Structure and supportive activities for EBS
At the national level, surveillance, through the SID, is part of the HEEC General Directorate. The overall structure of the SID at national level consists of 4 sub-directorates with a unit called “Supportive Activities” (Figure 2). The EBS components (Partner-based surveillance-PEBS, CEBS, HEBS, POE, hotline and media scanning-HMS) are under the Supportive Activities unit with a focal person for each and a coordinator for all EBS activities. There was no written job description to show the roles and responsibilities of the EBS coordinator and focal persons, but there were SOPs for each project including responsibilities at different levels. At the state level a very simple structure was adopted (Figure 3) where IBS and EBS are under the umbrella of the Surveillance Unit with 1-3 persons responsible for the work. Overall, states give less attention to EBS as compared to IBS, and EBS at the state level is equivalent to CEBS. In fact, very few EBS trained focal persons remained at states indicating high turnover due to political instability and low salary.
The surveillance and epidemic control arrangements and activities are governed by the Sudan Constitution and by the National Public Health Law, 2008 in addition to IHR, 2005. The establishment of HEEC General Directorate at states levels (and hence surveillance and Information department) was guided by a letter from the Undersecretary of Health (Federal MOH) in 2014. No law, regulation or decree is designed for EBS separately, nor is there an enforcement mechanism in place to accelerate the implementation of EBS. The government contribution was limited to meet the salaries for surveillance officers and to cover the free telephone network (with paid internet). This reflects low institutional and political commitment to the system since its establishment.
Apart from regularly scheduled coordination meetings between implementers (Federal and States MoH) and stakeholders during an epidemic or health emergencies, there was no outlined mechanism for regular coordination at national and state levels regarding EBS implementation. There was no technical working group of key implementers or broader coordination committee of partners to manage coordination at the national level. However, the Emergency Operation Centre (EOC) daily meeting (during times of public health crises) involves partners (WHO, UNICEF, Non-health sectors) and implementation bodies, and it is the forum that reviews the surveillance data and the response activities. No formal link between national and states apart from expecting immediate reports for the detected signals/ events in addition to monthly reports. Ad hoc phone calls were sometimes arranged by the national level particularly when there are rumours or notification needs triage and/ or verification at state level.
The national level has developed and availed soft and printed format guidelines and SOPs for EBS (PEBS, CEBS and POE) to direct the implementation at states level. The guidelines identified the priority events and signals, defined the role and responsibilities of each level, and stated clearly the information flow. While some states currently use the SOPs and guidelines and reported to have shortage of supply of SOPs and guidelines, others did not know it existed.
In 2016-17, the national level trained states’ EBS focal persons together with 18-22 partners at each state. Partners at state level include governmental sectors (animal, agriculture, police, climate and meteorology, education, public mass media), civil societies, UN agencies, international NGOs, and big development schemes. These partners differed from state to state. Furthermore, all focal persons for CEBS at states level were trained in 2018 to be trainers at their state’s “TOT- Training of Trainers”. No formal refreshment training and no regular follow-up or supportive supervision for focal persons was provided. The exact need of personnel for EBS and the target for training was not clear at both national and states levels.
EBS has its own reporting format and data flow which was partially integrated at national and states levels. At the national level, the weekly meetings foster the information sharing and coordination between the different projects as per the current structure of SID; in these meetings, both EBS and IBS reports are presented and discussed and the final decision about the disease/ event under discussion make use of both sources of data. The EBS monthly report compiled all the signals/ events from different states and submitted separately to the Head of the Department.
EBS core functions
The FMOH developed signals to be detected by the EBS. The CEBS for instance is expected to detect and report unusual, unexpected signals with particular emphasis on acute respiratory symptoms, haemorrhagic fever, acute diarrhoea, jaundice, acute neurological symptoms, guinea worm, floods, draught, displacement, conflicts, and death among animals. The CEBS was based on trained community volunteers. Each group of volunteers assigned identified one person to be the coordinator. When the community volunteers detected a signal, she/ he reported either to volunteer coordinator or directly to the locality level using telephone calls, direct contact, or through another person. The contribution of partners (including other governmental sectors like animal sector) was limited to the detection of signals and reporting it to state health authorities. On some occasions, partners (e.g. animal sector) report to its relevant authority at the national level and this authority informed the national health authority. No system to capture rumours, official or media reports about unusual or unexpected events apart from phone calls from individuals to the emergency call centres (ECC) at national and state levels (using the emergency numbers). With the exception of Gedarif state (out of 6 states visited), there were no official rumours logbooks or databases for the registration of suspected public health events from informal sources, making the follow-up of signals after detection very difficult. Efforts were ongoing to enhance follow-up based on the OSM (Online Signal Module). Some volunteers and focal persons used a notebook for registration, but it was not standardized to an official format. There are no weekly or monthly reports required from volunteers. Volunteers were expected to report when there is a signal; “no report means zero signals!!” as stated by one surveillance officer in a state.
States report immediately when there is a signal or event. By the end of the month, states compile all reported signals and events and send to Federal MOH using a structured format which covers the what, where, when, who, and how of the signal or event. The focal points for EBS and CEBS at the national level would compile the reports from all states and issue their monthly reports. The contents of these reports are discussed as part of “Surveillance and Information Department” and “HEEC General Directorate” formal meetings. Few states showed a monthly EBS or CEBS reports but there are separate reports for each event. There was no attempt to use database for signals/ events reporting at state level.
Once the locality surveillance officer received a notification from a community volunteer or another source, they informed the state and started arrangements for triage, verification, and risk assessment, if needed. This process depends on the locality resources and, in most cases, is completed jointly with the state team. The team sends a written report to the Director General of Health at the state, and if the event represents a public health event of concern, the director informs the Federal MOH. The state conducts verification, risk assessment, and response, which is carried out by trained rapid response teams (RRTs). The training process of RRTs was accelerated by the COVID-19 pandemic (Figure 4).
Performance of state EBS: After visiting the states and analysing the data using mixed quantitative and qualitative methods, the assessment teams gave a score for each state. In 14 out of the 21 items, the overall score was high. However, the assessment teams have concerns about the presence of a structured collaboration with partners: on most occasions there was no collaboration, or it was weak. Moreover, in 2 states there was no EBS unit or focal persons. Most states did not have a written organogram or define roles and responsibilities for EBS staff. Although the current personnel were trained in surveillance and in EBS, the trained personnel were not sure about their capability to do the assigned work. Free access to the internet was limited and supportive supervision from the state to localities and to frontline personnel was lagging (See Table 1 in the appendix).
The above mentioned findings were confirmed by the data obtained from 53 surveillance officers working at the state level. Around 60% of respondents reported to have a list of signals with standard definition. More than 75% of respondents stated there was a presence of a community-based system to capture unusual, unexpected or new event. Ninety percent of the information captured was through the call centre, volunteers or health care workers.
All respondents reported detecting signals/ events in the last year. Over two-thirds of the respondents stated having personal notes in which they recorded information about signals such as date, time, place, source of information, initial cause, description of the signal/ event, and number of cases/ deaths occurred as a result. Less attention was given to have a unique serial number to signal/ event (37.7%). The other important finding was that states were inadequate in the following areas: database development (54.7%), electronic system (39.6%), list of experts (47.2%) and public health laboratory (35.8%). A total of 33 (62.3%) respondents knew the recommended time for verification, but more than that stated having risk analysis team (67.9%) and conducted risk analysis (86.8%) using Federal MOH or WHO tools. Unfortunately, only 30 candidates analysed the last risk. Generally, limited numbers of respondents (41.5%) attempted to analyse paper-based EBS and IBS data at state level as shown in Table 1.
Respondents also reported their self-assessment related to detection, reporting, verification, risk assessment, perception, planning, implementation and monitoring of EBS at states level (Figure 5). Many of them stated that states have a list of signals/ events for immediate notification (84.9%) and knew the time for notification (77.4%). The lower level notified to higher level immediately or within 24 hours using the telephone in most of the cases. Likewise, states reported to a higher level immediately. States reported signals and events immediately; however, limited number of states reported on weekly or monthly basis, and the telephone is the preferred tool. States have a report for each event, they keep a copy for the sent reports, and they shared the report with the non-health sector and NGOs. Sending or receiving feedback report was not identified by reviewers as a common practice. The response to an event and to an emergency, in general, looks good as perceived by the respondents. The findings related to supporting activities for EBS and surveillance were encouraging. More than 80% of respondents stated having plans for surveillance and response, coordination committees with partners, supported telephone calls, guidelines for CBES, and have integrated EBS into broader surveillance. Respondents have concerned about meeting with partners, buffer stock, and guidelines for overall surveillance for response. Few candidates reported having free access to internet, HEEC being established in the state based on law or decree, or an EBS team.
Table 1
Detection, registration, verification and risk analysis of signals and events (n=53)
Variables
|
Frequency
|
%
|
Ever detect a signal/ event at state level
|
45
|
84.9
|
State with a register for signals/events
|
38
|
71.7
|
Event has a unique serial number
|
20
|
37.7
|
Event notification date and time documented
|
40
|
75.5
|
Initial cause of the event registered
|
33
|
62.3
|
There is a description for the event
|
36
|
67.9
|
Cases and deaths reported
|
40
|
75.5
|
Event place stated
|
41
|
77.4
|
Event source of information stated
|
38
|
71.7
|
State has databases
|
29
|
54.7
|
State has e-system
|
21
|
39.6
|
Respondents know verification time
|
33
|
62.3
|
State has a list of experts
|
25
|
47.2
|
State has a Public Health Lab
|
19
|
35.8
|
State analyses data on regular basis
|
22
|
41.5
|
State has risk analysis team
|
36
|
67.9
|
State conduct risk analysis for the detected signals/ events
|
46
|
86.8
|
State use MOH or WHO tool for risk analysis
|
44
|
83.0
|
Last risk analysed
|
30
|
56.6
|
EBS at state level as perceived by the community volunteers
Following the TOT training in 2018, states, through support from the Federal MOH and other partners, identified target areas and trained community volunteers. States keep records of the volunteers which includes telephone numbers. During the visits to five states, the assessment teams) randomly selected 5 – 7 volunteers from the list and communicated with them by phone. Surprisingly, almost all attempts succeeded. Out of 26 volunteers, 13 were female. The mean (SD) age was 37.9 (11.1) years ranging between 23 to 62 years. Fourteen have basic education and 10 have university/ above university education. Eighteen designated themselves as community volunteers and 4 as health care providers. The majority (21 respondents) were involved with CEBS for 2 years or less, and 5 of them were involved in such work for more than 5 years. Twenty-two of them were trained and knew what their role was, and almost all knew what needed to be reported. Eighteen of the respondents had reported an event before. Most of the reported events could be classified as biological (diseases) and a few were social (displacement). The events came to the attention of the volunteers during engagement in social gathering, personal contact and observation. Volunteers used phones to notify to the higher level. The majority of respondents at the community level identified no hindrances apart from communication network problems. Only 11 respondents reported having notification forms, and 10 had a register for events. Of those ten, only 4 registered the last event they had. One third of them received occasional feedback from the lower level. What is outstanding is that 20 were satisfied with CBS and 22 were willing to continue. The volunteers’ suggestions to improve the project include support to phone calls, training and supplies such as notification forms and registers.