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Policy Briefs Integrated Disease Surveillance and Response

Burkina Faso

Background Surveillance and Response (IDSR) program to strengthen the existing national program In November 2002, the World Health Organizations urkina Faso has been plagued with disease Regional Office for Africa (WHO/AFRO) sent a team outbreaks in the past decade Most recently, B to document the IDSR programs experiences and a new strain of meningitis emerged in 2002, lessons learned resulting in over 1400 deaths Prior to 1994 Burkinas surveillance systems addressed the specific needs of various vertical programs such as Findings and Major Results meningitis, polio, HIV/AIDS, malaria, and tuberculosis These programs were disease specific The team found a marked improvement in the and operated concurrently within the national coordination of all surveillance activities, including surveillance system This situation resulted in an better coordination of epidemiological information overproduction of tools for data collection and centers at both the regional and district levels The reporting, lack of a coordinated national effort, and team noted that several critical changes within the an overworked and undercompensated sector of national system have strengthened Burkinas ability health workers to respond to disease outbreaks These included:

To address these weaknesses, the government of u Creating a new national public health Burkina Faso restructured its national surveillance laboratory and a national epidemic system in 1994 into central, regional, and district response committee; levels All are coordinated by epidemiological units that respond to various disease outbreaks, analyze u Strengthening the national laboratory data, report to immediate supervisors, and through extensive training programs and subsequently implement epidemic responses In the use of better tools for data collection 1998, Burkina Faso adopted an Integrated Disease and reporting;

u Posting highly educated and motivated epidemiologists in direct surveillance units at the regional and district levels, many of whom have taken training courses in intervention epidemiology; and

u Improving rapid epidemic response at the community level by equipping regional and district surveillance teams with radios Photo: WHO/TDR/Crump Photo:

August 2003 Lessons Learned Recommendations

Despite these advances, Burkina Fasos national u Empower the national committee and the epidemic response system needs a more effective national public health laboratory to respond to mechanism for coordinating between vertical Burkinas epidemics in a more coordinated programs and multiple partners Several fashion; independently supported programs continue to carry out surveillance activities Although a national u Accelerate the implementation of the IDSR committee exists, its authority to influence field plan of action, which would strengthen the activities in IDSR is limited National-level program surveillance and response capacities at central, directors will need to share decision-making intermediate, peripheral, and community authority and budgets in order to scale up IDSR levels; activities IDSR activities have been effectively integrated at the regional and district levels, but u Expand the responsibilities of the IDSR greater effort is needed to make the national system department to include all infectious diseases more effective (presently this department heavily emphasizes meningitis, polio, and measles);

u Ensure that the MOH has the technical and financial support necessary to implement the national plan of action; and

u Promote more effective integration and consensus of programs supported by different partners Photo: WHO/TDR/Crump Photo: Integrated Disease Surveillance and Response

Ethiopia

Background partners assessed the countrys surveillance system and used the results to adapt a five-year national plan It has been five years since the adoption of thiopia has suffered severe social, political, and the national plan, and in November-December humanitarian crises that have deteriorated the E 2002, a team from WHO and the US Centers for health infrastructure, putting the health of the Disease Control and Prevention (CDC) visited countrys most vulnerable populations at risk Ethiopia to document successes, challenges, and Communicable diseases, nutritional deficiency, and lessons learned from Ethiopias experience HIV/AIDS dominate Ethiopias burden of disease Largely preventable diseases, such as malaria, infectious diarrhea, and respiratory infections are Findings and Major Results common, and epidemic-prone diseases, such as meningococcal meningitis, cholera, measles, and Ethiopia has made notable advances in communi- bacillary dysentery, are chronic public health cable disease surveillance since adopting the IDSR problems strategy in 1996 Informants credited consistent and reliable political support as a significant contribu- To meet this challenge, the public health system and tion to IDSR implementation, especially at the other government sectors are becoming national level This support included the endorse- decentralized In 1996, as part of the response to ment of national and regional plans of action and the growing public health problem with the establishment of a national IDSR unit in the communicable diseases, Ethiopia introduced an MOHs Disease Prevention and Control Program Integrated Disease Surveillance and Response (IDSR) Dissemination of standard case definitions has taken strategy focusing on 17 priority diseases Ethiopia place, and a quarterly bulletin is published with adopted the World Health Organizations IDSR support from the polio eradication program and the strategy in 1998, and in October 1999, the Ministry Expanded Program on Immunization (EPI) The of Health (MOH) of Ethiopia and its development establishment of a national IDSR task force, the adaptation of technical guidelines, training materials, and modules, and the implementation of training activities at the national and regional levels have contributed to an overall improvement in data collection, analysis, and interpretation for public health action Additional evidence of progress includes:

u Increased awareness and use of IDSR indicators At the regional and national levels, officials are aware of indicators for case fatality ratio, timeliness and completeness of reporting,

Photo: Harvey Nelson Harvey Photo: and thresholds for selected epidemic-prone

August 2003 diseases Informants report being able to use of information and implementation of training and the indicator results to cite specific areas of regional IDSR activities Finally, activities are improvement, such as timely detection of impacted by delays in receiving allocated resources outbreaks from the national level and donor agencies u Improved integration efforts and coordina- Recommendations tion between IDSR and vertical programs At the national and regional levels, disease Recommendations for the national level focus on control programs for EPI, polio, malaria, and promoting approaches to maximize synergies tuberculosis share data, resources, transporta- between vertical programs and IDSR Specific tion, and communication facilities In an effort recommendations are to: to integrate programs, the AFP/EPI bulletin has been renamed the AFP/EPI/IDSR Bulletin and Provide administrative support to the MOH and is supported by WHO The national IDSR team u WHO and its partners to ensure a more timely has established a national Emergency Response release of government and donor funds to the Task Force to coordinate response activities in different levels; famine-affected areas in Ethiopia u Strengthen technical and supervisory support to Strengthened role of laboratories in surveil- u the regional and district levels; lance and response Laboratories participate in coordination meetings and investigation activi- u Develop and promote strategies to address high ties with the surveillance teams at the national, attrition rate of personnel (eg, for the short regional, and district levels In October 2002, and intermediate terms, retrain personnel; for an assessment of national public health labora- the long term, offer career opportunities, tory capacity was carried out, and strengthen- incentives, and transfers); ing a laboratory network with emphasis on data and information sharing between the laborato- u Advocate to professional associations, non- ries and surveillance units is a priority governmental organizations (NGOs), and training institutions for assistance with IDSR Lessons Learned implementation at the national and regional levels The MOH should provide support for Most of the IDSR activities have taken place at the orientation, training, and funding; national and regional levels Awareness of IDSR at u At the regional level, accelerate sensitization and peripheral levels is low, and it is at these levels that orientation sessions for community-based technical guidelines, training manuals, and revised organizations, NGOs, and local authorities and surveillance formats should be distributed Resources involve research institutions in IDSR and training support from the national level are assessments, planning, implementation, and necessary to ensure that activities can be monitoring and review of activities; and implemented u Provide supervisory and technical support to Further integration and coordination with vertical district offices and health facilities, including on- programs that includes promoting communication, the-job orientation and skills development on building consensus, and evaluating progress would the basics of IDSR help to accelerate IDSR throughout the regions A need also exists to consolidate data collection formats with those of the Health Management Information System In addition, IDSR progress is hindered by the shortage of personnel at all levels, and difficult terrain and poor communication services have contributed to delays in transmission Integrated Disease Surveillance and Response

Ghana Background Findings and Major Results

ommunicable diseases, such as malaria, The documentation team found that sensitization cholera, tuberculosis, and HIV, continue to activities and the assessment of national surveillance, C preparedness, and response systems have had a be leading causes of death in Ghana Yellow fever is endemic in Ghana, and reported cases of significant impact on the increased awareness of measles and neonatal tetanus are critical public IDSR at the national, regional, and district levels health problems In the past, disease elimination Informants cited an increase in the proportion of and eradication programs for Guinea worm, leprosy, health facilities submitting their monthly reports on and poliomyelitis provided resources for individual time from 30 percent before the surveillance surveillance activities However, these activities assessment took place to 80 percent by the end of placed a burden on health workers who were asked the assessment period Similarly, an increase in the to respond to separate vertical systems, especially number of suspected yellow fever reports and timely at the peripheral and district levels investigations of suspected acute flaccid paralysis (AFP) cases was observed following surveillance In 1996-1997, Ghana experienced devastating orientation and sensitization Additional efforts outbreaks of meningococcal meningitis, cholera, and undertaken by national disease control programs yellow fever In response, health leaders in Ghana to share common resources and structures have joined ministers of health from other African resulted in maximized resources for strengthening countries to call for improved surveillance capacity surveillance For example: for early detection and rapid response to communicable disease threats u Disease control program managers and laboratory workers were involved in modifying In 1998, Ghana created a National Surveillance Unit the integrated surveillance monthly reporting (NSU) to coordinate the collection, collation, form; analysis, and dissemination of surveillance data for communicable diseases In 2000, Ghanas Ministry of Health (MOH) assessed the surveillance system and developed a five-year national plan for strengthening the national system consistent with the Integrated Disease Surveillance and Response (IDSR) strategy adopted by the World Health Organization, Regional Office for Africa (WHO/

AFRO) member states in September 1998 In Photo: WHO/TDR/Crump November 2002, WHO and the US Centers for Disease Control and Prevention (CDC) sent an international team to Ghana to document experiences and lessons learned during the implementation of Ghanas IDSR program

August 2003 donors and high-level public health leaders adopt an integrated approach when new program activities are designed Indeed, this is not an easy process, but it would facilitate and strengthen integration at the mid and peripheral levels Recommendations

u Accelerate implementation of IDSR at the regional, district, and community levels;

Photo: WHO/TDR/Crump Photo: u Regularly measure and evaluate the IDSR indicators to monitor progress towards an improved surveillance and response system; u Weekly and quarterly feedback bulletins are prepared by the NSU and the Expanded Accelerate training of surveillance personnel at Program on Immunization (EPI); u the regional and district levels using onsite u Standard case definitions have been adopted training whenever possible; and disseminated for 23 priority diseases under surveillance; u Promote enhanced links between central, regional, and district laboratories through u National laboratory workers participated in onsite technical supervision and the monthly surveillance meetings in Accra and in development of a standard internal quality quarterly meetings with regional surveillance control system; directors; and u Encourage development of financial and non- u A principal biologist has been appointed as an financial incentives for retaining skilled health IDSR activities coordinator at the national personnel and recruiting well-trained staff into laboratory IDSR activities;

u Develop an annual budget for outbreak Lessons Learned investigation and response; and

Surveillance activities have progressed significantly u Promote a functional central supply office to through the implementation of IDSR, but much of ensure a consistent supply of good quality the important work has taken place at the national laboratory media and reagents to regional level A critical goal and major challenge is to bring laboratories technical skills and tools to the local level, where a need exists for concerted sensitization, orientation, and onsite training in basic surveillance principles and the use of adapted surveillance tools This is especially important given high turnover rates at all levels The formal coordination between programs, such as EPI and malaria, can support the integration of surveillance capacities and enhance production of common sensitization materials and feedback bulletins Further, informants interviewed during the documentation activity recommended that Integrated Disease Surveillance and Response

Mali Background Centers for Disease Control and Prevention (CDC), and national program coordinators reviewed numerous regulatory texts, workplans, and reports he nation of Mali is situated within the and conducted field visits to hold qualitative focal meningitis belt of Africa and has consistently T group discussions and informal interviews with experienced outbreaks of meningitis and numerous national- and district-level health other epidemic-prone diseases In 1995, a lethal directors meningitis epidemic resulted in over 11,000 documented cases and over 1,000 fatalities The 1995 and 1996 cholera outbreaks in Mali resulted Findings and Major Results in 2,675 documented cases and caused almost 400 deaths, and a measles outbreak in 1998 resulted in The team noted a structured framework for IDSR over 10,000 cases and caused 35 deaths Poor data implementation in Mali and reported four major analysis and interpretation of results, unclear developments since 1998 First, an Epidemiological guidelines and case definitions, dysfunctional Disease Surveillance (EDS) unit was created to epidemic committees, and a lack of a clear national coordinate IDSR implementation Second, a national strategy contributed to Malis inability to respond public health reference laboratory was established effectively to these outbreaks and is actively engaged with the EDS unit Third, the National Health Directorate (NHD) currently has To address this problem, the Malian Ministry of a center for data processing and analysis that is Health (MOH) adopted an Integrated Disease operated by technical staff and equipped with more Surveillance and Response (IDSR) strategy in 1998 advanced electronic equipment The NHD now has to strengthen the existing national program Four systems in place to routinely monitor data for quality years later, the World Health Organizations Regional control Last, the IDSR communication system Office for Africa (WHO/AFRO) conducted a employs a radio network that transmits data on documentation activity to describe successes, epidemic diseases and other communicable priority challenges, and opportunities for future IDSR diseases Although some areas of the country are implementation A team from WHO, the US still not covered by the radio network, coverage has been greatly improved since 1998

Although Mali has developed a strategy to integrate the national systems, the team found that central- level health officers lacked a clear understanding of how to formulate an integrated approach The MOH has not yet established a decentralized laboratory network, and the capacity of district-level laboratories is low and in dire need of technical and financial support Private health facilities are not yet involved in surveillance activities, and WHO administrative processes have delayed implementation of the plan of action Photo: CDC

August 2003 Recommendations

The team recommends that to coordinate Malis IDSR activities better, a national laboratory network must be created and supported The team also recommends scaling up the distribution of technical guidelines and tools for data collection and data analysis at the central and district levels and implementing a system to monitor the use of the guidelines The team specifically recommended that the NHD:

u Integrate community surveillance into the Photo: WHO/TDR/Crump Photo: national system;

Lessons Learned u Mobilize resources to implement activities; and With financial support from the MOH, the NHD has bought drugs and conducted a mass vaccination u Organize a workshop to finalize the role of campaign The NHD was restructured in 2001, health centers within the IDSR system putting Malis disease surveillance programs under the responsibility of the Division for Public Health This support has trickled down to community health centers and now allows officers-in-charge to manage disease outbreaks and send laboratory specimens to the central laboratory This has greatly improved the coordination of different health programs There are two districtsNiono and Kolondiébathat have done particularly well in community surveillance and could serve as models for replication elsewhere

Additionally, collaboration between the public health schools and the IDSR training program has worked well to integrate IDSR training modules into the curricula Integrated Disease Surveillance and Response

Southern Sudan Background Liberation Movement (SPLM), and the United Nations to sign an agreement to deliver humanitarian aid under the Operation Lifeline Sudan udan is a country that has endured more than (OLS) initiative In 1998, the World Health three decades of internal conflict, massive S Organization (WHO), building upon this agreement, population displacement, repeated drought, established a Southern Sudan liaison office in and frequent disease outbreaks The conflict has Nairobi and a field office in Loki (Kenya) been mainly in Southern Sudan, which consists of the Bahr Ghazal, Equatoria, and Upper Nile regions Communicable diseases are the leading causes of The health infrastructure has been largely destroyed; health problems in Southern Sudan, accounting for training of health workers has been disrupted; and significantly high rates of morbidity and mortality most of those trained have either migrated or been within the population Epidemic diseases are displaced The 1989 humanitarian crisis was one of frequent and, too often, the response is slow and the worst emergency situations in Sudanan the disease poorly diagnosed On many occasions, estimated two million people are believed to have thousands of lives were claimed and six months died as a result of conflict, famine, and epidemic passed before any response was initiated Prior to diseases The situation was worse in Southern 1999, surveillance and response activities were Sudan, where no central authority existed to conducted on an ad hoc basis and were poorly coordinate response efforts This crisis prompted the coordinated Government of Sudan, the Sudans People In 1998-1999, WHO, UNICEF/OLS, and the US Centers for Disease Control and Prevention (CDC) sponsored field assessments on the health information systems (HIS) investigation and management practices and outbreak preparedness The assessment revealed a need to create a more effective surveillance and response system Accordingly, an early warning and response network (EWARN) was initiated in July 1999 In May 2000, the United Nations Foundation funded a three-year project to strengthen surveillance and response to epidemic-prone and vaccine-preventable diseases In December 2002, a team of international experts, sponsored by WHO and CDC, documented the experiences and lessons learned from this project Photo: WHO/TDR/Crump Photo:

August 2003 Results Before the implementation of EWARN it took several months to detect, alert, verify, and respond to suspected outbreaksat huge costs and many lives In general, EWARN has succeeded in bringing Today it usually takes days and rarely more than together various local and international partners to two weeks Overall, the project to strengthen improve surveillance and response to epidemics by surveillance and response using EWARN has establishing a viable system Thus, EWARN has succeeded despite the enormous challenges posed succeeded in improving outbreak surveillance and by Southern Sudans physical, social, economic, and response These findings were consistent with earlier political landscape monitoring and field reviews and in agreement with the observations and beliefs of partners The team observed that practical approaches were effective Challenges in initiating and establishing the system These approaches included: Despite these encouraging achievements, a number of major challenges remain Sudan is still within a Conducting needs assessment, advocacy, and u conflict zone and experiences chronic emergencies sensitization that were incorporated into a Lack of strong central authority in the south and project plan; continued conflict threaten the consolidation and sustainability of gains The limited number and u Involving WHO/Southern Sudan directly in precarious situation of health facilities, poor training, outbreak investigations, and infrastructure, and inadequate funding make it confirmation and response and facilitating difficult to access more areas for further expanding human and material resources, information the system Moreover, dependency of health analysis and dissemination, intervention services on humanitarian organizations and the rapid planning, and feedback to partners; turnover of NGO and UN agency staff pose challenges that need to be addressed u Engaging stakeholders (UNICEF/OLS, WHO, NGOs, and community-based organizations) and creating synergies in surveillance and Recommendations response activities (training, alert, and response); u Consolidate and sustain gains and expand the u Building local capacity in clinical and lab skills system to more areas and establishing a laboratory referral network system supported by locally adapted courses u Encourage international partners, particularly and technical inputs from collaborating institu- NGOs working in Southern Sudan, to recruit tions, such as the African Medical and Research more South Sudanese health workers to Foundation (AMREF), the Kenya Medical decrease the rapid turnover of staff Research Institute (KEMRI), and the Interna- tional Committee of the Red Cross (ICRC); u Increase investments to improve basic health care delivery by supporting preservice and in- u Establishing practical communication channels service training of health workers, making and an alert system using high-frequency radio supplies available, and strengthening lab networks with simplified reporting tools and services technical guidelines; u Support training school partnerships with u Maintaining regular feedback and disseminating technical and material inputs and integrate timely information for action using updates, field surveillance and response training into visits, and radio communication; and curricula u Ensuring a skilled and committed EWARN core staff Integrated Disease Surveillance and Response

Uganda

Background Findings and Major Results

ike many countries in sub-Saharan Africa, the Within the system, the team found great LRepublic of Uganda experiences severe disease improvements in coordination and training and outbreaks that heavily impact the population noted the use of new and updated materials and the health systems The Ebola virus alone killed Selected sections of IDSR generic technical 224 people in 2001, and meningitis, yellow fever, guidelines were initially adapted to provide the typhoid, and malaria continue to afflict the Ugandan peripheral level with basic surveillance tools, such people as standard case definitions, action thresholds, supervisory checklists, and reporting forms The In 1996, Uganda initiated an integrated approach generic technical guidelines were then fully adapted, to surveillance and response Until this time, the and other materials, such as job aids, laboratory national surveillance and response system used guidelines, district-level planning guides for varying surveillance tools and lacked standard case surveillance, and guidelines for rapid response to definitions at the peripheral level and a functioning epidemics were produced method for reporting Moreover, the quality of data analysis at the district and health facility levels was Some training on integrated surveillance started questionable Although epidemic management before the adaptation of IDSR generic training committees were in place in some districts, modules in August 2002, first at the central level supervisory activities were irregular and not and then at the peripheral level Following the structured at any level Two years later, in an effort adoption of the IDSR strategy, a series of regional to improve the situation, the Ugandan Ministry of workshops were held to sensitize district personnel, Health (MOH) adopted the World Health including laboratory workers The Institute of Public Organizations Integrated Disease Surveillance and Health has assisted the implementation of IDSR by Response (IDSR) strategy and performed a nationwide assessment of its surveillance systems

In late-2002, a team of three consultants (two epidemiologists and one laboratory expert) carried out an IDSR documentation activity in collaboration with a national counterpart This activity aimed to document successes, challenges, and opportunities for IDSR implementation The activity was primarily qualitative and consisted of discussions with focal

groups, interviews, field visits, and document CDC Photo: reviews

August 2003 supporting training activities, data analysis, and epidemic investigations and helping to develop plans of actions Laboratory personnel from all levels have been trained in outbreak investigation and diagnosis of cholera, meningitis, shigellosis, and typhoid Moreover, all districts have established rapid response teams with members from various sectors

A national Health Management Information System (HMIS)IDSR joint committee meets monthly to CDC Photo: coordinate surveillance activities between programs A weekly newsletter and a quarterly feedback bulletin are published by the MOH and widely distributed A national daily newspaper publishes Recommendations data on cases and death from epidemic-prone diseases on a weekly basis Meetings of district The IDSR committee should mobilize all stakeholders surveillance representatives are held every six to: months at the central level, with an award granted to the best performing district in terms of surveillance Support districts and subdistricts in building activities u capacity in data analysis and outbreak investigation by recruiting and training Lessons Learned personnel (eg, clinicians, lab personnel, health educators, health inspectors, etc) in surveillance strategies in order to ensure sustainability; The introduction of IDSR in Uganda has clearly strengthened district and MOH surveillance u Strengthen communication links between capacity, particularly for diarrhea disease outbreaks levels; and other febrile diseases, such as Ebola Because the vertical health programs have been hesitant in u Increase efforts on ensuring multisectoral embracing IDSR implementation in Uganda, the outbreak responses; IDSR committee has been instrumental in clarifying issues and building consensus u Sustain the weekly and quarterly feedback publications for advocacy and resource- The health subdistricts in Uganda are somewhat mobilization purposes; young, and as a result, the implementation of IDSR at the district level has been a considerable u Review and update the indicators through challenge In addition, the private sector is not quarterly and annual monitoring and evaluation adequately participating in the reporting of activities; and surveillance data Means of communications between levels are often not adequate, which can u Consider the inclusion of HIV/AIDS in IDSR impede the smooth flow of information Data implementation management at the periphery level is weak, despite the availability of computer technology Often, data management software is not standardized, so coordination between districts can be problematic PreparedPrepar byed theby t Supporthe Suppo forrt f Analysisor Analys andis a Researchnd Resear inch Africain Afri (SARA)ca (SAR ProjectA) Proje whichct whi isch operatedis operat byed theby t Academyhe Academ fory f Educationalor Education Developa Populat l and Medicine, D of School Morehouse e JHPIEGO, University, Tulane subcontractors with ment ve

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