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Mremi IR, George J, Rumisha SF, Sindato C, Kimera SI, Mboera LEG. Twenty years of integrated disease surveillance and response in Sub-Saharan Africa: challenges and opportunities for effective management of infectious disease epidemics. ONE HEALTH OUTLOOK 2021; 3:22. [PMID: 34749835 PMCID: PMC8575546 DOI: 10.1186/s42522-021-00052-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/18/2021] [Indexed: 05/15/2023]
Abstract
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.
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Affiliation(s)
- Irene R Mremi
- Department of Veterinary Medicine and Public Health, Sokoine University of Agriculture, Morogoro, Tanzania.
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro, Tanzania.
- National Institute for Medical Research, Dar es Salaam, Tanzania.
| | - Janeth George
- Department of Veterinary Medicine and Public Health, Sokoine University of Agriculture, Morogoro, Tanzania
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro, Tanzania
| | - Susan F Rumisha
- National Institute for Medical Research, Dar es Salaam, Tanzania
- Malaria Atlas Project, Geospatial Health and Development, Telethon Kids Institute, West Perth, Australia
| | - Calvin Sindato
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro, Tanzania
- National Institute for Medical Research, Tabora Research Centre, Tabora, Tanzania
| | - Sharadhuli I Kimera
- Department of Veterinary Medicine and Public Health, Sokoine University of Agriculture, Morogoro, Tanzania
| | - Leonard E G Mboera
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro, Tanzania
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Tsheten T, Clements ACA, Gray DJ, Gyeltshen K, Wangdi K. Medical practitioner's knowledge on dengue management and clinical practices in Bhutan. PLoS One 2021; 16:e0254369. [PMID: 34270594 PMCID: PMC8284660 DOI: 10.1371/journal.pone.0254369] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Accepted: 06/24/2021] [Indexed: 12/02/2022] Open
Abstract
Background Dengue has emerged as a major public health problem in Bhutan, with increasing incidence and widening geographic spread over recent years. This study aimed to investigate the knowledge and clinical management of dengue among medical practitioners in Bhutan. Methods We administered a survey questionnaire to all practitioners currently registered under the Bhutan Medical and Health Council. The questionnaire contained items on four domains including transmission, clinical course and presentation, diagnosis and management, and surveillance and prevention of dengue. Participants were able to respond using an online Qualtrics survey, with the invitation and link distributed via email. Results A total of 97 respondents were included in the study (response rate: 12.7%), of which 61.86% were Health Assistants/Clinical Officers (HAs/COs) and 38.14% were medical doctors. The afternoon feeding behaviour of Aedes mosquito was correctly identified by only 24.7% of the respondents, and ~66.0% of them failed to identify lethargy as a warning sign for severe dengue. Knowledge on diagnosis using NS1 antigen and the clinical significance of elevated haematocrit for initial fluid replacement was strikingly low at 47.4% and 27.8% respectively. Despite dengue being a nationally notifiable disease, ~60% of respondents were not knowledgeable on the timing and type of cases to be reported. Respondent’s median score was higher for the surveillance and reporting domain, followed by their knowledge on transmission of dengue. Statistically significant factors associated with higher knowledge included respondents being a medical doctor, working in a hospital and experience of having diagnosed dengue. Conclusion The study revealed major gaps on knowledge and clinical management practices related to dengue in Bhutan. Physicians and health workers working in Basic Health Units need training and regular supervision to improve their knowledge on the care of dengue patients.
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Affiliation(s)
- Tsheten Tsheten
- Department of Global Health, Research School of Population Health, Australian National University, Canberra, Australia
- Royal Centre for Disease Control, Ministry of Health, Thimphu, Bhutan
- * E-mail:
| | - Archie C. A. Clements
- Faculty of Health Sciences, Curtin University, Perth, Australia
- Telethon Kids Institute, Nedlands, Australia
| | - Darren J. Gray
- Department of Global Health, Research School of Population Health, Australian National University, Canberra, Australia
| | | | - Kinley Wangdi
- Department of Global Health, Research School of Population Health, Australian National University, Canberra, Australia
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Saleh F, Kitau J, Konradsen F, Mboera LEG, Schiøler KL. Assessment of the core and support functions of the integrated disease surveillance and response system in Zanzibar, Tanzania. BMC Public Health 2021; 21:748. [PMID: 33865347 PMCID: PMC8052932 DOI: 10.1186/s12889-021-10758-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/01/2021] [Indexed: 11/10/2022] Open
Abstract
Background Disease surveillance is a cornerstone of outbreak detection and control. Evaluation of a disease surveillance system is important to ensure its performance over time. The aim of this study was to assess the performance of the core and support functions of the Zanzibar integrated disease surveillance and response (IDSR) system to determine its capacity for early detection of and response to infectious disease outbreaks. Methods This cross-sectional descriptive study involved 10 districts of Zanzibar and 45 public and private health facilities. A mixed-methods approach was used to collect data. This included document review, observations and interviews with surveillance personnel using a modified World Health Organization generic questionnaire for assessing national disease surveillance systems. Results The performance of the IDSR system in Zanzibar was suboptimal particularly with respect to early detection of epidemics. Weak laboratory capacity at all levels greatly hampered detection and confirmation of cases and outbreaks. None of the health facilities or laboratories could confirm all priority infectious diseases outlined in the Zanzibar IDSR guidelines. Data reporting was weakest at facility level, while data analysis was inadequate at all levels (facility, district and national). The performance of epidemic preparedness and response was generally unsatisfactory despite availability of rapid response teams and budget lines for epidemics in each district. The support functions (supervision, training, laboratory, communication and coordination, human resources, logistic support) were inadequate particularly at the facility level. Conclusions The IDSR system in Zanzibar is weak and inadequate for early detection and response to infectious disease epidemics. The performance of both core and support functions are hampered by several factors including inadequate human and material resources as well as lack of motivation for IDSR implementation within the healthcare delivery system. In the face of emerging epidemics, strengthening of the IDSR system, including allocation of adequate resources, should be a priority in order to safeguard human health and economic stability across the archipelago of Zanzibar.
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Affiliation(s)
- Fatma Saleh
- Department of Parasitology and Entomology, Kilimanjaro Christian Medical University College, Moshi, Tanzania. .,Department of Allied Health Sciences, School of Health and Medical Sciences, The State University of Zanzibar, Zanzibar, Tanzania.
| | - Jovin Kitau
- Department of Parasitology and Entomology, Kilimanjaro Christian Medical University College, Moshi, Tanzania.,World Health Organization, Country office, Dar es Salaam, Tanzania
| | - Flemming Konradsen
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Leonard E G Mboera
- SACIDS Foundation for One Health, Sokoine University of Agriculture, Morogoro, Tanzania
| | - Karin L Schiøler
- Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
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Wangari EN, Gichuki P, Abuor AA, Wambui J, Okeyo SO, Oyatsi HT, Odikara S, Kulohoma BW. Kenya's response to the COVID-19 pandemic: a balance between minimising morbidity and adverse economic impact. AAS Open Res 2021; 4:3. [PMID: 33709055 PMCID: PMC7921885 DOI: 10.12688/aasopenres.13156.2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/16/2021] [Indexed: 11/28/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) has ravaged the world's socioeconomic systems forcing many governments across the globe to implement unprecedented stringent mitigation measures to restrain its rapid spread and adverse effects. A disproportionate number of COVID-19 related morbidities and mortalities were predicted to occur in Africa. However, Africa still has a lower than predicted number of cases, 4% of the global pandemic burden. In this open letter, we highlight some of the early stringent countermeasures implemented in Kenya, a sub-Saharan African country, to avert the severe effects of the COVID-19 pandemic. These mitigation measures strike a balance between minimising COVID-19 associated morbidity and fatalities and its adverse economic impact, and taken together have significantly dampened the pandemic's impact on Kenya's populace.
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Affiliation(s)
- Edwin N. Wangari
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Peter Gichuki
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Angelyne A. Abuor
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Jacqueline Wambui
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Stephen O. Okeyo
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Henry T.N. Oyatsi
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Shadrack Odikara
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Benard W. Kulohoma
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
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Wolfe CM, Hamblion EL, Dzotsi EK, Mboussou F, Eckerle I, Flahault A, Codeço CT, Corvin J, Zgibor JC, Keiser O, Impouma B. Systematic review of Integrated Disease Surveillance and Response (IDSR) implementation in the African region. PLoS One 2021; 16:e0245457. [PMID: 33630890 PMCID: PMC7906422 DOI: 10.1371/journal.pone.0245457] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 12/30/2020] [Indexed: 01/02/2023] Open
Abstract
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.
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Affiliation(s)
- Caitlin M. Wolfe
- Health Emergency Information and Risk Assessment, Health Emergencies Programme, World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo
- University of South Florida College of Public Health, Tampa, Florida, United States of America
- * E-mail:
| | - Esther L. Hamblion
- Health Emergency Information and Risk Assessment, Health Emergencies Programme, World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo
| | - Emmanuel K. Dzotsi
- Health Emergency Information and Risk Assessment, Health Emergencies Programme, World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo
| | - Franck Mboussou
- Health Emergency Information and Risk Assessment, Health Emergencies Programme, World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo
| | - Isabelle Eckerle
- Division of Infectious Diseases, Geneva Centre for Emerging Viral Diseases, University Hospital of Geneva, Geneva, Switzerland
| | - Antoine Flahault
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Claudia T. Codeço
- National School of Public Health (ENSP/Fiocruz), Fundação Oswaldo Cruz (FIOCRUZ), Rio de Janeiro, Brazil
| | - Jaime Corvin
- University of South Florida College of Public Health, Tampa, Florida, United States of America
| | - Janice C. Zgibor
- University of South Florida College of Public Health, Tampa, Florida, United States of America
| | - Olivia Keiser
- Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - Benido Impouma
- Health Emergency Information and Risk Assessment, Health Emergencies Programme, World Health Organization Regional Office for Africa, Brazzaville, Republic of Congo
- Institute of Global Health, University of Geneva, Geneva, Switzerland
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Wangari EN, Gichuki P, Abuor AA, Wambui J, Okeyo SO, Oyatsi HT, Odikara S, Kulohoma BW. Kenya's response to the COVID-19 pandemic: a balance between minimising morbidity and adverse economic impact. AAS Open Res 2021; 4:3. [PMID: 33709055 PMCID: PMC7921885 DOI: 10.12688/aasopenres.13156.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 09/26/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) has ravaged the world's socioeconomic systems forcing many governments across the globe to implement unprecedented stringent mitigation measures to restrain its rapid spread and adverse effects. A disproportionate number of COVID-19 related morbidities and mortalities were predicted to occur in Africa. However, Africa still has a lower than predicted number of cases, 4% of the global pandemic burden. In this open letter, we highlight some of the early stringent countermeasures implemented in Kenya, a sub-Saharan African country, to avert the severe effects of the COVID-19 pandemic. These mitigation measures strike a balance between minimising COVID-19 associated morbidity and fatalities and its adverse economic impact, and taken together have significantly dampened the pandemic's impact on Kenya's populace.
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Affiliation(s)
- Edwin N. Wangari
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Peter Gichuki
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Angelyne A. Abuor
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Jacqueline Wambui
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Stephen O. Okeyo
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Henry T.N. Oyatsi
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Shadrack Odikara
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
| | - Benard W. Kulohoma
- Centre for Biotechnology and Bioinformatics, University of Nairobi, Nairobi, Kenya
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Machini B, Zurovac D, Amboko B, Malla L, Snow RW, Kipruto H, Achia TNO. Predictors of health workers' knowledge about artesunate-based severe malaria treatment recommendations in government and faith-based hospitals in Kenya. Malar J 2020; 19:267. [PMID: 32703215 PMCID: PMC7379778 DOI: 10.1186/s12936-020-03341-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 07/17/2020] [Indexed: 11/24/2022] Open
Abstract
Background Health workers’ knowledge deficiencies about artesunate-based severe malaria treatment recommendations have been reported. However, predictors of the treatment knowledge have not been examined. In this paper, predictors of artesunate-based treatment knowledge among inpatient health workers in two hospital sectors in Kenya are reported. Methods Secondary analysis of 367 and 330 inpatient health workers randomly selected and interviewed at 47 government hospitals in 2016 and 43 faith-based hospitals in 2017 respectively, was undertaken. Multilevel ordinal and binary logistic regressions examining the effects of 11 factors on five knowledge outcomes in government and faith-based hospital sectors were performed. Results Among respective government and faith-based health workers, about a third of health workers had high knowledge of artesunate treatment policies (30.8% vs 32.9%), a third knew all dosing intervals (33.5% vs 33.3%), about half knew preparation solutions (49.9% vs 55.8%), half to two-thirds knew artesunate dose for both weight categories (50.8% vs 66.7%) and over three-quarters knew the preferred route of administration (78.7% vs 82.4%). Eight predictors were significantly associated with at least one of the examined knowledge outcomes. In the government sector, display of artesunate administration posters, paediatric ward allocation and repeated surveys were significantly associated with more than one of the knowledge outcomes. In the faith-based hospitals, availability of artesunate at hospitals and health worker pre-service training were associated with multiple outcomes. Exposure to in-service malaria case-management training and access to malaria guidelines were only associated with higher knowledge about artesunate treatment policy. Conclusion Programmatic interventions ensuring display of artesunate administration posters in the wards, targeting of health workers managing adult patients in the medical wards, and repeated knowledge assessments are likely to be beneficial for improving the knowledge of government health workers about artesunate-based severe malaria treatment recommendations. The availability of artesunate and focus on improvements of nurses’ knowledge should be prioritized at the faith-based hospitals.
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Affiliation(s)
- Beatrice Machini
- University of Nairobi, Institute of Tropical and Infectious Diseases, Nairobi, Kenya. .,Division of National Malaria Programme, Ministry of Health, Nairobi, Kenya.
| | - Dejan Zurovac
- KEMRI-Welcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | | | - Lucas Malla
- KEMRI-Welcome Trust Research Programme, Nairobi, Kenya
| | - Robert W Snow
- KEMRI-Welcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Hillary Kipruto
- University of Nairobi, Institute of Tropical and Infectious Diseases, Nairobi, Kenya.,World Health Organization, Nairobi, Kenya
| | - Thomas N O Achia
- University of Nairobi, Institute of Tropical and Infectious Diseases, Nairobi, Kenya.,School of Mathematics and Computer Science, University of Kwa Zulu Natal, Durban, South Africa
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Njeru I, Kareko D, Kisangau N, Langat D, Liku N, Owiso G, Dolan S, Rabinowitz P, Macharia D, Ekechi C, Widdowson MA. Use of technology for public health surveillance reporting: opportunities, challenges and lessons learnt from Kenya. BMC Public Health 2020; 20:1101. [PMID: 32660509 PMCID: PMC7359619 DOI: 10.1186/s12889-020-09222-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 07/06/2020] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Ian Njeru
- International Training and Education Centre for Health (I-TECH Kenya), Nairobi, Kenya.
| | | | | | | | - Nzisa Liku
- International Training and Education Centre for Health (I-TECH Kenya), Nairobi, Kenya
| | - George Owiso
- International Training and Education Centre for Health (I-TECH Kenya), Nairobi, Kenya
| | - Samantha Dolan
- International Training and Education Centre for Health (I-TECH Kenya), Nairobi, Kenya
| | - Peter Rabinowitz
- International Training and Education Centre for Health (I-TECH Kenya), Nairobi, Kenya
| | - Daniel Macharia
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Chinyere Ekechi
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Marc-Alain Widdowson
- Division of Global Health Protection, Centers for Disease Control and Prevention, Nairobi, Kenya.,Division of Global Health Protection, Centers for Disease Control and Prevention, Atlanta, GA, USA
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