Sentinel Health Surveillance System

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Sentinel Health Surveillance System

• Kamal Mustafa
• TO/RBM
• WHO, Afghanistan

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Sentinel Health Surveillance System

• Sentinel Health Surveillance System
• Is one of the public health surveillance methods
  for systematic collection, analysis,
  interpretation, investigation and control
  response, and dissemination of data regarding a
  health-related event for use in public health
  action to reduce morbidity and mortality and to
  improve health.
• The aim of this approach is to obtain high
  quality and consistent data from a limited number
  of sites.
• reliable results can be achieved if appropriate
  indicators are selected, representative
  facilities are chosen and active cooperation of
  the staff and the community is ensured

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Sentinel Health Surveillance System

• An optimal sentinel health surveillance
  system will have the following characteristics
• be representative of geographic areas
• include facilities from all sectors of the health
  care system that provide the relevant care
• have information about the population represented
• have information on the total number of patients
  seen during the surveillance exercise in the
  facility to allow for trend determination.

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Sentinel Health Surveillance System

•  Data obtained through sentinel site surveillance
  system can be used to
• Initiate and guide immediate action for cases of
  public health importance
• measure the burden of a disease (or other
  health-related event), including the
  identification of populations at high risk
• monitor trends of a disease including the
  detection of epidemics
• support the planning, implementation, and
  evaluation of programs to prevent and control
  disease, injury, or harmful exposure
• evaluate public policy
• detect changes in the environment, and risk
  factors and health practices among the community
  and the effects of these changes
• help prioritize the allocation of health
  resources
• describe the course of disease in the community
• provide a basis for and inputs to epidemiological
  research.

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Sentinel Health Surveillance System Afghanistan
(an initiative by WHO, USAID/REACH and MOH)

• This initiative aims for developing a sentinel
  surveillance system that focuses on a small
  number of diseases and conditions of major public
  health importance in Afghanistan that require
  urgent action for disease control, and that
  complements the work of current Health Management
  Information System.
• It was initiated in June 2004 by discussions
  between WHO, USAID/REACH and MOH on the lack of
  rapid epidemiological information about major
  diseases in Afghanistan, the need for proper
  national diseases surveillance and quick response
  systems as a function of Public Health, and the
  importance of collaborative efforts in developing
  these systems

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Sentinel Health Surveillance System Afghanistan

• Goal
• The overall goal of this initiative is to
  develop a functional national sentinel health
  surveillance and response system in Afghanistan
  focusing on a set of diseases of public health
  importance to produce actionable data in a timely
  manner

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Sentinel Health Surveillance System Afghanistan

• Specific Objectives 
• To develop a surveillance system that is simple,
  feasible, affordable and sustainable
• To develop a system that complements current HMIS
  systems by producing data from a wider variety of
  sources and linking it with rapid response health
  teams for intervention
• To make use of facilities and resources which are
  already functional and reliable, such as the, the
  WHO polio/EPI surveillance network.

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Sentinel Health Surveillance System Afghanistan

• To measure the burden of a limited number of
  diseases of high public health importance in a
  rapid and continuous manner.
• To have a training and capacity-building
  component for field epidemiologists through
  regular training and mentoring at the provincial
  level.
• Improve data quality at the local level through
  rigorous application of epidemiological methods
  and simple tools such as the weekly watch
  chart.

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Sentinel Surveillance Approach Afghanistan
Malaria endemic provinces
Provinces to pilot integrated sentinel
surveillance
Sentinel sites established to monitor AM drug
resistance
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Sentinel Surveillance Approach in Afghanistan

• Conceptual Framework 
• Guiding Principles of the Proposed Sentinel
  Surveillance System
•  
• Establish baseline prevalence
• Detect outbreaks and epidemics
• Develop rapid response to epidemics/outbreaks
• Monitor changes of disease over time
• Focus resources to solve problems
• System uses syndromic approach as appropriate

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Sentinel Health Surveillance System Afghanistan

• B. Proposed Priority Diseases to be initially
  addressed by the (Sentinel) Health Surveillance
  System 
• TB
• Malaria
• Severe ARI pneumonia under 5
• Severe diarrhea/diarrhea with dehydration
• Maternal deaths (pending review of feasibility
  for study)
• (These diseases are listed initially because
  they emerged as the top 5 priorities in the
  Provincial Planning Process recently completed in
  15 provinces.)

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Sentinel Health Surveillance System Afghanistan

• C. Strategies  
• Use of whole, or sub-sample of, WHO Polio
  surveillance Focal Points at district level. WHO
  currently has a system encompassing 458 sentinel
  sites and up to 4,000 community based reporting
  points throughout Afghanistan primarily set up to
  monitor polio and measles cases
• Expanding Focal Points responsibility to include
  extended list of diseases for surveillance (
  such as TB and malaria)
• Define syndromes more precisely and develop
  workable case and outbreak definitions    
• Define surveillance roles and responsibilities of
  staff at each level of the system
• Develop procedures for notification,
  investigation and control action for each disease
  or condition (cases and outbreaks)
• Encourage active and rigorous use of the WHO
  weekly watch chart as a method of improving
  data collection and use at the local level
• Encourage focal points to visit sites for
  confirmation of cases, also to make more
  efficient use of regular visitations of focal
  points to sites
• Training and costs
• o       At present 15/mo fixed incentive for
  data reporting, plus 15 per polio case
  investigation and follow up. Establishment of
  one S. Site to monitor AM drug efficacy costs
  5,000
• o       Support for equipment, materials and
  forms
• o       Investigation of potential sources of
  incentives, such as per diems for training
• A staged implementation of the surveillance
  system in the provinces of Baghlan and Takhar

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Sentinel Health Surveillance System Afghanistan

• Expand involvement to a range of stakeholders and
  interested parties such as
• o       Technical Deputy Minister of Health
• o       Directorate of Planning, MOH
• o       Directorate of HMIS, MOH
• o       UNICEF
• o       CCM/Global Fund
• o       CDC Atlanta
• o       PHC providers at the provincial level
• A stakeholder analysis and definition of
  responsibilities be carried out to include those
  who provide data for the system and those who use
  the information generated by the system, such as
  health-care providers, provincial health
  officials government officials at local and
  central levels community residents
  nongovernmental organizations and donor
  organizations. All involved stake holders must be
  consulted and given an opportunity to provide
  feedback in order to establish a system
  acceptable to all. 
• Particular attention should be paid to the
  particular geographical, environmental, political
  and economic conditions present in Afghanistan
  when establishing the surveillance system.

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Sentinel Health Surveillance System Afghanistan

• D. Operational framework
• When establishing a surveillance system, all
  aspects of the system and its procedures should
  be described in detail to allow stakeholders to
  review and validate the description of the system
  and for other involved parties to understand the
  complexity and resources needed to operate such a
  system. Duplication and repetition of existing
  gathering strategies data and systems should be
  avoided. The description of the surveillance
  process should address
• 1) system wide characteristics , including data
  and transmission standards to facilitate
  interoperability and data sharing between
  information systems, security, privacy, and
  confidentiality
• 2) data sources used broadly in this framework to
  include the data-producing facility (such as, the
  reporting point), the data type (e.g., chief
  complaint, survey form, diagnosis, laboratory
  test ), and the data format (e.g., electronic or
  paper, text descriptions of events or illnesses,
  or structured data stored in standardized
  formats)
• 3) data processing before analysis (the data
  collation, filtering, transformation, and routing
  functions required for public health to use the
  data)
• 4) statistical analysis (tools for automated
  screening of data for potential outbreaks)
• 5) epidemiologic analysis, interpretation, and
  investigation (the rules, procedures, and tools
  that support decision-making in response to a
  system signal, including adequate staffing with
  trained epidemiologists who can review, explore,
  and interpret the data in a timely manner).
• 6) type of outbreak response
• 7) Provincial level procedures design a
  process by which the provincial surveillance team
  is established and participates in applying the
  case definitions and recommended notification,
  investigation and control procedures to the
  specific condition of the provinces with clear
  definition of local responsibilities.

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Sentinel Health Surveillance System Afghanistan

• E. System costs
• Cost is a vital factor in assessing the relative
  value of surveillance in a given context. Costs
  can be broken down into
• 1) Direct costs, include the fees paid for
  software and data, the personnel salary and
  support expenses (e.g., training, equipment
  support, and travel), and other resources needed
  to operate the system and produce information for
  public health decisions (e.g. office supplies,
  Internet and telephone lines, and other
  communication equipment).
• 2) Variable costs include the cost of follow-up
  activities (e.g., for diagnosis, case-management,
  or community interventions).

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Sentinel Health Surveillance System Afghanistan

• F. Evaluation and Analysis
• Effective program evaluation is a systematic way
  to improve and account for public health actions
  by involving procedures that are useful,
  feasible, ethical, and accurate. Regular
  evaluation and monitoring specially is an
  essential component of a surveillance system and
  establishes the usefulness of surveillance
  systems for outbreak detection or the best ways
  to support this function.

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Sentinel Health Surveillance System Afghanistan

• Issues and Next steps
•  
• Review of mechanisms of information flow and data
  reporting
• Drafting of Action Plans, including
• Implementation of sentinel surveillance systems
  in Afghanistan
• Response to outbreaks
• Estimations of budget costs and resources needed
• Specific definitions of indicators and cases
• Further investigation and analysis of gaps in
  current systems, suggested methods for
  improvement, including site visits at focal
  points and National Reference Labs in Pakistan.

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Sentinel Health Surveillance System Afghanistan

• Malaria inputs for the new approach
• National treatment guidelines and case
  definitions
• National EPR plan and trained EPR focal points
• Sentinel site with trained staff to monitor drug
  resistance in Takhar Province
• National ITNs strategy and trained ITNs
  implementers
• National social mobilization strategy (COMBI) and
  trained facilitators
• Standardized training materials in local
  languages
• National and sub-national ME focal points

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THANK YOU