Integrated Disease Surveillance System Research Articles

IJCM_292A: Chikungunya Outbreak Investigation at Village Bolasa, Petlawat, Jhabua, Madhya Pradesh, India, September 2023

Background: Chikungunya, a resurging vector-borne disease caused by chikungunya virus, remains a global health challenge. In 2023, globally 4.4 lakhs suspected cases and 365 fatalities were estimated; India accounting for 21% of the global burden. On 5 September 2023, suspected outbreak of chikungunya was reported at Bolasa village, Jhabua, Madhya Pradesh by local newspaper. Objective: We investigated to confirm the outbreak, describe the epidemiology and provide evidence-based recommendations. Methodology: We compared past three years Integrated Disease Surveillance System (IDSP) data to confirm the outbreak. We defined a suspect case as fever with arthralgia in a resident of Bolasa village, during 20 August-30 October 2023, searched cases by reviewing patients register from health-care-facilities and house-to-house in Bolasa village. Cases were interviewed using semi- structured questionnaire prepared by modifying WHO chikungunya toolbox and data analyzed using Microsoft-Excel. We conducted environmental survey at domestic and peri-domestic areas and serum samples collected for laboratory confirmation. Results: No chikungunya case was reported in the last three years. We identified 117 suspected cases (56% females) with median age of 40 years (range 27-52 years). Other than fever and arthralgia, the other symptoms included bodyache (78%) and headache (67%). Overall attack rate (AR) was 8%; highest AR in Tadvifaliya of 18% followed by Harijan and Patidar faliya with 12% each. Among the cases, 76% stored water in containers without cover, mosquito larvae were found in the containers in the house or nearby place of 60% cases. Of the 20 serum samples tested, nine were positive for chikungunya IgM-antibody. Conclusion: We detected a confirmed chikungunya outbreak in a rural setting with vector breeding sites identified in a community. Outbreak investigation led to vector control by eliminating breeding sites and community sensitization on water storage practices. We recommended early case reporting, periodic entomological surveys and source reduction.

Assessment of the impact of integrated disease surveillance and response system on surveillance management at healthcare facilities in Pakistan.

Disease surveillance is very crucial especially in high vulnerability settings like Pakistan. However, surveillance and outbreak response management are still evolving in the country and research studies are needed to assess the existing system. To assess the impact of integrated disease surveillance and response system (IDSRS) implemented by the provincial government to strengthen infectious disease surveillance and reporting in 6 districts of Pakistan in 2016. A baseline cross-sectional assessment of health facilities and the healthcare workforce was conducted in 2016 to identify needs and gaps in public sector health facilities and the health system of 6 selected districts of Khyber Pakhtunkhwa Province, Pakistan. This was followed by a 2018 endline survey of the same facilities using the same variables. Overall, there was improvement in district management and facility level performance (χ2 (1, 314) = 21.19, P < 0.001, V = 0.26). District level management improved significantly in areas with relatively lower Gross Domestic Product (GDP)? χ2(1, 154) = 30.41, P <0.001, V = 0.44). Facilitation domain variables improved in the lower GDP districts (χ2 (1, 74) = 5.76, P = 0.016, V = 0.28) and showed counterintuitive deterioration (χ2 (1, 74) = 4.80, P = 0.028, V = 0.25) in relatively higher GDP areas. IDSRS is effective in improving surveillance and response systems, however, its effectiveness appears to depend on locale-specific economies and can be enhanced by modifying the implementation approach. Better empowerment of the local workforce can contribute to such improvement.

Characteristics and related factors of waterborne and foodborne infectious disease outbreaks before and after the onset of the COVID-19 pandemic (2017-2021) in the Republic of Korea: a descriptive study.

The incidence of waterborne and foodborne infectious diseases (WFIDs) continues to increase annually, attracting significant global attention. This study examined trends in WFID outbreaks in the Republic of Korea over the 5-year period before and during the coronavirus disease 2019 (COVID-19) pandemic and provided foundational data to establish measures for the prevention and control of WFID outbreaks. We analyzed 2,541 WFID outbreaks from 2017 to 2021 (42,805 cases) that were reported through the Integrated Disease Surveillance System of the Korea Disease Control and Prevention Agency. Outbreaks were defined as the occurrence of gastrointestinal symptoms in ≥2 individuals within a group with temporal and regional epidemiological associations. The related factors associated with WFID outbreaks during the observation period were statistically analyzed. The total number of WFID outbreaks significantly decreased in 2020 during the COVID-19 pandemic and increased to the pre-pandemic level in 2021. Different patterns were observed for each pathogen. The incidence of Salmonella outbreaks more than doubled, while norovirus outbreaks decreased significantly. WFID outbreaks in the Republic of Korea showed different patterns before and during the COVID-19 pandemic, influenced by infection control measures and changes in dietary consumption patterns. Outbreaks of some diseases increased, but the infection control measures applied during the pandemic resulted in a significant decrease in the overall number of WFID outbreaks. This highlights the importance of strengthening the management strategies for outbreak prevention through hygiene inspections, long-term monitoring, education, and promotion by conducting multidimensional analyses to understand the complex related factors.

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

In 2021, a regional strategy for integrated disease surveillance was adopted by member states of the World Health Organization Eastern Mediterranean Region. But before then, member states including Somalia had made progress in integration of their disease surveillance systems. We report on the progress and experiences of implementing an integrated disease surveillance and response system in Somalia between 2016 and 2023. We reviewed 20 operational documents and identified key integrated disease surveillance and response system (IDSRS) actions/processes implemented between 2016 and 2023. We verified these through an anonymized online survey. The survey respondents also assessed Somalia's IDSRS implementation progress using a standard IDS monitoring framework Finally, we interviewed 8 key informants to explore factors to which the current IDSRS implementation progress is attributed. Between 2016 and 2023, 7 key IDSRS actions/processes were implemented including: establishment of high-level commitment; development of a 3-year operational plan; development of a coordination mechanism; configuring the District Health Information Software to support implementation among others. IDSRS implementation progress ranged from 15% for financing to 78% for tools. Reasons for the progress were summarized under 6 thematic areas; understanding frustrations with the current surveillance system; the opportunity occasioned by COVID-19; mainstreaming IDSRS in strategic documents; establishment of an oversight mechanism; staggering implementation of key activities over a reasonable length of time and being flexible about pre-determined timelines. From 2016 to 2023, Somalia registered significant progress towards implementation of IDSRS. The 15 years of EWARN implementation in Somalia (since 2008) provided a strong foundation for IDSRS implementation. If implemented comprehensively, IDSRS will accelerate country progress toward establishment of IHR core capacities. Sustainable funding is the major challenge towards IDSRS implementation in Somalia. Government and its partners need to exploit feasible options for sustainable investment in integrated disease surveillance and response.

Integration of disease surveillance in the English context: a qualitative study

ObjectivesThe world is experiencing increasing threats from infectious diseases and environmental hazards. Integration of disease surveillance systems has been put forth as one way to ensure more timely analysis of data and response. This study sought to explore the current context and state of integration of disease surveillance in England, including the barriers and facilitators to integration, as well as opportunities for improvement. Study designQualitative study with focus groups and key informant interviews. MethodsFocus group discussions (FGDs) and key informant interviews (KIIs) were conducted with key national, regional, and local stakeholders involved in surveillance activities in August and September 2022. These discussions and interviews were recorded, transcribed, and coded using a within-case content and thematic analysis. ResultsIn total, five FGDs and 10 KIIs were conducted with 27 participants. Participants had different views on what integration is, though mostly agreed that surveillance systems in England are not integrated. Lack of standardisation, governance and oversight, and structural and financial barriers were hindering the current system from being more integrated. The additional benefits of integration above and beyond the ‘status quo’ during response activities were questioned by some. ConclusionEngland does not have a single integrated disease surveillance system but has a range of disease-specific surveillance systems that have evolved largely independently to meet operational needs. Greater integration may be desired and to a certain extent is important, but it is essential that it is understood as a means to an end and the overall purpose of surveillance is kept in mind.

Epidemiological Patterns of Seasonal Respiratory Viruses during the COVID-19 Pandemic in Madagascar, March 2020-May 2022.

Three epidemic waves of coronavirus disease-19 (COVID-19) occurred in Madagascar from March 2020 to May 2022, with a positivity rate of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) of 21% to 33%. Our study aimed to identify the impact of COVID-19 on the epidemiology of seasonal respiratory viruses (RVs) in Madagascar. We used two different specimen sources (SpS). First, 2987 nasopharyngeal (NP) specimens were randomly selected from symptomatic patients between March 2020 and May 2022 who tested negative for SARS-CoV-2 and were tested for 14 RVs by multiplex real-time PCR. Second, 6297 NP specimens were collected between March 2020 and May 2022 from patients visiting our sentinel sites of the influenza sentinel network. The samples were tested for influenza, respiratory syncytial virus (RSV), and SARS-CoV-2. From SpS-1, 19% (569/2987) of samples tested positive for at least one RV. Rhinovirus (6.3%, 187/2987) was the most frequently detected virus during the first two waves, whereas influenza predominated during the third. From SpS-2, influenza, SARS-CoV-2, and RSV accounted for 5.4%, 24.5%, and 39.4% of the detected viruses, respectively. During the study period, we observed three different RV circulation profiles. Certain viruses circulated sporadically, with increased activity in between waves of SARS-CoV-2. Other viruses continued to circulate regardless of the COVID-19 situation. Certain viruses were severely disrupted by the spread of SARS-CoV-2. Our findings underline the importance and necessity of maintaining an integrated disease surveillance system for the surveillance and monitoring of RVs of public health interest.

Beyond Lassa Fever: Systemic and structural barriers to disease detection and response in Sierra Leone.

BackgroundLassa fever (LF) often presents clinically as undifferentiated febrile illness. Lassa Fever cases in Sierra Leone have been falling since the 2014–2016 Ebola epidemic. Data from other LF endemic countries suggest that this is not a true reflection of local epidemiological decline, but rather a function of either health seeking behaviour or the health/referral system. In Sierra Leone, many other diseases present with a similar early clinical picture, including COVID-19 and Marburg Disease (which has recently emerged in neighbouring Guinea). This empirical study explores the implementation of health system processes associated with International Health Regulations (IHR) requirements for early detection and timely and effective responses to the spread of febrile disease, through the case study of LF in Sierra Leone.Methodology/Principal findingsThis study used a qualitative approach to analyse local policy and guidance documents, key informant interviews with policy and practice actors, and focus group discussions and in-depth interviews with health care workers (HCWs) and community health workers (CHWs) in Kenema District to examine the ways in which undifferentiated fever surveillance and response policies and processes were implemented in the post-Ebola period. Multiple challenges were identified, including: issues with the LF case definition, approaches to differential diagnosis, specimen transport and the provision of results, and ownership of laboratory data. These issues lead to delays in diagnosis, and potentially worse outcomes for individual patients, as well as affecting the system’s ability to respond to outbreak-prone disease.Conclusions/SignificanceIdentification of ways to improve the system requires balancing vertical disease surveillance programmes against other population health needs. Therefore, health system challenges to early identification of LF specifically have implications for the effectiveness of the wider Integrated Disease Surveillance and Response (IDSR) system in Sierra Leone more generally. Sentinel surveillance or improved surveillance at maternity facilities would help improve viral haemorrhagic fever (VHF) surveillance, as well as knowledge of LF epidemiology. Strengthening surveillance for vertical disease programmes, if correctly targeted, could have downstream benefits for COVID-19 surveillance and response as well as the wider health system—and therefore patient outcomes more generally.

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

The revised integrated disease surveillance and response (IDSR) guidelines adopted by African member states in 2010 aimed at strengthening surveillance systems critical capacities. Milestones achieved through IDSR strategy implementation prior to adopting the revised guidelines are well documented; however, there is a dearth of knowledge on the progress made post-adoption. This study aimed to review key recommendations resulting from surveillance assessment studies to improve implementation of the revitalised IDSR system in the African region based on health workers' perspectives. The review focused on literature published between 2010 and 2019 post-adopting the revised IDSR guidelines in the African region. A systematic literature search in PubMed, Web of Science and Cumulative Index for Nursing and Allied Health Literature was conducted. In addition, manual reference searches and grey literature searches using World Health Organisation Library and Information Networks for Knowledge databases were undertaken. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement checklist for systematic reviews was utilised for the review process. Thirty assessment studies met the inclusion criteria. IDSR implementation under the revised guidelines could be improved considerably bearing in mind critical findings and recommendations emanating from the reviewed surveillance assessment studies. Key recommendations alluded to provision of laboratory facilities and improved specimen handling, provision of reporting forms and improved reporting quality, surveillance data accuracy and quality, improved knowledge and surveillance system performance, utilisation of up-to-date information and surveillance system strengthening, provision of resources, enhanced reporting timeliness and completeness, adopting alternative surveillance strategies and conducting further research to improve surveillance functions. Recommendations on strengthening IDSR implementation in the African region post-adopting the revised guidelines mainly identify surveillance functions focused on reporting, feedback, training, supervision, timeliness and completeness of the surveillance system as aspects requiring policy refinement. PROSPERO registration number CRD42019124108.

Self-reported challenges to border screening of travelers for Ebola by district health workers in northern Ghana: An observational study.

BackgroundThe 2013–2016 Ebola Virus Disease (EVD) outbreak remains the largest on record, resulting in the highest mortality and widest geographic spread experienced in Africa. Ghana, like many other African nations, began screening travelers at all entry points into the country to enhance disease surveillance and response. This study aimed to assess the challenges of screening travelers for EVD at border entry in northern Ghana.Design and methodsThis was an observational study using epidemiological weekly reports (Oct 2014-Mar 2015) of travelers entering Ghana in the Upper East Region (UER) and qualitative interviews with 12 key informants (7 port health officers and 5 district directors of health) in the UER. We recorded the number of travelers screened, their country of origin, and the number of suspected EVD cases from paper-based weekly epidemiological reports at the border entry. We collected qualitative data using an interview guide with a particular focus on the core and support functions (e.g. detection, reporting, feedback, etc.) of the World Health Organization’s Integrated Disease Surveillance and Response system. Quantitative data was analyzed based on travelers screened and disaggregated by the three most affected countries. We used inductive approach to analyze the qualitative data and produced themes on knowledge and challenges of EVD screening.ResultsA total of 41,633 travelers were screened, and only 1 was detained as a suspected case of EVD. This potential case was eventually ruled out via blood test. All but 52 of the screened travelers were from Ghana and its contiguous neighbors, Burkina Faso and Togo. The remaining 52 were from the four countries most affected by EVD (Guinea, Liberia, Sierra Leone, and Mali). Challenges to effective border screening included: inadequate personal protective equipment and supplies, insufficient space or isolation rooms and delays at the border crossings, and too few trained staff. Respondents also cited lack of capacity to confirm cases locally, lack of cooperation by some travelers, language barriers, and multiple entry points along porous borders. Nonetheless, no potential Ebola case identified through border screening was confirmed in Ghana.ConclusionScreening for Ebola remains sub-optimal at the entry points in northern Ghana due to several systemic and structural factors. Given the likelihood of future infectious disease outbreaks, additional attention and support are required if Ghana is to minimize the risk of travel-related spread of illness.

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

BackgroundIntegrated 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.MethodThe 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.ResultsA 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.ConclusionsThe 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.

Toward the Development of an Integrated Climate-Sensitive Disease Surveillance in Southeast Asian Countries: A Situational Analysis.

Changes in climatic conditions influence the transmission of water and/or vector-borne diseases. It is one of the reasons for the emergence and re-emergence of various infectious diseases. This case study documents the learnings from selected Southeast Asian countries that can be useful for developing integrated disease surveillance and early warning system for selected climate-sensitive diseases. Through informal key-informant interviews and site-visits to Sri Lanka, Bhutan, and Thailand, we studied the disease surveillance, meteorological surveillance and early warning systems. These leanings suggest that an integrated data sharing mechanism is essential for real-time disease prediction. Further, there is immense scope for developing mechanisms on the uniform in data collection, data processing and analysis. There is an urgent need for developing a multi-sectoral collaborative plan for the integration of surveillance for real-time prediction of climate-sensitive diseases.

Electronic Processing of Antimicrobial Susceptibilities to Enhance Communicable Disease Surveillance

ObjectiveIllustrate how the Utah Department of Health automatically processes antimicrobial susceptibility results that are received electronically.IntroductionThe emerging threat of antimicrobial resistant organisms is a pressing public health concern. Surveillance for antimicrobial resistance can prevent infections, protect patients in the healthcare setting and improve antimicrobial use. In 2018, the Utah Department of Health mandated the reporting of antimicrobial susceptibility panels performed on selected organisms. Utah utilizes the Electronic Message Staging Area (EMSA), a home-grown application to translate, process, and enter electronic laboratory results into UT-NEDSS, Utah’s integrated disease surveillance system. Processing these results electronically is challenging due to the need to interpret results based on the antimicrobial agent combined with the organism it was performed on. The receipt of antimicrobial susceptibility panels has required enhancements to EMSA for these results to be automatically processed.MethodsStand-alone antimicrobial susceptibility LOINCs are configured within EMSA to concatenate during the preprocessing stage. This tells EMSA that when this LOINC is sent within an HL7 message to find the organism name in the corresponding OBR 26.3 (the parent result field). EMSA then creates a new fabricated code that combines the antimicrobial agent with the organism identified from the culture (example: ‘18906-8 Pseudomonas aeruginosa’ is the fabricated code for Ciprofloxacin susceptibility to Pseudomonas aeruginosa).Once these new fabricated antimicrobial susceptibility codes are created, interpretation rules are programmed using current Clinical and Laboratory Standards Institute (CLSI) breakpoints for each unique organism/antimicrobial combination to determine if the result is Susceptible/Intermediate/Resistant. The interpreted test is then run through a set of condition-specific rules to determine how it should be included into UT-NEDSS.ResultsAntimicrobial susceptibility panels performed on Acinetobacter species, Escherichia coli, Klebsiella species, Pseudomonas aeruginosa, Enterobacter species, Candida auris/haemulonii, Mycobacterium tuberculosis, Neisseria gonorrhoeae, Salmonella species, Shigella species, Streptococcus pneumoniae and invasive Staphylococcus aureus are now included in Utah’s Communicable Disease Reporting Rule. Currently, there are 36 antimicrobial agents programmed into EMSA and there are a total of 217 antimicrobial susceptibility codes programmed into the system.ConclusionsProcessing electronic antimicrobial susceptibility results presents unique challenges for processing. Interpretation of results can vary based on test method, performing laboratory, and organism. Enhancing functionality within EMSA was necessary for combining the antimicrobial agent and organism it was performed on. Implementing systems capable of automatically processing complicated antimicrobial susceptibility results should be a priority for any health department interested in expanding their communicable disease rule to include antimicrobial susceptibility testing.

Disease Surveillance System of Bangladesh: Combating Public Health Emergencies

Disease Surveillance System of Bangladesh: Combating Public Health Emergencies

Surveillance on Arboviral Infections in Georgia by using One Health Approach

ObjectiveIdentify cases of West Nile virus in Black Sea region of Georgia through active surveillance.IntroductionArbovirus infections are causing enormous global burden, while their geographic distribution expands and affects new regions and areas. West Nile virus (WNV), one of the most important pathogens among arboviruses, was historically associated with causing mild febrile illness, however, after the outbreak occurred in the North America, which caused more severe illness, it has received wider recognition. It is believed that the disease can reemerge after a hiatus of several years, and affect new territories, which has happened in 2018 in Greece, with 31 dead among 271 infections by the end of September. In Georgia, there is a lack of clinical suspicion on WNV because of the low awareness among medical society, and the existent passive surveillance system seems to be improved.MethodsIn order to assess the situation in Georgia, medical histories and Electronic Integrated Disease Surveillance System (EIDSS) database was studied, and active surveillance has been conducted with the following case selection criteria: residence - Black Sea region; diagnosis - fever of unknown origin (FUO). Enzyme-linked immunosorbent assay (ELISA) was performed. Mosquitoes were obtained by using light traps and aspirators, and are now being studied. Medical personnel was trained on using WNV case definition.ResultsThree laboratory positive cases were identified from 36 suspected cases. Two of them were males (66%). Age distribution – 28-35 y.o. All three cases resided in the city of Batumi in the Adjara region. A total of 572 mosquitoes were obtained. According to preliminary analysis, the species include: Culex pipiens, Aedes albopictus, A. aegypti, A. caspius, A. geniculatus, Anopheles claviger.ConclusionsThe preliminary data suggests that the burden of WNV in Georgia should be studied with more in-depth approaches and with just passive surveillance activities. It is very important to establish coordinated rapid efforts for disease identification by physicians and veterinarians; and to provide better harmonization of diagnostic tools and integrated national surveillance system. Disease transmission risk needs to be assessed for adequate planning of preventive measures. At this stage, no animals were studied, however, in order to fulfill the One Health approach, we are planning to study horses in the near future.

Establishment of an electronic integrated disease surveillance and response system in Sierra Leone

Purpose: The 2014–16 Ebola epidemic exposed weaknesses within Sierra Leone's disease surveillance system and served as a catalyst to improve detection systems. In 2015, the national Integrated Disease Surveillance and Response (IDSR) system consisted of health facilities (HF) calling/texting or hand-delivering reports to their District Health Management Team (DHMT), DHMT staff entering IDSR data from all HF into a spreadsheet, and each DHMT emailing the file weekly to the national level. When districts lacked adequate bandwidth to upload attachments, DHMT staff emailed a curtailed IDSR data summary to the national level, which jeopardized data timeliness and accuracy. In 2016, Sierra Leone introduced an electronic IDSR (eIDSR) system to gauge feasibility and efficacy in a resource-constrained setting. Methods & Materials: The U.S. Centers for Disease Control and Prevention and eHealth Africa supported the Ministry of Health and Sanitation to establish eIDSR, which transmits data into the web-based District Health Information System (DHIS2). In 2016, district-level eIDSR was piloted then rolled out to all fourteen districts. District-level eIDSR entails HF staff calling the DHMT, then DHMT staff entering data directly into the national DHIS2 database. From 2016–17, facility-level eIDSR was piloted in one district to enable data entry using tablets at all 112 HF in the district, and in 2018, a national scale-up of facility-level eIDSR is underway to reach all 1285 HF in Sierra Leone. Results: After implementing district-level eIDSR, IDSR reporting increased from <40% of HF in 2016 to >97% in 2017, an increase maintained in 2018. The district-level pilot revealed that data-entry time decreased by 63% and errors decreased by 45%. Analyses from the facility-level eIDSR pilot found that data accuracy was 12% higher than data reported through district-level eIDSR. The Joint External Evaluation (JEE) score for real-time surveillance went from “limited” to “developed” capacity between 2016 and 2017. Conclusion: District-level eIDSR improved the timeliness and accuracy of surveillance data. Additional benefits are anticipated with completion of the national scale-up of facility-level eIDSR, and JEE scores are projected to reach the next level of “demonstrated” capacity. Lessons learned in Sierra Leone can inform other low-resource settings considering implementation of electronic disease surveillance systems.

Assessment of laboratory diagnostic and surveillance system for enteric infections in Azerbaijan

Purpose: Our study sought to gain a better understanding of the etiology of infections that fall within the generalized diagnosis of enteric infections with unassigned etiological agent. We hypothesized that meticulous assessment of patient diagnostic and surveillance data from enteric infections in Azerbaijan would increase our knowledge of the enteric disease situation in the country. In consequence, our ability to assign causative agents to enteric infections would be enhanced and gaps in public health detection and reporting requirements could be identified. Methods & Materials: Given the high number of AEI cases with unknown etiology in Azerbaijan, AEI patient data from 2014 to 2016 were analyzed using the Electronic Integrated Disease Surveillance System (EIDSS) and patient information from annual reports from the Bacteriology Laboratory at the Republican Center of Hygiene and Epidemiology. Results: The analysis revealed that yersinosis (0.3% of the cases), shigellosis (0.6%), and salmonellosis (5.7%) were the most common AEI cases. Opportunistic bacterial infections accounted for remaining cases. Between 2014 and 2016, notification of enteric infections improved with every year (i.e., 2014: 67.4% of timely notifications; 2015: 80.4%; 2016: 87.3%). EIDSS entry deficiencies included the lack of antibiotic treatment information in 57.4% of the cases, and an overwhelming incidence of AEI diagnosis based on clinical-epidemiological data (78.6%) and not confirmatory laboratory assays, indicating that treatment received was not etiologically substantiated. Absence of point-of-care, pathogen detection assays covering more agents, especially viral agents, might in part explain the high rate of clinical diagnosis of AEIs as "acute enteric infections of unknown etiology". In fact, in Azerbaijan, only rotaviruses are currently tested when viral enteric infections are suspected. Conclusion: Better communication among health system databases with established minimum data entry requirements, including treatment and disease chronology information, capability for multiple pathogen testing and improvement in the quality of EIDSS entries to reconcile electronic and paper forms of notification are needed. Use of rapid immunological or molecular diagnostic methods, or test strips using immunochromatographic technology, rather than traditional long-term culture assays, should expedite pathogen identification. Altogether, such efforts will improve diagnosis, treatment and spread control of diarrheal diseases in the country.

Isolation of Brucella Melitensis in Azerbaijan in 2014

Purpose: Republican Anti-Plague Station (RAPS) in Azerbaijan provides confirmatory tests for especially dangerous pathogens (e.g.Yersinia pestis, Bacillus anthracis, Brucella spp., Francisella tularensis). In Azerbaijan RAPS and its regional Anti-Plague Divisions (APDs) are responsible for testing human samples for abovementioned pathogens. RAPS receives samples for confirmatory test from patients referred by Baku, regional hospitals and APDs.The aim of this study was to isolate and identify Brucella cultures from human blood samples. Methods & Materials: In 2014, 1,137 blood samples were collected by RAPS from patients with clinical symptoms such as high temperature, perspiration, chills, myalgia, arthralgia, headache, fatigue, lack of appetite. All samples were tested using the Azerbaijan Ministry of Health (EDPs Laboratory Guidelines, 2013) algorithm via bacteriology and serology tests. Blood serum was tested for the presence of the antibodies of Brucella spp. via Huddleson reaction, Rose Bengal test and Wright's reaction. Samples positive for Brucella spp. per Huddleson and Rose-Bengal reactions further were tested by Wright's reaction. Positive blood samples by Wright's reaction with titers 1/200 and higher were then cultured. Isolated pure cultures were examined by biochemical (Urease, Oxidase, Catalase, TSI/H2S, Dye sensitivities) and serology (Trypaflavine, Agglutination with specific polyvalent serum, anti -A and anti -M monospecific sera) tests. Results: Data showed that 54.3% from total number of serum samples were positive by Huddleson reaction; 35.6% from total were positive by Rose-Bengal reaction and 38.7% from total samples were positive by Wright's reaction. Positive blood samples with titer 1/200 and higher from first diagnosed patients (n = 89) were cultured. All isolates were identified as Brucella melitensis (an overall isolation rate was 16.9%). The reports about positive results are sent to the Ministry of Health and State Veterinary Control Service (SVCS) and entered into the Electronic Integrated Disease Surveillance System (EIDSS) database of the Ministry of Health of Azerbaijan. Data from the system allows tracking the incidence of brucellosis and making operational decisions. Conclusion: Future genetic analyses of these isolates can help identify subtypes of Brucella melitensis and establish the origin of B.melitensis circulating in the Azerbaijan territory and compare the results with those of neighboring countries.

Two parallel reporting systems for malaria surveillance in Pakistan, 2013–17: is exact burden reflected?

Background: Pakistan is facing challenges regarding the availability of reliable data for malaria surveillance. These include lack of coordination between different reporting systems and fragmented information system. This study aimed to compare the reporting of malaria surveillance systems in Pakistan. Methods: There are two parallel reporting systems for malaria surveillance in Pakistan, the District Health Information System (DHIS) and Malaria Information System (MIS). DHIS reports on all morbidity at health facility level, while MIS is only used for malaria surveillance in the donor supported districts. A cross sectional study was conducted between July-September 2018 by using the retrospective records of DHIS and MIS data reported to the Directorate of Malaria Control (DOMC) Islamabad during 2013-17. Descriptive and inferential analysis was performed to compare the coverage, outcome and impact indicators. Results: During 2013-17, all districts (n=145, 100%) across Pakistan reported on the DHIS. The MIS reporting coverage has gradually increased from 21 (14.5%) to 72 (49.7%) districts. Reported number of suspected screened and confirmed malaria cases were compared. MIS reported twice the number of suspects screened for malaria (100.5%) and confirmed malaria cases (124.4%) as compared to the DHIS. The difference in the reported average annual blood examination rate (ABER) was 3.8, test positivity rate (TPR) was -0.9 and the annual parasite incidence (API) was 4.9/1000 population over five years between two systems. DHIS reported only half the ABER and API as compared to MIS. Conclusion: There is huge under-reporting of suspected and confirmed malaria cases in the DHIS as compared to MIS. Urgent attention is needed to address this, as it is vital to have uniform reporting of true disease burden across the country. An integrated disease surveillance system, improved data validation systems, and use of the online DHIS-2 are potential options for better integrity and coherence of reported data.

Automated Processing of Electronic Data for Disease Surveillance

Automated Processing of Electronic Data for Disease Surveillance

Rates and risk factors for human cutaneous anthrax in the country of Georgia: National surveillance data, 2008–2015

IntroductionAnthrax is endemic in the country of Georgia. The most common cutaneous anthrax form accounts for 95% of anthrax cases and often is self-resolving. Humans are infected from processing contaminated animal products, contacting sick animals, or by insect bites.ObjectiveWe aimed to describe the burden of human cutaneous anthrax and associated risk factors using the national surveillance data.MethodsWe extracted all human cutaneous anthrax cases from Electronic Integrated Disease Surveillance System (EIDSS) from 1 January 2008 to 31 December 2015. We conducted descriptive analyses to characterize the number of confirmed, probable and suspected cases by age groups, gender, ethnicity, year and geographic area.ResultsOut of 911 reported cutaneous anthrax cases, 299 (33%) were rejected. Out of remaining 612 cases, 437 (71%), 172 (28%), and 3 (<0.004%) were classified as confirmed, probable and suspected cases of cutaneous Anthrax, respectively; 467 (76.3%) were male. Georgians accounted for 56% (343/612) of cutaneous anthrax cases. Handling animal products (aOR 4.36, 95% CI 2.61–7.26) and living near pastoralist routes (aOR 2.74, 95%CI 1.57–4.76) were associated with cutaneous anthrax.ConclusionsThis study provides eight-year trends for cutaneous anthrax in humans in the country of Georgia. A comprehensive explanation for the observed rise and fall of the incidence rates of human cutaneous anthrax in 2008–2015 remains to be clarified but is likely associated with discontinuation of mandatory national livestock vaccination in 2008 coupled with weakened human and animal national health systems which were disrupted after the Soviet Union collapsed. Our analysis identifies living near pastoralist routes, handling animal products and travel to endemic areas within two weeks before the disease onset as risk factors for cutaneous anthrax. The evidence underscores the importance of One Health recommendations to activate anthrax awareness campaigns, supervise the destruction of known anthrax carcasses, record global position system coordinates of sites and disinfect infected soils and introduce a participatory health education tool on anthrax.