INTEGRATED DISEASE SURVEILLANCE AND REPONSE Training Modules for Council (District) Health Management Teams

Transcription

1 THE UNITED REPUBLIC OF TANZANIA MINISTRY OF HEALTH INTEGRATED DISEASE SURVEILLANCE AND REPONSE Training Modules for Council (District) Health Management Teams Participant Manual NOVEMBER 2004

2 Integrated Disease Surveillance and Response (IDSR) in Tanzania is being implemented for the Ministry of Health through a collaboration of the following USAID-funded partners: Centres for Disease Control and Prevention Change Project National Institute for Medical Research Partner Partners for Health Reform plus

3 Integrated Disease Surveillance and Response (IDSR) in Tanzania is being implemented for the Ministry of Health in 12 districts through a collaboration of the following USAID-funded partners: U.S. Centers for Disease Control and Prevention (CDC), Change Project, Partners for Health Reform plus and National Institute for Medical Research (NIMR). List of contributors National Institute for Medical Research (NIMR) Peter K.L Mmbuji Leonard E.G. Mboera William M. Krekamoo Janneth Maridadi-Mghamba Susan F. Rumisha Elizabeth H. Shayo Kesheni P. Senkoro Jumanne M. Mayoka Emaya A. Kapange Andrew Kajeguka Debora M.M. Bulemo Ministry of Health Ahmed Seha Raphael Kalinga Amos Mwakilasa Vincent Mgaya Theopista Mbago Robert Mdoe Anna Nswilla Elias Martin Mohamed A Mohamed Centre for Development of Health, Arusha (CEDHA) Ben Mboya Melkiory Masatu World Health Organization Tanzania Mohamed Amri Partners for Health Reform-plus (PHRplus) Kathryn Banke Lynne Franco Debbie Gueye Margaret Morehouse Kathleen Novak Hirshini Patel Stephanie Posner Chris Tetteh Paul Richardson CHANGE Project Rebecca Fields Eileen Hanlon Ann Jimerson Julia Rosenbaum Mark Weeks TRG Graeme Frelick Fred Rosensweig Centers for Disease Control and Prevention (CDC) Kathy Cavallaro Jeanette St. Pierre USAID Mission/Tanzania Patrick Swai

4 Acknowledgements We would like to express our sincere gratitude to the WHO/AFRO, whose strategy, technical guidelines and self-administered training modules formed the foundation upon which materials were built. Appreciation is also extended to the regions and districts with whom we have worked for their continuous work and feedback in defining roles and responsibilities around which the modules are organized. We would like to thank the Regional Health Management Teams of Arusha/Manyara, Mtwara, Rukwa, Mwanza, Ruvuma, Dodoma, Kagera and Tabora together with Council Health Management Teams of Babati, Mbulu, Masasi, Nkasi, Sumbawanga rural, Mwanza Urban, Tunduru, Dodoma Rural, Mpwapwa, Muleba, and Igunga and Tabora Urban. We thank the Ministry of Health -Tanzania, and especially the IDSR Task Force for supervising the implementation of activities of IDSR in the12 chosen districts. We also acknowledge the Zonal Training Centres for their technical assistance in preparing the training modules. Lastly, we express our gratitude to USAID for the financial support which has enabled this work to be completed.

5 Table of Contents Module 1: Introduction to the Training Module 2: Overview of the Integrated Disease Surveillance and Response Strategy (IDSR) Module 3: Detect and Report Priority IDSR Diseases Module 4: Analyse Data on IDSR Priority Diseases Module 5: Interpreting and Using Data to Respond to Priority Diseases Module 6: Investigate and Respond to Suspected Outbreaks Module 7: Prepare for Disease Outbreaks Module 8: Supervise and Provide Feedback Module 9: Building Support for Successful Surveillance and Response Module 10: Monitor and Evaluate Performance of IDSR Implementation Module 11: Develop an Action Plan Module 12: Evaluation and Training Closure Annexes Annex 1: Acronyms Used in the IDSR Texts Annex 2: Glossary Annex 3: Guidelines for 13 Priority diseases Annex 4: Data collection Tools for Epidemic Preparedness Planning

6 Task 1-1 Introductions Please state: Name Work Station Your responsibilities related to IDSR How long you have worked with your Council Health Management team One thing you hope to learn during the training workshop

7 Task 1-2 Individual Task Think about the disease surveillance and response activities of your Council Health Management Team. Please identify and write down on a piece of paper: one thing you feel your team is doing well one thing you feel your team could be doing more effectively You have 5 minutes

8 Task 1-3 In four groups Reintroduce yourselves if necessary Share what you wrote with the others at your tables Identify any common responses. Have one person ready to make a brief summary and report out for the whole group You have 15 minutes

9 Document 1-1 IDSR Training For District Health Teams Training Objectives The by the end of this course participants will be able to: 1. Explain the IDSR strategy and the importance of the district role in its implementation 2. Support detection and accurate reporting of priority diseases to the regional level 3. Analyse data on IDR priority diseases 4. Interpret and use data to respond to priority diseases 5. Investigate and respond to suspect outbreaks 6. Prepare district for controlling outbreaks 7. Supervise and provide feedback 8. Advocate with communities and district officials to support IDSR implementation 9. Monitor and evaluate performance of IDSR implementation 10. Develop a plan to apply in each district what was learned in the workshop

10 Document 1-2 Workshop Agenda Day No Morning 8:30 12:30 Module 1 Welcome Introduction Pre-test Module 4 Analyse Data on IDSR Priority Diseases Module 7 Prepare for disease outbreaks Module 8 Supervise and provide feedback Module 6 Investigate and respond to suspected outbreaks and epidemics Module 10 Monitor and Evaluate Performance of IDSR I Implementation Module 2 Overview of IDSR Strategy Module 9 Build support for successful surveillance and response Module 11 Develop an action plan Afternoon 1:30 5:00 Module 3 Detect and report priority diseases Module 5 Interpret and Use Data to Respond to Priority Diseases Module 6 (continued) Module 7 (continued Module 9 (continued) Module 11 (continued) Module 12 Post-test Training evaluation Closure

11 Document 1-3 Proposed Working Norms Active participation and full presence Openness to new or different ideas Active listening Balanced participation Honour the schedule Turn cell phones off during sessions

12 Document 2-1 Module 2 Objectives By the end of the module, participants will be able to: 1. Describe how surveillance data helps to understand local public health issues 2. Explain the IDSR strategy for improving surveillance in Tanzania 3. Explain the essential surveillance functions that the Council Health Management Team (CHMT) is expected to perform 4. Discuss the district s role and that of other levels in carrying out the IDSR strategy

13 Document 2-2 Objectives of the IDSR Strategy Strengthen the capacity of the Tanzanian health system to conduct effective surveillance activities and provide better information for planning and managing services of all types. Integrate multiple surveillance and other health information systems so that forms, personnel, and resources can be used more efficiently and effectively. Improve the availability and use of information for decision-making. Improve the flow of surveillance information between and within levels of the health system. Strengthen laboratory capacity and involvement in confirmation of pathogens and monitoring of drug sensitivity. Strengthen the involvement of laboratory personnel in epidemiologic surveillance. Increase the involvement of health workers in the surveillance system. Emphasize community participation in detection and response to public health problems.

14 Document 2-3 Diseases that are the focus of IDSR in Tanzania A. Epidemic-prone diseases* Cholera Bacillary dysentery Plague Measles Yellow fever Cerebral spinal meningitis Rabies/animal bite B. Diseases which are targeted for elimination/eradication Acute flaccid paralysis (AFP) Neonatal tetanus C. Diseases of public health importance Diarrhoea in children aged <5 years Pneumonia in children aged <5 years Malaria Typhoid fever *The clinician must notify the District Medical Officer immeidately after seeing a case of any of the diseases in the epidemic-prone diseases list.

15 Document 2-4 Surveillance functions All levels of the health system are involved in conducting surveillance activities for detecting and responding to priority diseases and conditions and include the following: Step 1 - Identify cases. Using basic, standard case definitions identify priority diseases and conditions. Step 2 - Report suspected cases or conditions to the next level. If this is an epidemic prone disease, investigate and respond immediately. Step 3 - Analyse and interpret data. Compile the data, and analyze it for trends. Compare information with previous periods and summarize the results. Step 4 - Investigate and confirm suspected cases and outbreaks. Take action to ensure that the case or outbreak is confirmed including laboratory confirmation wherever it is feasible. Gather evidence about what may have caused the outbreak and use it to select appropriate control and prevention strategies. Step 5 - Respond. Mobilize resources and personnel to implement the appropriate outbreak or public health response. Step 6 - Provide feedback. Encourage future co-operation by communicating with levels that reported outbreaks and cases about the investigation outcome and success of response efforts. Step 7 - Evaluate and improve the system. Assess the effectiveness of the surveillance system, in terms of timeliness, quality of information, preparedness, thresholds, case management and overall performance. Take action to correct problems and make improvements.

16 Document 2-5a Flow chart for ID SR Steps at D istrict (C H M T) level W eekly reports rec d from facilities A. Decision to investigate/ respond B. N otify appropriate person/level C. Compile weekly sum m ary report and send to region D. Investigate (outbreak investigation and case confirmation) F. Feedback to site of outbreak (e.g. community/ facility) Immediate communication rec d from facilities or border districts A. Decision to investigate/ respond B. N otify appropriate person/level E. O utbreak Response F. Communicate outbreak to border districts G. Compile monthly sum m ary report and send to region Monthly reports rec d from facilities J. Feedback to stakeholders G. Compile monthly data H. Analyze Data I. E vidence based action Compiled reports from treatm ent cam p s during/after outbreak J. Feedback to facilities through supervision mechanism Results and inform ation from labs Feedback from Region on operations and info

17 Document 2-5b Matrix of Steps, Desired Performance, and Tasks for the District Level Steps Desired Performance Tasks DECISION TO INVESTIGATE/ RESPOND NOTIFY APPROPRIATE PERSON OR HIGHER LEVEL COMPILE WEEKLY SUMMARY REPORT AND SEND TO REGION INVESTIGATE (OUTBREAK INVESTIGATION)! Rapid decision to investigate based on incoming information is made! Rapid decision to communicate to appropriate person or higher level is made! Information is rapidly communicated to appropriate person or higher level! Completed weekly report is communicated to region on time! District performs outbreak investigation according to disease specific outbreak investigation protocol Receive weekly reports from facilities, immediate notifications and case based information from facilities or other districts, and rumours Recognize outbreak potential (including cross-facility outbreaks) Decide whether to investigate based on incoming information Decide whether extra support is needed from higher level (or different person) Rapidly communicate to appropriate person and/or level Compile weekly summary report from facilities Send weekly summary report to region on time Inform and assemble investigation team (as in guidelines) Prepare for outbreak investigation at district level Mobilize resources for outbreak investigation Complete outbreak investigation form on suspected cases (data on patient information, patient history, potential source of infection collected) Analyze/interpret data to determine appropriate response Search for other cases based on obtained information Produce investigation report and send to national level

18 Steps Desired Performance Tasks. INVESTIGATE, CONTINUED (CASE CONFIRMATION) OUTBREAK RESPONSE FEEDBACK TO SITE OF OUTBREAK/COMMUNI CATE OUTBREAK TO BORDER DISTRICTS COMPILE MONTHLY SUMMARY REPORT AND SEND TO REGION! District send specimens to appropriate lab! Cases of suspected outbreak are confirmed! Appropriate treatment and preventive measures to control suspected or confirmed outbreak! Feedback of outbreak is communicated to site of outbreak and districts at risk! Summary data are updated based on information on lab data and treatment camps! Completed monthly Prepare for outbreak confirmation at district level according to protocol (including requesting supplies from lab) Collect specimens according to protocol for all potential disease etiologies Fill out lab form requesting test(s) (including susceptibility) and supplying patient information Send specimen to appropriate level lab immediately Receive test results from lab within expected time (test-specific) to confirm epidemic Receive susceptibility information! Convene multi-sectoral epidemic response team Prepare for response at district level according to protocol Mobilise resources for outbreak response Treat cases according to treatment guidelines Initiate control measures according to outbreak protocols (including prevention and community mobilisation) Prepare outbreak response report and sent to national level Communicate results of outbreak investigation and summary of actions to stakeholders (including to those at site(s) of outbreak) Compile monthly data from facilities Review data and verify questionable data Update data based on cases external to facilities (e.g. treatment camps)

19 Steps Desired Performance Tasks report is communicated to region ANALYZE DATA! Analysis of data according to analysis protocols and needs EVIDENCE BASED ACTION! Address routine IDS decision making (adjusting resources, strategies for prevention and control programs)! Planning for surveillance and input into CCHP! Monitor surveillance and response operations! Address quality of incoming data! Identify additional inquiries (requiring further study)! Advocacy FEEDBACK! Feedback of disseminated, analysed data and actions to stakeholders, including facilities and communities Send completed report to region on time with supplementary information based on lab results or other information as appropriate Assess availability of data for denominators Perform analyses according to analysis protocols (including trends and forecasting, geographic and demographic comparisons, incidence rates, case fatality rates, etc) Perform analyses on operations (timeliness and completeness performance from facilities, supplies, managerial) Use data for decisions and action in addressing routine IDS decision making (adjusting resources, strategies, programs) Use data for planning Use data for decisions and action in monitoring district operations (supplies, communications, needs, etc) including when needing extra resources (e.g. human, drugs) Use data for decisions and action in addressing quality of incoming data (including facility information, timeliness, completeness, lab information, denominator data) Use data for identifying additional inquiries (requiring further study) Use of data for advocacy Communicate interpretations of analysed data and summary of actions to stakeholders (incl. Facilities and communities)

20 Document 2-6a Case Study The District s role in Surveillance and Response Dr. Kinga, a new graduate from the Institute of Public Health, Muhimbili University of Health Sciences, Dar-es-salaam has just been posted as the new District Medical Officer (DMO) of Babati District by the Permanent Secretary of the Ministry of Health (Tanzania). Babati district is in a newly created region and is being supported by the Local Government (LG) in collaboration with the National Institute for Medical Research and the National IDSR Task Force in the implementation of the Integrated Disease Surveillance and Response (IDSR) strategy to strengthen communicable disease surveillance and response systems. The DMO decided to do an assessment of the disease surveillance system in the district as a first task. He started to assess the flow of surveillance data from the health facility to the district health office and to the regional health office. At the health facility level, Dr. Kinga visited a sample of the reporting sites: the district hospital, five health centres and ten dispensaries. All the facility in charges interviewed told him that they attended the IDSR training the previous year. He observed that they had the standard case definition booklets in their consulting rooms, which they said they used in identification of cases. When asked about supervision by the district level, they said it happened twice a year. The DMO decided to verify the accuracy of the past month s facility priority diseases report and found that the numbers in two of the monthly IDSR reports were considerably different from the information in the actual facility registers. Dr. Kinga then visited the District Health Office and talked to the Disease Health Officer (DHO) who had been acting as the DMO. The DHO said that every month he planned on spending more time on scrutinising the surveillance data but he never got the time. The DHO said he is aware that some of the health facilities are not reporting in a timely manner and most of the time not all facilities submit their reports but he has not been able to get the time to fix the problem. The DMO said that completeness and timeliness of reporting to the regional level has been good. Dr. Kinga saw line graphs displayed on the wall in the office and observed that data for the past two months had not been plotted. When the DHO was asked whether there had been a recent disease outbreak in the district he answered that there was a cerebral spinal meningitis (CSM) outbreak in the district in the previous year that was detected when 2 cases showed up in the district hospital on the same day. The CHMT investigated the outbreak and instituted the necessary control measures. Dr. Kinga asked about feedback. The DHO showed him a weekly epidemiological bulletin that they had been receiving regularly from the National level through the Regional Office. The DHO also told Dr. Kinga that they also receive a report from the Region showing timeliness and completeness of all districts in the region. This past month s report showed 50% timeliness and 90% completeness.

21 Task 2-1 Individual Task Use the boxes below to identify: A. What is going well in relation to the 7 surveillance functions at each level (mark with a+) B. What needs to be improved in relation to the 7 surveillance functions at each level (mark with a-) For each surveillance function, explain your answer by noting down why you think it is going well or why improvement is needed. If the case study does not provide enough information to assess a particular function at a particular level mark that box with a 0. Facility Level +/- Explanation 1. Identify cases 2. Report to next level 3. Analyse and interpret data 4. Investigate and confirm suspected cases and outbreaks 5. Respond 6. Provide feedback 7.Evaluate and improve the system

22 District Level +/- Explanation 1. Identify cases 2. Report to next level 3. Analyse and interpret data 4. Investigate and confirm suspected cases and outbreaks 5. Respond 6. Provide feedback 7.Evaluate and improve the system Regional Level +/- Explanation 1. Identify cases 2. Report to next level 3. Analyse and interpret data 4. Investigate and confirm suspected cases and outbreaks 5. Respond 6. Provide feedback 7. Evaluate and improve the system

23 Task 2-2 Case study group task Share your individual responses to the task for each of the three levels within the health system Reach agreement on a group response to the task and have one person ready to report. You have 20 minutes

24 Document 2-7 Application-Planning sheet Module 2 Please take a few minutes to think about this module and how it applies to your work. Then answer the following questions. 1. What may you need to clarify regarding your district s role and that of other levels in implementing the IDSR strategy? If so, with whom do you need to clarify this role? 2. What are some ideas you have about ways of clarifying that understanding?

25 Document 3-1 Module 3 Objectives By the end of the module, participants will be able to: 1. Describe Standard Case Definitions (SCDs), thresholds, and urgent notification requirements for outbreak diseases 2. Describe districts expectations of the facility level for detecting and reporting IDSR diseases 3. Review reports that come from facilities to ensure quality data and provide feedback 4. Report on priority diseases to the regional level in a complete and timely manner

26 Document 3-2 Standard Case Definition and Epidemic/Action Thresholds for Communicable Diseases for Health Facility Level Disease Age Cardinal signs Epidemic/Action threshold Acute flaccid paralysis <15 years Sudden lameness (Guillain Barre Syndrome) any suspect of polio Bacillary dysentery All ages Bloody diarrhoea, abdominal pain 2 cases per week at health facility 1 case Cholera 5 years Severe dehydration, acute watery diarrhoea 1 case Diarrhoea + some dehydration + severe dehydration Malaria (Uncomplicated) 2 months 5 years Diarrhoea, restless/ irritable, sunken eyes, drinks eagerly, skin pinch goes back slowly. Diarrhoea + unconscious, sunken eyes, not able to drink, skin pinch goes back very slowly Number of cases clearly exceeding number of cases of previous year/ season All ages High fever ± joint pains, sweats, nausea, chills, vomiting Number of cases in facility or defined area for that period exceeds the expected by 50% Severe Malaria All ages High fever +/- altered consciousness, behavioural change, convulsions, passing black urine, extreme body weakness, severe pallor, jaundice For infants: also inability to drink or breastfeed, or vomiting everything Number of cases for that period exceeds the expected by 50% Measles All ages Fever, rash ± cough, running nose, red eyes 5 cases/ health facility Cerebro-spinal meningitis All ages Sudden fever ± neck stiffness, intense headache, nausea and vomiting, altered consciousness and convulsions, bulged 1 case

27 Neonatal tetanus Newborn days anterior fontanelle (in infants) Unable to suck/feed, stiffness, convulsions Plague All ages Fever, headache, painful swelling of inguinal/ axillary lymph node. Cough with blood stained sputum Pneumonia Severe pneumonia 2 months 5 years 2 months 5 years Cough, rapid/ difficult breathing (2-12mo = >50/ min; 2mo- 5yr = 40/min) Cough, difficult breathing ± chest indrawing, stridor, unable to drink/ breastfeed, vomiting, convulsions, lethargy or unconsciousness Rabies All ages History of animal bite ± fever, mental confusion, fear of drinking water, altered consciousness or death Typhoid All ages Long-standing fever, abdominal pain ± skin rash, constipation/ diarrhoea 1 case 1 case Number of cases for the period clearly exceeds cases of previous year/season 1 case Yellow fever All ages Sudden fever, jaundice within 2 weeks 1 case *AIDS All ages Any person with a positive HIV test and with features of opportunistic infection e.g. TB, fungal infection, etc. *Tuberculosis All ages Person presenting with chronic cough, weight loss, and night sweats. Mycobacterium tubercle isolated from the body specimens. *Viral Hemorrhagic Fever All ages Mild/ severe fever, bleeding from nose, gums, vagina, skin or eyes and vomiting blood 2 cases/ week at health facility 1 case NB: * Not a priority disease in National IDSR guidelines (Sept 2001), but a national priority and very important for health facility to note (Mboera, 2002)

28 Document 3-3 Reporting Requirements for Integrated Disease Surveillance and Response When and Which Form(s) Notify Immediately Which Disease What Data Facility Standard Yellow Fever Cholera Measles Cerebral spinal Meningitis Acute Flaccid Paralysis Rabies Plague # Report any reportable / notifiable disease to the DMO if a suspected case presents Report IMMEDIATELY as soon as a case is suspected Make the initial report by fastest means possible (telephone, facsimile, , radio-call) Report due to District within 24 hours of case identification District Standard Report due to Region within 48 hours of case identification Case Investigation forms Report Weekly IDSR Weekly (Form 3 (b) from IDSR Guidelines) Report Monthly* IDSR Monthly Form 2 (b). Yellow Fever Cholera Measles Cerebral spinal Meningitis Acute Flaccid Paralysis Plague Neonatal Tetanus Viral Hemorrhagic Fever Yellow Fever Cholera Measles Cerebral spinal Meningitis Acute Flaccid Paralysis Rabies/Animal bites Plague Yellow Fever Cholera Measles Cerebral spinal Meningitis Acute Flaccid Paralysis Rabies/animal bite Plague Bacillary Dysentery Neonatal Tetanus Pneumonia <5 Years Pneumonia 5 Years Diarrhoea < 5 Years Diarrhoea 5 Years Malaria Typhoid Fever Report case-based information IMMEDIATELY as soon as a case is suspected Make the initial report by fastest means possible (telephone, facsimile, , radio-call) Follow up with a written report of the case information recorded on the case investigation form # Summary information on these diseases should be reported weekly despite their immediate notification Enter zero in the appropriate space on the form if no cases have been identified during the reporting period. # Summary information on these diseases should be reported monthly despite the immediate notification, and weekly reporting requirement for some. Enter zero in the appropriate space on the form if no cases have been identified during the reporting period. Report due to District by date set by district Report due to District by 5 th of following month Report due to Region by Thursday of the following week Report due to Region by 15 th day of the following month

29 Task 3-1 Task in threes Review and compare data from the three sample health facility IDSR monthly forms (Documents 3-13, 3-14, 3-15) Determine the level of completeness and accuracy for each form Identify any discrepancies, anything you think needs to be double checked to ensure quality, and agree on how you would do this Have one person ready to report out You have 20 minutes

30 Document 3-4 thru 3-15 IDSR Reporting Forms The following pages contain the documents listed below: Doc. 3-4: IDSR Health Facility monthly Form 2 (b) Doc. 3-5: IDSR District monthly Form 2 (b) Doc. 3-6: Monthly data sheet for in/out-patients, Form 2 (a) Doc. 3-7: IDSR Health Facility weekly Form 3 (b) Doc. 3-8: IDSR District weekly Form 3 (b) Doc. 3-9: Weekly data sheet at each level, Form 3 (c) Doc. 3-10: Case investigation, Form 10 (blank) Doc. 3-11: An example of a Completed IDSR Health Facility Weekly Form Doc. 3-12: An example of a Completed Case Investigation Form Doc. 3-13: An Example of Completed IDSR Health Facility monthly Form 2 (b) Doc. 3-14: An Example of Completed IDSR Health Facility monthly Form 2(b) Doc. 3-15: An Example of Completed IDSR Health Facility monthly Form 2(b)

31 Document 3-4: IDSR Health Facility monthly Form 2 (b) Form for health facility to sum up monthly data for in-patient and out patient Send completed form to district level. Name of Health Facility: Month: Year: In-patient $ Outpatient $ < 5 Years 5 Years Disease Cases Deaths Cases Deaths Uncomplicated Malaria Severe Malaria Diarrhoea with some dehydration Diarrhoea with severe dehydration Typhoid Neonatal Tetanus (NNT) Bacillary dysentery Pneumonia Severe pneumonia Cholera Acute Flaccid Paralysis (AFP) Measles Cerebral Spinal Meningitis (CSM) Plague Yellow fever Animal/dog bites Rabies Date of filling the form: Has this form been discussed/reviewed at the health facility? Y / N Name of health facility in-charge: Name of reporting officer: Title: Signature: Date received at District Received at District on Time (T) or Late (L)? T / L

32 Document 3-5: IDSR District monthly Form 2 (b) Form for district to sum up monthly data for in-patient and out patient Send completed form to regional level. Name of District: Month: Year: Number of health facilities reporting Total facilities < 5 Years 5 Years Disease Cases Deaths Cases Deaths Uncomplicated Malaria Severe Malaria Diarrhoea with some dehydration Diarrhoea with severe dehydration Typhoid Neonatal Tetanus (NNT) Bacillary dysentery Pneumonia Severe pneumonia Cholera Acute Flaccid Paralysis (AFP) Measles Cerebral Spinal Meningitis (CSM) Plague Yellow fever Animal/dog bites Rabies Date of filling the form: Has this form been discussed/reviewed at the district? Y / N Name of District Medical Officer: Name of reporting officer: Title: Signature: Date received at Region Received at Region on Time (T) or Late (L)? T / L

33 Document 3-6: Monthly data sheet for in/out-patients, Form 2 (a) Monthly working data sheet for in/out-patients. (Keep this form). Name of Health facility/district/region: Year: In-patient $ Outpatient $ Months Disease Total Uncomplicated Malaria Severe Malaria Diarrhoea with some dehydration Diarrhoea with severe dehydration Typhoid Fever <5 5 <5 5 <5 5 <5 5 < 5 5 C D C D C D C D C D C D C D C D C D C D < 28 C

34 Months Disease Total Neonatal Tetanus (NNT) Bacillary Dysentery Pneumonia Severe pneumonia Cholera Measles days D <5 5 < 5 5 < 5 5 < 5 5 < 5 >5 C D C D C D C D C D C D C D C D C D C D

35 Months Disease Total Cerebral Spinal Meningitis Acute Flaccid Paralysis Animal/Dog bite <5 5 <5 5 <5 5 C D C D C D C D C D C D Rabies Plague <5 >5 <5 >5 Key: C= cases; D= deaths This form will be kept at each level (Health Facility/District/Region) to keep a record of communicable diseases which occurred for the whole year and to monitor trends by month: District level use this form to monitor disease trends by health facility and in the whole district Regional use this form to monitor disease trends by districts and in the whole region Central - use this form to monitor disease trends by region, district, and country as a whole

36 Document 3-7: IDSR Health Facility weekly Form 3 (b) Form for health facility to report weekly new cases/deaths Send completed form to district level. Name of Health Facility: Week no / Starting Date: Year: In-patient $ Outpatient $ < 5 Years 5 Years Disease Cases Deaths Cases Deaths Cholera Acute Flaccid Paralysis (AFP) Measles Cerebral Spinal Meningitis (CSM) Plague Yellow fever Animal/dog bites Rabies Date of filling the form: Has this form been discussed/reviewed at the health facility? Y / N Name of health facility in-charge: Name of reporting officer: Title: Signature: Date received at District Received at District on Time (T) or Late (L)? T / L

37 Document 3-8: IDSR District weekly Form 3 (b) Form for district to report weekly new cases/deaths Send completed form to regional level. Name of District: Week no / Starting Date Month: Year: Number of health facilities reporting Total facilities < 5 Years 5 Years Disease Cases Deaths Cases Deaths Cholera Acute Flaccid Paralysis (AFP) Measles Cerebral Spinal Meningitis (CSM) Plague Yellow fever Animal/dog bites Rabies Date of filling the form: Has this form been discussed/reviewed at the district? Y / N Name of District Medical Officer: Name of reporting officer: Title: Signature: Date received at Region Received at Region on Time (T) or Late (L)? T / L

38 Document 3-9: Weekly data sheet at each level, Form 3 (c) Working data sheet at each level for weekly reported New Cases/Deaths Part 1 Name of Health facility/district/region: Year: In-patient $ Outpatient $ Week Disease Cholera < 5 C 5 D C Acute Flaccid < 5 D C Paralysis (AFP) D 5 C Measles < 5 D C 5 D C Cerebral Spinal < 5 D C Meningitis (CSM) D 5 C Plague < 5 D C 5 D C Yellow fever < 5 D C 5 D C Animal/dog bites < 5 D C 5 D C Rabies < 5 D C 5 D C D This form will be kept at each level to keep record of weekly communicable diseases which occurred for the whole year to monitor trend.

39 Document 3-9: Weekly data sheet at each level, Form 3 (c) Working data sheet at each level for weekly reported New Cases/Deaths Part 2 Name of Health facility/district/region: Year: In-patient $ Outpatient $ Week Disease Cholera < 5 C 5 D C Acute Flaccid < 5 D C Paralysis (AFP) D 5 C Measles < 5 D C 5 D C Cerebral Spinal < 5 D C Meningitis (CSM) D 5 C Plague < 5 D C 5 D C Yellow fever < 5 D C 5 D C Animal/dog bites < 5 D C 5 D C Rabies < 5 D C 5 D C D This form will be kept at each level to keep record of weekly communicable diseases which occurred for the whole year to monitor trend.

40 Document 3-10: Case investigation, Form 10 (blank)

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42 Document 3-11: An example of a Completed Health Facility Weekly Form IDSR Form 3(b) Form for health facility to report weekly new cases/deaths Send completed form to district level. In-patient Name of Health Facility: CHALINZE HEALTH CENTRE Week no / Starting Date: 14/10 Year: 2003 Outpatient < 5 Years >5 Years Disease Cases Deaths Cases Deaths Cholera Acute Flaccid Paralysis (AFP) Measles Cerebral Spinal Meningitis (CSM) Plague Yellow fever Animal/dog bites Rabies Date of filling the form: 14/10/2003 Has this form been discussed/reviewed at the health facility? Y / N YES Name of health facility in-charge: DR.J.B.MWAKIJYALA Name of reporting officer: DR.J.B.MWAKIJYALA Title AMO Signature: DR.J.B.MWAKIJYALA Date received at District Received at District on Time (T) or Late (L)? T / L

43 Document 3-12: An example of a Completed Case Investigation Form

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45 Document 3-13: An example of Completed Health Facility Monthly Form IDSR Form 2(b) Form for health facility to sum up monthly data for in-patient and out patient Send completed form to district level. Name of Health Facility: Health Facility XX Month: JULY Year: 2003 In-patient $ Outpatient $ < 5 Years 5 Years Disease Cases Deaths Cases Deaths Uncomplicated Malaria Severe Malaria Diarrhoea with some dehydration Diarrhoea with severe dehydration Typhoid Neonatal Tetanus (NNT) Bacillary dysentery Pneumonia Severe pneumonia Cholera Acute Flaccid Paralysis (AFP) Measles Cerebral Spinal Meningitis (CSM) Plague Yellow fever Animal/dog bites Rabies Date of filling the form: 4/7/2003 Has this form been discussed/reviewed at the health facility? Y / N Name of health facility in-charge: Name of reporting officer: Title: AMO Signature: Date received at District Received at District on Time (T) or Late (L)? T / L

46 Doc 3-14 An example of Completed Health Facility Monthly Form IDSR Form 2(b) Form for health facility to sum up monthly data for in-patient and out patient Send completed form to district level. Name of Health Facility: Health Facility YY Month: JULY Year: 2003 In-patient $ Outpatient $ < 5 Years 5 Years Disease Cases Deaths Cases Deaths Uncomplicated Malaria Severe Malaria Diarrhoea with some dehydration Diarrhoea with severe dehydration Typhoid Neonatal Tetanus (NNT) Bacillary dysentery Pneumonia Severe pneumonia Cholera Acute Flaccid Paralysis (AFP) Measles Cerebral Spinal Meningitis (CSM) Plague Yellow fever Animal/dog bites Rabies Date of filling the form: 2/8/2003 Has this form been discussed/reviewed at the health facility? Y / N Name of health facility in-charge: MR. Hassan Name of reporting officer: Title: ACO Signature: Date received at District 3/8/2003 Received at District on Time (T) or Late (L)? T / L

47 Document 3-15 An example of Completed Health Facility Monthly Form IDSR Form 2(b) Form for health facility to sum up monthly data for in-patient and out patient Send completed form to district level. Name of Health Facility: Month: DECEMBER Health Facility ZZ Year: 2003 < 5 Years 5 Years Disease Cases Deaths Cases Deaths Uncomplicated Malaria Severe Malaria Diarrhoea with some dehydration Diarrhoea with severe dehydration Typhoid Neonatal Tetanus (NNT) Bacillary dysentery Pneumonia Severe pneumonia Cholera Acute Flaccid Paralysis (AFP) Measles Cerebral Spinal Meningitis (CSM) Plague Yellow fever Animal/dog bites Rabies Date of filling the form: 15/1/2003 In-patient $ Outpatient $ Has this form been discussed/reviewed at the health facility? Y / N Name of health facility in-charge: DR. KAZI Name of reporting officer: Title: AMO Signature: Date received at District Received at District on Time (T) or Late (L)? T / L

48 Document 3-16 Application-Planning sheet Module 3 Please take a few minutes to think about this module and how it applies to your work. Then answer the following questions 1. What can you do to improve the way you review reports that come from facilities in order to ensure quality? 2. What are some steps to ensure that you are reporting on priority diseases to the regional level in a complete and timely manner?

49 Document 4-1 Module 4 Objectives By the end of the module, participants will be able to: 1. Organise, summarise, and display surveillance data using tables, graphs, charts, and maps 2. Calculate frequencies, percentages, and rates 3. Analyse data to show trends over time 4. Analyse data by person, place and time to characterise populations at risk

50 Document 4-2 Measures of Disease Frequencies What it is What it is used for Examples Tells the number of cases or deaths that occurred To know the extent of disease or death in one group of people % # children < 5 with measles reported % # of deaths reported due to measles Percentages (Proportions) Tells the number of specific events being measured (such as cases) compared to the number of all events being measured (such as size of population in which given disease occurred). No. of people in a group with disease or characteristic X 100 Total number of people in the group To compare information from populations of different sizes or characteristics (age, gender, etc.) within a same time period % Percent of children <5 with measles: 100* # children < 5 with measles all children < 5 % Percent of malaria cases that are in children 5-14: 100 * # of reported malaria cases among 5-14 years Total # of reported Malaria cases Rates Tells the number of specific events being measured compared to the number of all events within a specific unit of time. No. of people in a group with disease total number in group unit of time when disease occurred To compare information from different events occurring at different time periods (e.g. compare 2002 to 2003). % Yearly Case fatality rate: percentage of cases that died in one year (2003). % Monthly incidence rate: number of new cases occurring in one month (e.g. January) / total population

51 Document 4-3 Types of Data Analysis Type of analysis Objective Tools Activity Time For immediately reportable diseases and monthly summary totals of cases and deaths for priority diseases Detect abrupt or longterm changes in disease occurrence, how many occurred, and the period of time from exposure to onset of symptoms. Record summary totals in a table or on a line graph or histogram, with time on the x-axis. Compare the number of case reports received for the current period with the number received in a previous period (days, weeks, months, seasons or years) Place Usually for immediately reportable diseases and outbreaks Determine where more cases are occurring (for example, to identify high risk area or locations of populations at risk for the disease) Plot cases on a spot map of the district or area affected during an outbreak. Plot cases on a map and look for clusters or relationship of the location of the cases to the health event being investigated. Person Usually for immediately reportable diseases and outbreaks, or for understanding results from time analysis Describe reasons for changes in disease occurrence, how it occurred, who is affected most by the disease, and potential risk factors Extract specific data about the population affected on a table to calculate rates, ratios and proportions. Can also use a graphic format, such as a bar chart. Depending on the disease, characterize cases according to the data reported for casebased surveillance such as age, gender, place of work, place of residence, immunization status, school attendance, and other known risk factors for the diseases.

52 Document 4-4 Examples of types of analysis 1. Time analysis The purpose of time analysis is to detect changes in disease occurrence over time. Irregular change over a specified time period means a potential epidemic or event. For example, the malaria threshold defines what the limit is that s normal. If the monthly number of malaria cases goes above the threshold, this indicates a potential epidemic. Regular (periodic, repeated) change helps to predict future occurrence and can be used to estimate human/financial/material resource needs. For example, data show that every four years, the number of measles cases tends to increase. Therefore, we can predict what years might have increased measles cases. By examining events that occur before a disease rate increases or decreases such as the onset of rainy season, it may be possible to identify causes and appropriate public health actions for controlling or preventing further occurrence of the disease. Presentation and examples Data about time is usually shown on a graph. Bar graph: Number of cholera cases by day of onset # of cases July 16 - August 11

53 Line Graph: 30 Number of cases of bloody diarrhoea by month during frequency Cases Deaths 5 0 Jan FebMar Apr May JunJul Aug SepOct Nov DecJan Feb MarApr Month May JunJul Aug SepOct Nov Dec 2. Place analysis The purpose of place analysis is to compare disease occurrence across different geographic locations (e.g. facilities, households, villages, facility catchments areas). Place analysis provides information about where a disease is occurring. Establishing and regularly updating a spot map of cases for selected diseases can give ideas as to where, how, and why the disease is spreading. An analysis of place provides information that is used to spot locations of disease occurrence and identify populations at highest risk for transmission of specific diseases. Presentation and example The following is an example of a spot map. It shows the major towns/villages, geographic features, and suspected and confirmed cases of a disease.

54 Place analysis can also be presented using bar graphs, particularly to compare cases across health facilities (see example below). Distribution of pneumonia cases among health facilities Number of cases Health facility A Health facility B Health facility C Health facility D Health facility E Health facilities 3. Person analysis The purpose of person analysis is to describe the characteristics, such as age, gender, or employment, of the cases. Analysis by person can help identify the population at risk for epidemic-prone diseases and diseases targeted for eradication or elimination. Data about personal characteristics are available from case-investigation forms. Presentation and examples Person analysis can be presented using bar graphs, with the number or proportion of cases on the y-axis and the category being analysed (i.e. age, gender, etc.) on the x-axis. Discuss the following example: Distribution of diarrheoa cases by age group 100% Proportion of total cases 80% 60% 40% 20% 0% 0-4 years 5-14 years 15 years and older Age unknown Age groups

55 Document 4-5 Steps for presenting data in a graph 1. Select the disease to be analysed. For example, you have reviewed your monthly reports from the facilities this month and there seem to be too many pneumonia cases this month. You are interested in finding out what is going on with pneumonia. 2. Specify the question being addressed. For example: Is there a specific facility where there is the increase in pneumonia cases, or is this increase in cases happening in many facilities? (WHERE = Place analysis) What are the characteristics of the persons who are getting pneumonia? (WHO = Person analysis) 3. Select appropriate measure of disease: frequency (cases or deaths), percentage, rates. Are you going to compare disease occurrence between characteristics? If No & use frequencies (cases or deaths) If Yes & Are you going to compare cases in different time periods or different units of time? If No & use percentages If Yes & use rates 4. Select the type of analysis to be done (time, person or place) and the characteristic to be examined or compared (if relevant). Decide what information you will need to answer your question. For example: Which facility or facilities have the most pneumonia cases? This is a question that asks WHERE are the cases occurring? = Place analysis The characteristic of interest is facilities Information needed: cases per facility in month 5. Present the data First, organize a table that summarizes the selected disease measure by the unit of time or the characteristic.

56 a) Below is an example of a table to help organize cases by month Cases of diarrhoea with blood by month, District XX, 2003 Characteristic or time unit: Disease measure: Month Number of reported cases January 24 February 25 March 30 April 28 May 27 June 18 July 19 August 22 September 26 October 25 November 23 December 25 b) Draw the graph using the data from the table following these steps i. Write a title that describes what the graph will contain that includes what disease, where the information is from, and the time period (for example, Cases of Diarrhoea with blood by month, District XX, 2003) ii. A graph is made up of an x-axis (horizontal) and a y-axis (vertical) y-axis x-axis iii. Put the disease measure on the y-axis (e.g. number or percentage of cases or deaths, case fatality rate). Write down what the numbers represent. iv. Decide on the range of numbers to show on the vertical axis.

57 Start with 0 as the lowest number on the bottom of the y-axis Write numbers, going up until you reach a number higher than the highest value of the disease measure you are graphing Chose an interval if the numbers you will show on the y-axis are large (for example, every 5 or 10 cases). v. Put the characteristic you are analysing on the x-axis (e.g. time units, age group categories) vi. Write a name for the x-axis and mark the units on it. For time analysis, the x-axis is divided into equal units of time. Usually you will begin with the period when the outbreak started, or the beginning of a calendar period, such as a month or year. Cases Cases of Diarrhoea with blood by month, District XX, Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec Month 2003

58 vii. Mark the number of cases on the graph. For each unit of time on the x-axis, find the number of cases on the y-axis. Draw a cross or make a point where the horizontal and vertical lines cross. Cases of Diarrhoea with blood by month, District XX, Cases January February March April May June July August September October November December Time viii. For time analysis, connect the points on the graph to show the trend going up or down over time. Cases of Diarrhoea with blood by month, District XX, Cases January February March April May June July August September October November December Time

59 ix. For analysis other than time (e.g. age, gender, facility), do not connect the dots. Instead, fill in a bar, as in the following example. Cases of pneumonia among health facilities, District XX, December 2003 Number of cases Health facility A Health facility B Health facility C Health facility D Health facility E Health facilities 6. Interpreting your graph Ask yourself the following questions: a. What does the information in the graph tell you? Is there a difference between the categories (such as between months)? Is there a change? POSSIBLE ANSWER: i. There were two peak periods during the year March and September. The fewest cases were seen in June. b. Does it cause you to ask other questions? POSSIBLE ANSWER: i. Why did they increase in March and September and decrease in June? ii. How do these trends compare to the previous year (seasonality, magnitude of the cases)? c. What do you conclude? POSSIBLE ANSWER i. Ignoring the seasonal variation, the number of cases did not change significantly over the year. There was no systematic decrease in cases.

60 Document 4-6 Data for Group Exercise Reported Malaria Cases in x district for the past 3 years ( ) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Total

61 Task 4-1 As a group, discuss the data set provided Analyse the data using appropriate method(s) (person, place, time) Determine the most effective way to display the data to others (e.g. graph, table, maps, etc.) Develop the appropriate data presentation Put your results on a flip chart to present to the rest of the groups Prepare a report explaining why you did that analysis Take 50 minutes Select a spokesperson to report out

62 Document 4-7 Application-Planning sheet Module 4 Please take a few minutes to think about this module and how it applies to your work. Then answer the following questions. 1. What methods for analyzing and presenting data still require further practice for you? 2. Which methods for analysis and presentation do you need to use more of in your district? 3. What can your district health team do to improve its analysis and presentation of data?

63 Document 5-1 Module 5 Objectives By the end of the module, participants will be able to: 1. Interpret and draw conclusions based on the analysed data 2. Link analysis to appropriate public actions for control of priority diseases

64 Document 5-2 Interpreting Data Decide if: The number of cases for each graph is the same, higher or lower than in previous months, seasons, or years and If you are making progress toward your targets. Also consider non-disease reasons for changes in trends. For example, is the increase or decrease due to: A new health facility or hospital has opened in the catchment area resulting in a change in referral patterns. New clinicians in the area are using different diagnostic criteria or case definitions. Data recording errors. Inconsistent recording across health workers. Compiling and reporting quality. Change in the number of health facilities reporting information. Seasonal variation. Change in community awareness of the signs and symptoms of ARI that accounts for an increase in the number of people seeking care. Recent immigration or emigration. Change in the quality of services being offered at the health facility (drug availability, shorter lines, health workers are more helpful. Successful referral of severe pneumonia, antimicrobial treatment and oxygen therapy in hospitals should decrease case fatality rate.

65 Task 5-1 As a group, Discuss the malaria data that you just analysed and presented. Interpret the data and draw conclusions, thinking particularly of: comparisons with previous time periods comparisons across months and years possible interpretations for the patterns you see probability of your interpretations being correct non-disease data influences that might change reported disease patterns over time Use Doc. 5-2 to help you with other logical interpretations. After having completed the interpretation, discuss any other questions you might want to answer other analyses you might want to do based on your interpretation of your analysis presentation. Record the interpretation and conclusions on a flip chart. Record any other questions you might have as a result of this interpretation. Take 30 minutes Select a spokesperson to report out

66 Document 5-3 Guidance for Linking Analysis to Public Health Action Guidance for analysing disease specific time trends and appropriate responses for three common priority diseases (from MoH District Analysis Book): 1. Malaria: Background: In Tanzania, malaria accounts for 34% of outpatient attendances, 15% of inpatients, and 16-20% of all hospital deaths in children aged < 5 years. Analysis of time, place, and person: If the trend in in-patient malaria cases and deaths is not declining significantly (i.e. by >10% per year), then the CHMT should review the effectiveness of the control measures for malaria in the district. In addition, the CHMT must consider several other factors that may cause the trend not to decline such as: Increase in community referral due to improved community aspects of the Integrated Management of Childhood Illnesses (IMCI) program Improved availability of affordable drugs at the health facilities Improved health facility quality of health care services Seasonal variation after rainy season Increasing drug resistance Change in health workers or health worker diagnosis An increase in malaria-like fever-causing illness The use of insecticide-treated mosquito nets (ITNs), personal protection, and vector control will decrease the number of malaria cases seen as outpatients, decrease he number and percentage of lab-diagnosed malaria cases, and decrease the number of hospitalised cases and deaths. Effective treatment at home or in the community will also decrease the number of malaria cases seen at out-patient health facilities, decrease the number and percentage of lab-diagnosed malaria cases, and decrease the number of hospitalised cases and deaths. Effective bed nets, personal protection, and adequate home/community treatment should result in a decline of outpatient cases diagnosed as malaria by >25%. The CHMT should be aware that it is more difficult to get the number of malaria cases and deaths to decline among outpatients than among in-patients because only approximately 50% of the illnesses diagnosed as malaria are actually due to malaria. Appropriate treatment in the health facility will not decrease the number of outpatient cases or number and percentage of lab-diagnosed malaria cases, but should decrease the number of hospitalised malaria cases and deaths.

67 Increasing drug resistance to anti-malaria drugs should increase both in-patient and outpatient malaria cases. Since most of the malaria and severe anaemia deaths occur in children aged <5 years old, trends in these malaria cases, malaria severe anaemia cases, and deaths are therefore important parameters and should be monitored closely. Public health action, response and targets for malaria: The following are strategies for malaria control. The CHMT should ensure that they are strengthened in order to achieve the set target: 1. Quality case management at the health facility level: early diagnosis, prompt and appropriate treatment of malaria cases at health facility 2. Community-based interventions Early recognition and treatment of malaria/fever cases at home and at the community level Promotion of use of insecticide treated mosquito nets (ITNs) and other insecticide treated materials Chemophylaxis/intermittent malaria treatment in pregnancy Indoor residual spraying where applicable Integrated management of the environment by different sectors. 3. Forecasting, early detection, prevention, and control of epidemics (in applicable districts) 4. Ensuring availability of drugs, equipment, and supplies 5. Health education and promotion Studies have indicated that a good district-wide bed net program can decrease malaria mortality in children aged <5 years by 20-35% in two years time. It is estimated that malaria mortality in children aged <5 years can be decreased by 50%-60% if all components of a district-wide malaria program (excluding vector control) are operating effectively. Therefore, the initial target for most Council should be to achieve at least a 50% decline in patient deaths. Action should also be taken in order to achieve a reduction of severe malaria and severe anaemia cases in a district. Outpatient cases should also decline by at least 25%. Public health action and response for outpatient laboratory malaria confirmed cases Background: In a typical outpatient setting, only approximately 50% of the cases clinically diagnosed as malaria are actually due to malaria. Therefore, laboratory diagnosis can increase the chance that those who are clinically diagnosed and confirmed by laboratory investigation are true cases of malaria (positive predictive value). It is expected that out-patient laboratory-confirmed malaria cases should decline by >50% if the following interventions are effective:

68 Community-based interventions. These include early recognition and treatment of malaria/fever cases at home and at the community level, promotion of use of insecticide treated mosquito nets, and indoor residual spraying where applicable. Integrated management of the environment. When interpreting trends in laboratory-confirmed cases, the CHMT should consider the number of persons tested. For example, if supplies for lab tests run short for several months, then a declining trend in the number of laboratoryconfirmed cases may be artificial and will not represent a true decline in malaria cases. In that case, the council may consider collecting information on the total number of persons tested and graph the percentage lab-test-positive as well as the absolute number of lab-positive. NB: The interpretation of surveillance data and action taken should be recorded for in-patient and outpatient malaria trends and laboratory positive cases. 2. Pneumonia in children aged < 5 years Background: Pneumonia kills approximately 1 per 100 children aged <5 years per year in a district. The causative organisms for pneumonia in children include Hemophilus influenza type B, which accounts for 20% of pneumonia deaths in this age group, and Streptococcus pneumoniae, which accounts for 50% of pneumonia deaths in children. Pneumonia is one of the priority diseases in the IMCI strategy and therefore surveillance for pneumonia in children aged < 5 years will be most effective if all clinicians are using the IMCI classification system for pneumonia and severe pneumonia. A high incidence or increasing incidence of HIV in districts will increase the incidence of pneumonia in children aged < 5 years. Analysis of data according to time, place, and person: The introduction of IMCI strategy in Tanzania is expected to decrease the incidence of severe pneumonia although it will not have a significant change on mild pneumonia. However, the increasing incidence of HIV/AIDS will interfere with the impact of IMCI strategy on severe pneumonia and is likely to increase the number of cases of severe pneumonia. Measles immunization and pertussis (routine DPT) vaccine may decrease the number of pneumonia cases by a small amount. Vaccination against Hemophilus influenza type B and Streptococcus pneumoniae may result in a significant reduction of total pneumonia cases, severe pneumonia cases, and deaths due pneumonia.

69 When interpreting child pneumonia time trends, the CHMT must take into account other factors influencing trends, such as availability of drugs. Public health action and targets on pneumonia in children aged < 5 years: In order to achieve reduction in the incidence of severe pneumonia in children, CHMTs should be able to strengthen the implementation of IMCI strategy. In order to facilitate the reduction of pneumonia associated with HIV/AIDS, CHMTS should strengthen their efforts in the control of HIV/AIDS. Sketches for analysis of pneumonia cases and deaths should be done as for malaria. NB: The interpretation of surveillance data and action taken should be recorded for in-patient and outpatient pneumonia cases and deaths. 3. Diarrhoea in children aged < 5 years Background: Diarrhoea is the most common cause of death in Africa and accounts for approximately 5 deaths per 1000 children aged < 5 years in a year. An additional 5 deaths per 1000 children in this age group die from persistent diarrhoea. In Tanzania, a child gets about 5 episodes of diarrhoea per year. An increasing prevalence of HIV in a district may increase the number of under five deaths due to diarrhoea related to HIV. For districts to conduct surveillance for diarrhoea with dehydration, health workers must classify diarrhoea with dehydration cases according to the IMCI classification system. For more details, refer to IMCI guidelines. Sketches for trend analysis of diarrhoea with some and severe dehydration should be drawn. The graphs should also be drawn to indicate for in-patient and outpatient cases and deaths. The CHMT should always remember to summarise and record the analysis and action taken on yearly basis. Linking data analysis for diarrhoea in children aged < 5 years to action and response Analysis of data according to time, place and person: Trend analysis of cases and deaths due to diarrhoea should be plotted for 3-5 years consecutively. If interventions are done effectively, health workers should expect a significant decline of cases of severe dehydration both for in-patient and outpatient cases. If there is no such decline, CHMT should review their control strategies including critically analysing the available data. Likewise, there should be a significant reduction in outpatient cases of diarrhoea with some dehydration if the community based oral rehydration therapy is being properly implemented. For proper classification and management of diarrhoea cases, health workers should be trained in IMCI. This is because the IMCI program has been shown to decrease diarrhoea deaths by 50%.

70 Trends in hospitalised diarrhoea deaths may show less reduction because more than 50% of diarrhoea deaths are persistent diarrhoea deaths. It is known that persistent diarrhoea deaths are more difficult to prevent. In addition, HIV may cause some deaths in children aged < 5 years that may be classified as diarrhoea deaths. Also, HIV may have some effect on the number of persistent diarrhoea cases populations with higher HIV infection rates would be expected to have more persistent diarrhoea cases. Short-term trends in cases with some dehydration may detect non-cholera or cholera diarrhoea outbreaks. Public health action and targets on diarrhoea in children aged <5 years: In order to achieve reduction in the incidence of diarrhoea with severe and some dehydration in children aged < 5 years, CHMTs should strengthen the implementation of the IMCI strategy for management of diarrhoea including the IMCI community component of provision of home-based home fluids. Provision of plenty of potable water and food and improvements of sanitation services throughout the district have the potential to significantly decrease diarrhoea with severe dehydration cases and deaths due to diarrhoea. NB: The interpretation of surveillance data and action taken should be recorded for in-patient and outpatient under five diarrhoea cases and deaths.

71 Task 5-2 In groups:! Interpret the data for your assigned disease (Document 5-4) by using the graph provided! Identify appropriate actions for strengthening control of the disease assigned to your group (using Document Guidance for Linking Analysis to Public Health Action)! Determine the resources needed to implement the actions (general categories only, not a detailed budget) Prepare your report on a flipchart You have 40 minutes

72 Document 5-4 Data set for Mvumi Hospital December 2002-November 2003 Facility: DCT Mvumi Hospital (inpatient), Dodoma Rural District Year: 2003 Dec 02 Jan 03 Feb Mar Apr May Jun <5 5+ <5 5+ <5 5+ <5 5+ <5 5+ <5 5+ <5 5+ DISEASES C D C D C D C D C D C D C D C D C D C D C D C D C D C D Malaria Diarrhoea with some dehydration Diarrhoea with severe dehydration Typhoid NNT Bacillary dysentery Pneumonia Severe pneumonia Cholera AFP Measles CSM Plague Yellow fever Animal/dog bites Rabies

73 Facility: DCT Mvumi Hospital (inpatient), Dodoma Rural District Year: 2003 Jul Aug Sep Oct Nov Dec TOTAL <5 5+ <5 5+ <5 5+ <5 5+ <5 5+ <5 5+ <5 5+ DISEASES C D C D C D C D C D C D C D C D C D C D C D C D C D C D Malaria Diarrhoea with some dehydration Diarrhoea with severe dehydration Typhoid NNT Bacillary dysentery Pneumonia Severe pneumonia Cholera AFP Measles CSM Plague Yellow fever Animal/dog bites Rabies

74 Document 5-5 Application-Planning sheet Module 5 Please take a few minutes to think about this module and how it applies to your work. Then answer the following questions. 1. What can your district health team do to use data analysis more effectively in the district health planning process? 2. What are the key obstacles in your district to developing and implementing a strategy based on data? 3. What can you do to overcome those obstacles?

75 Document 6-1 Module 6 Objectives By the end of the module, participants will be able to: 1. Describe the responsibilities of the CHMT for Outbreak investigation and response 2. Describe how to conduct an outbreak investigation 3. Analyse the results of the investigation to make recommendations for response 4. Organize an outbreak response plan

76 Document 6-2

77 Document 6-3 Outbreak line list (Day to day register of patients during an outbreak) Outbreak disease Health Facility Division District Region Name of Facility In charge Designation Period covered by report: / / to / / (Use this form when the action/epidemic threshold of a disease is reached) S/No Name Physical address Age (yrs) Date of Onset Immunisation status (for vaccine preventable diseases) Laboratory investigation Specimen taken Yes/No Results +/- Treatment Outcome 1=Alive 2=Died 3=Unknown Remarks

78 Document 6-4 Case Study Part I 1. Outbreak of a mysterious disease in Babati District - 1 st November th April On 20 th January 2000 the Dr. Nzali the District Medical Officer (DMO) of Babati District, received a disturbing report from Babati Dispensary. He was informed of an outbreak of a mysterious disease in the area that had killed 2 adults, a males and a female after a very short period of illness. The report further stated that they had attended a wedding party a day earlier. They had initially presented with history of severe painless watery diarrhoea of acute onset, which began about three hours before they died. Questions For the district assigned to your group, answer the following questions: 1. Does this situation merit an investigation? Why? What disease are you suspecting? Why do you suspect this disease? 2. Determine the key questions you want to answer from the investigation. 3. Develop a plan with the following: - Main tasks to accomplish during the investigation - Person responsible for each task - Organizations and people who needs to be involved in each task - List of information and other data sources that should be consulted or exploited to better investigate the situation. Use the attached format (Doc 6-5) to develop the plan.

79 Task 6-1 Group Task Based on the case study, answer the following questions: 1. Does this situation merit an investigation? Why? What disease are you suspecting? Why do you suspect this disease? 2. Determine what additional information youneed in order to proceed. 3. Develop a plan with the following: - List of information and data sources that should be consulted to better investigate the situation - Main tasks to accomplish during the investigation - Person responsible for each task - Organisations and persons that need to be involved in each task Be sure that all tasks mentioned above for an investigation (1-7) are included in your plan. Take 45 minutes Record your plan on Doc. 6-5, Format for Developing an Investigation Plan

80 Document 6-5 Format for Developing an Investigation Plan Tasks Lead Responsibility Others who need to be involved Information needed Timing

81 Document Babati District, Part 2 Case Study Part II Rectal swabs were taken from the two cases and sent to the laboratory. Laboratory tests confirmed the presence of Vibrio cholera. Cases of the illness continued to occur in the community and came to Galapo Dispensary for treatment. Epidemiological data was collected throughout the outbreak and summarised each day by the hospital staff. The following table presents the line list of suspected cases and deaths from the outbreak of Cholera in Galapo Dispensary, recorded between 4 th November 1999 and 28 th November 1999.

82 Task 6-2 In groups 1.Based on the case study, determine and conduct appropriate analysis of the data from the investigation By time (epidemic curve) By place (map) By person (tables, risk factors) 3. Interpret the results of: The possible causal agent of the outbreak based on available laboratory results Source of infection Transmission pattern Persons at risk for further infection Take 45 minutes for this task. Be sure to monitor your time so you have sufficient time for the interpretation of your analysis. Record your responses on flipchart for presentation to larger group.

83 Name of health facility----babati Dispensary Name of the Village---Riroda- Name of the District----Babati Name of the Region Manyara-- Date when the disease started Serial No. Name Age Sex Address Nearest Relative Ten cell leader Disease Treatment Outcome t. p.k 27 m Riroda q.m.w Asmini Cholera IV drips, Dead (D) Erythromycin tablets b. j n 32 f Riroda q.w.d Asmini Cholera IV drip, Alive Erythromycin tablets k.m.g 41 f Riroda t.w.m Asmini Cholera IV drips, Alive Erythromycin tablets m.w.d 30 m Riroda q.7 d Ali Cholera ORS, Alive Erythromycin tablets d.m.l 24 m Riroda q.k, d Ali Cholera ORS, Erythromycin tablets D a.m.e 30 f Riroda vny Ali Cholera ORS, Erythromycin tablets Alive k.d.m 32 m Riroda o,b k Bayi Cholera IV drips, Erythromycin tablet Alive m.b.k 44 m Riroda q,7,d Bayi Diarrhoea Erythromycin D disease tablets ORS, k.k.l 25 m Riroda q.a.d Likindikoki Cholera ORS, Alive Erythromycin tablets j.n.t 30 f Riroda q,7,d Likindikoki Cholera IV drips, D Erythromycin tablets a.t.o 38 f Riroda q,7,d Likindikoki Cholera ORS, Alive Erythromycin tablets a.g.p 26 m Riroda q,g,d Likindikoki Cholera IV drips, D Erythromycin tablets l.b.a 28 m Riroda q,v,d Likindikoki Cholera IV drips, Alive Erythromycin tablets s.a.n 20 f Riroda q,m,d Likindikoki Cholera IV drips, Alive Erythromycin tablets t.s.m 22 m Riroda q,7,d Likindikoki Cholera D m.r.a 28 f Riroda q,7,d Saibuli Cholera ORS, Erythromycin tablets a.l.h 22 f Riroda q,7,d Saibuli Cholera IV drips, Erythromycin tablets k.g.p 33 m Riroda q,m,d Saibuli Cholera IV drips, Erythromycin tablets u.t.v 24 f Riroda q,g,d Ole Cholera ORS, Erythromycin tablets b.s.h 31 m Riroda c,c,w Ole Cholera IV Drips, Erythromycin tablets alive alive alive Alive D

84 Date when the disease started Serial No. Name Age Sex Address Nearest Relative Ten cell leader Disease Treatment Outcome a.d.a 44 f Riroda q,m,d Ole Cholera ORS, Erythromycin tablets b.b.o 23 m Riroda q,7,d Ole Cholera ORS, Erythromycin tablets l.n.p 17 f Riroda q,m,d Ole Cholera Erythromycin tablets, ORS d.k.i 31 m Riroda q,t,d Ali Cholera IV drip, Erythromycin tablets h.r.n 45 f Riroda q,a,d Ali Cholera IV drips, Erythromycin tablets a.f.n 45 f Mamiri- v,t,k, Anna Cholera IV drips, Erythromycin tablets a. l e. 72 f Mamiri q,n,d Anna Cholera ORS, Erythromycin tablets a.l.m 46 f Mamiri q,n,d Anna Cholera ORS, Erythromycin tablets m.m.y 28 m Mamiri q,t,w, Anna Cholera ORS, Erythromycin tablets a.d.a 38 m Mamiri v,m,k. Anna Cholera IV drips, Erythromycin tablets a.t.o. 52 m Mamiri q,n,d Maria Cholera IV drips, Erythromycin tablets m.r.ie 36 f Mamiri q,d,d Maria Cholera IV drips, Erythromycin tablets b.a.m 36 m Mamiri q,t,m Maria Cholera IV drips, Erythromycin tablets o.m.t 20 m Mamiri q,d,a Maria Cholera ORS, Erythromycin tablets D Alive alive D Alive D Alive D Alive D Alive D alive alive

85 Document 6-7 District Outbreak Report Format Title/Description (include disease/condition investigated) Period Place (villages/towns, sub-district, region) Executive summary: Introduction: Background: Reasons for investigation (public health significance, threshold met, etc.): Investigation and outbreak preparedness: Methods: Dates of investigation: Site(s) of investigation (health care facilities, villages, other): Case finding (indicate what was done regarding case finding, e.g. register review, contact investigation, alert other health facilities, other): Lab specimen collected: Describe response and intervention (include dates): Results: Date and location of first known (index) case: Date and health facility of first case seen by the health care system:

86 Results of additional case finding: Lab analysis and results: With text, describe key features of results of time, place and person analysis: for detailed results by time (epi curve), place (map) and person characteristics (table), and line lists. Attach line lists, maps, etc as appropriate. Results of response and evidence of impact: Interpretations, discussion and conclusions: Recommended public health actions: comment on following levels: community, health facility, district, partners, regional and national

87 Document 6-8 Application-Planning sheet Module 6 Please take a few minutes to think about this module and how it applies to your work. Then answer the following questions. 1. What does your district health team need to do to improve in planning and implementing investigations of outbreak diseases? 2. What should your district health team do to respond more effectively to a confirmed outbreak of a priority disease? 3. Who else needs to be involved in developing a more effective response capacity?

88 Document 7-1 Module 7 Objectives By the end of the module, participants will be able to: 1. Explain the importance of preparedness for disease outbreaks 2. List the key components of an epidemic preparedness plan for their district 3. Identify the people who need to be involved in plan preparation and implementation 4. Develop Epidemic Preparedness Plans for their districts (to be incorporated in the annual CCHP)

89 Document 7-2 Key elements to be addressed in an epidemic preparedness plan 1. Forecasting an outbreak: data requirements for forecasting, district-specific disease history, changes in conditions, and early warning 2. Routine reporting system, feedback and monitoring: completeness and timeliness of reporting, feedback mechanisms, monitoring the functioning of the IDSR system 3. Staffing for epidemic investigation and response: roles and responsibilities, laboratory confirmation, multi-sectoral representation 4. Buffer stocks: calculation of buffer stock and laboratory support materials requirements, inventory of available resources, procedures to obtain supplies, and resources 5. Training: staff training needs to meet epidemic preparedness standards 6. Health education and Health promotion: capacity and materials to communicate with the public

90 Document 7-3: District Epidemic Preparedness Planning Template (Name of the district) 1. INTRODUCTION (This section can be completed upon return to the district) 1.1 General Discuss importance of epidemic preparedness for your district The purpose of this District Epidemic Preparedness Plan is to get well prepared for the best way to guarantee a rapid, appropriate, and effective response to an epidemic, as well as to reduce morbidity and mortality; having a plan that clearly defines roles, responsibilities, and activities that happen during an outbreak, and by assuring in advance that people know their responsibilities and have the resources they need to meet them 1.2 District Profile Please give a general description of your district as it relates to epidemics. Topics to consider include: Administration Geography, occurrence of natural disasters Socio-economic development indicators o Accessibility to health facilities: number and types of health facilities o Water access and supply (tape water, wells, boreholes, water bodies-rivers, lakes etc) Environmental sanitation (latrine coverage, waste disposal) o Transport and communications roads and their conditions; waterways, railways, telephones, radio-calls o Ethnic groups, o Main economic activities, employment situation, o Educational status Population Total population Growth rate Urban distribution Rural distribution Children under five Children under one year Under five mortality Immunisation coverage Measles Polio TT DPT TB

91 2. FORECASTING 2.1 Standard for epidemic preparedness: Districts should be able to predict diseases of epidemic potential using disease information and other early warning information 2.2 Approach to reach preparedness Disease history It is necessary to review current and historical data, for example for 10 years, to elicit the trends that will help to interpret and predict outbreaks in the following years. Using the district disease history tables, you should be able to forecast which diseases of epidemic potential are likely to occur in the coming year in your district Based on the disease history tables that you completed, list the diseases of epidemic potential that occur every year What are challenges in your district related to collecting sufficient data for outbreak forecasting (e.g. for 10 years or more)? How can your district address those challenges? Changes in conditions and early warning What are the areas in your district with the lowest vaccination coverage in the under-five population? If your district has less than optimal vaccination coverage rates, please indicate which diseases could be of outbreak potential over the next year. What information is available from other sectors that can help you to assess whether changes have occurred that lead to an increased risk for disease outbreak next year?

92 Identify the sectors and the kind of information they could provide (i.e. water and sanitation access to safe water). What are the conditions or changes in conditions that may put an area in your district at risk of an outbreak during the coming year? Based on the diseases that occur every year and the conditions or changes in the conditions, predict which diseases may occur as outbreaks in the coming year These are the diseases that you should focus on for epidemic preparedness in the following sections.

93 3. STAFFING FOR EPIDEMIC INVESTIGATION AND RESPONSE AT THE DISTRICT LEVEL 3.1 Standards for epidemic preparedness: a. Having the tasks clearly defined for each set of functions for investigation and response i. Verification of suspected outbreaks or rumours ii. Lab confirmation iii. Full investigation of outbreaks iv. Full response to outbreaks b. Having staff/teams in each district who know what the tasks are. c. For teams, the team knows when to meet and who is responsible (who convenes and who is Chair). 3.2 Current status Please describe your district s experience in terms of assuming responsibilities for tasks in preparing for, investigating, and responding to outbreaks. What teams or committees, related to investigation or response, are currently in place? Who are the members of each team? Is there documentation on the assignment of responsibilities for team members? 3.3 Approach to reach preparedness Verification of suspected outbreaks. Imagine a case of meningitis is immediately reported to the district. Who are the key people responsible for the following tasks for verification of suspected cases? (Fill in table) Task / Responsibility Who reviews the data to assess whether a threshold has been surpassed? Who decides to verify suspected cases from the facilities? Person responsible (title) Does this person know this responsibility?

94 Who prepares and plans for the verification? Who visits the affected area, bringing prepared forms? Who else participates in the verification? (List all key personnel) Laboratory confirmation In the event of an outbreak, who is responsible for specimen collection to verify the outbreak? Please list the responsible person, and an alternate person, in your district. Who will be responsible for transporting the specimen to the laboratory? Please give the name of the laboratory (in or nearest to your district) to which confirmatory specimens will be delivered/transported. What method(s) of transport will be used to send specimen to this particular laboratory? Who will communicate with the laboratory to get the laboratory results? How will this communication take place? Investigation of cases during an outbreak Imagine that 20 cases of cholera are reported within a week. Is there an existing investigation team for investigation of outbreaks? If there is a team in your district, what triggers the team to meet? (i.e. When does the team first meet: at first case reported, at threshold reached, after lab confirmation, never?)

95 Whether you have a team or not, who has the following responsibilities? (Fill in table.) Responsibility for investigation Organise persons (investigation team) to assist with investigation Obtain materials for investigation (supplies, materials, forms, specimen collection kits, etc.) Isolate cases as needed and treat them Who on the team has this responsibility? Search for additional cases Record information about additional cases Analyse data about outbreak Interpret analysis results Prepare investigation report and inform epidemic response committee Report daily or weekly to district council Solicit funds from council Evaluate situation and estimate supply requirements Ensure appropriate specimen collection and transport with adequate information Provide technical support and supervision to health facility Communicate feedback on outbreak to site of outbreak and districts at risk Other: Other: Other: Under what conditions will the district ask for technical assistance from the Regional level? Epidemic response team What are the existing response teams in your district?

96 A district should have a single epidemic response team with key members from the health sector, to facilitate integration of available resources. In your district, who are the key members of the epidemic response team and what are their responsibilities? (Fill in table.) Responsibilities of key members Convene epidemic response team (including appropriate coopted multi-sectoral members). Review information from laboratory confirmation Who on the team has this responsibility? Organise outbreak response activities Gather supplies, materials, drugs for case management Gather supplies, materials, drugs for appropriate public health responses (including multi-sectoral responses) Inform community Case management Initiate public health responses (including multi-sectoral responses) Educate community Enforce by-laws Routinely review data from investigation team and discuss progress of response Report daily or weekly to district Evaluate response timeliness, effectiveness of response, and original preparedness and make recommendations for changes in the system and for next response How often should these key responsible people/team meet for discussing preparedness on a regular basis? When will be the first (or next) meeting of the key persons of this team?

97 An epidemic response team should be multi-sectoral and include representatives that can address issues beyond the health sector (e.g. water and sanitation, vector control). In addition to the key members on the district epidemic response team, what human resources from other sectors could you co-opt for each disease to strengthen the effectiveness of your team? What would their responsibilities be? (Fill in table.) Disease Cholera Bacillary dysentery Plague Measles Yellow fever Cerebral spinal meningitis Rabies Acute flaccid paralysis/ Polio Neonatal tetanus Diarrhoea in children <5 years Pneumonia in children <5 years Malaria Typhoid fever Local disease priority 1 Local disease priority 2 Local disease priority 3 Co-opted multi-sectoral human resources Responsibilities of coopted members 3.4 Strengths and Challenges Please describe the current strengths of your district that will facilitate efforts to improve staff organisation and ability to investigate and respond to an outbreak. Please describe challenges you might face in improving staff organisation and ability to investigate and respond to an outbreak.

98 4. BUFFER STOCKS 4.1 Standards for epidemic preparedness: Districts have identified what amounts of reserve/buffer supplies are needed and where they will be kept Districts have a defined and clear process for placing the reserve stock (every 6 months) into the normal delivery system so that the reserve supplies are not outdated. Distrits have a defined and clear process for reordering reserve supplies to replenish Districts know how and where to obtain logistical support and other resources 4.2 Current status In order to be ready for an outbreak, it is essential for a district to do an inventory of the resources on hand so that the amount of buffer stock needed is known and can be obtained. When you return to your district, use the inventory assessment tool for buffer stocks and material availability at the end of this section to assess your resources and determine what additional resources may be needed to ensure that the district has adequate buffer stocks for priority diseases. Please comment on your prior experiences with obtaining necessary drugs and supplies during an outbreak. Did you have difficulty getting the things you needed to appropriately respond? If yes, what kinds of problems did you have? If no, what mechanisms did you use to facilitate the process? 4.3 Estimating buffer stock requirements: cholera and measles The purpose of the following section is to learn how to calculate estimates of the buffer stocks required for selected epidemic-prone diseases. Two examples have been included cholera, which many districts encounter, and measles, which represents vaccinepreventable diseases. These are provided to help you work through the processes involved in calculating buffer stocks. Example 1: Calculation of resource requirements for cholera Assumptions: The amount of drugs and supplies given in the table is the minimum needed to treat 100 patients during a cholera outbreak, based on an example from the World Health Organisation. It is assumed that 20 of the 100 patients would have severe dehydration and require IV fluids for initial hydration, followed by oral rehydration solution (ORS). The

99 remaining 80 would be given ORS alone. Note also that the selection of antimicrobials should be based on susceptibility testing and may differ for adult and paediatric cases. Formula to determine number of cases of cholera: The most important step in calculating resource requirements is to determine the size of the target population, i.e. the number of people who might get the disease (cases). To calculate the number of cases of cholera, multiply the catchment/district population by an attack rate of 0.2% (0.002), unless you have a specific attack rate for your district based on previous outbreaks. For example, if the attack rate was approximately 3% in your district during the last outbreak, use 0.03 as the attack rate. The resulting number is the number of cases expected in a defined population. Calculate the expected number of cholera cases for your catchment/district population: x % = population attack rate* expected # cases *use 0.2% (0.002) unless you have a specific rate for your district Divide the number of expected cases by 100 in order to determine the population factor to use in the table below. / 100 = expected # cases population factor

100 In the following table, multiply the minimum quantity for each item (based on 100 cases) by the population factor to determine the quantity needed for your population. Resource category Drugs Materials and supplies Laboratory support Resource item Minimum Quantity per 100 cases (q) Assumptions Doxycycline capsules, 100mg 60 3 per severely dehydrated case Tetracycline capsule, 250mg per severely Trimethoprim-sulfamethoxazole tablet (for children) dehydrated case 300 Assume 50 children affected, each needs 2 tablets/day for 3 days ORS packets 1 litre each 650 Bags of Ringer s lactate solution or 120 saline, 1 litre each Adult IV giving sets 120 Scalp vein sets 10 Nasogastric tubes for adults 3 Nasogastric tubes for children 3 Large water dispensers 2 One litre bottles for ORS solution 20 Half litre bottles for ORS solution 20 Tumblers 40 Teaspoons 20 Cotton wool, kg 5 Rolls of adhesive tapes 3 Sterile swabs 19 Assume 1 per sample; take 1 sample of first 10 cases and every 10 th after that Test tubes 19 Same as above Cary Blair medium 19 Same as above Quantity necessary for your population (q multiplied by population factor) Note that disease-specific guidelines should be consulted to determine exact types and quantities of resources needed for different disease outbreaks.

101 Example 2: Calculation of resource requirements for a vaccine-preventable disease (using measles as an example) Note that the same calculations can be used for other vaccine-preventable diseases, with the target population and immunisation coverage rates adjusted accordingly. Steps to determine the number of doses of vaccine needed 1. Define the target population (for example: school children, children under 15 ) For measles, the target population depends on what age group is most susceptible. Have there been any measles vaccination campaigns in the district recently? The timing of the last vaccination campaign, if any, can help determine the target population. If a campaign took place 3 years ago and reached most children at that time, then children under age 3 (who did not get vaccinated in that campaign) are most at risk and should be targeted. If no campaigns have been conducted, and if vaccination coverage is low, then a more appropriate target would be all children aged 1-14 years. Adults are not typically targeted in measles vaccination campaigns, because they are likely to have already been infected with measles or vaccinated at some point in their lives, and are no longer susceptible. 2. Multiply the target population by the expected vaccination coverage (in other words, what proportion of the target population do you expect to vaccinate?). This gives you the number of children targeted for vaccination. Expected vaccination coverage may vary for different diseases. However, a good rule of thumb is that at least 80% of the target population should be vaccinated to stop an outbreak and to raise population immunity. If in doubt, use 80%. (Note that 100% would be ideal, but is difficult to achieve in most settings.) 3. Multiply the number of children targeted for vaccination by 1.17 (assuming wastage factor of 17%) to get the number of doses required. Can use district wastage factor if known and different than 17%. For example, if district wastage factor is 20%, then use 1.20.). 4. Multiply the number of doses required by 0.25 to determine the number of extra doses (buffer stock) needed. In general, 25% (0.25) is a standard amount of buffer stock suggested. 5. Add the number of doses required plus the number of extra doses required to determine the total number of doses required. Example: Target population of children under one year (a) = Immunization coverage (disease specific) (b) = 0.8 (80%) Number of children targeted for vaccination (c) =(a x b) = 0.8 x = Wastage factor (d) = 1.17 Number of doses required (e) = (c) x (d ) = 0.8 x x 1.17 = Doses buffer stock (f)= (e x 0.25) = 0.8 x x 1.17 x 0.25 = 4680 Total number of doses (e + f ) = Calculate the number of vaccine doses needed for your catchment population: x % = Estimated target population (a) Immunisation coverage (b) # Children targeted for vaccination (c)

102 x 1.17 = # Children targeted (c) Wastage factor(d) Number doses required (e) x 0.25 = + = # Doses required (e) Buffer factor Doses buffer stock (f) # Doses required (e) Total # doses(g) Example of types of resources needed to ensure adequate buffer stocks for outbreak response for measles. May be adapted for other vaccine-preventable diseases. Resource category Resource item Minimum Quantity Vaccine Measles vaccine See result of calculation Drugs Antibiotics to treat complications (depends on complication and causative agent) Analgesics Vitamin A capsules for treatment and prevention For prevention (given once per child): IU children 6-11 months IU children months For treatment of measles (2 doses over 2 days): IU children 6-11 months IU children months Materials and supplies Auto destruct Syringes* Needles* Vaccine carriers (# of vaccines per carrier must be determined) Cold packs/ice Safety boxes Laboratory support Specimen collecting tubes (1 st 5 cases) Specimen carriers *The number of syringes and needles is the same as the number of doses of vaccine. Note that laboratory support quantities are not tied to the number of children vaccinated, but rather to expected outbreak size and proportion of cases requiring lab confirmation.

103 Illustrative inventory assessment tool for buffer stocks of medical supplies and availability of materials. This list is not comprehensive, but is meant to guide the district in thinking through the types and quantities of various resources needed for different priority diseases. Each district must consider the different types of resources likely to be needed to control outbreaks of different infectious diseases. (Please note that non-medical supplies are also needed and should be planned for.) Resource category Resource item Quantity required for: Cholera Meningitis Bacillary Dysentery Vaccine - preventable diseases Maximum quantity needed (a) Current inventory (b) Stock to procure (c) Drugs Vaccine Materials and Doxycycline capsules, 100mg or Tetracycline capsule, 250mg Trimethoprimsulfamethoxazo le tablet (for children) Nalidixic acid, 1gm (adults) Nalidixic acid, 1gm (children) IM Oily chloramphenico l, 3gm (adult) and 100mg/kg for children Antibiotics for treatment (depends on causative agent) of disease or its complications Ampicillin, penicillin, amoxicillin Cotrimozaxole Anticonvulsants Analgesics (Paracetamol) Antiemetics Vitamin A Other Measles vaccine Yellow fever vaccine Meningococcal vaccine TT vaccine ORS packets 1 litre each a-b=c

104 Resource category Resource item Quantity required for: Cholera Meningitis Bacillary Dysentery Vaccine - preventable diseases Maximum quantity needed (a) Current inventory (b) Stock to procure (c) supplies Bags of Ringer s lactate solution or saline, 1 litre each Adult IV giving sets Scalp vein sets Nasogastric tubes for adults Nasogastric tubes for children Large water dispensers One litre bottles for ORS solution Half litre bottles for ORS solution Tumblers Teaspoons Cotton wool, kg Rolls of adhesive tapes Hand soap, kg Washing soap for clothes, boxes Cleaning solution- 1 litre bottle (2% chlorine or 1-2% phenol) Auto destruct syringes Needles Vaccine carriers Cold packs/ice Safety boxes Health education materials Disinfectant for cleaning skin Containers for used needle disposal Lumbar puncture set a-b=c

105 Resource category Resource item Quantity required for: Cholera Meningitis Bacillary Dysentery Vaccine - preventable diseases Maximum quantity needed (a) Current inventory (b) Stock to procure (c) Laboratory support Sterile swabs Test tubes Cary Blair medium Rectal swab Specimen collecting tubes Specimen carriers Rapid test kit Trans isolate bottles Syringes and needles a-b=c 4.4 Approach to reach preparedness In your district, who is responsible for ensuring that buffer stocks of supplies needed to respond to outbreaks are available? Who is responsible for the calculation of supplies and drugs for vaccine-preventable diseases? Your district should have clear procedures for obtaining supplies and funds. If your district already has procedures to access (or request from a higher level) the following items that are needed for an immediate response to an outbreak, please summarise them here. 1. Vaccines 2. Drugs 3. Materials for specimen collection 4. Supplies and other materials

106 5. Additional funds If your district does not have procedures to obtain these items, how will they be developed and who will be responsible for this task? When an outbreak occurs, who is responsible for planning and obtaining the necessary supplies and materials for the response? How will buffer stocks be rotated so that stocks do not get outdated? 4.5 Strengths & Challenges Please describe the current strengths of your district that will facilitate efforts to improve the management of buffer stocks and other resources. Please describe challenges you might face in improving the management of buffer stocks and other resources.

107 5. TRAINING 5.1 Standards for epidemic preparedness: Staff will be competent to carry out their IDSR duties, resulting in improved epidemic preparedness 5.2 Approach to reach preparedness Review the IDSR training needs in your district and list the types of training that are needed in your district and the personnel that you expect to participate in that training. Some possible training areas are listed below:! Information on local diseases! General computer skills! Laboratory testing! Logistics management! Specimen collection and transport! Specific staffing responsibilities! Messages to the community! Outreach methods! Health promotion! Identification of disease in communities! Refresher training periodically! Training for new staff Training topic Target group 5.3 Strengths & Challenges Please describe the current strengths of your district that will facilitate building staff capacity for integrated disease surveillance and response in your district. Please describe challenges you might face in building staff capacity for integrated disease surveillance and response in your district.

108 6.0 HEALTH EDUCATION AND PROMOTION DURING AN OUTBREAK 6.1 Standards for epidemic preparedness: Districts will have appropriate health education materials on hand that can be used to communicate information to the public before, during, and after an outbreak Health sector personnel will have the capacity to increase awareness about infectious disease surveillance in the community 6.2 Current status Please comment on your previous experiences communicating with the public during an outbreak. During the last outbreak, how did you communicate with the community about the outbreak (e.g. what mechanisms)? If you held meetings to inform the public, whom did you target for the meetings (e.g. mothers, community leaders, school teachers )? Did you have all the information that you needed to inform the community about the status of the outbreak (i.e. number and location of cases)? Did you have the information and materials you needed to inform the community about actions that households or communities should take (i.e. cholera prevention, vaccination requirements)?

109 6.3 Approach to reach preparedness For the important diseases in your district, please think about the educational materials you have currently available for use during an outbreak. What other materials might be necessary to help your district become prepared? Disease What health education messages are required during an outbreak? (e.g. what information needs to be conveyed) Who is the target audience for each message? (e.g. mothers, schools, community leaders, traditional healers ) What types of materials are needed to convey those messages to a population at risk? (e.g. posters, radio messages, brochures, videos ) How many copies of each item are required for your district? From the table above, select the 3 most important materials to make available at the district level:

110 6.4 Strengths and Challenges Please describe the current strengths of your district that will facilitate the actions, tasks, and processes listed above for making health education materials available and communicating with the public in your district. Please describe challenges you might face in implementing actions that you have listed above for making health education materials available and communicating with the public in your district.

111 Document 7-4 Example of use of data for forecasting Measles incidence, Chile Interepidemic periods Rate/100,000 population Pre-vaccine era 2 years 2 years years 4 years Source: HVP/PAHO PAHO The above graph shows the incidence of measles for the period 1960 to 1976 in Chile. On the y axis is the number of measles cases and on the x axis is the year. As the graph shows, in the pre-vaccine era the incidence of measles cases was higher approximately every two years. After the introduction of routine measles vaccination in 1966, the interval between peaks increased to four years and the overall incidence steadily declined nearly every year. Based on the observed trends, health officials could have expected and prepared for the next measles outbreak to occur in 1978, four years after the last outbreak.

112 Task 7-1 In your District Group Review the key elements that need to be addressed for forecasting outbreaks Review the information gathered in your data collection tools Use the information gathered to complete the forecasting section of the preparedness template You have 30 minutes to complete this section

113 Document 7-5 The outbreak response and outbreak investigation teams 1) Response An epidemic response team, which is multi-sectoral, should be formed and periodically meet whether or not there is an epidemic (for example, on a quarterly basis). During an epidemic, the team should meet as soon as the epidemic is confirmed, and further meetings may be held at least twice a week. The epidemic response team is responsible for both preparedness and implementation. Its key tasks include the following: Routine/Preparedness Mobilise human, material, and financial resources for epidemic prevention and control Review surveillance data for trends that cause a concern for public health Review and update supplies and resources for epidemic response of priority diseases and conditions. Check emergency stock of supplies every month. Set up procedures for obtaining emergency funds Set up procedures for transportation of laboratory specimens from remote areas Assign clear responsibilities to individuals or units for specific response activities During an epidemic Monitor response activities by keeping detailed records on response activities; reviewing data on cases, laboratory confirmation, and treatment; identifying problems; and modifying activities as necessary Make sure health supervisors in districts and health facilities know and use case management protocols for priority diseases Alert nearby districts or catchment areas about the outbreak and coordinate efforts if they have cases Coordinate public information and education during an epidemic in order to maintain calm and encourage cooperation with response activities After an epidemic Conduct a review of the outbreak response. Note any changes that were made to the initial response activities and recommended changes to improve epidemic response in the future Prepare outbreak reports and submit to higher levels as required Sustain preventive measures The District Response Team (sometimes referred to as the District Outbreak Management Committee) should include the following members: District Medical Officer District Health Officer Health Secretary District Nursing Officer District Laboratory Technician

114 District Pharmacist Medical Officer In-Charge of the hospital Head of Health Training Centres Representatives of health facilities and communities Representatives of other public sectors especially Defence, Police, Water, Community development, Education, Agriculture and Livestock, Planning, Culture, and others Health partners for example NGOs involved in health and development activities. 2) Investigation Following timely detection of a suspected outbreak, investigation is done to confirm the presence of an outbreak. The Investigation Team will often be composed of the following people: Epidemiologist/Disease Control Officer Clinician (Medical Officer/clinical officer) Laboratory Technician Public Health Nurse Environmental Health Officer The general responsibilities of the Investigation Team are: To carry out the investigation To verify any suspected outbreaks or rumours in the district, including collection of specimens and communication with the laboratory To propose appropriate strategies and measures of rapid containment of epidemics to the district response team

115 Task 7-2 In your District Group Review the key elements that need to be addressed for staffing for epidemic investigation and response Complete the staffing section of the preparedness template You have 55 minutes to complete this section.

116 Task 7-3 In your District Group Review the key elements that need to be addressed for buffer stocks Complete the buffer stock section of the preparedness template You have 75 minutes to complete this section.

117 Task 7-4 In your District Group Review the key elements that need to be addressed for training Complete the training section of the preparedness template You have 30 minutes to complete this section.

118 Task 7-5 In your District Group Review the key elements that need to be addressed for health education and promotion Complete the health education and promotion section of the preparedness template You have 45 minutes to complete this section

119 Document 7-6 Application Planning sheet Please take a few minutes to think about this module and how it applies to your work. Then answer the following questions. 1. Identify the steps that should be taken in your district in order to incorporate the preparedness plan into your Comprehensive Council Health Plan (CCHP). 2. When will be the best time to incorporate epidemic preparedness into the CCHP. 3. Who should be involved in the preparedness plan for your district? How should they be involved? 5. How often does the district need to review and modify the plan?

120 Document 8-1 Module 8 Objectives By the end of the module, participants will be able to: 1. Determine the most important aspects of facility-level performance that need to be monitored for IDSR to be successful 2. Identify opportunities to obtain information about performance and compare to norms, standards, and guidelines 3. Identify opportunities and methods to provide feedback to facilities in 4. Reinforce the importance of performance review, supportive communication, and feedback as a key aspect of routine supervision 5. Use positive and constructive approaches for motivating people to be an active part of the surveillance system

121 Document 8-2 Functions and aspects of facility-level performance that need to be monitored Function of surveillance Regularly monitor whether health facilities Identify and record suspected cases Confirm suspected cases Report weekly and monthly data Review and analyze data Notify the district in case of any suspected outbreak Respond to outbreak thresholds and analysis results Use standard case definitions Use a clinical register Correctly record information in the register Correctly use the register and fill in the tally sheets Have access to a functioning laboratory that can reliably process specimens (sputum, stool, blood, serum, cerebral spinal fluid, for example) for confirmation of priority diseases. Correctly test the specimen for routine cases Safely collect and properly package specimens for transport to higher level laboratory Submit specimens of priority diseases for confirmation in a timely way Have weekly and monthly report forms Submit weekly and monthly report on time Submit reports that are accurately and completely filled Keep up-to-date trend (line graphs) for each selected of the IDSR priority diseases Have an epidemic threshold for epidemic prone disease and have detected a new epidemic Have case investigation forms for reporting suspected cases Report the suspected outbreaks within 24 hours Used local information to conduct a community disease prevention and control activity during the last 12 months. Implemented prevention and control measures based on local data for at least one epidemic-prone disease Provide feedback Received a report from district or higher level about data health facility reported to these levels during the year Met with community members to discuss investigation results during last 6 months. Have a time table of providing health information to the community- through clinics, OPD or attending village meetings. Maintain readiness for epidemic response Use standard case management guidelines and protocols for priority diseases Use the minimum level of standard precautions for the suspected disease with all patients, especially febrile ones, regardless of infection status Maintain an emergency stock of urgent drugs and treatment supplies for responding to epidemic-prone diseases seen previously in the area.

122 Document 8-3 Elements of the Feedback Message Behaviour Describe a specific, observable action/behaviour what the person did or did not do. Impact/consequence State the impact or consequences of the behaviour on the team, work, timeliness of reporting, accuracy, etc Change required (corrective) or Continued performance (supportive) Identify the specific changes in behaviour/performance required or the specific behaviours you want continued. Example of supportive feedback: B I C When you sent the report on time and with accurate information I was really appreciative because of the hard work I know it represented for you and as a result we have been able to respond more quickly to this outbreak than ever before lives may have been saved thanks to your actions. In supportive feedback no change is required. We want to support continued performance at the same level. Example of corrective feedback: B I C When you repeatedly send in reports that are late and with inaccurate information..."..we may have a serious outbreak and not realize it s importance until several people have died from problems that we could have prevented."...it is important that you check your reports for accuracy before submission and be sure to get them to the district by the scheduled time.

123 Task 8-1 Individual Task Think of a person to whom you would typically give feedback at the facility level. Identify one thing this person has done well, Prepare a supportive feedback message Think of one thing you would like this person to change or improve Write a corrective feed back message Please write down your messages. Be sure to include the Behaviour, the Impact, and the Change You have 15 minutes

124 Task 8-2 Group Task Practice giving your feedback messages to one another in front of the rest of the group After each person s practice, the group will Analyse the message to see if it has the three necessary components:! Behaviour! Impact/consequences! Change required or Continued performance Identify the effective parts of the messages, and Suggest possible improvements There will be 5 minutes for each person to give the messages and to receive feedback from the group You have 40 minutes

125 Document 8-4 Application-Planning sheet Module 8 Please take a few minutes to think about this module and how it applies to your work. Then answer the following questions. 1. What are the aspects of IDSR specific facility-level performance you plan to monitor? 2. How can you use constructive feedback on an ongoing basis to improve performance and motivate people? 3. What are some approaches you can use to motivate people to be a more active part of the surveillance system?

126 Document 9-1 Module 9 Objectives By the end of the module, participants will be able to: 1. Explain the importance of involving a range of stakeholders in supporting IDSR 2. Identify key stakeholders or partners in their district and the roles they can play 3. Discuss ways of involving and communicating with them

127 Document 9-2a MATRIX OF PRIORITY STAKEHOLDERS AND POSSIBLE ACTIONS FOR IMPROVING LINKAGES BEYOND THE HEALTH SYSTEM IN ORDER FOR THIS GROUP.. Community leaders: VEOs, WEOs, CORPs (in areas with IMCI) Elected and Appointed Officials District Council M.P. District Exec. Dir. Private sector providers (traditional): Traditional healers Traditional birth attendants Other traditional providers Private Sector Health Providers (conventional):! Pharmacists! Chemical sellers! Private clinics Community Groups Women s Groups Volunteer Health Workers School Teachers Religious Leaders TO TAKE THIS SPECIFIC ACTION OBSTACLES OR CONSTRAINTS TO ACTION 1. To inform and involve the community to refer cases 2. To inform the facility of suspected cases 3. Demand timely and appropriate response 4. Participate in the investigation 5. Promote adherence to, and participate in control measures as part of response 1. Allocate necessary human and financial resources for disease surveillance annually. 2. Provide financial, human, material support needed for outbreak investigation and response 3. Invoke by-laws, when needed, to help contain outbreaks. 4. Disseminate appropriate messages to the community during and following outbreaks. 5. Mobilize other heads of district government to assist with outbreak response (e.g., water, community development) 1. Refer cases of IDS diseases to health facility 1. Alert community leaders and/or nearest health facility when they detect certain conditions 2. Participate in the investigation 3. Promote the use/application of control measures as part of response. 1. Alert community leaders and/or nearest health facility when they detect certain conditions 2. Participate in outbreak investigations 3. Promote the use/application of control measures as part of response. 4. Report using MOH forms (clinics, maternity homes) 1. Alert community leaders and/or nearest health facility when they detect certain conditions 2. Participate in outbreak investigations 3. Promote the use/application of control measures as part of response. 1. Alert community leaders and/or nearest health facility when they detect certain conditions 2. Participate in the investigation 3. Promote the use/application of control measures as part of response. THE CHMT NEEDS TO DO WHAT?

128 Task 9-1 In Groups (by district) Review the list of priority actions for the stakeholder group assigned to you, and identify possible obstacles to their contributions. (From THE POINT OF VIEW OF THE STAKEHOLDER GROUP, what makes it hard to carry out the action? What are the disadvantages or bad things that might come from carrying out the action?) Suggest some steps that can be taken to overcome the obstacles. What could the CHMT or health worker do to overcome these obstacles? When discussing this, try to think on the points below (From THE POINT OF VIEW OF THE STAKEHOLDER GROUP, What are the advantages or good things that would come from carrying out the action? What makes it easy to do the action?) How could the CHMT or health worker emphasise the advantages to these groups? Write your answers on a flip chart. Identify a spokesperson. Report outs should be brief (only 5 minutes). You have 20 minutes to complete this exercise.

129 Document 9-3 Developing a Strategic Communication Developing a communication that is both strategic and effective requires some thought and planning. Elements to consider include: 1. Target Audience: To whom is your communication directed? Who is it that you want to take action? Audiences must be prioritised. A separate worksheet analysis is needed for each audience. 2. Communication Objective(s). What do you want this communication to make the audience feel, think, believe, or DO? Each objective should: Be directed to a single target audience Specify the desired ACTION the audience is to take Describe the expected results A common pitfall is to describe activities and not results: teaching village leaders is a program activity, but the communication objective should describe what village leaders are expected to do as a result of the teaching. Be specific and precise A well-defined objective will be interpreted in the same way by all those who read it. An objective should not include vague or confusing or words that may lend themselves to a number of different interpretations. Examples of action words: complete, use, try, define, explain, design, summarize, communicate, resolve, construct, prepare, make, arrange, organize, select, compare. Examples of confusing words: understand, be aware, appreciate, value, enjoy, motivate, sensitise, support 3. Obstacles. What beliefs, cultural practices, pressures, and misinformation might keep your audience from taking the action you specify in your communication objectives? These have already been outlined on your Worksheet: Matrix of Priority Actors and Possible Actions for Improving Linkages beyond the Health System. 4. Benefit. From the perspective of the stakeholder, what is the benefit of doing, thinking, or feeling what you want them to do? 5. Message Content. The purpose of the message is to persuade the stakeholder to take action. So, what specific information should the stakeholder receive? What key points should the audience of stakeholders remember? Key elements of message include: What you want to achieve. Why you want to achieve it (the positive result of taking action/or the negative consequence of inaction). Action you want the stakeholders to take.

130 6. What is the best way to reach your audience? The following are some alternative ways of communicating with stakeholders Formal or informal face-to-face meetings Informal conversations at social, religious, political, or business gatherings Briefing meetings Program site visits Fact sheets Pamphlets or brochures Computer presentations Overhead or slide presentations Advertisements News release Press conference Letter to the editor Newspaper articles Broadcast commentary or coverage Letters: personal, organizational, or coalition 7. Who are the best people to carry the message? 8. Is there a specific time and place that would be best for the delivery of the message?

131 EXAMPLE: STRATEGIC COMMUNICATION PLANNING WORKSHEET Target Audience: Whom is your communication directed to? Which audience segment needs to take action? Primary: Rural women who are pregnant Communication Objective(s). What will this communication make the audience feel, think, believe or DO? To urge that pregnant women are prevented from getting malaria using IPT during the 2 nd trimester (20-28 weeks) and the 3 rd trimester (30-36 weeks) To assure that SP is safe during pregnancy To explain that SP is effective *IPT= Intermittent Preventive Treatment, using SP during Pregnancy. Obstacles. What beliefs, cultural practices, pressures, and misinformation might keep your audience from feeling, thinking, believing or acting in the desired manner? Fear of taking medicine during pregnancy that may hurt unborn child SP is new, unfamiliar. (Need to increase knowledge of it as preventive treatment for malaria in pregnancy) Delay in starting treatment Benefit: From the perspective of the stakeholder, what is the advantage of doing, thinking, or feeling the way that you want them to? Pregnant women who follow IPT regimen are responsible and take care of themselves and their unborn children Message Content. What few things are key to achieving your objectives? What do you want your audience to remember? Prevent malaria during pregnancy using SP in specified time. SP is safe during pregnancy SP is effective Media What is the best way to reach your audience? Radios TV Dialogue/Sessions/Video during Ante Natal Clinic Visits Newspaper Poster/Leaflets Who are the best people to carry the message? Respected woman from a village Is there any specific time and place that would be best for the delivery of the message? Make sure messages are given for the whole period but emphasised before and during the malaria season

132 Task 9-2 In groups Using Doc. 9-4, fill out the Strategic Communication Planning Worksheet for the scenario and audience assigned to your group. Scenario Audience Scenario Audience Scenario Audience Scenario Audience A: Suspected Cholera outbreak A: DED B: Suspected Cholera outbreak B: Village Executive Officer C: Annual summary of pneumonia in children under age 5 years C: District Commissioner D: Suspected typhoid outbreak D: District department heads Take 40 minutes

133 Document 9-4 STRATEGIC COMMUNICATION PLANNING WORKSHEET Target Audience: Whom is your communication directed to? Which audience segment needs to take action? Communication Objective(s). What will this communication make the audience feel, think, believe, or DO? Obstacles: What beliefs, cultural practices, pressures, and misinformation might prevent your audience from feeling, thinking, believing, or acting in the desired manner? Benefit: From the perspective of the stakeholder, what is the advantage of doing, thinking, or feeling what you want them to? Message Content: What few things are key to achieving your objectives? What are the key points the audience should remember? Media: What is the best way to reach your audience? Who are the best people to carry the message? Is there any specific time and place that would be best for the delivery of the message?

134 Task 9-3 Task 9-3 Group Task: Using the communication planning worksheet you completed in the previous exercise, develop a 5 minute strategic communication and present to your target group as a role-play. You will have 20 minutes

135 Document 9-5 Application-Planning sheet Module 9 Please take a few minutes to think about this module and how it applies to your work. Then answer the following questions. 1. How will you ensure that you have identified all of the key stakeholders or partners in your district and the roles they can play? 2. How do you plan to involve them and communicate with them?

136 Document 10-1 Module 10 Objectives By the end of the module, participants will be able to: 1. Explain the importance of monitoring surveillance activities 2. Understand the key IDSR indicators that should be routinely monitored 3. Calculate the indicators and interpret the results 4. Identify appropriate actions to improve IDSR performance in the district

137 Document 10-2 Examples of Indicator Interpretation Timeliness of Reporting from Health Facilities 80.0% % of reports submitted on time 70.0% 60.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Weekly reporting Monthly reporting Nzulu Akaro Ngaya Gossas Pobe Karimama Ulumba Ntundu Skori Ikembala Masari Faluni Health Facilities Completeness of Weekly Reporting from Health Facilities 1-Oct 8-Oct 15-Oct 22-Oct 29-Oct 5-Nov 12-Nov 19- Nov 26- Nov 3-Dec 10- Dec 17- Dec 24- Dec 31- Dec % Complete Nzulu X X X X X X X X X 64% Akaro X X X X X X 43% Ngaya X X X X X X X 50% Gossas X X X X X 36% Pobe X X X 21% X = report received

138 Document 10-3 Tanzania IDSR Indicators at the District Level Task to Measure IDSR Indicator Numerator (num) Denominator (den) National Targets 1. Timeliness of facility Proportion of weekly facility reports Total number of weekly health facility Total number of weekly health facility 80% reporting to the district received by district on time reports received on time by the district reports expected by the district 2. Proportion of monthly facility reports received by district on time Total number of monthly health facility reports received on time by the district Total number of monthly health facility reports expected by the district 3. Reporting of priority diseases using case investigation forms 80% Proportion of cases of priority diseases (AFP, Cholera, Measles, CSM, NNT, Plague, VHF, Yellow Fever) which were reported to the district using case investigation forms 4. Complete facility Proportion of expected weekly health reporting to the district facility reports that are received by district Total cases of priority diseases (AFP, Cholera, Measles, CSM, NNT, Plague, VHF, Yellow Fever), which were reported to the district using case investigation forms Total number of weekly health facility reports that are received by district Total cases of suspected priority diseases (AFP, Cholera, Measles, CSM, NNT, Plague, VHF, Yellow Fever) reported to the district and expected to have a CIF (see laboratory job aids) Total number of expected weekly health facility reports 90% 5. Proportion of expected monthly health facility reports that are received by district Total number of monthly health facility reports that are received by district Total number of expected monthly health facility reports 6. Effective laboratory confirmation process 7. Appropriate investigation of suspected outbreaks 8. Appropriate response to confirmed outbreaks 9. Quality of case management and surveillance activities 10. Routine analysis of data Proportion of suspected outbreaks of epidemic-prone disease in which specimen collection and laboratory confirmation are completed according to guidelines Proportion of suspected outbreaks of epidemic-prone disease that are investigated according to guidelines Proportion of confirmed outbreaks of epidemic-prone disease with appropriate response according to guidelines Case fatality rate for each epidemicprone disease (cerebral spinal meningitis, cholera, plague and rabies) and nonepidemic prone disease (pneumonia, malaria, and diarrhoea) reported in a confirmed outbreak Proportion of facilities with all three of the following: 1) use of summary data sheet, 2) use of MTUHA book 2, and 3) presence of updated graphs of disease trends for malaria, diarrhoea < 5 years, and pneumonia < 5 years *Suggested checklists are included as Documents 10-8, 10-9, and Total number of suspected outbreaks of epidemic-prone disease in which specimen collection and laboratory confirmation procedures are followed (measured by score of 6/6 on checklist*) Total number of suspected outbreaks of epidemic-prone disease that are investigated according to guidelines (measured by score of 7/7 on checklist*) Total number of confirmed outbreaks of epidemic-prone disease with recommended response according to guidelines (measured by score of 5/5 on checklist*) Total number of deaths reported from epidemic-prone disease outbreaks Total number of health facilities with all three of the following: 1) use of summary data sheet, 2) use of MTUHA book 2, and 3) presence of updated graphs of disease trends for malaria, diarrhoea < 5 years, and pneumonia < 5 years Total number of suspected outbreaks of epidemic-prone disease Total number of suspected outbreaks of epidemic-prone disease 80% Total number of confirmed outbreaks 80% Total number of cases reported from the epidemic-prone disease outbreak Total number of health facilities 80% Disease-specific

139 Document 10-4 Tanzania Integrated Disease Surveillance and Response (IDSR) Preconditions for Indicators IDSR Indicator Pre-condition Pre-condition met 1 and 2. Proportion of health facilities that submitted IDS forms on Yes -or- No time to the district 4 and 5. Proportion of expected health facility reports that are received by the district 3. Proportion of cases of priority diseases (AFP, Cholera, Measles, CSM, NNT, Plague, VHF, Yellow Fever) that were reported to the district using case investigation forms 6. Proportion of suspected outbreaks of epidemic-prone diseases in which specimen collection and laboratory confirmation are completed according to guidelines 7. Proportion of suspected outbreaks of epidemic-prone disease that are investigated according to guidelines 8. Proportion of confirmed outbreaks of epidemic-prone disease with appropriate response according to guidelines 9. Case fatality rate for each epidemic-prone disease (cerebral spinal meningitis, cholera, plague and rabies) and non-epidemic prone disease (pneumonia, malaria, and diarrhoea) reported in a confirmed outbreak 10. Proportion of facilities with all three of the following: 1) use of summary data sheet, 2) use of MTUHA book 2, and 3) presence of updated graphs of disease trends for malaria, diarrhoea < 5 years, and pneumonia < 5 years *Suggested checklists are included as Documents 10-8, 10-9, and Availability and use of IDS forms at the health facilities for reporting summary data to the districts on time System to note date that reports are received Availability and use of logbook or register to monitor compiled information on timeliness and completeness Availability and use of case investigation forms at the health facilities for reporting priority diseases to the districts District keeps copies of case investigation forms District has laboratory job aids and uses them to determine sampling frame and appropriate denominators for different diseases requiring CIFs Availability and use of logbook at the district of suspected outbreaks and rumors Availability and use of checklist for what constitutes specimen collection and laboratory confirmation according to guidelines * Information included in outbreak reports Guide to calculating outbreak management indicators Availability and use of logbook at the districts of suspected outbreaks and rumors Availability and use of checklist for what constitutes investigation according to guidelines * Information included in outbreak reports Guide to calculating outbreak management indicators Availability and use of checklist for what constitutes an appropriate response for each disease* Availability and use of the logbook at the districts of suspected outbreaks and rumors District keeps copies of outbreak investigation reports Guide to calculating outbreak management indicators Availability and use of case-based forms at the districts Routine reports and outbreak reports Availability and use of analysis guidelines at the districts Supervisory visit reports Yes -or- No Yes -or- No Yes -or- No Yes -or- No Yes -or- No Yes -or- No Yes -or- No Yes -or- No Yes -or- No Yes -or- No Yes -or- No Yes -or- No Yes -or- No

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141 Task 10-1 Using the sample data, Calculate the indicators Interpret the results, looking specifically at the performance of each facility across time and comparing the facilities to each other Suggest actions to improve performance Take 40 minutes

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143 Document 10-5 Timeliness and completeness of weekly facility reporting to districts Sample Data Collection Forms Source(s) of data: log book of weekly facility reports, or actual weekly reports Codes: T= received on time L = received late(within one week of deadline) W = report not received(not received within one week of deadline) Proportion of weekly facility reports received on time by district Week ending Months Month: July 2003 Month: August 2003 Month: September 2003 Total reports on time (T) Total reports late (L) Total reports not received(w) Timeliness = 100xT/N Completeness = 100x(N-W)/N Facilities 1. Mtima 2. Kiuma 3. Nakapanya 4. Mbesa 5. Mkasale 6. Kalulu 7. Marumba 8. Masuguru 9. Tinginya 10. Ngapa Total reports expected (N) Total reports on time (T) Total reports late (L) Total reports not received(w) Timeliness = 100xT/N Completeness = 100x(N-W)/N

144 Document 10-6 Timeliness and completeness of monthly facility reporting to districts Sample Data Collection Forms Source(s) of data: log book of monthly facility reports, or actual monthly reports Codes: T = received on time L = received late(within one week of deadline) W = report not received (not received within one week of deadline) Proportion of monthly facility reports received on time by district Totals for Quarter N = 3 Facilities Month Month Month Total reports Total on time (T) reports late (L) Total reports not received (W) Timeliness = 100xT/N Completeness = 100x(N-W)/N Total reports expected (N) Total reports on time (T) Total reports late (L) Total reports not received(w) Timeliness = 100xT/N Completeness = 100x(N-W)/N

145 Document 10-7 Proportion of cases reported to the district using case investigation forms If there were cases of these diseases, note below the number of cases and forms received for each Source(s) of data: district log book of suspected outbreaks and rumours, case investigation forms Priority Month: Month: Month: Total for Quarter Disease # Cases # Forms # Cases # Forms # Cases # Forms # Cases # Forms AFP Tally NNT Total Tally Measles Total Tally Meningitis Total Tally Cholera Total Tally Plague Total Tally Yellow fever Total Tally VHF Total Tally Total Monthly total (A) (B) (A) (B) (A) (B) (A) (B) Indicator value (B)/(A) % % % %

146 Document 10-8: Guide to Calculating Outbreak Management Indicators Investigation Fill in requested information or circle the appropriate response for each question. 1. Date epidemic threshold was met 2. Date suspected outbreak reported to district 3. Interval from day threshold was met to day outbreak reported (difference between #1 and #2) Less than or equal to 24 hours? Y / N 4. CHMT prepares for investigation? Y / N 5. Date investigation initiated 6. Interval from day district was notified to day investigation initiated (difference between #2 and #5) Less than or equal to 48 hours? 7. Clinical history compared to standard case definition to verify presumptive diagnosis? 8. Search for additional cases? (mark YES only if all three types of searching done) Y / N Y / N Y / N - in facility records? - in other health facilities? - in community? 9. Record information about cases? Y / N 10. Case-based information analysed (person, place or time analysis)? Y / N Total Y answers circled: / 7 TOTAL SCORE FOR INVESTIGATION % of criteria met

147 Document 10-9: Guide to Calculating Outbreak Management Indicators Laboratory confirmation Fill in requested information or circle the appropriate response for each question. 1. Date first specimen collected 2. Type of specimen collected 3. Appropriate specimen? Y / N Plague: aspirate, blood, Cholera: stool/rectal swab sputum, throat swab Measles: serum blood Meningitis: cerebral spinal Yellow fever: blood serum fluid Bacillary dysentery: stool AFP (polio): stool samples 4. Number of initial specimens collected 5. Total number of specimens collected during outbreak 6. Appropriate number of specimens collected? Y / N Cholera : first 5-10 cases, then every 10th Measles : first 5 suspected cases Yellow fever : first 5-10 suspected cases Bacillary dysentery : first 5-10 cases, then every 10th Plague : first 5-10 suspected cases Meningitis: first 5 cases, then every 10 th AFP: 2 from each suspected case 7. Specimens properly prepared/handled (able to be analysed)? *Note that this indicator requires feedback from lab Y / N 8. Specimen documentation sufficient? *Note that this indicator requires feedback from lab Y / N 9. Date specimens received at laboratory 10. Interval from day first specimen collected to day specimens received at laboratory (difference between #11 and #19) 11.Specimens received at laboratory within appropriate timeframe? Y / N Meningitis: 24 hours Dysentery: 48 hours Plague: 24 hours AFP: 72 hours Yellow fever: 72 hours Cholera: 48 hours Typhoid: 24 hours Measles: 72 hours Rabies: 24 hours 12. Laboratory results received? Y / N Total Y answers circled: / 6 TOTAL SCORE FOR LABORATORY CONFIRMATION % of criteria met

148 Document 10-10: Guide to Calculating Outbreak Management Indicators Response FOR CONFIRMED OUTBREAKS ONLY Fill in requested information or circle the appropriate response for each question. 1. CHMT meets to discuss / plan response Y / N 22. Data used as basis for response Y / N 23. Outbreak information provided to community? How to prevent the disease Symptoms to watch for Actions to take if a person becomes ill Y / N 24. Specific response actions (circle actions taken) All Diseases: 1. Treat cases 2. Public education Cholera : 3. Assess/treat water supply 4. Ensure safe water supply through boiling or chlorination 5. Establish treatment camps where necessary 6. Improve environmental sanitation 7. Ensure food safety Measles: 8. Mass vaccination 9. Distribution of Vitamin A Yellow fever: 10. Mass vaccination 11. Mosquito control 25. Appropriate response? Appropriate response should include treatment of cases, prevention activities, and public education activities. 26. Outbreak report written? Bacillary dysentery: 12. Instruction on proper food handling, hygiene, and water and environmental hygiene Plague: 13. Surveillance for human plague cases 14. Surveillance for rodent plague cases 15. Use of insecticide to control rodent fleas Rabies: 16. Vector control Meningitis: 17. Mass vaccination *NOTE THAT THIS IS NOT A COMPREHENSIVE LIST, BUT A GUIDE TO TYPES OF RESPONSES THAT MAY BE TAKEN Y / N 27. Report includes case-based data? Y / N Number of Y answers circled: / 5 TOTAL SCORE FOR APPROPRIATE RESPONSE % of criteria met TOTAL SCORE FOR OUTBREAK MANAGEMENT / 18 % of criteria met

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150 Document Example: Timeliness and completeness of weekly facility reporting to districts Sample Data Collection Forms Source(s) of data: log book of weekly facility reports, or actual weekly reports Codes: T= received on time L = received late (within one week of deadline) W = report not received (not received within one week of deadline) Proportion of weekly facility reports received on time by district Months Month: July 2003 Month: August 2003 Week ending 2-Jul 9- Jul Facilities 16-Jul 23-Jul 30-Jul 6-Aug 13- Aug 20- Aug 27- Aug Month: September Sep 10- Sep 1. Mtima T T T W T L L T T T T L W % 85% 2. Kiuma W W W L T T T W L L T T 3. Nakapanya T T T T T T T T T T T T T 4. Mbesa L T T L W T L L W T T L W 5. Mkasale W W W W W W W W W W W W W 6. Kalulu T T T L T T T L T T T L T 7. Marumba L L L T L L L T L L L T L % 100% 8. Masuguru T T T T T L T T T T T W W 9. Tinginya L L T T T T T L T T L L L 10. Ngapa T T T T T T T W T T T T T Total reports expected (N) Total reports on time (T) Total reports late (L) Total reports not received(w) Timeliness = 100xT/N 50% 60% 70% Completeness = 100x(N-W)/N 80% 90% 90% 17- Sep 24- Sep Total reports on time (T) N=13 Total reports late (L) Total reports not received(w) Timeliness = 100xT/N Completeness = 100x(N-W)/N

151 Document Example: Timeliness and completeness of monthly facility reporting to districts Source(s) of data: log book of monthly facility reports, or actual monthly reports Codes: T = received on time L = received late(within one week of deadline) W = report not received (not received within one week of deadline) Proportion of monthly facility reports received on time by district Facilities Month: July 2003 Month: August 2003 Month: September 2003 Totals for Quarter N = 3 Total reports Total on time (T) reports late (L) Total reports not received (W) Timeliness = 100xT/N Completeness = 100x(N-W)/N 1. Mtima T T T % 100% 2. Kiuma T L L 3. Nakapanya T W T 4. Mbesa W L W 5. Mkasale W W W 6. Kalulu L L T 7. Marumba T T T 8. Masuguru T L T 9. Tinginya W W L 10. Ngapa T W T % 67% Total reports expected (N) 10 Total reports on time (T) 6 Total reports late (L) 1 Total reports not received(w) 3 Timeliness = 100xT/N 60% Completeness = 100x(N-W)/N 70%

152 Document Example: Proportion of cases reported to the district using case investigation forms If there were cases of these diseases, note below the number of cases and forms received for each Source(s) of data: district log book of suspected outbreaks and rumours, case investigation forms Priority Month: July 2003 Month: August 2003 Month: September 2003 Total for Quarter Disease # Cases # Forms # Cases # Forms # Cases # Forms # Cases # Forms AFP Tally NNT Total Tally X x x Total 1 0 Measles Tally Xx x xx xx Total Meningitis Tally xxxxx xxxxx Cholera Total Tally xxxxx xxxxxxxxx xx xxxx x Total 4 0 Plague Tally Yellow fever Total Tally VHF Total Tally Total Monthly total 7 1 (A) (B) (A) (B) (A) (B) (A) (B) Indicator value (B)/(A) % % % %

153 Document 10-13a Model Answers for Document Proportion of cases reported to the district using case investigation forms Source(s) of data: district log book of suspected outbreaks and rumours, case investigation forms As forms are reviewed, tally the number of cases and forms received for each disease and each month and then calculate the totals. Add across rows to get totals for the quarter. Add down columns to get totals for the month. Priority Month: July 2003 Month: August 2003 Month: September 2003 Total for Quarter Disease # Cases # Forms # Cases # Forms # Cases # Forms # Cases # Forms AFP Tally NNT Total Tally x x x Total Measles Tally xx x xx xx Total Meningitis Tally xxxxx xxxxx Total Cholera Tally xxxxx xxxxxxxxx xx xxxx x Total Plague Tally Yellow fever Total Tally VHF Total Tally Total Monthly total (A) (B) (A) (B) (A) (B) (A) (B) Indicator value (B)/(A) 14% 50% 42.8% 32.1%

154 Task 10-1 Using the sample data, Calculate the indicators Interpret the results, looking specifically at the performance of each facility across time and comparison of facilities to each other Suggest actions to improve performance Take 40 minutes

155 Document Sample Baseline Data Task to Measure IDSR Indicator Results Timeliness of facility reporting to the district Proportion of weekly facility reports received by district on time 7% Proportion of monthly facility reports received by district on time 8% 41/560 9/120 Observations 3. Reporting of priority diseases using caseinvestigation forms Proportion of cases of each disease which were reported to the district using case-investigation forms 38% 24 cases of measles and 2 cases of meningitis reported, 10 case investigation forms found for measles, but none for meningitis Complete coverage of facility reporting to the district Effective laboratory confirmation process Appropriate investigation of suspected outbreaks Appropriate response to confirmed outbreaks Quality of case management and surveillance activities Routine analysis of data Proportion of expected weekly health facility reports that are received by district Proportion of expected monthly health facility reports that are received by district Specimen collection and laboratory confirmation completed according to guidelines Score on lab confirmation checklist (maximum 6) Suspected outbreaks of epidemicprone disease investigated according to guidelines Score on outbreak investigation checklist (maximum 5) Confirmed outbreaks with appropriate response according to guidelines Score on outbreak response checklist (maximum 5) Case fatality rate for each epidemicprone disease (priority disease) reported Score on routine analysis of data checklist (maximum 4) 22% 20% 4/6 3/5 4/5 x x x x x x x x x x x Appropriate # samples taken Appropriate handling & transportation of samples Samples sent to appropriate lab Samples accompanied by appropriate documentation Samples sent within appropriate timeframe Lab confirmation received Timely notification Timely investigation Confirm diagnosis Search for additional cases Compile and analyse data (including CFR) CHMT meets Response based on data Inform and educate community Disease specific actions Outbreak report includes casebased data Cholera 0% x Meningitis 1/4 74/560 13/120 x Yellow Fever District does routine trend analysis Monthly malaria cases and deaths for children <5 Long-term trend analysis of malaria in children <5 Includes data from last 3 months

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