Health systems strengthening via surveillance in a rural district of Sierra Leone: ensuring lessons learned from Ebola are not lost Antonio Isidro Carrion Martin, Yassin Jalloh, Parastou Sara Valeh, Donald Sonne Kazungu, Augustine S. Jimmisa, Suleiman Jr.Tejan, Mohammed O. Sankoh, Kassim Kamara, Alphonso Sankoh, Anthony Omoko, Robert N Musoke , Sibylle Sang, Idriss Ait-Bouziad, Grazia Caleo. My name is Isidro carrion and today I am here to explain to you how we are strengthening the Health systems using surveillance in a rural district of Sierra Leone and how we are trying to ensure that the lessons learned from Ebola are not lost.

MSF in Tonkolili District, Sierra Leone Population 434,793(Area:7,003 km²) 11 chiefdoms ~1000 villages - mostly rural and hard to reach MSF maternal and child health programme since January 2016 Figure 1: Tonkolili District Our story takes place in Tonkolili District. Tonkolili has a Population of around 430000 inahbitants and an area of 7000 km² The district is divided in 11 chiefdoms and it has around 1000 villages – most of them in rural and hard to reach areas. MSF started here a maternal and child health programme in January 2016 following the Ebola related intervention. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

EVD in Tonkolili District >450 confirmed EVD (Ebola virus disease) cases in 2014-2015 MSF Ebola Management Centre (EMC) December 2014 – May 2015 In October 2015 MSF started to support surveillance activities Resurgence (2 EVD cases) in January 2016 Figure 2: MSF EMC in Magburaka, Tonkolili district  The EVD outbreak highlighted surveillance gaps Tonkolili district was badly affected by the Ebola outbreak (with more than 450 cases). The last flare up of Ebola was in January 2016 MSF had an Ebola Management Centre here from December 2014 until May 2015. And MSF has supported surveillance activities since October 2015. The Ebola outbreak revealed the weakness of the surveillance system in Tonkolili to detect and respond to public health emergencies Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Isidro Carrión, MSF-OCA, health system strengthening via surveillance Surveillance in MSF Main “traditional” approaches: Reporting of health events through health facilities supported by MSF Active surveillance outside of MSF’s area e.g. calling health facilities and District Surveillance Officers Household level surveillance by community health workers Before explaining what we actually did in Surveillance in Tonkolili I will briefly explain what are the main “traditional” approaches in MSF when working in surveillance so we can understand what innovative about our approach: First, we have the reporting of health events through health facilities supported by MSF, this is a typical approach in stable contexts. Second we have the active surveillance outside of MSF’s area, for example when we call health facilities to obtain information, this approach has been taken in countries like Nigeria or DRC. And finally we have the combination of health facility statistics and surveillance at the household level done by community health workers. An this is a common approach in refugees and displacement settings, like South Sudan. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Health facility-based surveillance in Tonkolili Integrated Disease Surveillance and Response system (IDSR) adapted following the Ebola outbreak in 2014-2016 Weekly paper-based reporting of 27 notifiable diseases + deaths 103 Peripheral health units (PHU) + 3 hospitals 2 District Surveillance Officer (DSO)+ 1 District Surveillance Superintendent National Ministry of Health and Sanitation (MoHS) in Freetown Figure 3: IDSR information flow Now, coming back to Sierra Leone, I will briefly explain how the the surveillance works in Tonkolili: In Sierra Leone the traditional Integrated Disease Surveillance and Response system (IDSR) was adapted by WHO and Ministry of Health following the Ebola outbreak This system is based in a weekly paper-based reporting of 27 notifiable diseases and deaths. In the right you can see how the information flow works: first the Periferal Health Units (PHUs) and Hospitals send their report to the surveillance team and then the surveillance team sends all the reports they have received to the national level in Freetown. The arrows go both ways there because the surveillance team also calls those PHUs which fail to submit their reports by the deadline which is 12 noon on Mondays. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Health facility-based surveillance in Tonkolili Integrated Disease Surveillance and Response system (IDSR) adapted following the Ebola outbreak in 2014-2016 Weekly paper-based reporting of 27 notifiable diseases + deaths Gaps: Lack of routine surveillance analysis & reporting Large unmapped remote area Poor performance indicators (e.g. timeliness and completeness) EVD focus 103 Peripheral health units (PHU) + 3 hospitals 2 District Surveillance Officer (DSO)+ 1 District Surveillance Superintendent National Ministry of Health and Sanitation (MoHS) in Freetown Figure 3: IDSR information flow Unfortunately there were some issues which challenge the performance of this surveillance system, such as: The lack of routine surveillance data analysis, reporting and mapping The fact that there was a large remote area under surveillance, which supposed a big challenge in terms of communication, and access The performance indicators such as timeliness and completeness were very poor when MSF started to support And finally, the fact that, originally, the system was completely focused in EVD, which made sense at the time, but now this supposes a challenge because other diseases do not receive enough attention Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Isidro Carrión, MSF-OCA, health system strengthening via surveillance Objective To strengthen public health surveillance in a large network of rural PHUs and hospitals to improve the detection and response to epidemics and deaths beyond MSF’s area of intervention For all this reasons we decided to strengthen the public health surveillance in this large network of rural PHUs and hospitals in order to improve the detection and response to epidemics and deaths beyond the MSF’s area of intervention. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Methods: MSF approach (1/2) A multi-faceted approach to strengthen: Triage and case detection Quality of reporting Analysis of reported data So, what did we do to improve the performance of this surveillance system? We decided to use a multi-faceted approach to strengthen: the triage and case detection, the quality of reporting, and the analysis of reported data How did we do this: MSF deployed and epidemiologist (expatriate) and, hired an MSF national epidemiology assistant We decided to work closely with and in continuous collaboration with the MoHS and with WHO We organized IDSR trainings at district level and supported PHU supervision visits. In this PHU visits we used an Open Data Kit checklist developed by WHO using the Kobo platform. And we developed an open source dashboard software tool that helped us to iidentify poor performing health facilities (in terms of reporting completeness and data quality) and to detect outbreaks and unusual trends. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Methods: MSF approach (1/2) A multi-faceted approach to strengthen: Triage and case detection Quality of reporting Analysis of reported data via MSF epidemiologist & MSF national staff epidemiology assistant Working with MoHS/WHO IDSR training at district level and PHU visits (WHO checklist) Open source dashboard software tool to: - Identify poor performing PHUs/hospitals - Detect outbreaks and unusual trends So, what did we do to improve the performance of this surveillance system? We decided to use a multi-faceted approach to strengthen: the triage and case detection, the quality of reporting, and the analysis of reported data How did we do this: MSF deployed and epidemiologist (expatriate) and, hired an MSF national epidemiology assistant We decided to work closely with and in continuous collaboration with the MoHS and with WHO We organized IDSR trainings at district level and supported PHU supervision visits. In this PHU visits we used an Open Data Kit checklist developed by WHO using the Kobo platform. And we developed an open source dashboard software tool that helped us to iidentify poor performing health facilities (in terms of reporting completeness and data quality) and to detect outbreaks and unusual trends. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Methods: MSF approach (2/2) 4. Strengthen response and plan activities: via Exhaustive mapping with field validation (MoHS) Joint case investigation with MoHS/WHO of cases reported within 24h Supporting vaccination campaigns Reviewing malaria data and maternal deaths Weekly surveillance meetings /weekly epi bulletins Apart from reinforcing detection of events, reporting etc, we decided to also Strengthen response and activity planning: In order to do this we decided to: We did an exhaustive mapping of the district We supported MoHS and WHO in case investigation of epidemic prone diseases We supported vaccination campaigns We collaborated in the review and analysis of malaria and maternal deaths data. And we also supported the surveillance team when preparing the weekly surveillance meetings, and the weekly epi bulletins. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Isidro Carrión, MSF-OCA, health system strengthening via surveillance Methods: dashboard Figure 4: Screenshot of surveillance dashboard In this slide we can see an example of the output of the dashboard. We can see how it helps visualization of disease trends and geographical distribution of cases. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Methods: exhaustive mapping Health structures (PHUs and hospitals) Villages Catchment area example Figure 5: Geographical distribution of IDSR surveillance network, Tonkolili District, Sierra Leone Here we can see the map that we did for Tonkolili. First we mapped all HF (red corsses), then we mapped all all the villages (grey dots) and finally we matched all villages to HF to create the catchment area (example in green). Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Isidro Carrión, MSF-OCA, health system strengthening via surveillance Results: training 4 IDSR district trainings and 130 PHU visits: Figure 6: IDSR training at district level Figure 7: Checking data quality and triage at PHU And now Regarding the results of the MSF support to surveillance system in Tonkolili: First we managed to organize 4 IDSR trainings and to support 103 PHU supervision visits, all this in collaboration with the MoHS and with WHO. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Results: reporting completeness health facilities not reporting health facilities reporting Figure 8: Completeness of reporting epi week 6, 2016 Figure 9: Completeness of reporting epi week 6, 2017 One of the most important achievements of our support to the surveillance system in Tonkolili was the improvement in completeness of reporting. In this slide we can see how the completeness improved from around 50% of health structures reporting in week 6 2016 to 100% of them reporting in week 6 2017. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Results: disease misclassification Figure 10: Distribution of cases of diarrhoea/severe dehydration and severe pneumonia by week of report, Tonkolili district, Sierra Leone, epi week 43-2015 to 52-2016. In this slide we can see how the misclassification of severe pneumonia and diarrhoea/severe dehydration decreased after the continuous training to reinforce the use of correct case definition. Before this the PHUs were reporting all respiratory presentations as severe pneumonia and all the diarrhoea cases as severe dehydration. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Results: investigations and vaccinations 63 case investigations performed 5 vaccination campaigns supported (polio and measles) Figure 11: Joint case investigation with MoHS DSO Figure 12: Case investigations supported by MSF The MSF team supported 63 case investigations of different diseases, being the most common measles. This is because of the measles outbreak affecting Sierra Leone in the first months of 2016. MSF also supported the subsequent vaccination that took place in May 2016 and other vaccinations campaigns, especially polio. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Results: malaria and maternal deaths Dashboard analysis (malaria burden and geo-distribution) identified priority PHUs and villages for MSF to set up a community-based malaria programme MoHS maternal death data reviewed by MSF to identify areas to: -Reinforce maternal death surveillance -Improve documentation of death -Improve timeliness of maternal referrals An other result of this intervention was the identification priority areas to set up a community based malaria program. We analyzed the malaria burden and its geographical distribution Using the MSF developed dashboard. Furthermore we helped the MoHS to analyze and review the maternal death data. Doing so we reinforce the maternal death surveillance improving the documentation of deaths, which allowed us to identify aspects that needed attention such as the timeliness of maternal referrals Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Isidro Carrión, MSF-OCA, health system strengthening via surveillance Challenges Poor quality mapping data and mainly related to EVD response Lack of local resources Communication issues MoHS not using the dashboard independently New national data health system in place This intervention had some challenges: Before the mapping the geographic location of the PHUs and their catchment areas was unavailable and the only mapping data was mainly related to EVD response The lack of local resources, with very few human and logistic resources alocated by the MoH to the Surveillance office. Other challenge is that, despite our efforts to train the MoH staff they are still not using it independently, We have some communication issues with MoH or WHO, for example they try to implement new systems without communicating properly with us or with the health facilities staff which creates some confussion. And finally there is a new national data health system in place, a very good one, but the surveillance officers are not proficient in their use yet, so they still use our dashboard for certain things, and therefore this supposes a duplication of systems Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Isidro Carrión, MSF-OCA, health system strengthening via surveillance Conclusions (1/2) Surveillance: powerful public health tool to strengthen clinical skills (e.g. to recognize disease) National epidemiology assistant: key to build relationships, acceptance, and ensure continuity Dashboard: supported data quality training and real-time analysis to plan interventions Engagement with MoHS/WHO: fundamental to surveillance So in conclusion: By reinforcing the surveillance system we were also able to strengthen the clinical skills. For example by reinforcing case definitions we also improved the triage and diagnose of different diseases. The national epidemiology assistant, Yassin, was and is key to build relationships, acceptance, and to ensure continuity. The dashboard is a very powerful tool which helped us during the data quality training and ensured real-time analysis to indentify alerts and to plan interventions The engagement and partnership with MoHS/WHO: working in continuous and close collaboration with them was fundamental in the success of this new surveillance approach Finally and most importantly, this intervention supposes a novel approach for MSF: with limited human and technological resources we managed to strengthen a large network of rural health facilities in their ability to report and respond to epidemics beyond the MSF area of intervention. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Isidro Carrión, MSF-OCA, health system strengthening via surveillance Conclusions (2/2) Novel approach for MSF: with limited human and technological resources a large network of rural health facilities were strengthened in their ability to report and respond to epidemics So in conclusion: By reinforcing the surveillance system we were also able to strengthen the clinical skills. For example by reinforcing case definitions we also improved the triage and diagnose of different diseases. The national epidemiology assistant, Yassin, was and is key to build relationships, acceptance, and to ensure continuity. The dashboard is a very powerful tool which helped us during the data quality training and ensured real-time analysis to indentify alerts and to plan interventions The engagement and partnership with MoHS/WHO: working in continuous and close collaboration with them was fundamental in the success of this new surveillance approach Finally and most importantly, this intervention supposes a novel approach for MSF: with limited human and technological resources we managed to strengthen a large network of rural health facilities in their ability to report and respond to epidemics beyond the MSF area of intervention. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

Isidro Carrión, MSF-OCA, health system strengthening via surveillance Acknowledgements MoHS PHU staff, GIS volunteers, MSF Field epidemiologists, Jane Greig, Phil du Cros, Kim West, Miranda MacDonald, people of Tonkolili To finalize I would like to ackknowledge all the PHU staff, the GIS volunteers, the colleagues from the Manson Unit and especially the people of Tonkolili. Isidro Carrión, MSF-OCA, health system strengthening via surveillance

THANK YOU FOR YOUR ATTENTION QUESTIONS? Contact: grazia.caleo@london.msf.org Thanks for your attention. Isidro Carrión, MSF-OCA, health system strengthening via surveillance