Monitoring and evaluation of integrated disease surveillance and response in selected districts in Tanzania

Integrated Disease Surveillance and Response (IDSR) is a strategy developed by the World Health Organization Regional Office for Africa in 1998. The Ministry of Health, Tanzania has adopted this strategy for strengthening communicable diseases surveillance in the country. In order to improve the effectiveness of the implementation of IDSR monitoring and evaluating the performance of the surveillance system, identifying areas that require strengthening and taking action is important. This paper presents the findings of baseline data collection for the period October-December 2003 in 12 districts representing eight regions of Tanzania. The districts involved were Mbulu, Babati, Dodoma Rural, Mpwapwa, Igunga, Tabora Urban, Mwanza Urban, Muleba, Nkasi, Sumbawanga Rural, Tunduru and Masasi. Results are grouped into three key areas: surveillance reporting, use of surveillance data and management of the IDSR system. In general, reporting systems are weak, both in terms of receiving all reports from all facilities in a timely manner, and in managing those reports at the district level. Routine analysis of surveillance data is not being done at facility or district levels, and districts do not monitor the performance of their surveillance system. There was also good communication and coordination with other sectors in terms of sharing information and resources. It is important that districts' capacity on IDSR is strengthened to enable them monitor and evaluate their own performance using established indicators.     

Surveillance, detection and response: managing emerging diseases at national and international levels

Globalisation is leading to a rise in the emergence of diseases and the author describes the new challenges that this brings for individual countries and the international community. The paper describes the existing international early warning systems and response mechanisms, discusses the role of international organisations in managing diseases that have the potential for cross-border spread, and underlines the importance of disease surveillance, detection and response at national level. While international collaboration exists in dealing with disease emergency situations, there is a need to develop regional and international contingency plans that can be launched as soon as an emergency situation arises. This will only be possible if there is the political will to tackle problems wherever they occur. The Global Early Warning System, which is a system currently being developed jointly by the Food and Agriculture Organization of the United Nations, the World Organisation for Animal Health and the World Health Organization, could provide an effective framework in which to achieve a higher level of international emergency preparedness.     

International law and communicable diseases

Historically, international law has played a key role in global communicable disease surveillance. Throughout the nineteenth century, international law played a dominant role in harmonizing the inconsistent national quarantine regulations of European nation-states; facilitating the exchange of epidemiological information on infectious diseases; establishing international health organizations; and standardization of surveillance. Today, communicable diseases have continued to re-shape the boundaries of global health governance through legally binding and "soft-law" regimes negotiated and adopted within the mandate of multilateral institutions - the World Health Organization, the World Trade Organization, the Food and Agriculture Organization, and the Office International des Epizooties. The globalization of public health has employed international law as an indispensable tool in global health governance aimed at diminishing human vulnerability to the mortality and morbidity burdens of communicable diseases.     

Impediments to global surveillance of infectious diseases: consequences of open reporting in a global economy

Globalization has led to an increase in the spread of emerging and re-emerging infectious diseases. International efforts are being launched to control their dissemination through global surveillance, a major hindrance to which is the failure of some countries to report outbreaks. Current guidelines and regulations on emerging and re-emerging infectious diseases do not sufficiently take into account the fact that when developing countries report outbreaks they often derive few benefits and suffer disproportionately heavy social and economic consequences. In order to facilitate full participation in global surveillance by developing countries there should be: better and more affordable diagnostic capabilities to allow for timely and accurate information to be delivered in an open and transparent fashion; accurate, less sensationalist news reporting of outbreaks of diseases; adherence by countries to international regulations, including those of the World Trade Organization and the International Health Regulations; financial support for countries that are economically damaged by the diseases in question. The article presents two cases--plague in India and cholera in Peru--that illuminate some of the limitations of current practices. Recommendations are made on measures that could be taken by WHO and the world community to make global surveillance acceptable.     

Beyond traditional surveillance: applying syndromic surveillance to developing settings – opportunities and challenges

Background  

All countries need effective disease surveillance systems for early detection of outbreaks. The revised International Health Regulations [IHR], which entered into force for all 194 World Health Organization member states in 2007, have expanded traditional infectious disease notification to include surveillance for public health events of potential international importance, even if the causative agent is not yet known. However, there are no clearly established guidelines for how countries should conduct this surveillance, which types of emerging disease syndromes should be reported, nor any means for enforcement.     

From the field side of the binoculars: a different view on global public health surveillance

It is generally assumed by the donor community that the targeted funding of global, regional or cross-border surveillance programmes is an efficient way to support resource-poor countries in developing their own national public health surveillance infrastructure, to encourage national authorities to share outbreak intelligence, and ultimately to ensure compliance of World Health Organization (WHO) Member States with the revised (2005) International Health Regulations. At country level, a number of factors and constraints appear to contradict this view. Global or regional surveillance initiatives, including syndromic surveillance and rumour surveillance projects, have been conceived in neglect of fragile health systems, from which they extract scarce human resources. In contradiction with a rightful stance promoting 'integrated surveillance' by WHO, the nurturing of donor-driven, poorly coordinated and redundant surveillance networks generally adds further fragmentation to national health priorities set up by developing countries. In their current categorical format, ignoring the overwhelming deficits in governance and health care capacity, global surveillance strategies seem bound to benefit mainly the most industrially developed nations through the provision of early warning information or scientific data. In lower-income countries, a focus of resources on strengthening the health system first would ultimately be a more efficient way to achieve proper detection and response to outbreaks at national or sub-national level. As documented in several pilot initiatives at sub-national level (India, South Africa, Tuvalu and Cambodia), the empowerment of frontline health workers and communities is a key element for an efficient surveillance system. Such simple measures centred on human resources and community values appear to be more beneficial than massive and conditional monetary inputs.     

The effect of Integrated Management of Childhood Illness on observed quality of care of under-fives in rural Tanzania

Integrated Management of Childhood Illness (IMCI) has been adopted by over 80 countries as a strategy for reducing child mortality and improving child health and development. It includes complementary interventions designed to address the major causes of child mortality at community, health facility, and health system levels. The Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (IMCI-MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. The MCE is coordinated by the Department of Child and Adolescent Health and Development of the World Health Organization. MCE studies are under way in Bangladesh, Brazil, Peru, Tanzania and Uganda. In Tanzania, the IMCI-MCE study uses a non-randomized observational design comparing four neighbouring districts, two of which have been implementing IMCI in conjunction with evidence-based planning and expenditure mapping at district level since 1997, and two of which began IMCI implementation in 2002. In these four districts, child health and child survival are documented at household level through cross-sectional, before-and-after surveys and through longitudinal demographic surveillance respectively. Here we present results of a survey conducted in August 2000 in stratified random samples of government health facilities to compare the quality of case-management and health systems support in IMCI and comparison districts. The results indicate that children in IMCI districts received better care than children in comparison districts: their health problems were more thoroughly assessed, they were more likely to be diagnosed and treated correctly as determined through a gold-standard re-examination, and the caretakers of the children were more likely to receive appropriate counselling and reported higher levels of knowledge about how to care for their sick children. There were few differences between IMCI and comparison districts in the level of health system support for child health services at facility level. This study suggests that IMCI, in the presence of a decentralized health system with practical health system planning tools, is feasible for implementation in resource-poor countries and can lead to rapid gains in the quality of case-management. IMCI is therefore likely to lead to rapid gains in child survival, health and development if adequate coverage levels can be achieved and maintained.     

Pacific-wide simplified syndromic surveillance for early warning of outbreaks

The International Health Regulations require timely detection and response to outbreaks. Many attempts to set up an outbreak early warning system in Pacific island countries and territories (PICTs) have failed. Most were modelled on systems from large countries; large amounts of data often overwhelmed small public health teams. Many conditions required overseas laboratory confirmation, further reducing timeliness and completeness. To improve timeliness and reduce the data burden, simplified surveillance was proposed, with case definitions based on clinical signs and symptoms without the need for laboratory confirmation or information on symptoms, location, sex and age. After trials in three PICTs, this system was implemented throughout the Pacific. Enthusiastic adoption by public health staff resulted in 20 of 22 PICTs reporting weekly to the World Health Organization within 12 months of starting to use the system. In the first year, the system has detected many infectious disease outbreaks and facilitated timely implementation of control measures. For several Pacific countries and territories, this is the first functional and timely infectious disease surveillance system. When outbreak detection is the principal objective, simplification of surveillance should be a priority in countries with a limited public health system capacity.     

Occupational lung diseases and global occupational health on the Net

Occupational lung disease is a major area of concern in occupationalhealth, exhibiting a diverse panorama across countries. Whilepneumoconiosis is deemed to be the most common occupationaldisease in many developing countries, emphasis is shifting towardsasbestos-related lung diseases and occupational asthma in industrializedcountries. Following the Occupational Health for All strategiesset forth by the World Health Organization, we propose thata model system based upon the Global Health Network can serveas an effective vehicle towards the prevention of occupationallung diseases on a global scale. It has the potential to: (1)enhance transmission of data and collaboration with the primaryhealth care system in disease surveillance; (2) strengthen researchand information transfer and (3) promote education and trainingat all levels of prevention, with a possible application tothe interpretation of chest radiograms.     

The role of the Biological Weapons Convention in disease surveillance and response

This article assesses the role and significance of the Biological Weapons Convention (BWC) with respect to infectious disease surveillance and response to outbreaks. Increasingly, the BWC is being used as a platform for addressing infectious disease threats arising naturally as well as traditional concerns about malicious dissemination of pathogenic microorganisms. The latter have long had a place on the security agenda, but natural disease outbreaks too are now being partially 'securitized' through the use of the BWC as a forum for exchanging information and ideas on disease surveillance and response. The article focuses on two prominent issues discussed at recent meetings of BWC member states: enhancing capacity for disease surveillance and response; and responding to allegations of biological weapons use and investigating outbreaks deemed suspicious. It concludes, firstly, that the BWC supports the efforts of international health organizations to enhance disease surveillance and response capacity worldwide. And secondly, that the BWC, rather than the World Health Organization (WHO), is the appropriate institution to deal with biological weapons allegations and investigations of suspicious outbreaks. The overall message is that securitization in the health sphere cuts both ways. Adding a security dimension (BW) alongside the task of detecting and responding to naturally occurring disease outbreaks is beneficial, but requiring a non-security organization (the WHO) to assume a security role would be counterproductive.     

Sustaining surveillance: Evaluating syndromic surveillance in the Pacific

Prior to the 2009 H1N1 pandemic, the Pacific Island Countries and Territories (PICTs) had agreed to develop a standardised, simple syndromic surveillance system to ensure compliance with International Health Regulations requirements (rapid outbreak detection, information sharing and response to outbreaks). In October 2010, the new system was introduced and over the next 12 months implemented in 20 of 22 PICTs. An evaluation was conducted to identify strengths and weaknesses of the system, ease of use and possible points for improvement. An in-country quantitative and qualitative evaluation in five PICTs identified that the most important determinants of the system's success were: simplicity of the system; support from all levels of government; clearly defined roles and responsibilities; feedback to those who collect the data; harmonisation of case definitions; integration of data collection tools into existing health information systems; and availability of clinical and epidemiological advice from external agencies such as the World Health Organization and the Secretariat of the Pacific Community. Regional reporting of alerts, outbreaks and outbreak updates has dramatically increased since implementation of the system. This syndromic system will assist PICTs to detect future influenza pandemics and other emerging infectious diseases and to rapidly contain outbreaks in the Pacific.     

Emergent pathogens, international surveillance and international health regulations (2005)

In order to address the vitality of the microbial world, to detect emerging infectious diseases, to determine their potential threat to public health, and to establish effective interventions, the World Health Organization (WHO) has developed and coordinates the Global Outbreak Alert and Response Network (GOARN) which connects several surveillance networks. Some of these networks are specific to epidemic-prone diseases, such as influenza, dengue, yellow fever or meningitis. Others were especially designed to track unusual events--such as the emergence of SARS--that are naturally-occurring, accidental, or deliberately created (biological weapons, bio-terrorism). Lastly, a special effort is being made at the international level to modernize the International Health Regulations, now obsolete, and to support all the countries in the reinforcement of their outbreak alert and response capacity.     

EU-Strukturen zur Überwachung und Bekämpfung von Infektionskrankheiten

Since 1999, EU Member States have had a number of obligations in the area of surveillance and control of communicable diseases (Decision 2119/98/EC). Specific technical standards to be applied by Member States are determined by the Commission, following an opinion of the network committee. Those concern among others the list of diseases under surveillance, case definitions, epidemiological and microbiological surveillance methods, and guidelines for emergency situations. Since the founding of the European Centre for Disease Prevention and Control (ECDC) in 2005, capacity at the EU level to support Member States has been extended considerably. At the same time at the international level, the World Health Organization (WHO) issued new Interna- tional Health Regulations (2005) (IHR), which include broader obligations for notification than the old International Health Regulations. In order to address this new situation, the Commission is working on a revision of the network decision and the ECDC regulation. These proposals should be submitted to the Council and Parliament in 2010. Important aims are simplified decision- making procedures, more clarity about the distribution of tasks between Member States, Commission, and ECDC, fewer working groups and committees, as well as an adaptation to the IHR of WHO.     

Comparison of cost-effectiveness of preventive and reactive mass immunization campaigns against meningococcal meningitis in West Africa: a theoretical modeling analysis

For epidemic meningitis control in sub-Saharan Africa, the World Health Organization recommends a strategy of emergency vaccination with meningococcal A + C polysaccharide vaccine when epidemic thresholds are exceeded. An alternative strategy for areas without effective surveillance systems is mass preventive campaigns before outbreaks occur. A model was formulated to simulate epidemics and to compare the cost-effectiveness of these two strategies for the district of Matam, Senegal, where an actual preventive campaign was performed during 1997. The preventive strategy prevented 59% of the cases compared to 49% for the emergency strategy. The cost per case prevented was US$59 for the preventive strategy and US$133 for the reactive strategy, and the preventive strategy saved US$0.20 per habitant. Preventive meningococcal vaccination through mass campaigns prevented more outcomes at a lower cost, provided that the occurrence of an epidemic could be predicted within 3 years and that the vaccination coverage rates for the preventive and standard strategies were > 70% and < 94%, respectively. Sub-Saharan African countries without effective surveillance systems should consider mass preventive campaigns while awaiting an affordable conjugate vaccine.     

Spatial dependency of Buruli ulcer prevalence on arsenic-enriched domains in Amansie West District,Ghana: implications for arsenic mediation in <Emphasis Type="Italic">Mycobacterium ulcerans</Emphasis>infection

Background  

In 1998, the World Health Organization recognized Buruli ulcer (BU), a human skin disease caused by Mycobacterium ulcerans (MU), as the third most prevalent mycobacterial disease. In Ghana, there have been more than 2000 reported cases in the last ten years; outbreaks have occurred in at least 90 of its 110 administrative districts. In one of the worst affected districts, Amansie West, there are arsenic-enriched surface environments resulting from the oxidation of arsenic-bearing minerals, occurring naturally in mineral deposits.     

Measles epidemiology and vaccination coverage in Oromia Region,Ethiopia: Evidence from surveillance, 2011–2018

Despite a reported high coverage of measles-containing vaccine (MCV), low-income countries including, Ethiopia, have sustained high measles transmission with frequent outbreaks. We investigated the distribution of measles infection and vaccination in Oromia Regional State, Ethiopia. According to the World Health Organization (WHO) and the Ethiopian measles case classification guidelines, measles cases were classified as laboratory-confirmed, clinically compatible, and epidemiologically linked. We derived measles vaccination coverage estimates using reported measles vaccine efficacy and, the proportion of measles cases vaccinated with measles vaccine at least once from the surveillance data. We calculated measles effective reproduction number (R_e) in the region. Almost twenty-five thousand measles cases were reported through the surveillance system, with more than 50% of the suspected and confirmed measles cases reported in 2015. Measles had sustained and high transmission rate with uneven distribution among the zones. Children between 1 and 4 years of age and MCV unvaccinated individuals were the most affected groups. In all the zones, the average surveillance-estimated MCV coverage among both infants and under-five children was significantly lower than the WHO recommended minimum 90% threshold herd-immunity. With this level of vaccination coverage, an infected case can transmit to more than four individuals. Nevertheless, the administrative coverage reports for the concurrent period were consistently above 90%. The estimated MCV coverage across the Oromia region was well below the recommended herd-immunity threshold. It partly explains the apparent mismatch of sustained measles transmission and outbreaks despite the very high administrative coverage estimates. Oromia regional health bureau, in collaboration with key stakeholders, should make a concerted effort to increase the effective-coverage of MCV to at least 90%. Additionally, multiple-dose MCV has to be scaled-up and accompanied with appropriate geographic and age targeting using evidence from surveillance data. Immediate programmatic action is needed to improve the quality of measles surveillance.     

The Scottish Centre for Infection and Environmental Health (SCIEH)

The Scottish Centre for Infection and Environmental Health has four core functions: the monitoring and surveillance of communicable diseases and environmental hazards in Scotland; operational advice and support at national and local level; research; and education and training. Its work is determined by a specification drawn up by the Public Health Policy Unit of the Scottish Office Department of Health. To fulfill its remit it works closely with a wide range of professionals, including those in the Scottish Office Department of Health, the health service, local government, and in organisations concerned with the environment. It also has close relationships with the Communicable Disease Surveillance Centre, Public Health Laboratory Service, London, the World Health Organization and other international bodies.     

Infectious disease outbreak preparedness and response in Nigeria: history,limitations and recommendations for global health policy and practice

Effective disease outbreak response has historically been a challenging accomplishment for the Nigerian health system due to an array of hurdles not unique to Nigeria but also found in other African nations which share its large size and complexity. However, the efficiency of the response mounted against the Ebola Virus Disease (EVD) outbreak of 2014 proved that indeed, though challenging, proactive and effective outbreak response is not impossible. With over 20 public health emergencies and infectious disease outbreaks between 2016 and 2018 alone, Nigeria is one of only five members of the World Health Organization (WHO) African Region to report five or more public health events per annum. There are many lessons that can be drawn from Nigeria''s experience in handling outbreaks of infectious diseases. In this review, we discuss the history of emerging and re-emerging infectious disease outbreaks in Nigeria and explore the response strategies mounted towards each. We also highlight the significant successes and note-worthy limitations, which we have then utilized to proffer policy recommendations to strengthen the Nigerian public health emergency response systems.     

Assessment of infectious disease surveillance--Uganda, 2000

In 1998, member states of the African region of the World Health Organization (WHO-AFRO) adopted the integrated disease surveillance (IDS) strategy to strengthen national infectious disease surveillance systems (1). The first step of the IDS strategy is to assess infectious disease surveillance systems. This report describes the results of the assessment of these systems of the Uganda Ministry of Health (UMoH) and indicates that additional efforts are needed to develop the basic elements of an effective surveillance system.     

Measles outbreaks and progress toward measles preelimination --- African region, 2009-2010

In 2008, the World Health Organization (WHO) African Region (AFR) measles technical advisory group (TAG) recommended establishing a measles preelimination goal, to be achieved by the end of 2012. The goal sets the following targets for the 46 AFR countries: ≥98% reduction in estimated regional measles mortality compared with 2000; measles incidence of <5 cases per 1 million population per year nationally; >90% national measles-containing vaccine (MCV) first dose (MCV1) coverage and >80% MCV1 coverage in all districts; and ≥95% MCV coverage by supplementary immunization activities (SIAs) in all districts. The goal also sets surveillance performance targets of ≥2 cases of nonmeasles febrile rash illness per 100,000 population, ≥1 suspected measles cases investigated with blood specimens in ≥80% of districts, and routine reporting from all districts. In addition, introduction of a routine second MCV dose (MCV2) was recommended for countries meeting specific criteria for MCV1 coverage and measles surveillance. This report updates progress toward the preelimination goal during 2009--2010 and summarizes measles outbreaks occurring in AFR countries since 2008. Of the 46 AFR countries, 12 (26%) reported measles incidence of <5 cases per 1 million population during 2010, compared with 28 (61%) in 2008. Furthermore, 28 (61%) countries reported a laboratory-confirmed measles outbreak during 2009--2010. The recent measles outbreaks highlight the need for renewed dedication by donors and governments to ensure that national multiyear vaccination plans, national budgetary line items, and financial commitments exist for routine immunization services and measles control activities.