Evaluating the sensitivity of a passive diarrheal disease surveillance system during a post-drought

ObjectiveTo evaluate the difference in sensitivity between passive and active diarrheal and malnutrition disease surveillance system post-drought period in SwazilandIntroductionOver the past decade Swaziland has experienced recurring drought episodes. In 2016 the country experienced challenges regarding water supplies in both urban and rural areas due to the drought impact. A rapid health and Nutrition Assessment was conducted in 2016 revealed an increase in number of cases of acute watery diarrhea of all age groups. While there is a high demand for epidemiological data in the country a passive system through Health Management Information System (HMIS) and Immediate Disease Notification System (IDNS) has been used to monitor acute watery diarrhea and a set of priority notifiable diseases in the country.MethodsAn active sentinel surveillance system was set up in four regional hospitals for monitoring of all diarrheal cases of the under-fives. A data abstraction form was developed and used to extract data from outpatient registers and inpatient mainly from the children’s ward over a period of 15 weeks. Two surveillance officers trained on Integrated Disease Surveillance and Response (IDSR) collected and analyzed on weekly basis and further compared with data from a passive surveillance system that included the HMIS and IDNS.ResultsWhile acute gastroenteritis was the most prevalent type of diarrheal disease (93%), about 35.5% (1788 in active surveillance vs 1147 passive surveillance) of the cases of diarrheal cases are being underreported in the passive surveillance. Similar observation was made on malnutrition with more than 51% of the cases not reported in passive surveillance (186 cases vs 91 cases).ConclusionsThe process exposed gaps in data collected for passive surveillance and also differing data standards indicating inconsistency and under reporting which may be misleading for public health purposes. Low sensitivity in terms missing cases within the passive surveillance was observed when comparing within the active surveillance sentinel sites. It was also noted that having multiple data sources poses challenges in the country as they provide varying diseases trends and burden estimate.References1. WHO. Integrated Disease Surveillance and Respons

Implementation of Integrated Disease Surveillance and Response (IDSR) in Swaziland

Objective: To strengthen public health surveillance and monitor implementation of Integrated Disease Surveillance and Response in the Kingdom of Swaziland.Introduction: Swaziland adopted the Integrated Disease Surveillance and Response (IDSR) strategy in 2010 to strengthen Public Health Surveillance (PHS) that fulfills International Health Regulations (2005) and the Global Health Security Agenda (GHSA). This strategy allows the Ministry of Health (MoH), Epidemiology and Disease Control Unit (EDCU) to monitor, prevent and control priority diseases in the country. We used a health systems strengthening approach to pilot an intervention model for IDSR implementation at five hospitals in Swaziland over a pilot phase of three months.Methods: Our intervention included cross-country IDSR trainings, sensitizations and onsite trainings targeting national and regional health teams for over 250 health workers. The EDCU developed and disseminated standardized case definitions for health facilities (HFs) to detect, confirm and report priority conditions. Trained health care workers were tasked to cascade knowledge sharing and sensitization about IDSR with their HFs during in-service trainings. The facilities were to use IDSR standard case definition as guidelines for diagnosing and reporting cases; submit monthly reports on all priority conditions to Health Management Information System (HMIS) and intensify reporting through immediate disease notification system (IDNS) for all notifiable conditions. Indicators and monitoring tools for disease surveillance and response as recommended by the technical guidelines for IDSR in the African region were developed. The intervention was evaluated at five purposively selected high-volume referral hospitals (attending to ≥1500 to 15000 outpatient visits per month), which also have maternity services.Structured questionnaires in the form of a monitoring tool, checklists and observations were used to collect data. Quantitatively, monthly reports submitted by the five facilities to HMIS were reviewed and analyzed for completeness and timeliness. Clinic supervisors were identified from outpatient, inpatient, maternity and laboratory departments as key informants to explore successes and challenges of IDSR implementation. Additionally, IDSR officers visited health facilities and observed the registers and reporting forms used to report IDSR priority conditions and the availability of IDSR guidelines.Results: The five HFs submitted monthly reports from June to August 2017 with a calculated completeness of 80% in June 2017, 60% in July and 40% in August. Timeliness was calculated was at 20% in June, 20% in July and 40% in August. IDSR officers observed that all five HFs document cases of priority diseases in registers during consultations and use daily tally sheets. However, it was observed that diseases reported through the immediate diseases notification system were not all documented in the morbidity registers and vice versa. Health workers reported to be unaware about all diseases that require immediate notification to trigger investigation, hence some disease like perinatal deaths were never notified through the IDNS system during the period of evaluation. All five hospitals reported not utilizing the standard cases definitions provided to identify and report IDSR priority diseases.Conclusions: The proportion of completeness and timeliness from the five HFs during the evaluation period was low compared to WHO recommended standards of >= 80% from all HFs. This therefore, poses challenges in monitoring and responding to the priority conditions as per IDSR standards and recommendations. All five hospitals reported not utilizing the standard cases definitions to identify and report IDSR priority diseases and this poses challenges in comparison of data across sites, monitoring priority diseases, conditions and events and also identifying the alert or epidemic thresholds. There is need to capacitate more health workers on IDSR for Swaziland to strengthen PHS and be able to prevent and control public health threats timely

Baseline Assessment of Public Health Surveillance in the Kingdom of Swaziland

ObjectiveTo assess essential support functions for Integrated DiseaseSurveillance and Response(IDSR) in the Kingdom of Swaziland andmake recommendations for a national IDSR Roadmap.IntroductionImplementation of the IDSR framework for fulfillment of theInternational Health Regulations (2005) ([IHR 2005]) has beenchallenging in Swaziland due to distribution of IDSR functions acrossunits within the Strategic Information Department (SID) and otherexternal departments within the Ministry of Health. We conducted aqualitative assessment and a Strength, Weaknesses, Opportunities andThreats (SWOT) analysis of current public health surveillance (PHS)support structures to inform implementation of IDSR.MethodsKey informant interviews, focus group discussions, and a deskreview were performed. Participants were personnel at essential units,departments and programs at the national level as well as at healthfacilities and clinics at regional and local levels. Transcripts werecoded into SWOT matrices using MAXQDA for each building blockof PHS: structures, workforce, resources, processes (detect, report,assess/analyze, respond, feedback), and informatics.ResultsSelected Strengths included existence of immediate notifiabledisease reporting through the Epidemic and Pandemic Response unit(EPR) and reporting of summary health facility data to the HealthManagement Information System (HMIS) unit and laboratorynetwork. Weaknesses included lack of clear roles and responsibilitiesfor IDSR among SID units, limited coordination between SID units,lack of data sharing, lack of Standard Operating Procedures (SOPs),uncoordinated case investigations and response, minimal analysisconducted for public health surveillance and limited feedback forreporters..Identified opportunities were political will for establishing ofroles and responsibilities and mechanisms for coordination anddata sharing. Threats were limited data access, limited funding forfeedback, lack of analysis for IDSR and paper-based reportingConclusionsCurrently there is limited use of surveillance data for decisionmaking due to lack of coordination. Findings were presented at adissemination meeting to representatives of relevant departments,and there was consensus on the need to clearly define the role andresponsibilities of different programs for IDSR. In March 2016, aconsensus meeting was held to designate roles and responsibilitiesfor IDSR, a direct result of this assessment. Additional resourcesand funding is needed to support these highly important initiatives toensure the safety and health security of the Swazi nation

Baseline Assessment of Public Health Surveillance in the Kingdom of Swaziland

ObjectiveTo assess essential support functions for Integrated DiseaseSurveillance and Response(IDSR) in the Kingdom of Swaziland andmake recommendations for a national IDSR Roadmap.IntroductionImplementation of the IDSR framework for fulfillment of theInternational Health Regulations (2005) ([IHR 2005]) has beenchallenging in Swaziland due to distribution of IDSR functions acrossunits within the Strategic Information Department (SID) and otherexternal departments within the Ministry of Health. We conducted aqualitative assessment and a Strength, Weaknesses, Opportunities andThreats (SWOT) analysis of current public health surveillance (PHS)support structures to inform implementation of IDSR.MethodsKey informant interviews, focus group discussions, and a deskreview were performed. Participants were personnel at essential units,departments and programs at the national level as well as at healthfacilities and clinics at regional and local levels. Transcripts werecoded into SWOT matrices using MAXQDA for each building blockof PHS: structures, workforce, resources, processes (detect, report,assess/analyze, respond, feedback), and informatics.ResultsSelected Strengths included existence of immediate notifiabledisease reporting through the Epidemic and Pandemic Response unit(EPR) and reporting of summary health facility data to the HealthManagement Information System (HMIS) unit and laboratorynetwork. Weaknesses included lack of clear roles and responsibilitiesfor IDSR among SID units, limited coordination between SID units,lack of data sharing, lack of Standard Operating Procedures (SOPs),uncoordinated case investigations and response, minimal analysisconducted for public health surveillance and limited feedback forreporters..Identified opportunities were political will for establishing ofroles and responsibilities and mechanisms for coordination anddata sharing. Threats were limited data access, limited funding forfeedback, lack of analysis for IDSR and paper-based reportingConclusionsCurrently there is limited use of surveillance data for decisionmaking due to lack of coordination. Findings were presented at adissemination meeting to representatives of relevant departments,and there was consensus on the need to clearly define the role andresponsibilities of different programs for IDSR. In March 2016, aconsensus meeting was held to designate roles and responsibilitiesfor IDSR, a direct result of this assessment. Additional resourcesand funding is needed to support these highly important initiatives toensure the safety and health security of the Swazi nation

Morbidity patterns associated with seasonal influenza A/H1N1in Swaziland

ObjectiveTo establish morbidity patterns of influenza A/H1N1 in Swaziland from 10th July to 15th August 2017.IntroductionInfluenza infection is caused by the influenza virus, a single-stranded RNA virus belonging to the Orthomyxoviridae family. Influenza viruses are classified as types A, B and C. Influenza A and B viruses can cause epidemic disease in humans and type C viruses usually cause a mild, cold-like illness. The influenza virus spreads rapidly around the world in seasonal epidemics, resulting in significant morbidity and mortality. On the 10th of July 2017, a case of confirmed Influenza A/H1N1 was reported through the immediate disease notification system from a private hospital in the Hhohho region. A 49 year old female was diagnosed of Influenza A/H1N1 after presenting with flu-like symptoms. Contacts of the index case were followed and further positive cases were identified.MethodsUpon identification of the index case, the rapid response teams conducted further investigations. Two nasal swaps from each sample were taken and sent to a private laboratory in South Africa for the detection of the virus RNA using RT-PCR to assess for the presence Influenza A, B and Influenza A/H1N1. Further laboratory results were sourced from a private laboratory to monitor trends of influenza. Data was captured and analyzed in STATA version 12 from STATA cooperation. Descriptive statistics were carried out using means and standard deviations. The Pearson Chi square test and student t test were used to test for any possible association between influenza A/H1N1 and the explanatory variables (age and sex).ResultsSurveillance data captured between 10th July 2017 and 15th August 2017 indicated that a total of 87 patients had their samples taken for laboratory confirmation. There were 45 females and 42 males and the mean age was 27 years (SD= 17). At least 25 of the 87 patients tested positive for influenza A while only 1 tested positive for influenza B. The prevalence of influenza A/H1N1 was 16%. The prevalence of influenza A/H1N1 among males was 19% compared to 13% in females; however the difference was not statistically significant (p=0.469). There was no association noted between age and influenza A/H1N1 (p=427). Upon further sub-typing results indicated that the circulating strain was influenza A/H1N1 pdm 09 strain which is a seasonal influenza. The epidemic task forces held weekly and ad-hoc meetings to provide feedback to principals and health messaging to the general population to allay anxiety.ConclusionsThough WHO has classified the influenza A/H1N1 strain pdm 0029 as a seasonal influenza, surveillance remains important for early detection and management. There is therefore an urgent need to set up sentinel sites to monitor and understand the circulating influenza strains. Health promotion remains crucial to dispel anxiety as the general public still link any influenza to the 2009 pandemic influenza. Finally the Ministry of Health should consider introducing influenza vaccines into the routine immunization schedule especially for children.References1. Global Epidemiological Surveillance Standards for Influenza. 2014 [cited 2015 15 April]; Available from: http://www.who.int/influenza/resources/documents/influenza_surveillance_manual/en/.2. Human cases of influenza at the human-animal interface, 2013. Wkly Epidemiol Rec, 2014.89(28): p. 309-20.3. WHO Global Influenza Surveillance Network. Manual for the laboratory diagnosis and virological surveillance of influenza. 2011 [cited 2015 April27]; Available from: http://www.who.int/influenza/gisrs_laboratory/manual_diagnosis_surveillance_influenza/en/

Public Health Surveillance Strengthening in the Kingdom of Swaziland

ObjectiveTo enable coordination of Swaziland Ministry of Health units forpublic health surveillance (PHS).IntroductionIn the Kingdom of Swaziland, a baseline assessment found thatmultiple functional units within the Ministry of Health (MoH) performPHS activities. There is limited data sharing and coordination betweenunits; roles and responsibilities are unclear. The Epidemiology andDisease Control Unit (EDCU) is mandated to coordinate efforts andstrengthen PHS through implementing Integrated Disease Surveillanceand Response (IDSR) to fulfill requirements of International HealthRegulations (2005) (IHR[2005]), and the Global Health SecurityAgenda (GHSA).MethodsA baseline assessment that included key informant interviewsof unit representatives was conducted. Data flows were developed.Results were disseminated at a facilitated stakeholder workshop withunit representatives. A database was then built containing all distinctactivities found within the IDSR Technical Guidelines (2010), IHR[2005], GHSA Action Packages, the baseline assessment, a previousCDC IDSR assessment, and suggestions from the stakeholderworkshop. Activities were categorized by IDSR function (identify,report, analyze, investigate, prepare, respond, provide feedback,and evaluate) and designated as an ongoing “role” or a one-timeimplementation activity. A document containing all PHS roles waspresented at a facilitated consensus workshop; unit representativesdiscussed and designated a lead unit/agency for each role.One-time implementation activities were assigned a lead actor, targetcompletion date, and compiled into a 3-year IDSR Roadmap to guideimplementation.ResultsA Roles and Responsibilities Framework was developed thatpresents a consensus on lead units for all roles within an IDSR-basedPHS system that fulfills requirements of IHR [2005] and GHSA.This document enables coordination by EDCU. The IDSR Roadmapprovides time-bound activities with assigned actors to implementIDSR. EDCU is using these documents to guide coordination ofmultiple MOH units already performing PHS activities.ConclusionsCoordinating well-established programs that already collectepidemiological data increases efficiency and enables more completeepidemiologic analysis. Stakeholder engagement and clarity of rolesis critical for EDCU to coordinate PHS. Consolidating activitiesfor IDSR, IHR [2005], and GHSA in guiding documents enables astreamlined approach for public health surveillance strengthening.Future work aims to achieve data sharing through an electronicplatform and introduce data standards for interoperability among datasets.

Active case-finding and enhanced data collection to identify neglected tropical diseases

ObjectiveTo strengthen public health surveillance to monitor neglected tropical diseases (NTDs) like leprosy as a control measure to avert disabilities in the Kingdom of Swaziland.IntroductionLeprosy is a chronic infectious disease caused by Mycobacterium leprae. It is a contagious disease that affects the skin, mucous membrane, and nerves causing discoloration and lumps on the skin and in severe cases disfigurement and deformities. The mode of transmission remains uncertain, but is believed that M.leprae is spread from person to person primarily as a nasal droplet infection. The incubation period for a bacterial disease generally is 5 – 7 years. Progress in the fight against leprosy has been one of the greatest public health success and in the country, was eliminated in the mid-1990s. However on the 22nd August 2017 a confirmed leprosy cases was reported by the National Referral Hospital.MethodsFollowing the confirmed case an investigation was conducted to fully understand the possible source of the case and identify further cases. The assessment was done in three parts that is, hospital visit to follow up on the index case; conducting home visits to collect data for leprosy and their contact and a file review of all clients who were once diagnosed as having leprosy.ResultsThe index case was identified and his condition is improving as he has been initiated on MDT which he will be taking for a minimum of six months. Eleven clients were visited in their homes. Their age range was 31 to 91 years but the majority were above 60 years with a median age of 70 years. There were 7 females and 4 males. . The clients presented with permanent nerve damage either from the face, upper or lower limbs. The common disabilities and deformities post treatment were sagging of face, nasal collapse, blindness and clawing of fingers and feet. Other patients had plantar-palmar ulcers and abscesses from trauma, injuries or burns sustained due to nerve damage and inadequate protection. They reported to be experiencing stigma and are being discriminated. None of the clients presented with clinical signs and symptoms suggestive of leprosy. There were 18 files that were reviewed out of 58 who are known to exist. Six of the 18 files belonged to clients who were seen during home visits. One of the clients was epidemiologically linked to the index case as they used to live together in 1994.ConclusionsThe country seem to be experiencing the re-emerging of leprosy. Since the index case is epidemiologically linked to one of the old cases this therefore confirms the incubation period of leprosy being from 15 to 20 years. There is need to strengthen leprosy prevention and control measures as well as strengthening of leprosy surveillance in the context of IDSR. There is an urgent need to raise public awareness and provide clients with protective clothing. Furthermore, there is need to strengthen the Bilharzia and Worms Control Program to incorporate leprosy as it is one of the NTDs targeted for elimination in Swaziland.References1. Heymann D.L 2008, Control of Communicable Diseases Manual, 18th Edition, American Public Health Association, Geneva, Switzerland

Public Health Surveillance Strengthening in the Kingdom of Swaziland

ObjectiveTo enable coordination of Swaziland Ministry of Health units forpublic health surveillance (PHS).IntroductionIn the Kingdom of Swaziland, a baseline assessment found thatmultiple functional units within the Ministry of Health (MoH) performPHS activities. There is limited data sharing and coordination betweenunits; roles and responsibilities are unclear. The Epidemiology andDisease Control Unit (EDCU) is mandated to coordinate efforts andstrengthen PHS through implementing Integrated Disease Surveillanceand Response (IDSR) to fulfill requirements of International HealthRegulations (2005) (IHR[2005]), and the Global Health SecurityAgenda (GHSA).MethodsA baseline assessment that included key informant interviewsof unit representatives was conducted. Data flows were developed.Results were disseminated at a facilitated stakeholder workshop withunit representatives. A database was then built containing all distinctactivities found within the IDSR Technical Guidelines (2010), IHR[2005], GHSA Action Packages, the baseline assessment, a previousCDC IDSR assessment, and suggestions from the stakeholderworkshop. Activities were categorized by IDSR function (identify,report, analyze, investigate, prepare, respond, provide feedback,and evaluate) and designated as an ongoing “role” or a one-timeimplementation activity. A document containing all PHS roles waspresented at a facilitated consensus workshop; unit representativesdiscussed and designated a lead unit/agency for each role.One-time implementation activities were assigned a lead actor, targetcompletion date, and compiled into a 3-year IDSR Roadmap to guideimplementation.ResultsA Roles and Responsibilities Framework was developed thatpresents a consensus on lead units for all roles within an IDSR-basedPHS system that fulfills requirements of IHR [2005] and GHSA.This document enables coordination by EDCU. The IDSR Roadmapprovides time-bound activities with assigned actors to implementIDSR. EDCU is using these documents to guide coordination ofmultiple MOH units already performing PHS activities.ConclusionsCoordinating well-established programs that already collectepidemiological data increases efficiency and enables more completeepidemiologic analysis. Stakeholder engagement and clarity of rolesis critical for EDCU to coordinate PHS. Consolidating activitiesfor IDSR, IHR [2005], and GHSA in guiding documents enables astreamlined approach for public health surveillance strengthening.Future work aims to achieve data sharing through an electronicplatform and introduce data standards for interoperability among datasets.