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

2. AFRO

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

4. Diseases targeted for eradication/eliminationDiseases targeted for eradication/elimination Epidemic Prone DiseasesEpidemic Prone Diseases Diseases of Public Health ImportanceDiseases of Public Health Importance WHO/AFRO Priority Infectious Diseases

5. General Objective of IDS To provide evidence on which to base decisions and public health interventions for the control of communicable diseases

6. 1. To of health workers to conduct activities. 1. To strengthen the capacity of health workers to conduct surveillance activities. 2.To Integrate multiple surveillance systems for efficiency of staff, forms, resources. 3. Improve use of Information for decision making. 4. To improve the flow of surveillance information between and within levels of the health system 5. To strengthen laboratory capacity and involvement in confirmation 6. To increase involvement of clinicians Specific Objectives of IDS

7. Steps for IDS Strategy implementation Sensitize Assess Plan Implement Plan

8. 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

9. 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

10. Challenges Ownership and sustainability Availability of resources Commitment of stakeholders Involvement of all levels

11. Expected Outcomes of IDS Simplification of recording and reportingSimplification of recording and reporting Information is more accessible and timelyInformation is more accessible and timely Action taken is more timely and appropriateAction taken is more timely and appropriate Resources are used more effectivelyResources are used more effectively

12. Developing experience and evidence in surveillance implementation in Tanzania Dr. Patrick Swai USAID/Tanzania

13. Milestones of IDS in Tanzania 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 diseases2001 National IDS guidelines for 13 priority diseases 2001 Lab networking guidelines2001 Lab networking guidelines 2002 Development of draft District analysis book2002 Development of draft District analysis book 2002 The coordinated implementation team initiated implementation in focus districts2002 The coordinated implementation team initiated implementation in focus districts

14. Source of USAID funds for IDS implementation in Tanzania Africa Bureau – Providing support to WHO, (including the 1998 assessment)Africa Bureau – Providing support to WHO, (including the 1998 assessment) Tanzania Mission – operationalizing the IDS strategy and strengthening surveillance implementationTanzania 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 countriesBureau of Global Health – developing evidence of successful programming around surveillance; dissemination of tools, materials, and lessons learned to other countries

15. USAID-funded partners in local IDS implementation in Tanzania National Institute for Medical Research (NIMR)National Institute for Medical Research (NIMR) Partners for Health Reform plus (PHRplus)Partners for Health Reform plus (PHRplus) Centers for Disease Control and Prevention -- NCID and EPO/DIHCenters for Disease Control and Prevention -- NCID and EPO/DIH CHANGE ProjectCHANGE Project HealthTechHealthTech

16. 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

17. How the implementation team contributes to IDS strengthening WHO/AFRO – support to creating strategy, guidelines, and toolsWHO/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 guidelinesLocal-level (country) implementation: operationalize the strategy and guidelines

18. Questions for country level implementation: What obstacles do districts, facilities, and communities face in operationalizing the system?What obstacles do districts, facilities, and communities face in operationalizing the system? What are the best strategies for overcoming these obstacles?What are the best strategies for overcoming these obstacles?

19. What are some of the obstacles that districts in Tanzania face? Very limited diagnostic confirmation capacityVery limited diagnostic confirmation capacity Lack of adequate communications between levelsLack of adequate communications between levels Barriers to adequate transport of specimensBarriers to adequate transport of specimens Low motivation and capacity for analysis (and use) of information for public health actionLow motivation and capacity for analysis (and use) of information for public health action 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

20. How we are breaking ground in implementation in Tanzania Support the development of new ID surveillance and public health action technologies and tools for both epidemic and non-epidemic diseasesSupport 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 countriesConduct 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 responseCoordinate with global and national institutions to provide training to develop the necessary skills needed for ID surveillance and response

21. How we are breaking ground in implementation in Tanzania Disseminate lessons learnedDisseminate 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 levelsDevelop 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

22. Implications for other countries for implementing IDSR Provide a model for other countriesProvide a model for other countries Answer questions with operations researchAnswer questions with operations research Development of best practicesDevelopment of best practices Documentation and transfer of experiences and lessons learnedDocumentation and transfer of experiences and lessons learned Dissemination of tools and materials for implementationDissemination of tools and materials for implementation

23. Thank you!

24. Milestones of IDS in Tanzania 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

25. Source of USAID funds for IDS implementation in Tanzania 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

26. USAID-funded partners in local IDS implementation in Tanzania 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

27. 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

28. How the implementation team contributes 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

29. Questions for country level implementation: What obstacles do districts, facilities, and communities face in operationalizing the system?What obstacles do districts, facilities, and communities face in operationalizing the system? What are the best strategies for overcoming these obstacles?What are the best strategies for overcoming these obstacles?

30. What are some of the obstacles 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

31. How we are breaking ground in implementation in Tanzania 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

32. How we are breaking ground in implementation in Tanzania 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

33. Implications for other countries for implementing IDSR 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

34. Epidemic Preparedness and Response Yellow Fever epidemics in Cote d'Ivoire, Ghana, Guinea and Liberia in 2000-2001Yellow Fever epidemics in Cote d'Ivoire, Ghana, Guinea and Liberia in 2000-2001 5 Countries accounted for 75% of the 61,988 Meningitis cases and 67% of the 6,172 deaths:Burkina, Niger, Benin, Mali, Ethiopia, and Chad5 Countries accounted for 75% of the 61,988 Meningitis cases and 67% of the 6,172 deaths:Burkina, Niger, Benin, Mali, Ethiopia, and Chad Cholera in South Africa, Malawi, Madagascar, ZambiaCholera in South Africa, Malawi, Madagascar, Zambia Ebola: Gabon, RDC, UgandaEbola: Gabon, RDC, Uganda

35. Meningitis Epidemics in Africa Meningitis epidemics historically caused by serogroup A meningococciMeningitis epidemics historically caused by serogroup A meningococci Other serogroups (B, C, W135) often associated with sporadic disease in AfricaOther serogroups (B, C, W135) often associated with sporadic disease in Africa However, W135 outbreak in Saudi Arabia in 2000 created alert (264 cases)However, W135 outbreak in Saudi Arabia in 2000 created alert (264 cases)

36. Meningitis Epidemic Preparedness and Response 1. Epidemic Management committee1. Epidemic Management committee 2. Laboratory-based surveillance and alert system2. Laboratory-based surveillance and alert system 3. Strengthen Laboratory3. Strengthen Laboratory 4. Vaccination with A/C vaccine4. Vaccination with A/C vaccine 5. Case management5. Case management 6. Social mobilisation6. Social mobilisation

37. Definition of Alert and Epidemic Thresholds for Meningococcal Meningitis in Highly Endemic Countries in Africa [a] 5 cases in the same week Or Doubling of the number of cases in a three-week period[c] [c] Or Other situations should be studied on a case-by-case basis [b, d] If (1) No epidemic for at least three years and vaccination coverage is under 80%, or (2) Alert threshold crossed early in the dry season [b] (2) Alert threshold crossed early in the dry season [b][b] 10 cases / 100,000 inhabitants / week Other situations 15 cases / 100,000 inhabitants / week Epidemic threshold 2 cases in the same week Or An increase in the number of cases in relation to previous non-epidemic years 5 cases / 100,000 inhabitants / week Alert threshold Population Under 30,000 Population Over 30,000

38. Meningitis Epidemic, Burkina Faso 2002 (Jan 1 to May 5, 2002) 12,284 cases and 1,411 deaths identified12,284 cases and 1,411 deaths identified Overall case fatality ratio (CFR) 11.5%Overall case fatality ratio (CFR) 11.5% Overall disease incidence rate: 99 cases/100,000 populationOverall disease incidence rate: 99 cases/100,000 population 33 health districts in (22 in epidemic, 12 in alert) at peak of the epidemic (week 14)33 health districts in (22 in epidemic, 12 in alert) at peak of the epidemic (week 14)

39. Challenges Presented W135 meningococci as the predominate causeW135 meningococci as the predominate cause First W135 epidemic of this magnitudeFirst W135 epidemic of this magnitude W135-containing meningitis vaccine not currently available for large use in Africa (low quantity, high cost)W135-containing meningitis vaccine not currently available for large use in Africa (low quantity, high cost)

40. Issues Regarding Serogroup W-135 Epidemiological questions Causes for emergence of W-135 disease?Causes for emergence of W-135 disease? – Changes in carriage – Changes in immunity – Other changes in host (risk factors) – Other changes in pathogen – Changes in environment – Implication of previous vaccination (A/C)campaigns

41. Issues Regarding Serogroup W-135 Implications for Public Health Response in the Future Maintain/improve meningitis laboratory- based surveillance 2002-2003Maintain/improve meningitis laboratory- based surveillance 2002-2003 W-135 containing polysaccharide vaccine for future epidemicsW-135 containing polysaccharide vaccine for future epidemics – Monovalent (W135) Vs Quadrivalent (A/C/Y/W135) Development and introduction of W-135- containing conjugate vaccineDevelopment and introduction of W-135- containing conjugate vaccine Case managementCase management EconomicsEconomics Lessons learntLessons learnt

42. Support Impacts Success IDS requires: CommitmentCommitment ResourcesResources –human –budgetary TransportTransport CommunicationsCommunications TrainingTraining SupervisionSupervision LaboratoriesLaboratories