Journal of International Health Vol.32 No.1 2017

[Field Report] Strengthening the communicable disease surveillance and response system, , , 2012-2014: Review of a technical cooperation project

Masaki Ota1）, Yumi Toyama1）, Mami Kon1）, Takashi Yoza2）, Belay Bezabih Beyene3）

1）Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association 2）Toryu Development Inc. 3）Amhara National Regional State Health Bureau, Bahir Dar, Amhara Region, Ethiopia

Abstract Objectives The International Health Regulations (2005) bound the member states of the World Health Organization (WHO) to initiate epidemiological investigations of disease outbreaks and to notify WHO within 24 hours of their detection if the event is deemed to constitute public health emergency of international concern. The Japan International Cooperation Agency started the Amhara Regional Infectious Disease Surveillance Project to strengthen the surveillance and response system in the Amhara Region of Ethiopia in 2008. The objectives of the study were to review the project activities and to share the experiences and lessons learned in 22 districts of the North and South and West Gojjam Zones from mid-2012 through 2014. Methods We conducted training for district surveillance officers and focal point personnel at health centres (HCs), monitoring visits to district health offices and HCs, held review meetings on surveillance, and provided technical assistance in outbreak investigations. We evaluated the project activities in terms of the timeliness of the surveillance reports submitted by the health facilities, provision of technical assistance in outbreak investigations, and the number of training sessions held for the surveillance personnel. Results The timeliness of submission of surveillance reports had improved to almost 100% at end of 2014 compared with before the review period (about 68%). From the third quarter of 2013, we conducted monitoring visits to 59 HCs every semester. We were involved in 11 outbreak investigations of measles, anthrax, pertussis, neonatal tetanus, and typhoid fever. We held a total of 25 training sessions for district surveillance officers and HC focal points. Conclusion The project successfully strengthened the surveillance and response system. We recommend that the Amhara Regional Health Bureau maintain its commitment to the system in terms of human resources and funding. Training for surveillance officers and focal points should be conducted periodically.

Keywords: Communicable disease surveillance, Epidemiology, Health system strengthening, International Health Regulations

Contact address: Research Institute of Tuberculosis, Japan Anti-Tuberculosis Association Matsuyama 3-1-24, Kiyose City, Tokyo, 204-8533 Japan TEL: 042-493-5711 FAX: 042-492-4600 E-mail: [email protected] （Received：2015. 11. 17，Accepted：2017. 01. 16）

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I. Introduction II. Methods The International Health Regulations (IHR)1）, revised Settings in 2005, have bound the member states of the World Ethiopia has nine semi-autonomous administrative Health Organization (WHO) to initiate epidemiological regions that have the power to raise and spend their investigations on outbreaks and epidemics and to own revenues6）. Amhara is the second most populous notify WHO within 24 hours of their detection if the region located in northwestern Ethiopia, with a popu- event is deemed to constitute a public health emer- lation of 20 million people. It has ten zones with 167 gency of international concern. Thus, the countries districts and three special designated city administra- had until 15 June 2012 to meet their IHR core sur- tions. The project selected 22 districts (Fig. 1) in the veillance and response requirements, including at North and South Gondar and West Gojjam zones, of designated airports, ports and certain ground cross- which six districts (Burie Zuria, Dembia, Mecha, ings. Ebinat, Semada, and Takusa) were initially closely The Federal Ministry of Health (FMoH) of Ethiopia focused on, and then the activities were expanded to initiated surveillance and response activities under the other 16 districts. the Integrated Disease Surveillance and Response Description of the surveillance system (IDSR) programme in 19992）. In 2009, a newer FMoH designated 14 diseases requiring immediate program, Public Health Emergency Management notification (acute flaccid paralysis/polio, measles, (PHEM), was introduced3）, under which health neonatal tetanus, cholera, etc.) and eight weekly facilities (HFs), including health centres (HCs) and reportable diseases and conditions (malaria, meningo- hospitals, now are required to report notifiable coccal meningitis, dysentery, etc.)3）. The surveillance diseases either immediately or weekly, rather than reports are filled out in a printed format at the HFs monthly under the IDSR. The FMoH also established and sent to the DHOs either physically or verbally the Field Epidemiology and Laboratory Training by cellphone. The DHOs aggregate the data and Programme (FELTP) at the Ethiopian Health and send them on paper or by phone to the zonal health Nutrition Research Institute in 20094） to increase the offices (ZHOs). The ZHOs normally enter the data capacity for surveillance and response. into a Microsoft Excel (Microsoft Corp., Seattle, WA, The Japan International Cooperation Agency and USA) file and send it to the ANRS-HB by e-mail (Fig. the Health Bureau of the Amhara National Regional 2). HPs with health extension workers can diagnose State (ANRS-HB) started a five-year project for and treat malaria cases, and are required to report strengthening the communicable disease surveillance the number of cases weekly to designated HCs. HPs and response system in the Amhara Region of are required to report 13 more simplified conditions, Ethiopia in January 2008. In May 2012, it was decided defined such as acute febrile illness, bloody diarrhoea, that the project would be extended by two years rashes, etc. until January 2015 to further improve the surveil- Project activities lance and response capacity of ANRS-HB. The main The project conducted five main activities: (1) reason was that the core surveillance and response training of surveillance officers at DHOs and surveil- system did not function well, with only about 68% of lance focal point personnel at HCs, (2) monitoring the project district health offices (DHOs) reporting visits to DHOs and HCs, (3) holding review meetings surveillance data within one week in April 20125）, on surveillance and response, (4) analyses of weekly interpreted as the timeliness of the surveillance reports surveillance data, and (5) technical assistance in was about two thirds. outbreak investigations. This article reviews the overall project activities We provided three types of training: an initial two- from mid-2012 to 2014, when the authors were in- day training for the surveillance officers at DHOs and volved, to share the experiences and lessons learned focal points at the HCs, a four-day refresher training in the field, and discuss the challenges in communicable for surveillance officers of DHOs, and a three-day disease surveillance and response in resource limited refresher training for surveillance focal point person- settings. nel of HCs in selected districts. In the initial two-day

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Figure 1 Map of the study districts, Amhara Region, Ethiopia Legend: Districts in a - Debark, b - , c - , d - Lay Almacho, e - , f - Takusa, g - , h - Dembia, i - , j - West , Districts in South Gondar Zone, k - Libo Kemkem, l - Ebinat, m - Andabiet, n - Semada, o - Tach Gaint, Districts in West Gojjam Zone, p - North Achefer, q - Mecha, r - Sekela, s - Burie Zuria, t - Jab Tehnan, u - Dembecha, v - Yilmana Densa

Figure 2 Flow of surveillance data, Ethiopia

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training, various topics were covered, including the review meetings supported by the project. principles of public health surveillance, the surveil- The timeliness of the surveillance reports was lance system in Ethiopia, the reporting format, moni- defined as the proportion of actual reporting units toring and evaluation of the surveillance system and (HFs or HPs) within a certain area (district, zone, or the case definitions for the reportable diseases. In the region) on time (within five days of the particular four-day refresher training, topics on community week). We calculated the quarterly average of the involvement in the surveillance system and brief timeliness of surveillance reports and 95 percent epidemiology lectures were covered in addition, confidence intervals were calculated using R software including the steps in an outbreak investigation and (The R Foundation for Statistical Computing, Viena, group work on a case-study of a meningococcal men- Austria). Holmʼs pairwise t test was employed to ingitis outbreak investigation. In the three-day refresher conduct multiple comparisons among the quarterly training, similar topics were covered with the two- averages of the timeliness of the surveillance reports. day training. Dissemination of surveillance reports and analyses We conducted monitoring visits to the HCs and were evaluated as the frequency of the dissemination DHOs in the project area with a supervision checklist and the proportion of health offices, particularly in developed in collaboration with ANRS-HB. In the terms of DHOs, that provided the dissemination. visits to the HCs, the surveillance report sheets sent Provision of technical assistance in outbreak investi- from HPs to the HC were physically checked in their gation was evaluated as the number of such events files to verify whether the reporting system was in which the project involved, including provision of functional, i.e. the reports existed and to review the field investigation, epidemiological analyses, and content. The number of communicable disease cases response, such as vaccine campaign. (usually malaria cases for four consecutive weeks randomly chosen in a quarter) reported in the sur- III. Results veillance was crosschecked against that of the cases There were 176 HFs and 723 HPs in the 22 districts diagnosed in the laboratory. the project covered. Timeliness data on submission of Annual review meetings on the surveillance and surveillance reports by district were only available response were supported and held once a year, inviting from the 16th week of 2013 and thereafter. The time- all the ZHOs and selected DHOs. Sometimes a special liness of surveillance reports significantly improved review meeting was held to discuss urgent matters. from early 2013 to the end of 2014 both for HFs and In the meetings, the participants shared their activities, HPs in the project districts (Fig. 3). The immediately challenges, and possible solutions. notifiable diseases (measles, etc) were reported The project obtained surveillance reports every weekly together with the weekly reportable diseases, week from the PHEM department of ANRS-HB, rather than immediately as instructed in the guideline. analyzed and closely monitored the trends of the From the third quarter of the 2013, we conducted reportable communicable diseases, and gave alerts monitoring visits to 59 HCs: almost all the HCs of the when any unusual increase or decrease of the number six districts and to one to two selected HCs of the of cases was detected. When the project detected or rest of the project districts every semester. Verification was informed of any communicable disease outbreak of the surveillance reporting sheets sent from HPs and was asked to provide assistance, it provided and filed at the 59 HCs the authors visited revealed technical and material assistance to the districts in that 82%, 78%, 77% and 85% of the sheets were filed close collaboration with ANRS-HB and WHO. for the first, second, third and fourth quarters of Project evaluation 2014, though the data for the fourth quarter were We evaluated the project activities with indicators, only verified until the 46th week (West Gojjam) and such as the timeliness of the surveillance reports, 47th week (North and South Gondar). dissemination of the surveillance reports and analyses, The PHEM department of ANRS-HB analyzed the provision of technical assistance in outbreak investi- surveillance data and distributed the PHEM Weekly gations, and the numbers of training sessions and Bulletin every week to ZHOs in Amhara throughout

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Figure 3 The trend of weekly (graph) and quarterly averages (table) of timeliness of the surveillance reports by type of reporting unit in 22 project districts, Amhara Region, Ethiopia, 2013-2014 1The data for the second quarter of 2013 only include weeks 16-26. Q = quarter, # = Number, % = Percent, HF = health facility, HP = health post *p < 0.05, **p < 0.01

2013 and 2014. The PHEM teams of the ZHOs also shortage of vaccines for the livestock. The pertussis disseminated the surveillance data and analyses outbreak was successfully contained with timely every month to DHOs in their jurisdictions in 2014. distribution of antibiotics. A cluster of neonatal teta- At the district level, 15 (68%) project districts dissem- nus cases reported was ruled out as the cases did not inated the surveillance data and analyses every meet the standard case definition. The typhoid fever month to the HCs at the end of 2014, being improved outbreak was successfully contained with distribution from none in April 2012. of sodium hypochlorite. The project also verified the From October 2012 through December 2014 the decline of malaria cases in three selected districts in project was involved in 11 outbreak investigations of Amhara8）. measles (7 events), anthrax (1), pertussis (1), neonatal We held 16 initial two-day training sessions for the tetanus (1), and typhoid fever (1) (Table 1). The main district surveillance officers and HC focal points in activities in the outbreak responses were provision of 2012, five four-day training sessions for district technical assistance, including verification of the surveillance officers of the 22 districts from December outbreak, epidemiological investigations and analyses, 2013 through August 2014. We also held four, three- and vaccination campaigns7）. One of the measles day training sessions for surveillance focal points of outbreaks in North Gondar occurred in December HCs of four selected districts from April to October 2013 to February 2014 was contained with a successful 2014. The training material was initially developed by vaccine campaign, however the others were not so FMoH and the project staff revised it in collaboration successful as the number of vaccines were not with ANRS-HB. sufficient for multiple campaigns. In another measles The project supported six review and special meet- outbreak in Sekela district, West Gojjam, we conducted ings, five at the regional level and one at the zonal a case-control study and the finding suggested a pos- level. Three of these were annual review meetings; sible cold-chain issue, resulting in very low vaccine one on measles epidemics that occurred in early 2014, efficacy in that area. Anthrax outbreaks were still and two on the Ebola virus disease response. The occurring in northern Amhara, mainly because of number of staff members at the PHEM department

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Table 1 Outbreak investigations and response

of ANRS-HB increased from five in May 2012 to ten lance reports significantly improved, particularly in December 2014, including six FELTP graduates. from the HFs, suggesting the provision of the initial training was the primary driver for the improvement. IV. Discussion The improvement in the timeliness of the reports We reviewed the activities of a technical coopera- from HPs lagged behind that of HFs, however, it tion project on strengthening the communicable started in late 2013 and reached over 95% on average disease surveillance and response system in the in early 2014. This may have been helped by the Amhara Region of Ethiopia from late 2012 to 2014. In monitoring visits to HCs, because in the meeting with the project areas, the timeliness of surveillance the HC heads and surveillance focal points, we reports improved from about two-thirds in early 2012 emphasized the importance of collecting reports from to almost 100% at the end of 2014. ANRS-HB and the HPs and checked physically the reports. Although project responded to 11 outbreaks and unusual events. the IDSR and PHEM guidelines stipulate the impor- Various efforts must have contributed to the im- tance of monitoring and supervision3, 9）, it does not provement in timeliness of surveillance reports, emphasize the importance of monitoring visits to however, we would like to emphasize the importance HFs. We believe it is essential to enforce reporting of (1) provision of training for the surveillance system periodically at the HF level, because those personnel, (2) monitoring visits to the project HCs, who work there are primarily clinicians, not public and (3) holding review meetings on surveillance at health personnel, and they may not understand fully the regional and the zonal levels. Before 2012, the the importance of communicable disease surveillance. training on the PHEM was provided only to the six Another reason may probably be peer pressure that districts out of the 22 project districts5）, though the motivated the heads of DHOs with suboptimal PHEM had already been introduced in 2009. About timeliness in surveillance reports to improve and six months after the initial training was provided to catch up with other districts with better perfor- the rest of the districts, the timeliness of the surveil- mance, since in the review meetings the ANRS-HB

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or the ZHOs announced the ranking of the perfor- and the transfer of trained staff members without mance of the zones or the districts based primarily replacement hampered programme continuity in some on the timeliness of the reports. African countries13） and we also experienced this. Political commitment to the communicable disease Since the authors visited almost all the HCs in six surveillance and response system at the regional districts and one or two HCs in each of the other 16 level was one of the drivers that led to the increase districts in the project area, and verified the in the number of officers at the PHEM department of reporting practices, including those from HPs, we are ANRS-HB, including several FELTP graduates, confident that the surveillance system was functional which further provided the surveillance officers with in all the districts that the project covered. more time and opportunities to be able to communi- One of the limitations of the study may be that the cate with, visit and encourage the surveillance IHR core capacity monitoring framework14）, which is officers at the district and ZHOs, leading to improve- recommended by WHO to monitor the development ment of the timeliness. The provision of technical of IHR core capacities, was not employed to assess assistance in outbreak investigations in the field by the project activities. One of the reasons for not the project staff as well as the FELTP graduates using the framework was that the framework is too may have empowered and encouraged the surveil- comprehensive to assess the project activities: The lance officers and focal points at the district and HC framework includes the national legislation and policy, levels to continue the efforts in reporting the surveil- the national focal point, laboratory strengthening, lance data because they came to know that actions points of entry, chemical events, and radiation emer- were taken to control outbreaks and epidemics. gencies that were specifically out of the scope of the Dissemination of surveillance reports may also have project activities. However, the authors used the provided the frontline workers with a sense that the specific indicators that are also included in the frame- surveillance reports were well-utilized at the upper work and we are confident that they were sufficient levels, resulting in improved timeliness of the reports. and useful in evaluating the technical cooperation With the efforts of training, monitoring visits, and project. review meetings mentioned above as well as the In conclusion, the project has successfully achieved political commitment, other districts and regions with key goals, including strengthening surveillance lower performance in surveillance and response could reports and responses to outbreaks. The authors improve their performance. recommend that the ANRS-HB strengthen and main- Our studyʼs findings are mostly consistent with tain its commitment to the surveillance and response other studies. In Indonesia the performance of the activities in terms of human resources and funding. communicable disease surveillance and response In particular, training should periodically be conducted system, in terms of timeliness of reporting, regular for surveillance officers and focal point personnel at feedback of surveillance reports, and outbreak DHOs and HCs to maintain the human resources verification and investigation, improved through the working on surveillance. Also, HCs and DHOs should strong commitment of the government at various be visited and their activities should be monitored levels, development of a guideline, training, and simu- on-site to make sure the system is properly collecting lation exercises10）. In India, a communicable disease surveillance data and providing responses to unusual surveillance system with reports sent by post cards health events. was successfully initiated by a research institute and expanded to other districts by the state government. Acknowledgements Its success was attributed to low-budget, regular The project was funded by the Japan International dissemination of surveillance data, monitoring visits Cooperation Agency. From March 2013 through of surveillance staff to the reporting units, and January 2015, the project was run by the Japan Anti- holding educational meetings for health profession- Tuberculosis Association. We declare no conflicts of als11, 12）. A review of IDSR implementation in the interest in the study. The authors would like to African Region of WHO reported that high attrition thank the staffs of the Amhara National Regional

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State Health Bureau, the zonal and the DHOs of and lessons learnt in the field. Western Pacific Amhara Region for their close collaboration. Surveillance and Response Journal, 2015, 6(3): 1-6. doi: 10.5365/wpsar.2015.6.2.002. References 8）Toyama Y, Ota M, Getinet M, Belay BB. Sharp 1）World Health Organization. Part II. Information decline of malaria cases in the Burie Zuria, Dem- and public health response. In: International bia, and Mecha districts, Amhara Region, Ethio- Health Regulations (2005) Second Edition. pia, 2012-2014: descriptive analysis of surveil- Geneva: World Health Organization; 2008: 12. lance data. Malar J., 2016, 15(1): 104. doi: 10.1186/ Available at http://www.who.int/ihr/9789241 s12936-016-1133-9. 596664/en/. Accessed August 28 2015. 9）World Health Organization, Regional Office for 2）World Health Organization. 2015. Ethiopia | Africa. Monitor, evaluate and improve surveil- Integrated Disease Surveillance and Response lance and response. In: Technical guidelines for (IDSR) [Web page]. World Health Organization integrated disease surveillance and response in Web site. Available at http://www.afro.who.int/ the African Region 2nd ed. Brazzaville, 2010: en/ethiopia/country-programmes/topics/4590- 195-210. Available at http://www.afro.who.int/ ethiopia-integrated-disease-surveillance-and- en/clusters-a-programmes/dpc/integrated- response-idsr.html Accessed August 28 2015. disease-surveillance/features/2775-technical- 3）Public Health Emergency Management Centre. guidelines-for-integrated-disease-surveillance- Section 3. Early warning and surveillance. In: and-response-in-the-african-region.html. Accessed Public Health Emergency Management 2012 Jun 2 2016. Guidelines for Ethiopia. Addis Ababa: Ethiopian 10）Hanafusa S, Muhadir A, Santoso H, et al. A Health and Nutrition Research Institute; 2012: 23. surveillance model for human avian influenza Available at http://www.ephi.gov.et/images/ with a comprehensive surveillance system for guidelines/phem-guideline-final.pdf. Accessed 28 local-priority communicable diseases in South August 2015. Sulawesi, Indonesia. Tropical Medicine and 4）Daddi J, Getnet M, Zegeye H, et al. The Ethiopi- Health, 2012, 40(4): 141-147. doi: 10.2149/tmh. an Field Epidemiology and Laboratory Training 2012-10. Program: strengthening public health systems 11）John TJ, Samuel R, Balraj V, John R. Disease and building human resource capacity. Pan surveillance at district level: a model for devel- African Medical Journal 2011; 10 (Supp 1): 1-5. oping countries. Lancet, 1998, 352; 47-50. Available at http://www.panafrican-med-journal. 12）John TJ, Rajappan K, Arjunan KK. Communica- com/content/series/10/1/5/full/. Accessed 28 ble diseases monitored by disease surveillance in August 2015. Kottayam district, Kerala state, India. Indian 5）Japan International Cooperation Agency. Chapter Journal of Medical Research, 2004, 120; 86-93. 3 Project performance. In: Joint terminal evalua- 13）Phalkey RK, Yamamoto S, Awate P, Marx M. tion report on Amhara Regional Infectious Challenges with the implementation of an Inte- Disease Surveillance Project. Tokyo: Japan Inter- grated Disease Surveillance and Response (IDSR) national Cooperation Agency; 2013: 18-19. system: systematic review of the lessons learned. Available at http://libopac.jica.go.jp/images/ Health Policy and Planning, 2013, 1-13. doi: report/12086799_02.pdf. Accessed August 28 10.1093/heapol/czt097. 2015. 14）World Health Organization. IHR core capacity 6）Mekkonen YK ed. Regions, zones, and districts. monitoring framework, Checklist and indicators In: Ethiopia, The land, its people, history and for monitoring progress in the development of culture. Pretoria: New Africa Press; 2013: 116- IHR core capacities in states parties. Available 117. at: http://apps.who.int/iris/bitstream/10665/ 7）Toyama Y, Ota M, Belay BB. Event-based sur- 84933/1/WHO_HSE_GCR_2013.2_eng.pdf?ua=1. veillance in north-western Ethiopia: experience Accessed on 14 December 2016.

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