Feedback Integrated Disease Surveillance Programme (IDSP) district surveillance officers (DSO) course

Preliminary questions to the group Were you already involved in feedback of surveillance data? If yes, what difficulties did you face? What would you like to learn about feedback of surveillance data? The usual warm up… 2

Warm up exercise Diphtheria persists in Delhi One hospital used at a sentinel centre Data analyzed from 1954-1997 A warming up exercise. 3

Diphtheria incidence and case fatality, sentinel unit, New Delhi, India, 1954-97 1800 40% 1600 Cases 35% Case fatality 1400 30% 1200 25% 1000 Number of cases Case fatality 20% Examine this set of data about Diphtheria in Delhi. Describe before you interpret. 800 15% 600 10% 400 200 5% 0% 1954 1956 1958 1960 1962 1964 4 1966 1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 Year

Diphtheria incidence by month, sentinel unit, New Delhi, India, 1997 35 Cases 30 Deaths 25 20 Number of cases More on seasonality. 15 10 5 5 J F M A M J J A S O N D Month

Characteristics of diphtheria cases, sentinel unit, New Delhi, India, 1997 % Total Death CFR (%) Age <1 20 14 10 50 1-4 73 51 22 30 5-9 38 27 13 34 10+ 12 8 Sex Male 90 63 Female 53 37 18 Religion Hindu 89 62 25 28 Muslim * 54 Vaccine Yes 15 1 7 No 114 80 43 ? Total 143 100 45 31 Characteristics of the persons affected. * Account for 9%, 17% ad 5% of the population in Delhi, UP and Haryana 6

Questions for the group: Propose messages for feedback Describe what you see Recommend action to report in your feedback bulletin Summarize the data. Propose interpretations. What would you report in a feedback bulletin? 7

Key findings messages re: diphtheria in Delhi, India,1997 Incidence decreases Case fatality increased Seasonality: August to October Most cases among unvaccinated, at at age when they should be protected from primary vaccination The solution. 8

Key recommendations re: diphtheria in Delhi, India,1997 Increase vaccine coverage and reach unvaccinated pockets Store and use anti-toxin early Recommendations. 9

Group exercise to conclude Outline of the session Rationale for feedback Content of feedback Feedback mechanisms Group exercise to conclude Outline of the session. 10

Difficulties with surveillance system with no feedback Lack of motivation Data disappear in a black hole Unreliability Mistakes are not corrected Sluggishness The various levels do not communicate Data falsification The data is opaque Weak human resources The actors do not see the system in action These are the consequences of a surveillance system with no feedback. Self explanatory. 11

Rationale for feedback of surveillance data Motivation Everyone sees how their data fit in the bigger picture Reliability Identifies errors Reactivity Places everyone on the same page Quality Increases transparency Education Demonstrates how the system works So we need to have a feedback, with its advantages. See how the advantages parallel the problems in the previous slide. 12

A dynamic vision of surveillance Collect and transmit data Make decisions All levels use information to make decisions Feedback information Analyze data Feedback closes the loop and brings life to the system. 13 Surveillance

Data flow and feedback: Level by level Centre State Data District Feedback Feedback must go down the system in the same way that the data comes up. Primary / Community health centre Community 14

Content of feedback Information on diseases under surveillance Information on quality of data collected Feedback must contain two types of information: Data on the diseases themselves Information on the quality of the data 15

Content of feedback Information on diseases under surveillance Summary data tables Analyzed epidemiological information Time (Graphs with trends) Place (Maps) Persons (Tables) Information on quality of data collected An expansion of the first point. Again, recurrence of the time, place and persons aspects: That is the information that needs to be feedback. 16

Content of feedback Information on diseases under surveillance Information on quality of data collected Regularity of reporting Timeliness of reporting Completeness of reporting Responses initiated by the unit Validity of data An expansion of the second point. A list of the points that will reflect data quality. 17

Feedback methods Newsletters, bulleting Monthly review meetings Outbreak investigation reports Informal feedback Electronic communication Feedback can use various methods (media) 18

Newsletter Regular epidemiological bulletin Educational tool Contains Summary tables and graphs Commentary on diseases or topic One of them is the newsletter. 19

Monthly review meetings District / block monthly meeting Presentation of data during meetings Generates comments from peers Need to stress positive aspects Public negative comments may de-motivate Monthly meeting are an opportunity to get feedback. But that feedback needs to have some consistence: Some real data. 20

Outbreak investigation reports Excellent for feedback and learning Allow sharing of experiences that may be encountered in other places Content Information about the epidemiological characteristics of disease Lessons learned in the investigation process Outbreak investigation reports are excellent for feedback. They demonstrate the usefulness of the system. They provide information about disease patterns. They disseminate outbreak investigation methods. 21

Informal feedback Oral feedback Useful for pointing out mistakes Does not suffice by itself Informal feedback is fine but not sufficient. 22

Electronic methods Through email, websites Fast and efficient May be updated rapidly Allows Dynamic data presentation Queries Electronic methods may be faster, more dynamic and interactive. 23

Take home messages Feedback closes the surveillance loop Feedback Epidemiological information Time Place Person Information on data quality Use all possible mechanisms of feedback to get the information across The take home messages of the session. 24

Exercise Read the article on the analysis of measles surveillance data in Uttar Pradesh in 1996 Singh J. et al. Widespread outbreaks of measles in rural Uttar Pradesh, India, 1996: High risk areas and groups. Indian Pediatrics 1999; 36: 249-255. Imagine you need to prepare a feedback meeting with health officials in Uttar Pradesh You need to prepare a presentation Now an exercise. Obtain that article on measles in Uttar Pradesh. This article is made of a secondary analysis of surveillance data. Imagine you need to provide feedback to health officials in UP. 25

Group work Sit down by by groups of 4 or 5 Extract information from the article to structure your feedback Use a table format to prepare your presentation Organize for some group work. 26

Empty table shell to organize feedback information Findings Interpretation Recommendations Epi data Time … Place Person Data quality issues Surveillance issues Each group should use this empty table shell and see how the time, place and person information can be used for recommendations. For each element (time, place and person), extract: The finding Its interpretation (the conclusion) The recommendation to offer Note your feedback also needs to include some points on data quality. You can make 4 groups for time, place, person and data quality. 27

Break in groups Take 15 minutes Now on to the group work.

Key elements of feedback for measles in Uttar Pradesh, India, 1996 Findings Interpretation Recommendations Epi data Time Most cases in low transmission months Measles all year long Be mobilized all year long Place Deaths concentrates in 10 districts Higher incidence? Better reporting? Compare reporting practices in the 10 districts with the others Person 85% cases not vaccinated Measles persists because of low vaccine coverage Increase coverage Efficacy 92% Vaccine works in UP Data quality issues Surveillance 1% of estimated cases reported Measles surveillance is weak Improve reporting This is a template of response. 29

Presenting your feedback Present the background Explain how you collected the data Display the key results presented in the summary table Back up data with tables, graphs and maps Interpret the data Summarize the recommendations that can be deducted from the data This summarizes the method you could use to extract the information, interpret it and propose recommendations when preparing some feedback. 30

Additional reading Section 4 of IDSP operations manual (Report 2-7, page 57-64) Section 10 of IDSP operations manual Module 10 of training manual Additional reading. 31