Status of surveillance and routine immunization performances in Amhara Region, Ethiopia: findings from in-depth peer review

Progress and experiences of implementing an integrated disease surveillance and response system in Somalia; 2016-2023

Introduction

In 2021, a regional strategy for integrated disease surveillance was adopted by member states of the World Health Organization Eastern Mediterranean Region. But before then, member states including Somalia had made progress in integration of their disease surveillance systems. We report on the progress and experiences of implementing an integrated disease surveillance and response system in Somalia between 2016 and 2023.

Methods

We reviewed 20 operational documents and identified key integrated disease surveillance and response system (IDSRS) actions/processes implemented between 2016 and 2023. We verified these through an anonymized online survey. The survey respondents also assessed Somalia's IDSRS implementation progress using a standard IDS monitoring framework Finally, we interviewed 8 key informants to explore factors to which the current IDSRS implementation progress is attributed.

Results

Between 2016 and 2023, 7 key IDSRS actions/processes were implemented including: establishment of high-level commitment; development of a 3-year operational plan; development of a coordination mechanism; configuring the District Health Information Software to support implementation among others. IDSRS implementation progress ranged from 15% for financing to 78% for tools. Reasons for the progress were summarized under 6 thematic areas; understanding frustrations with the current surveillance system; the opportunity occasioned by COVID-19; mainstreaming IDSRS in strategic documents; establishment of an oversight mechanism; staggering implementation of key activities over a reasonable length of time and being flexible about pre-determined timelines.

Discussion

From 2016 to 2023, Somalia registered significant progress towards implementation of IDSRS. The 15 years of EWARN implementation in Somalia (since 2008) provided a strong foundation for IDSRS implementation. If implemented comprehensively, IDSRS will accelerate country progress toward establishment of IHR core capacities. Sustainable funding is the major challenge towards IDSRS implementation in Somalia. Government and its partners need to exploit feasible options for sustainable investment in integrated disease surveillance and response.

The Magnitude of NCD Risk Factors in Ethiopia: Meta-Analysis and Systematic Review of Evidence

Background: Non-communicable Diseases (NCDs) and their risk factors are the leading contributors to morbidity and mortality globally, particularly in low- and middle-income countries including Ethiopia. To date, there has been no synthesis of the literature on the relative prevalence of NCD risk factors in Ethiopia. Methodology: We conducted a systematic review and meta-analysis of primary studies reporting on the prevalence of NCD risk factors in Ethiopia published in English from 2012 to July 2020. Pre-tested NCD search terms were applied to Medline, Embase, Scopus, CINAHL, and Global Health. Three reviewers screened and appraised the quality of the identified papers. Data extraction was conducted using a pilot tested proforma. Meta-analysis was conducted using Stata 16 and pooled prevalence estimated with associated 95% confidence intervals. Clinically heterogeneous studies that did not fulfil the eligibility criteria for meta-analysis were narratively synthesised. I² was used to assess statistical heterogeneity. Results: 47 studies fulfilled the inclusion criteria and contributed 68 NCD risk factor prevalence estimates. Hypertension was the most frequently examined NCD risk factor, with a pooled prevalence of 21% (n = 27 studies). The pooled prevalence percentages for overweight and obesity were 19.2% and 10.3%, respectively (n = 7 studies each), with a combined prevalence of 26.8% (n = 1 study). It was not possible to pool the prevalence of alcohol consumption, smoking, metabolic disorders, or fruit consumption because of heterogeneity across studies. The prevalence of alcohol use, as reported from the included individual studies, ranged from 12.4% to 13.5% (n = 7 studies). More than 90% of participants met the WHO-recommended level of physical activity (n = 5 studies). The prevalence of smoking was highly variable, ranging between 0.8% and 38.6%, as was the prevalence of heavy alcohol drinking (12.4% to 21.1%, n = 6 studies) and metabolic syndrome (4.8% to 9.6%, n = 5 studies). Fruit consumption ranged from 1.5% up to the recommended level, but varied across geographic areas (n = 3 studies). Conclusion and recommendations: The prevalence of NCD risk factors in Ethiopia is relatively high. National NCD risk factor surveillance is required to inform the prioritisation of policies and interventions to reduce the NCD burden in Ethiopia.

Development and validation of a framework to improve neglected tropical diseases surveillance and response at sub-national levels in Kenya

BACKGROUND

Assessment of surveillance and response system functions focusing on notifiable diseases has widely been documented in literature. However, there is limited focus on diseases targeted for elimination or eradication, particularly preventive chemotherapy neglected tropical diseases (PC-NTDs). There are limited strategies to guide strengthening of surveillance and response system functions concerning PC-NTDs. The aim of this study was to develop and validate a framework to improve surveillance and response to PC-NTDs at the sub-national level in Kenya.

METHODS

A multi-phased approach using descriptive cross-sectional mixed-method designs was adopted. Phase one involved a systematic literature review of surveillance assessment studies to derive generalised recommendations. Phase two utilised primary data surveys to identify disease-specific recommendations to improve PC-NTDs surveillance. The third phase utilised a Delphi survey to assess stakeholders' consensus on feasible recommendations. The fourth phase drew critical lessons from existing conceptual frameworks. The final validated framework was based on resolutions and inputs from concerned stakeholders.

RESULTS

The first phase identified thirty studies that provided a combination of recommendations for improving surveillance functions. Second phase described PC-NTDs specific recommendations linked to simplified case definitions, enhanced laboratory capacity, improved reporting tools, regular feedback and supervision, enhanced training and improved system stability and flexibility. In the third phase, consensus was achieved on feasibility for implementing recommendations. Based on these recommendations, framework components constituted human, technical and organisational inputs, four process categories, ten distinct outputs, outcomes and overall impact encompassing reduced disease burden, halted disease transmission and reduced costs for implementing treatment interventions to achieve PC-NTDs control and elimination.

CONCLUSION

In view of the mixed methodological approach used to develop the framework coupled with further inputs and consensus among concerned stakeholders, the validated framework is relevant for guiding decisions by policy makers to strengthen the existing surveillance and response system functions towards achieving PC-NTDs elimination.

Feasibility of implementing recommendations to improve neglected tropical diseases surveillance and response in Kenya: a modified Delphi study

BACKGROUND

Effective health information systems (HIS) are critical towards achieving timely response to preventive chemotherapy neglected tropical diseases (PC-NTDs) and their eventual elimination. Strengthened HIS enable prompt case detection and effective response to halt disease transmission and prevent probable outbreaks. This study aimed to assess the importance and feasibility of implementing recommendations for improving surveillance core functions, support functions and surveillance attributes concerning PC-NTDs in Kenya.

METHODS

A descriptive web-based Delphi process comprising of two survey rounds was used to achieve group consensus on the importance of recommended actions and feasibility of their implementation. In the first round, participants were enrolled to complete a five-point likert-type self-administered electronic questionnaire comprising of 60 statements across 12 sub-domains on the importance of recommendations. In the second round, participants reappraised their responses following completion of a questionnaire with 56 rephrased statements on feasibility of implementing the recommendations to improve PC-NTDs surveillance and response. Data from both rounds were analysed using descriptive statistics and thematic analysis performed for the open-ended responses.

RESULTS

Sixty-two key stakeholders actively involved in surveillance and response activities in seven PC-NTDs endemic counties in Kenya were invited to participate. Of these, 50/62 completed the first round (81 % response rate) and 45/50 completed the second round (90 % response rate). Consensus was achieved (defined as > 70 % agreement) on the importance (93 %) of recommendation statements and feasibility (82 %) of implementing the important recommendations. Stakeholders agreed on the importance and feasibility of specific recommendations across the 12 sub-domains: case detection and registration, reporting, data analysis, feedback, epidemic preparedness and response, supervision, training, resources, simplicity, acceptability, stability and flexibility. However, there was lack of consensus on the feasibility of conducting routine data analysis, increasing supervision of surveillance activities at lower levels and retaining trained surveillance staff across all levels.

CONCLUSIONS

Consensus among health stakeholders on implementation of the important and feasible recommendations will inform relevant strategies for strengthening specific surveillance system functions in view of PC-NTDs in Kenya.

A systematic review on improving implementation of the revitalised integrated disease surveillance and response system in the African region: A health workers' perspective

Background

The revised integrated disease surveillance and response (IDSR) guidelines adopted by African member states in 2010 aimed at strengthening surveillance systems critical capacities. Milestones achieved through IDSR strategy implementation prior to adopting the revised guidelines are well documented; however, there is a dearth of knowledge on the progress made post-adoption. This study aimed to review key recommendations resulting from surveillance assessment studies to improve implementation of the revitalised IDSR system in the African region based on health workers’ perspectives. The review focused on literature published between 2010 and 2019 post-adopting the revised IDSR guidelines in the African region.

Methods

A systematic literature search in PubMed, Web of Science and Cumulative Index for Nursing and Allied Health Literature was conducted. In addition, manual reference searches and grey literature searches using World Health Organisation Library and Information Networks for Knowledge databases were undertaken. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement checklist for systematic reviews was utilised for the review process.

Results

Thirty assessment studies met the inclusion criteria. IDSR implementation under the revised guidelines could be improved considerably bearing in mind critical findings and recommendations emanating from the reviewed surveillance assessment studies. Key recommendations alluded to provision of laboratory facilities and improved specimen handling, provision of reporting forms and improved reporting quality, surveillance data accuracy and quality, improved knowledge and surveillance system performance, utilisation of up-to-date information and surveillance system strengthening, provision of resources, enhanced reporting timeliness and completeness, adopting alternative surveillance strategies and conducting further research to improve surveillance functions.

Conclusion

Recommendations on strengthening IDSR implementation in the African region post-adopting the revised guidelines mainly identify surveillance functions focused on reporting, feedback, training, supervision, timeliness and completeness of the surveillance system as aspects requiring policy refinement.

Systematic review registration

PROSPERO registration number CRD42019124108.

Systematic review of Integrated Disease Surveillance and Response (IDSR) implementation in the African region

Background

The WHO African region frequently experiences outbreaks and epidemics of infectious diseases often exacerbated by weak health systems and infrastructure, late detection, and ineffective outbreak response. To address this, the WHO Regional Office for Africa developed and began implementing the Integrated Disease Surveillance and Response strategy in 1998.

Objectives

This systematic review aims to document the identified successes and challenges surrounding the implementation of IDSR in the region available in published literature to highlight areas for prioritization, further research, and to inform further strengthening of IDSR implementation.

Methods

A systematic review of peer-reviewed literature published in English and French from 1 July 2012 to 13 November 2019 was conducted using PubMed and Web of Science. Included articles focused on the WHO African region and discussed the use of IDSR strategies and implementation, assessment of IDSR strategies, or surveillance of diseases covered in the IDSR framework. Data were analyzed descriptively using Microsoft Excel and Tableau Desktop 2019.

Results

The number of peer-reviewed articles discussing IDSR remained low, with 47 included articles focused on 17 countries and regional level systems. Most commonly discussed topics were data reporting (n = 39) and challenges with IDSR implementation (n = 38). Barriers to effective implementation were identified across all IDSR core and support functions assessed in this review: priority disease detection; data reporting, management, and analysis; information dissemination; laboratory functionality; and staff training. Successful implementation was noted where existing surveillance systems and infrastructure were utilized and streamlined with efforts to increase access to healthcare.

Conclusions and implications of findings

These findings highlighted areas where IDSR is performing well and where implementation remains weak. While challenges related to IDSR implementation since the first edition of the technical guidelines were released are not novel, adequately addressing them requires sustained investments in stronger national public health capabilities, infrastructure, and surveillance processes.

Assessment of surveillance core and support functions regarding neglected tropical diseases in Kenya

BACKGROUND

Effective surveillance and response systems are vital to achievement of disease control and elimination goals. Kenya adopted the revised guidelines of the integrated disease surveillance and response system in 2012. Previous assessments of surveillance system core and support functions in Africa are limited to notifiable diseases with minimal attention given to neglected tropical diseases amenable to preventive chemotherapy (PC-NTDs). The study aimed to assess surveillance system core and support functions relating to PC-NTDs in Kenya.

METHODS

A mixed method cross-sectional survey was adapted involving 192 health facility workers, 50 community-level health workers and 44 sub-national level health personnel. Data was collected using modified World Health Organization generic questionnaires, observation checklists and interview schedules. Descriptive summaries, tests of associations using Pearson's Chi-square or Fisher's exact tests and mixed effects regression models were used to analyse quantitative data. Qualitative data derived from interviews with study participants were coded and analysed thematically.

RESULTS

Surveillance core and support functions in relation to PC-NTDs were assessed in comparison to an indicator performance target of 80%. Optimal performance reported on specimen handling (84%; 100%), reports submission (100%; 100%) and data analysis (84%; 80%) at the sub-county and county levels respectively. Facilities achieved the threshold on reports submission (84%), reporting deadlines (88%) and feedback (80%). However, low performance reported on case definitions availability (60%), case registers (19%), functional laboratories (52%) and data analysis (58%). Having well-equipped laboratories (3.07, 95% CI: 1.36, 6.94), PC-NTDs provision in reporting forms (3.20, 95% CI: 1.44, 7.10) and surveillance training (4.15, 95% CI: 2.30, 7.48) were associated with higher odds of functional surveillance systems. Challenges facing surveillance activities implementation revealed through qualitative data were in relation to surveillance guidelines and reporting tools, data analysis, feedback, supervisory activities, training and resource provision.

CONCLUSION

There was evidence of low-performing surveillance functions regarding PC-NTDs especially at the peripheral surveillance levels. Case detection, registration and confirmation, reporting, data analysis and feedback performed sub-optimally at the facility and community levels. Additionally, support functions including standards and guidelines, supervision, training and resources were particularly weak at the sub-national level. Improved PC-NTDs surveillance performance sub-nationally requires strengthened capacities.

[Equity of access to immunization services in the Center-East health region in 2018, Burkina Faso]

INTRODUCTION

The Central East region of Burkina Faso has vaccine coverage which is among the lowest in the country with an epidemiological profile marked by the occurrence of measles or meningitis outbreaks. This study was conducted with the aim of carrying out an equity analysis of the organization of immunization services in this region in order to identify factors that cause potential inequities in vaccination offer.

MATERIALS AND METHOD

This descriptive cross-sectional study covered the seven districts in the Central East region. Data collection was done in two weeks combined with observation method, individual interviews and document review. Part of the data was collected using a self-administered questionnaire. The data analysis was performed with the Epi info 7 software using a plan designed for this purpose.

RESULTS

A total of 144 health centers in the region (93.0% coverage) were surveyed. The average distance between villages and health facilities was 5.2 km with 16.2% of villages that were located more than 10 km from a health facility. Health centers had an average of four health workers, however the urban health centers had more workers than those in rural areas. About 16% of the villages did not benefit from an on-site vaccination trip due to the unavailability of transport logistics. More than half of the health centers (53.9%) had experienced vaccine shortages in the last six months before the study. More than 5,000 safety boxes containing used syringes were stored in the districts of the region.

CONCLUSION

This study identified factors potentially responsible for an inequity in providing vaccination services in the Central East region. These factors include, but are not limited to, the geographical distribution of the health centers, the availability of transport logistics, and the shortage in vaccines and deficiencies in the waste disposal system. Concerted actions should be developed, involving all stakeholders in the health system in order to address these issues.