehydration or die from acute watery 2016 to discuss and agree on the activities to diarrhoea and vomiting. If cholera control be implemented to support control of activities are not coordinated, they can cholera outbreaks in Morogoro and Dar es cause panic and public health authorities Salaam, Tanzania. The meeting was attended may resort to closing down food vending by DODRES team, District Medical Officers places locally called ‘Mama Lishe’ in an (from Temeke, Kilosa and Morogoro-urban attempt to stop the spread. Such actions districts), Health Officers (from Morogoro- although necessary, might disrupt local urban and Temeke districts), representatives economic activities, induce fear and attaches from the Ministry of Health (National Health stigma to families who have a suspected Laboratory Quality Assurance and Training cholera patient(s). Centre), Sokoine University of Agriculture and National Institute for Medical Research. Thanks to Skoll Global Threats Fund, the

SACIDS through project titled “Enhancing Resolutions from the planning meeting Community-Based Disease Outbreak included the need to conduct inventories of Detection and Response in East and laboratory facilities in Morogoro and Dar es Southern Africa (DODRES)” extended its Salaam to identify gaps in cholera activities to support national cholera control confirmation and differential diagnosis of efforts. This support is being implemented in cholera, development of protocols and partnership with National Institute for guidelines for sample collection and Medical Research (NIMR), Ministry of Health processing, procurement of consumables Community Development Gender Elderly and mobile phones and development of data and Children as well as Local Government /information flow model, development of

tools to support capture, submission and

2 access to cholera data/information. Other officials, deployment of the system in the planned activities included development of community, improved data collection and intervention designs/protocols, analysis via mobile phones, and sharing of development of training manual/tools for reports with stakeholders. The plan is to community health reporters (CHRs) and conduct these activities in the next four district officials, training of CHRs and district months.

Designing of a community-based model to fight cholera

During a consultative planning meeting to residing in the community to capture control cholera outbreaks that was held at information on cholera cases as well as other NIMR Headquarters in Dar es Salaam on environmental risky practices occurring at June 14, 2016, a community-based model community level. Use of mobile technology was designed to support early detection, was recommended to expedite sharing of diagnosis and managing of cholera and other information between District Cholera diarrheal diseases. Control and Response team (dCRT), Cholera Treatment Camps (CTC), nearby health It was agreed that community engagement facilities, laboratories and DODRES team. A for early detection of cases and reporting of typical scenario and flow of information is risky behaviors and practices that contribute summarized as follows: to environmental contamination was essential. In this regards, it was A community-based CHR or Health Officer recommended to use both Community identifies a suspected cholera case or risky Health Reporters and Health Officers behavior and practice (e.g. release of toilet

3 effluents in the environment) in the done while at dCRT a cholera line list registry community, captures the event and activates will be updated as they receive laboratory flow of information to dCRT, the CTC and the results from the laboratory. neighboring health care facilities.

The patient will be advised and referred to With the proposed model, it is envisaged the CTC or may also seek medical service that when properly implemented, it would from a nearby health facility. The facility will significantly reduce number of challenges refer the patient to a CTC in case symptoms that affect the efficiency of the daily and signs are suggesting the patient to be operations related to detection, diagnosis suspected cholera case. and management of cholera. Of particular At CTC, the patient is registered in a paper- importance was the need to revolutionize based cholera line register and a sample is the paper based-system currently being used taken and submitted to regional laboratory to share information and management of for confirmation. The meeting cholera cases. The model also exploited the recommended the adoption and use of a opportunity of engaging the community in bar-coded sampling container whose assisting reporting, referring and tracking information will be automatically shared with other authorized staff at the diagnostic suspected cholera cases. In addition, other facility, dCRT and DODRES Project members risky practices and behaviors occurring in the in digital format using a ‘Master Register’. community could be easily detected, reported and attended promptly by the In case of reported contamination of the district health authorities. environment, the CHRs or Health Officer will share this information with dCRT so that the As from July 2016, the DODRES will latter could mount community sanitation customize and use AfyaData ICT tools to and hygiene awareness campaigns. assist in cholera management and co-

At the diagnostic laboratory, the diagnosis ordination using the proposed community- will be confirmed and results of uniquely based model. The community-based identified sample will be keyed in and reporters, health officers as well as district automatically virtually shared with CTC, dCRT cholera response team members will be and DODRES in near to real time. trained on how to use the technology in

detection, response and management of For the suspected cholera cases, the dCRT cholera cases in the pilot districts in will use data on the bar-coded sample, which includes laboratory results and physical Morogoro region (Morogoro-Urban, location of the suspected patient, to update Mvomero and Kilosa) and Dar es Salaam and plan appropriate responses. region (Temeke and Kinondoni).

At the CTC, appropriate case management based on results from the laboratory will be

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Cholera control model

Cholera outbreak linked to a funeral event in Kilosa

As of May 27, 2016, cholera has been The major clinical manifestations of the reported in 106 persons and killed three index cases were diarrhoea and vomiting. By patients in Kilosa district, Morogoro since May 27, 2016 additional 28 cases of cholera the epidemic began there on May 1, 2016. were reported in Msimba village. The Cholera is transmitted principally by outbreak spread to 13 neighbouring villages ingestion of food or water contaminated namely (number of cases in parentheses) with the bacterium Vibrio cholera and can kill Mgoma (19), Kidoma (15), Molemu (8), humans within hours if left untreated. Tambukareli (8), Igoji (6), Mfilisi (5), Vikweme (3), Kikwalaza (3), Iyovi (2), Contact with the bodies and fluids of Mbegesela (2), Ng’apa (2), Mikumi mjini (2) persons who have died of any cause is and Rwele-kota (1). The two patients from especially common in Tanzania, where family Mbegesela and one patient from Igoji and community members often wash the villages died. All other cases were treated body of the deceased ones in preparation successfully at the cholera treatment camp for funerals. This cultural practice was established following the reports of index associated with onset of cholera outbreak in cases in the district. Other control measures Msimba village Kilosa district on May 1, 2016. that were implemented included public The outbreak involved two index cases of health education, ban of food vending and adult men who participated in the sales of local brews, disinfection of affected preparation of deceased body of a premises and treatment of water for community member on April 29, 2016 domestic use. The control measures (whose cause of death had not been implemented were perceived by the district established). authority to be effective as there were no

5 more reports of cholera cases in the district standard operating procedures for safe after May 27, 2016. There is however a need burial practices to facilitate prevention and to scale-up public health education and control of cholera and other potential inform the implementation of national infectious diseases.

Simulated performance of One Health Knowledge Repository for enhancing detection of mysterious disease outbreak in central Tanzania

Recently the Southern African Centre for support presumptive diagnosis of the Infectious Diseases Surveillance (SACIDS) unidentified mysterious disease outbreak through the research project titled that killed seven people in Chemba and Enhancing community-based disease Kondoa districts of in central outbreak detection and response in East and Tanzania. The Government of Tanzania, Southern Africa (DODRES) developed One through the Ministry of Health Community Health Knowledge Repository (OHKR). This a Development Gender Elderly and Children database of expertly authored health (MoHCDGEC), officially reported an outbreak content of priority infectious diseases of of unidentified disease on June 13, 2016. It all human and livestock, and it includes started in Mwaikisabe village in Chemba guidelines, fact sheets, standard case when nine members of the same family definitions, response protocols and consumed meat of a cow slaughtered on recommendations and first aid advice from emergency after it had sustained an broken human and livestock health perspectives. legs>. However, other people (number not available) who also consumed meat from the The OHKR serves as a knowledge-based same cow were unaffected. It was further decision support tool to enhance early reported that nine people (who did not detection, reporting and prompt response to consume the meat) from neighboring disease outbreaks. It works by creating villages of Chemka, Gubali, Ilesi, Itolwa, automatic targeted intelligent responses to Kelema Balai, Kintima and Soya in Chemba key public health stakeholders and district and Ubembeni village in Kondoa community based on the information district developed similar symptoms of the collected and submitted from community by mysterious disease. Based on these community health reporters (CHRs) using observations it was reasonably suggested the AfyaData tool. AfyaData is a tool that the cow with broken leg was unlikely to developed by SACIDS to enhance be the source of the outbreak. participatory disease surveillance in selected . This system is being As of June 25, 2016 the Ministry reported 32 tested in Ngorongoro and Morogoro-Urban people to have been affected by the disease districts in Tanzania with ambition to expand and seven of them died, translating to Case it to other areas of East and Southern Africa. Fatality Rate of 21.9%.The major symptoms presented by affected people include The DODRES team comprising of ICT vomiting, diarrhea, jaundiced mucous programmers and epidemiologists simulated membranes especially those of eyes and skin how the recently developed OHKR could turning yellow as well as swollen abdomen.

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It was further reported that affected people including restriction of the contents to complained of abdominal pains. To prevent infectious diseases only thus unable to the disease from spreading further; patients capture involvement of the non-infectious were managed at Dodoma Regional Hospital conditions. It is further recommended that and Kondoa District Hospital. more epidemiological information would be needed to improve prediction of possible Based on the symptoms being reported, the disease(s) involved. As we go to press, the OHKR identifies potential likely diseases, and aetiology of the disease is being investigated sends tips to key stakeholders who then the MoHCDGEC. There is a need to establish makes appropriate actions including asking the source of infection, mechanism of onset more questions to the reporter. The most and spread and proportion of community in probable infectious conditions identified by the two districts that were affected. The the OHKR and likelihood percentage (p) TechnoHealth Surveillance team will update were Yellow fever (p=90.0%), Cholera the readership on confirmatory diagnosis (p=77.5%) and Dengue (70.0%). The team also when official information is released. acknowledged some deficits in the system,

Map showing districts and villages that reported mysterious disease in humans in central Tanzania.

Key Partners:

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