Preventing the preventable through effective surveillance: the case of diphtheria in a rural district of Maharashtra, India

Background: Epidemic diphtheria is still poorly understood and continues to challenge both developing and developed countries. In the backdrop of poor immunization coverage, non-existent adult boosters, weak case based surveillance and persistence of multiple foci, there is a heightened risk of re-emergence of the disease in epidemic forms in India. Investigating each outbreak to understand the epidemiology of the disease and its current status in the country is therefore necessary. Dhule a predominantly tribal and rural district in Northern Maharashtra has consistently recorded low vaccination coverages alongside sporaidic cases of diphtheria over the last years. Methods: This study reports the findings of an onsite survey conducted to assess a recent outbreak of diphtheria in Dhule district and the response mounted to it. Secondary data regarding outbreak detection and response were obtained from the district surveillance office. Clinical data were extracted from hospital records of eleven lab confirmed cases including one death case. Frequency distributions were calculated for each identified clinical and non- clinical variable using Microsoft™ Excel® 2010. Results: Our findings suggest a shift in the median age of disease to adolescents (10-15 years) without gender differences. Two cases (18%) reported disease despite immunization. Clinical symptoms included cough (82%), fever (73%), and throat congestion (64%). About 64% and 36% of the 11 confirmed cases presented with a well defined pseudomembrane and a tonsillar patch respectively. Drug resistance was observed in all three culture positive cases. One death occurred despite the administration of Anti-Diphtheric Serum in a partially immunized case (CFR 9%). Genotyping and toxigenicity of strain was not possible due to specimen contamination during transport as testing facilities were unavailable in the district. Conclusions: The outbreak raises several concerns regarding the epidemiology of diphtheria in Dhule. The reason for shift in the median age despite consistently poor immunization coverage (below 50%) remains unclear. Concomitant efforts should now focus on improving and monitoring primary immunization and booster coverages across all age groups. Gradually introducing adult immunization at ten year intervals may become necessary to prevent future vulnerabilities. Laboratory networks for genotyping and toxigenicity testing are urgently mandated at district level given the endemicity of the disease in the surrounding region and its recent introduction in remote Dhule. Contingency funds with pre- agreements to obtain ADS and DT/Td vaccines at short notice and developing standard case management protocols at district level are necessary. Monitoring the disease, emerging strains and mutations, alongside drug resistance through robust and effective surveillance is a pragmatic way forward

Challenges with the implementation of an Integrated Disease Surveillance and Response (IDSR) system: systematic review of the lessons learned

Introduction: Despite a realistic strategy and availability of resources, multiple challenges still overwhelm countries grappling with the challenges of communicable disease surveillance. The Integrated Disease Surveillance and Response (IDSR) strategy is by far the most pragmatic strategy in resource-poor settings. The objective of this study was to systematically review and document the lessons learned and the challenges identified with the implementation of the IDSR in low- and middle-income countries and to identify the main barriers that contribute to its sub-optimal functioning.Methods: A systematic review of literature published in English using Web of Knowledge, PubMed, and databases of the World Health Organization (WHO) and the Centers for Disease Control (CDC) between 1998 and 2012 was undertaken. Additionally, manual reference and grey literature searches were conducted. Citations describing core and support functions or the quality attributes of the IDSR as described by WHO and CDC were included in the review.Results: Thirty-three assessment studies met the inclusion criteria. IDSR strategy has been best adopted and implemented in the WHO–AFRO region. Although significant progress is made in overcoming the challenges identified with vertical disease surveillance strategies, gaps still exist. Mixed challenges with core and support IDSR functions were observed across countries. Main issues identified include non-sustainable financial resources, lack of co-ordination, inadequate training and turnover of peripheral staff, erratic feedback, inadequate supervision from the next level, weak laboratory capacities coupled with unavailability of job aids (case definitions/reporting formats), and poor availability of communication and transport systems particularly at the periphery. Best outcomes in core functions and system attributes were reported when support surveillance functions performed optimally. Apart from technical and technological issues, human resources and the health care system structures that receive the IDSR determine its output.Conclusions: The challenges identified with IDSR implementation are largely ‘systemic’. IDSR will best benefit from skill-based training of personnel and strengthening of the support surveillance functions alongside health care infrastructures at the district level