Public Health Event Based Surveillance.pptx

Event based surveillance is the a type of surveillance where signals are used to report possible Public Health Events

1. Community Event Based Surveillance (CEBS) System in Nakuru County Moses o.

2. Training objectives

3. Participants’ expectations To learn a lot /gain knowledge on CEBS for easier implementation To know CEBS how it can reverse the notifiable disease trends Role of sub county health managers on CEBS How CHVs involvement in the CEBS activity Updates on CEBS/ lessons learned from the pilot CEBS Learn more on one health approach Importance of EBS and how the reports will be used for decision making To know what EBS is and the role as an animal health officer To know how to use EBS data Understand difference between CEBS surveillance and other surveillance To understand how to collaborate with animal health department

4. General objective To build the capacity of County and Sub County TOTs on the use of community event based surveillance (CEBS) in early warning and response (EWAR) to public health threats

5. Specific objectives To improve participants knowledge, understanding and skills on the use of community event based surveillance (CEBS) for early warning and response To induct participants on the roles and responsibilities of the various actors in the CEBS system To orient participants on the CEBS organizational structure and surveillance information flow To improve participants’ understanding of the use of CEBS to enhancing surveillance for the COVID-19 events

6. Expected outputs TOTs with a good grasp of CEBS system Implementable way forward for scaling up of CEBS in Nakuru County

7. Expected outcome Improved early warning and response (prompt detection, timely reporting and rapid response) to all public health threats including COVID-19 events in Nakuru County

8. Teaching methods Lectures with power point presentations Discussions Role play Practical sessions Case studies

9. Karibuni ! Questions

10. Overview of Public Health Surveillance, Integrated Disease Surveillance and Response (IDSR) and International Health Regulations (IHR) 2005 Elizabeth / Ngere

11. Participants will gain: Knowledge of the concept of public health surveillance Understanding on the IDSR strategy Knowledge of the IHR (2005) Learning objectives

12. What is public health surveillance? Ongoing, systematic collection, analysis, and interpretation of health-related data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those responsible for prevention and control - World Health Organization Regardless of the type of surveillance, remember that surveillance is data that is used for action!

13. Uses of Public Health Surveillance Detect outbreaks of diseases and other conditions of public health importance Measure the burden of diseases and other conditions of public health importance Monitor the burden of a disease over time Determine risk factors for the disease and populations at greatest risk Guide planning for immediate public health actions for individual patients or the community Guide programs to prevent and control disease and evaluate those programs

14. Outbreak investigation Disease control Vaccination / prophylaxis Elimination of cause Interruption of transmission Development, targeting of programs (education, risk reduction, etc.) Development of policies, regulations Linking public health surveillance to action

15. Health facility-based surveillance or community-based surveillance Disease (indicator) based surveillance or event based surveillance Sentinel surveillance Types of surveillance methods

16. Active / Passive (Health-agency solicited or Provider-initiated) Categorical / Integrated (One disease or Many ) Syndromic / Laboratory (Case definition or laboratory confirmation) Approaches to public health surveillance

17. A good network of motivated people Clear case definition and reporting mechanism Efficient communication system Basic but sound epidemiology Laboratory support Good feedback and rapid response Surveillance is a backbone of disease control Basic ingredients of public health surveillance

18. Kenya conducts public health surveillance using the Integrated Disease Surveillance and Response (IDSR) strategy IDSR strategy is an indicator based surveillance which: Integrates surveillance, laboratory and response activities at all levels Tracks a list of priority diseases and conditions Uses standard/lay case definitions for detection Undertakes routine notifications – immediately, weekly, monthly Links surveillance to action/response Public health surveillance in Kenya

19. List of IDSR Priority Diseases in Kenya

20. Public health surveillance challenges before IDSR Failure to report diseases of epidemic potential Incomplete and late reporting Inadequate data analysis and use Inadequate involvement of the laboratory Inadequate involvement of the clinicians Programmatic surveillance programs Poor feedback to health workers and community 20

21. IDSR is a strategy of the WHO Afro Region for improving public health surveillance and response IDSR strategy coordinates and integrates surveillance, laboratory and response activities at all levels Scarce resources are combined to collect information from a single focal point at each level What is IDSR?

22. Background of IDSR IDSR strategy adopted by WHO Afro member states in 1998 Goal Improve the ability of all levels of the health system to detect and respond to diseases and conditions that cause high levels of death, illness and disability at district level by providing timely and reliable data for taking action

23. Background of IDSR Kenya developed IDSR Technical Guidelines in 2001 Emphasis on: Epidemic prone diseases Diseases targeted for elimination and eradication Diseases of public heath importance Revised IDSR Technical Guidelines (2010) include : Non communicable diseases Zoonotic Diseases Maternal and child health events Public Health Emergencies of International Concern (IHR 2005)

24. Strengthen capacity for effective surveillance Integrate disease surveillance systems for efficiency Improve use of surveillance information for decision making Improve laboratory involvement in epidemic detection and confirmation Increase involvement of clinicians in surveillance Objectives of IDSR

25. Improve surveillance information flow in all levels of the health care system Emphasize community participation in surveillance (detection and response) Trigger epidemiological investigations in detection, investigation and reporting of public health problems, and in the implementation of effective public health interventions Objectives of IDSR -/2

26. Pillars of IDSR Data Management Coordination Epidemic Response Laboratory capacity Support Functions Communication Training Support Supervision Resource mobilization and management

27. Case detection Standard/lay case definitions Laboratory confirmation Case registration and reporting Registers Reporting tools MOH 502, MOH 503, MOH 504, MOH 505 Data analysis and interpretation Response IDSR core functions

28. Purpose and Scope of IHR (2005) IHR (2005) is legally binding requirement for WHO 194 member states Includes all 46 WHO Member States in the African region Objective is to prevent, protect against, control and provide public health response to the international spread of disease in ways commensurate with and restricted to public health risks Avoid unnecessary interference with international trade and traffic

29. Why IHR (2005)? Our world is changing as never before Populations grow, age and move Diseases travel fast Microbes adapt Chemical, radiation, food risks increase Health security is at stake

30. Strengthened national capacity for surveillance and control, including in travel and transport Prevention, alert and response to international public health emergencies Global partnership and international collaboration Rights, obligations and procedures, and progress monitoring IHR (2005) calls for:

31. IHR (2005) Core Capacity Requirements 8 Core capacities Legislation Policy and Coordination Surveillance Preparedness Response Risk Communications Laboratory Human Resources 3 levels National Intermediate Peripheral/Community Potential Hazards Infectious Zoonosis Food safety Chemical Radio nucle ar Points of Entry

32. What’s new in IHR (2005)?

33. Reportable diseases, conditions & events under IHR 2005 Four diseases require notification to WHO under all circumstances: Human influenza caused by a new subtype Wild-type poliomyelitis SARS Smallpox Public Health Event of International Concern (PHEIC) as per the IHR 2005 decision instrument (Annex 2)

34. IDSR IDSR will serve as a vehicle for IHR IHR will serve as the engine for IDSR Synergy between IDSR and IHR Implementing IHR through IDSR

35. Thank you Questions?

36. One health approach to disease surveillance Ngere /CDVS

37. Global paradigm Increasing animal-human-environment interactions Complex challenges like disease , food insecurity, poverty and famine, climate change One discipline, a single approach or perspective cannot address One Health (OH) approach

38. The One Health (OH) approach Human Health Animal Health Environmental Health A holistic and multifaceted approach to manage health and related conditions OH is the collaborative efforts of multiple disciplines working locally, nationally and globally to attain optimal health for people, animals and our environment American Medical Association, 2007

39. Evolution of OH A new phrase, ancient concept! 400 BC - Hippocrates: “On airs, waters and places” 1700s - Pope Clement XI: Rinderpest and human food 1821-1902 - Rudolf Virchow: “ Zoonosis " 1927-2006 - Calvin Schwabe : “ One Medicine ” 2004 - The Wildlife Conservation Society - “ One Health , One World” concept 2007 - FAO-OIE-WHO and partners - adopts Concept on OH

40. Why OH approach? There are 1415 human pathogens (217 viruses and prions; 538 bacteria and rickettsia; 307 fungi; 66 protozoa and 287 helminths) 868 ( 61% ) are zoonotic 175 are considered to be emerging infectious diseases (EIDs) 132 ( 75% ) are zoonotic Taylor et al, 2001; OIE, 2013; Jones, 2008 Zooanthroponosis (reverse zoonosis) vs anthropozoonosis methicillin-resistant Staphylococcus aureus , H1N1 influenza A virus, Mycobaterium tuberculosis , Cryptosporidium parvum , and Ascaris lumbricoides . Messenger et al, 2014

41. Why OH approach? Emergence and re-emergence of diseases and pathogens of animal origin Ebola, Marburg, Yellow Fever, Rift Valley Fever, H1N1 Virus Neglected zoonotic diseases have high impacts in some of the poorest communities in the world Brucellosis, zoonotic tuberculosis, cysticercosis , trypanosomosis , rabies, salmonellosis, anthrax

42. Why OH approach? Antimicrobial resistance Dangerous drug residues in the food chains & resistance to therapeutic substances Multi-drug resistant bacteria e.g. TB, Salmonella, E. coli ) Globalization and advancement is travel technology Increasingly close interaction between animals and humans on farm and in the wild Changes in agriculture, conservation and livelihood patterns

43. Why OH approach? Implementation of IHR and OIE requirements Managing zoonotic events key to implementing IHR Early detection and control of zoonoses key to prevent it from infecting human population. Well established and defined communication procedures when outbreaks occur is crucial for early warning and better controlling the disease.

44. Transmission of Ebola virus

45. DAY Human Cases Lab Confirmation Sequence of events in a zoonotic Disease outbreak WITHOUT the OH approach Response Detection/Reporting First Case Opportunity for prevention

46. DAY Sequence of events in a zoonotic Disease outbreak WITH the OH approach in place First Case Detection/Reporting Lab Confirmation Response Potential cases prevented Signal -1 -14 -7 Verification Event Risk assessment

47. Brain Storm How can we strengthen One Health at County and sub-county level? 4 October, 2024

48. Thank you Questions

49. Overview of Event Based Surveillance (EBS) Carol/Tabitha

50. Define event based surveillance Understand the importance of event based surveillance Understand the sources (types) of event based surveillance Describe functions (steps) in event based surveillance Understand the levels of event based surveillance Learning objectives

51. What is EBS? The organized collection , monitoring, assessment and interpretation of mainly unstructured , ad hoc information regarding events which may present an acute risk to human health - WHO

52. Background of EBS Public health surveillance serves two primary functions: To early detect public health events requiring rapid investigation and response, in order to ensure that events of all origins are rapidly controlled To measure disease burden, including monitoring morbidity/mortality trends, in order to effectively guide control programs and corresponding allocation of resources EBS contributes to the 1 st function

53. Why EBS is important? Since most disease outbreaks are preceded by events, EBS provides a lead time for putting measures in place to prevent or reduce adverse outcomes of the outbreak Due to multiplicity of sources, it improves the reporting rate of diseases/conditions Uses signals which are non disease specific hence supports the detection of known and unknown/emerging diseases/conditions 54

54. Types (sources) of EBS

55. EBS functions/steps

56. Signal detection Process of recognizing one of the signals used in EBS pre-defined by the Ministry of Health A signal is a set of observations that may present a health event occurring in a population

57. Signal reporting Process of communicating detected signals to public health officers at higher health service levels Detected signals MUST be reported immediately

58. Signal triaging The process of sorting out reported signals to identify the ones likely to be real events It involves screening out signals that: Don’t match any of the pre-fined signals Are not relevant for early warning and response (EWAR) Are duplicates (repeated signals)

59. It is confirming the authenticity of the signal (whether true or false) All triaged signals should be verified Any signal that is verified becomes an event Signal verification 60

60. RA means determining the level of risk of an event to human health None, low, moderate, high, very high All reported events should undergo a risk assessment within 48 hours of signal reporting RA is required to support prioritization of response activities Event risk assessment (RA) 61

61. Response / public health action Response are public health actions taken for an event based on its risk assessment outcome The actions can be: Maintain standard/routine response Enhanced surveillance; vaccination campaign Additional control measures to be put in place Immediate action required at all time even out of normal working hours

62. Levels of EBS

63. Summary EBS improves the sensitivity, timeliness and detection rate of public health surveillance EBS involves signal detection, triage and verification; risk assessment and response/action EBS can be done at all the levels of health system Types/sources of EBS includes: community, health facilities. Hotlines and media scanning 64

64. Thank you Questions

65. Indicator Based Surveillance (IBS) vs Event Based Surveillance (EBS) Charles/Maurice

66. Introduction Public health surveillance serves two main objectives: To measure disease burden, including monitoring morbidity/mortality trends, in order to effectively guide control programs and corresponding allocation of resources To early detect public health events requiring rapid investigation and response, in order to ensure that events of all origins are rapidly controlled

67. Introduction Organized mechanism to meet the 2 nd objective is referred to as Early Warning and Response (EWAR) EWAR utilizes two channels of information: Indicator based surveillance Event based surveillance

68. What is indicator-based surveillance? Is the more traditional way of reporting diseases to public health officials Defined as systematic collection, monitoring, analysis, and interpretation of structured data, i.e. indicators, produced by a number of well-identified, predominantly health-based formal sources Involves reports of specific diseases from health care providers to public health officials

69. What is Event-based Surveillance? Organized and rapid capture of information about events that are a potential risk to public health Events related to the occurrence of disease in humans (clusters, unusual patterns, unexpected deaths… Events related to potential exposures (diseases in animals, contaminated food or water, environmental hazards… Such information may be described as unstructured because the information obtained is non-standardized or subjective Information collected for EBS is diverse in nature and originates from multiple sources

70. Important Epidemic Intelligence (EI) is defined as the systematic collection, analysis and communication of any information to detect, verify, assess, and investigate events and health risks with an early warning objective (as opposed to monitoring of disease trends or burdens) EI integrates both sources of information (IBS and EBS) IBS and EBS are complementary sources of information, and both contribute to EWAR The two are not necessarily separate surveillance systems; both are processed through a single activity (EI) and some surveillance functions might be common to both types Both systems should be seen as essential components of a single national surveillance system

71. Comparison of Event-based and Indicator-based surveillance Indicator-based Surveillance Event-based Surveillance Objective Detect outbreaks; define disease trends, seasonality, burden, risk factors Detect outbreaks Definitions Diseases and syndromes have a corresponding case definition which may include one or all of the following: • Clinical presentation • Characteristics of people affected • Laboratory criteria Definitions are more specific than those used in EBS Definitions can be used to help guide reporting. Definitions are broad, such as a cluster of deaths in the same village during the same time period. Definitions are more sensitive than those used in IBS Information sources Reports of cases of diseases from health care providers, including physicians and hospital laboratories Official and unofficial reports of potential disease events from a wide variety of sources including media, rumors , blogs, community members, etc Information credibility Reports are usually credible because health care providers are instructed to only report cases that meet specific case definitions, but the most credible reports involve laboratory-confirmed cases Reports need verification Timeliness Reported by health care provider after ill persons have sought medical attention; may sometimes be delayed while awaiting laboratory confirmation or due to reporting requirements May be reported early, even before ill persons have sought medical attention

72. Comparison of Event-based and Indicator-based surveillance Indicator-based Surveillance Event-based Surveillance Where is it used? Where health infrastructure exists and health care providers and laboratories are willing to participate in public health surveillance Can be used anywhere What diseases is it used for? Usually known diseases All public health events involving potential disease, including events caused by unknown disease Reporting structure Clearly defined Reporting forms are used by reporting units to pass information through the system often on pre-defined days of the week or month Zero reporting is often used Unit/team is designated to analyze surveillance data at regular intervals Loose structure Reports are unstructured and can enter the system at any time Forms are used to capture the event information, but the format is sufficiently flexible to collect qualitative and quantitative data Unit/team is designated to triage, confirm and assess each reported event and trigger a response, as appropriate

73. Comparison of Event-based and Indicator-based surveillance Indicator-based Surveillance Event-based Surveillance Trigger for initial action Pre-defined thresholds A report that is confirmed and assessed as a potential risk to public health. Analysis Pre-defined intervals (weekly, monthly) Rapid risk assessment Response May be delayed as a result of the time taken to collect and analyze data. The response to an outbreak is built into the surveillance system. Immediate. The response to an event is built into the surveillance system.

74. Indicator Based surveillance versus Event Based Surveillance

75. Thank you Questions

76. Part II Community Event Based Surveillance (CEBS)

77. Understanding CEBS Signals Paul/Maurice

78. Introduction CEBS Definition: “The systematic detection and reporting of events of public health significance within a community by community members ” WHO and stakeholders in 2018 Principles To be sustainable and effective, CEBS needs to be linked and integrated with existing national surveillance structures and platforms Decentralize CEBS to the lowest level possible so as not to overburden intermediate and national level

79. Process (steps) of CEBS

80. What is a signal? SIGNAL = SMOKE coming from a building The smoke could signal that the building is on fire or it could be simply coming from the cooking place

81. What is a signal? A signal a set of observations used in EBS as an indicator of an event (a possible public health threat) Signals are designed to help detect known and unknown phenomena including emerging and reemerging diseases that are not yet known A signal is the equivalent to a standard/lay case definitions used in indicator based surveillance and response (IDSR) However, signals are broader, simpler and not disease specific

82. Standard case definition Lay case definition Signal Suspected case : Any person with fever and maculopapular (non-vesicular) generalized rash and any one of the following: cough, coryza or conjunctivitis (red eyes) or any person in whom a clinician suspects measles Confirmed case : A suspected case with laboratory confirmation or with epidemiological linkage to confirmed cases in an outbreak Any person with hotness of the body and a rash Any clustering of a rash or hotness of the body Any health condition causing public anxiety Measles example

83. What is an event? Event is an occurrence that presents a possible threat to public health E.g. a confirmed cluster of health conditions with similar symptoms within a week Once a signal is verified (confirmed to be true), it becomes an event 84

84. List of routine CEBS signals -/1 Code Narative 1 Two or more people presenting with similar signs and symptoms in a community (village, estate, school, other institution, community gathering e.g. funeral, wedding, market) within a week 2 Any death in the community deaths due to unknown cause 3 Any child less than 15 years with a sudden onset of weakness of the limb/s not due to injury 4 Any person 5 years of age or more with lots of watery diarrhea on the same day

85. 86 Code Narative 5 Increased sickness including abortions and/or deaths of animals (wild or domestic and poultry/ birds or fish) 6 Any person who has been bitten by a sick looking animal including dogs 7 Any event that causes public health anxiety/concern List of routine CEBS signals -/2

86. Code Narative 8 Any recent local (cross county border) or international (cross national border) traveler with or without symptoms of respiratory illness (hotness of the body, cough or difficulty in breathing) 9 Any person who has had recent close contact (work, transport, residence, visit, etc.) with a person confirmed or suspected to be having COVID-19 with or without symptoms of respiratory illness (hotness of the body, cough or difficulty in breathing) 10 Two or more cases with a respiratory illness (hotness of the body, cough or difficulty in breathing) from the same village or social group (family, school, workplace, social function, estate, etc.) within one week List of CEBS signals for COVID-19 events

87. Summary Signal detection is key for CEBS Community networks and CHVs/CDRs should detect/recognize signals pre-defined by the DDSR/MOH and report immediately 88

88. Thank you Questions

89. CEBS Signal detection, reporting, triage and verification Tabitha/Carol

90. Signal detection Detecting a signal means identifying or suspecting the occurrence of one of a public health threat using a preset criteria (signals) Signals are most likely to be captured by CHVs and key informants because of their linkages to the community CHVs can improve signal capture from their communities by empowering key informants – community residents who hold strong links to the community – to assist in the identification of signals, and report them to CHVs These key informants may include traditional healers, village chiefs, school teachers, and petty shopkeepers

91. Signal detection at community level A signal is a set of information on a happenings that represents a potential public health threat Community EBS signals should be: Short statements Simple and non-technical Flexible Broad Sensitize community members, key informants and CHVs on the signals

92. How to detect signals The CHVs and CDRs sensitize the community members and networks on CEBS and signals The community members, networks, CHVs and CDRs during their routine/normal day to day activities get information through: Being informed by members Following discussions Observing possible events occur The information gotten is matched against the pre-defined signals If the information matches a pre-defined signal, it is reported as that signal

93. Reporting signals means communicating the information on detected signals to a public health authority Reporting of signals must take place immediately Acting as the interface between the community and the health care system, the CHVs/CDRs should report a signal to the CHAs/AHAs immediately through the agreed method of reporting Community members, networks and healthcare workers who detect signals MUST report them immediately CEBS signal reporting -/1

94. CEBS signal reporting -/2 A clear and simple reporting structure is a prerequisite for a well-functioning CEBS system Methods of reporting are diverse Phone call Use unstructured SMS In-person Electronic platforms mobile applications Social media Consider pros and cons of each method. Lessons from previous such systems and the interoperability with existing platforms

95. Under the CEBS, there should be: Designate a focal point at the community / health facility level responsible to receive signal information and report to public health authorities at the intermediate level Contacts (physical/phone) of the focal point shared with the members and the networks The community members, networks and healthcare workers should: Record all detected signals in the EBS logbook / notebooks capturing detection date, signal code and reported date Report all detected signals to the focal points using any available means such as SMS, phone, in-person, etc CEBS signal reporting -/3

96. Signals feedback The focal person should provide routine feedback to community members, CHVs, CDRs, networks and health workers on signals reported Regular feedback on the signals and events reported is imperative to sustain motivation to report 97

97. CEBS signal triage Due to its high sensitivity, CEBS is likely to generate signals for real and non-real events Signal triage is the process of sorting out reported signals to identify which ones are mostly likely to be real events Guiding triage questions are: Does the reported information match any pre-defined CEBS signal? Is the information relevant for EWAR? Has the signal been reported previously (Is the signal a duplicate)? Any signal that gets a “yes” to all the three questions is subjected to verification Done by the community level focal person (CHAs/AHAs)

98. The community level focal person MUST verify all triaged signals Verification is confirming if a signal is authentic/valid (that is, true or false) Guiding questions during verification: What is the credibility of the source? Is the event still ongoing? A signal that is confirmed true (verified) becomes an event Verification may require gathering of additional information from the reporting community member, network, health worker, etc CEBS signal verification

99. Verification Once verified, a signal becomes an event All Events (verified signals) should be immediately notified to next level

100. Events feedback Sub county program managers should provide routine feedback to the community or health facility focal points on the outcomes of events reported Regular feedback on the signals and events reported is imperative to sustain motivation of the focal points 101

101. Thank you Questions

102. Risk Assessment and Response to CEBS Events Ngere / Charles

103. Hazard : Anything that can cause injury, illness or death to animals and humans if not controlled properly. Biological, chemical, physical, radioactive Risk : Is the probability experiencing adverse health effects if exposed to a hazard Risk = likelihood x consequences of a hazard Risk assessment : A systematic process for gathering, assessing and documenting information to characterize & assign a level of risk CEBS risk assessment: concepts

104. RA means determining the level of risk of an event poses to human health and the appropriate level response needed RA is done after verification of a signal Risk assessment is conducted as part of an investigation of an event Cons: Very subjective, should be done by a team RA should be led by the sub county level and if need be, supported by the higher levels CEBS risk assessment (RA) -/1 105

105. Sub county public health authorities gather, evaluate all available information and then assess or characterize the level of risk that the situation poses to public health based on: Likelihood of the exposure to the hazard Consequence of exposure The first risk assessment of an event MUST take place within 48 hours of the detection of one or more signals CEBS risk assessment (RA) -/2 106

106. 107 Risk characterization matrix Overall risk level

107. Response/Take Action Take appropriate public health action taken depending on outcome of the risk assessment (vary depending on the level of risk assigned to the event) This will include: No action is required and the event is closed The event should be monitored closely A response must be initiated immediately

108. 109 Suggested response actions based on the risk levels Overall level of risk Suggested response Low Risk Managed according to standard/routine response protocols Moderate Risk Specific Monitoring or control measures are required: Enhanced surveillance; vaccination campaign High Risk Attention of Senior management, needed; Establishment of IMS might be needed; Additional control measures to be put in place Very High Risk Immediate action required at all time even out of normal working hours; immediate senior management attention required; additional control measures may include stringent actions

109. CEBS RA Summary Sub county public health authorities will receive reports of events from CEBS focal points Sub county public health authorities will conduct RA and respond to all events with the support of county and national level teams if needed Sub county public health authorities MUST keep records of all events received, assessed and responded to 110

110. Thank you Questions

111. CEBS Case Scenarios Charles/ Ngere

112. A CHV hears from her friend that many people in one area today have been looking for remedies to nausea, vomiting and diarrhea. These people attended a wedding yesterday are now sick with nausea, vomiting, and diarrhea. One adult has been taken to a health center. At least 8 other adults are sick. No one is sure whether anyone has a fever. No one is sure whether any children were affected Case study 1: scenario

113. Case study 1: Questions Does this constitute a signal(s)? Which one(s)? Is this important to report? Why? What are the next step(s)? What information is required?

114. Case study 2: scenario An inhabitant of the village leads his child to the health center. The child has confusion, hallucinations, visual, delusions and drooling. The child is referred to the county referral hospital (CRH) where he is hospitalized for better support. However, 5 days later, another child and an elderly man are referred to the CRH with the same symptoms. The three are from the same village.

115. Case study 2: Questions Does this constitute a signal(s)? Which one(s)? Is this important to report? Why? What are the next step(s)? What information is required?

116. Case study 3: scenario A community health volunteer receives information from the teacher in a primary school that in the last one week, three children were absent from school. They were all reported to have had a rash, hotness of body and cough. They were sent to the nearby dispensary and are all at home.

117. Case study 3: Questions Does this constitute a signal(s)? Which one(s)? Is this important to report? Why? What are the next step(s)? What information is required?

118. Case study 4: Scenario A chief in Nakuru reports that the KPC pipeline ruptured, spilling oil into Salgaa river, which is an important water resource for the one of the communities. The river is main source of water for domestic use and irrigation in Salgaa.

119. Case study 4: Questions Does this constitute a signal(s)? Which one(s)? Is this important to report? Why? What are the next step(s)? What information is required?

120. Case study 5: Scenario Fishermen at the lake have reported that of late, they find a lot of dead fish floating at the lake. This is unusual and they have never seen anything like it. A farmer reported to the agricultural office that he has lost three chicken over the last two days, his neighbor has also lost a whole flock of chicken

121. Case study 5: Questions Does this constitute a signal(s)? Which one(s)? Is this important to report? Why? What are the next step(s)? What information is required?

122. Case study 6: Scenario In a Marsabit village, an elderly man is reported to have died after he developed fever, joint pain and yellow coloration of the eyes. Two days later, a young man of 25 years also from Marsabit died. It is reported that he also had fever and was confused. No one seems to know what caused the death, the two did not have any contact or share a meal, they however had both been in the same fora .

123. Case study 6: Questions Does this constitute a signal(s)? Which one(s)? Is this important to report? Why? What are the next step(s)? What information is required?

124. Thank you Questions

125. CEBS data recording and flow of information Paul/Maurice

126. CEBS data recording Data recording is the entry of details of the CEBS signals into the designated logbooks or data bases Data recording is important for reporting purposes Data recording also facilitates follow up during verification, risk assessment, response and analysis Data is recorded by all CEBS actors

127. CEBS data recording by the CHV/CDR The CHV/CDR are advised to record following signal information in their note books upon detection: Date Signal type Place of signal Date signal reported Recording data eases reference during follow up verification, assessment and response

128. Data recording by the CHAs/AHAs Upon receipt of a signal from the CHV/CDR, the CHA/AHA undertakes signal triage and verification and updates the appropriate column of the CEBS logbook with the following information: Date signal received Date signal triaged Final signal code Date of verification Verification outcome If event, date submitted to the SCDSC

129. CEBS data recording by the SCDSC Upon receipt of an event information from the CHA/AHA, the SCDSC leads the process of risk assessment and updates the appropriate column of the CEBS logbook with the following information: Date event received Date risk assessment initiated Date risk assessment concluded Risk status Recommended public health action Date of risk assessment report submitted to the sub county This can be done online or during routine/support supervision visits to the reporting health facility

130. CEBS data recording by the SCMOH Upon receipt of a risk assessment report from the SCDSC, the SCMOH leads the process of public health action The SCMOH then updates the appropriate columns of the EBS logbook with the following information: Date risk assessment report received Date public health response initiated Date public health response concluded Status of the event This can be done online or during routine/support supervision visits to the reporting health facility

131. EBS logbook

132. CEBS data recording summary All the officers involved in the CEBS must record details of their activities in the CEBS logbook, that is: CHA/AHA SCDSC / SCVO SCMOH / SCVO

133. CEBS primarily takes place at the community and sub county levels of the health system The county and national levels provide supportive role if needed e.g. Events with very severe consequences Event with very high risks Inadequate technical capacity Inadequate resources The community level also provide additional information needed e.g. in verification, risk assessment and response Levels of CEBS information

134. Information generated by each level Level Function Information Community Signal detection Date detected, signal type, date reported to CHA/AHA Signal t riage Reporting health worker, date reported, date triaged, triage outcome Signal verification Date triaged, date verified, verification outcome, date reported to sub county Sub County Risk assessment Date event reported, nature of event, date risk assessment started, date risk assessment completed, level of risk, recommended response, date risk status communicated Response Date risk assessment report received, Date response started, date response completed, status of event

135. The CEBS information will be captured using: CEBS note books by the CHVs/CDRs at the community level CEBS logbook at the CHAs/AHAs and Sub County levels Data will be relayed from one level to another through either personal communication, SMS, telephone calls or emails Recommended reporting timelines are: Signals– immediately detected Triage – immediately (within 4-8 hours of signal receipt) Events – immediately (within 4-8 hours of signal receipt) Risk assessment – Within 48 hours of signal report Response – Daily from receipt of risk assessment CEBS data tool, information flow and timelines

136. triage verification Flow of information for CEBS Public health authorities Report Feedback risk assessment Require action Community 137 Intermediate level CHVs / CDR CHAs / AHAs

137. Flow of CEBS information

138. The following will be responsible for reports: Signals – CHV / CDR Triage – CHA / AHA Events – CHA / AHA Risk assessment – Sub County DSC / VO Response – Sub County MOH / VO Responsible persons

139. Feedback CEBS information flow Every data flowing from the lower to upper levels must be accompanied by a downward feedback flow Prompt and regular feedback on reports is imperative to sustain motivation to report among those generating the reports

140. Reporting Once a CHV/CDR detects signals Record the details on his/her note book Immediately report to CHA/AHA Reporting is via SMS into electronic system If SMS system fails then se hotlines: County / Sub County Health facility PHEOC 0800 721316 / 0732 353535 / 0729 471414

141. CEBS information flow summary Reporting must take place immediately at each level Timelines for reporting should be observed Feedback on all reports is imperative to motivate reporting levels

142. Thank you Questions

143. Organization of CEBS in Kenya Carol/Tabitha

144. CEBS structures CEBS is implemented within the existing community health strategy structures 1 Community Unit: 5000 persons/1000HH 50 CHVs/ CDRs Supervisors: 2 CHAs/ AHAs Sub-County focal points / SCVOs County focal points / CDVS National focal points / DVS

145. CEBS work force At national and intermediate level Use existing networks and resources for public health surveillance system Sub-County SCDSC and SCVO County CDSC and CDVS National DDSR and DVS

146. CEBS Work Force At community level CHVs/CDRs Community networks are an important resource for CBS as key informants Traditional healers, schoolteachers, village health chiefs, pharmacists, farmers and small traders, among others, who reside in the community and regularly interact with other residents should form these networks as key informants Community networks are “eyes and ears” on the ground, assisting CHVs and greatly increasing chances of signal detection in the community Important aspect recruitment and retention of signal reporters

147. Resources for CEBS CHV/CDR Stationery: Notebook , pen Handbook with signals/pictorials Phone IEC materials Other incentives: jackets, aprons, badges, bags, etc. Key informants and community IEC materials Local supervisors ride on other existing surveillance resources Logbook Mechanism for reporting to intermediate level Airtime

148. Thank you Questions

149. Roles and responsibilities Charles/ Ngere

150. Community Health Volunteer (CHV)/Community disease reports(CDR) Role Responsibility Identify Use signals to identify potential public health threats in the community Build networks, with other community key informants include animal health workers, drug stores (chemists and agro vets), traditional healers, nyumba kumi admin heads, women groups, community treatment shops, local admin leaders, religious leaders, teachers, livestock traders, youth groups, CBOs, private veterinary practitioners ) Sensitize community, key informants, on CEBS Record Maintain an update record of detected and reported signals in notebook Report Report signal to CHA/AHA immediately (within 6 hours) Verification Support CHA/AHA during event verification Respond Sensitizing community to report potential public health threats Initiate mobilization of community members in collaboration with local authorities to support response activities Referrals of community members with illness to the health facilities Refer community members with sick animal to seek the services of animal health service providers(AHSP) Feedback Give feedback to community members about reported public health signals/events

151. Community health assistant (CHA)/Animal Health Assistant (AHA) Role Responsibility Identify Ensure appropriate use of signal definitions to identify potential public health threats in the community Record Maintain an updated log of all reported signals from his/her community unit Triage Conduct triaging of signals immediately Verification Conduct verification of signals reported within 6 hours Report Report events to SCDSC/SCVO Risk assessment Work with SCDSC/SCVO to conduct rapid risk assessment of events Respond Support Sub-County RRT during response Feedback Give feedback to CHVs/CDRs and community on reported signals, prevention and control measures of events Analyze and Interpret Analyze EBS data and prepare and disseminate monthly reports to the SCDSC/SCVO and local authority Support function Periodic sensitization of CHVs/CDRs and provide regular positive reinforcement and feedback Supervise CHVs/CDR Convene quarterly review meetings for CHVs /CDRs Maintain and update database of trained CHVs /CDRs in his/her CU To ensure CHVs/CDRs have required logistics

152. SCDSC/sub-county veterinary officer Role Responsibility Identify Ensure appropriate use of signals to identify potential public health threats in the community /subcounty Record Maintain a log of all reported events in his sub-county by CHA/AHA Keep an updated record of the signals communicated from the National level Verification follow up F ollow up on delayed verifications by CHA/AHA Immediately inform the CHA/AHA about signals communicated from National level for prompt verification Report Receive event reports from the CHA/AHAs Report risk assessment findings to county and national level Risk assessment Conduct preliminary rapid risk assessment of event Respond Respond to public health events When sub county response capacity is exceeded, he/she communicate to County for support Analyze and Interpret Analyze EBS data, prepare and disseminate monthly reports to the county Feedback Give feedback to CHA/AHAs and community about reported events after analyses and interpretation Support function Sensitization / training of CHAs/AHAs and Supervise CHAs/AHAs Convene quarterly review meetings for CHVs and CHAs Maintain and update database of trained CHVs/CAHVs in the sub county Monitoring and evaluation of EBS Mobilization of resources Coordination meetings between CHA and AHA

153. County Disease Surveillance Coordinator(CDSC)/County Veterinary Officer Role Responsibility Identify Ensure appropriate use of signals to identify potential public health threats in the community Record Keep a record of all events detected by the CEBS system at the county Verification follow up Follow up on the verification and notify the SCDSC/SCVO on the signal from whatever source or (National level) Risk assessment Support SCDSC/SVO to conduct preliminary rapid assessment of public health events Follow up with SCDSC/SCVO on delayed risk assessments Respond Support SCHMT to respond to public health events When response exceeds capacity of the county, he/she should communicate with National level for support Analyze and Interpret Analyze EBS data and prepare and disseminate monthly reports to the national level Feedback Immediate feedback to stakeholders (community, MOH, Veterinary) Support function Sensitization/training of SCDSCs Monitoring and evaluation of EBS Coordinate joint meetings between health and veterinary officers on EBS Supervise SCDSC/SCVO Convene quarterly review meetings for SCDSCs/SCVOs Resource mobilization for EBS and response

154. National Surveillance Officers Role Responsibility Identify Define signals and ensure appropriate use of signals to identify potential public health threats in community Triage signals reported by CHVs (hotline) Record Maintain EBS reporting system ( sms and hotline) Maintain a log of all reported signals and events (hotline) Verification Contact respective SCDSC/SCVO and inform them of reported signals for verification (hotline) Feedback Give feedback to CHVs/CAHVs about reported signals (hotline) Response Support county-level response activities (e.g., contact tracing, active case search) Support function Provide technical support to counties Conduct continuous training/sensitization of counties and sub-counties on CEBS Resource mobilization for EBS and response

155. Thank you Questions

156. Thank you Questions

157. Part III: m- Dharura application for Community Event Based Surveillance (CEBS)

158. Introduction to m- Dharura platform Paul/Maurice

159. m- Dharura SMS reporting platform m -Dharura is a mobile phone based application that runs on android platform Developed by Medic mobile in partnership with MoH and CDC It has an SMS component interphases with web based component Uses both feature phone and smart phone To use this platform you must be registered into system System organized by CUs/Sub-County/County Restricted viewing to ones jurisdiction e.g. CHA/AHA to their CU Payment for SMS currently done centrally

160. m- Dharura SMS reporting platform Signal reporting done by a coded SMS or filling a digital form This digital platform seek to make reporting system simple, effective and sustainable by: Increase the speed of reporting of community event-based surveillance (CEBS) Reduced the time between reporting and action taken Improved access to real-time data for decision-making

161. m- Dharura SMS reporting platform CHV/CDR send an SMS to OR CHA/AHA fills a form in the system A new row is created in the in the system’s database for every signal logged The CHA/AHA will be expected to call the CHV triage and verify the report and enter the details into the system Added on the same row created for the signal Logged info can be viewed by Sub County, County and DDSR through the dashboard

162. m-Dharura CEBS workflow Signal Detection CHVs and key informants identify signals at the community. CHV sends the signal code to the system using signal reporting form. 1 Triaging The CHA receives an SMS notification, calls back the CHV to gather more information on the signal. Assesses whether the signal has been reported before and matches one of the signals on the list. a2a Verification CHA confirms that the signal is indeed happening and submits a verification form. 3 Signal form Risk Assessment The SCDSC evaluates all of the available information and assesses the level of risk that the situation poses to public health. Submits an event investigation report 5 Response The SCDSC responds to the event based on the level of risk.. He/she can direct the CHAs to respond to the event if they have the capacity and expertise 6a SMS notification Investigation The SCDSC receives an SMS notification that a signal has been verified, triages the verified signal and confirms it is as an event SCDSC investigates the event by gathering information on signs and symptoms being reported 4 CHA report Escalation In cases where the SCDSC does not have capacity to respond to the PHE, the event is escalated to the County and National teams to provide response 4b 6b SCDSC report

163. Installation and navigation of m-Dharura application (Medic Collect) Medic Mobile

164. Download the m-Dharura APK Instal the m-Dharura application Set your phone number Understanding the m- Dharura main menu Update the CEBS forms Steps in m -Dharura installation

165. •Start the search (google) app in your phone. •Type http://tiny.cc/fezxpz f or CHAs/AHAs OR http://tiny.cc/xfzxpz for SCDSCs in the URL text box •Click ‘ Go ’ on your keypad to start download the APK . Downloading the m- Dharura training APK

166. Depending on your phone type , open file manager in your smartphone. Open ‘Apps’ file m -Dharura installation

167. In the Apps file, press to open Medic Collect-snapshot-cdcmokedsru Press ‘ Install ’ to load the app in your device. m -Dharura installation

168. Press‘ Open ’ to launch the m-Dharura App . The m-Dharura App will appear on the home screen. Open the m-Dharura app . m -Dharura installation

169. Adjusting applications settings Picking up a new blank form to fill Editing of forms whose filing was not finalized Submission of forms whose filling is finalized Getting updated forms from the server Deleting forms from the application Understanding m -Dharura’s main menu page 1 4 5 6 2 3

170. Inside the App,go to the 3-dot menu at the top right corner. Select ‘General Settings.’ In General settings,press ‘Own phone number’, enter Own phone number and press Ok. S etting phone number

171. How to update form on m- Dharura : Delete old forms In case of form updates CHAs and SCDSC should delete the existing form(s) first by: Go to the main menu and open Delete Saved Form Open Saved forms, Toggle All and Delete Selected . Repeat this in Blank forms

172. How to update form on m- Dharura : Get Updated Forms Connect device to internet/WIFI Go back to the main menu and open Get Blank Form Select relevant forms or Toggle All to select All and then press Get Selected . Once download is complete, Press OK and confirm all selected forms in Fill Blank forms

173. Thank you Questions

174. Reporting through the m-Dharura application Medic Mobile

175. m-Dharura CEBS reporting forms CHA/AHA CEBS signal reporting form CHA/AHA CEBS signal triage/verification form SCDSC CEBS investigation (risk assessment form) CEBS learning guide

176. CHV/CDR signal reporting through m-Dharura CHV/CDR detects a signal, forms a message with the signal code as content, i.e. 1 or 2 or 3 or 4 or 5 or 6 or 7 or 8 or 9 or 10 CHV/CDR to submit message to short code 40327 CHV/CDR receives an auto response: Signal 1-7: “ Thank you {CHV/ CDR_name } for reporting a public health signal. Signal unique ID is {Signal_ID}. {CHA/ AHA_name } will contact you soon ” Signal 8-10 : “ Thank you {CHV/ CDR_name } for reporting a public health signal. Signal unique ID is { Signal_ID }. Please isolate the person. {CHA/ AHA_name } will contact you soon ” The auto response is a feedback from the system signifies a successful submission of a signal

177. CHA/AHA signal notification As the CHV?CDR get the feedback, the CHA/AHA is simultaneosly notified of the signal as follows: Signal 1-7: “( CHV/ CDR_name ) (Phone number) has reported public health signal { Signal_code }. Signal Unique ID is (12345) ” Signal 8-10: “ ( CHV/CDR_name) (Phone number) has reported a COVID-19 related signal. Signal Unique ID is (12345). Please reach out to them immediately for more information ”

178. Open m- Dharura app on your phone. Open ‘ Fill Blank Form’ to access the CHA Signal reporting form. Filling the CHA Signal Reporting Form

179. Open CHA Signal Reporting form Use the back and forward arrows or swipe your screen to move to the next page. Select one signal (single select) you wish to report (Signal 1-10) by pressing on available boxes and swipe to the next page Filling the CHA Signal Reporting Form -/2

180. Press Save Form and Exit to ensure the completed form is saved Use the back and forward arrows or swipe your screen to move to the next page. The next step takes you back to main menu. All saved forms are stored in Send Finalized Form Tab Press to open Send Finalised Form Tab to view all saved reports Filling the CHA Signal Reporting Form -/3

181. You will view all the saved forms not submitted in the Send Finalized Form Tab. Make sure to mark/tick the empty next to the form you wish to submit. Use Toggle All button to select all forms at once for submission. Select Send (SMS) to submit through the free SMS platform. This is the recommended method. Use Send ( internet ) to submit through the internet. Filling the CHA Signal Reporting Form -/4

182. How to fill the Surveillance Focal Person Signal form You will view all the saved documents not submitted in the Send Finalized Form Tab. Make sure to mark/tick the empty box next to the form you wish to submit. Use Toggle All button to select all forms at once for submission. Select Send (SMS) to submit through the free SMS platform. This is the recommended method. Use Send(internet) to submit through the internet.

183. CHA Signal Verification form Form filled by Community Health Assistant (CHA) Filled upon receipt of an SMS notification OR getting information from CHV/CDR/networks and reporting a signal He/she calls the respective CHV/CDR and gathers information that is used to fill and submit the verification form Upon submission of this form, the CHA receives an auto response message and an SMS notification is triggered to SCDSC informing him/her that a public health threat has been reported If no verification report is submitted, CHA/AHA will receive 3 sets of reminder messages 8 hourly for signals 1-7 and 4 hourly for signals 8-10 The last reminder also triggers a simultaneous notification to the SCDSC Reminder messages are muted by submission of CHA signal verification form

184. CHA Signal Verification form -/2 Open m- Dharura app on your phone. Open ‘Fill Blank Form’

185. CHA Signal Verification F orm -/3 Open CHA Signal Verification form. Use the back and forward arrows or swipe your screen to move to the next page. Enter Signal ID received when CHV submitted a Signal (5-13 digits)

186. CHA Signal Verification form -/4 Swipe through and fill all consecutive questions. If you select Yes or No to the question, Has this signal been reported before?, the next set of questions change . This applied for all Yes or No questions. After completing the form, you will be required to save the form before submitting the form.

187. CHA Signal Verification form -/5 Press Save Form and Exit to ensure the completed form is saved Use the back and forward arrows or swipe your screen to move to the next page. The next step takes you back to main menu. All saved forms are stored in Send Finalized Form Tab Press to open Send Finalised Form Tab to view all saved reports

188. CHA Signal Verification form -/6 You will view all the saved forms not submitted in the Send Finalized Form Tab. Make sure to mark/tick the empty next to the form you wish to submit. Use Toggle All button to select all forms at once for submission. Select Send (SMS) to submit through the free SMS platform. This is the recommended method. Use Send( internet ) to submit through the internet.

189. SCDSC Signal Investigation form Form filled by Sub-County Disease Surveillance Coordinator (SCDSC) Filled when the SCDSC receives an SMS notification that a CHA/AHA has verified a public health signal, he/she calls the respective CHA/AHA and gathers information that is used to fill this form. If Sub County Disease Surveillance Coordinator does not send an investigation form, he/she will receive 8 hourly reminder messages for signals 1-7 and 4 hourly reminders for signals 8-10 (COVID-19 related signals) Reminder messages are muted by submission of SCDSC investigation form Submission of this form marks the end of CEBS reporting process

190. SCDSC Signal Investigation form Open m- Dharura app on your phone. Open ‘Fill Blank Form’ to find the SCDSC Investigation form.

191. SCDSC Signal Investigation form Open SCDSC Signal Investigation form. Use the back and forward arrows or swipe your screen to move to the next page. Swipe through and fill all consecutive questions. Note: If you select Yes or No to the question, the next set of questions change . This applies for all Yes or No questions.

192. How to fill the SCDSC Signal Investigation form Press Save Form and Exit to ensure the completed form is saved Use the back and forward arrows or swipe your screen to move to the next page. The next step takes you back to main menu. All saved forms are stored in Send Finalized Form Tab Press to open Send Finalised Form Tab to view all saved reports

193. How to fill the SCDSC Signal Investigation form You will view all the saved forms not submitted in the Send Finalized Form Tab. Make sure to mark/tick the empty next to the form you wish to submit. Use Toggle All button to select all forms at once for submission. Select Send (SMS) to submit through the free SMS platform. This is the recommended method. Use Send( internet ) to submit through the internet.

194. The m-Dharura dashboard Charles/ Ngere

195. CEBS Dashboard m-Dharura has a web based interactive dashboard that: Tracks indicators for monitoring CEBS Presents downloadable data that can be used for more detailed analysis Runs basic analytics too Access to the dashboard provided by the system administrator The Sub County, County (including CHO and CEC) and National level users are e provided with access to the dashboard A super administrator is able to monitor activities on the dashboard by those who have access

196. CEBS Dashboard: Indicators

197. CEBS Dashboard: CEBS signal log

198. CEBS Dashboard: Accuracy analytics

199. CEBS Dashboard: Accuracy analytics

200. CEBS Dashboard: Timeliness analytics

201. CEBS Dashboard: Timeliness analytics

202. CEBS Dashboard: COVID-19

203. Thank you Questions

204. Group work I Group work ( CHAs/AHAs CEBS training) Training contents Training agenda Training methods Training strategies

205. Group work I Group work ( CHVs/CDRs CEBS training) Training contents Training agenda Training methods Training strategies