Integrated Disease Surveillance and Response: Updating the IDSR Matrix

1. Integrated Disease Surveillance and Response:Updating the IDSR Matrix Helen Perry, PhD Team lead, IDSR Division of Public Health Systems and Workforce Development (PPHSWD) FELTP and Systems (Africa) Branch Centers for Disease Control and Prevention Atlanta, GA IANPHI Regional Meeting for Africa November 3, 2010

2. What is IDSR? What problem is it solving? The first 10 years: how IDSR began The next 10 years: responding to change Updating the framework

3. In mid-1990s, Africa experienced several devastating outbreaks – (I then say the 4 instances on the slide). This situation led African countries to request WHO-AFRO and their technical partners to work with countries to improve surveillance capacity for detecting and responding to diseases that impact African communities. In mid-1990s, Africa experienced several devastating outbreaks – (I then say the 4 instances on the slide). This situation led African countries to request WHO-AFRO and their technical partners to work with countries to improve surveillance capacity for detecting and responding to diseases that impact African communities.

4. IDSR Vision “Within ten years, all Member States will have established an effective and functional IDSR system that will generate information for timely action thus contributing to the reduction of mortality, disability and morbidity.” WHO-AFRO Regional Committee September 1998 So in S2008, the the WHO AFRO Regional Committee comprised of Ministers of Health from all 46 Members of the WHO African region adopted IDSR. The vision they laid out for themselves was that …”……I say what’s on the slide…”So in S2008, the the WHO AFRO Regional Committee comprised of Ministers of Health from all 46 Members of the WHO African region adopted IDSR. The vision they laid out for themselves was that …”……I say what’s on the slide…”

5. IDSR priority diseases: 1998-2008 Epidemic prone diseases Cholera Diarrhea with blood Measles Meningitis Plague Viral hemorrhagic fevers Yellow fever Diseases for elimination/eradication Acute flaccid paralysis / poliomyelitis Dracunculiasis Leprosy Neonatal tetanus Diseases of public health importance AIDS Diarrhea with dehydration <5 y old Malaria Onchocerciasis Pneumonia < 5 y old Sexually transmitted infections Trypanosomyasis Tuberculosis Diseases targeted by IHR (2005) IDSR aimed to prioritize the leading causes of illness, death and disability in the African region and in 2008, began to incorporate the diseases and conditions targeted by the revised International Health Regulations such as pandemic influenza.IDSR aimed to prioritize the leading causes of illness, death and disability in the African region and in 2008, began to incorporate the diseases and conditions targeted by the revised International Health Regulations such as pandemic influenza.

6. Among the problems that IDSR addressed was to alleviate the burden placed on district level officers from the demands of multiple, vertical disease programs. Each program had its own form, defintions, relquirements and resources. The result was the district struggled with too many forms, too many bosses, conflicting defintions and competing priorities and requirements with no consistent feedback. The result was a lack of efficiency in expending of resources and duplication of work.. Among the problems that IDSR addressed was to alleviate the burden placed on district level officers from the demands of multiple, vertical disease programs. Each program had its own form, defintions, relquirements and resources. The result was the district struggled with too many forms, too many bosses, conflicting defintions and competing priorities and requirements with no consistent feedback. The result was a lack of efficiency in expending of resources and duplication of work..

7. In IDSR, forms were aligned into more streamlined processes and integrated forms. Surveillance case definitions were standardized throughout national systems to ensure all sites were reporting according to the same definitions, feedback was highlighted and supported. The outcome has been information for continued strengthening, better understanding of the implementation gaps, and even public health action.In IDSR, forms were aligned into more streamlined processes and integrated forms. Surveillance case definitions were standardized throughout national systems to ensure all sites were reporting according to the same definitions, feedback was highlighted and supported. The outcome has been information for continued strengthening, better understanding of the implementation gaps, and even public health action.

8. Planning an integrated system: a matrix of skills and activitiesPerry et al, BMC Medicine 2007 This the framework that illustrates how IDSR implementation aims to improve the generic functions of surveillance across all levels of the health system. This includes the support functions of laboratory, training, logistics, and communications. This the framework that illustrates how IDSR implementation aims to improve the generic functions of surveillance across all levels of the health system. This includes the support functions of laboratory, training, logistics, and communications.

9. As part of the implementation process, countries adapted generic guidelines in order to incorporate their particular disease priorities and national context. This is an example of the guidelines for Ghana.As part of the implementation process, countries adapted generic guidelines in order to incorporate their particular disease priorities and national context. This is an example of the guidelines for Ghana.

10. IDSR Technical guidelines promote data for action Standard case definition for reporting cases Surveillance threshold for taking action Cholera: a single suspected case triggers an investigation including laboratory confirmation Laboratory guidelines and standards Training objectives for surveillance and for laboratory steps for confirming cholera Disease-specific recommendations for response to confirmed outbreak. The guidelines contain information such as the standard case defintions for the priority diseases, surveillance thresholds for action, laboratory guidance for the collection of specimens for confirmation of suspected outbreaks, training stratgies and disease-specific recommendations.The guidelines contain information such as the standard case defintions for the priority diseases, surveillance thresholds for action, laboratory guidance for the collection of specimens for confirmation of suspected outbreaks, training stratgies and disease-specific recommendations.

11. Examples of action thresholdsPerry et al., BMC Medicine 2007 An example of the disease specific thresholds: epidemic-prone diseases such as cholera, eradication programs such as polic and endemic epidemics in Africa such as malaria. Each threshold is linked to action.An example of the disease specific thresholds: epidemic-prone diseases such as cholera, eradication programs such as polic and endemic epidemics in Africa such as malaria. Each threshold is linked to action.

12. IDSR performance indicators  Summary and case-based data reported on time to next level Trend analysis for priority diseases is current Reported outbreaks are investigated Reported outbreaks are laboratory confirmed Response implemented for confirmed outbreak and evaluated to illustrate what IDSR hopes to see as success, these are the core IDSR indicators that describe what we hope to accomplish at this point in the initiative. Progress towards implementation is being measured through evidence of improved timely reporting, reporting of case-based data, data analysis at local levels, investigation and laboratory confirmation of outbreaks, and an appropriate response. Several disease programs have CFR targets, and IDSR provides data to those programs so that can monitor their disease targets. to illustrate what IDSR hopes to see as success, these are the core IDSR indicators that describe what we hope to accomplish at this point in the initiative. Progress towards implementation is being measured through evidence of improved timely reporting, reporting of case-based data, data analysis at local levels, investigation and laboratory confirmation of outbreaks, and an appropriate response. Several disease programs have CFR targets, and IDSR provides data to those programs so that can monitor their disease targets.

13. Role of laboratory in IDSR Confirm epidemics Monitor trends An integral component of IDSR involves inclusion and strengthening of the laboratory for confirming epidemics and monitoring trends.An integral component of IDSR involves inclusion and strengthening of the laboratory for confirming epidemics and monitoring trends.

14. Laboratory performance indicators Laboratory data is reported on time. Transport of adequate specimens to referral laboratory Supervision and quality control at periphery Correct culture and antimicrobial results for bacterial specimens Participate in outbreak investigation Participate in External Quality Assurance Program IDSR promoted laboratory indicators to monitor progress towards functional laboratory surveillance programs in countries. A successful public health laboratory system is one where … (and then I read/paraphrase the indicators).IDSR promoted laboratory indicators to monitor progress towards functional laboratory surveillance programs in countries. A successful public health laboratory system is one where … (and then I read/paraphrase the indicators).

15. IDSR has been able to focus on guidance for improving systems such as the development of laboratory networks as illustrated by the guide for national public health laboratory networking and in supporting skills for laboratorians in the safe collection, handling, storing, transporting and processing of specimens for confirming suspected public health threats.IDSR has been able to focus on guidance for improving systems such as the development of laboratory networks as illustrated by the guide for national public health laboratory networking and in supporting skills for laboratorians in the safe collection, handling, storing, transporting and processing of specimens for confirming suspected public health threats.

16. The second decade: what is making us change?

19. Megacitiesmetropolitan area in excess of 10 million peopleby 2030, 3 out of 5 people will live in cities 7 rapidly growing cities Accra Johannesburg Pretoria Khartum Kinshasa / Brazzaville Lagos Nairobi Changing health priorities due to: Slums Traffic Pollution Urban life pressures Diabetes Hypertension

20. While some progress is being made in sub-Saharan Africa on decreasing rates of under-5 mortality and other MDG health indicators, African countries continue to lag behind the rest of the world. Strengthened surveillance systems are important for early detection, confirmation and results of these leading causes of illness to support countries in detecting, characterizing and responding to disease threats in time to do something about them….While some progress is being made in sub-Saharan Africa on decreasing rates of under-5 mortality and other MDG health indicators, African countries continue to lag behind the rest of the world. Strengthened surveillance systems are important for early detection, confirmation and results of these leading causes of illness to support countries in detecting, characterizing and responding to disease threats in time to do something about them….

21. International Health Regulations (2005) Finally, the adoption by all countries in WHO of the revised International Health Regulations which went into force in 2007 place an obligation on African countries to meet the surveillance capacity requirements noted in the IHR document. Specifically, Annex 1 of the IHR (2005) call for creation of core competencies for surveillance and response at all levels of the health system. In the WHO African region, implementation of the IHR is taking place through the IDSR strategy of streamlining resources, processes and assets towards creation of functional disease surveillance systems reaching all levels of the health system.Finally, the adoption by all countries in WHO of the revised International Health Regulations which went into force in 2007 place an obligation on African countries to meet the surveillance capacity requirements noted in the IHR document. Specifically, Annex 1 of the IHR (2005) call for creation of core competencies for surveillance and response at all levels of the health system. In the WHO African region, implementation of the IHR is taking place through the IDSR strategy of streamlining resources, processes and assets towards creation of functional disease surveillance systems reaching all levels of the health system.

22. “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade" (Article 2) Not intended to "interfere" with purely national events The traffic and trade objective comes AFTER the health objectiveNot intended to "interfere" with purely national events The traffic and trade objective comes AFTER the health objective

23. The implementation strategy for IHR highlights as significant the strengthening of national capacity for surveillance, prevention, control and rapid response to health threats. This is a compatible strategy with IDSR and provides for synergistic investments that will help African countries address their own national priorities through IDSR as well as meeting global priorities through IHR.The implementation strategy for IHR highlights as significant the strengthening of national capacity for surveillance, prevention, control and rapid response to health threats. This is a compatible strategy with IDSR and provides for synergistic investments that will help African countries address their own national priorities through IDSR as well as meeting global priorities through IHR.

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26. IDSR matrix evolves to include IHR (2005)

29. Revised IDSR Technical Guidelines – October 2010 Non-communicable diseases New public health priorities (e.g., pandemic influenza) Focus on community surveillance Preparedness Disease specific fact-sheets

30. Summary New communicable and non-communicable diseases are emerging as public health priorities in African communities. Stronger public health systems for responding to existing and new priorities require data for action. Integrating resources for surveillance and response can lead to national public health systems that contribute to healthier African communities.

31. Thank you and nowLet’s hear your ideas…!