Emergency Health Training Programme for Africa

WHO/EHA

EMERGENCY HEALTH TRAINING PROGRAMME FOR AFRICA

2. TOOLS

2.6. Surveillance

Panafrican Emergency Training Centre, Addis Ababa, July 1998

2.6. Surveillance

Overhead Transparencies

2.6.1. Surveillance, Definitions

2.6.2. From Rapid Assessment to Surveillance

2.6.3. Which Information?

2.6.4. Which Quality of Information?

2.6.5. Establishing a surveillance system.

2.6.6. Establishing the Objectives

2.6.7. Developing Case Definitions and Choosing Indicators

2.6.8. Benchmarks

2.6.9. Data Sources, Data-Collection Tools and Information Flows

2.6.10., 2.6.11. Sample Morbidity and Mortality Surveillance Form

2.6.12. Keep the data disaggregated

2.6.13. Field Testing and Training, Developing and Testing the Strategy of Analysis

2.6.14. What Must We Look At?

2.6.15., 2.6.16. Health Information for Monitoring Needs and Co-ordination, Vital Needs

2.6.17. Mechanisms for Disseminating Information, Monitoring and Assessing the System

2.6.18. Provincial Health Information System, Semi-quantitative Analysis

2.6. Surveillance

Trainers' Guide

Objective:

To illustrate the role of surveillance in information management; to present the steps needed to establish a surveillance system; to highlight the link between Rapid Assessment and Surveillance. (Knowledge and Skills)

Key-messages:

Don't re-invent the wheel. Involve the nationals and as many partners as possible. Information management and Co-ordination go hand-in hand. Crude mortality rates greater than 1/10.000/day are a warning for a serious situation. Rates are expressed in 'per day', because in an acute emergency mortality monitoring must be continuous. Look at other sectors in terms of sources of data and users of information. Surveillance is expensive, if it doesn't contribute to decision, it is useless. Lack of information is information. If you want perfect knowledge go and meditate on the Himalayas: as long as you are of this world do with what you have.

2.6.1. Surveillance, Definitions

Present and discuss. Key-words are: Close observation, Scrutiny; On-going, Trends; Changes; Specific events; Purpose, ”in order to”, Use. Surveillance is an exercise that must be sustainable and clearly aimed at facilitating decision making.

2.6.2. From Rapid Assessment to Surveillance

Present and discuss. The Rapid Health Assessment can be the first step in organising a surveillance system. Use whatever is already in place or anyway easily accepted, think from the start about the outputs and the objectives of the system.

2.6.3. Which Information?

Present. It is necessary to get information about what may happen and what is happening. Information is needed about the area, population, hazards, available resources and plans/procedures/arrangements to mobilise them. The information needed is different for preparedness and for response

2.6.4. Which Quality of Information?

Present and discuss. Disaggregated: data must be collected and dealt with according to operational areas: e.g. a Country’s administrative divisions. Qualified: one must know the time and place to which the information refers, the source, and the eventual limitations. User-friendly: it has to be expressed in a way that it is easily understood. Economic: information systems must be sustainable. Reliable: the information has to be correct, data handlers have to be trained. Complementing: information from different health programmes can contribute to the overall picture. If other sectors have relevant information, one must use it, e.g. agriculture, demography.

2.6.5. Establishing a surveillance system.

Present and discuss. The sequence of steps needed to establish the surveillance system. Underline the three key principles: Standardisation (because you want to be understood and comparable), Continuity (because you are dealing with CHANGES IN TRENDS), Simplicity (because you don’t have time to waste and you want to have as many partners as possible).

2.6.6. Establishing the Objectives

Present and discuss. Objectives must be clearly chosen on the basis of priorities: to detect epidemics, in order to reduce the risk of death and illness; to monitor changes in the population, in order to estimate denominators, to identify hazards and the main factors of vulnerability; to facilitate the management of relief. To detect changes and plan activities

2.6.7. Developing Case Definitions and Choosing Indicators

Present and discuss. Definitions make terms and issues clear, all stakeholders talk about the same thing. There must be general agreement on case- definitions and indicators used. WHO guideline can help. Key messages: if everybody speaks a different language, there cannot be any Co-ordination: “ the clearer the objectives, the easier the choice of indicators”.

2.6.8. Benchmarks

Use this transparency to illustrate what you have just said about standard definitions. Most important benchmark: >1.0/10,000/day is a very acute emergency situation: do not let things get worse!

2.6.9. Data Sources, Data-Collection Tools and Information Flows

Present and discuss. Passive surveillance usually produces less data, but it is cheaper and easier to sustain than active surveillance. Involve all that provide health care. Use data from non-health programmes/ sectors, too. Do not re-invent the wheel, always involve the nationals and use what is already in place. Keep always in mind that the data collected will have to be first transmitted and then processed.

2.6.10., 2.6.11. Sample Morbidity and Mortality Surveillance Form

Present, to clarify and re-enforce the previous message. Example of a morbidity and mortality surveillance form for weekly reporting developed by WHO.

2.6.12. Keep the data disaggregated

Present and discuss. Each country has its own administrative divisions: distribute the points of data-collection accordingly. Keep the data disaggregated when processing and presenting. Mark on a map the areas that do not produce data.

2.6.13. Field Testing and Training, Developing and Testing the Strategy of Analysis

Present and discuss. Field testing, training, and feedback from the people in charge of data collection are necessary for the data to be good and for the system to work and be sustainable. Encourage de-centralised analysis and local use of the data for immediate decisions. The analysis should give a picture of the hazards, of the health status of the population, of the resources used, of the services provided and of their effectiveness. Differentiate the data according to the type of population to whom they refer.

2.6.14. What Must We Look At?

Use this checklist to reinforce the message of the previous transparency. Denominators, Priority concerns, Vital needs and Support systems. It is very much the same checklist, which applies for Rapid Assessment

2.6.15., 2.6.16. Health Information for Monitoring Needs and Co-ordination, Vital Needs

Present and discuss. For every category of information, it is possible to define appropriate indicators. Ask for contributions from the audience.

2.6.17. Mechanisms for Disseminating Information, Monitoring and Assessing the System

Present and discuss. Information must be shared otherwise it is useless. Set up mechanisms to monitor how the surveillance system works. "Lack of information is information": a health unit that does not report must have a problem: maybe it has been destroyed, or it needs a radio, or maybe just supervision and in-service training.

2.6.18. Provincial Health Information System, Semi-quantitative Analysis

Present to clarify the previous message. Example of analysis of the flow of information from different districts during the war in Mozambique: the most severely affected district transmitted less information.

Stand-alone. Complementary with Rapid Health Assessment (2.4.).

Essential Reading:

§  Public Health Action in Emergencies Caused by Epidemics, P. Brès, WHO, 1986

§  African Disaster Handbook, M. S. Zaman, WHO/PTC, 1990

§  UN-DMTP Training Modules, UN-DMTP, 1990

§  Handbook on War and Public Health, P. Perrin, ICRC, 1995

2.6.1. Surveillance, Definitions

SURVEILLANCE

Close observation (Oxford. P.D, 1992)

On-going scrutiny by methods that are practical, uniform and rapid. It has the purpose of detecting changes in trends or distributions, in order to initiate investigations or control measures (J.M. Last)

The on-going systematic collection, analysis and interpretation of data about specific events. These data are used in planning, implementing and evaluating programmes (E. Noji)

2.6.2. From Rapid Assessment to Surveillance

FROM RAPID ASSESSMENT TO SURVEILLANCE

The Rapid Assessment provides an opportunity to establish the Surveillance system.

Involve local staff

Use standard check- lists and forms

Use existing information systems

THINK:

giving the situation, WHAT MUST BE MONITORED in order to

·  best satisfy the current vital needs,

·  and be prepared for new emergencies

2.6.3. Which information?

Which Information?

FOR PREPAREDNESS / FOR RESPONSE
AREA / Name
Location, limits
Main features
Route of access / Is it still accessible? fully?
POPULATION / Present: No and characteristics / Affected:
No and characteristics
HAZARDS / What is known to occur?
What may occur / When, How did it occur? is it
continuing? Has something else occurred?
RESOURCES / What is in place? / Is it enough?
PLANS AND ARRANGEMENTS / Are they ready? / Do they work?

2.6.4. Which Quality of Information?

WHICH QUALITY OF INFORMATION?

·  Disaggregated

·  Qualified:

-  space

-  time

-  source

-  limitations

·  User- friendly

·  Economic

·  Reliable

·  Complementing

-  Other information from the sector

-  Information from other sectors

2.6.5. Establishing a surveillance system.

ESTABLISHINGA SURVEILLANCESYSTEM

STEPS

8.  Establish Objectives

9.  Develop Case Definitions

10.  Choose the Indicators

11.  Determine Data Sources

12.  Develop Data Collection Tools and Flows

13.  Field-test and Train

14.  Develop and Test Analysis Strategy

15.  Develop Mechanisms for Dissemination

16.  Monitor and Assess the System

PRINCIPLES

·  Standardization

·  Continuity

·  Simplicity

2.6.6. Establishing the Objectives

ESTABLSHING A SURVEILANCE SYSTEM

1.  ESTABLISHING THE OBJECTIVES

·  to detect epidemics

·  to monitor changes in the population:

numbers

health status

security

access to food

access to water

shelter and sanitation
access to health services

·  to facilitate the management of relief

2.6.7. Developing Case Definitions and Choosing Indicators

ESTABLISHING A SURVEILLANCE SYSTEM

2.  DEVELOPING CASE DEFINITIONS

Standard case definitions of health conditions simplify reporting and analysis.

Also the “beneficiary population’ and the standards of relief must be defined.

3.  CHOOSING THE INDICATORS

The clearer the objectives of the operations, the easier the choice of indicators.

Indicators must

-  illustrate the status of the population
(e.g. Death rates)

-  measure the effectiveness of relief
(e.g. immunization coverage)

‘Case definitions’ and ‘Indicators’ need to be agreed upon by all those involved in the relief operations (see co-ordination)

2.6.8. Benchmarks

BENCHMARKS

Crude Mortality Rates

·  Normal rate indeveloped countries: 0.2/10,000/day

·  Normal rate in developing countries 0.5/10,000/day

·  Relief programme-under control <1.0/10,000/day

·  Relief programme-very serioussituation >1.0/10,000/day

·  Emergency-out of control >2.0/10,000/day

·  Famine, majorepidemic-catastrophic >5.0/10,000/day

2.6.9. Data Sources, Data-Collection Tools and Information Flows

ESTABLISHING A SURVEILLANCE SYSTEM

4.  DETERMINING DATA SOURCES

Data can come from health-care facilities (‘passive surveillance’) and from surveys in the community (‘active surveillance’).

Involve all those provide health care.

Health surveillance in an emergency requires inputs also from other sectors.

5.  Development data-collection tools and information flows

Use pre-existing local formats and/or international standards.

Use formats that facilitate data entry (see Epi Info).

How will the data be transmitted?

Who will process the information?

Where? How?

···

Involve the nationals and utilize existing flows

2.6.10 Sample Morbidity and Mortality Surveillance Form

SAMPLE MORBIDITY AND MORTABILITY SURVEILLANCE FROMS

Weekly Surveillance Reporting Form

From: ______/______/ To ______/ ______/ ______/

Town/Village/Settlement/Camp: ______

I.  Population

Population at beginning of week: ______

Births this week: ______Deaths this week: ______

Arrivals this week: ______Departures this week: ______

Estimated population end of week: ______

Total population under five years of age: ______

II.  Mortality

Reported Primary Cause of Death / Children 0-4 years / 5 + years / total
Diarrhoeal Disease
Respiratory Disease
Malnutrition
Malaria
Measles
Trauma
Other/Unknown
Total

·  Average Total Mortality Rates
(Deaths/10 000 Total population/day)

·  Average Under-Five year old Mortality Rates
(Deaths/10 000 Total Under-Five/day)

2.6.11. Sample Morbidity and Mortality Surveillance Form

This form should be adapted for specific situations and may include separate categories for sex.

III.  Morbidity

Primary Symptom/Diagnosis / Age / Total
0-4 years / 5+years
Number / Number / Number
Diarrhoea/Dehydration
Fever with cough
Fever and chills/Malaria
Measles
Trauma
Other/Unknown
Total

IV.  Comments

______

2.6.12.  Keep the data disaggregated

KEEP THE DATA DISAGGREGATED ACCORDING TO THE COUNTRY’S ADMINISTRATIVE DIVISION

2.6.13. Field Testing and Training, Developing and Testing the Strategy of Analysis

ESTABLISHING A SURVEILLANCE SYSTEM

6.  Field-Testing and Training

Can these data produce the information required?

Training field workers will improve data quality and facilitate local analysis.

7.  Developing & Testing the Strategy of Analysis

Data analysis should cover:

·  the hazards and their impact on the population’s health

·  the quantity and quantity of services provided

·  the impact of the services on the population’s health

·  the relation between services provided to different groups (e.g. refugees and hosts)

·  the deployment and utilization of resources

Major operations may require a central epidemiological unit

2.6.14. What Must We Look At?

RAPID ASSESSMENT

WHAT MUST WE LOOK AT?

1.  The Population

·  Numbers and trends

·  Death rates and causes

2.  The Vital Needs

·  security

·  food

·  water

·  shelter and sanitation

·  clothes and blankets

·  domestic utensils and fuel

·  health care

3.  The Support Systems

·  information

·  logistics

·  co-ordination

·  resource flow

2.6.15 Health Information for Monitoring Needs and Co-ordination, Vital Needs

VITAL NEEDS

/

INDICATORS

Overview / ·  No of population
·  N° of new arrivals/week
·  N° of deaths/day
·  N° of deaths/day among under-5
·  First causes of death
1.1. Security / ·  N° of intentional and landmines injuries (new cases)
·  Attacks against health facilities or agencies
1.2. Water / ·  N° of cases of diarrhoea
·  Litres per person per day
·  Distance between settlement and water source
·  Type of water sources/ N° households per source
·  Availability of Chlorine
1.3 Food / ·  N° of cases of acute PC malnutrition
·  N° of cases of growth faltering
·  Distribution of general and supplementary rations
·  N° of cases for therapeutic feeding
·  N° of cases of clinical micro- nutrient deficiencies
1.4. Shelter and /sanitation / ·  N° of cases of diarrhoea
·  State of shelters
·  State of environment
·  N° of latrines/households
·  Availability of tools for digging latrines, etc
1.5. Soap buckets and Pots / ·  N° of cases of diarrhoea
·  N° of cases of eye and skin infection
·  Activities of health education
1.6. Health Care / ·  N° cases of measles, cholera, dysentery, meningitis
·  State of stockpiles against epidemic outbreaks
·  N° of cases of ARI, malaria and STD
·  Immunizations by antigen and age-group
·  N° of MCH consultations
·  Availability of condoms
·  N° of TB patients under treatment
·  State of personnel
·  State of drugs and materials
·  State of infrastructures and equipment

Health Information for Monitoring Needs and Co-ordination, Vital Needs