Integrated Disease Surveillance and Response: a strategy for strengthening national public health surveillance systems DPHSWD Resident Advisor Orientation Helen N. Perry, PhD IDSR Team Lead Public Health Systems Strengthening Branch August 8, 2011

IDSR is a WHO AFRO strategy CDC is key technical partner supported with USAID funding * * * * First Annual IDSR Taskforce Meeting Harare, Zimbabwe November 2, 2000

Thousands of cases in East Africa Mid-1990s Cholera Thousands of cases in East Africa 1996-98 Meningococcal Meningitis 300,000 cases and 35,000 deaths 1996 Yellow fever Reported outbreaks in 7 countries In mid-1990s, Africa experienced several devastating outbreaks – (I then say the 4 instances on the slide). This situation led African countries to request WHO-AFRO and their technical partners to work with countries to improve surveillance capacity for detecting and responding to diseases that impact African communities. 1995-1996 Ebola Zaire and Gabon High case fatality rates 68% to 90%

IDSR priority diseases: 1998-2008 Epidemic prone diseases Cholera Diarrhea with blood Measles Meningitis Plague Viral hemorrhagic fevers Yellow fever Diseases for elimination/eradication Acute flaccid paralysis / poliomyelitis Dracunculiasis Leprosy Neonatal tetanus Diseases of public health importance AIDS Diarrhea with dehydration <5 y old Malaria Onchocerciasis Pneumonia < 5 y old Sexually transmitted infections Trypanosomyasis Tuberculosis Diseases targeted by IHR (2005) IDSR aimed to prioritize the leading causes of illness, death and disability in the African region and in 2008, began to incorporate the diseases and conditions targeted by the revised International Health Regulations such as pandemic influenza.

Planning an integrated system: a matrix of skills and activities Perry et al, BMC Medicine 2007 This the framework that illustrates how IDSR implementation aims to improve the generic functions of surveillance across all levels of the health system. This includes the support functions of laboratory, training, logistics, and communications.

Guidelines for IDSR WHO-CDC IDSR Guidelines Ghana IDSR Guidelines As part of the implementation process, countries adapted generic guidelines in order to incorporate their particular disease priorities and national context. This is an example of the guidelines for Ghana. WHO-CDC IDSR Guidelines Ghana IDSR Guidelines

Examples of action thresholds An example of the disease specific thresholds: epidemic-prone diseases such as cholera, eradication programs such as polic and endemic epidemics in Africa such as malaria. Each threshold is linked to action.

IDSR performance indicators Summary and case-based data reported on time to next level Trend analysis for priority diseases is current Reported outbreaks are investigated Reported outbreaks are laboratory confirmed Response implemented for confirmed outbreak and evaluated to illustrate what IDSR hopes to see as success, these are the core IDSR indicators that describe what we hope to accomplish at this point in the initiative. Progress towards implementation is being measured through evidence of improved timely reporting, reporting of case-based data, data analysis at local levels, investigation and laboratory confirmation of outbreaks, and an appropriate response. Several disease programs have CFR targets, and IDSR provides data to those programs so that can monitor their disease targets.

Role of laboratory in IDSR Confirm epidemics Monitor trends An integral component of IDSR involves inclusion and strengthening of the laboratory for confirming epidemics and monitoring trends.

Laboratory performance indicators Laboratory data is reported on time. Transport of adequate specimens to referral laboratory Supervision and quality control at periphery Correct culture and antimicrobial results for bacterial specimens Participate in outbreak investigation Participate in External Quality Assurance Program IDSR promoted laboratory indicators to monitor progress towards functional laboratory surveillance programs in countries. A successful public health laboratory system is one where … (and then I read/paraphrase the indicators).

2010 - Preparedness at country level: existence of guidelines, regulations, and policies   Item No of Countries (43 of 45 responses) % (n=43 ) 1 Have national guidelines for IDSR 41 95.3 2 Have regulations governing public health surveillance 30 69.8 3 Have national policy for IDSR implementation 33 76.7 4 Have a national budget line for IDSR 22 51.2 5 Receive funds from donors Ref: WHO-AFRO and CDC-IDSR team (2011). Draft summary results from the IDSR Rapid Assessment of IDSR Implementation in African countries. CDC authors include C. Alu (OSELS), T.Taylor (NCEZID), K.Embrey (ASPH Fellow) and H. Perry (DPHSWD)

International health regulations (2005) Call for surveillance and response capacity at all levels of the health system

( Epidemic prone diseases Diseases targeted for eradication or elimination Other major diseases of public health importance Cholera1 Meningococcal meningitis Diarrhoea with blood (Shigella) Viral hemorrhagic fevers*1 Dengue Typhoid fever Yellow fever 1 Measles Influenza-like illness Plague 1 Anthrax Chikungunya 1 Disease specified by IHR (2005) for notification. *Ebola, Marburg, Rift Valley, Lassa, Crimean Congo, West Nile Fever Neonatal tetanus Poliomyelitis 1 (AFP) Dracunculiasis Leprosy Onchocerciasis Buruli ulcer Filariasis Noma Diarrhoea with dehydration <5 Severe pneumonia New HIV/AIDS STIs Tuberculosis Malaria Trypanosomiasis Trachoma Acute viral hepatitis Rabies Malnutrition Maternal deaths Hypertension Diabetes mellitus Adverse events following immunization (AEFI) Diseases or events of international concern In addition to those noted in other columns Any public health event of international concern (infectious, zoonotic, food borne, chemical, radio nuclear, or due to unknown condition) Draft July 15, 2010

Revised IDSR Technical Guidelines – October 2010 International Health Regulations (2005) Non-communicable diseases New public health priorities (e.g., pandemic influenza) Focus on community surveillance Preparedness Disease specific fact-sheets

IDSR and FELTP FELTP practicum opportunities at district and national levels Detecting public health communicable and non-communicable events Conducting training for district level Evaluating IDSR components Participating in laboratory network Innovative problem solving- FELTP graduates become national leaders for surveillance, laboratory and response capacities

Summary IDSR is a framework for strengthening public health surveillance and response at all levels of the health system IDSR and FELTP work together to reduce illness, death and disability and contribute to healthier African and global communities

THANK YOU IDSR PARTNERS WHO-AFRO CDC-Atlanta USAID Africa Bureau WHO ISTs Ministries of Health