Implementing Nationwide Facility-based Electronic Disease Surveillance in Sierra Leone: Lessons Learned

Availability of published evidence on coverage, cost components, and funding support for digitalisation of infectious disease surveillance in Africa, 2003-2022: a systematic review

BACKGROUND

The implementation of digital disease surveillance systems at national levels in Africa have been challenged by many factors. These include user applicability, utility of IT features but also stable financial support. Funding closely intertwines with implementations in terms of geographical reach, disease focus, and sustainability. However, the practice of evidence sharing on geographical and disease coverage, costs, and funding sources for improving the implementation of these systems on the continent is unclear.

OBJECTIVES

To analyse the key characteristics and availability of evidence for implementing digital infectious disease surveillance systems in Africa namely their disease focus, geographical reach, cost reporting, and external funding support.

METHODS

We conducted a systematic review of peer-reviewed and grey literature for the period 2003 to 2022 (PROSPERO registration number: CRD42022300849). We searched five databases (PubMed, MEDLINE over Ovid, EMBASE, Web of Science, and Google Scholar) and websites of WHO, Africa CDC, and public health institutes of African countries. We mapped the distribution of projects by country; identified reported implementation cost components; categorised the availability of data on cost components; and identified supporting funding institutions outside Africa.

RESULTS

A total of 29 reports from 2,033 search results were eligible for analysis. We identified 27 projects implemented in 13 countries, across 32 sites. Of these, 24 (75%) were pilot projects with a median duration of 16 months, (IQR: 5-40). Of the 27 projects, 5 (19%) were implemented for HIV/AIDs and tuberculosis, 4 (15%) for malaria, 4 (15%) for all notifiable diseases, and 4 (15%) for One Health. We identified 17 cost components across the 29 reports. Of these, 11 (38%) reported quantified costs for start-up capital, 10 (34%) for health personnel compensation, 9 (31%) for training and capacity building, 8 (28%) for software maintenance, and 7(24%) for surveillance data transmission. Of 65 counts of external funding sources, 35 (54%) were governmental agencies, 15 (23%) foundations, and 7 (11%) UN agencies.

CONCLUSIONS

The evidence on costing data for the digitalisation of surveillance and outbreak response in the published literature is sparse in quantity, limited in detail, and without a standardised reporting format. Most initial direct project costs are substantially donor dependent, short lived, and thus unsustainable.

Project design and technology trade-offs for implementing a large-scale sexual and reproductive health mHealth intervention: Lessons from Sierra Leone

Background

The Coronavirus 2019 (COVID-19) pandemic threatened decades of progress in sexual and reproductive health (SRH) and gender-based violence as attendance at health facilities plummeted and service uptake dwindled. Similarly, misinformation regarding COVID-19 was rife. The demographics in Sierra Leone are diverse in the education, economic, and rural/urban divide. Telecommunications coverage, phone ownership, and preference for information access medium also vary greatly in Sierra Leone.

Aim

The aim of the intervention was to reach Sierra Leoneans at scale with information about SRH during the early stages of the COVID-19 pandemic. This paper presents the approach and insights from designing and implementing a large-scale mobile health (mHealth) messaging campaign.

Method

Between April and July 2020, a cross-sectional multichannel SRH messaging campaign was designed and launched in Sierra Leone. Through a secondary analysis of project implementation documents and process evaluation of the messaging campaign report, the project design trade-offs and contextual factors for success were identified and documented.

Result

A total of 1.16 million recorded calls were initiated and 35.46 million text messages (short message service, SMS) were sent to telecommunication subscribers through a two-phased campaign. In phase one, only 31% of the 1,093,606 automated calls to 290,000 subscribers were picked up, dropping significantly at 95% confidence level (p = 1) after each of the four weeks. In addition, the listening duration dropped by one-third when a message was repeated compared to the first 3 weeks. Lessons from phase one were used to design an SMS and radio campaign in the scale-up phase. Evidence from our analysis suggests that the successful scaling of mHealth interventions during a pandemic will benefit from formative research and depend on at least six factors, including the following: (1) the delivery channels’ selection strategy; (2) content development and scheduling; (3) the persona categorization of youths; (4) stakeholder collaboration strategies; (5) technology trade-offs; and (6) cost considerations.

Discussion and Conclusion

The design and implementation of a large-scale messaging campaign is a complex endeavor that requires research, collaboration with other diverse stakeholders, and careful planning. Key success ingredients are the number of messages to be delivered, the format, cost considerations, and whether engagement is necessary. Lessons for similar low-and-middle-income countries are discussed.

Extending and Strengthening Routine DHIS2 Surveillance Systems for COVID-19 Responses in Sierra Leone, Sri Lanka, and Uganda

The COVID-19 pandemic challenged countries to protect their populations from this emerging disease. One aspect of that challenge was to rapidly modify national surveillance systems or create new systems that would effectively detect new cases of COVID-19. Fifty-five countries leveraged past investments in District Health Information Software version 2 (DHIS2) to quickly adapt their national public health surveillance systems for COVID-19 case reporting and response activities. We provide background on DHIS2 and describe case studies from Sierra Leone, Sri Lanka, and Uganda to illustrate how the DHIS2 platform, its community of practice, long-term capacity building, and local autonomy enabled countries to establish an effective COVID-19 response. With these case studies, we provide valuable insights and recommendations for strategies that can be used for national electronic disease surveillance platforms to detect new and emerging pathogens and respond to public health emergencies.

After action review of the response to an outbreak of Lassa fever in Sierra Leone, 2019: Best practices and lessons learnt

Background

In November 2019, an outbreak of Lassa Fever occurred among health workers in a non-endemic district in Sierra Leone. The outbreak resulted in five cases, including two that were exported to the Netherlands. The outbreak tested multiple technical capacities in the International Health Regulations (2005) in a real-life setting. As such, an after action review (AAR) was undertaken as recommended by World Health Organization. We report on the findings of the AAR including best practices and lessons learnt.

Methods

A two stage review process was employed. The first stage involved national pillar level reviews for each technical pillar and one review of the district level response. The second stage brought together all pillars, including participants from the national and sub-national level as well as health sector partners. National guidelines were used as references during the deliberations. A standardized template was used to report on the key findings on what happened, what was supposed to happen, what went well and lessons learnt.

Results

This was a hospital associated outbreak that likely occurred due to a breach in infection prevention and control (IPC) practices resulting in three health workers being infected during a surgical operation. There was a delay in detecting the outbreak on time due to low index of suspicion among clinicians. Once detected, the outbreak response contained the outbreak within one incubation period. Areas that worked well included coordination, contact tracing, active case search and ring IPC. Notable gaps included delays in accessing local emergency funding and late distribution of IPC and laboratory supplies.

Conclusions

The incident management system worked optimally to contain this outbreak. The core technical gaps identified in surveillance, IPC and delay in deployment of resources should be addressed through systemic changes that can mitigate future outbreaks.

The International Health Regulations (IHR) Monitoring and Evaluation Framework was developed by the World Health Organization to provide strategies to monitor and assess how countries are building their core public health capacities under IHR (2005). The framework has four components: annual reporting on IHR capacities (mandatory), Joint External Evaluation, simulation exercises and After Action Review (AAR). In November 2019, an outbreak of Lassa Fever occurred among health workers in a non-endemic district in Sierra Leone. The outbreak resulted in five cases, including two deaths and two exported cases to the Netherlands. The outbreak tested multiple technical capacities in the IHR (2005) in a real-life setting. We therefore conducted an AAR to assess how well the country responded to the outbreak. This hospital associated outbreak likely occurred due to a breach in infection prevention and control (IPC) practices. The response launched after detection of the outbreak successfully contained the outbreak within one incubation period. Areas that worked well included coordination, contact tracing, active case search and ring IPC. Areas that needed improvement were clinicians’ knowledge on Lassa Fever, delays in accessing local emergency funding and late distribution of IPC and laboratory supplies.

Implementation of DHIS2 for Disease Surveillance in Guinea: 2015–2020

A robust epidemic-prone disease surveillance system is a critical component of public health infrastructure and supports compliance with the International Health Regulations (IHR). One digital health platform that has been implemented in numerous low- and middle-income countries is the District Health Information System Version 2 (DHIS2). In 2015, in the wake of the Ebola epidemic, the Ministry of Health in Guinea established a strategic plan to strengthen its surveillance system, including adoption of DHIS2 as a health information system that could also capture surveillance data. In 2017, the DHIS2 platform for disease surveillance was piloted in two regions, with the aim of ensuring the timely availability of quality surveillance data for better prevention, detection, and response to epidemic-prone diseases. The success of the pilot prompted the national roll-out of DHIS2 for weekly aggregate disease surveillance starting in January 2018. In 2019, the country started to also use the DHIS2 Tracker to capture individual cases of epidemic-prone diseases. As of February 2020, for aggregate data, the national average timeliness of reporting was 72.2%, and average completeness 98.5%; however, the proportion of individual case reports filed was overall low and varied widely between diseases. While substantial progress has been made in implementation of DHIS2 in Guinea for use in surveillance of epidemic-prone diseases, much remains to be done to ensure long-term sustainability of the system. This paper describes the implementation and outcomes of DHIS2 as a digital health platform for disease surveillance in Guinea between 2015 and early 2020, highlighting lessons learned and recommendations related to the processes of planning and adoption, pilot testing in two regions, and scale up to national level.

Implementing mHealth Interventions in a Resource-Constrained Setting: Case Study From Uganda

Background

Mobile health (mHealth) interventions are becoming more common in low-income countries. Existing research often overlooks implementation challenges associated with the design and technology requirements of mHealth interventions.

Objective

We aimed to characterize the challenges that we encountered in the implementation of a complex mHealth intervention in Uganda.

Methods

We customized a commercial mobile survey app to facilitate a two-arm household-randomized, controlled trial of home-based tuberculosis (TB) contact investigation. We incorporated digital fingerprinting for patient identification in both study arms and automated SMS messages in the intervention arm only. A local research team systematically documented challenges to implementation in biweekly site visit reports, project management reports, and minutes from biweekly conference calls. We then classified these challenges using the Consolidated Framework for Implementation Research (CFIR).

Results

We identified challenges in three principal CFIR domains: (1) intervention characteristics, (2) inner setting, and (3) characteristics of implementers. The adaptability of the app to the local setting was limited by software and hardware requirements. The complexity and logistics of implementing the intervention further hindered its adaptability. Study staff reported that community health workers (CHWs) were enthusiastic regarding the use of technology to enhance TB contact investigation during training and the initial phase of implementation. After experiencing technological failures, their trust in the technology declined along with their use of it. Finally, complex data structures impeded the development and execution of a data management plan that would allow for articulation of goals and provide timely feedback to study staff, CHWs, and participants.

Conclusions

mHealth technologies have the potential to make delivery of public health interventions more direct and efficient, but we found that a lack of adaptability, excessive complexity, loss of trust among end users, and a lack of effective feedback systems can undermine implementation, especially in low-resource settings where digital services have not yet proliferated. Implementers should anticipate and strive to avoid these barriers by investing in and adapting to local human and material resources, prioritizing feedback from end users, and optimizing data management and quality assurance procedures.

Trial Registration

Pan-African Clinical Trials Registration PACTR201509000877140; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=877