Factors influencing operationalization of Integrated Disease Surveillance in Malawi

OBJECTIVES

Malawi's disease surveillance system is built on several different data sources and systems and is informed by the Integrated Diseases Surveillance and Response (IDSR) strategy. This study was carried out as part of a larger multicountry study to identify context-specific factors, which influence the operationalization of integrated disease surveillance.

STUDY DESIGN AND METHODS

A total of six focus group discussions were conducted with 43 relevant personnel at the primary and secondary healthcare levels in two districts (Lilongwe and Dowa) and at the national level. The discussions were analyzed and sorted into predefined categories based on the domains of the International Association of Public Health conceptual framework.

RESULTS

We found ongoing efforts to enhance integrated disease surveillance operationalization, including the establishment of the Public Health Institute of Malawi for coordination, digitalizing the surveillance system through One Health Surveillance Platform, and improving communication among rapid response teams using WhatsApp. The adoption of World Health Organization's third edition IDSR technical guidelines was also underway. Nonetheless, there were major implementation barriers such as parallel and uncoordinated surveillance systems, priority conditions that cannot be diagnosed at the point of reporting, lack of case definitions and diagnostic codes for priority conditions, reporting forms with unexplained acronyms, illegible data sources, unstable electronic data transfers, inadequate supervision and training, poor enforcement of reporting from private health facilities, high reporting burden, and lack of and feedback to those reporting.

CONCLUSIONS

The results fit well into the predefined categories used. The study reveals basic problems with the operationalization, tools, and reporting forms used for IDSR. These findings may have implications for practice and policy in Malawi and other countries where IDSR is the national strategy for surveillance.

Does integration with national registers improve the data completeness of local COVID-19 contact tracing tools? A register-based study in Norway, May 2020 - September 2021

BACKGROUND

During the COVID-19 response in Norway, many municipalities used the Fiks contact tracing tool (FiksCT) to register positive individuals and follow-up contacts. This tool is based on DHIS2, an open source, web-based platform. In this study we examined if data completeness in FiksCT improved after integration with national registers between May 2020 and September 2021.

METHODS

Data from municipalities using FiksCT was extracted from the Norwegian Emergency Preparedness Register for COVID-19 (Beredt C19). We linked FiksCT data to the Norwegian Surveillance System for Communicable Diseases (MSIS), the National Population Register (FREG), and the Norwegian Vaccine Registry (SYSVAK) using unique identification numbers (ID). Completeness for each variable linked with a national register was calculated before and after integration with these registers.

RESULTS

Of the 125 municipalities using FiksCT, 87 (69.6%) agreed to share and upload their data to Beredt C19. Data completeness for positive individuals improved after integration with national registers. After integration with FREG, the proportion of missing values decreased from 12.5 to 1.6% for ID, from 4.5 to 0.9% for sex, and from 1.2 to 0.4% for date of birth. Missing values for vaccine type decreased from 63.0 to 15.2% and 39.3-36.7% for first and second dose, respectively. In addition, direct reporting from FiksCT to MSIS increased the proportion of complete records in MSIS (on the selected variables) from 68.6% before to 77.0% after integration.

CONCLUSION

The completeness of local contact tracing data can be improved by enabling integration with established national registers. In addition, providing the option to submit local data to the national registers could ease workload and reduce the need to collect duplicate data.

The state of integrated disease surveillance in seven countries: a synthesis report

OBJECTIVES

Integrated disease surveillance (IDS) offers the potential for better use of surveillance data to guide responses to public health threats. However, the extent of IDS implementation worldwide is unknown. This study sought to understand how IDS is operationalized, identify implementation challenges and barriers, and identify opportunities for development.

STUDY DESIGN

Synthesis of qualitative studies undertaken in seven countries.

METHODS

Thirty-four focus group discussions and 48 key informant interviews were undertaken in Pakistan, Mozambique, Malawi, Uganda, Sweden, Canada, and England, with data collection led by the respective national public health institutes. Data were thematically analysed using a conceptual framework that covered governance, system and structure, core functions, finance and resourcing requirements. Emerging themes were then synthesised across countries for comparisons.

RESULTS

None of the countries studied had fully integrated surveillance systems. Surveillance was often fragmented, and the conceptualization of integration varied. Barriers and facilitators identified included: 1) the need for clarity of purpose to guide integration activities; 2) challenges arising from unclear or shared ownership; 3) incompatibility of existing IT systems and surveillance infrastructure; 4) workforce and skills requirements; 5) legal environment to facilitate data sharing between agencies; and 6) resourcing to drive integration. In countries dependent on external funding, the focus on single diseases limited integration and created parallel systems.

CONCLUSIONS

A plurality of surveillance systems exists globally with varying levels of maturity. While development of an international framework and standards are urgently needed to guide integration efforts, these must be tailored to country contexts and guided by their overarching purpose.

Health communication in and out of public health emergencies: to persuade or to inform?

Much health communication during the COVID-19 pandemic has been designed to persuade people more than to inform them. For example, messages like “masks save lives” are intended to compel people to wear face masks, not to enable them to make an informed decision about whether to wear a face mask or to understand the justification for a mask mandate. Both persuading people and informing them are reasonable goals for health communication. However, those goals can sometimes be in conflict. In this article, we discuss potential conflicts between seeking to persuade or to inform people, the use of spin to persuade people, the ethics of persuasion, and implications for health communication in the context of the pandemic and generally. Decisions to persuade people rather than enable them to make an informed choice may be justified, but the basis for those decisions should be transparent and the evidence should not be distorted. We suggest nine principles to guide decisions by health authorities about whether to try to persuade people.

National Hand Hygiene Campaigns in Europe, 2000-2009

Hand hygiene represents the single most effective way to prevent healthcare-associated infections. The World Health Organization, as part of its First Global Patient Safety Challenge, recommends implementation of multi-faceted strategies to increase compliance with hand hygiene. A questionnaire was sent by the European Centre for Disease Prevention and Control to 30 European countries, regarding the availability and organisation of their national hand hygiene campaigns. All countries responded. Thirteen countries had organised at least one national campaign during the period 2000-2009 and three countries were in the process of organising a national campaign. Although the remaining countries did not have a national campaign, several reported regional and local hand hygiene activities or educational resources on national websites.

National hand hygiene campaigns in Europe, 2000-2009

Hand hygiene represents the single most effective way to prevent healthcare-associated infections. The World Health Organization, as part of its First Global Patient Safety Challenge, recommends implementation of multi-faceted strategies to increase compliance with hand hygiene. A questionnaire was sent by the European Centre for Disease Prevention and Control to 30 European countries, regarding the availability and organisation of their national hand hygiene campaigns. All countries responded. Thirteen countries had organised at least one national campaign during the period 2000-2009 and three countries were in the process of organising a national campaign. Although the remaining countries did not have a national campaign, several reported regional and local hand hygiene activities or educational resources on national websites.

Prevalence of nosocomial infections in hospitals in Norway, 2002 and 2003

The Norwegian Institute of Public Health initiated a national surveillance system for nosocomial infections in 2002. The system is based on two annual one-day prevalence surveys recording the four most common types of nosocomial infection: urinary tract infections; lower respiratory tract infections; surgical site infections and septicaemia. All acute care hospitals in Norway (N=76) were invited to participate in the four surveys in 2002 and 2003. The total prevalence of the four recorded nosocomial infections varied between 5.1% and 5.4% in the four surveys. In all surveys, nosocomial infections were located most frequently in the urinary tract (34%), followed by the lower respiratory tract (29%), surgical sites (28%) and septicaemia (8%). The prevalence surveys give a brief overview of the burden and distribution of nosocomial infections. The results can be used to prioritize further infection control measures and more detailed incidence surveillance of nosocomial infections.

Prevalence of nosocomial infections and use of antibiotics in long-term care facilities in Norway, 2002 and 2003

There were 42900 institution-beds in long-term care facilities for elderly persons in Norway in 2000. This is twice as many as in 1984. Of those living in an elderly people's care institution 77% were above 80 years. To determine the magnitude and distribution of nosocomial infections in such institutions, the Norwegian Institute of Public Health initiated a surveillance system. The system is based on two annual one-day prevalence surveys recording the four most common nosocomial infections: urinary tract infections, lower respiratory tract infections, surgical-site infections and skin infections, as well as antibiotic use. All long-term care facilities were invited to participate in the four surveys in 2002 and 2003. The total prevalence of the four recorded nosocomial infections varied between 6.6 and 7.3% in the four surveys. Nosocomial infections occurred most frequently in the urinary tract (50%), followed by infections of the skin (25%), of the lower respiratory tract (19%) and of surgical sites (5%). The prevalence of nosocomial infections was highest in rehabilitation and short-term wards, whereas the lowest prevalence was found in special units for persons with dementia. In all the surveys the prevalence of the four recorded nosocomial infections was higher than the prevalence of patients receiving antibiotics. The frequency of nosocomial infections in such facilities highlights the need for nosocomial infection surveillance in this population and a need to implement infection control measures, such as infection control programmes including surveillance of nosocomial infections.

[Morbidity and mortality in pandemic influenza in Norway]

This article is partly based on a newly published influenza pandemic preparedness plan and risk analysis for future pandemics in Norway, and presents estimates on morbidity and mortality in influenza pandemics in Norway in the 20th century. In addition, estimates on morbidity and mortality for a future pandemic are given. One of the main conclusions is that excess mortality in connection with Spanish influenza and Asian influenza is highly underestimated. The proportion of the infected that died in the pandemics was low, and was highest for Spanish influenza. The morbidity will be highest if a pandemic similar to Asian influenza reappears, while mortality will be highest if a Spanish flu is repeated. In the worst case scenario for a pandemic today, based on the figures from the Spanish flu, the number of excess deaths could reach 29,000, an increase of 60% compared to the average annual number of deaths seen in the 1990s.

[Infections during the 1995 flood in Ostlandet. Prevention and incidence]

During the 1995 river floods in eastern Norway, 7,000 people were forced to abandon their houses and the public water supplies of some 150,000 people were threatened. The National Institute of Public Health feared outbreaks of waterborne diseases. We supplemented the local preventive efforts with expert advice and public information. We emphasised measures to maintain safe water supplies and to provide information on safe management of flood water during evacuation and clean-up. We observed no increase in the incidence of acute gastroenteritis or other possibly flood-related communicable diseases among the 329,000 people living in the municipalities affected by the floods. We conclude that the floods did not cause a measurable increase in the incidence of communicable diseases. This was probably due to some extent to the measures taken to protect the water supplies.

Meningococcal disease in Norway 1992-1995. Epidemiology and fatality

We analysed data on all cases of meningococcal disease (MCD) reported to the Norwegian Notification System for Infectious Diseases during the period 1992-1995. For 1994, additional information on fatalities was gathered. Notifications were received from laboratories and clinicians. A total of 586 patients were included. The incidence decreased from 4.6 per 100000 in 1992 to 2.4 in 1994, and then rose to 3.7 in 1995. The initial decrease, a trend also observed in previous years, was seen in both main serogroups B and C. This decline was broken with the increase of serogroup B in 1995. MCD predominantly affects children below 5 years and teenagers. In 1994, 17/105 (16%) patients died. Main risk factors for fatal outcome were age above 30 years (adjusted odds ratio (OR) 19.8; 95% confidence interval (CI) 2.4-164), septicaemia (adjusted OR 9.5; 95% CI 2.2-41) and disease caused by strains B:15 (adjusted OR 6.4; 95% CI 1.2-35) or C:2a (adjusted OR 10.1; 95% CI 1.6-62). We conclude that the incidence of MCD in Norway is unpredictable and that the case fatality rate is substantially higher than previously believed.

[Evaluation of the National Notification System for infectious diseases during an outbreak of Shigella epidemic in Norway 1994]

The National Notification System for Infectious Diseases, in Norwegian abbreviated to MSIS, registered 110 cases of Shigella sonnei-infection in persons with debut of symptoms during weeks 21 to 25, 1994, and where we did not receive information that the patients had been abroad. We evaluated the notification system during this outbreak of infectious disease by looking at delays in the notification process and estimating the proportion of patients who received an etiological diagnosis. It took a median time of seven days from onset of illness until a faecal specimen was obtained and a further ten days (maximum 15 days) until the result was registered in MSIS. The time lapse between receiving the specimen until MSIS had registered the result varied from six to 15 days among the laboratories which sent more than four notifications. In the summarical notification system we registered an increase of 712 cases (86%) of acute gastroenteritis compared with the same week the previous two years.

Outbreak of Shigella sonnei infection traced to imported iceberg lettuce

In the period from May through June 1994, an increase in the number of domestic cases of Shigella sonnei infection was detected in several European countries, including Norway, Sweden, and the United Kingdom. In all three countries epidemiological evidence incriminated imported iceberg lettuce of Spanish origin as the vehicle of transmission. The outbreaks shared a number of common features: a predominance of adults among the case patients, the presence of double infections with other enteropathogens, and the finding of two dominant phage types among the bacterial isolates. In Norway 110 culture-confirmed cases of infection were recorded; more than two-thirds (73%) were adults aged 30 to 60 years. A nationwide case-control study comprising 47 case patients and 155 matched control individuals showed that the consumption of imported iceberg lettuce was independently associated with an increased risk of shigellosis. Epidemiological investigation of a local outbreak incriminated iceberg lettuce from Spain, consumed from a salad bar, as the source. The presence of shigellae in the suspected food source could not be documented retrospectively. However, high numbers of fecal coliforms were detected in iceberg lettuce from patients' homes. Three lettuce specimens yielded salmonellae. The imported iceberg lettuce harbored Escherichia coli strains showing resistance to several antimicrobial agents, including ampicillin, ciprofloxacin, gentamicin, and trimethoprim-sulfamethoxazole. During the outbreak it is likely that thousands of Norwegians and an unknown number of consumers in other countries were exposed to coliforms containing antibiotic resistance genes.