Integrated Disease Surveillance 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.

IJCM_305A: Forecasting Dengue and Chikungunya incidence using Time Series Analysis Modelling

Background: In recent years, the rise in vector-borne diseases, particularly Dengue and Chikungunya, has posed a significant public health challenge globally. Epidemiological data from the Integrated Disease Surveillance Program (IDSP) is a useful resource for forecasting and early outbreak identification by applying effective models like Sessional Autoregressive Integrated Moving Average (SARIMA) models has proven effective in capturing temporal dependencies in various fields. Objective: To forecast the dengue and chikungunya cases in India using Seasonal Autoregressive Integrated Moving Average models. Methodology: we preprocessing the IDSP dataset to extract relevant temporal patterns and trends. Subsequently, SARIMA models are applied to capture the time dependent dynamics of disease occurrences. The model’s performance is evaluated through rigorous validation processes, including cross-validation techniques, to ensure its reliability and generalizability. Results: This study considered a secondary data set of weekly dengue and chikungunya cases over the period of 2019 to 2023. The time plot shows several spikes in the data, indicating periods where the number of dengue cases increased significantly in the most recent years. Forecast of the future dengue and chikungunya cases was done for the next one year (2024). we observed that the number of dengue and chikungunya cases has fluctuated over time but has generally remained within a certain range. The forecast predicts a significant increase in cases as we move towards the latter half of 2024, with a very sharp spike towards the end of the forecast period. Conclusion: In conclusion, utilizing a secondary dataset spanning from 2019 to 2023, this study employed time series analysis to forecast future Dengue and Chikungunya cases. The forecast predicts a significant increase in dengue cases during 2024 which can lead to potential implications for public health practitioners, policymakers, and researchers involved in infectious disease management.

IJCM_369A: Notification of malaria and dengue outbreaks during COVID-19 pandemic: A secondary analysis of weekly IDSP reporting

Background: Like many other diseases, vector borne diseases related health activities got affected during COVID-19 due to disruption in health services. The preventive measures, vector surveillance, diagnostics, early diagnosis, and management are likely to have been affected. Objective: To explore the vector-borne disease trends as outbreaks from January 2021 to December 2023 using weekly reports of Integrated Disease Surveillance Programme (IDSP). Methodology: We used the secondary data of the weekly reports of IDSP weekly reports from Jan 2020 Dec 2023. We included dengue and malaria as two important diseases to represent the prevailing vector borne diseases in the country. The outbreak data collected were entered in MS Excel and reported as frequency and proportions to visualize the time trends during the COVID-19 pandemic. Results: The outbreaks of malaria were found to occur mainly in the second half of the year with 63% and 80% outbreaks in the years 2020 and 2021 respectively, coinciding with the onset of monsoons. Maximum number of outbreaks was reported in the year of 2021, followed by 2022 with number of outbreaks being 20 and 19 respectively. Maximum number of dengue outbreaks were reported in the year 2021 followed by year 2022 with the numbers being 114 and 81 respectively. The year 2020 had around half the number of outbreaks as of the year 2022 (42 outbreaks). The first half of the year 2023 reported 25 outbreaks. Conclusion: Both malaria and dengue had maximum number of outbreaks in the year 2021 followed by a slight dip in the year 2022. At the onset of pandemic, the number of outbreaks were quite less compared to the subsequent years, probably due to the lockdown imposed.

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.

Factors influencing operationalization of Integrated Disease Surveillance in Malawi

ObjectivesMalawi's disease surveillance system is built on several different data sources and systems and is informed by the Integrated Diseases Surveillance and Response (IDSR) strategy. This study was carried out as part of a larger multicountry study to identify context-specific factors, which influence the operationalization of integrated disease surveillance. Study design and methodsA total of six focus group discussions were conducted with 43 relevant personnel at the primary and secondary healthcare levels in two districts (Lilongwe and Dowa) and at the national level. The discussions were analyzed and sorted into predefined categories based on the domains of the International Association of Public Health conceptual framework. ResultsWe found ongoing efforts to enhance integrated disease surveillance operationalization, including the establishment of the Public Health Institute of Malawi for coordination, digitalizing the surveillance system through One Health Surveillance Platform, and improving communication among rapid response teams using WhatsApp. The adoption of World Health Organization's third edition IDSR technical guidelines was also underway. Nonetheless, there were major implementation barriers such as parallel and uncoordinated surveillance systems, priority conditions that cannot be diagnosed at the point of reporting, lack of case definitions and diagnostic codes for priority conditions, reporting forms with unexplained acronyms, illegible data sources, unstable electronic data transfers, inadequate supervision and training, poor enforcement of reporting from private health facilities, high reporting burden, and lack of and feedback to those reporting. ConclusionsThe results fit well into the predefined categories used. The study reveals basic problems with the operationalization, tools, and reporting forms used for IDSR. These findings may have implications for practice and policy in Malawi and other countries where IDSR is the national strategy for surveillance.

The state of integrated disease surveillance globally: synthesis report of a mixed methods study

ObjectivesDisease surveillance is an essential public health function needed to prevent, detect, monitor and respond to health threats. Integrated disease surveillance (IDS) enhances its utility and has been advocated for decades by the World Health Organization. This study sought to examine the state of IDS implementation worldwide. Study designThe study used a concurrent mixed methods approach consisting of a systematic scoping review of the literature on IDS, a survey of International Association of National Public Health Institutes (IANPHI) members and qualitative deep dive case studies in seven countries. MethodsThis report collates, analyses and synthesises the findings from the three components. The scoping review consisted of a review of summarised evidence on IDS. Eight reviews and five primary studies were included. The cross-sectional survey was conducted of 110 IANPHI members representing ninety-five countries. Qualitative case studies were conducted in Malawi, Mozambique, Uganda, Pakistan, Canada, Sweden, and England, which involved thirty-four focus group discussions and forty-eight key informant interviews. ResultsIn the different countries, IDS is conceptualised differently and there are differing levels of maturity of IDS functions. Although the role of National Public Health Institutes has not been well defined in the IDS, they play a significant role in IDS in many countries. Fragmentation between sectors and resourcing (human and financial) issues were common. Good governance measures such as appropriate legislative and regulatory frameworks and roles and responsibilities for IDS were often unclear. The COVID-19 pandemic has strengthened some surveillance systems, often through leveraging existing respiratory surveillance systems. In some instances, improvements were seen only for COVID-19 related data but these changes were not sustained. Evaluation of IDS was also reported to be weak. ConclusionsIntegration should be driven by a clear purpose and contextualised. Political commitment, clear governance, and resourcing are needed. Technology and the establishment of technical communities of practice may help. However, the complexity and cost of integration should not be under-estimated, and further economic and impact evaluations of IDS are needed.

Online capacity building for the health workforce: the case of the Integrated Disease Surveillance and Response for the African region.

The World Health Organisation (WHO) Regional Office for Africa (AFRO) has developed a comprehensive capacity devel-opment programme to support the successful implementation of the Integrated Disease Surveillance and Response 3rd edition Technical Guidelines (IDSR). As part of the learning program, a series of asyn-chronous online courses are offered on OpenWHO in English, French and Portuguese. This paper describes the use of five IDSR online courses and reports on feedback received from learners on Course 1 in the English series. An online learner survey was developed, and a descriptive analysis was conducted. This paper also reports on use related empirical metadata from the OpenWHO platform. Overall, learners (97%-n/N) of Course 1 IDSR English series indicated a positive perception toward their online learning experience because of the quality of course content, its organization, ease of use and relevance to their workplace needs. In addition, 88% (n/N) of learners reported that they had used their acquired knowledge at least sometimes and 54.4% (n/N) had shared their learning with others. Lastly, the quiz analyses showed an average of right answers of 78.97% for quiz 1 and 69.94% for quiz 2. Online learning is an essential component of a blended capacity development programme and provides cost effective, equitable and impactful learning. Learners who have a learning goal and find their needs met in courses tend to show more satisfaction and motivation to share their learning.

Factors influencing integrated disease surveillance and response system in selected districts in the Eastern Region of Ghana.

Ghana adopted the Integrated Disease Surveillance and Response (IDSR) system, which is an integration of the various programs in the surveillance system and can contain disease outbreaks and pandemics. Implementation of the IDSR is influenced by several factors which can affect its functionality and ability to contain disease outbreaks. This study assessed the factors influencing the IDSR system in selected districts in the Eastern Region of Ghana. A cross-sectional study was conducted between February-March, 2022 in Fanteakwa North, Abuakwa South and New Juaben South districts in the Eastern Region of Ghana among health care workers who are involved in IDRS activities. Both primary and secondary data were collected and analyzed using descriptive statistics and regression analysis at 0.05 significant level with 95% confidence interval. Three hundred and forty-seven (347) health care workers participated in the study with 56.2% (195/347) indicating that rumor registers were available at the health facilities. Most of the respondents (64.8%, 225/347) had means of transport for disease surveillance activities while majority (61.9%, 215/347) had case-based forms for case investigation. About half (51.9%, 180/347) of the participants revealed that they did not receive any feedback from the next higher level in the past year. Availability of transport for IDSR activities was almost 3.4 times more likely to contribute positively to IDSR system compared to facilities without transport (AOR = 3.36; 95% CI = 1.44-7.83; p = 0.005). Respondents who have the capacity to apply case definition are 2 times more likely to contribute to an effective IDSR system compared to health workers who cannot apply case definition (AOR = 1.94; 95% CI = 1.17-3.21; p = 0.013). Respondents who did not receive feedback from the next higher level were 52% less likely to have an effective IDSR system compared to respondents who received feedback from the next higher level (AOR = 0.48; 95% CI = 0.23-1.00; p = 0.05). Effective operation of IDSR is affected by the application of case definition and means of transport at health facilities. In addition, the capacity of health care workers to provide feedback can influence the smooth operation of the IDSR in the studied area in Ghana.

Mortality Associated with Priority Diseases in Flood-Affected Areas Using District Health Information System (DHIS2) During September-December 2022: Pakistan Experience.

To quantify the burden of communicable diseases and characterize the most reported infections during public health emergency of floods in Pakistan. The study's design is a descriptive trend analysis. The study utilized the disease data reported to District Health Information System (DHIS2) for the 12 most frequently reported priority diseases under the Integrated Disease Surveillance and Response (IDSR) system in Pakistan. In total, there were 1,532,963 suspected cases during August to December 2022 in flood-affected districts (n = 75) across Pakistan; Sindh Province reported the highest number of cases (n = 692,673) from 23 districts, followed by Khyber Pakhtunkhwa (KP) (n = 568,682) from 17 districts, Balochistan (n = 167,215) from 32 districts, and Punjab (n = 104,393) from 3 districts. High positivity was reported for malaria (79,622/201,901; 39.4%), followed by acute diarrhea (non-cholera) (23/62; 37.1%), hepatitis A and E (47/252; 18.7%), and dengue (603/3245; 18.6%). The crude mortality rate was 11.9 per 10 000 population (1824/1,532,963 [deaths/cases]). The study identified acute respiratory infection, acute diarrhea, malaria, and skin diseases as the most prevalent diseases. This suggests that preparedness efforts and interventions targeting these diseases should be prioritized in future flood response plans. The study highlights the importance of strengthening the IDSR as a Disease Early Warning System through the implementation of the DHIS2.

Penggunaan Kobotoolbox sebagai Prosesor Data Surveilans Terpadu Penyakit (STP) Puskesmas Guntung Manggis

The Integrated Disease Surveillance (IDS) Program at the Guntung Manggis Public Health Center has a problem: the data processing stage only changes tabulation. Data processing is not continued in the form of diagrams, graphs, and mapping, so it will not describe disease trends based on epidemiological characteristics. This will complicate the next stage, namely analyzing the data to produce follow-up recommendations that are not on target. This problem is solved by using the kobotoolbox application for processing IDS data. The use of the kobotoolbox application in processing IDS data was monitored from October to November 2022. The evaluation results used the TAM evaluation model with a score of 95%, and all variables were declared good to very good with a score of (?68,01%), indicating that the kobotoolbox application was very effective in processing IDS data both through questionnaires and interviews. Then the supporting media used, both modules and tutorial videos, are feasible to use with a score of (&gt;61%) in understanding data processing using the kobotoolbox application. It’s hoped that the Surveillance Unit of the Guntung Manggis Public Health Center will continue to use the kobotoolbox application in processing IDS data so that the resulting recommendations are more targeted.

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.

Community health surveillance via digital collection of syndromic and behavior data by community healthcare workers in rural Kenya: a pilot study

Disease surveillance is essential to enable adequate detection and response to disease outbreaks. Syndromic surveillance is used to augment traditional approaches, especially in community-based surveillance. Here we demonstrate that Community Healthcare Workers (CHWs) supported by a mobile phone application can provide community-based syndromic disease surveillance in low-resource settings, and that they are able to generate relevant symptom-based and behavior data such as cough symptoms, use of mosquito nets and availability of household handwashing facilities. We analyzed 1.6 million data points collected by CHWs during home visits in rural Kenya as a proof of principle that the symptoms and behavior they observe can be used as a community-based health surveillance tool. To demonstrate the relevance of the data, we show that national covid-19 case numbers did not align with reported cough symptoms in remote populations, which implies that rural populations did not experience covid-19 outbreaks in tandem with urban populations. We also found that the behavior of using long-lasting insecticidal nets could be tracked by the CHWs, and it followed the seasonality of the mosquito burden. Strengthening community-based syndromic and behavior surveillance through CHWs is therefore a great opportunity to strengthen national public health surveillance and response in Africa and should be included in the Integrated Disease Surveillance and Response (IDSR) strategy.

Mapping cholera risk in Nairobi County, Kenya: a comprehensive analysis of environmental, socio-economic, and WASH factors

Background : Cholera, a globally prevalent waterborne disease, is closely monitored in Kenya as part of the Integrated Disease Surveillance and Response strategy. Understanding regional variations in cholera risk factors and trends is crucial, particularly in Sub-Saharan Africa. This study aimed to construct a risk map for cholera outbreaks in Nairobi County, based on the spatial-temporal dynamics of environmental and socio-cultural factors, Water, Sanitation, and Hygiene (WASH) conditions, and historical cases reported between 2009 and 2019.&#x0D; Methodology : We retrospectively analyzed historical cholera cases in Nairobi, employing spatial analysis to map the spatiotemporal variations in factors associated with cholera outbreaks. A cross-sectional descriptive research design was adopted to investigate the relationship between WASH conditions and cholera outbreaks. Stratified random sampling selected 399 respondents from all 85 wards in Nairobi County. We employed descriptive statistics (percentages and frequencies) and inferential statistics (Chi-square) to assess variable relationships.&#x0D; Results : Cholera cases are concentrated in densely populated, especially informal, settlements. Population size significantly correlated with cholera cases (p-value=0.03). Dumping sites in Nairobi emerged as potential cholera sources within residential areas, with the vicinity showing a slight association with reported cases. Rainfall patterns and humidity levels across Nairobi County also influenced cholera risk.&#x0D; Conclusions : Areas within 400 meters of rivers and sewage lines faced elevated cholera risk. Most cases occurred in slum or regular residential areas. Proximity to dumping sites increased the risk of cholera outbreaks. These findings offer valuable insights for cholera prevention and control strategies in Nairobi County.

Mhealth tools for community-based infectious disease surveillance in Africa: a scoping review protocol

IntroductionCountries in the WHO’s African region have found community-based surveillance useful in ensuring the effectiveness of the Integrated Disease Surveillance and Response strategy. This approach encourages community participation in the...

The role of digital surveillance during outbreaks: the Ghana experience from COVID-19 response.

Over the years, Ghana has made notable strides in adopting digital approaches to address societal challenges and meet demands. While the health sector, particularly the disease surveillance structure, has embraced digitization to enhance case detection, reporting, analysis, and information dissemination, critical aspects remain to be addressed. Although the Integrated Disease Surveillance and Response (IDSR) structure has experienced remarkable growth in digitization, certain areas require further attention as was observed during the COVID-19 pandemic. Ghana during the COVID-19 pandemic, recognized the importance of leveraging digital technologies to bolster the public health response. To this end, Ghana implemented various digital surveillance tools to combat the pandemic. These included the 'Surveillance Outbreak Response Management and Analysis System (SORMAS)', the digitalized health declaration form, ArcGIS Survey123, Talkwalker, 'Lightwave Health information Management System' (LHIMS), and the 'District Health Information Management System (DHIMS)'. These digital systems significantly contributed to the country's success in responding to the COVID-19 pandemic. One key area where digital systems have proved invaluable is in the timely production of daily COVID-19 situational updates. This task would have been arduous and delayed if reliant solely on paper-based forms, which hinder efficient reporting to other levels within the health system. By adopting these digital systems, Ghana has been able to overcome such challenges and provide up-to-date information for making informed public health decisions. This paper attempts to provide an extensive description of the digital systems currently employed to enhance Ghana's paper-based disease surveillance system in the context of its response to COVID-19. The article explores the strengths and challenges or limitations associated with these digital systems for responding to outbreaks, offering valuable lessons that can be learned from their implementation.

Challenges to Effective Implementation of Integrated Disease Surveillance and Response Among Health Workers in Nigeria: A Systematic Review

Challenges to Effective Implementation of Integrated Disease Surveillance and Response Among Health Workers in Nigeria: A Systematic Review

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

ObjectivesIntegrated disease surveillance (IDS) offers the potential for better use of surveillance data to guide responses to public health threats. However, the extent of IDS implementation worldwide is unknown. This study sought to understand how IDS is operationalized, identify implementation challenges and barriers, and identify opportunities for development. Study designSynthesis of qualitative studies undertaken in seven countries. MethodsThirty-four focus group discussions and 48 key informant interviews were undertaken in Pakistan, Mozambique, Malawi, Uganda, Sweden, Canada, and England, with data collection led by the respective national public health institutes. Data were thematically analysed using a conceptual framework that covered governance, system and structure, core functions, finance and resourcing requirements. Emerging themes were then synthesised across countries for comparisons. ResultsNone of the countries studied had fully integrated surveillance systems. Surveillance was often fragmented, and the conceptualization of integration varied. Barriers and facilitators identified included: 1) the need for clarity of purpose to guide integration activities; 2) challenges arising from unclear or shared ownership; 3) incompatibility of existing IT systems and surveillance infrastructure; 4) workforce and skills requirements; 5) legal environment to facilitate data sharing between agencies; and 6) resourcing to drive integration. In countries dependent on external funding, the focus on single diseases limited integration and created parallel systems. ConclusionsA plurality of surveillance systems exists globally with varying levels of maturity. While development of an international framework and standards are urgently needed to guide integration efforts, these must be tailored to country contexts and guided by their overarching purpose.

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

BackgroundIn 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.MethodsWe 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.ResultsDespite 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.ConclusionOur 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.

Collaboration between the National Institute of Health Somalia and the Public Health Agency of Sweden

Abstract Public Health Agency Sweden (PHAS) has been funded by Sida to provide support and assist in capacity building of the National Institute of Health (NIH) Somalia for six years (2019-2025). The PHAS work closely with the Federal Ministry of Health Somalia, Member States and partners like WHO Somalia, Africa CDC and academic institutions to establish NIHS as an institution that can be sustained and grow over time, and that can contribute to the public health and health system infrastructure of Somalia. Main areas of collaboration 2019-2023 have been technical support to the joint taskforce on Integrated Disease Surveillance and Response (IDSR); supporting basic level field epidemiology training to front line health care workers; organizing workshops in data analyses, visualisation and reporting together with SPIDER/Stockholm University and Statistics Sweden. Building research capacity has included organizing a digital workshop: Reconstructing public health institutions in Somalia at the16th World Congress on Public Health 2020, Rome, Italy and support to the 1st NIH Research Conference 30 January - 1 February 2022 in Garowe, Puntland: “Laying the Foundation for Health Research in Somalia”. The hybrid conference attracted more than 180 participants from different universities. The tentative plan for the remaining project period include recruiting two Somali-speaking public health experts to develop the human resources and institutional capacities in order for NIH to become a centre of excellence for public health in Somalia. The main focus area for the remaining project period is supporting the development of the disease surveillance system including methods for analysis and reporting data. Research capacity workshops will be organized and supported, as well as a 2nd NIH Research Conference in 2024. Another important task is resource mobilization for long-term sustainability and coordination with other stakeholders. Key messages • Supporting the development of the disease surveillance system including analytical skills and reporting of data is key. • Coordination with other stakeholders and resource mobilization for long-term sustainability is essential.

Facilitators and Barriers in the Implementation of a Digital Surveillance and Outbreak Response System in Ghana Before and During the COVID-19 Pandemic: Qualitative Analysis of Stakeholder Interviews.

In the past 2 decades, many countries have recognized the use of electronic systems for disease surveillance and outbreak response as an important strategy for disease control and prevention. In low- and middle-income countries, the adoption of these electronic systems remains a priority and has attracted the support of global health players. However, the successful implementation and institutionalization of electronic systems in low- and middle-income countries have been challenged by the local capacity to absorb technologies, decisiveness and strength of leadership, implementation costs, workforce attitudes toward innovation, and organizational factors. In November 2019, Ghana piloted the Surveillance Outbreak Response Management and Analysis System (SORMAS) for routine surveillance and subsequently used it for the national COVID-19 response. This study aims to identify the facilitators of and barriers to the sustainable implementation and operation of SORMAS in Ghana. Between November 2021 and March 2022, we conducted a qualitative study among 22 resource persons representing different stakeholders involved in the implementation of SORMAS in Ghana. We interviewed study participants via telephone using in-depth interview guides developed consistent with the model of diffusion of innovations in health service organizations. We transcribed the interviews verbatim and performed independent validation of transcripts and pseudonymization. We performed deductive coding using 7 a priori categories: innovation, adopting health system, adoption and assimilation, diffusion and dissemination, outer context, institutionalization, and linkages among the aspects of implementation. We used MAXQDA Analytics Pro for transcription, coding, and analysis. The facilitators of SORMAS implementation included its coherent design consistent with the Integrated Disease Surveillance and Response system, adaptability to evolving local needs, relative advantages for task performance (eg, real-time reporting, generation of case-base data, improved data quality, mobile offline capability, and integration of laboratory procedures), intrinsic motivation of users, and a smartphone-savvy workforce. Other facilitators were its alignment with health system goals, dedicated national leadership, political endorsement, availability of in-country IT capacities, and financial and technical support from inventors and international development partners. The main barriers were unstable technical interoperability between SORMAS and existing health information systems, reliance on a private IT company for data hosting, unreliable internet connectivity, unstable national power supply, inadequate numbers and poor quality of data collection devices, and substantial dependence on external funding. The facilitators of and barriers to SORMAS implementation are multiple and interdependent. Important success conditions for implementation include enhanced scope and efficiency of task performance, strong technical and political stewardship, and a self-motivated workforce. Inadequate funding, limited IT infrastructure, and lack of software development expertise are mutually reinforcing barriers to implementation and progress to country ownership. Some barriers are external, relate to the overall national infrastructural development, and are not amenable even to unlimited project funding.