Original research

Evaluation of the Indonesian Early Warning Alert and Response System (EWARS) in West Papua, Indonesia Mersi K Manurung1,2, Sarce EN Reo1,3, Jerico F Pardosi4, David J Muscatello1 1University of New South Wales, Kensington, New South Wales, Australia, 2Health Department of West Papua Province, Manokwari, Indonesia, 3Health Department of Kupang Regency, East Nusa Tenggara, Indonesia, 4Queensland University of Technology, Brisbane, Queensland, Australia Correspondence to: Dr David J Muscatello ([email protected])

Abstract Background The Early Warning and Response System (EWARS) is Indonesia’s national syndromic and early warning surveillance system for the rapid detection of infectious diseases and outbreaks. We evaluated EWARS in the remote West Papua province of Indonesia. Methods Structured telephone interviews were conducted with 11 key informants from West Papuan health services. EWARS data were analysed for usefulness of reporting. Results Most respondents reported that EWARS is important and useful in improving early detection of outbreaks. The system has led to increased disease control coordination among health jurisdictional levels in the province. However, respondents noted that the limited number of districts involved in the system affected representativeness, and some stated that only about 30–35% of districts in each regency were involved and trained in EWARS reporting, partly owing to lack of a mobile telephone network. Barriers to complete reporting and response to alerts included limited human and funding resources for surveillance, lack of epidemiological training, and technical limitations imposed by limited internet and mobile communication infrastructure in this remote region. Conclusion Great progress has been made in integrating West Papua into a nationally consistent disease and outbreak detection system. Strategies for addressing barriers resulting from remoteness, constrained human, funding and laboratory resources, lack of training, and limited internet and communications infrastructure are needed if EWARS in West Papua is to advance.

Keywords: emerging diseases, Indonesia, outbreaks, remote settings, surveillance, West Papua

Background centres (puskesmas, short for Pusat Kesehatan Masyarakat in Indonesian). An internet-based wide area network is used Disease surveillance is a core capacity under the International to distribute the processed surveillance statistics and resulting Health Regulations, 2005 (IHR), and for strategies to improve reports to regional health jurisdictions for review and possible early detection of outbreaks that have been developed action. The aim is to detect cases of certain serious infectious in various countries.1 Increasing automation of disease diseases or unusual disease patterns signalling possible reports in low-resource settings can reduce the workload outbreaks of common or rare infectious diseases.7,8 of health workers and increase surveillance sensitivity.2,3 West Papua (Papua Barat in Indonesian) is one of the least However, implementation of automated surveillance must be developed provinces of Indonesia. It includes 13 administrative accompanied by an evaluation to assess whether or not the subregions (12 regencies and one city). The total area of West system achieves its objectives.4 Papua is approximately 100 000 km2, and in 2017 it had a total In 2009, to improve infectious disease control and to population of 915 361; its Human Development Index score is comply with the IHR, Indonesia developed a national Early the second lowest among those of the 34 Indonesian provinces.9 Warning Alert and Response System (EWARS).5 In 2015, the With regard to health, the number of infectious diseases, such EWARS website, an automated data capture system, was as malaria and diarrhoeal diseases, has decreased over time developed in the capital, Jakarta, to provide the infrastructure but is still higher than those of other provinces. For instance, in for more rapid detection of outbreaks.6 The system uses short 2015 West Papua’s number of positive malaria cases per 1000 messaging service (SMS) text messaging for source data population was 31.3, the second highest rate in Indonesia after transmission by surveillance officers in district public health that of Papua province.10

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It is essential to evaluate the implementation of EWARS in Committee (HC180628). Permission to conduct the research low-resource settings with high rates of infectious diseases. This was obtained from the Health Department of West Papua study used well-established guidelines to evaluate the operation Province, and Indonesian ethical exemption was granted by of EWARS in Indonesia’s West Papua province. the Indonesian Ministry of Health (LB.02.01/2/KE.297/2018).

Methods Results

Study design System objective and description The Updated guidelines for evaluating public health surveillance The aims and operation of EWARS in West Papua are the same systems published by the Centers for Disease Control and as in all the Indonesian provinces; the objective is to reduce Prevention (CDC) were applied.11 Qualitative data on the the size and impact of outbreaks through earlier detection. operation of the system were collected during September 2018 The reporting structure is outlined in Fig. 1. Surveillance data using semi-structured interviews with key informants involved collection begins in subdistrict health centres (pustu). Aggregate in the operation of EWARS at various levels of the provincial counts of diseases and disease syndromes are collected by health governance structure. The questionnaire, developed health workers (nurses, midwives, etc.) and forwarded to the using the CDC guidelines in English and Bahasa Indonesia, surveillance officer at the puskesmas by SMS, phone or hand is available from the corresponding author. The questionnaire delivery. These data from the pustu are then aggregated by was piloted in another province and revised as a result. the puskesmas surveillance officer with data from the district Count data relating to the diseases and syndromes puskesmas and sent as one SMS to the national Ministry of monitored by EWARS from week 42 (week commencing Health’s application programming interface (API) in the central 12 October) 2015 to week 52 of 2017 were extracted from EWARS computer system. The API transfers the data to the central the EWARS database. The EWARS database includes only EWARS database, where they are automatically aggregated, aggregated weekly counts of diseases reported by health analysed and reported on the central EWARS website. centres, which can be retrieved using the EWARS website The SMS message constructed by the surveillance officer is provided by the Indonesian Ministry of Health. assembled as follows: epidemiological week, disease code 1 In 2018, there were 159 puskesmas in West Papua and number of cases, disease code 2 and number of cases, province, and most were registered in EWARS. Participants and so on, plus the total number of patients visiting the site in were identified based on the human resource database for 1 week along with the code for the site. The disease codes are EWARS. There are no guidelines on the number of surveillance single alphabetical characters unique to the system.7 officers per puskesmas. Since infectious disease surveillance Each week, surveillance officers at the regency/city and is a health programme operating through puskesmas and the provincial levels review the data reported on the national District Health Office, there should be at least one person EWARS website for their jurisdiction. They verify alerts and dedicated to running the programme at each site. coordinate with surveillance officers at the puskesmas level. Purposive sampling was used to select participants in the If necessary, they initiate a response, including outbreak interview. We chose sites to give a selection of urban, rural investigation and control measures. This may include collecting and remote settings. Prior to the interview, the respondents specimens from cases. The specimens are sent to the national were asked how long they had been working as a person with diagnostic laboratory. Based on the results, regency/city and EWARS responsibility. If the duration was more than 1 year, provincial officials determine whether or not an outbreak or they were included in the study. Fourteen key informants and other response is required. Laboratory confirmation for some stakeholders responsible for the EWARS programme in West diseases, such as malaria, can be carried out by a local Papua were selected for interview, consisting of eight managers laboratory at the puskesmas level. and EWARS officers in health departments at provincial and Each disease under surveillance has an alert threshold, regency government levels and six EWARS data providers in with criteria varying by disease or syndrome category. The puskesmas at local government level. threshold values consist of criteria such as “increase in Interviews lasted between 30 and 60 minutes and were cases” (meaning the number of cases has doubled or more carried out in Bahasa Indonesia by telephone from Sydney, than doubled compared with the previous period); that Australia. Verbal consent for participation and audio recording particular criterion is used for categories including diarrhoea, was obtained from each informant before the interview. malaria, suspected cases of dengue fever, bloody diarrhoea, Following the CDC guidelines, interview recordings and influenza-like illness and pneumonia. For categories with very written notes were thematically analysed and the themes were low probability per unit of time, such as suspected typhoid reviewed by the research team. Aggregate surveillance count or chikungunya, a Poisson distribution-based threshold is data from EWARS for West Papua from 2015 to 2017 were applied. The category “cluster of unknown disease” uses used to assess the usefulness of reporting. a “three cases” threshold criterion. Suspected cases of measles, diphtheria or pertussis have a “one case” criterion Ethics for reaching the alert threshold.7 The procedures followed were in accordance with the ethical standards of the responsible committee on human Interview results experimentation (institutional or regional) and with the Helsinki Six of the eight selected provincial and regency key informants Declaration of 1975, as revised in 2000. The study was approved and five of the six in puskesmas were interviewed; there were by the University of New South Wales Human Research Ethics 11 respondents in total from the 14 invited to participate. The

112 WHO South-East Asia Journal of Public Health | September 2020 | 9(2) Manurung et al.: Early Warning Alert and Response System in West Papua, Indonesia

Fig. 1. Early Warning and Response System (EWARS) data flow, West Papua, Indonesia

Pustu Puskesmas Regencycity Province (subdistrict health (district health Sureillance officer EWAS officers centre) centre) reies ata on EWAS in proince ata recore ata from pustu ebsite each ee access ata usin EWAS ata sent are combine Officer checs alerts each ee case efinitions b SS ith EWAS Officer erifies alerts Officers conuct Sureillance phone call case ata (call or isit to pusesmas monitorin an officers sen ata or b han from pusesmas folloe b confirmation coorinate ith from pustu to Sureillance of erification throuh the recenccit pusesmas officer sens EWAS ebsite) f necessar ata to the f reuire officer arranes specimens are central serer specimen collection from eliere to (the EWAS pusesmas or pustu national ebsite) Officer oranises specimen laborator elier to proince aborator f necessar officer feebac is conucts outbrea proie to inestiations recenccit ontrol measures ontrol ata implemente measures transferre aborator feebac ecie b SS proie to pusesmas

ata iee ata accesse eebac on EWAS usin the Specimen on results ebsite internet elier b email

Ministry of Health of Indonesia (EWARS website) National laboratory ata sae in atabase Specimen Automate sureillance analsis prouce eamination Analsis of reportin completeness an accurac eebac on carrie out results

Note: There are several pustu reporting to each puskesmas, there are several puskesmas in each regency or city, and there may be several regencies and cities reporting to each province. remaining selected informants were unable to be contacted for needed to conduct an outbreak investigation. At the regency interview. City-level informants could not be contacted. Five and provincial levels, two of six stated that they did not have respondents had a bachelor’s degree in health and six had access to Wi-Fi or internet services, while the remaining four health diploma qualifications. Respondents included managers reported that, although they did have Wi-Fi in their workplace, of the surveillance programmes and EWARS officers at it was not always reliable. They considered this and limited provincial and regency health offices, and designated EWARS mobile network connectivity to be the biggest challenges surveillance officers in puskesmas. they faced. Two respondents mentioned having a workplace computer for EWARS, while the remaining four used their own Personnel and infrastructure to operate EWARS private laptop computers. At the puskesmas level, two of five respondents reported that there were two surveillance officers in their workplace, while Funding resources the rest reported one surveillance officer. Four had attended At the puskesmas level, the majority of respondents reported EWARS training. At the regency and provincial levels, all that, apart from their salary, funding for EWARS operations was respondents reported being the only surveillance officer in limited. One respondent mentioned having funds for increasing their workplace and all had attended EWARS training. All community knowledge about diseases such as diarrhoea and respondents had multiple work roles, including their EWARS one reported having a budget for outbreak investigations, responsibilities, and four of 11 noted difficulties in managing while the rest of the participants mentioned not having funds competing priorities. to support the EWARS programme. In the cases of puskesmas Nine of 11 respondents were aware of, and had a copy officers who had access to EWARS funds, those funds were of, the EWARS guidebook. Seven had access to the forms provided by a national government funding programme. At the

WHO South-East Asia Journal of Public Health | September 2020 | 9(2) 113 Manurung et al.: Early Warning Alert and Response System in West Papua, Indonesia regency and provincial levels, only two respondents reported members informally trained by health workers (kader) to the availability of funding for EWARS and surveillance activities, support community health programmes in distant villages to and they stated that those funds were insufficient for capacity- send surveillance reports or text messages to the puskesmas. building and outbreak investigations. At the regency level, the Alternatively, puskesmas officers collect data directly during source of funds is the regional government funding programme, field visits, when operating mobile health centres (pusling) and at the provincial level funding comes from both national and and when implementing other programme activities such as regional programmes. malaria control programmes and immunization programmes. Most respondents at all levels reported that funding was essential for implementing the system. Limited funds for Timeliness investigating outbreaks, examining specimens and travelling to All puskesmas respondents noted that the delivery of each remote areas cause difficulties in verifying all alerts produced report usually occurs every Monday or Tuesday for the previous by the system. week’s reporting period but that some delays occur owing to competing work priorities, mobile network instability and System attributes changes to EWARS officers’ mobile phone numbers. Around Simplicity half of all respondents reported that EWARS, and not rumour, All puskesmas respondents considered the system easy to use often provided the first indication of an outbreak. Outbreaks because reports were sent using SMS. They also thought that not detected by EWARS occurred in areas not participating in the EWARS SMS reporting format was easy to understand, EWARS or were reported by hospitals or private doctors. especially after attending EWARS training. Automatic feedback from the central server when the data report was successfully Data quality sent was an advantage of the system. All regency and All puskesmas respondents reported that they understood provincial respondents reported that the system was simple the EWARS case definitions and all were able to give correct to implement. They considered it an advantage that analysis examples of cases meeting the definitions. Some case and monitoring of EWARS reports could be done through the definitions caused confusion, such as influenza-like illness, EWARS website. suspected human avian influenza, cluster of unknown disease and suspected chikungunya. This was partly as a result of Acceptability limited knowledge of these diseases and situations. Moreover, All respondents considered that the system was important not all diagnoses are made by doctors at the puskesmas. In for early detection of infectious disease outbreaks. One at least one puskesmas, diagnoses are made by nurses, and puskesmas officer stated, “I think this system is important there are concerns about accuracy. Errors in SMS reports and very good because if there is a dangerous disease in the can cause false alerts. A solution implemented by puskesmas village, by sending an SMS, the government will immediately officers was, during field visits, to promote to pustu officers the know [translated from Indonesian].” The respondents believed importance of sending accurate data and reports. that the system was suitable for areas with a functioning mobile At the regency level, efforts to improve data quality included telephone network, because of its ease of use and simplicity. providing regular feedback to puskesmas and providing monthly reports back to puskesmas and pustu. Provincial Stability officers provide capacity-building training to district officials The majority of respondents reported never having and technical guidance to puskesmas officers, if funds for experienced an EWARS outage lasting more than 1 day or these activities are available from annual national or regional 1 week. Some puskesmas respondents had experienced programmes. In addition, reviews of and feedback on the limited availability of mobile telephone networks for sending quality of EWARS data are also carried out regularly. SMS messages, especially in rural areas. There were delays in weekly reporting from some pustu to puskesmas. EWARS Usefulness officers who change their cell phone number must re-register Based on aggregate data obtained from the EWARS website, it in EWARS and this does not always occur, leading to delays there was an increase in alert responses during 2015–2017 (see in SMS data reports. Regency and provincial respondents Fig. 2). Respondents perceived that the system’s usefulness reported that the central EWARS system was quite stable in reflected the EWARS objectives, namely early detection of providing surveillance information. However, unstable internet outbreaks of infectious diseases, minimizing mortality and health and Wi-Fi services affected their ability to review surveillance risks due to outbreaks, monitoring infectious disease trends information. and assessing the impact of disease control programmes. One puskesmas official stated, “With the reporting of this system, we Representativeness can know the increasing or decreasing trend of certain diseases Regency and provincial respondents reported that the in our region so that we can detect outbreaks quickly [translated limited number of puskesmas involved in the system affected from Indonesian].” Some puskesmas officers reported that not representativeness, and some stated that only about 30– all objectives were being met. 35% of puskesmas in each regency were involved and Most regency and provincial officers stated that EWARS was trained in EWARS reporting, partly owing to lack of a mobile very useful because of its ability to produce alerts and stimulate telephone network. At the puskesmas level, the proportion of prevention and control measures. Some respondents at all participating pustu varied. Some reported that it was difficult levels reported that usefulness was hampered by operational to obtain data from pustu in remote villages. The solution difficulties such as poor mobile networks and inability to include adopted by puskesmas officers was to empower community all pustu because of remoteness.

114 WHO South-East Asia Journal of Public Health | September 2020 | 9(2) Manurung et al.: Early Warning Alert and Response System in West Papua, Indonesia

Fig. 2. Number of Early Warning and Response System (EWARS) alerts and number of alerts with a response activity recorded, by epidemiological week, 2015 (weeks 42–52) to 2017, West Papua, Indonesia

35

EWARS alert Response action taken

30

25

20

15 Number of alerts/actions 10

5

0 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 2016 2017 Year and week number

Respondents thought usefulness could be enhanced the proportion of malaria alerts that indicate actual outbreaks through advocacy for improving mobile network infrastructure is difficult to determine. in remote areas, increased stewardship from all administrative levels, and increased funding support for capacity-building, Positive predictive value laboratory diagnostics and outbreak investigations. They also Although we do not have data regarding this attribute, suggested that there was a need for improved integration with respondents estimated that less than 50–70% of alerts signalled other surveillance and disease control programmes. Single- actual outbreaks. Regency and provincial respondents stated sideband modulation radio for data communication from remote that there was difficulty in determining positive predictive value pustu was also proposed. Two regencies had established a because some disease cases or outbreaks are not confirmed rapid response team (Tim Gerak Cepat in Indonesian) for early or laboratory diagnostic results are sometimes delayed. response to outbreaks. Respondents reported difficulty in confirming infections or outbreaks because local laboratories are only able to carry Discussion out limited diagnostics. While there is an absolute threshold (“one case”) set for conditions such as measles, diphtheria The results of this evaluation indicate that, compared with and acute flaccid paralysis (for poliomyelitis), an inability to previous paper-based approaches used in West Papua,12 diagnose these conditions locally prevents confirmation of EWARS is simple to implement and operate at the provincial infections or outbreaks. Confirmatory diagnostics for many level. The method for weekly reporting of disease data via SMS conditions can be provided only by the national reference by health workers at puskesmas is a practical and rapid means laboratory. of reporting diseases based on EWARS case definitions. The majority of respondents reported that this system was Sensitivity important and useful in improving early detection of outbreaks. Sensitivity was hampered by incomplete population coverage The system has led to increased disease control coordination because of a lack of mobile network infrastructure in some among health jurisdictional levels in the province. areas. For example, regency and provincial officers found two Factors such as limited human and funding resources outbreaks of dengue fever during 2017–2018 not detected for surveillance, lack of epidemiological training, and by EWARS. These were detected in puskesmas with mobile technical limitations imposed by limited internet and mobile network difficulties and from hospital reports. Sensitivity is communication infrastructure in this remote region present also influenced by the threshold level used nationally for some barriers to complete reporting and responding to alerts. These diseases, which may not be appropriate in some locations. For obstacles illustrate the difficulty of detecting outbreaks in areas instance, as malaria is a frequently reported endemic disease, with the greatest need for syndromic surveillance.13 A possible EWARS officers reported difficulty in determining the number solution is very low-frequency radio or single-sideband of malaria cases that would indicate an outbreak. As a result, modulation radio.14,15

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