EARLY WARNING EARLY WARNING SYSTEMSYSTEM

Greater Darfur RegionGreater Darfur Region

WHO office SudanWHO office SudanFederal/ State Ministry of Federal/ State Ministry of

HealthHealthRepublic of SudanRepublic of Sudan

RATIONALERATIONALE IDP settlements areas are at high risk IDP settlements areas are at high risk

of outbreaks. Initially there was not of outbreaks. Initially there was not surveillance system covering these surveillance system covering these areasareas

NGOs were collecting surveillance NGOs were collecting surveillance data but not using standardized data but not using standardized reporting forms nor standardized reporting forms nor standardized case definitionscase definitions

Need of complementing the national Need of complementing the national surveillance system with a system surveillance system with a system that allows early detection of that allows early detection of possible outbreaks in order to give possible outbreaks in order to give prompt responseprompt response

OBJECTIVES:OBJECTIVES: To ensure timely detection response and To ensure timely detection response and

control of outbreaks by early detection at local control of outbreaks by early detection at local level of time and place clustering of cases level of time and place clustering of cases among IDPsamong IDPs

To monitor trends of communicable diseases in To monitor trends of communicable diseases in order to take appropriate public health actionsorder to take appropriate public health actions

To estimate workload of different health units To estimate workload of different health units involved in the system to rationalize resource involved in the system to rationalize resource allocationallocation

MAIN CHARACTERISTICS OF MAIN CHARACTERISTICS OF THE SYSTEM:THE SYSTEM:

Very sensitiveVery sensitive detect all detect all possible casespossible cases

Simple Simple good acceptability good acceptability among health personnelamong health personnel

Short periodicity of reportingShort periodicity of reporting detectdetect

sudden increase of cases sudden increase of cases

Early Warning Systems

Monitor RespondRecognise

Epidemiology & Laboratory

capacity

Detect cases& outbreaks

Implement effectiveinterventions

Reduce morbidity& mortality

Function of EWARNS

Core capacityOutput

Impact

EWARNS, One Component of Surveillance Systems

• Rumour verification• EWARNS

– Detect clusters in time, place or persons– Change in trend

• Programme monitoring– Programme impact indicators

• Surveillance system monitoring– Operation indicators– Support indicators– Output indicators

Requiring immediate

investigation

Requiring programmeadjustment

Requiring system

improvement

Requiring verification

Early Detection

• Relies on alert network– Local and national– Addressing the unexpected risks

• Early warning systems– Subset of surveillance systems– Addressing the known risks

• Adequate tools and procedures– Preparedness: appropriate, methods, training,

guidelines• Sensitisation of primary health care providers

EARLY WARNING SYSTEM HAS EARLY WARNING SYSTEM HAS SHOWN TO BE USEFUL IN OTHER SHOWN TO BE USEFUL IN OTHER

COMPLEX EMERGENCY COMPLEX EMERGENCY CONTEXTSCONTEXTS

Distribution of rash with fever by Week of onset,Albania early warning system, 1999/31-2000/29

MAIN CONSTRAINTS FOR THE EWARS IN DARFUR

• Communications

• Access/distances

• Limited access to health services

TYPE OF SYSTEM:TYPE OF SYSTEM: PassivePassive ExhaustiveExhaustive Aggregated dataAggregated data

Continuous collection of data with a weeklyContinuous collection of data with a weeklyreporting periodicity.reporting periodicity.Verification of rumors: Informal Verification of rumors: Informal

Information.Information.

POPULATION UNDER POPULATION UNDER SURVEILLANCESURVEILLANCE

All internal displaced populationAll internal displaced population living at living at present in different conditionspresent in different conditions

Data is aggregated at camp levelData is aggregated at camp level

To calculate incidences, the denominator is To calculate incidences, the denominator is based on the based on the OCHA estimated population OCHA estimated population datadata (other sources: NGOs surveys, HAC). (other sources: NGOs surveys, HAC).

Population figures:Population figures:

Internal displaced population figures Internal displaced population figures have to be reported every week in have to be reported every week in order to record major events of order to record major events of population movementspopulation movements

Reporting unitsReporting units Cases and deaths will be reported at state Cases and deaths will be reported at state

level level

Reporting units are health units and mobile Reporting units are health units and mobile units acting at administrative unit level on units acting at administrative unit level on IDPsIDPs

Each health unit inside or outside the camps Each health unit inside or outside the camps report through the standardized data report through the standardized data collection form.collection form.

HEALTH EVENTS UNDER HEALTH EVENTS UNDER SURVEILLANCESURVEILLANCE

All new casesAll new cases of the 12 selected health of the 12 selected health events that attend the health unit events that attend the health unit

All deathsAll deaths detected by health units detected by health units should be reportedshould be reported

New caseNew case: a person attending the health : a person attending the health facility during the week and having new facility during the week and having new diagnose. Subsequent visits for the same diagnose. Subsequent visits for the same health problem should not be reported health problem should not be reported (repeated case)(repeated case)

HEALTH EVENTS UNDER HEALTH EVENTS UNDER SURVEILLANCESURVEILLANCE

Acute Watery DiarrhoeaAcute Watery Diarrhoea Diarrhoea with blood (dysentery)Diarrhoea with blood (dysentery) Suspected MeaslesSuspected Measles Acute Jaundice syndromeAcute Jaundice syndrome Suspected meningitisSuspected meningitis AFPAFP MalariaMalaria Neonatal tetanusNeonatal tetanus InjuriesInjuries Severe malnutritionSevere malnutrition Unexplained feverUnexplained fever OtherOther

CASE DEFINITIONSCASE DEFINITIONS

Health event Definition

Acute Watery Diarrhoea

Acute watery diarrhoea with severe dehydration in a patients older than five

years of age .Diarrhoea with

blood (Dysentery)

More than 3 loose stools per day (24 hours) with visible blood

Acute respiratory infection

Fever and at least one of the following : rhinitis, cough, redness or soreness of

throatOR

Fever and fast breath (> 50 breaths/min) and at least one of the following : cough,

difficulty in breathing

Suspected Measles

Rash with fever and cough, runny nose or conjunctivitis

Acute Jaundice syndrome

Acute onset of yellows eyes or skin

Suspected meningitis

12 months and over: sudden onset of fever (> 38° C) with stiff neckUnder 12 months: fever with bulging fontanel

AFP Acute flaccid paralysis in a child aged < 15 years, including Guillain Barré syndrome or any acuteparalytic illness in a person of any age.

Malaria

Person with fever or history of fever >38°C within the last 48 hours

with one or more of the following symptoms: such as nausea, vomiting and diarrhoea, headache, back joint

pain, chills, myalgiawith positive

laboratory test for malaria parasites blood film (thick or thin smear) or rapid

diagnostic test .

Neonatal tetanus

Suspected case:Any neonatal death between 3 and 28 days of age in which the cause of death is unknown or any neonate reported as having suffered from neonatal tetanus between 3 and 28 days of age and not investigated

Confirmed case:Any neonate with a normal ability to suck and cry during the first two days of life, and who between 3 and 28 days of age cannot suck normally, and becomes stiff or has convulsions or both

Injuries

Any person with traumas or wounds from any cause that require surgical treatment and hospitalisation

Severe malnutrition

Malnutrition: In children 6 to 59 months (65cm to 110cm in height):<70%Weight for height (W/H) index OR < –3z scores (on table of NCHS/WHOnormalized reference values of weight-for-height by sex).OR MUAC < 11 cmBilateral pitting oedema irrespective of W/H, in absence of other causes.

Unexplained fever Fever (> 38°C) for more than 48 hours and not meeting the above case definitions

Others All others medical conditions not meeting the above case definitions

This category is used to compute Total Attendance

FLOW OF DATA:FLOW OF DATA: PeriodicityPeriodicity: weekly (from Saturday to : weekly (from Saturday to

Friday)Friday)

Health units should send the forms to the Health units should send the forms to the state ministry of health on Saturday or to state ministry of health on Saturday or to the WHO office in the State locality.the WHO office in the State locality.

The State health office will send not later The State health office will send not later than Sunday the data to the federal than Sunday the data to the federal epidemiology department.**epidemiology department.**

INFORMAL COMMUNICATION, INFORMAL COMMUNICATION, Data transmission Data transmission

From health units, NGOs and mobile From health units, NGOs and mobile units to State health office: car, units to State health office: car, radio, paper support.radio, paper support.

From State health office to the From State health office to the federal state epidemiology federal state epidemiology department: by telephonedepartment: by telephone

DATA FLOW

DATA COLLECTION FORMDATA COLLECTION FORM Form identification number to be Form identification number to be

completed by the State epidemiology completed by the State epidemiology unit officeunit office

Date of reception at State to be Date of reception at State to be completed at State epidemiology unitcompleted at State epidemiology unit

Date of reception at federal stateDate of reception at federal state

Identification of the health Identification of the health Units/NGO, mobile unit:Units/NGO, mobile unit:

Admin UnitAdmin Unit VillageVillage Camps/IDP settlementsCamps/IDP settlements Name of health unitName of health unit NGONGO

Period of reporting:Period of reporting: week for which the week for which the cases are reported. cases are reported.

Reporting Units should indicates the dates Reporting Units should indicates the dates (starting Saturday to ending Friday) of (starting Saturday to ending Friday) of weekweek

Health events under surveillance: Health events under surveillance: According standardized case definitions of According standardized case definitions of the surveillance system. Each health the surveillance system. Each health facility should have a list with the case facility should have a list with the case definitions available.definitions available.

Only new cases and deaths have to Only new cases and deaths have to be reportedbe reported

The cases and deaths have to be The cases and deaths have to be reported by age groups:reported by age groups:– 0-4 YRS0-4 YRS– 5 and more years5 and more years

DATA ENTRY AND ANALYSISDATA ENTRY AND ANALYSIS An Epi info application (version 6.04) An Epi info application (version 6.04)

was developed allowing simple data was developed allowing simple data entry, analysis and automatic entry, analysis and automatic reports.reports.

The application has been installed at The application has been installed at State ministry of health and WHO State ministry of health and WHO state officesstate offices

INDICATORSINDICATORSIndicators are computed in the application for weekly reports Indicators are computed in the application for weekly reports

and at different geographic level (camp, administrative unit, and at different geographic level (camp, administrative unit, State, Federal):State, Federal):

– Number of new cases and deaths for each health event by weekNumber of new cases and deaths for each health event by week– Total attendanceTotal attendance– Case fatality ratioCase fatality ratio– Proportional morbidity by age group (0-4 and 5+)Proportional morbidity by age group (0-4 and 5+)– Distribution of new cases by geographical levedlDistribution of new cases by geographical levedl– Number of health facilities reporting and number of health Number of health facilities reporting and number of health

facilites expected to reportfacilites expected to report– Incidence rate of health events by weekIncidence rate of health events by week– Under five mortality rate per 10,000 pop per weekUnder five mortality rate per 10,000 pop per week– Crude mortality rate per 10,000 population per weekCrude mortality rate per 10,000 population per week– Completeness of reporting unitsCompleteness of reporting units– Timeliness from camps to the stateTimeliness from camps to the state

DATA VALIDATIONDATA VALIDATION

Health Units:Health Units: Check that cases reported Check that cases reported

correspond to the case definitions correspond to the case definitions and that only new cases are and that only new cases are reported.reported.

Before sending the forms to the State Before sending the forms to the State ministry of health check that all the ministry of health check that all the information is completedinformation is completed

Check that the period of reporting is Check that the period of reporting is correctcorrect

Check the number of cases and Check the number of cases and deaths reported for each health event:deaths reported for each health event:– CoherenceCoherence e.g. neonatal tetanus in e.g. neonatal tetanus in

children over 5 years is not coherentchildren over 5 years is not coherent– Excessive or (abnormally smallExcessive or (abnormally small) )

number of cases: Is this a real increase of number of cases: Is this a real increase of the cases diagnosed or is it an error while the cases diagnosed or is it an error while completing the form completing the form

DATA VALIDATION AT THE HEALTH UNIT DATA VALIDATION AT THE HEALTH UNIT (CONTINUATION)(CONTINUATION)

State level:State level: Write the number record form on the formWrite the number record form on the form Check that the period of reporting is correctCheck that the period of reporting is correct Check the number of cases and deaths Check the number of cases and deaths

reported for each health eventsreported for each health events Coherence Coherence After producing the weekly report check After producing the weekly report check

results (tables, graphs, maps) for errorsresults (tables, graphs, maps) for errors Check if population figures are correctCheck if population figures are correct

DATA VALIDATIONDATA VALIDATION

Timeliness of reporting is important!Timeliness of reporting is important!

Reporting forms from health units Reporting forms from health units should arrive in State ministry of should arrive in State ministry of health or WHO on Saturday/Sundayhealth or WHO on Saturday/Sunday

Sunday data is send via e-mail or fax Sunday data is send via e-mail or fax to Federal MoH and WHO Khartoum to Federal MoH and WHO Khartoum officeoffice

CALL BACK!CALL BACK!

THRESHOLDS TRIGGERING THRESHOLDS TRIGGERING ACTIONSACTIONS

Measles:Measles:– One case of measles detected among One case of measles detected among

IDPs is considered an outbreak and will IDPs is considered an outbreak and will require immediate investigation and require immediate investigation and response from EPI teamresponse from EPI team

AFPAFP– One case of AFP detected among IDPs is One case of AFP detected among IDPs is

considered an outbreak and will require considered an outbreak and will require immediate investigation specimen immediate investigation specimen collection and response from EPI team.collection and response from EPI team.

MeningitisMeningitis– Doubling of the number of suspected Doubling of the number of suspected

meningitis cases from one week to the next meningitis cases from one week to the next for a period of three weeks will be considered for a period of three weeks will be considered an alert and will require laboratory an alert and will require laboratory confirmation and active case finding.confirmation and active case finding.

– Five cases of suspected meningitis per Five cases of suspected meningitis per 100,000 IDPs per week in areas with more 100,000 IDPs per week in areas with more than 30,000 displaced will be considered an than 30,000 displaced will be considered an alert and will require laboratory confirmation.alert and will require laboratory confirmation.

THRESHOLDSTHRESHOLDS

MeningitisMeningitis– Two cases of suspected meningitis per Two cases of suspected meningitis per

week during two weeks, detected week during two weeks, detected among IDPs in camps under 30,000 among IDPs in camps under 30,000 persons is considered an outbreak and persons is considered an outbreak and will require immediate laboratory will require immediate laboratory confirmation and active case findingconfirmation and active case finding

THRESHOLDSTHRESHOLDS

Bloody diarrhoeaBloody diarrhoea

– Sudden rise of clustered cases of bloody Sudden rise of clustered cases of bloody diarrhoea, or doubling cases in two consecutive diarrhoea, or doubling cases in two consecutive weeks is considered an alert and will require weeks is considered an alert and will require immediate laboratory confirmation and active immediate laboratory confirmation and active case findingcase finding

– An increase in the percentage of bloody An increase in the percentage of bloody diarrhoea (bloddy diarrhea*100/Total diarrhea) is diarrhoea (bloddy diarrhea*100/Total diarrhea) is considered an alert and will require immediate considered an alert and will require immediate laboratory confirmation and active case findinglaboratory confirmation and active case finding

THRESHOLDSTHRESHOLDS

Watery DiarrhoeaWatery Diarrhoea

– One death for watery diarrhoea among One death for watery diarrhoea among patients of five years and older will patients of five years and older will require immediate laboratory require immediate laboratory confirmation and active case findingconfirmation and active case finding

– Steady increase of watery diarrhoea in Steady increase of watery diarrhoea in the age group older than five years will the age group older than five years will require immediate investigation, require immediate investigation, laboratory confirmation and active case laboratory confirmation and active case findingfinding

THRESHOLDSTHRESHOLDS

Neonatal TetanusNeonatal Tetanus– One case of neonatal tetanus will One case of neonatal tetanus will

require immediate investigation for the require immediate investigation for the related hygienic practices applied for related hygienic practices applied for deliveriesdeliveries

MalariaMalaria– Steady and unusual increase of Steady and unusual increase of

confirmed severe malaria cases or of the confirmed severe malaria cases or of the case fatality ratio will need immediate case fatality ratio will need immediate actionaction

THRESHOLDSTHRESHOLDS

Severe malnutritionSevere malnutrition– Detection of one severe malnourished child will Detection of one severe malnourished child will

require further nutritional investigation in the require further nutritional investigation in the communitycommunity

Unexplained feverUnexplained fever– Steady and progressive increase of unexplained Steady and progressive increase of unexplained

fever with related unusual mortality will require fever with related unusual mortality will require immediate investigationimmediate investigation

Acute jaundice syndromeAcute jaundice syndrome– Clustered cases of jaundice will require Clustered cases of jaundice will require

laboratory confirmation and active case finding.laboratory confirmation and active case finding.

THRESHOLDSTHRESHOLDS

Laboratory confirmation

EWAR ACTIONSHealth Units, NGOs:• The health personnel in charge at the reporting

units should report immediately to the State health office and camp managers the occurrence of:

• A case of suspected measles• A case of AFP• A case of suspected NNT• A case of suspected Meningitis• A case of suspected VHF

ANY CLUSTER OF SEVER DISEASE ANY CLUSTER OF SEVER DISEASE SHOULD BE REPORTED AND SHOULD BE REPORTED AND

INVESTIGATEDINVESTIGATED

Health Units, NGOs should report Health Units, NGOs should report immediately:immediately:

Unusual deaths among patients older Unusual deaths among patients older than 5 years of age with watery than 5 years of age with watery diarrhoeadiarrhoea

Any unexpected health event (e.g. Any unexpected health event (e.g. cluster of sever diseases, cluster of cluster of sever diseases, cluster of deaths)deaths)

RUMOURS VERIFICATIONRUMOURS VERIFICATION The health personnel in charge at the The health personnel in charge at the

reporting units should reporting units should verify verify immediately the consistencyimmediately the consistency of the of the informal informationinformal information

In case of confirmation of the In case of confirmation of the rumours they should report rumours they should report immediately to the camp immediately to the camp managers/State ministry of healthmanagers/State ministry of health

EWAR ACTIONS: EWAR ACTIONS:

Epidemiology State Department:Epidemiology State Department: Check weekly reports (reported health Check weekly reports (reported health

events) against defined thresholds for each events) against defined thresholds for each of themof them

All health events that match the defined All health events that match the defined thresholds in terms of number of cases or, thresholds in terms of number of cases or, rates or percentage have to be immediately rates or percentage have to be immediately investigated and reported to Federal MoH.investigated and reported to Federal MoH.

Epidemiology State Department:Epidemiology State Department: Ensure that the appropriate specimen Ensure that the appropriate specimen

samples are collected and sent to samples are collected and sent to Khartoum for analysisKhartoum for analysis

If the field reference laboratory in If the field reference laboratory in Nyala is already operative two samples Nyala is already operative two samples from the same patient, one is sent to from the same patient, one is sent to Nyala and the other for QI to Khartoum.Nyala and the other for QI to Khartoum.

The State epidemiology department The State epidemiology department produce in weekly bases a summary produce in weekly bases a summary report (bulletin) including:report (bulletin) including:

A summary table with the number of A summary table with the number of new cases reported new cases reported

Any relevant epidemiological Any relevant epidemiological informationinformation

Any suspected outbreakAny suspected outbreak

EWAR ACTIONSEWAR ACTIONS

Federal Epidemiology Department:Federal Epidemiology Department:

Confirm or not, alerts and analyze the data Confirm or not, alerts and analyze the data produced at Sate levelproduced at Sate level

Guarantee together with the international Guarantee together with the international agencies and NGOs involved that the agencies and NGOs involved that the necessary sources are available at state necessary sources are available at state level to allow the response and control of level to allow the response and control of outbreaksoutbreaks

EWAR ACTIONSEWAR ACTIONS

National Public Health Laboratory:National Public Health Laboratory:

Keep records (registry) of all the Keep records (registry) of all the information related to the specimen in information related to the specimen in the way to facilitate the identificationthe way to facilitate the identification

Make diagnosis and communicate Make diagnosis and communicate immediately to the State the results immediately to the State the results by telephone, Fax, e-mail or radioby telephone, Fax, e-mail or radio

Summary procedures at each level:Summary procedures at each level:

Health Unit, NGOsHealth Unit, NGOs::

At the end of the week the doctor/nurse or At the end of the week the doctor/nurse or health assistant in charge will fill the form health assistant in charge will fill the form using the information of the registry bookusing the information of the registry book

Check the data for possible errors Check the data for possible errors

Send data collection form filled to the State Send data collection form filled to the State MoHMoH

State Epidemiology Unit:State Epidemiology Unit: Receive and collect the formsReceive and collect the forms Write the sequential identification number Write the sequential identification number

on the formon the form Check the form for any possible mistakeCheck the form for any possible mistake Contact the health units that haven’t sent Contact the health units that haven’t sent

on time the formson time the forms Check the data entry for possible errorsCheck the data entry for possible errors Keep a file with all paper formsKeep a file with all paper forms

Send a copy of the forms or electronic file to Send a copy of the forms or electronic file to Federal epidemiology dept.Federal epidemiology dept.

Prepare the weekly reportPrepare the weekly report Do a copy of the data in the PC and in a Do a copy of the data in the PC and in a

diskettediskette Implement response and control according Implement response and control according

defined threshold in coordination with all defined threshold in coordination with all other partnersother partners

Collect and send specimen samples to the Collect and send specimen samples to the reference laboratoryreference laboratory

THANKS YOU