1. 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.

2. 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 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

3. EVD in Tonkolili District
>450 confirmed EVD (Ebola virus disease) cases in
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

4. 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

5. Health facility-based surveillance in Tonkolili
Integrated Disease Surveillance and Response system (IDSR) adapted following the Ebola outbreak in
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

6. Health facility-based surveillance in Tonkolili
Integrated Disease Surveillance and Response system (IDSR) adapted following the Ebola outbreak in
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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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 to 100% of them reporting in week
Isidro Carrión, MSF-OCA, health system strengthening via surveillance

15. 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 to
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

16. 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 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. THANK YOU FOR YOUR ATTENTION
QUESTIONS?
Contact:
Thanks for your attention.
Isidro Carrión, MSF-OCA, health system strengthening via surveillance