Evaluation of Integrated Disease Surveillance and Response (IDSR) using Bacillary Dysentery as a Priority Disease,Tanzania, 2012

Objective

To determine whether the IDSR system meets its purpose and objectives, to evaluate the system attributes, and provide recommendations to improve the IDSR system, using the example of bacillary dysentery, a priority disease in Tanzania.

Introduction

Each year Ministry of Health and Social welfare of Tanzania under Epidemiology Section has been reporting many suspected cases of Shigella throughout the country. However only fewer laboratories have been reporting the confirmed cases.

Methods

The study was conducted between November 2011 and February 2012. Hospital staff including nurses, physicians and laboratory personnel and other stakeholders from the Ministry of Health and Social Welfare (MOHSW) were enrolled in the study. Data was collected from a review of documents, questionnaires and interview of stakeholders. Surveillance system attributes were evaluated using updated guidelines for evaluating public health surveillance system (2007) from Morbidity and Mortality Weekly Report (MMWR).

Results

Questionnaires were administered to fifteen health personnel from four regional hospitals. Four health staff from epidemiology and laboratory section of MOHSW were interviewed. Only one regional hospital laboratory was conducting laboratory diagnosis for bacillary dysentery and sending reports to MOHSW. Data from this laboratory was reviewed. Out of 641 records from bacillary dysentery testing, 271 (42.3%) did not include age data, 5 (0.78%) missed sex, 624 (97.3%) missed the district where the patient came from, 26 (4.4%) did not include information on specimen quality, 1(0.2%) had no report of pathogens found and 636 (99.2%) did not include antimicrobial sensitivity testing (AST). The Predictive Value Positive (PVP) of the system was 0.62%. One (6.7%) of the health workers was trained in IDSR.

Conclusions

IDSR in Tanzania generally is not performing well as only one (25%) of the four visited hospitals conducts and reports laboratory diagnosis of bacillary dysentery. However the system is representative as it covers all regions of the United Republic of Tanzania and all ages of people. The system is flexible since National IDSR guideline (2001) was revised in 2011. More emphasis should be placed on strengthening laboratory capacity in disease diagnosis and reporting at all levels.     

The use of community-based animal health workers to strengthen disease surveillance systems in Tanzania

An 18 month trial was conducted in three districts of Arusha region, northern Tanzania, to assess the use of community-based animal health workers (CAHWs) in an official disease surveillance system. Disease reports provided by CAHWs were assessed using six indicators for effective disease surveillance, i.e. sensitivity, specificity, timeliness, representativeness, simplicity and acceptability. To assess sustainability issues and determine the incentives required by CAHWs to report disease, three different incentive models were tested in the trial. None of the incentive models involved direct payments to CAHWs. Before involving CAHWs in disease surveillance in the three trial districts, disease case reports as a proportion of cattle population were 0.13%, 0.20% and 0.12%. During the trial, disease case reports as a proportion of cattle population increased to 5.0%, 5.6% and 6.3%. The CAHWs also improved the spatial and temporal coverage of the disease surveillance system and provided timely reports. During the trial, national-level disease reporting in Tanzania increased by 17% owing to the sensitisation and support activities of the Pan African Programme for the Control of Epizootics in Tanzania. In Arusha region, disease reporting increased by 118%, and 49% of this improvement was attributable to increased reporting in the three trial districts. Reporting from these districts far exceeded that from any other district in Tanzania. Veterinarians confirmed the CAHWs' clinical diagnosis in 88% of the 170 clinical cases examined. The increase in disease reporting resulting from CAHW activities was sufficient to enable the national epidemiology unit to achieve its target in relation to World Organisation for Animal Health (OIE) guidelines. The authors conclude that the use of CAHWs should be promoted in the national strategy for disease reporting. Additionally, CAHWs must be brought under the control of the Tanzanian veterinary authorities, a process that will include appropriate legislative reform.     

Structure and performance of infectious disease surveillance and response, United Republic of Tanzania, 1998

OBJECTIVE: To assess the structure and performance of and support for five infectious disease surveillance systems in the United Republic of Tanzania: Health Management Information System (HMIS); Infectious Disease Week Ending; Tuberculosis/Leprosy; Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome; and Acute Flaccid Paralysis/Poliomyelitis. METHODS: The systems were assessed by analysing the core activities of surveillance and response and support functions (provision of training, supervision, and resources). Data were collected using questionnaires that involved both interviews and observations at regional, district, and health facility levels in three of the 20 regions in the United Republic of Tanzania. FINDINGS: An HMIS was found at 26 of 32 health facilities (81%) surveyed and at all 14 regional and district medical offices. The four other surveillance systems were found at <20% of health facilities and <75% of medical offices. Standardized case definitions were used for only 3 of 21 infectious diseases. Nineteen (73%) health facilities with HMIS had adequate supplies of forms; 9 (35%) reported on time; and 11 (42%) received supervision or feedback. Four (29%) medical offices with HMIS had population denominators to use for data analyses; 12 (86%) were involved in outbreak investigations; and 11 (79%) had conducted community prevention activities. CONCLUSION: While HMIS could serve as the backbone for IDSR in the United Republic of Tanzania, this will require supervision, standardized case definitions, and improvements in the quality of reporting, analysis, and feedback.     

Implementing integrated disease surveillance and response: Four African countries' experience, 1998–2005

Abstract

The Integrated Disease Surveillance and Response (IDSR) strategy was developed by the Africa Regional Office (AFRO) of the World Health Organisation (WHO) and proposed for adoption by member states in 1998. The goal was to build WHO/AFRO countries' capacity to detect, report and effectively respond to priority infectious diseases. This evaluation focuses on the outcomes in four countries that implemented this strategy.

Major successes included: integration of the surveillance function of most of the categorical disease control programmes; implementation of standard surveillance, laboratory and response guidelines; improved timeliness and completeness of surveillance data and increased national-level review and use of surveillance data for response.

The most challenging aspects were: strengthening laboratory networks; providing regular feedback and supervision on surveillance and response activities; routine monitoring of IDSR activities and extending the strategy to sub-national levels.     

Health systems barriers to effective use of infectious disease surveillance data in the context of decentralization in Georgia: a qualitative study

OBJECTIVES: In Georgia, a country where there has been extensive decentralization of public health responsibilities, an intervention was recently piloted to strengthen district-level vaccine-preventable disease (VPD) surveillance and response activities. The purpose of this qualitative research study is to provide an in-depth assessment of the perceived value and need for the analysis and use of VPD surveillance data at various levels of the infectious disease surveillance and response (IDSR) system in Georgia. METHODS: Focus groups were conducted with individuals working at different levels of the IDSR system in intervention districts in order to obtain qualitative data to better understand the process of surveillance and barriers to data availability, analysis, and response. RESULTS: The results of the study suggest that in Georgia, health care system has many barriers to effective analysis and use of VPD surveillance data for decision-making at local level. Extensive decentralization that took place in Georgia may have adversely affected the IDSR system. CONCLUSION: In resource poor countries, decentralization can leave districts with insufficient resources, which may seriously affect the ability to carry out IDSR. In Georgia, this seems to be related to inadequate financing of IDSR with major gaps observed at the local level.     

Eighty years on: A history of Halstead Urban and Rural District Councils

The Halstead Urban and Rural District Councils were established in 1894 and ceasedto exist with the reorganization of local government in 1974. The total population of the two districts in 1974 was approximately 27,000 of whom 7000 lived in the urban district. The combined districts cover an area of 120 sq. miles in North-East Essex. A review of the 80 years is made from old reports and minute books which traces the gradual introduction of basic public health facilities and emphasizes some of the problems of rural areas.     

The costs of a sexually transmitted infection outreach and treatment programme targeting most at risk youth in Tajikistan

Background

Communicable diseases are the leading causes of illness, deaths, and disability in sub-Saharan Africa. To address these threats, countries within the World Health Organization (WHO) African region adopted a regional strategy called Integrated Disease Surveillance and Response (IDSR). This strategy calls for streamlining resources, tools, and approaches to better detect and respond to the region's priority communicable disease. The purpose of this study was to analyze the incremental costs of establishing and subsequently operating activities for detection and response to the priority diseases under the IDSR.

Methods

We collected cost data for IDSR activities at central, regional, district, and primary health care center levels from Burkina Faso, Eritrea, and Mali, countries where IDSR is being fully implemented. These cost data included personnel, transportation items, office consumable goods, media campaigns, laboratory and response materials and supplies, and annual depreciation of buildings, equipment, and vehicles.

Results

Over the period studied (2002–2005), the average cost to implement the IDSR program in Eritrea was $0.16 per capita, $0.04 in Burkina Faso and $0.02 in Mali. In each country, the mean annual cost of IDSR was dependent on the health structure level, ranging from $35,899 to $69,920 at the region level, $10,790 to $13,941 at the district level, and $1,181 to $1,240 at the primary health care center level. The proportions spent on each IDSR activity varied due to demand for special items (e.g., equipment, supplies, drugs and vaccines), service availability, distance, and the epidemiological profile of the country.

Conclusion

This study demonstrates that the IDSR strategy can be considered a low cost public health system although the benefits have yet to be quantified. These data can also be used in future studies of the cost-effectiveness of IDSR.     

Disease surveillance system: a mandatory conduit for effective control of infectious diseases in pakistan

In Pakistan, absence of a nationwide surveillance mechanism and strategy is the main reason for the failure in effectively controlling communicable diseases. The seasonal outbreaks of various infectious diseases every year call for an integrated surveillance system on a national level for planning effective preventive strategies. Opportunity to adopt a tested and tried model exists at this time in terms of the "Disease Early Warning System" set up by World Health Organization in conflict-affected districts. Replicating this system in other districts is both practical and feasible as technical support is readily available through the World Health Organization. Such a system once put in place has potential to not only decrease morbidity and mortality through early detection and prompt control of outbreaks but also to facilitate effective financial, human resource, and materials management at the district level. This would be a step toward a more responsive health system at the local level.     

Community-based monitoring of safe motherhood in the United Republic of Tanzania

OBJECTIVE: To examine the progress made towards the Safe Motherhood Initiative goals in three areas of the United Republic of Tanzania during the 1990s. METHODS: Maternal mortality in the United Republic of Tanzania was monitored by sentinel demographic surveillance of more than 77,000 women of reproductive age, and by prospective monitoring of mortality in the following locations; an urban site; a wealthier rural district; and a poor rural district. The observation period for the rural districts was 1992-99 and 1993-99 for the urban site. FINDINGS: During the period of observation, the proportion of deaths of women of reproductive age (15-49 years) due to maternal causes (PMDF) compared with all causes was between 0.063 and 0.095. Maternal mortality ratios (MMRatios) were 591-1099 and maternal mortality rates (MMRates; maternal deaths per 100,000 women aged 15-49 years) were 43.1-123.0. MMRatios in surveillance areas were substantially higher than estimates from official, facility-based statistics. In all areas, the MMRates in 1999 were substantially lower than at the start of surveillance (1992 for rural districts, 1993 for the urban area), although trends during the period were statistically significant at the 90% level only in the urban site. At the community level, an additional year of education for household heads was associated with a 62% lower maternal death rate, after controlling for community-level variables such as the proportion of home births and occupational class. CONCLUSION: Educational level was a major predictor of declining MMRates. Even though rates may be decreasing, they remained high in the study areas. The use of sentinel registration areas may be a cost-effective and accurate way for developing countries to monitor mortality indicators and causes, including for maternal mortality.     

The development of alcohol strategies in England and Wales.

Alcohol has become a major public health problem in the UK. In order to coordinate the work of both statutory and non-statutory agencies more efficiently and effectively, a government circular HN(89)4 has emphasized the need for development of local multi-agency alcohol misuse prevention strategies. Despite expressed enthusiasm for alcohol strategies, information about their development, effectiveness and overall national progress is scarce and needs to be improved. This national survey reports the most recent and accurate information about the development of district and regional alcohol strategies in England and Wales. Although only 51 (27%) districts stated they had a strategy, it was encouraging to find 90 (47%) other districts that were in the process of, or planning to develop such a document. Of the 51 districts with a strategy, the following key findings were noted: (1) Forty-three (84%) districts stated that they had started to implement their strategy, but none claimed to have fully implemented it. (2) Thirty-six (71%) districts stated that their strategy had an action plan. (3) Thirty-four (67%) districts stated that their strategy had been officially endorsed by the district health authority. (4) Thirty-eight (76%) districts stated that they had identified an individual or group to monitor the strategies' implementation. The results of the survey could be of interest to the Department of Health, the Faculty of Public Health Medicine, the Health Education Authority and the regional alcohol coordinators.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cause-specific adult mortality: evidence from community-based surveillance--selected sites, Tanzania, 1992-1998

Mortality data are a standard information resource to guide public health action. Because Tanzania did not have a representative mortality surveillance system, in 1992 the Adult Morbidity and Mortality Project (AMMP) was established by the Muhimbili University College of Health Sciences, the Ministry of Health of Tanzania (MOH), and the University of Newcastle upon Tyne, United Kingdom. The purpose of the surveillance system is to provide cause-specific death rates among adults in three areas of Tanzania and to link community-based mortality surveillance to evidence-based planning for health care. This report describes the results of AMMP surveillance during 1992-1998, which indicated that human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) was the leading cause of death reported by decedents' relatives and caretakers for adults of both sexes in all study areas, and suggests that a range of other causes of death exist across the three surveillance sites.     

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.     

2004—2010年连云港市急性出血性结膜炎流行特征

目的分析2004—2010年连云港市急性出血性结膜炎(AHC)的流行病学特征,为制定预防控制措施提供科学依据。方法对2004—2010年疾病监测信息报告系统及同期突发公共卫生事件报告管理信息系统报告的AHC暴发疫情进行描述流行病学分析。结果 2004—2006年及2008—2009年连云港市AHC发病水平相对平稳,2007和2010年发生了AHC较高强度流行,8—10月为流行期,9月为发病高峰;2004—2010年全市8个县区仅有新浦区及连云区每年均有急性出血性结膜炎病例报告;各年龄均有发病,患者群以15～19岁、10～14岁、5～9岁和35～39岁为主,男性略多于女性;职业分布以学生、工人及农民为主;暴发均发生在学校。结论加强监测,做好学校、农村和工厂急性出血性结膜炎防治知识、良好卫生习惯的宣传教育是控制急性出血性结膜炎暴发和流行的重要环节。     

Decentralisation and health services delivery in Tanzania: Analysis of decision space in planning,allocation, and use of financial resources

While decentralisation of health systems has been on the policy agenda in low‐income and middle‐income countries since the 1970s, many studies have focused on understanding who has more decision‐making powers but less attention is paid to understand what those powers encompass. Using the decision space approach, this study aimed to understand the amount of decision‐making space transferred from the central government to institutions at the periphery in the decentralised health system in Tanzania. The findings of this study indicated that the decentralisation process in Tanzania has provided authorities with a range of decision‐making space. In the areas of priority setting and planning, district health authorities had moderate decision space. However, in the financial resource allocation and expenditure of funds from the central government, the districts had narrow decision‐making space. The districts, nevertheless, had wider decision‐making space in mobilising and using locally generated financial resources. However, the ability of the districts to allocate and use locally generated resources was constrained by bureaucratic procedures of the central government. The study concludes that decentralisation by devolution which is being promoted in the policy documents in Tanzania is yet to be realised at the district and local levels. The study recommends that the central government should provide more space to the decentralised district health systems to incorporate locally defined priorities in the district health plans.     

Tracking pediatric asthma: the Massachusetts experience using school health records

The Massachusetts Department of Public Health, in collaboration with the U.S. Centers for Disease Control and Prevention Environmental Public Health Tracking Program, initiated a 3-year statewide project for the routine surveillance of asthma in children using school health records as the primary data source. School district nurse leaders received electronic data reporting forms requesting the number of children with asthma by grade and gender for schools serving grades kindergarten (K) through 8. Verification efforts from an earlier community-level study comparing a select number of school health records with primary care provider records demonstrated a high level of agreement (i.e., > 95%). First-year surveillance targeted approximately one-half (n = 958 schools) of all Massachusetts's K-8 schools. About 78% of targeted school districts participated, and 70% of the targeted schools submitted complete asthma data. School nurse-reported asthma prevalence was as high as 30.8% for schools, with a mean of 9.2%. School-based asthma surveillance has been demonstrated to be a reliable and cost-effective method of tracking disease through use of an existing and enhanced reporting structure.     

Improving health information systems for decision making across five sub-Saharan African countries: Implementation strategies from the African Health Initiative

Background

Weak health information systems (HIS) are a critical challenge to reaching the health-related Millennium Development Goals because health systems performance cannot be adequately assessed or monitored where HIS data are incomplete, inaccurate, or untimely. The Population Health Implementation and Training (PHIT) Partnerships were established in five sub-Saharan African countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia) to catalyze advances in strengthening district health systems. Interventions were tailored to the setting in which activities were planned.

Comparisons across strategies

All five PHIT Partnerships share a common feature in their goal of enhancing HIS and linking data with improved decision-making, specific strategies varied. Mozambique, Ghana, and Tanzania all focus on improving the quality and use of the existing Ministry of Health HIS, while the Zambia and Rwanda partnerships have introduced new information and communication technology systems or tools. All partnerships have adopted a flexible, iterative approach in designing and refining the development of new tools and approaches for HIS enhancement (such as routine data quality audits and automated troubleshooting), as well as improving decision making through timely feedback on health system performance (such as through summary data dashboards or routine data review meetings). The most striking differences between partnership approaches can be found in the level of emphasis of data collection (patient versus health facility), and consequently the level of decision making enhancement (community, facility, district, or provincial leadership).

Discussion

Design differences across PHIT Partnerships reflect differing theories of change, particularly regarding what information is needed, who will use the information to affect change, and how this change is expected to manifest. The iterative process of data use to monitor and assess the health system has been heavily communication dependent, with challenges due to poor feedback loops. Implementation to date has highlighted the importance of engaging frontline staff and managers in improving data collection and its use for informing system improvement. Through rigorous process and impact evaluation, the experience of the PHIT teams hope to contribute to the evidence base in the areas of HIS strengthening, linking HIS with decision making, and its impact on measures of health system outputs and impact.

     

Need for dedicated focus on urban health within National Rural Health Mission

National Rural Health Mission represents an important public health initiative to address essential health needs of the country's underserved population. For the Mission to achieve its goals, urban population needs to be included in its scope. Urban poor population constitutes nearly a third of India's urban population and is growing at three times the national population growth rate. Health status and access of reproductive and child health services of slum dwellers are poor and comparable to the rural population. Efforts to improve the conditions of urban poor necessitate strengthening national policy and fiscal mandate, augmenting and strengthening the urban health delivery system, coordinating among multiple stakeholders, involving private sector, strengthening municipal functioning and building community capacities. National Rural Health Mission should be broadened to National Public Health Mission. This paper discusses issues pertaining to health conditions of the urban poor, present status of services, challenges and suggests options for NRHM to bridge the large gap.     

Use of a new global indicator for vaccine safety surveillance and trends in adverse events following immunization reporting 2000–2015

Reporting of adverse events following immunization (AEFI) is a key component for functional vaccine safety monitoring system. The aim of our study is to document trends in the AEFI reporting ratio globally and across the six World Health Organization (WHO) regions. We describe the number of AEFI reports communicated each year through the World Health Organization/United Nations Children's Fund Joint Reporting Form on Immunization from 2000 to 2015. The AEFI reporting ratios (annual AEFI reports per 100,000 surviving infants) were calculated to identify WHO countries (n = 191 in 2000 and n = 194 by 2015) that met a minimal reporting ratio of 10, a target set by the Global Vaccine Action Plan for vaccine safety monitoring as a proxy measure for a functional AEFI reporting system. The number of countries reporting any AEFI fluctuated over time but with progress from 32 (17%) in 2000 to 124 (64%) in 2015. In 2015, the global average AEFI reporting ratio was 549 AEFI reports per 100,000 surviving infants. The number of countries with AEFI reporting ratios greater than 10 increased from 8 (4%) in 2000 to 81 (42%) in 2015. In 2015, 60% of countries in the WHO Region of the Americas reported at least 10 AEFI per 100,000 surviving infants, followed by 55% in European Region, 43% in Eastern Mediterranean Region, 33% in Western Pacific Region, 27% in South-East Asia Region and 21% in African Region. Overall, AEFI reporting has increased over the past sixteen years worldwide, but requires strengthening in a majority of low- and middle- income countries. The AEFI reporting ratio is useful for benchmarking and following trends over time; but does not provide information on the quality of the reporting system and does not guarantee capacity to detect and manage a vaccine safety problem at a national level. Additional efforts are required to ensure and improve data quality, AEFI reporting and surveillance of immunization safety in every country.     

Tuberculosis surveillance in the United States: case definitions used by state health departments.

Health departments in all 53 reporting areas in the United States were asked to submit the case definition they used for tuberculosis surveillance. Sixteen areas used the 1990 case definition; two areas sent 1977 guidelines; and 34 areas sent other definitions. Case reports sent to the Centers for Disease Control and Prevention (CDC) in 1992 were analyzed; 4% of cases did not meet the 1990 definition. Tuberculosis case reporting criteria are not uniformly applied in the United States. CDC, in collaboration with state and local health officials, is evaluating the current definition and will implement uniform national criteria for tuberculosis surveillance.