Assessment of the integrated disease surveillance and response system implementation in health zones at risk for viral hemorrhagic fever outbreaks in North Kivu, Democratic Republic of the Congo, following a major Ebola outbreak, 2021.

BACKGROUND: The Democratic Republic of the Congo (DRC) experienced its largest Ebola Virus Disease Outbreak in 2018-2020. As a result of the outbreak, significant funding and international support were provided to Eastern DRC to improve disease surveillance. The Integrated Disease Surveillance and Response (IDSR) strategy has been used in the DRC as a framework to strengthen public health surveillance, and full implementation could be critical as the DRC continues to face threats of various epidemic-prone diseases. In 2021, the DRC initiated an IDSR assessment in North Kivu province to assess the capabilities of the public health system to detect and respond to new public health threats. METHODS: The study utilized a mixed-methods design consisting of quantitative and qualitative methods. Quantitative assessment of the performance in IDSR core functions was conducted at multiple levels of the tiered health system through a standardized questionnaire and analysis of health data. Qualitative data were also collected through observations, focus groups and open-ended questions. Data were collected at the North Kivu provincial public health office, five health zones, 66 healthcare facilities, and from community health workers in 15 health areas. RESULTS: Thirty-six percent of health facilities had no case definition documents and 53% had no blank case reporting forms, limiting identification and reporting. Data completeness and timeliness among health facilities were 53% and 75% overall but varied widely by health zone. While these indicators seemingly improved at the health zone level at 100% and 97% respectively, the health facility data feeding into the reporting structure were inconsistent. The use of electronic Integrated Disease Surveillance and Response is not widely implemented. Rapid response teams were generally available, but functionality was low with lack of guidance documents and long response times. CONCLUSION: Support is needed at the lower levels of the public health system and to address specific zones with low performance. Limitations in materials, resources for communication and transportation, and workforce training continue to be challenges. This assessment highlights the need to move from outbreak-focused support and funding to building systems that can improve the long-term functionality of the routine disease surveillance system.

1-3-7 surveillance and response approach in malaria elimination: China's practice and global adaptions.

There has been a significant reduction in malaria morbidity and mortality worldwide from 2000 to 2019. However, the incidence and mortality increased again in 2020 due to the disruption to services during the COVID-19 pandemic. Surveillance to reduce the burden of malaria, eliminate the disease and prevent its retransmission is, therefore, crucial. The 1-3-7 approach proposed by China has played an important role in eliminating malaria, which has been internationally popularized and adopted in some countries to help eliminate malaria. This review summarizes the experience and lessons of 1-3-7 approach in China and its application in other malaria-endemic countries, so as to provide references for its role in eliminating malaria and preventing retransmission. This approach needs to be tailored and adapted according to the region condition, considering the completion, timeliness and limitation of case-based reactive surveillance and response. It is very important to popularize malaria knowledge, train staff, improve the capacity of health centres and monitor high-risk groups to improve the performance in eliminating settings. After all, remaining vigilance in detecting malaria cases and optimizing surveillance and response systems are critical to achieving and sustaining malaria elimination.

Reactive surveillance and response strategies for malaria elimination in Myanmar: a literature review.

Myanmar, a country in Greater Mekong Sub-region, aims to eliminate malaria by 2030. To achieve malaria elimination, Myanmar adopted a reactive surveillance and response strategy of malaria case notification within 1 day and case investigation, foci investigation and response activities within 7 days. A literature review was conducted to gain a better understanding of how the reactive surveillance and response strategies are being implemented in Myanmar including enablers and barriers to their implementation. Only two assessments of the completeness and timeliness of reactive surveillance and response strategy in Myanmar have been published to date. The proportion of positive cases notified within one day was 27.9% and the proportion of positive cases investigated within 7 days as recommended by the national guidelines varied from 32.5 to 91.8% under different settings in reported studies. Strong collaboration between the National Malaria Control Programme and implementing partners, and adequate human resource and financial support contributed to a successful and timely implementation of reactive surveillance and response strategy. Documented enablers for successful implementation of reactive surveillance and response strategy included frontline health workers having good knowledge of reactive surveillance and response activities and availability of Basic Health Staff for timely implementation of foci response activities. Barriers for implementation of reactive surveillance and response activities were also identified, including shortage of human resources especially in hard-to-reach settings, limited mobile phone network services and internet coverage leading to delays in timely notification of malaria cases, lengthy and complex case investigation forms and different reporting systems between Basic Health Staff and volunteers.

Performance and feasibility of reactive surveillance and response strategies for malaria elimination in Vietnam: a mixed-methods study.

BACKGROUND: To enhance malaria elimination, Vietnam adopted a Reactive Surveillance and Response (RASR) Strategy in which malaria case notification and investigation must be completed within 2 days followed by a focus investigation within 7 days. The nationwide performance of Vietnam's RASR strategy has yet to be evaluated. This study aims to evaluate the performance and feasibility of RASR in Vietnam, thereby providing recommendations for improved RASR. METHODS: To assess malaria RASR in Vietnam, a mixed-methods study of (1) secondary data analysis of nationwide malaria case-based dataset from 2017 to 2021; (2) a quantitative survey, and (3) qualitative in-depth interviews and focus group discussions administered to central, provincial and district level stakeholders/staff and to the commune and community level front line health services providers was conducted. RESULTS: In Vietnam, there are guidelines and procedures for implementation of each step of RASR. The completeness of case notification on the reported monthly aggregated data was very high in both the paper-based (12,463/12,498, 99.7% in 2017-2020) and electronic reporting systems (467/467, 100% in 2021 when electronic reporting was introduced); however, there were delays in notification while using the paper-based system (timely notification-7,978/12,498, 63.8%). In 2021, the completeness (453/467, 97.0%) and timeliness (371/467, 79.4%) of case investigation were found to be high. Reactive case detection was the major focus investigation response, with fever screening achievement of 88.6% (11,481 / 12,965) and 88.5% (11,471 / 12,965) among index case and neighbouring household members, respectively. CONCLUSIONS: Overall, there was policy commitment for implementation of RASR in Vietnam. The completeness and timeliness of case notification and case investigation were high and improved after the introduction of the electronic reporting system. More evidence is required for reactive case detection in defining the screening area or population.

Documenting the development, adoption and pre-ebola implementation of Liberia's integrated disease surveillance and response (IDSR) strategy.

BACKGROUND: In the immediate aftermath of a 14-year civil conflict that disrupted the health system, Liberia adopted the internationally recommended integrated disease surveillance and response (IDSR) strategy in 2004. Despite this, Liberia was among the three West African countries ravaged by the worst Ebola epidemic in history from 2014 to 2016. This paper describes successes, failures, strengths, and weaknesses in the development, adoption, and implementation of IDSR following the civil war and up until the outbreak of Ebola, from 2004 to early 2014. METHODS: We reviewed 112 official Government documents and peer-reviewed articles and conducted 29 in-depth interviews with key informants from December 2021 to March 2022 to gain perspectives on IDSR in the post-conflict and pre-Ebola era in Liberia. We assessed the core and supportive functions of IDSR, such as notification of priority diseases, confirmation, reporting, analysis, investigation, response, feedback, monitoring, staff training, supervision, communication, and financial resources. Data were triangulated and presented via emerging themes and in-depth accounts to describe the context of IDSR introduction and implementation, and the barriers surrounding it. RESULTS: Despite the adoption of the IDSR framework, Liberia failed to secure the resources-human, logistical, and financial-to support effective implementation over the 10-year period. Documents and interview reports demonstrate numerous challenges prior to Ebola: the surveillance system lacked key components of IDSR including laboratory testing capacity, disease reporting, risk communication, community engagement, and staff supervision systems. Insufficient financial support and an abundance of vertical programs further impeded progress. In-depth accounts by donors and key governmental informants demonstrate that although the system had a role in detecting Ebola in Liberia, it could not respond effectively to control the disease. CONCLUSION: Our findings suggest that post-war, Liberia's health system intended to prioritize epidemic preparedness and response with the adoption of IDSR. However, insufficient investment and systems development meant IDSR was not well implemented, leaving the country vulnerable to the devastating impact of the Ebola epidemic.

District-led malaria surveillance and response as an effective way to manage malaria upsurges following the withdrawal of indoor residual spraying: a case study from Nwoya District, northern Uganda.

BACKGROUND: Malaria remains the number one cause of morbidity and mortality in Uganda. In 2009, the United States President's Malaria Initiative (PMI) funded an indoor residual spraying (IRS) project in 10 mid-northern districts, resulting in marked reductions in malaria prevalence over 5 years, from 62.5 percent to 7.2 percent. When the project ended and IRS withdrawn, malaria prevalence increased exponentially to pre-IRS level of 63 percent in 2016 and was characterized by frequent life-threatening upsurges that were exacerbated by a weak national led malaria surveillance system with delayed and piece meal responses. Malaria Consortium, in collaboration with Nwoya district local government implemented a district led malaria surveillance and response system. This study was conducted to compare the impact of District led and national led surveillance and response systems on overall malaria burden in two sub-counties in Nwoya district, Northern Uganda. METHODS: The assessment was conducted between week 41 of 2018 and week 10 of 2019 in Anaka and Alero sub counties following the shift from the national to district led malaria surveillance and response system. A district multi-sectoral malaria response taskforce team, known as the District Malaria Surveillance and Response Team (DMSRT), was formed by the Nwoya District Health Team (DHT). The DMSRT was trained and equipped with new surveillance tools for early detection of and response to malaria upsurges within the district, and were mandated to develop a costed district specific malaria response plan. RESULTS: All (18) targeted health facilities provided weekly malaria reports and continuously updated the malaria normal channel graphs. There was an overall reduction in weekly new malaria cases from 12.9 in week 41 of 2018 to 6.2 cases in week 10 of 2019. Malaria positivity rates (TPR) for Alero and Anaka sub-counties reduced from 76.0 percent and 69.3 percent at week 42 of 2018 to 28 percent and 30.3 percent, respectively at week 10 of 2019. CONCLUSIONS: Malaria surveillance and response, with precisely targeted multipronged activities, when led and implemented by local district health authorities is an effective, efficient, and sustainable approach to prevent malaria upsurges and associated morbidity and mortality.

Innovative approach to monitor performance of integrated disease surveillance and response after the Ebola outbreak in Sierra Leone: lessons from the field.

BACKGROUND: Supervision of healthcare workers improves performance if done in a supportive and objective manner. Regular supervision is a support function of Integrated Disease Surveillance and Response (IDSR) strategy and allows systematic monitoring of IDSR implementation. Starting 2015, WHO and other development partners supported the Ministry of Health and Sanitation (MoHS) to revitalize IDSR in Sierra Leone and to monitor progress through supportive supervision assessments. We report on the findings of these assessments. METHODS: This was a cross-sectional study where six longitudinal assessments were conducted in randomly selected health facilities. Health facilities assessed were 71 in February 2016, 99 in July 2016, 101 in May 2017, 126 in August 2018, 139 in February 2019 and 156 in August 2021. An electronic checklist based on selected core functions of IDSR was developed and uploaded onto tablets using the Open Data Kit (ODK) platform. Supervision teams interviewed health care workers, reviewed documents and made observations in health facilities. Supervision books were used to record feedback and corrective actions. Data from the supervisory visits was downloaded from ODK platform, cleaned and analysed. Categorical data was summarized using frequencies and proportions while means and medians were used for continuous variables. Z test was used to test for differences in proportions. RESULTS: Completeness of IDSR reporting improved from 84.5% in 2016 to 96% in 2021 (11.5% points; 95% CI 3.6, 21.9; P-value 0.003). Timeliness of IDSR reports improved from 80.3 to 92% (11.7% points; 95% CI 2.4, 22.9; P-value 0.01). There was significant improvement in health worker knowledge of IDSR concepts and tools, in availability of IDSR standard case definition posters and reporting tools and in data analysis practices. Availability of vaccines and temperature monitoring tools in health facilities also improved significantly but some indicators dropped such as availability of IDSR technical guidelines and malaria testing kits and drugs. CONCLUSION: Supervision using electronic tool contributed to health systems strengthening through longitudinal tracking of core IDSR indicators and other program indicators such as essential malaria commodities and availability and status of routine vaccines. Supervision using electronic tools should be extended to other programs.

Electronic reporting of integrated disease surveillance and response: lessons learned from northeast, Nigeria, 2019.

BACKGROUND: Electronic reporting of integrated disease surveillance and response (eIDSR) was implemented in Adamawa and Yobe states, Northeastern Nigeria, as an innovative strategy to improve disease reporting. Its objectives were to improve the timeliness and completeness of IDSR reporting by health facilities, prompt identification of public health events, timely information sharing, and public health action. We evaluated the project to determine whether it met its set objectives. METHOD: We conducted a cross-sectional study to assess and document the lessons learned from the project. We reviewed the performance of the local government areas (LGAs) on timeliness and completeness of reporting, rumors identification, and reporting on the eIDSR and the traditional paper-based system using a checklist. Respondents were interviewed online on the relevance, efficiency, sustainability, project progress and effectiveness, the effectiveness of management, and potential impact and scalability of the strategy using structured questionnaires. Data were cleaned, analyzed, and presented as proportions using an MS Excel spreadsheet. Responses were also presented as direct quotes. RESULTS: The number of health facilities reporting IDSR increased from 103 to 228 (117%) before and after implementation of the eIDSR respectively. The timeliness of reporting was 43% in the LGA compared to 73% in health facilities implementing eIDSR. The completeness of IDSR reports in the last 6 months before the evaluation was ≥85%. Of the 201 rumors identified and verified, 161 (80%) were from the eIDSR pilot sites. The majority of the stakeholders interviewed believed that eIDSR met its predetermined objectives for public health surveillance. The benefits of eIDSR included timely reporting and response to alerts and disease outbreaks, improved timeliness, and completeness of reporting, and supportive supervision to the operational levels. The strategy helped stakeholders to appreciate their roles in public health surveillance. CONCLUSION: The eIDSR has increased the number of health facilities reporting IDSR, enabled early identification, reporting, and verification of alerts, improved timeliness and completeness of reports, and supportive supervision of staff at the operational levels. It was well accepted by the stakeholder as a system that made reporting easy with the potential to improve the public health surveillance system in Nigeria.

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.

Maternal death surveillance and response in Tanzania: comprehensiveness of narrative summaries and action points from maternal death reviews.

BACKGROUND: Maternal deaths reviews are proposed as one strategy to address high maternal mortality in low and middle-income countries, including Tanzania. Review of maternal deaths relies on comprehensive documentation of medical records that can reveal the sequence of events leading to death. The World Health Organization's and the Tanzanian Maternal Death and Surveillance (MDSR) system propose the use of narrative summaries during maternal death reviews for discussing the case to categorize causes of death, identify gaps in care and recommend action plans to prevent deaths. Suggested action plans are recommended to be Specific, Measurable, Attainable, Relevant and Time bound (SMART). To identify gaps in documenting information and developing recommendations, comprehensiveness of written narrative summaries and action plans were assessed. METHODS: A total of 76 facility maternal deaths that occurred in two regions in Southern Tanzania in 2018 were included for analysis. Using a prepared checklist from Tanzania 2015 MDSR guideline, we assessed comprehensiveness by presence or absence of items in four domains, each with several attributes. These were socio-demographic characteristics, antenatal care, referral information and events that occurred after admission. Less than 75% completeness of attributes in all domains was considered poor while 95% and above were good/comprehensive. Action plans were assessed by application of SMART criteria and according to the place of planned implementation (community, facility or higher level of health system). RESULTS: Almost half of narrative summaries (49%) scored poor, and only1% scored good/comprehensive. Summaries missed key information such as demographic characteristics, time between diagnosis of complication and commencing treatment (65%), investigation results (47%), summary of case evolution (51%) and referral information (47%). A total of 285 action points were analysed. Most action points, 242(85%), recommended strategies to be implemented at health facilities and were mostly about service delivery, 120(42%). Only 42% (32/76) of the action points were deemed to be SMART. CONCLUSIONS: Abstraction of information to prepare narrative summaries used in the MDSR system is inadequately done. Most recommendations were unspecific with a focus on improving quality of care in health facilities.

Measuring Timeliness of Outbreak Response in the World Health Organization African Region, 2017-2019.

Large-scale protracted outbreaks can be prevented through early detection, notification, and rapid control. We assessed trends in timeliness of detecting and responding to outbreaks in the African Region reported to the World Health Organization during 2017-2019. We computed the median time to each outbreak milestone and assessed the rates of change over time using univariable and multivariable Cox proportional hazard regression analyses. We selected 296 outbreaks from 348 public reported health events and evaluated 184 for time to detection, 232 for time to notification, and 201 for time to end. Time to detection and end decreased over time, whereas time to notification increased. Multiple factors can account for these findings, including scaling up support to member states after the World Health Organization established its Health Emergencies Programme and support given to countries from donors and partners to strengthen their core capacities for meeting International Health Regulations.

Engaging community health workers in maternal and infant death identification in Khayelitsha, South Africa: a pilot study.

BACKGROUND: Engaging community health workers in a formalised death review process through verbal and social autopsy has been utilised in different settings to estimate the burden and causes of mortality, where civil registration and vital statistics systems are weak. This method has not been widely adopted. We piloted the use of trained community health workers (CHW) to investigate the extent of unreported maternal and infant deaths in Khayelitsha and explored requirements of such a programme and the role of CHWs in bridging gaps. METHODS: This was a mixed methods study, incorporating both qualitative and quantitative methods. Case identification and data collection were done by ten trained CHWs. Quantitative data were collected using a structured questionnaire. Qualitative data were collected using semi-structured interview guides for key informant interviews, focus group discussions and informal conversations. Qualitative data were analysed thematically using a content analysis approach. RESULTS: Although more than half of the infant deaths occurred in hospitals (n = 11/17), about a quarter that occurred at home (n = 4/17) were unreported. Main causes of deaths as perceived by family members of the deceased were related to uncertainty about the quality of care in the facilities, socio-cultural and economic contexts where people lived and individual factors. Most unreported deaths were further attributed to weak facility-community links and socio-cultural practices. Fragmented death reporting systems were perceived to influence the quality of the data and this impacted on the number of unreported deaths. Only two maternal deaths were identified in this pilot study. CONCLUSIONS: CHWs can conduct verbal and social autopsy for maternal and infant deaths to complement formal vital registration systems. Capacity development, stakeholder's engagement, supervision, and support are essential for a community-linked death review system. Policymakers and implementers should establish a functional relationship between community-linked reporting systems and the existing system as a starting point. There is a need for more studies to confirm or build on our pilot findings.

A rapid assessment of the implementation of integrated disease surveillance and response system in Northeast Nigeria, 2017.

BACKGROUND: Integrated disease surveillance and response (IDSR) is the strategy adopted for public health surveillance in Nigeria. IDSR has been operational in Nigeria since 2001 but the functionality varies from state to state. The outbreaks of cerebrospinal meningitis and cholera in 2017 indicated weakness in the functionality of the system. A rapid assessment of the IDSR was conducted in three northeastern states to identify and address gaps to strengthen the system. METHOD: The survey was conducted at the state and local government areas using standard IDSR assessment tools which were adapted to the Nigerian context. Checklists were used to extract data from reports and records on resources and tools for implementation of IDSR. Questionnaires were used to interview respondents on their capacities to implement IDSR. Quantitative data were entered into an MS Excel spreadsheet, analysed and presented in proportions. Qualitative data were summarised and reported by thematic area. RESULTS: A total of 34 respondents participated in the rapid survey from six health facilities and six local government areas (LGAs). Of the 2598 health facilities in the three states, only 606 (23%) were involved in reporting IDSR. The standard case definitions were available in all state and LGA offices and health facilities visited. Only 41 (63%) and 31 (47.7%) of the LGAs in the three states had rapid response teams and epidemic preparedness and response committees respectively. The Disease Surveillance and Notification Officers (DSNOs) and clinicians' knowledge were limited to only timeliness and completeness among over 10 core indicators for IDSR. Review of the facility registers revealed many missing variables; the commonly missed variables were patients' age, sex, diagnosis and laboratory results. CONCLUSIONS: The major gaps were poor documentation of patients' data in the facility registers, inadequate reporting tools, limited participation of health facilities in IDSR and limited capacities of personnel to identify, report IDSR priority diseases, analyze and interpret IDSR data for decision making. Training of surveillance focal persons, provision of IDSR reporting tools and effective supportive supervisions will strengthen the system in the country.

Causes of maternal deaths and delays in care: comparison between routine maternal death surveillance and response system and an obstetrician expert panel in Tanzania.

BACKGROUND: To reduce maternal mortality Tanzania introduced Maternal Death Surveillance and Response (MDSR) system in 2015 as recommended by World Health Organization (WHO). All health facilities are to notify and review all maternal deaths inorder to recommend quality improvement actions to reduce deaths in future. The system relies on consistent and correct categorization of causes of maternal deaths and three phases of delays. To assess its adequacy we compared the routine MDSR categorization of causes of death and three phases of delays to those assigned by an independent expert panel with additional information from Verbal Autopsy (VA). METHODS: Our cross-sectional study included 109 reviewed maternal deaths from two regions in Tanzania for the year 2018. We abstracted the underlying medical causes of death and the three phases of delays from MDSR system records. We interviewed bereaved families using the standard WHO VA questionnaire. The obstetrician expert panel assigned underlying causes of death based on information from medical files and VA according to International Classification of Disease to Death in Pregnancy Childbirth and Puerperium (ICD-MM). They assigned causes to nine ICD-MM groups and identified the three phases of delays. We used Cohen's K statistic to compare causes of deaths and delays categorization. RESULTS: Comparison of underlying causes was done for 99 deaths. While 109 and 84 deaths for expert panel and MDSR respectively were analyzed for delays because of missing data in MDSR system. Expert panel and MDSR system assigned the same underlying causes in 64(64.6%) deaths (K statistic 0.60). Agreement increased in 80 (80.8%) when causes were assigned by ICD-MM groups (K statistic 0.76). The obstetrician expert panel identified phase one delays in 74 (67.9%), phase two in 24 (22.0%) and phase three delays in all 101 (100%) deaths that were assessed for this delay while MDSR system identified delays in 42 (50.0%), 10 (11.9%) and 78 (92.9%).The expert panel found human errors in management in 94 (93.1%) while MDSR system reported in 53 (67.9%) deaths. CONCLUSIONS: MDSR committees performed reasonably well in assigning underlying causes of death. The obstetrician expert panel found more delays than reported in MDSR system indicating difficulties within MDSR teams to critically review deaths.

Analysis of the Iranian maternal mortality surveillance system and providing system improvement strategies: study protocol for strategy formulation.

BACKGROUND: The implementation of the maternal mortality surveillance system in Iran has significantly reduced the incidence of maternal mortality. However, the pattern of the causes of the mortalities, which has remained constant over the years, are still concerning. This study aimed to explain the experiences of the actors of the Iranian maternal mortality surveillance and provide strategies for improving this system. METHODS: This research is a qualitative study to develop strategies, that will be conducted in two phases. In the first phase, purposive sampling will be performed, and the data will be collected based on the experiences of the Iranian maternal mortality surveillance system actors in Iran's Ministry of Health and the selected universities (Shiraz, Isfahan, Tehran, Zahedan, Alborz, Shahrekord) through semi-structured interviews. Moreover, during this phase, some part of the data will be collected through random participation of the researcher in some maternal mortality committees of the selected universities. In order to carry out the second phase, a panel of experts will be set up to discuss the best strategies for improving the Iranian maternal mortality surveillance by considering the above results. DISCUSSION: The analysis of maternal mortality surveillance system needs to evaluate the experiences of the actors who are the policymakers of this system and can be effective in identifying its challenges. This analysis and formulation of the subsequent strategies can lead to maternal health indicators remaining within the range of international standards or even beyond those standards in Iranian universities and countries with similar surveillance system.

Prospects and strategies for malaria elimination in the Greater Mekong Sub-region: a qualitative study.

BACKGROUND: As malaria elimination becomes a goal in malaria-endemic nations, questions of feasibility become critical. This article explores the potential challenges associated with this goal and future strategies for malaria elimination in the Greater Mekong Sub-region. METHODS: Thirty-two semi-structured interviews were conducted with policy makers (n = 17) and principal investigators (n = 15) selected based on their involvement in malaria prevention, control and elimination in the GMS. Interviews were audio-recorded and transcribed for qualitative content (thematic) analysis using QSR NVivo. RESULTS: All respondents described current malaria control and elimination strategies, such as case detection and management, prevention and strengthening of surveillance systems as critical and of equal priority. Aware of the emergence of multi-drug resistance in the GMS, researchers and policy makers outlined the need for additional elimination tools. As opposed to a centralized strategy, more targeted and tailored approaches to elimination were recommended. These included targeting endemic areas, consideration for local epidemiology and malaria species, and strengthening the peripheral health system. A decline in malaria transmission could lead to complacency amongst funders and policy makers resulting in a reduction or discontinuation of support for malaria elimination. Strong commitment of policymakers combined with strict monitoring and supervision by funders were considered pivotal to successful elimination programmes. CONCLUSION: Against a backdrop of increasing anti-malarial resistance and decreasing choices of anti-malarial regimens, policy makers and researchers stressed the urgency of finding new malaria elimination strategies. There was consensus that multi-pronged strategies and approaches are needed, that no single potential tool/strategy can be appropriate to all settings. Hence there is a need to customize malaria control and elimination strategies based on the better surveillance data.

Evaluation of the Maternal Death Surveillance and response system in Hwange District, Zimbabwe, 2017.

BACKGROUND: Maternal Death Surveillance and Response (MDSR) system was established to provide information that effectively guides actions to eliminate preventable maternal mortality. In 2016, Hwange district sent six maternal death notification forms (MDNF) to the province without maternal death audit reports. Timeliness of MDNF reaching the province is a challenge. Two MDNF for deaths that occurred in February and May 2016 only reached the provincial office in September 2016 meaning the MDNF were seven and four months late respectively. We evaluated the MDSR system in Hwange district. METHODS: A descriptive cross-sectional study was conducted. Health workers in the sampled facilities were interviewed using questionnaires. Resource availability was assessed through checklists. Epi Info 7 was used to calculate frequencies, means and proportions. RESULTS: We recruited 36 respondents from 11 facilities, 72.2% were females. Inadequate health worker knowledge, lack of induction on MDSR, unavailability of guidelines and notification forms and lack of knowledge on the flow of information in the system were reasons for late notification of maternal deaths. Workers trained in MDSR were 83.8%. Only 36.1% of respondents had completed an MDNF before. Respondents who used MDSR data at their level were 91.7%, and they reported that MDSR system was useful. Responsibility to complete the MDNF was placed on health workers. Maternal death case definitions were available in 2/11 facilities, 4/11 facilities had guidelines for maternal death audits. It costs $60.78 to notify a maternal death. CONCLUSION: Reasons for late notification of maternal deaths were inadequate knowledge, lack of induction, unavailability of guidelines and notification forms at facilities. The MDSR system is useful, acceptable, flexible, unstable, reliable but not simple. Maternal case definitions and maternal death audit guidelines should be distributed to all facilities. Training of all health workers involved in MDSR is recommended.

Evaluation of integrated disease surveillance and response (IDSR) core and support functions after the revitalisation of IDSR in Uganda from 2012 to 2016.

BACKGROUND: Uganda is a low income country that continues to experience disease outbreaks caused by emerging and re-emerging diseases such as cholera, meningococcal meningitis, typhoid and viral haemorrhagic fevers. The Integrated Disease Surveillance and Response (IDSR) strategy was adopted by WHO-AFRO in 1998 as a comprehensive strategy to improve disease surveillance and response in WHO Member States in Africa and was adopted in Uganda in 2000. To address persistent inconsistencies and inadequacies in the core and support functions of IDSR, Uganda initiated an IDSR revitalisation programme in 2012. The objective of this evaluation was to assess IDSR core and support functions after implementation of the revitalised IDSR programme. METHODS: The evaluation was a cross-sectional survey that employed mixed quantitative and qualitative methods. We assessed IDSR performance indicators, knowledge acquisition, knowledge retention and level of confidence in performing IDSR tasks among health workers who underwent IDSR training. Qualitative data was collected to guide the interpretation of quantitative findings and to establish a range of views related to IDSR implementation. RESULTS: Between 2012 and 2016, there was an improvement in completeness of monthly reporting (69 to 100%) and weekly reporting (56 to 78%) and an improvement in timeliness of monthly reporting (59 to 93%) and weekly reporting (40 to 68%) at the national level. The annualised non-polio AFP rate increased from 2.8 in 2012 to 3.7 cases per 100,000 population < 15 years in 2016. The case fatality rate for cholera decreased from 3.2% in 2012 to 2.1% in 2016. All districts received IDSR feedback from the national level. Key IDSR programme challenges included inadequate numbers of trained staff, inadequate funding, irregular supervision and high turnover of trained staff. Recommendations to improve IDSR performance included: improving funding, incorporating IDSR training into pre-service curricula for health workers and strengthening support supervision. CONCLUSION: The revitalised IDSR programme in Uganda was associated with improvements in performance. However in 2016, the programme still faced significant challenges and some performance indicators were still below the target. It is important that the documented gains are consolidated and challenges are continuously identified and addressed as they emerge.

The score of integrated disease surveillance and response adequacy (SIA): a pragmatic score for comparing weekly reported diseases based on a systematic review.

BACKGROUND: The Integrated Disease Surveillance and Response (IDSR) strategy implemented by the World Health Organization (WHO) in Africa has produced a large amount of data on participating countries, and in particular on the Democratic Republic of Congo (DRC). These data are increasingly considered as unevaluable and, therefore, as requiring a rigorous process of validation before they can be used for research or public health purposes. The aim of this study was to propose a method to assess the level of adequacy of IDSR morbidity data in reflecting actual morbidity. METHODS: A systematic search of English- and French-language articles was performed in Scopus, Medline, Science Direct, Springer Link, Cochrane, Cairn, Persée, and Erudit databases. Other types of documents were identified through manual searches. Selected articles focused on the determinants of the discrepancies (differences) between reported morbidity and actual morbidity. An adequacy score was constructed using some of the identified determinants. This score was applied to the 15 weekly reported diseases monitored by IDSR surveillance in the DRC. A classification was established using the Jenks method and a sensitivity analysis was performed. Twenty-three classes of determinants were identified in 35 IDSR technical guides and reports of outbreak investigations and in 71 out of 2254 researched articles. For each of the 15 weekly reported diseases, the SIA was composed of 12 items grouped in 6 dimensions. RESULTS: The SIA classified the 15 weekly reported diseases into 3 categories or types: high score or good adequacy (value > = 14), moderate score or fair adequacy (value > = 8 and < 14), and low score or low or non-adequacy (value < 8). Regardless of the criteria used in the sensitivity analysis, there was no notable variation in SIA values or categories for any of the 15 weekly reported diseases. CONCLUSION: In a context of sparse health information in low- and middle-income countries, this study developed a score to help classify IDSR morbidity data as usable, usable after adjustment, or unusable. This score can serve to prioritize, optimize, and interpret data analyses for epidemiological research or public health purposes.

Evaluation of the maternal deaths surveillance and response system at the health district level in Guinea in 2017 through digital communication tools.

BACKGROUND: Reducing maternal mortality still remains a major challenge in low-income countries. This study aims to explore how digital communication tools can be used to evaluate the maternal deaths surveillance and response (MDSR) system at the health district level in Guinea. METHODS: A descriptive cross-sectional study was conducted, using an innovative digital approach called District.Team, from April to September 2017. This study targeted all 38 district medical officers in Guinea. In addition to district medical officers, the participation of health actors from regional and central levels were also expected in the online discussion forum. Data collected through the questionnaire were mixed and those from the online discussion forum were entirely qualitative. RESULTS: In total, 23 (61%) district medical officers (DMOs) participated in the study. Out of health districts (87%) which had updated guidelines and standards for the MDSR, 4 (20%) did not apply the content. In two health districts (8.7%), not all health facilities had maternal deaths notification forms. Three districts (13%) did not have maternal death review committees. In 2016, only half (50.2%) of reported maternal deaths were reviewed. The main recommendation formulated was related to quality of care. Other needs were also highlighted including continuous training of health care providers on emergency obstetric and neonatal care. Less than half (45%) of the review committee's recommendations were implemented. Six health districts (26.1%) did not have a response plan to reported maternal deaths and no district annual report on the MDSR was published in 2016. The weaknesses identified were, among others, insufficiency of human resources and lack of financial resources. Fifty-eight messages related to MDSR weaknesses and improvement solutions were posted in the online discussion forum by 28 participants (23 DMOs and 5 health actors from regional and central levels). CONCLUSION: Digital tools can be used to assess the functioning of a system like maternal deaths surveillance and response. Moreover, the findings of the evaluation conducted will help stakeholders (starting from the health districts themselves) to design strategies and interventions for an effective MDSR.