Module 1: How To Transform Infectious Disease Surveillance in Africa

Ambitious topic?

Maybe.

We hope you would understand when you’re done reading our story.

Agents screening travellers at the Murtala Muhammed Airport during the Ebola Outbreak of 2014

Our first experience with the disease surveillance framework in Nigeria was in 2014 during the Ebola Outbreak. This was how my current team first met; we were volunteering to help contain the outbreak.

Our task at the time was to help manage communications — It involved setting up a call center where we hoped to gather information from the public and other channels — web, social media, etc. through which we delivered information. As simple as this setup was at the time, it was instrumental in the disease control process. Two Ebola cases that could have started secondary outbreaks were detected and a prompt response delivered.

The Response Team at a site to pickup and quarantine an Ebola case after a report to the Call Center

This experience shifted our thinking. We were inspired by how a set-up as simple as a call center could have such a significant impact in halting an outbreak. Communication made all the difference, and we better understood that this would be of great importance in the control of other diseases of public health importance (Lassa Fever, Cholera, etc.).

We initially moved the motion for the then Health Ministry NGR and other involved partner organizations to consider sustaining the system.

When our expectations were not met, we decided to set up an initiative with similar goals-using communication as a powerful tool in disease control.

A detailed analysis revealed that it was beyond a call center; it was a surveillance system close enough to the people to ensure easy communication flow. This is quite different to, and more penetrative than existing traditional surveillance systems.

How does Disease Surveillance Work?

Surveillance Data Flow in Nigeria. Source — NCDC, IDSR Guideline

Nigeria currently utilizes the Integrated Disease Surveillance & Response (IDSR) Framework. The framework allows the detection and response activities to diseases of public health importance to be tightly linked. It also necessitates the systematic flow of information from the Local Government Level to the State Level and then the Federal Level. A Disease Surveillance and Notification Officer typically roams Health Facilities within the Local Government on a periodic basis to collect Disease Notification Forms, filled by contact persons within the health facilities when cases of notifiable diseases are diagnosed.

There are challenges with this system!

First, the system is heavily dependent on health facilities; this has limitations when one considers the health utilization patterns in our communities-particularly in remote areas.

A surveillance system that requires diagnosis in health facilities to detect diseases is only as sensitive as the level of health utilization within that community.

The recent Meningitis outbreak in Nigeria, for instance, and the comments of an elected official on the cause of the outbreak speak vastly to health facility penetration when people experience disease symptoms.

If health utilization is low, only a fraction of the cases would visit the hospital, if at all. As time passes, the disease silently spreads in the community, with the potential of becoming a full blown outbreak, even before the surveillance system is able to detect it.

Also, there are challenges with sensitivity in a system focused on health facilities as well as challenges with speed of detection. Time is really a big deal in disease control — a seemingly short time can be the difference between containing cases and an outbreak spiraling into an epidemic.

The Disease Control Agencies know this problem

Our disease control authorities are not oblivious to these challenges. Attempts to strengthen the surveillance system encouraged the integration of community informants within the community to improve disease notification and early disease detection.

The Disease Control Office for the Lagos State Ministry of Health, for instance has over 700 community informants across the 20 Local Government Areas, who are trained to report public health events to the Disease Notification Officers. As basic as this seems, this delivers better results as informants carry out event-based disease surveillance across the community on a real-time basis. The shortcomings are the fact that these informants are regular individuals who volunteer to report observed public health events to authorities, but they are not employed for this purpose. In a community with several thousands of people, what number of these community informants would be satisfactory?

In spite of the shaky framework, these are the people who are keeping our communities safe from infectious disease threats.

How do we make Disease Surveillance Better?

Obviously,

The more connected the disease surveillance system, the more sensitive it becomes. The higher the number of community informants we have reporting symptoms of notifiable diseases, the better for us all.

Then birthed our epiphany — “we should all be community informants!”

This, we observed when we setup the call center during the outbreak in 2014. The widespread messages with great media coverage across online and offline platforms helped a great number of people learn the simple means of identifying symptoms. In addition, as many people as possible had the ability to call a toll free line to report suspicious symptoms.

We decided to build AlertClinic

How the AlertClinic Offline & Digital Channels contribute to Disease Surveillance

We decided to build a system that would empower as many people as possible to contribute to disease detection irrespective of their language, socioeconomic status or technology literacy. A system that would allow the surveillance framework gather information directly from members of the community, utilizing the channels with which they’re most comfortable ( be it web/mobile, telephony or even word of mouth).

For people who have access to the internet and use smartphones, we built an app available on Google Play. For people who do not, this is where things get interesting. We developed this system of word-of-mouth interaction through agents (we call them Alert Officers) who roam Local Government Areas and maintain relationships through House-to-House Visits, and then Group Interactions. These agents are our link to the unconnected public and in this way we are able attain “last mile access”.

Through the channel of interaction, individuals can learn how to identify diseases of public health importance and then report cases of those diseases. Furthermore, information delivery in outbreak situations is also more effective than ever before; the same set of people who serve as community informants can also become channels through which information can reach the people around them.

We launched the very first version of the application on August 31, in partnership with the Lagos State Ministry of Health and the Lagos State Primary Healthcare Board. We will be piloting in the Lagos Mainland Local Government Area to see how this helps improve sensitivity of the surveillance system and the speed of detection and scaling across the State and beyond.

You should join the network of people helping to keep our communities safe from infectious disease threats.

Download the Android app HERE,
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Learn about EpidAlert Informative Initiative, the organization behind AlertClinic.

Ibrahim Yekinni, MD.

Health Project & Planning Administrator,

EpidAlert Informative Initiative.