Journal of International Health Vol.32 No.1 2017 [Field Report] Strengthening the communicable disease surveillance and response system, Amhara Region, Ethiopia, 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 Gondar 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） ─ 1 ─ 国際保健医療 第 32 巻 第 1 号 2017 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 ─ 2 ─ Journal of International Health Vol.32 No.1 2017 Figure 1 Map of the study districts, Amhara Region, Ethiopia Legend: Districts in North Gondar Zone a - Debark, b - Dabat, c - Wegera, d - Lay Almacho, e - Chilga, f - Takusa, g - Alefa, h - Dembia, i - Gondar Zuria, j - West Belessa, 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 ─ 3 ─ 国際保健医療 第 32 巻 第 1 号 2017 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