Integrated Disease Surveillance and Response (IDS/R) in the African Region Mary Harvey and Patrick Swai SOTA June 12, 2002

Integrated Disease Integrated Disease Surveillance and Surveillance and

Response (IDS/R) in the Response (IDS/R) in the African RegionAfrican Region

Mary Harvey and Patrick SwaiMary Harvey and Patrick Swai

SOTASOTA

June 12, 2002June 12, 2002

AFROAFRO

Improve the well-being Improve the well-being of the 600 million of the 600 million people living in the 46 people living in the 46 Member States of the Member States of the WHO Regional Office WHO Regional Office for Africa through for Africa through implementation of implementation of integrated disease integrated disease surveillance for surveillance for infectious diseases and infectious diseases and improved preparedness improved preparedness for epidemic responsefor epidemic response

GOALGOAL

• Diseases targeted for Diseases targeted for eradication/eliminationeradication/elimination

• Epidemic Prone DiseasesEpidemic Prone Diseases• Diseases of Public Health ImportanceDiseases of Public Health Importance

WHO/AFRO Priority WHO/AFRO Priority Infectious DiseasesInfectious Diseases

General Objective of IDSGeneral Objective of IDS

To provide evidence on To provide evidence on which to base decisions which to base decisions

and public health and public health interventions for the interventions for the

control of communicable control of communicable diseasesdiseases

1. To 1. To strengthen the capacity of health workers of health workers to conduct to conduct surveillance activities. activities.

2.To 2.To Integrate multiple surveillance systemsIntegrate multiple surveillance systems for for efficiency of staff, forms, resources.efficiency of staff, forms, resources.

3. 3. Improve use of InformationImprove use of Information for decision for decision making.making.

4. 4. To improve the flow of surveillance informationTo improve the flow of surveillance information between and within levels of the health systembetween and within levels of the health system

5. 5. To strengthen laboratory capacityTo strengthen laboratory capacity and and involvement in confirmation involvement in confirmation

6. 6. To increase involvement of cliniciansTo increase involvement of clinicians

Specific Objectives of IDSSpecific Objectives of IDS

Steps for IDS Strategy implementation

Sen

siti

ze

Ass

ess P

lan

Impl

emen

t

Plan

Major achievements

• Completion of IDSR TG, tools / instruments

• Strengthening of the Laboratory

• Training

• Indicators drafted and being field tested

• Support from MOH, USAID, UNF ,CDC, WHO

• National IDS coordinating committees

• Progress observed on implementation of IDSR in Member States

Status of IDS Implementation

Non AFRO country

Not started

Initial contact made

Preparing assessment

Assessment completed

Plan of action completed

Guidelines adaptation initiated

Guidelines adapted

Challenges

• Ownership and sustainability

• Availability of resources

• Commitment of stakeholders

• Involvement of all levels

Expected Outcomes of IDS Expected Outcomes of IDS

• Simplification of recording and Simplification of recording and reportingreporting

• Information is more accessible Information is more accessible and timelyand timely

• Action taken is more timely Action taken is more timely and appropriateand appropriate

• Resources are used more Resources are used more effectivelyeffectively

Developing experience Developing experience and evidence in and evidence in

surveillance surveillance implementation in implementation in

Tanzania Tanzania Dr. Patrick SwaiDr. Patrick Swai

USAID/TanzaniaUSAID/Tanzania

Milestones of IDS in Milestones of IDS in TanzaniaTanzania

• 1998 National level assessment1998 National level assessment• 1998 Adoption of IDS strategy1998 Adoption of IDS strategy• 1999 Implementation plan developed1999 Implementation plan developed• 2000 IDS Task Force created2000 IDS Task Force created• 2001 National IDS guidelines for 13 priority 2001 National IDS guidelines for 13 priority

diseasesdiseases• 2001 Lab networking guidelines2001 Lab networking guidelines• 2002 Development of draft District analysis 2002 Development of draft District analysis

book book • 2002 The coordinated implementation team 2002 The coordinated implementation team

initiated implementation in focus districtsinitiated implementation in focus districts

Source of USAID funds Source of USAID funds for IDS implementation for IDS implementation

in Tanzaniain Tanzania• Africa Bureau – Providing support to Africa Bureau – Providing support to

WHO, (including the 1998 WHO, (including the 1998 assessment)assessment)

• Tanzania Mission – operationalizing Tanzania Mission – operationalizing the IDS strategy and strengthening the IDS strategy and strengthening surveillance implementation surveillance implementation

• Bureau of Global Health – developing Bureau of Global Health – developing evidence of successful programming evidence of successful programming around surveillance; dissemination of around surveillance; dissemination of tools, materials, and lessons learned tools, materials, and lessons learned to other countriesto other countries

USAID-funded partners USAID-funded partners in local IDS in local IDS

implementation in implementation in TanzaniaTanzania

• National Institute for Medical National Institute for Medical Research (NIMR) Research (NIMR)

• Partners for Health Reform plus Partners for Health Reform plus (PHRplus)(PHRplus)

• Centers for Disease Control and Centers for Disease Control and Prevention -- NCID and EPO/DIHPrevention -- NCID and EPO/DIH

• CHANGE ProjectCHANGE Project• HealthTechHealthTech

WHO

Nat’l

District

Facilities

Communities

Reg’l

Strategy, guidelines, tools

Policy, direction, plan, country guidelines

Support for lab, outbreak investigation, training

Hub of decision making, response/ action and resource mobilisation

Identify cases, report, respond and participate in public health actions

Know what to report when to health care system for action;Participate in response and prevention

Structure of the Tanzania Health System and Relevance for IDS

How the How the implementation team implementation team

contributes to IDS contributes to IDS strengtheningstrengthening

• WHO/AFRO – support to creating WHO/AFRO – support to creating strategy, guidelines, and tools strategy, guidelines, and tools

– IDSR guidelines provide a IDSR guidelines provide a comprehensive technical definition comprehensive technical definition of a functioning system.of a functioning system.

– Local implementation process is Local implementation process is beyond the scope of regional beyond the scope of regional guidelinesguidelines

• Local-level (country) implementation: Local-level (country) implementation: operationalize the strategy and operationalize the strategy and guidelines guidelines

Questions for country level Questions for country level implementationimplementation::

• What obstacles do districts, What obstacles do districts, facilities, and communities facilities, and communities face in operationalizing the face in operationalizing the system?system?

• What are the best strategies What are the best strategies for overcoming these for overcoming these obstacles?obstacles?

What are some of the What are some of the obstacles that districts obstacles that districts

in Tanzania face?in Tanzania face?• Very limited diagnostic confirmation capacityVery limited diagnostic confirmation capacity• Lack of adequate communications between Lack of adequate communications between

levelslevels• Barriers to adequate transport of specimensBarriers to adequate transport of specimens• Low motivation and capacity for analysis Low motivation and capacity for analysis

(and use) of information for public health (and use) of information for public health actionaction

• Poor coordination of available resourcesPoor coordination of available resources• Undefined roles and responsibilities for IDSUndefined roles and responsibilities for IDS• National level standards and policies missingNational level standards and policies missing

Need a guiding “road map” for operationalizing IDSR

How we are breaking How we are breaking ground in ground in


• Support the development of new ID Support the development of new ID surveillance and public health action surveillance and public health action technologies and tools for both epidemic technologies and tools for both epidemic and non-epidemic diseasesand non-epidemic diseases

• Conduct research into critical issues Conduct research into critical issues surrounding ID surveillance and response surrounding ID surveillance and response that will support its successful adoption that will support its successful adoption by other countriesby other countries

• Coordinate with global and national Coordinate with global and national institutions to provide training to develop institutions to provide training to develop the necessary skills needed for ID the necessary skills needed for ID surveillance and responsesurveillance and response

How we are breaking How we are breaking ground in ground in


• Disseminate lessons learned Disseminate lessons learned • Develop successful examples Develop successful examples

of ID surveillance and response of ID surveillance and response that can be adopted by other that can be adopted by other districts in Tanzania and other districts in Tanzania and other countries to address the real countries to address the real obstacles at local levelsobstacles at local levels

Implications for other Implications for other countries for countries for

implementing IDSRimplementing IDSR• Provide a model for other countriesProvide a model for other countries• Answer questions with operations Answer questions with operations

researchresearch• Development of best practicesDevelopment of best practices• Documentation and transfer of Documentation and transfer of

experiences and lessons learnedexperiences and lessons learned• Dissemination of tools and Dissemination of tools and

materials for implementationmaterials for implementation

Thank you!

Milestones of IDS in Milestones of IDS in TanzaniaTanzania

• 1998 National level assessment• 1998 Adoption of IDS strategy• 1999 Implementation plan developed• 2000 IDS Task Force created• 2001 National IDS guidelines for 13 priority

diseases• 2001 Lab networking guidelines• 2002 Development of draft District analysis

book • 2002 The coordinated implementation team

initiated implementation in focus districts

Source of USAID funds for Source of USAID funds for IDS implementation in IDS implementation in

TanzaniaTanzania• Africa Bureau – Providing support to

WHO, (including the 1998 assessment)• Tanzania Mission – operationalizing the

IDS strategy and strengthening surveillance implementation

• Bureau of Global Health – developing evidence of successful programming around surveillance; dissemination of tools, materials, and lessons learned to other countries

USAID-funded partners in USAID-funded partners in local IDS implementation in local IDS implementation in

TanzaniaTanzania

• National Institute for Medical Research (NIMR)

• Partners for Health Reform plus (PHRplus)

• Centers for Disease Control and Prevention -- NCID and EPO/DIH

• CHANGE Project• HealthTech

WHO

Nat’l

District

Facilities

Communities

Reg’l

Strategy, guidelines, tools

Policy, direction, plan, country guidelines

Support for lab, outbreak investigation, training

Hub of decision making, response/ action and resource mobilisation

Identify cases, report, respond and participate in public health actions

Know what to report when to health care system for action;Participate in response and prevention

Structure of the Tanzania Health System and Relevance for IDS

How the implementation team How the implementation team contributes to IDS strengtheningcontributes to IDS strengthening

• WHO/AFRO – support to creating strategy, guidelines, and tools

– IDSR guidelines provide a comprehensive technical definition of a functioning system.

– Local implementation process is beyond the scope of regional guidelines

• Local-level (country) implementation: operationalize the strategy and guidelines

Questions for country level Questions for country level implementationimplementation::

• What obstacles do districts, What obstacles do districts, facilities, and communities facilities, and communities face in operationalizing the face in operationalizing the system?system?

• What are the best strategies What are the best strategies for overcoming these for overcoming these obstacles?obstacles?

What are some of the obstacles What are some of the obstacles that districts in Tanzania face?that districts in Tanzania face?

• Very limited diagnostic confirmation capacity• Lack of adequate communications between

levels• Barriers to adequate transport of specimens• Low motivation and capacity for analysis (and

use) of information for public health action• Poor coordination of available resources• Undefined roles and responsibilities for IDS• National level standards and policies missing

Need a guiding “road map” for operationalizing IDSR

How we are breaking ground How we are breaking ground in implementation in in implementation in

TanzaniaTanzania

• Support the development of new ID surveillance and public health action technologies and tools for both epidemic and non-epidemic diseases

• Conduct research into critical issues surrounding ID surveillance and response that will support its successful adoption by other countries

• Coordinate with global and national institutions to provide training to develop the necessary skills needed for ID surveillance and response

How we are breaking ground How we are breaking ground in implementation in in implementation in

TanzaniaTanzania• Disseminate lessons learned • Develop successful examples

of ID surveillance and response that can be adopted by other districts in Tanzania and other countries to address the real obstacles at local levels

Implications for other Implications for other countries for implementing countries for implementing

IDSRIDSR• Provide a model for other countries• Answer questions with operations

research• Development of best practices• Documentation and transfer of

experiences and lessons learned• Dissemination of tools and

materials for implementation

Epidemic Preparedness Epidemic Preparedness and Responseand Response

• Yellow Fever epidemics in Cote Yellow Fever epidemics in Cote d'Ivoire, Ghana, Guinea and Liberia d'Ivoire, Ghana, Guinea and Liberia in 2000-2001in 2000-2001

• 5 Countries accounted for 75% of 5 Countries accounted for 75% of the 61,988 Meningitis cases and the 61,988 Meningitis cases and 67% of the 6,172 deaths:Burkina, 67% of the 6,172 deaths:Burkina, Niger, Benin, Mali, Ethiopia, and Niger, Benin, Mali, Ethiopia, and ChadChad

• Cholera in South Africa, Malawi, Cholera in South Africa, Malawi, Madagascar, ZambiaMadagascar, Zambia

• Ebola: Gabon, RDC, UgandaEbola: Gabon, RDC, Uganda

Meningitis Epidemics in Africa Meningitis Epidemics in Africa

• Meningitis epidemics Meningitis epidemics historically caused by historically caused by serogroup A meningococciserogroup A meningococci

• Other serogroups (B, C, W135) Other serogroups (B, C, W135) often associated with sporadic often associated with sporadic disease in Africadisease in Africa

• However, W135 outbreak in However, W135 outbreak in Saudi Arabia in 2000 created Saudi Arabia in 2000 created alert (264 cases)alert (264 cases)

Meningitis Epidemic Meningitis Epidemic Preparedness and ResponsePreparedness and Response

• 1. Epidemic Management 1. Epidemic Management committeecommittee

• 2. 2. Laboratory-basedLaboratory-based surveillance and alert system surveillance and alert system

• 3. 3. Strengthen Laboratory Strengthen Laboratory • 4. Vaccination 4. Vaccination with A/C vaccinewith A/C vaccine• 5. Case management5. Case management• 6. Social mobilisation 6. Social mobilisation

Definition of Alert and Epidemic Thresholds forMeningococcal Meningitis in Highly Endemic

Countries in Africa [a]

5 cases in the same week5 cases in the same weekOrOr

Doubling of the number of Doubling of the number of cases in a three-week cases in a three-week periodperiod[c][c]OrOr

Other situations should be Other situations should be studied on a case-by-case studied on a case-by-case basis basis [b, d][b, d]

If If (1)(1) No No epidemic for at epidemic for at least three years and least three years and vaccination coverage is vaccination coverage is under 80%, orunder 80%, or

(2) Alert threshold crossed (2) Alert threshold crossed early in the dry season early in the dry season [b[b]]

10 cases / 100,000 10 cases / 100,000 inhabitants / weekinhabitants / week

Other situationsOther situations


Epidemic Epidemic threshold threshold

2 cases in the same week2 cases in the same weekOrOr

An increase in the number of An increase in the number of cases in relation to previous cases in relation to previous non-epidemic yearsnon-epidemic years


Alert thresholdAlert threshold

PopulationPopulation

Under 30,000Under 30,000 PopulationPopulation

Over 30,000Over 30,000

Meningitis Epidemic, Meningitis Epidemic, Burkina Faso 2002 Burkina Faso 2002

(Jan 1 to May 5, 2002)(Jan 1 to May 5, 2002)

• 12,284 cases and 1,411 deaths 12,284 cases and 1,411 deaths identified identified

• Overall case fatality ratio Overall case fatality ratio (CFR) 11.5%(CFR) 11.5%

• Overall disease incidence rate: Overall disease incidence rate: 99 cases/100,000 population99 cases/100,000 population

• 33 health districts in (22 in 33 health districts in (22 in epidemic, 12 in alert) at peak epidemic, 12 in alert) at peak of the epidemic (week 14)of the epidemic (week 14)

Challenges PresentedChallenges Presented

• W135 W135 meningococcimeningococci as as the the predominate cause predominate cause

• First W135 epidemic of this First W135 epidemic of this magnitudemagnitude

• W135-W135-containing containing meningitismeningitis vaccine not vaccine not currently available for large currently available for large use in Africause in Africa (low quantity, (low quantity, high cost)high cost)

Issues Regarding Serogroup W-135Issues Regarding Serogroup W-135Epidemiological questionsEpidemiological questions

• Causes for emergence of W-135 Causes for emergence of W-135 disease?disease?

–Changes in carriageChanges in carriage

–Changes in immunityChanges in immunity

–Other changes in host (risk Other changes in host (risk factors)factors)

–Other changes in pathogenOther changes in pathogen

–Changes in environmentChanges in environment

–Implication of previous Implication of previous vaccination (A/C)campaignsvaccination (A/C)campaigns

Issues Regarding Serogroup W-135Issues Regarding Serogroup W-135Implications for Public Health Response in the Implications for Public Health Response in the

FutureFuture• Maintain/improve meningitis laboratory-Maintain/improve meningitis laboratory-

based surveillance 2002-2003based surveillance 2002-2003• W-135 containing polysaccharide vaccine W-135 containing polysaccharide vaccine

for future epidemicsfor future epidemics

– Monovalent (W135) Vs Quadrivalent Monovalent (W135) Vs Quadrivalent (A/C/Y/W135)(A/C/Y/W135)

• Development and introduction of W-135-Development and introduction of W-135-containing conjugate vaccinecontaining conjugate vaccine

• Case management Case management • EconomicsEconomics• Lessons learntLessons learnt

Support Impacts SuccessSupport Impacts Success

IDS requires:IDS requires:• CommitmentCommitment• ResourcesResources

– humanhuman– budgetarybudgetary

• TransportTransport• CommunicationsCommunications• TrainingTraining• SupervisionSupervision• LaboratoriesLaboratories

Documents

Integrated Disease Surveillance and Response (IDS/R) in the African Region Mary Harvey and Patrick Swai SOTA June 12, 2002