MINIMINISTRY OF EDUCATION AND TRAINING MINISTRY OF HEALTH NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY * NGUYEN THI PHUONG LIEN ASSESSMENT OF COMMUNICABLE DISEASE SURVEILLANCE SYSTEM AND PILOT INTERVENTION MEASURES Specialization: Social Hygience and Health Management Code: 62.72.01.64 AN EXECUTIVE SUMMARY OF PhD THESIS HANOI - 2012 THE THESIS HAS BEEN COMPLETED IN NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY Scientific supervisors: 1. Assoc. Prof. PhD. Nguyen Thi Thu Yen 2. Assoc. Prof. PhD. Phan Trong Lan Opponent 1: Prof. PhD. Truong Viet Dung Opponent 2: Prof. PhD. Nguyen Van Hieu Opponent 3: Assoc. Prof. PhD. Doan Huy Hau The thesis shall be defended in the National Doctorate Thesis Grading Committee established by the Decision No. 404/QD – VSDTTƯ dated 10 th May, 2012, at: NATIONAL INSTITUTE OF HYGIENE AND EPIDEMIOLOGY At: 9h00, 10 th July, 2012 This thesis is available to access at: - National Library; - Library of National Institute of Hygiene and Epidemiology. ABBREVIATION CD: Ccummunicable disease CDC: Center of Disease Prevention and Control CDSS: communicabe disease surveillance system CHS: Commune health station DPMC: District Preventive Medicine Center ECDC: European Center of Disease Prevention and Control EI: Effectiveness and efficiency index HW: Health worker ILI: Influenza-like Illness MOH: Ministry of Health PMC: Preventive Medicine Center PPMC: Provincial Preventive Medicine Center PPV: Positive Predict Value SARS: Severe Acute Respiratory Syndrome VHW: Volunteer health worker WHO: World Health Organization 1 RATIONAL In the last decades of the 20th century and early decades of 21st century, diseases in the world have been evolving in a more complicated manner with many appearance of emerging and re-ermerging diseases like SARS, Ebola, HIV/AIDS, Influenza A/H5N1, etc. Some dangerous CDs that used to be stopped or under control but now continue with complicated developments, additionally there are possible risks of biological terriorisms, environmental and lifestyle-related diseases have also been increasing that has caused harmful impacts on socio-economic development and human lives. At present, Vietnam is a hotspot in the region as well as in the world in terms of being vulnerable to newly emerging and re-emerging diseases. To confront with this situation, surveillance activities must be effective, efficient and preventive health system must be able to provide forecast, detection and control of CDs in order to reduce and mitigate prevalence of morbility and mortality caused by such CDs. As WHO recommended, a structured approach to strengthen national communicable disease surveillance systems must include evaluation of existing systems to review strengths, weaknesses, and opportunities for improvement, and the components of surveillance sysem for evaluating comprise the public health imporance of the targeted disease, the structure, the functions, and the attributes of the system. CDSS in Vietnam has been established and consolidated from the central down to local levels. MOH has issued a regulation on reporting of 26 CDs applicable to all at all levels. However, until now we have not had a full understanding of real capacity of CDSS in the current context of a change in organizational structure of provincial and district health agencies and in the context of confronting with risks of new CDs. To address the above-mentioned questions, the research “Asessment of communicable disease surveillance system and pilot intervention measures” has been conducted with 2 objectives: 1. To assess the status of communicabe disease surveillance system in 8 provinces of Vietnam in 2008 - 2009. 2. To pilot and evaluate the effectiveness and efficiency of influenza surveillance model in Tan Hong district, Dong Thap province in 2009 - 2010. RESEARCH SIGNIFICANCE Results of this thesis are expected: - To contribute to presenting objectively and scientifically strengthes, weaknesses, opportutinies, as well as challenges of existing CDSS in provinces, districts and communes in Vietnam. - To contribute to laying a foundation for MOH for its reference in a process of development and implementation of the Circular No. 48/2010/TT-BYT dated 31 st December, 2010 issued by Minister of MOH providing ”guidance on CDs declaration, communication, and reporting ". From February, 2011 onwards, CDSS shall be implemented in accordance with stipulations of the Circular at local level, which are as similar as results of intervention models have been proposed. - Achieved results of ìnluenza surveillance model reveal capacity of community in detecting disease cases or ”health event” in general. Reliable data generated from pilot 2 surveillance models are used as a basis for policy makers to develop policies to overcome shortings of the existing CDSS. - Implementation of influenza surveillance model in Tan Hong district, Dong Thap province is a pre-condition for Tan Hong district and other districts of Dong Thap province to expand and develop surveillance systems for other CDs as regulated by MOH. STRUCTURE OF THESIS The thesis including 141 pages, 4 chapters: Rational: 3 pages, Chapter 1 -Background: 30 pages, Chapter 2: Methodology 22 pages, Chapter 3: Results - 45 pages, Chapter 4: Discussion - 38 pages, Conclusion 2 pages, Recommendations:1 page. The thesis have 32 tables, 32 Figures, and 146 refferences. CHAPTER 1 – LITERATURE REVIEW 1.1 SITUATION OF COMMUNICABLE DISEASE AROUND THE WORLD AND IN VIETNAM CDs have a long history, which goes along with evolution of human being. They are not only the heaviest disease burden put on individual’s shoulders but also on shoulders of all human being in the world. By record of WHO, About 15 million (>25%) of 57 million annual deaths worldwide are estimated to be related directly to infectious diseases. Lower respiratory tract infections, HIV/AIDS, diarrhoeal disease, tuberculosis and malaria are the main infectious causes of death. The burden of morbidity (ill health) and mortality associated with infectious diseases falls most heavily on people in developing countries, and particularly on infants and children (about three million children die each year from malaria and diarrhoeal diseases alone). In the early of 21st century, the outbreak of human-affected SARS and influenza A/H5N1 outbreak has drawn attention of the entire world to newly- emerging challenges to disease burdens caused by these diseases, seriously threatening socio-economic issues. Newly-emerging and re - emerging CDs or deliberately emerging disease like biological terriorisms and biological wars are threatening public security and safety and also require many other resources due to their seriousness. Annually statistic data reveal that CDs are becoming a serious health issue in Vietnam. It is a hotspot for emerging infectious diseases, including those with pandemic potential in the region. Over the past 10 years, 2000 – 2009, the 10 leading prevalence of CDs are influenza, diarrheoa, dysentery syndrome, malaria, Dengue fever, Shigella, mumps, adenovirus, chickenpox, and HIV/AIDS. Mortality of vaccine preventable diseases are decreasing gradually. However the respiratory infectious diseases without vaccines such as mump, influenza, varicella are either sill high or has cycles. Some infectious diseases which were controlled now re-emerged such as cholera, measles, dengue hemorrhagic fever, streptococcus suis, rabies, hand foot mouth disease. Especially, new emerged infectious diseases in the last ten years were SARS, avian influenza and pandemic influenza A/H1N1p. 1.2 COMMUNICABLE DISEASE SURVEILLANCE SYSTEM 3 1.2.1 Definition and purpose Disease surveillance is the ongoing systematic collection and analysis of data and the provision of information which leads to action being taken to prevent and control a disease, usually one of an infectious nature. A CDSS serves two key functions; early warning of potential threats to public health and programmed monitoring functions which may be disease specific or multi-disease in nature. Good surveillance provides the data needed to give: - an accurate assessment of the status of health in a given population; - an early warning of disease problem to guide immediate control measures; - a quantitative base to define objectives for action, - measures to define specific priorities, - information to design and plan public health programmes, - measures to evaluate interventions and programs, and - Information to plan and conduct research. In short, surveillance data provide a scientific and fractural basis for appropriate policy and disease control decisions in public health practice as well as an evaluation of public health efforts and allocation of resources. 1.2.2 Types and data sources of surveillance There are many ways to classify the type of surveillance. Based on the method of collecting data, surveillance has been classified as either active, passive and sentinel. Based on the source of data, surveillance has been classified as either hospital – based surveillance, laboratory – based surveillance, community-based surveillance. On the other hand, there are syndrome and case surveillance types. Data source including: morbidity and mortality data, laboratory data, individual case reports, epidemic reporting, data of sentinel surveillance, surveys of health in general populations and special databases, knowledge of vertebrate and arthropod vector species, demographic and environment factors. 1.2.3 Main activities of surveillance system Establishment of CDSS must be based on its seriousness of diseases in locality in question, needs for evaluation of community health programs and rational for establishment of a database on CDs. A list of CDs depends on specific country’s resource, which is characterized by disease patterns, geographical conditions, climate, socio-economic conditions, trade and available resources of that country. Any CDSS must also have a similar in organizational structures, technical procedures and human resources. Surveillance includes case definition, reporting, analysis and publication of data, epidemic investigation and response to diseases, feedback information, regular monitoring and evaluation. 1.2.4 Communicable disease surveillance systems in the world Global infectious disease surveillance system using 3 different sources of information are in the world. The first source of information is the official information source from government 4 agencies and universities, medical testing laboratories, and Pasteur institutes; the second source of information is an informal source of information from mass media, information and internet like ProMED, TravelMed, or Sentiweb… or forums of non-governmental organizations and religious organizations, and the third source of information is a legislative information like a Charter of International Health of WHO. There are wide-coverage CDSSs like CDC of US, ECDC of EU, ProMED, ProMED –Mail and HealthMap… CDSSs of developed countries: it is often managed by one organization and many CDSSs for individual groups of diseases like CDC of US, ECDC of EU, etc. are deployed. Their current concence is to prevent re-outbreak of diseases and CD rather than focus on early- warning and detection of CDs like developing countries. CDSSs of developing countries: The concern of developing countries is to detect CDs early enough and mitigate fatal risks that might have impacted on commerce and tourism. The common constraints of CDSSs are lack of human and material resources, weak infrastructure, poor coordination, and uncertain linkages between surveillance and response. Weaknesses in these countries thus substantially impair global capacity to understand, detect, and respond to infectious disease threats. 1.3 COMMUNICABLE DISEASE SURVEILLANCE SYSTEM IN VIETNAM A CD reporting system has been systematically in place by a Direction No. 10/1998/CT- BYT dated 28 th December, 1998 of MOH applicable to 26 CDs. After mandates and organizational structures of PPMCs were clearly defined, surveillance activities has increasingly been consolidated and strengthened, the information system of CDs regulated by the Decision No. 4880/2002/QD-BYT has been valid until February, 2011. Since March, 2011, CDSS in Vietnam is implemented in accordance with the Circular 48/TT-BYT/2010 of MOH, which has listed 28 CDs under surveillance. This system has been established and consolidated from central down to local levels and under direct instruction of the General Department of Preventive Medicine, which is mandated to detect and report CDs as regulated. Influenza is one infectious disease in the list of 28 CCs under surveillance. Now, there are two types of existing influenza surveillance in Vietnam: - Regular CDSS: Influenza is one of 26 CDs under surveillance as stipulated by the Decision No. 4880/QD-BYT in 2002. In this system, ILI and severe viral pneumonia are supervised by units in accordance with regulation of MOH - National Influenza Sentinel Surveillance has been deployed since 2005 in 15 localities nationwide. Strengths of this system are to provide more evidences on operation of influenza virus rather than epidemiology of influenza virus. - Additionally, some donors are deploying pilot community-based influenza A/H5N1 surveillance models. However, weaknesses of these models are not to create linkages with operations of agencies in charge of surveillance. 1.4 QUALITY OF COMMUNICABLE DISEASE SURVEILLANCE SYSTEM Quality of CDSS is a basis for prevention and control of CDs. According to guidelines of WHO and CDC, any CDSS have similar structures, processes and personnel. Guidelines for assessment of CDSS have been developed by CDC since 1988 with four components as: the 5 priority diseases targeted for surveillance, structure of system, core functions of system, support functions and quality of the system. In Vietnam, studies on assessment of CDSS have recently been mentioned. Findings from the 2002 study reveal that it was not easy (25%-58%) or simple (37%-59%) to conduct micrological testing for surveillance. At present, a majority of illness cases reported by commune and district levels are based on symptoms. Even at provincial level, capacity for diagnosis and confirmation the diseases by microbiological testing is also limited as a result the sensitivity and positive predict value of CDSS are not high. This prevents active involvement of PMCs in surveillance, prevention and control of CDs. These studies reaffirm that surveillance still has to face with many challenges in the 21 st century. Therefore, The International Health Regulation 2005 called for increased national capacity development for surveillance and response of all countries in the world. The resolutions stressed the need for countries to give more attention to the strengthening of national surveillance and response capacity, especially developing countries with limited resources like Vietnam. CHAPTER 2 - METHODOLOGY 2.1. DESCRIBE RESEARCH 2.1.1. Subjective: Surveillance units including provincial and district PMC (PPMC and DPMC), CHSs, and provincial and district hospitals; HWs involved in the surveillance system; related documents 2.1.2. Time and place: The research were conducted form 1/2008 - 4/2009 in 8 provinces: Hai Phong, Nam Đinh, Thanh Hoa, Nghe An, Quang Tri, Đak Lak, Đong Nai and Ben Tre. 2.1.3. Study design: The study utilized a cross-sectional survey developed by following the conceptual framework of communicable disease surveillance proposed by US CDC and WHO. 2.1.4. Sample size Qualitative study: p is the proportion of surveillance units sent reports in a timely and completely manner (p=0.5), d is the absolutely precise, α = 0.05. With these data, the sample size needed is 105 surveillance units. 13 surveillance units including 1 PPMC, 2 DPMCs and 10 CHSs were chosen in each province meanwhile the needed provinces of the study are 8 (105/13 = 8). These provinces were chosen representative of 4 regions in the whole country including 4 provinces in the North; 1 province in the Central; 1 province in the Highland and 2 provinces in the South region. These DPMCs and CHSs were chosen random following the list of those units in each province or each district. 6 Quantitative study: In-dept interview was used to assess individual opions of CDSS in these provinces. The participants were 8 leaders of Province Department of Health, 24 leaders of province and district PMCs, and 24 leaders of province and district hospitals. Case study: Reviewed the report, case-based report of 15 in which of 23 influenza A/H5N1 cases and 2 clusters of influenza A/H5N1 from 2004-4/2009 to assess the capacity of detection and response in these provinces. 2.2. INTERVENTION RESEARCH 2.2.1. Subjective: agencies involved in surveillance at district and commune level, HWs at district and commune levels, VHWs, and secondary data. 2.2.2. Place and time: This study had been conducted from June, 2009 – June, 2010 in Tan Hong district (intervention district) and Hong Ngu district (control district) of Dong Thap province. 2.2.3. Study design: The effectiveness of intervention package was assessed with a pre-post quasi - experimental research design with a control group. 2.2.4. Intervention strategy: Develop and deploy a pilot of influenza surveillance model in Tan Hong district using a “step-wise” and “participatory” approach of relevant units involved in surveillance activities in the entire district. Contents of interventions are as follows: - Develop a pilot influenza surveillance model in Tan Hong district including establishment of an organizational structure, development of surveillance procedures and monitoring and evaluation procedures. - Provide training for HWs at district and commune levels and VHWs at village level. - Provide some essential surveillance tools. - Conduct monitoring and evaluation of implementation of models at lower levels. 2.2.5. Sample size: - 9 CHS of Tan Hong district and 11 CHS of Hong Ngu district, Tan Hong and Hong Ngu DPMCs - HWs and VHWs: The minimum sample of HWs or VHWs needed for this study in each district is 45. In fact the sample of the 1 st survey was 100 HWs and 110 VHWs. The sample of the 2 nd survey was 101 HWs and 148 VHWs. The HWs and VHWs have fulfilled requirements of the research. - Surveillance data of ILI during the follow-up period - In-depth interviews, focus group discussions and workshops 2.2.6. Evaluation of intervention measures: Chi square test was used to compare the difference between pre and post time within each districts, as well as between the intervention and control district. The significant level was 0.05. Assess effectiveness 7 and efficiency of intervention measures using indicator of effectiveness and efficiency (EI%) determined by a formula: EI (%) = - p1 is % of the outcome indicator of the study in pre - intervention. - p2 is % of the outcome indicator of the study in post - intervention. - EI is an effectiveness and efficiency index of both intervention group and control group. Net effect = EI (intervention group) – EI(control group) 2.3. STEPS FOR IMPLEMENTATION OF THIS STUDY Step 1. Study and describe the current status of CDSS in 8 provinces during 2008 - 2009. Step 2. Identify issues that need to be intervened and propose intervention measures Step 3. Implement intervention measures from June, 2009- June, 2010: - Conduct a survey prior to interventions in order to assess the current status and needs for interventions. - Develop an influenza surveillance model in Tan Hong district. - Implement intervention measures in Tan Hong district including training, provision of some key surveillance tools, follow-up and support for implementation of models at lower levels. - Conduct mid-term and final evaluations of implementation of pilot models. CHAPTER 3 - RESULT 3.1. STATUS OF COMMUNICABLE DISEASE SURVEILLANCE SYSTEM IN 8 PROVINCES IN 2008-2009 3.1.1. The structure of CDSS in 8 provinces in 2008-2009 The structure of CDSS in general in 8 provinces has been set up and operating in accordance with the Decision No. 4880/2002/QD-BYT of MOH. Within this system, PMCs play a key role and collaborate with hospitals and clinics to conduct surveillance of CDs in their designated localities and deploy timely preventive measures of CDs. Eight out of eight PPMCs are fully equipped with Disease Prevention and Control Departments, Laboratory Department and HWs. Sixteen out of sixteen DPMCs are equipped with Disease Prevention and Control Departments but only 11 out of 16 DPMCs are equipped with designated HWs in charge of surveillance for CDs and 10 out of 16 DPMCs are equipped with laboratory department. Generally in a CHS, one HW is assigned to be in charge of CD surveillance. In provincial and district hospitals, a planning department is a designated unit to be in charge of database management but none of surveyed hospitals has assigned any designated HWs to take care of this issue. [...]... application of technology in reporting was also observed 2 The results of the assessment of ILI surveillance model tested in Tan Hong district, Dong Thap province from 7/2009 – 6/2010: - The model made changes in the structure of the surveillance system in the study district such as increasing the coverage of the system; improving and maintaining the reporting flow, and making it more professional at surveillance. .. accordance with the Decision No 4880/2002/QD-BYT isused by the Ministry of Health The system owned a clear and simple structure but was not profesional enough, especially at the commune and district levels Addiationaly, insufficient involvement of the private health sector and community in the system was also observed The core functions of the system were not well performed, especially at the district and commune... charge of disease surveillance in both preventive and curative sectors at provincial and district levels thus specialization in this case is very low Implementer and stakeholder involvement: CDSS requires involvement of many implementing units and support of political setting, legislation and also resources of other partners The flow of surveillance data through the system, and the dissemination and utilization... and epidemidology are rather low (10.1%- 14.1%) Findings from knowledge assessment, from practice assessment, and assessment of the current situation of surveillance units are similar Thus it is believed that capacity building for HWs is one of main measures to improve quality of surveillance in the time being Essential equipments and tools: Lacking of essential equipment used for surveillance is the. .. Decision No.26/QD-BYT in 2005 of MOH At the DPMCs, “there is a shortage of capacity of HWs in disease prevention and control department therefore in the event of outbreak/epidemic, additional HWs of other departments/units has to be mobilized” Qualification of HWs in charge of surveillance at both provincial and district levels is mainly medical doctor degree (50% and 35.3%) and assisstant medical doctor... to integrate surveillance requirements into a legal provision for management of private health services under supervision of District Helth Department in order to guarantee involvement of these private health units in surveillance activities - 23 CONCLUSIONS 1 - - - - The results of the assessment of the CD surveillance system in 8 provinces from 2008 to 2009: The existing CD surveillance system was... only available where there is an outbreak or applicable only to vaccinated diseases program or of a project.100% of HWs at all levels are awared of the importance of supervision visits provided by higher health agencies but they are also convinced that quality of those supervision visits fails to meet the demands of local levels 4.1.4 Quality of communicable disease surveillance system in 8 provinces,... provincial, district, and commun levels (12.5% - 6.25% 42.5%) The leader of PPMC said that “these activities are done within a framework of a national target program or surveillance of abnormal or dangerous diseases As for other diseases, adequate attention to surveillance has not yet been paid” 3.1.4 The quality of communicabe disease surveillance system in 8 provinces, 2008 2009 Interviews of HW at provincial,... improve surveillance activities at local levels (district and commune level) because they receive most of patients of the entire health system but their capacity to conduct surveillance is rather limited 4 Strengthen capacity of HWs involved in surveillance and medical testing HWs through various forms of training and technical support 5 It is recommended that informatics technology be applied in surveillance. .. has been brought by interventions Intervention models have contributed significantly to improvement of detection and early response to CDs if any outbreak occurs 4.2.3 Usefulness of inflenza surveillance model in Tan Hong district Improvement of knowledge and skills of HWs and VHWs: there has been a significant improvement of knowledge and practical skills in ILI surveillance of HWs and VHWs Improvement . involvement of many implementing units and support of political setting, legislation and also resources of other partners. The flow of surveillance data through the system, and the dissemination and. as: the 5 priority diseases targeted for surveillance, structure of system, core functions of system, support functions and quality of the system. In Vietnam, studies on assessment of CDSS. for Tan Hong district and other districts of Dong Thap province to expand and develop surveillance systems for other CDs as regulated by MOH. STRUCTURE OF THESIS The thesis including 141