Assessing the Surveillance System for Priority Zoonotic Diseases in the Democratic Republic of the Congo, 2017

District health information system (DHIS2) as integrated antimicrobial resistance surveillance platform: An exploratory qualitative investigation of the one health stakeholders' viewpoints in Ethiopia

INTRODUCTION

There is an unmet need for One Health (OH) surveillance and reporting systems for antimicrobial resistance (AMR) in resource poor settings. District health information system, version 2 (DHIS2), is a globally recognized digital surveillance platform which has not been widely utilized for AMR data yet. Our study aimed to understand the local stakeholders' viewpoints on DHIS2 as OH-AMR surveillance platform in Jimma, Ethiopia which will aid its further context specific establishment.

METHODS

We performed an exploratory qualitative study using semi-structured key informant interviews (KIIs) in Jimma Zone at Southwest Ethiopia. We interviewed 42 OH professionals between November 2020 and February 2021. Following verbatim transcription of the audio recordings of KIIs, we conducted thematic analysis.

RESULTS

We identified five major themes which are important for understanding the trajectory of OH-AMR surveillance in DHIS2 platform. The themes were: (1) Stakeholders' current knowledge on digital surveillance platforms including DHIS2. (2) Stakeholders' perception on digital surveillance platform including DHIS2. (3) Features suggested by stakeholders to be included in the surveillance platform. (4) Comments from stakeholders on system implementation challenges. (5) Stakeholders' perceived role in the process of implementation. Despite several barriers and challenges, most of the participants perceived and suggested DHIS2 as a suitable OH-AMR surveillance platform and were willing to contribute at their current professional roles.

CONCLUSIONS

Our study demonstrates the potential of the DHIS2 as a user friendly and acceptable interoperable platform for OH-AMR surveillance if the technology designers accommodate the stakeholders' concerns. Piloting at local level and using performance appraisal tool in all OH disciplines should be the next step before proceeding to workable format.

Data flows during public health emergencies in LMICs: A people-centered mapping of data flows during the 2018 ebola epidemic in Equateur, DRC

In infectious outbreaks, rapid case detection and reporting, coordination, and context-specific strategies are needed for rapid containment. Data sharing between actors, and the speed and content of data flows, is essential for expediting epidemic response. In this study, researchers mapped data flows during the 2018 Ebola Virus Disease (EVD) outbreak in Equateur Province in the Democratic Republic of the Congo using semi-structured interviews, ethnographic research, and focus groups with EVD response actors. During this research, we mapped and tracked data collection, transmission, storage, sharing, and use patterns. Target participants included: key organizational actors in the EVD outbreaks responses, including local (primary health, community-based, hospital), provincial (MoPH, DRC Red Cross), and international (WHO, UN organizations, international first-responders) stakeholders. We found that a community-based surveillance system enabled the rapid detection of a hemorrhagic fever outbreak, resulting in the rapid laboratory confirmation of EVD. With the arrival of international organizations to provide support to the EVD response, routine surveillance systems continued to function robustly. However, the establishment of a vertical EVD response architecture created challenges for the response. Data flows during the Equateur outbreak were hampered by numerous challenges in the domains of early warning, line lists of cases, and contact tracing, which impeded surveillance and data flows. We therefore argue that structuring health information systems for preparedness requires taking a person-centered approach to data production, flow, and analysis.

The role of health systems for health security: a scoping review revealing the need for improved conceptual and practical linkages

BACKGROUND

Practical links between health systems and health security are historically prevalent, but the conceptual links between these fields remain under explored, with little on health system strengthening. The need to address this gap gains relevance in light of the COVID-19 pandemic as it demonstrated a crucial relationship between health system capacities and effective health security response. Acknowledging the importance of developing stronger and more resilient health systems globally for health emergency preparedness, the WHO developed a Health Systems for Health Security framework that aims to promote a common understanding of what health systems for health security entails whilst identifying key capacities required.

METHODS/ RESULTS

To further explore and analyse the conceptual and practical links between health systems and health security within the peer reviewed literature, a rapid scoping review was carried out to provide an overview of the type, extent and quantity of research available. Studies were included if they had been peer-reviewed and were published in English (seven databases 2000 to 2020). 343 articles were identified, of those 204 discussed health systems and health security (high and medium relevance), 101 discussed just health systems and 47 discussed only health security (low relevance). Within the high and medium relevance articles, several concepts emerged, including the prioritization of health security over health systems, the tendency to treat health security as exceptionalism focusing on acute health emergencies, and a conceptualisation of security as 'state security' not 'human security' or population health.

CONCLUSION

Examples of literature exploring links between health systems and health security are provided. We also present recommendations for further research, offering several investments and/or programmes that could reliably lead to maximal gains from both a health system and a health security perspective, and why these should be explored further. This paper could help researchers and funders when deciding upon the scope, nature and design of future research in this area. Additionally, the paper legitimises the necessity of the Health Systems for Health Security framework, with the findings of this paper providing useful insights and evidentiary examples for effective implementation of the framework.

Dog rabies control in West and Central Africa: A review

Rabies is a neglected but preventable zoonotic disease that predominantly affects the most vulnerable populations living in remote rural areas of resource-limited countries. To date, every country on the African mainland is considered endemic for dog-mediated rabies with an estimated 21'500 human rabies deaths occurring each year. In 2018, the United Against Rabies collaboration launched the Global Strategic Plan to end human deaths from dog-mediated rabies by 2030. The epidemiology of rabies from most Western and Central African countries remains poorly defined, making it difficult to assess the overall rabies situation and progress towards the 2030 goal. In this review, we attempt to provide an overview of the current rabies situation in 22 West and Central African countries based on published scientific literature and information obtained from rabies focal points. To this end, information was collected on i) established surveillance, ii) diagnostic capacity, iii) post-exposure prophylaxis (PEP) availability and coverage, iv) dog population estimates, v) dog vaccination campaigns, vi) animal and human health communication (One Health), vii) molecular studies, viii) Knowledge, Attitude and Practices (KAP), ix) cost estimates and x) national control strategies. Although rabies is a notifiable disease in the majority of the studied countries, national surveillance systems do not adequately capture the disease. A general lack of rabies diagnostic capacity has an additional negative impact on rabies surveillance and attempts to estimate rabies burden. Recurrent shortages of human rabies vaccine are reported by all of the countries, with vaccine availability usually limited to major urban centers but no country has yet adopted the new WHO-recommended 1-week intradermal vaccination regimen. Most countries carry out subsidized mass dog vaccination campaigns on World Rabies Day. Such activities are indispensable to keep rabies in the public consciousness but are not of the scale and intensity that is required to eliminate rabies from the dog population. Countries will need to scale up the intensity of their campaigns, if they are to progress towards the 2030 goal. But more than half of the countries do not yet have reliable figures on their dog populations. Only two countries reached stage 2 on the Stepwise Approach towards Rabies Elimination ladder - indicating that their national governments have truly prioritized rabies elimination and are thus providing the necessary support and political buy-in required to achieve success. In summary, the sub-region of West and Central Africa seems to be divided into countries which have accepted the challenge to eliminate rabies with governments committed to pushing forward rabies elimination, while other countries have achieved some progress, but elimination efforts remain stuck due to lacking government commitment and financial constraints. The possibility to meet the 2030 goal without international solidarity is low, because more than two-thirds of the countries rank in the low human development group (HDI ≤ 152). Leading countries should act as role models, sharing their experiences and capacities so that no country is left behind. Unified and with international support it is possible to reach the common goal of zero human rabies deaths by 2030.

Twenty years of integrated disease surveillance and response in Sub-Saharan Africa: challenges and opportunities for effective management of infectious disease epidemics

INTRODUCTION

This systematic review aimed to analyse the performance of the Integrated Disease Surveillance and Response (IDSR) strategy in Sub-Saharan Africa (SSA) and how its implementation has embraced advancement in information technology, big data analytics techniques and wealth of data sources.

METHODS

HINARI, PubMed, and advanced Google Scholar databases were searched for eligible articles. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols.

RESULTS

A total of 1,809 articles were identified and screened at two stages. Forty-five studies met the inclusion criteria, of which 35 were country-specific, seven covered the SSA region, and three covered 3-4 countries. Twenty-six studies assessed the IDSR core functions, 43 the support functions, while 24 addressed both functions. Most of the studies involved Tanzania (9), Ghana (6) and Uganda (5). The routine Health Management Information System (HMIS), which collects data from health care facilities, has remained the primary source of IDSR data. However, the system is characterised by inadequate data completeness, timeliness, quality, analysis and utilisation, and lack of integration of data from other sources. Under-use of advanced and big data analytical technologies in performing disease surveillance and relating multiple indicators minimises the optimisation of clinical and practice evidence-based decision-making.

CONCLUSIONS

This review indicates that most countries in SSA rely mainly on traditional indicator-based disease surveillance utilising data from healthcare facilities with limited use of data from other sources. It is high time that SSA countries consider and adopt multi-sectoral, multi-disease and multi-indicator platforms that integrate other sources of health information to provide support to effective detection and prompt response to public health threats.

Lessons Learned from Reinforcing Epidemiologic Surveillance During the 2017 Ebola Outbreak in the Likati District, Democratic Republic of the Congo

On May 12, 2017, the Democratic Republic of Congo (DRC) publicly declared an outbreak of Ebola virus disease (EVD) in the Likati District of the Bas-Uélé Province, 46 days after the index case became symptomatic. The delayed EVD case detection and reporting highlights the importance of establishing real-time surveillance, consistent with the Global Health Security Agenda. We describe lessons learned from implementing improved EVD case detection and reporting strategies at the outbreak epicenter and make recommendations for future response efforts. The strategies included daily coordination meetings to enhance effective and efficient outbreak response activities, assessment and adaptation of case definitions and reporting tools, establishment of a community alert system using context-appropriate technology, training facility and community health workers on adapted case definitions and reporting procedures, development of context-specific plans for outbreak data management, and strengthened operational support for communications and information-sharing networks. Post-outbreak, surveillance officials should preemptively plan for the next outbreak by developing emergency response plans, evaluating the case definitions and reporting tools used, retraining on revised case definitions, and developing responsive strategies for overcoming telecommunications and technology challenges. The ongoing EVD outbreak in the North Kivu and Ituri provinces of DRC, currently the second largest EVD outbreak in history, demonstrates that documentation of successful context-specific strategies and tools are needed to combat the next outbreak. The lessons learned from the rapid containment of the EVD outbreak in Likati can be applied to the DRC and other rural low-resource settings to ensure readiness for future zoonotic disease outbreaks.

Optimizing Pandemic Preparedness and Response Through Health Information Systems: Lessons Learned From Ebola to COVID-19

Strengthening health systems and maintaining essential service delivery during health emergencies response is critical for early detection and diagnosis, prompt treatment, and effective control of pandemics, including the novel coronavirus disease 2019 (COVID-19). Health information systems (HIS) developed during recent Ebola outbreaks in West Africa and the Democratic Republic of the Congo (DRC) provided opportunities to collect, analyze, and distribute data to inform both day-to-day and long-term policy decisions on outbreak preparedness. As COVID-19 continues to sweep across the globe, HIS and related technological advancements remain vital for effective and sustained data sharing, contact tracing, mapping and monitoring, community risk sensitization and engagement, preventive education, and timely preparedness and response activities. In reviewing literature of how HIS could have further supported mitigation of these Ebola outbreaks and the ongoing COVID-19 pandemic, 3 key areas were identified: governance and coordination, health systems infrastructure and resources, and community engagement. In this concept study, we outline scalable HIS lessons from recent Ebola outbreaks and early COVID-19 responses along these 3 domains, synthesizing recommendations to offer clear, evidence-based approaches on how to leverage HIS to strengthen the current pandemic response and foster community health systems resilience moving forward.

Contextual, Social and Epidemiological Characteristics of the Ebola Virus Disease Outbreak in Likati Health Zone, Democratic Republic of the Congo, 2017

While the clinical, laboratory and epidemiological investigation results of the Ebola outbreak in Likati Health Zone, Democratic Republic of the Congo (DRC) in May 2017 have been previously reported, we provide novel commentary on the contextual, social, and epidemiological characteristics of the epidemic. As first responders with the outbreak Surveillance Team, we explain the procedures that led to a successful epidemiological investigation and ultimately a rapid end to the epidemic. We discuss the role that several factors played in the trajectory of the epidemic, including traditional healers, insufficient knowledge of epidemiological case definitions, a lack of community-based surveillance systems and tools, and remote geography. We also demonstrate how a collaborative Rapid Response Team and implementation of community-based surveillance methods helped counter contextual challenges during the Likati epidemic and aid in identifying and reporting suspected cases and contacts in remote and rural settings. Understanding these factors can hinder or help in the rapid detection, notification, and response to future epidemics in the DRC.

Use of technology for public health surveillance reporting: opportunities, challenges and lessons learnt from Kenya

BACKGROUND

Effective public health surveillance systems are crucial for early detection and response to outbreaks. In 2016, Kenya transitioned its surveillance system from a standalone web-based surveillance system to the more sustainable and integrated District Health Information System 2 (DHIS2). As part of Global Health Security Agenda (GHSA) initiatives in Kenya, training on use of the new system was conducted among surveillance officers. We evaluated the surveillance indicators during the transition period in order to assess the impact of this training on surveillance metrics and identify challenges affecting reporting rates.

METHODS

From February to May 2017, we analysed surveillance data for 13 intervention and 13 comparison counties. An intervention county was defined as one that had received refresher training on DHIS2 while a comparison county was one that had not received training. We evaluated the impact of the training by analysing completeness and timeliness of reporting 15 weeks before and 12 weeks after the training. A chi-square test of independence was used to compare the reporting rates between the two groups. A structured questionnaire was administered to the training participants to assess the challenges affecting surveillance reporting.

RESULTS

The average completeness of reporting for the intervention counties increased from 45 to 62%, i.e. by 17 percentage points (95% CI 16.14-17.86) compared to an increase from 49 to 52% for the comparison group, i.e. by 3 percentage points (95% CI 2.23-3.77). The timeliness of reporting increased from 30 to 51%, i.e. by 21 percentage points (95% CI 20.16-21.84) for the intervention group, compared to an increase from 31 to 38% for the comparison group, i.e.by 7 percentage points (95% CI 6.27-7.73). Major challenges for the low reporting rates included lack of budget support from government, lack of airtime for reporting, health workers strike, health facilities not sending surveillance data, use of wrong denominator to calculate reporting rates and surveillance officers having other competing tasks.

CONCLUSIONS

Training plays an important role in improving public health surveillance reporting. However, to improve surveillance reporting rates to the desired national targets, other challenges affecting reporting must be identified and addressed accordingly.