INTEGRATED DISEASE SURVEILLANCE AND RESPONSE Training Modules for Health Facilities Facilitator Guide

Transcription

1 THE UNITED REPUBLIC OF TANZANIA MINISTRY OF HEALTH INTEGRATED DISEASE SURVEILLANCE AND RESPONSE Training Modules for Health Facilities Facilitator Guide NOVEMBER 2004

2 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: Centers for Disease Control and Prevention(CDC), Change Project, Partners for Health Reform plus, Ministry of Health and National Institute for Medical Research. 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

3 Acknowledgements We would like to express our sincere gratitude to the WHO/AFRO whose strategy, techincal 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 na Tabora together with Council Health Management Teams of Babati, Mbulu, Masasi, Nkasi, Sumbawanga Rural, Mwanza Urban, Tunduru, Dodoma Rural, Mpwapwa, Muleba, Igunga and Tabora Urban. We thank Ministry of Health-Tanzania especially the IDSR Task Force for supervising the implementation of activities of IDSR in the 12 chosen districts. We also acknowledge Zonal Training Centres for their technical assistance in preparing the training modules. Lastly but by means least, we express our gratitude to USAID for the financial support which enabled this work to be completed.

4 COURSE PREPARATION 1. Selection of Course Management Team A course coordinator will, with the support from three or four facilitators make a course management team. The course facilitators will be selected from those who underwent a course of Facility or District Training of Trainers on Integrated Disease Surveillance and Response (IDSR). Outside resource persons should generally not be asked to present a module, unless they are very familiar with the course and its methodology. Though the course coordinator is responsible for the overall smooth running of the course it is highly recommended that he delegates administrative tasks to a course manager. The course manager will, for example, make administrative arrangements, supervise support staff, (secretary, drivers), ensure that participants and facilitators receive the necessary support to travel to and from the course site, and that financial obligations and support tasks during and after the workshop are carried out promptly. He or she will be a member of the course management team. 2. Invitation of Authorities to Open or Close the Course It is encouraged to have a high official from the Ministry of Health or Presidents Office Regional Administration and Local Government representative to be invited to open and/or close the course.

5 Table of Contents Module 1: Introduction to the Workshop... 1 Module 2: Introduction to IDSR Module 3: Detect and Record Priority Diseases Using Standard Case Definitions Module 4: Report Priority Diseases Module 5: Analyse and Interpret Data for Action Module 6: Investigate and Respond to Outbreaks/Epidemics Module 7: Successful Community Relations for Surveillance Module 8: Application Planning Module 9: Evaluation and Workshop Closure Annex 1: Glossary of key terminologies used in IDSR Facility level training

6 Introduction 1. Overview This document is a trainer s guide for preparing health facility personnel involved in disease control and surveillance to perform their tasks competently. The workshop is designed for hospital, health centre and dispensary staff. This guide contains all the instructions needed for the trainers to conduct the workshop. It is intended to be used in conjunction with the Participant Manual, which includes all the technical material the participants will receive during the workshop. The Participant Manual is distributed at the beginning of the workshop. 2. Participants This training workshop is designed for participants. This includes dispensary in-charges, three representatives from each health centre, and five representatives from each hospital, including hospital medical officers-in charge, nursing officers-in charge, hospital secretaries, laboratory personnel, and medical recorders 3. Training methodology The training workshop is conducted in a five-day workshop format with approximately 35 hours of instruction excluding breaks. All session times are based on knowledgeable estimates and may vary slightly during in any specific application of the workshop. The workshop is based on the principles of adult learning and a participatory methodology that uses a mix of presentations, individual tasks, small group tasks, case studies and full group discussions. Participants will be asked to identify and propose solutions to difficulties they have in using the knowledge and skills acquired and will be given the opportunity to reflect on what they have learned. The workshop is designed to be delivered in the sequence presented. Each session will address the what (performance expectations and technical content), the how (how technical content translates to specific tasks and problemsolving), and the why (why these actions are important). 4. Goals The overall workshop goals are the following: By the end of the workshop, all participants will be able to: 1. Explain the IDSR strategy and the importance of the health facility in its implementation 2. Detect and accurately report on priority diseases to the district level 3. Analyse and interpret data on priority diseases 4. Use data to respond to diseases 5. Investigate and respond to suspected outbreaks 6. Advocate with communities to support IDSR implementation 7. Develop a plan to apply in each facility what was learned in the workshop

7 5. Workshop Schedule Monday Tuesday Wednesday Thursday Friday 8: : Detect Priority Report Priority Diseases Diseases 8: Introduction to the Workshop Analyse and Interpret for Action Investigate and Respond to Outbreaks/Epid emics Successful Community Relations 11: Introduction to IDSR Detect Priority Diseases Analyse and Interpret for Action Investigate and Respond to Outbreaks/Epid emics Application Planning 12: Lunch Introduction to IDSR 12: Lunch Report Priority Diseases 12: Lunch 1: Analyse and Interpret for Action 12: Lunch 1: Investigate and Respond to Outbreaks/Epid emics Lunch Evaluation and Workshop Closure 3: Successful Community Relations 6. Trainers Trainers should have an in-depth understanding of IDSR and the tasks and functions that take place at the health facility level. In addition, the lead trainers should be reasonably skilled in conducting interactive, participatory workshops since the training design is based on such an approach. 7. Participant Manual This Facilitator Guide should be used in conjunction with the Participant Manual that is given to all participants at the beginning of the workshop and contains all the learning materials that are required. The participant workbook is organized by sessions with documents numbered in sequence. The Facilitator Guide makes specific reference to these numbered documents and when and how they should be used. 8. Workshop Venue The workshop should be conducted in an offsite location where participants can stay overnight. The venue should have a large training room that can accommodate up to four small groups without overcrowding. The room should be arranged with a number of tables that seat up to eight participants, and not

8 arranged in classroom style or theatre style. This will allow participants to interact easily. If possible, separate breakout space for the small group sessions should be available. The venue should also have two to four flipchart stands, markers and flipchart paper and adequate wall space to post flipcharts. 9. Evaluation of Training The final module includes an evaluation form that all participants are asked to complete. In addition, visits to the health facilities will be conducted in the months following the training workshop to assess the actual performance of trainees.

9 Module 1 Introduction to the Workshop Steps Session Overview 1. Welcoming remarks 20 minutes 2. Introductions and start-up activity 40 minutes 3. Workshop goals, agenda, working norms 20 minutes 4. Pre-test 25 minutes Total Duration 1 hour 45 minutes Materials needed: Doc. 1-1: Workshop Goals Doc. 1-2: Workshop Agenda Doc. 1-3: Proposed Working Norms Doc. 1-4: Pre-test 1. Welcoming Remarks 20 minutes The opening remarks may be given by a representative of the district CHMT, or if possible a regional representative of the Ministry of Health, depending on what is customary, appropriate, and practical. 2. Introductions and start-up activity 40 minutes A. Introductions The trainers introduce themselves briefly and ask the participants to do the same as follows: Task 1-1 Introductions Please state: Your name The health facility where you work How long you have worked with your health facility Your designation One thing you hope to learn during the workshop Record the things participants hope to learn on a flip chart and save for use later. 1

10 B. Start-up activity Once the introductions are over, indicate that you would like to give participants a chance to: Get to know one another better Explore some of the themes in the workshop Engage in an activity that encourages participation Create a friendly climate that is conducive to learning Explain that they will start with an individual task, and then talk with two other people about what they wrote. Here is the task: Task 1-2 Individual Task Think about the disease surveillance and response activities at your health centre, dispensary or hospital Please identify and write down on a piece of paper: one thing you feel your facility is doing well one thing you feel your facility could be doing more effectively You have 5 minutes Make sure the participants only write two items in total. Then ask them to find two other people they do not know or do not know well and do the following trio task: Task 1-3 In your trio (in threes) Reintroduce yourselves, if necessary. Each person shares with the others what he/she wrote. See if there are any commonalities. Have one person ready to make a brief summary for the whole group. You have 15 minutes For the report out, ask for volunteers to briefly share examples of what they discussed. Once 3 or 4 have answered, ask if there are any different examples and elicit those as well. This activity should go quickly, without comments that would make it last long. The trainers should just paraphrase and summarize, without making comments other than identifying similarities or differences between what people have reported out. 2

11 3. Workshop goals, agenda, working norms 20 minutes A. Workshop Goals Make a transition to the workshop goals, making connections between what they said they hoped to learn (listed on the flip chart) and the goals as appropriate. Present and explain the objectives. Workshop Goals The workshop goals are that, by the end of the workshop, participants will be able to: 1. Explain the IDSR strategy and the importance of the health facility in its implementation 2. Detect and accurately report on priority diseases to the district level 3. Analyse and interpret data on priority diseases 4. Use data to respond to diseases 5. Investigate and respond to suspected outbreaks 6. Advocate with communities to support IDSR implementation 7. Develop a plan to apply in each facility what was learned in the workshop Ask if there are any questions regarding the objectives. Be clear that even though no single participant will be responsible for all aspects of IDSR implementation at the facility level, we are presenting the full range of skills so everyone has a basic understanding of the entire process (the big picture). B. Schedule Then describe the schedule. Explain that this workshop will place an emphasis on participation and on practical applications so that each facility team will leave with elements of a plan for strengthening their IDSR system. C. Participant Manual and job aids Describe the Participant Manual and the other job aids. Note that the Participant Manual is organized by session with short documents related to the topics presented. The documents are numbered for easier reference. For example: Doc Workshop Objectives Doc Workshop Agenda D. Logistical issues Make sure that any logistical issues are addressed such as meals, lodging, transportation and other issues related to the training site. E. Working Norms Explain that you would like to develop agreements with the group on ways that everyone, both trainers and participants, can best work together to achieve the 3

12 workshop objectives, taking into account individual needs as well as group needs. Suggest the following working norms (Doc 1-3) with additions and revisions based on participant input. Proposed Working Norms Active participation and full attention Openness to new or different ideas Active listening Balanced participation; giving everyone a chance to participate Keep time Turn cell phones off during sessions Discuss and reach agreement on working norms that everyone is willing to commit to. Post them on the wall along with the course objectives so that people can refer to them throughout the course. 4. Pre-test 25 minutes Explain the purpose and procedures for the pre-test. Explain that the pre-test is a way to evaluate the effectiveness of the workshop. Note that there will be a posttest with the same questions in order to evaluate what they have learned during the workshop. The facilitators will mark the tests, but the results will not be delivered to the participants. 4

13 Document 1-1 Workshop Goals By the end of the workshop, the participants will be able to: 1. Explain the IDSR strategy and the importance of the health facility in its implementation 2. Detect and accurately report on priority diseases to the district level 3. Analyse and interpret data on priority diseases 4. Use data to respond to diseases 5. Investigate and respond to suspected outbreaks 6. Advocate with communities to support IDSR implementation 7. Develop a plan to apply in each facility what was learned in the workshop 5

14 Document 1-2 8: Introduction to the Workshop Workshop Schedule Monday Tuesday Wednesday Thursday Friday 8: : Detect Priority Report Priority Diseases Diseases Analyse and Interpret for Action Investigate and Respond to Outbreaks/Epid emics Successful Community Relations 11: Introduction to IDSR Detect Priority Diseases Analyse and Interpret for Action Investigate and Respond to Outbreaks/Epid emics Application Planning 12: Lunch Introduction to IDSR 12: Lunch Report Priority Diseases 12: Lunch 1: Analyse and Interpret for Action 12: Lunch 1: Investigate and Respond to Outbreaks/Epid emics Lunch Evaluation and Workshop Closure 3: Successful Community Relations Note: These times are approximate. The schedule assumes a half hour break in the morning and a 15 minute break in the afternoon. The assumption is that the training day will end at 5 pm. 6

15 Document 1-3 Working Norms Active participation and full attention Openness to new or different ideas Active listening Balanced participation; giving everyone a chance to participate Keep time Turn cell phones off during sessions 8

16 Document 1-4 Pre - Test Name: Facility Name: Designation/Cadre: Please answer all the questions: Time: 30 minutes. 1. Which of the following are the Tanzanian IDSR priority diseases? (Mark 13 diseases) HIV/AIDS plague trypanosomiasis rabies / animal bites onchocerciasis pneumonia in children < 5 years typhoid fever leprosy cholera schistosomiasis viral hepatitis bacillary dysentery measles cerebrospinal meningitis acute flaccid paralysis (AFP) diarrhoea in children < 5 years malaria viral haemorrhagic fevers (VHF) neonatal tetanus tuberculosis yellow fever sexually transmitted infections (STIs) 8

17 2. List the national IDSR priority diseases according to the following three categories (a.) Epidemic prone diseases (b) Diseases targeted for eradication/elimination (c.) Diseases of Public Health Importance What are the benefits/uses of disease surveillance? Tick against the correct answers Benefits and uses of disease surveillance Tick against correct answers Identify disease trends Identify risks in the community Information available to make good decisions Stop outbreaks earlier; reduce deaths Inform the community about disease burden so community can prepare The use of disease surveillance is limited when there is not enough data and thus one can not plan 9

18 Benefits and uses of disease surveillance Detect outbreaks Tick against correct answers Tracking of diseases is important only in health facilities as all patients present for treatment Call for help from the district Anticipate seasonal outbreaks and plan timing of prevention measures Plan and request for the supplies and resources you need 4. List the IDSR diseases according to the frequency of reporting. Weekly reported diseases: Monthly reported diseases: Circle the correct statement about Standard Case Definition a. A standard case definition is a set of criteria used to standardise presumptive diagnosis of all cases of a disease or condition in a given population b. An SCD can be used to help decide if a person has a presumed disease, or to exclude other potential disease diagnoses c. An SCD should be used to initiate action for reporting and investigation quickly if the clinical diagnosis takes longer to confirm d. Using the same case definition throughout the country s public health surveillance system ensures efficient tracking of particular diseases or conditions e. SCD is only necessary for health facilities with no laboratories f. Data can be compared more accurately from one area to another 10

19 g. When health facilities and districts use different case definitions, tracking the trend of a particular infectious disease will be impossible h. By using a standard case definition, we ensure that every case is diagnosed in the same way, regardless of where or when it occurred and who diagnosed it 6. List 2 differences between weekly and monthly report forms (a.) (b.) Circle the correct definitions for the terms timeliness and completeness as regards reporting in IDSR. Timeliness of facility reporting to the district means a. Proportion of weekly facility reports received by district on time b. Proportion of expected weekly health facility reports that are filled in and received by District c. Proportion of expected monthly health facility reports that are filled in and received by district d. Proportion of monthly facility reports received by district on time Completeness of facility reporting to the district means a. Proportion of weekly facility reports received by district on time b. Proportion of expected weekly health facility reports that are filled in and received by District c. Proportion of expected monthly health facility reports that are filled in and received by district d. Proportion of monthly facility reports received by district on time 8. Circle the correct meaning of the term zero reporting as used in IDSR. a. No cases were seen during the reporting period b. The task of completing reporting forms with 0 to document that no cases were seen during the reporting period. These reports are then sent to the next higher level on a regular basis 11

20 c. Reports not sent to district because no cases were seen during the reporting period 9. What do you expect after sending the report to the district? Circle the correct answers a. Visited immediately by the DMO b. Feedback on the quality of the reports sent c. The report are needed much by the districts so after sending we need only to wait from the district to act d. Prompt action e. Trends of disease on different health facilities as compared to mine 10. Circle three most critical consequences for not doing complete and timely reporting? a. If data is poor going into the system (from the facilities), then outputs from the system will also be poor. b. Disease outbreaks may be missed, leading to increased illness and deaths. c. The district cannot make appropriate decisions about resources. d. No supervision to facility 11. In data management, what comes first analysis or interpretation? a. Interpretation b. Analysis 12. Circle three uses of analysed data a. To compile data for reporting b. To know the trends and pattern of diseases c. Can take some action using evidence-based information d. Can use information obtained for planning at facility level 12

21 13. Draw a sketch of the following: (a.) Line graph Bar chart 13

22 Histogram 14. Imagine there is a cholera outbreak in your ward, and that your villages are involved. Circle one most appropriate sequential order of actions that you would take if you were in charge of health facility. a. Assist with investigation when the district team comes, Report immediately to the DMO, Treat the patients according to guidelines b. Report immediately to the DMO; Treat the patients according to guidelines and Assist with investigation when the district team comes 15. What information listed below would you need to report to your District Medical Officer? Put a tick against the correct answer. Information needed to report to DMO Tick here for correct answers (a) Name of the patient (b) Village of original of patients (c) Age and sex of patient (d) Ten cell leader (e) Date of start of illness (f) Presence of many mosquitoes (g) No need for report 14

23 16. What is the epidemic/action threshold for the following diseases/conditions? Circle against the correct epidemic/action threshold Disease Epidemic/Action threshold Cholera Measles Plague Yellow fever Cerebral Spinal Meningitis Rabies Acute Flaccid Paralysis List five actors that you think you can work with to strengthen surveillance at community level What are the types of health information needs to be provided to the community to support disease surveillance? Tick against the correct answers Type of health information needs Community Standard Case Definitions for different diseases Tick against correct answers Number of additional staff required at the facility Information of diseases before, during and after outbreaks Rumours of outbreaks Diseases prevention and control 15

24 19. Name 3 ways which community can contribute to disease surveillance. Tick against the correct answers Ways community can contribute to disease surveillance Tick against correct answers Report disease incidence to facility Sharing disease rumours with non health workers only Monitor quarantine procedures Taking measures proposed by the health team to contain an epidemic 20. Write down five different ways that can be used to communicate the surveillance information to the community?

25 Module 2 Introduction to IDSR Training Module Flow Introduction to IDSR Session Overview Detect and Record Priority Diseases using Standard Case Definitions Report Priority Diseases Successful Community Relations for Surveillance and Response Investigate and Respond to Epidemics/Outbreaks Analyse and Interpret Data for Action Objectives By the end of this module, participants will be able to: Explain the IDSR strategy for improving surveillance in Tanzania Describe how surveillance data helps in understanding local public health issues Explain the benefits and uses of surveillance in their community Discuss the role of the facility in carrying out the IDSR strategy Steps 1. Introduction 20 minutes 2. Presentation of IDSR Strategy 40 minutes 3. Small group work: Benefits of Surveillance 45 minutes 4. Plenary discussion 30 minutes 5. Presentation: Facility Role in IDSR 30 minutes 6. Summary 15 minutes 7. Application 10 minutes Total Duration 3 hours 50 minutes Materials needed: Doc 2-1: Learning objectives Doc 2.2: IDSR objectives and list of diseases Doc 2-3: Definition of Key Terms Doc 2-4: Facility level steps, desire level of performance and tasks Doc 2-5: Application planning sheet Resource documents National Guidelines for Integrated Diseases Surveillance and Response 17

26 1. Introduction 20 minutes Introduce the title of this module. Say that before going into the objectives for this module you would like to ask some questions about surveillance data in order to find out more about people s background and experiences related to the subject. Ask participants to define surveillance: What do you think of when you hear the term disease surveillance? Look for answers such as: Disease surveillance: Being watchful for health problems with the aim of preventing and controlling disease outbreaks Done through collecting data, recording it, analysing the data, taking action at the facility level, and sending data to others (at the District and/or National levels) so they can take action. Ask participants to describe the parts of their own jobs that pertain to surveillance. Write these down on the flipchart or blackboard. Keep the flipchart posted to use again later. Indicate which of parts of their jobs you will address through the training. Explain that you hope this training will make their IDSR tasks easier and more meaningful. Ask why we need to do disease surveillance. Look for such answers as the following: Surveillance is about action! The data we gather through IDSR or any other approach are important in order to guide the system (WHO is getting sick, from WHAT, HOW MANY are getting sick, WHERE do they live or get sick, WHEN, and WHY with respect to the health of the community) to choose the right response! Surveillance and action are important for all diseases, not just those which pose the threat of an explosive outbreak. We must also be vigilant to the threats posed by endemic diseases like malaria, diarrhoea and ARI. Surveillance data must guide us to respond appropriately to these threats too! Make the following points: Surveillance is an important public health tool to protect the health of communities. It is based upon data collected by the health system. Surveillance activities have been an integral component of the Tanzania health system for many years. IDSR is an approach/strategy to strengthen surveillance to make it more effective as a public health tool. 18

27 Review the module objectives [Doc.2-1]. By the end of the session, participants will be able to: Explain the IDSR strategy for improving surveillance in Tanzania Describe how surveillance data helps in understanding local public health issues Explain the benefits and uses of surveillance in their community Discuss the facility s role in carrying out the IDSR strategy Ask if there are any clarifying questions regarding the objectives. 2. Presentation of the IDSR Strategy 40 minutes A. The Why of Surveillance Build on the earlier points about the why of surveillance: it is designed to provide the essential information that is needed to reduce the burden of diseases, which includes containing an outbreak or reducing common illnesses over the longer term. Say that is why the IDSR strategy is so important. Make an interactive presentation on the IDSR Strategy. Draw from the following to make key points: B. You have been doing IDSR Mention that they have been doing many of the things we describe as Integrated Disease Surveillance and Response (IDSR). Give some examples based on your knowledge of what this group of participants has been doing, referring to their examples of surveillance in the introduction, and other examples that you may have identified in the first session or prior to the workshop. C. There are still problems Say that in spite of their best efforts, assessments have shown that there are still problems: surveillance data for communicable diseases in Tanzania is not always reported in a complete and timely manner. Sometimes, also, surveillance data are not regularly analysed and interpreted by staff at facility and district level. As a result, some opportunities to take action with an appropriate public health response and save lives are lost. Even in cases where adequate information is collected, it may be available but not used for local action. Give some examples of where this problem has led to serious consequences. D. The IDSR Strategy Note that, as a result, in 1998 the Ministry of Health adopted a comprehensive strategy for strengthening communicable disease surveillance and response, Integrated Disease Surveillance and Response (IDSR), linking community, health facility, district, region /province and national levels. 19

28 Highlight the objectives of the strategy [Doc.2-2]. Note that the points you are making are a simplified version of the official IDSR objectives. Integrate different surveillance programs so that forms, personnel and resources can be used more efficiently Encourage the use of information for making decisions Help staff become better able to conduct surveillance and response Improve laboratory skills and confirm pathogens for better diagnosis and treatment Increase community participation in disease detection and response. Say why these objectives are important. E. Definition of Key Terms Say that in working with IDSR we are using terms that may have different meanings to different people. In order to make sure we are using the same terminology we will review what we mean by the following list of some key terms: IDSR is the acronym for Integrated Disease Surveillance and Response. This is a system of recording and reporting a number of specific prioritised diseases of public health importance at the same time, in order to analyse the data, prevent and respond to outbreaks more efficiently. Surveillance: process of being systematically watchful/vigilant for health problems within the community with the intent to take measures that will control or prevent disease and improve the health of the community. Outbreak: The occurrence of a cluster of cases of disease in a specific time and location which exceeds the number of expected cases for that time and place. Refer to Annex 1 for a glossary of other terminology used. F. Thirteen diseases that are the focus of IDSR Tell the participants that the National Guidelines for IDSR focus on 13 IDSR priority diseases: Cholera Bacillary dysentery Plague Measles Yellow fever Cerebrospinal meningitis Rabies/ animal bites Acute Flaccid Paralysis Neonatal Tetanus Diarrhoea in children aged <5 years Pneumonia in children aged <5 years, Malaria Typhoid Fever This list is included in [Document 2-2 in the Participant Manual). These diseases can be grouped by 3 characteristics: Diseases of public health importance (malaria, pneumonia in children under 5, diarrhoea in children under 5, typhoid fever) 20

29 Diseases targeted for eradication (acute flaccid paralysis and neonatal tetanus) Diseases of potential for outbreaks (meningitis, yellow fever, bacillary dysentery, cholera, rabies, plague and measles). Briefly remind participants of the existence of other disease programmes. Note that other important diseases have their own surveillance and reporting programmes, including HIV/AIDS, leprosy and tuberculosis. Acknowledge that the 13 IDSR diseases are only one part of their surveillance work. Explain that this training will not address these other diseases, but will try to help participants learn skills to make all the systems better. 3. Group Work: Benefits and uses of Surveillance 45 minutes Explain that the next activity will focus on the benefits of surveillance. Ask participants to keep in mind any outbreaks in which they have been involved as they discuss the questions. Divide the participants into four groups and give the following task. Task 2-1 In groups, Answer the following question What are some benefits What are some uses of surveillance information? Record responses to both questions on flipchart Select a spokesperson to report out You have 40 minutes. Possible answers to the first question on the uses of surveillance include: Detect outbreaks Set priorities for prevention activities Plan and request for the supplies and resources you need Monitor progress of control program (discover how well the control program is working to control or prevent disease) Anticipate seasonal outbreaks and plan timing of prevention measures Inform community about health status so they can set priorities Call for help from the district and/or national level : 21

30 Possible answers to the second question on the benefits of disease surveillance include: Identify disease trends Identify risks in the community Information available to make good decisions Predict future epidemics Stop outbreaks earlier; reduce deaths Identify and track pathogens so the correct antibiotic can be used Plan improved disease control strategies for the future Inform the community about disease burden so community can prepare Allocate resources (staff and supplies) to fight diseases Know that the local community is healthy by seeing that there are no reports of communicable disease. 4. Plenary Discussion 30 minutes Ask each group to post its flipcharts. Ask the groups to walk around and read them. Then ask the following questions first about the uses of surveillance information and then the benefits. What are the similarities between the groups? What are the differences between the groups? Do the benefits pertain to all diseases, not just epidemic situations? Make sure to mention that these benefits only happen if the facilities start the process. 5. Presentation: Facility Role in IDSR 30 minutes Briefly introduce the facility level description of steps, desired performance and tasks. Ask participants to turn to Document 2-3 of their manuals and go through together along each step, desired performance and tasks from step A to M. Explain that these tasks are part of the participants jobs. These are the required activities. Stress the importance of the facility staff in making the system work. Introduce the concept of job expectations and feedback from higher levels. MOH expectations Reliance on facilities to be base of entire system Each staff has a role and a responsibility Others are relying on you to play your part; people are counting on you Supervisors are expected to give you supervision and feedback to help you Answer any questions they have about the table [Doc. 2-3] 22

31 Lead a group discussion on the presentation by asking the following questions: As you look at the tasks in Document 2-3, what do you expect will be the main challenges in carrying out these tasks? (E.g. resource constraints, lack of time, not enough staff, etc.) How might you overcome these constraints? 6. Summary 15 minutes In the full group, ask the following questions: What are the key insights that you have gained from this module on IDSR strategy? What have you learned about the role of the facility in IDSR implementation? What have you learned about your role specifically? Ensure that these key points are made: There are 13 priority diseases for integrated disease surveillance and response; additional diseases are reported separately. IDSR relies on you, at the facility, to collect the core information that the entire system needs to use to be watchful of disease status. It is part of your job to ensure that this data is documented and reported accurately and in a timely way. Early detection of cases can prevent outbreaks and mobilise resources. A watchful health system means better health for your community. 7. Application 10 minutes Ask the participants to turn to the Application Planning Sheet [Doc 2-4] and fill it out individually. Ask for a few examples of responses to the questions. Explain that the next module will be on the use of standard case definitions to detect priority diseases. 23

32 Document 2-1 Module 2 Objectives By the end of this session, participants will be able to: Explain the IDSR strategy for improving surveillance in Tanzania Describe how surveillance data helps in understanding local public health issues Explain the benefits of surveillance in their community Discuss the facility s role in carrying out the IDSR strategy 24

33 Document 2-2 Objectives of the Tanzania Ministry of Health IDSR Strategy (full version) Strengthen the capacity of the 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 other 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 epidemiological surveillance. Increase active participation of health workers in surveillance. Emphasize community participation in detection and response to public health problems. Ministry of Health IDSR Guidelines 13 IDSR priority diseases 1. Cholera 2. Bacillary dysentery 3. Plague 4. Measles 5. Yellow fever 6. Cerebral spinal meningitis 7. Rabies/ animal bites 8. Acute Flaccid Paralysis 9. Neonatal Tetanus 10. Diarrhea in children aged <5 years 11. Pneumonia in children aged <5 years 12. Malaria 13. Typhoid Fever 25

34 Document 2-3 Facility Level Steps, Desired Level of Performance and Tasks Steps Desired Performance Tasks A. IDENTIFY OR CONFIRM DX! Proper diagnosis (based on SCD & lab results) B. RECORD PRESUMPTIVE /CONFIRMED DX C. DIAGNOSIS/ OUTBREAK CONFIRMATON FROM LABORATORY! Complete and accurate record on register! Take specimen(s) (at lab or by clinician)! Test specimen(s)! Confirm diagnosis! Confirm outbreak using standard thresholds Make diagnosis using standard case definitions (SCDs) based on presenting symptoms, history and lab results Record all cases (including information requested in register) that present at the health facility in register Record diagnosis and treatment (presumptive/ confirmed) of all cases presenting at the health facility in register at time of clinician-patient interaction Decide if laboratory confirmation needed and request appropriate test(s) Collect specimen according to protocol for requested test(s) (in laboratory or in observation room) Test specimen(s) in lab according to standards Record lab result immediately Deliver results to requestor of test(s) Requestor confirms diagnosis on positive or develops alternative presumptive diagnosis Record confirmation of diagnosis Requestor confirms diagnosis on positive or develops alternative presumptive diagnosis Confirm an outbreak based on known thresholds 26

35 D. CASE TREAMENT /REFERRAL! Appropriate case management of presumptively or definitively diagnosed case E. RECORD OUTCOME! Record outcome for inpatients at discharge F. COMMUNICATE DIAGNOSIS FOR OUTBREAK PRONE DISEASES TO DISTRICT/COMMUNITY G. PARTICIPATION IN OUTBREAK INVESTIGATION AND RESPONSE AND CASE TREATMENT H. COMPILE WEEKLY SUMMARY DATA I. COMPILE MONTHLY SUMMARY DATA! Timely communication of potential disease for outbreak prone disease based on thresholds to district office! Participation and collaboration of case investigation and case treatment with district (teams)! Completed weekly summary reports on time! Completed monthly summary reports on time J. REPORT TO DISTRICT! Summary reports are communicated to district on time K. ANALYSE DATA! Analysis of data according to protocol and needs of facilities L. USE OF ANALYSED DATA FOR ACTION Manage treatment of case according to protocol for presumptive /confirmed diagnosis Based on result of lab test, clinician proceeds with treatment (or referral) according to protocol Record outcome (including deaths) of all inpatient cases in register at time of discharge Communicate information about outbreak-prone case(s) to district immediately and inform the community Assist district with case investigation according to roles and responsibilities of facility staff during outbreak Manage and treat cases according to outbreak protocol Prevention/control of outbreak Long term prevention measures after outbreak Compile summary reports from register of 7 priority diseases weekly Compile summary reports from register of 13 priority diseases monthly (including updated death information) Send weekly/ monthly summary reports to district on time (day and time defined by district) Analyse and interpret data according to protocol and needs of facility Analyse data for meeting thresholds of non-outbreak diseases Monitor disease trends and patterns within facility catchment s area regularly! Awareness of disease trends and patterns within facility catchment s area Determine needs for facility and outreach efforts 27

36 M. FEEDBACK ON ANALYSED DATA AND OUTBREAK INFORMATIONTO COMMUNITY! Determining needs for facility and outreach efforts! Feedback to communities and outreach/community health workers Use feedback data to monitor operations at facility Provide feedback on disease trends, patterns, actions, source of outbreak to communities on action Provide guidance and feedback to communities regarding treatment and control measures, including longer-term prevention activities Provide guidance and feedback regarding program needs and strategies to outreach and community-based health workers 28

37 Document 2-4 Application Planning Please take a few minutes to respond to the following questions. These questions are intended to help you think about how this module applies to your work. 1. What do you need to clarify regarding your facility s role in IDSR implementation? Is there anyone in particular that you need to discuss your role with? 2. What do you expect to be the main challenges in carrying out your IDSR responsibilities? What can you do to overcome those challenges? 29

38 Module 3 Detect and Record Priority Diseases Using Standard Case Definitions Training Module Flow Introduction to IDSR Session Overview Detect and Record Priority Diseases using Standard Case Definitions Report Priority Diseases Successful Community Relations for Surveillance and Response Investigate and Respond to Epidemics/Outbreaks Analyse and Interpret Data for Action Objectives By the end of this module, participants will be able to: Apply standard case definitions correctly to 13 IDSR priority diseases (+TB, AIDS, and viral hemorrhagic fever) Consistently record presumptive diagnoses from standard case definitions in facility register(s) Describe the epidemic/action thresholds for each of the priority diseases Become conversant with case investigation forms Steps 1. Introduction 10 minutes 2. Presentation: Standard case definitions 30 minutes 3. Pairs Activity: Using SCDs 30 minutes 4. Presentation: Epidemic/Action thresholds 20 minutes 5. Presentation: Case investigation forms 25 minutes 6. Summary 10 minutes 7. Application 10 minutes Total Duration: 2 hours 15 minutes Materials Needed: Doc 3-1: Learning Objectives Doc 3-2: Standard Case Definitions and Epidemic/Action Thresholds for IDSR priority Diseases for Health Facility Level Doc 3-3 Sample Registration for Out-Patient (OPD) - Regular forms Doc 3-4 Sample Registration for Out-Patient (OPD) - Reportable diseases form Doc 3-5 IPD registry form Doc 3-6: Exercise worksheet for applying standard case definitions Doc 3-7: Case investigation register form Doc 3-8: Application planning sheet Check for availability of National Standard Treatment Guidelines ( there should be at least 1 copy for each facility) 30

39 1. Introduction 10 minutes Ask participants if they are familiar with the standard case definitions for the 13 national priority diseases. Ask why standard case definitions are important. Note: Answers should include that using the same standard case definitions throughout Tanzania ensures an efficient and reliable tracking of particular diseases. Say that this module introduces the standard case definitions (SCD) and shows how to integrate them into routine care and case management activities within a facility level. This module relates the standard case definitions to the recording of the suspected diagnosis in the facility registers and the use of the case investigation forms. Review the module objectives [Doc 3-1] for this module. By the end of this module, participants will be able to: Apply standard case definitions correctly to 13 IDSR priority diseases (+TB, AIDS, and viral hemorrhagic fever) Consistently record presumptive diagnoses from standard case definitions in facility register(s) Describe the epidemic/action thresholds for each of the priority diseases Become conversant with case investigation forms 2. Presentation: Standard Case Definitions 30 minutes Make a presentation to the full group using the following talking points. A. What is a standard case definition (SCD)? A standard case definition is a set of criteria used to standardise presumptive diagnosis of all cases of a disease or condition in a given population. An SCD can be used to help decide if a person has a presumed disease, or to exclude other potential disease diagnoses. An SCD should be used to initiate action for reporting and investigation quickly if the clinical diagnosis takes longer to confirm. Using the same case definition throughout the country s public health surveillance system ensures efficient tracking of particular diseases or conditions. Data can be compared more accurately from one area to another. When health facilities and districts use different case definitions, tracking the trend of a particular infectious disease will be impossible. Health staff who analyse the data and take action will not know if the trends are due to the disease under surveillance or to some other cause. By using a standard case definition, we ensure that every case is diagnosed in the same way, regardless of where or when it occurred and who diagnosed it 31

40 Ask participants to turn to Document 3-2 on SCD. Review the SCDs and answer the participants questions. B. How to apply the Standard Case Definitions: Patient comes to consulting room Ask about symptoms, frequency and duration Conduct physical examination; if available, use a thermometer to verify fever Make clinical diagnosis based on signs and symptoms Match signs and symptoms with those of standard case definition Record the presumptive diagnosis based on the standard case definition Treat the patient according to standard treatment guidelines Assess what are the appropriate actions to be taken based on thresholds C. Where and how to record the presumptive diagnosis using Standard Case Definitions. Tell the participants to review Doc 3-3 Doc 3-5. These are the registry forms where they should record the presumptive diagnosis using the SCD. For the 3 diseases (malaria, diarrhoea and pneumonia) seen in the OPD, record the presumptive diagnosis in the front registry in MTUHA Book 5 (Sehemu ya Kawaida) For the 10 diseases (Typhoid fever, acute flaccid paralysis, neonatal tetanus, cerebrospinal meningitis, yellow fever, bacillary dysentery, cholera, rabies, plague and measles) seen in the OPD, record the presumptive diagnosis in the back of the registry in MTUHA Book 5 (Sehemu ya Magonjwa yanayotolewa Ripoti) For all IDS cases seen in the IPD, record the presumptive diagnosis in the IPD registry. If an IPD registry is not available, use the form in Doc 3-5 The participants should be encouraged to ask questions for clarification of how to record on these forms using standard case definitions 3. Pairs activity: Using SCDs 30 minutes Explain that the next activity is about using SCDs when recording in the facility register. Introduce the sample register form [Doc 3-6] and explain that this registry is from another country and will be used for this activity because it includes signs and symptoms. Explain how to record the presumptive diagnosis. Emphasise the use of standard diagnosis (standard disease nomenclature) and the importance of recording case outcomes in an in-patient register and updating confirmed cases. Ask participants to pick a partner from another facility. Say that Document 3-6 is from the Tumaini Health Centre register for new cases from 6-10 May,