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EWARN

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EWARN

  1. 1. EARLY WARNINGEARLY WARNING SYSTEMSYSTEM Greater Darfur RegionGreater Darfur Region WHO office SudanWHO office Sudan Federal/ State Ministry ofFederal/ State Ministry of HealthHealth Republic of SudanRepublic of Sudan
  2. 2. RATIONALERATIONALE  IDP settlements areas are at highIDP settlements areas are at high risk of outbreaks. Initially there wasrisk of outbreaks. Initially there was not surveillance system coveringnot surveillance system covering these areasthese areas  NGOs were collecting surveillanceNGOs were collecting surveillance data but not using standardizeddata but not using standardized reporting forms nor standardizedreporting forms nor standardized case definitionscase definitions
  3. 3.  Need of complementing the nationalNeed of complementing the national surveillance system with a systemsurveillance system with a system that allows early detection ofthat allows early detection of possible outbreaks in order to givepossible outbreaks in order to give prompt responseprompt response
  4. 4. OBJECTIVES:OBJECTIVES:  To ensure timely detection response andTo ensure timely detection response and control of outbreaks by early detection atcontrol of outbreaks by early detection at local level of time and place clustering oflocal level of time and place clustering of cases among IDPscases among IDPs  To monitor trends of communicableTo monitor trends of communicable diseases in order to take appropriatediseases in order to take appropriate public health actionspublic health actions  To estimate workload of different healthTo estimate workload of different health units involved in the system to rationalizeunits involved in the system to rationalize resource allocationresource allocation
  5. 5. MAIN CHARACTERISTICS OFMAIN CHARACTERISTICS OF THE SYSTEM:THE SYSTEM:  Very sensitiveVery sensitive detect alldetect all possible casespossible cases  SimpleSimple good acceptabilitygood acceptability among health personnelamong health personnel  Short periodicity of reportingShort periodicity of reporting detectdetect sudden increase of casessudden increase of cases
  6. 6. Early Warning Systems Monitor RespondRecognise Epidemiology & Laboratory capacity Detect cases & outbreaks Implement effective interventions Reduce morbidity & mortality Function of EWARNS Core capacity Output Impact
  7. 7. EWARNS, One Component of Surveillance Systems • Rumour verification • EWARNS – Detect clusters in time, place or persons – Change in trend • Programme monitoring – Programme impact indicators • Surveillance system monitoring – Operation indicators – Support indicators – Output indicators Requiring immediate investigation Requiring programme adjustment Requiring system improvement Requiring verification
  8. 8. Early Detection • Relies on alert network – Local and national – Addressing the unexpected risks • Early warning systems – Subset of surveillance systems – Addressing the known risks • Adequate tools and procedures – Preparedness: appropriate, methods, training, guidelines • Sensitisation of primary health care providers
  9. 9. EARLY WARNING SYSTEM HASEARLY WARNING SYSTEM HAS SHOWN TO BE USEFUL IN OTHERSHOWN TO BE USEFUL IN OTHER COMPLEX EMERGENCY CONTEXTSCOMPLEX EMERGENCY CONTEXTS
  10. 10. Distribution of rash with fever by Week of onset, Albania early warning system, 1999/31-2000/29
  11. 11. MAIN CONSTRAINTS FOR THE EWARS IN DARFUR • Communications • Access/distances • Limited access to health services
  12. 12. TYPE OF SYSTEM:TYPE OF SYSTEM:  PassivePassive  ExhaustiveExhaustive  Aggregated dataAggregated data Continuous collection of data with aContinuous collection of data with a weeklyweekly reporting periodicity.reporting periodicity. Verification of rumors: InformalVerification of rumors: Informal Information.Information.
  13. 13. POPULATION UNDERPOPULATION UNDER SURVEILLANCESURVEILLANCE  All internal displaced populationAll internal displaced population living atliving at present in different conditionspresent in different conditions  Data is aggregated at camp levelData is aggregated at camp level  To calculate incidences, the denominator isTo calculate incidences, the denominator is based on thebased on the OCHA estimated populationOCHA estimated population datadata (other sources: NGOs surveys, HAC).(other sources: NGOs surveys, HAC).
  14. 14. Population figures:Population figures: Internal displaced population figuresInternal displaced population figures have to be reported every week inhave to be reported every week in order to record major events oforder to record major events of population movementspopulation movements
  15. 15. Reporting unitsReporting units  Cases and deaths will be reported at stateCases and deaths will be reported at state levellevel  Reporting units are health units andReporting units are health units and mobile units acting at administrative unitmobile units acting at administrative unit level on IDPslevel on IDPs  Each health unit inside or outside theEach health unit inside or outside the camps report through the standardizedcamps report through the standardized data collection form.data collection form.
  16. 16. HEALTH EVENTS UNDERHEALTH EVENTS UNDER SURVEILLANCESURVEILLANCE  All new casesAll new cases of the 12 selected healthof the 12 selected health events that attend the health unitevents that attend the health unit  All deathsAll deaths detected by health unitsdetected by health units should be reportedshould be reported  New caseNew case: a person attending the health: a person attending the health facility during the week and having newfacility during the week and having new diagnose. Subsequent visits for the samediagnose. Subsequent visits for the same health problem should not be reportedhealth problem should not be reported (repeated case)(repeated case)
  17. 17. HEALTH EVENTS UNDERHEALTH EVENTS UNDER SURVEILLANCESURVEILLANCE  Acute Watery DiarrhoeaAcute Watery Diarrhoea  Diarrhoea with blood (dysentery)Diarrhoea with blood (dysentery)  Suspected MeaslesSuspected Measles  Acute Jaundice syndromeAcute Jaundice syndrome  Suspected meningitisSuspected meningitis  AFPAFP  MalariaMalaria  Neonatal tetanusNeonatal tetanus  InjuriesInjuries  Severe malnutritionSevere malnutrition  Unexplained feverUnexplained fever  OtherOther
  18. 18. CASE DEFINITIONSCASE DEFINITIONS
  19. 19. Health event Definition Acute Watery Diarrhoea Acute watery diarrhoea with severe dehydration in a patients older than five years of age . Diarrhoea with blood (Dysentery) More than 3 loose stools per day (24 hours) with visible blood Acute respiratory infection Fever and at least one of the following : rhinitis, cough, redness or soreness of throat OR Fever and fast breath (> 50 breaths/min) and at least one of the following : cough, difficulty in breathing
  20. 20. Suspected Measles Rash with fever and cough, runny nose or conjunctivitis Acute Jaundice syndrome Acute onset of yellows eyes or skin Suspected meningitis 12 months and over: sudden onset of fever (> 38° C) with stiff neck Under 12 months: fever with bulging fontanel AFP Acute flaccid paralysis in a child aged < 15 years, including Guillain Barré syndrome or any acute paralytic illness in a person of any age.
  21. 21. Malaria Person with fever or history of fever >38°C within the last 48 hours with one or more of the following symptoms: such as nausea, vomiting and diarrhoea, headache, back joint pain, chills, myalgia with positive laboratory test for malaria parasites blood film (thick or thin smear) or rapid diagnostic test .
  22. 22. Neonatal tetanus Suspected case: Any neonatal death between 3 and 28 days of age in which the cause of death is unknown or any neonate reported as having suffered from neonatal tetanus between 3 and 28 days of age and not investigated Confirmed case: Any neonate with a normal ability to suck and cry during the first two days of life, and who between 3 and 28 days of age cannot suck normally, and becomes stiff or has convulsions or both
  23. 23. Injuries Any person with traumas or wounds from any cause that require surgical treatment and hospitalisation Severe malnutrition Malnutrition: In children 6 to 59 months (65cm to 110cm in height): •<70%Weight for height (W/H) index •OR < –3z scores (on table of NCHS/WHOnormalized reference values of weight-for-height by sex). •OR MUAC < 11 cm •Bilateral pitting oedema irrespective of W/H, in absence of other causes.
  24. 24. Unexplained fever Fever (> 38°C) for more than 48 hours and not meeting the above case definitions Others All others medical conditions not meeting the above case definitions This category is used to compute Total Attendance
  25. 25. FLOW OF DATA:FLOW OF DATA:  PeriodicityPeriodicity: weekly (from Saturday to: weekly (from Saturday to Friday)Friday)  Health units should send the forms to theHealth units should send the forms to the state ministry of health on Saturday or tostate ministry of health on Saturday or to the WHO office in the State locality.the WHO office in the State locality.  The State health office will send not laterThe State health office will send not later than Sunday the data to the federalthan Sunday the data to the federal epidemiology department.**epidemiology department.**
  26. 26. INFORMAL COMMUNICATION,INFORMAL COMMUNICATION, Data transmissionData transmission  From health units, NGOs and mobileFrom health units, NGOs and mobile units to State health office: car,units to State health office: car, radio, paper support.radio, paper support.  From State health office to theFrom State health office to the federal state epidemiologyfederal state epidemiology department: by telephonedepartment: by telephone
  27. 27. DATA FLOW
  28. 28. DATA COLLECTION FORMDATA COLLECTION FORM  Form identification number to beForm identification number to be completed by the State epidemiologycompleted by the State epidemiology unit officeunit office  Date of reception at State to beDate of reception at State to be completed at State epidemiology unitcompleted at State epidemiology unit  Date of reception at federal stateDate of reception at federal state
  29. 29.  Identification of the healthIdentification of the health Units/NGO, mobile unit:Units/NGO, mobile unit:  Admin UnitAdmin Unit  VillageVillage  Camps/IDP settlementsCamps/IDP settlements  Name of health unitName of health unit  NGONGO
  30. 30.  Period of reporting:Period of reporting: week for which theweek for which the cases are reported.cases are reported.  Reporting Units should indicates the datesReporting Units should indicates the dates (starting Saturday to ending Friday) of(starting Saturday to ending Friday) of weekweek  Health events under surveillance:Health events under surveillance: According standardized case definitions ofAccording standardized case definitions of the surveillance system. Each healththe surveillance system. Each health facility should have a list with the casefacility should have a list with the case definitions available.definitions available.
  31. 31.  Only new cases and deaths have toOnly new cases and deaths have to be reportedbe reported  The cases and deaths have to beThe cases and deaths have to be reported by age groups:reported by age groups: – 0-4 YRS0-4 YRS – 5 and more years5 and more years
  32. 32. DATA ENTRY AND ANALYSISDATA ENTRY AND ANALYSIS  An Epi info application (version 6.04)An Epi info application (version 6.04) was developed allowing simple datawas developed allowing simple data entry, analysis and automaticentry, analysis and automatic reports.reports.  The application has been installed atThe application has been installed at State ministry of health and WHOState ministry of health and WHO state officesstate offices
  33. 33. INDICATORSINDICATORS Indicators are computed in the application for weekly reportsIndicators are computed in the application for weekly reports and at different geographic level (camp, administrativeand at different geographic level (camp, administrative unit, State, Federal):unit, State, Federal): – Number of new cases and deaths for each health event byNumber of new cases and deaths for each health event by weekweek – Total attendanceTotal attendance – Case fatality ratioCase fatality ratio – Proportional morbidity by age group (0-4 and 5+)Proportional morbidity by age group (0-4 and 5+) – Distribution of new cases by geographical levedlDistribution of new cases by geographical levedl – Number of health facilities reporting and number of healthNumber of health facilities reporting and number of health facilites expected to reportfacilites expected to report – Incidence rate of health events by weekIncidence rate of health events by week – Under five mortality rate per 10,000 pop per weekUnder five mortality rate per 10,000 pop per week – Crude mortality rate per 10,000 population per weekCrude mortality rate per 10,000 population per week – Completeness of reporting unitsCompleteness of reporting units – Timeliness from camps to the stateTimeliness from camps to the state
  34. 34. DATA VALIDATIONDATA VALIDATION Health Units:Health Units:  Check that cases reportedCheck that cases reported correspond to the case definitionscorrespond to the case definitions and that only new cases areand that only new cases are reported.reported.  Before sending the forms to theBefore sending the forms to the State ministry of health check thatState ministry of health check that all the information is completedall the information is completed
  35. 35.  Check that the period of reporting isCheck that the period of reporting is correctcorrect  Check the number of cases andCheck the number of cases and deaths reported for each healthdeaths reported for each health event:event: – CoherenceCoherence e.g. neonatal tetanus ine.g. neonatal tetanus in children over 5 years is not coherentchildren over 5 years is not coherent – Excessive or (abnormally smallExcessive or (abnormally small)) number of cases: Is this a real increasenumber of cases: Is this a real increase of the cases diagnosed or is it an errorof the cases diagnosed or is it an error while completing the formwhile completing the form DATA VALIDATION AT THE HEALTH UNITDATA VALIDATION AT THE HEALTH UNIT (CONTINUATION)(CONTINUATION)
  36. 36. State level:State level:  Write the number record form on the formWrite the number record form on the form  Check that the period of reporting isCheck that the period of reporting is correctcorrect  Check the number of cases and deathsCheck the number of cases and deaths reported for each health eventsreported for each health events  CoherenceCoherence  After producing the weekly report checkAfter producing the weekly report check results (tables, graphs, maps) for errorsresults (tables, graphs, maps) for errors  Check if population figures are correctCheck if population figures are correct DATA VALIDATIONDATA VALIDATION
  37. 37. Timeliness of reporting is important!Timeliness of reporting is important!  Reporting forms from health unitsReporting forms from health units should arrive in State ministry ofshould arrive in State ministry of health or WHO on Saturday/Sundayhealth or WHO on Saturday/Sunday  Sunday data is send via e-mail or faxSunday data is send via e-mail or fax to Federal MoH and WHO Khartoumto Federal MoH and WHO Khartoum officeoffice CALL BACK!CALL BACK!
  38. 38. THRESHOLDS TRIGGERINGTHRESHOLDS TRIGGERING ACTIONSACTIONS  Measles:Measles: – One case of measles detected amongOne case of measles detected among IDPs is considered an outbreak and willIDPs is considered an outbreak and will require immediate investigation andrequire immediate investigation and response from EPI teamresponse from EPI team  AFPAFP – One case of AFP detected among IDPs isOne case of AFP detected among IDPs is considered an outbreak and will requireconsidered an outbreak and will require immediate investigation specimenimmediate investigation specimen collection and response from EPI team.collection and response from EPI team.
  39. 39.  MeningitisMeningitis – Doubling of the number of suspectedDoubling of the number of suspected meningitis cases from one week to themeningitis cases from one week to the next for a period of three weeks will benext for a period of three weeks will be considered an alert and will requireconsidered an alert and will require laboratory confirmation and active caselaboratory confirmation and active case finding.finding. – Five cases of suspected meningitis perFive cases of suspected meningitis per 100,000 IDPs per week in areas with100,000 IDPs per week in areas with more than 30,000 displaced will bemore than 30,000 displaced will be considered an alert and will requireconsidered an alert and will require laboratory confirmation.laboratory confirmation. THRESHOLDSTHRESHOLDS
  40. 40. MeningitisMeningitis – Two cases of suspected meningitis perTwo cases of suspected meningitis per week during two weeks, detectedweek during two weeks, detected among IDPs in camps under 30,000among IDPs in camps under 30,000 persons is considered an outbreak andpersons is considered an outbreak and will require immediate laboratorywill require immediate laboratory confirmation and active case findingconfirmation and active case finding THRESHOLDSTHRESHOLDS
  41. 41.  Bloody diarrhoeaBloody diarrhoea – Sudden rise of clustered cases of bloodySudden rise of clustered cases of bloody diarrhoea, or doubling cases in two consecutivediarrhoea, or doubling cases in two consecutive weeks is considered an alert and will requireweeks is considered an alert and will require immediate laboratory confirmation and activeimmediate laboratory confirmation and active case findingcase finding – An increase in the percentage of bloodyAn increase in the percentage of bloody diarrhoea (bloddy diarrhea*100/Total diarrhea)diarrhoea (bloddy diarrhea*100/Total diarrhea) is considered an alert and will requireis considered an alert and will require immediate laboratory confirmation and activeimmediate laboratory confirmation and active case findingcase finding THRESHOLDSTHRESHOLDS
  42. 42.  Watery DiarrhoeaWatery Diarrhoea – One death for watery diarrhoea amongOne death for watery diarrhoea among patients of five years and older willpatients of five years and older will require immediate laboratoryrequire immediate laboratory confirmation and active case findingconfirmation and active case finding – Steady increase of watery diarrhoea inSteady increase of watery diarrhoea in the age group older than five years willthe age group older than five years will require immediate investigation,require immediate investigation, laboratory confirmation and active caselaboratory confirmation and active case findingfinding THRESHOLDSTHRESHOLDS
  43. 43.  Neonatal TetanusNeonatal Tetanus – One case of neonatal tetanus willOne case of neonatal tetanus will require immediate investigation for therequire immediate investigation for the related hygienic practices applied forrelated hygienic practices applied for deliveriesdeliveries  MalariaMalaria – Steady and unusual increase ofSteady and unusual increase of confirmed severe malaria cases or of theconfirmed severe malaria cases or of the case fatality ratio will need immediatecase fatality ratio will need immediate actionaction THRESHOLDSTHRESHOLDS
  44. 44.  Severe malnutritionSevere malnutrition – Detection of one severe malnourished child willDetection of one severe malnourished child will require further nutritional investigation in therequire further nutritional investigation in the communitycommunity  Unexplained feverUnexplained fever – Steady and progressive increase ofSteady and progressive increase of unexplained fever with related unusualunexplained fever with related unusual mortality will require immediate investigationmortality will require immediate investigation  Acute jaundice syndromeAcute jaundice syndrome – Clustered cases of jaundice will requireClustered cases of jaundice will require laboratory confirmation and active caselaboratory confirmation and active case finding.finding. THRESHOLDSTHRESHOLDS
  45. 45. Laboratory confirmation
  46. 46. EWAR ACTIONS Health Units, NGOs: • The health personnel in charge at the reporting units should report immediately to the State health office and camp managers the occurrence of: • A case of suspected measles • A case of AFP • A case of suspected NNT • A case of suspected Meningitis • A case of suspected VHF
  47. 47. ANY CLUSTER OF SEVER DISEASEANY CLUSTER OF SEVER DISEASE SHOULD BE REPORTED ANDSHOULD BE REPORTED AND INVESTIGATEDINVESTIGATED
  48. 48. Health Units, NGOs should reportHealth Units, NGOs should report immediately:immediately:  Unusual deaths among patients olderUnusual deaths among patients older than 5 years of age with waterythan 5 years of age with watery diarrhoeadiarrhoea  Any unexpected health event (e.g.Any unexpected health event (e.g. cluster of sever diseases, cluster ofcluster of sever diseases, cluster of deaths)deaths)
  49. 49. RUMOURS VERIFICATIONRUMOURS VERIFICATION  The health personnel in charge at theThe health personnel in charge at the reporting units shouldreporting units should verifyverify immediately the consistencyimmediately the consistency of theof the informal informationinformal information  In case of confirmation of theIn case of confirmation of the rumours they should reportrumours they should report immediately to the campimmediately to the camp managers/State ministry of healthmanagers/State ministry of health
  50. 50. EWAR ACTIONS:EWAR ACTIONS: Epidemiology State Department:Epidemiology State Department:  Check weekly reports (reported healthCheck weekly reports (reported health events) against defined thresholds forevents) against defined thresholds for each of themeach of them  All health events that match the definedAll health events that match the defined thresholds in terms of number of cases or,thresholds in terms of number of cases or, rates or percentage have to berates or percentage have to be immediately investigated and reported toimmediately investigated and reported to Federal MoH.Federal MoH.
  51. 51. Epidemiology State Department:Epidemiology State Department:  Ensure that the appropriateEnsure that the appropriate specimen samples are collected andspecimen samples are collected and sent to Khartoum for analysissent to Khartoum for analysis  If the field reference laboratory inIf the field reference laboratory in Nyala is already operative twoNyala is already operative two samples from the same patient, onesamples from the same patient, one is sent to Nyala and the other for QIis sent to Nyala and the other for QI to Khartoum.to Khartoum.
  52. 52. The State epidemiology departmentThe State epidemiology department produce in weekly bases a summaryproduce in weekly bases a summary report (bulletin) including:report (bulletin) including:  A summary table with the number ofA summary table with the number of new cases reportednew cases reported  Any relevant epidemiologicalAny relevant epidemiological informationinformation  Any suspected outbreakAny suspected outbreak
  53. 53. EWAR ACTIONSEWAR ACTIONS Federal Epidemiology Department:Federal Epidemiology Department:  Confirm or not, alerts and analyze theConfirm or not, alerts and analyze the data produced at Sate leveldata produced at Sate level  Guarantee together with the internationalGuarantee together with the international agencies and NGOs involved that theagencies and NGOs involved that the necessary sources are available at statenecessary sources are available at state level to allow the response and control oflevel to allow the response and control of outbreaksoutbreaks
  54. 54. EWAR ACTIONSEWAR ACTIONS National Public Health Laboratory:National Public Health Laboratory:  Keep records (registry) of all theKeep records (registry) of all the information related to the specimeninformation related to the specimen in the way to facilitate thein the way to facilitate the identificationidentification  Make diagnosis and communicateMake diagnosis and communicate immediately to the State the resultsimmediately to the State the results by telephone, Fax, e-mail or radioby telephone, Fax, e-mail or radio
  55. 55. Summary procedures at each level:Summary procedures at each level: Health Unit, NGOsHealth Unit, NGOs::  At the end of the week the doctor/nurse orAt the end of the week the doctor/nurse or health assistant in charge will fill the formhealth assistant in charge will fill the form using the information of the registry bookusing the information of the registry book  Check the data for possible errorsCheck the data for possible errors  Send data collection form filled to theSend data collection form filled to the State MoHState MoH
  56. 56. State Epidemiology Unit:State Epidemiology Unit:  Receive and collect the formsReceive and collect the forms  Write the sequential identification numberWrite the sequential identification number on the formon the form  Check the form for any possible mistakeCheck the form for any possible mistake  Contact the health units that haven’t sentContact the health units that haven’t sent on time the formson time the forms  Check the data entry for possible errorsCheck the data entry for possible errors  Keep a file with all paper formsKeep a file with all paper forms
  57. 57.  Send a copy of the forms or electronic fileSend a copy of the forms or electronic file to Federal epidemiology dept.to Federal epidemiology dept.  Prepare the weekly reportPrepare the weekly report  Do a copy of the data in the PC and in aDo a copy of the data in the PC and in a diskettediskette  Implement response and control accordingImplement response and control according defined threshold in coordination with alldefined threshold in coordination with all other partnersother partners  Collect and send specimen samples to theCollect and send specimen samples to the reference laboratoryreference laboratory
  58. 58. THANKS YOU

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