REPORT ON THE

IN!CERCOUhTRY KEETING ON TRE USES OF EPIDEUIOLOGY FOR DISEASE PREYENTION AND CONTROL

Islamabad, Pakistan, 13-16 September 1992

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE EASTERN MEDITERRANEAN

November 1992

This document is not issued to the general public and all rights are reserved by the World Health Organization (WHO). The document may not be reviewed, abstracted, quoted, reproduced or translated, in part or in whole, without the prior written permission of WHO. No part of this document may be stored in a retrieval system or transmitted in any form or by any means - electronic, mechanical or other, without the prior written permission of WHO.

The views expressed in documents by named authors are solely the responsibility of those authors.

1 . INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . 2 . OBJECTIVES OF MEETING . . . . . . . . . . . . . . 3 . EMRO COLLABORATION WITH MEMBER STATES IN THE DEVELOPMENT

OF EPIDEMIOLOGICAL SERVICES/SURVEILLANCE . . . . . . . . . 3.1 Introduction . . . . . . . . . . . . . . . . . . . . . 3.2Training . . . . . . . . . . . . . . . . . . . . . . . 3.3 Guidelines on Epidemiological Surveillance . . . . . . 3.4 Preparedness and Response to Emergencies . . . . . . .

4 . COUNTRY PRESENTATIONS ON SURVEILLANCE OF DISEASES . . . . 5 . ROUTINE HEALTH SERVICES STATISTICS: WAYS OF IMPROVING

THE USEFULNESS OF THIS INFORMATION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1 Introduction

5.2 Routine Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3 Conclusions

6 . ESSENTIAL COMPONENTS OF A NATIONAL EPIDEMIOLOGICAL SURVEILLANCE SYSTEM FOR DISEASE PREVENTION AND CONTROL

6.1 Introduction . . . . . . . . . . . . . . . . . . . . . 6 . 2 Objectives of Surveillance . . . . . . . . . . . . . . 6 . 3 Components of a Surveillance System . . . . . . . . . . 6 . 4 Elements of Surveillance . . . . . . . . . . . . . . . 6 . 5 Monitoring and Evaluation . . . . . . . . . . . . . . .

7 . USES OF EPIDEMIOLOGY FOR DISEASE CONTROL . . . . . . . . . 7.1 Introduction . . . . . . . . . . . . . . . . . . . . . 7 . 2 Malaria Control in Zaire . . . . . . . . . . . . . . . 7.3 Injury Control in Indonesia . . . . . . . . . . . . . . 7.4 Conclusions . . . . . . . . . . . . . . . . . . . . . .

8 . FIELD TRAINING IN EPIDEMIOLOGY FOR DISTRICT HEALTH MANAGERS 8.1 The Epidemiological Process . . . . . . . . . . . . . . 8 . 2 The Training Process . . . . . . . . . . . . . . . . . . . . . . . . . . 8.3 The Liverpool Epidemiology Programme

9 . PANEL DISCUSSION . . . . . . . . . . . . . . . . . . . . . 10 . RECOMMENDATIONS . . . . . . . . . . . . . . . . . . . . . . Annexes

1 . Agenda . . . . . . . . . . . . . . . . . . . . . . . . 2 . Programme of Work . . . . . . . . . . . . . . . . . . 3 . List of Participants . . . . . . . . . . . . . . . . .

1. INTRODUCTION

The Regional Office for the Eastern Mediterranean (EMRO) of the World Health Organization (WHO) convened an Intercountry Meeting on the Uses of Epidemiology for Disease Prevention and Control from 13 to 16 September 1992, in Islamabad, Pakistan.

The objective of the meeting was to update the participants on, or acquaint them with, the methodology of using epidemiology for disease prevention and control.

At the opening session, the Acting WHO Representative to Pakistan, Dr Nabil A1 Tawil, read out a message from the Regional Director for the Eastern Mediterranean, Dr Hussein A. Gezairy. In his message, Dr Gezairy welcomed the participants and thanked the Government of Pakistan for hosting the meeting. He emphasized the importance of epidemiology in the national health services, and noted that epidemiology was not being accorded the priority it deserved. He considered that a part of the problem lays with the medical education establishments which tended to accord the teaching of public health-cum-epidemiology an insignificant status, in sharp contrast to the teaching of clinical medicine. Realizing this unsatisfactory situation, the Forty-first World Health Assembly adopted, in 1988, a resolution (WHA41.27) on the role of epidemiology in attaining the goal of health for all. The current meeting could be considered as a partial response to that resolution. He highlighted EMRO's continued support to public health training institutions through fellowships and consultancy services and provision of technical backstopping on the development of curricula more relevant and attuned to the needs of the Region.

With regard to the development of epidemiological services in the Region, Dr Gezairy referred to the satisfactory progress made in EMRO's collaboration with Member States in the formulation of epidemiological surveillance for diseases that were the target of specific programmes, e.g. some diseases under the Expanded Programme on Immunization (EPI), such as poliomyelitis, or, in another field, AIDS. Practical case-definitions were developed for these diseases. He, however, mentioned that routine health services statistics left much to be desired. The collection of such routine information consumed not inconsiderable resources in time, personnel and material, though the utility of such information remained doubtful. It was not so much the lack of information as the lack of valid and usable information. In the absence of such valid epidemiological information, he noted, gauging the magnitude of individual health problems, setting priorities and objectives, as well as realistic allocation of resources in the health sector became nothing more than a guesswork. When such an unsatisfactory situation prevailed in an environment of scare resources where there should be no room for waste, then the status of health services suffering from what could appropriately be described as "epidemiology deficiency" could only be surmised.

In conclusion, Dr Gezairy wished the participants successful deliberations.

The Director-General (Health) of Pakistan, Dr Mohsin Ali, commented on the serious deficiency of epidemiology in his country and attributed

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the main cause of the problem to lack of appreciation of the importance of epidemiology by the medical schools. Pakistan would be launching shortly a training programme in field epidemiology, with the support of WHO, UNICEF and the Centers for Communicable Diseases (CDC), Atlanta, U.S.A. He also outlined a programme supported by the USAID to overhaul and improve the health information system in the country.

The meeting was inaugurated by H.E. the Minister of Health for Pakistan, Mr Tasneem Nawaz Gardezi, who expressed his appreciation that the subject of the uses of epidemiology, vital to the understanding of population health problems, was to be discussed in depth during the meeting. He thanked WHO for holding the meeting in Pakistan and wished the participants a pleasant stay in Islamabad.

The agenda and the programme of work were adopted with some minor modifications (see Annexes 1 and 2 respectively).

The meeting was attended by participants from 16 countries of the Region (see Anuex 3). The participants elected Dr Abdul Majid Rajput (Pakistan) as Chairperson and Dr Awatif Abu Haliqa (United Arab Emirates) Rapporteur.

2. OBJECTIVES OF MEETING

The objectives of the meeting, as mentioned earlier, were to update or acquaint the participants with the methodology of using epidemiology for disease prevention and control.

However, this needed some elaboration to clarify further. Though a number of workshops, seminars and training courses on epidemiology and control of communicable diseases were conducted earlier in the Region, as mentioned elsewhere in the report, this was the first time that an intercountry meeting of this nature was being held in the Region. What set the present meeting apart from the previous ones in this field was the fact that this was meant to serve the purpose of addressing the question of improving health services statistics through better use of epidemiology.

This process entailed the participants to think in epidemiological terms in the national health planning and health services management. It is expected that this approach will lead to a situation where health problems will be seen in their correct perspective which will admit setting priorities. It will, in turn, facilitate rational allocation of resources and this will also help selecting what health problems should be placed under surveillance and what resources and technologies are available for the prevention and control of the targeted health problems. It is also at this stage that the relevant data to be collected on any particular health problem under surveillance can be determined.

In short, it was hoped that the meeting will stimulate the desire to make more use of epidemiology than has been the case in strategic national health planning, as well as in the day-to-day management of health services.

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3. EMRO'S COLLABORATION WITH HPIBER STATES IN THE DEVELOPWENT OF EPIDEMIOLOGICAL SERVICES/SURVEILLANCE

3.1 Introduction

Since its inception, WHO has been actively collaborating with countries in the development of a system for monitoring the performance of national health services. This monitoring system consists, in essence, of collection, analysis and interpretation of data about important events that serve as indicators of the health of the community. Such indicators take the form of morbidity/mortality rates and sub-units thereof and data about the utilization of medical and health services. Applied epidemiology provides the framework within which this whole process of monitoring or, more conventionally, epidemiological surveillance is developed in a rational manner.

As this all-important issue of epidemiological surveillance is central to the overall purpose of the meeting, it is suffice to say that lack of information generated by properly formulated and efficiently run epidemiological surveillance is an obstacle to meaningful resource allocation, as well as effective management of health services. It also makes practically impossible to make informed judgment or evaluation leading to improvement of health services.

Efforts to remedy the situation have not been spared and, on the part of EMRO, these efforts have been directed towards various activities that would collectively contribute to the establishment of viable epidemiological surveillance.

3.2 Training

It has been recognized, right from the start, that training in epidemiology, as applied to disease prevention and control, is the key to the development of epidemiological surveillance. In the years 1964 to 1979, EMRO sponsored a number of participants from the Region for the annual International Travelling Seminar in Epidemiology and Control of Communicable Diseases. Each course lasted several months and consisted of theoretical and practical components. The course was held in different centres (Moscow, Prague, Geneva, Alexandria), and hence the term 'Travelling'.

In JanuarylFebruary 1982, EMRO sponsored, jointly with the UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases, a two-week training workshop for teachers of epidemiology. Nineteen candidates from five countries of the Region participated in the workshop which was held in Khartoum, and the general objective of the workshop was to strengthen the national capabilities in teaching of, and research in, epidemiology.

To build on the experiences gained in the training workshop mentioned in the previous paragraph, EMRO organized a two-week training course in epidemiology, with similar content and objectives mentioned above, for teachers in epidemiology. The training course was held in November 1984 in Amman, Jordan, with 12 participants from six countries of the Region.

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EMRO collaborated with the Council of Arab Ministers of Health in organizing a training course in epidemiology leading to Master's degree and 12 medical officers from eight countries of the Region successfully completed the course in 1987. The training course was held in Ain Shams University in Cairo, Egypt.

In conformity with WHO'S policy, EMRO has been promoting health services development at the district level. To this end, EMRO conducted a three-week training course in epidemiology at the district level in Sudan in June 1991. The training course was held at Sennar and 17 participants from different districts attended the course. The major technical input was provided by the Unit of Statistics and Epidemiology (USE) of the Liverpool School of Tropical Medicine, in collaboration with the Ministry of Health, Sudan. Though it was planned to repeat the course in different states of the country, as an on-going training activity, unfortunately this has not yet happened.

For some time now, the main emphasis has been on the training locally of health workers in epidemiology in their own "environment", sometimes using the vernacular language to make the training more appropriate. For this purpose, WHO country programmes for disease prevention and control contain training components. The training in epidemiology and its uses can either be conducted locally, sometimes with the help of WHO consultants, or candidates can he sent abroad on fellowships.

3.3 Guidelines on Epidemiological Surveillance

As part of the attempts to develop national epidemiological surveillance, it has been found more practical and realistic to design guidelines on epidemiological surveillance for individual targeted diseases, e.g. diseases under the Expanded Programme on Immunization, control of diarrhoea1 diseases (CDD), malaria, tuberculosis, AIDS, etc. These guidelines contain, among other things, practical case- definitions for reporting purposes, with a view to collecting data that are comparable. In this connection, the role of laboratory services in epidemiological surveillance cannot be overemphasized, and EMRO, in its collaboration with countries, pays particular attention to the development of this aspect of epidemiological services.

For information exchange within the Region, EMRO publishes a quarterly Epidemiological Bulletin. This bulletin contains tables of the main endemic diseases reported by the countries. One purpose that the Bulletin serves is to indicate the pattern of reporting of the individual countries and to encourage them to improve their epidemiological surveillance systems. The Bulletin also contains articles on topics of special interest to the Region.

3.4 Preparedness and Response to Emergencies

During the last few years, there have been emergencies or disasters in the Region. These calamities, whether caused by natural forces or man-made, call for special approaches for their prevention, mitigation and management. To assist countries in developing their capacities for meeting such emergencies, guidelines were formulated by EMRO, in 1989, and copies of these were widely distributed in the Region. These

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guidelines are generic and so they can easily be adapted for such diverse emergencies as epidemics, earthquakes, floods, etc. Indeed, it is not unknown for some such emergencies to prompt the setting up of practical epidemiological surveillance system for particular diseases that are prone to give rise to epidemics, e.g. meningococcal meningitis and cholera, or for special situations, such as provision of health services for refugees or displaced populations. Where epidemiological surveillance does not pre-exist the emergency, then the one that is set up for the emergency can be used as a basis for developing epidemiological surveillance that will serve both emergency and non-emergency situations.

4. COUNTRY PRESENTATIONS ON SURVEILLANCE OF DISEASES

The national participants were informed, in advance of the meeting, that they were expected to make a brief presentation at the meeting on the epidemiological surveillance systems in their countries. They were also requested to indicate the first twenty diseases registered in their countries in 1991.

The purpose of the exercise was to: (1) induce those participants who might not be well acquainted with their routine national health services statistics to gain some insight into this type of health information, and (2) find out if the diseases reported by the participants might throw some light on the existence of a regional pattern in disease incidence.

It was considered more instructive to put the reported diseases by the participants in context and thus include general comments on this in Section 5 of the report which deals with routine health services statistics. An attempt was made to bring out the deficiencies and other features inherent in this type of routine reporting on morbidity and mortality.

The disease patterns reported clearly showed up the limitations of such disease reporting when a proper epidemiological surveillance system does not exist. Because of gross discrepancies and lack of internal consistency, it was not considered useful to reproduce the lists of diseases reported by the participants.

Summaries of country presentations by the participants are given in the following pages.

4.1 Bahrain

All doctors in health centres, hospitals and private clinics are required by law to report those diseases that are listed in the weekly notifiable diseases return forms. The completed forms, including NIL returns, are either hand-delivered or posted to the communicable diseases sectors of the Public Health Department. Diseases such as cholera, plague and yellow fever should be reported immediately by telephone.

The notification forms are reviewed daily in order to identify cases which need investigation. The data are consolidated and analysed

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weekly to determine any changes in the trend of the diseases.

Surveillance data become the basis for the four-weekly reports that are distributed to all doctors in health centres, hospitals and private clinics. The data consist of eight columns comparing the disease incidence in the current year with previous years.

Data of all immunizations administered are collected every month, by dose, type of vaccine and age-group. In addition, other surveys are carried out for evaluation of immunization coverage, diarrhoea1 morbidity and mortality and the coverage rate of the six EPI target diseases.

Vector populations are routinely controlled by rodenticide and antilarval spraying operations.

The Environmental Health Section monitors routinely the quality of drinking water and of foodstuffs, by sampling and subjecting them to bacteriological examination.

Since the pattern of diseases in Bahrain is now shifting more to noncommunicable diseases that will create a burden to the population, the proposed surveillance and intervention in the future could include the following priority areas:

1. Disease prevention and control activities that will include changes in behavioural patterns.

2. Genetic problems (including sickle cell G6PD anaemia, and thalassaemia).

3. Environmental and occupational health.

4.2 Djibouti

Djibouti is a small country with a population of 510 000.

There is a high influx of refugees into the country from neighbouring Ethiopia and Somalia.

The disease surveillance system was not functioning well until two WHO consultants visited Djibouti and advised on the reorganization of the system. A small Statistics Unit has been set up recently.

The surveillance system is district-based and reporting forms have been designed. The most prevalent diseases are listed in these forms, giving priority to those that can be diagnosed at the district level. Trained laboratory technicians are available at the periphery and the peripheral small laboratories are appropriately equipped to diagnose diseases such as malaria and tuberculosis, the latter having a well- functioning surveillance system.

The EPI target diseases are monitored to evaluate the impact of the programme on disease reduction. The AIDS programme is still being implemented as a vertical one and its surveillance is based on periodic ad hoc surveys and notifications from doctors at all levels of the national health services.

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Surveillance of nutrition and other conditions affecting the health of women and children is carried out through MCH services. Indicators such as low birth weight, and perinatal and neonatal mortalities are obtained from general hospitals. The hospitals also issue birth certificates for babies delivered in the hospitals, while the Town Council is responsible for babies delivered at home.

Deaths are underreported, and plans are under way for recruiting the imams of mosques to register deaths, since dead bodies of muslims are usually taken to mosques for prayers before burial.

Data collection starts at the periphery and ends at the Public Health Department where the data are compiled, analysed and interpreted. Feedback reports are prepared and sent to the Ministry of Health and to all health workers who participate in the surveillance.

4.3 Islamic Republic of Iran

An effective mechanism for data collection, recording and reporting is one of the main aspects of the country's health system. The epidemiological activities are integrated into the PHC network as shown in Figure 1.

Figure 1

ORGANIZATIONAL CIURT OF THE DISTRICT HEALTE NETYORK

RURAL AREA

HEALTH W S f S

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The process of data collection and reporting is mentioned below.

All health houses (HHs) and some urban health centres (UHCs) prepare a family file for each family. The file contains all information about the family members, including the family number, home, age, and literacy status, mother care sheet, child care form for each child under 6 years of age, a form for health condition and recording of the major diseases of each member of the family. There is also a form for recording the information about the environment of the house, water supply, latrine, source of heat energy, waste disposal system of the household, and a follow-up sheet for each case of the diseases which needs follow-up, including communicable diseases.

Services offered in or out of the health houses are carefully recorded daily in special sheets and booklets. The data recorded on the forms and booklets are cross-checked for accuracy. Vital statistics and other information are presented according to age-groups and sex.

At the end of each month all health facilities report their activities to their higher level, and all data are collected in district health centres. The data are in three different sheets according to the type of service: i.e. rural areas covered by HHs, rural areas covered by mobile teams (which have more restricted activities in comparison with HHs) and UHCs. The main job of mobile teams is in the field of disease control and immunization.

To ensure maximum reliability and ease in recording, almost all forms are designed in large dimensions for pinning them up, allowing daily recording with tallies in HHs.

District health centres (DHCs) summarize this monthly routine information received from their respective satellites and present it in a fashion that easily reveals the performance of an individual DHC and its satellites or PHC network (Figure 1). Feedback is provided to the reporting units and the information supplied by them is reported to the provincial health centres and from there to the central level (i.e. the Department of Communicable Diseases Control).

Diseases that are likely to give rise to epidemics, such as cholera, meningococcal meningitis, etc., are reported immediately through the reporting system described above.

Indicators are in use for assessing the effectiveness of the epidemiological surveillance. The aim is to decentralize epidemiological surveillance for disease control to the district level and to strengthen the expertise of various health personnel at this level. Thus there is an ongoing training for these health workers.

4.4 Iraq

Surveillance is a continuous and systematic process consisting of collection of relevant data on specified diseases in populations of a certain geographical area, consolidation of these data into meaningful information and analysis and interpretation of this information with the ultimate aim of taking action against the target diseases.

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Epidemiological surveillance started in Iraq in 1938. The system at that time involved quarantinable, epidemic, and certain endemic diseases. The system was mainly confined to the level of the Ministry of Health, but also involved a few districts in Iraq. During that period the surveillance system depended on routine notification which was inadequate in many respects.

In the 1950s, the malaria eradication programme was launched and this helped the surveillance system improve with regard to the training of personnel and better data processing methods. In the 1970s and 1980s, more disease control programmes, including the Expanded Programme on Immunization, programmes for the control of acute respiratory infections, diarrhoea1 diseases and other communicable and noncommunicable diseases, were introduced.

This led to a better surveillance system, and with the introduction of computerization at the central and regional levels, the system entered a new phase in Iraq, but unfortunately suffered badly during the 1991 conflict. The system is being gradually restored.

Major sources of data are:

- Morbidity reports - Mortality reports - Reports on epidemics and endemic diseases - Individual case investigation reports - Laboratory reports - Special surveys reports - Environmental data reports - Demographic data reports - Information on animal reservoirs and vectors.

The levels of reporting are:

Local level (primary health centres) Regional level (Health Directorate) Central level (Ministry of Health) International level (for example, diseases under the International Health Regulations).

The reporting system relies mostly on routine reporting from the different health levels mentioned above, using special notification forms for each disease. In case of communicable diseases, reporting is compulsory for all physicians (public and private), according to the public health law. Notification of diseases is done either daily, weekly or monthly, depending on the disease, while outbreaks are to be reported immediately.

At the regional level, data from different health facilities are summarized with limited analysis and submitted to the Ministry where further summarization, analysis, interpretation and feedback are done.

In order to evaluate the reliability of the routine reporting from the lower levels, the Ministry of Health conducts ad hoc surveys, in cooperation with the regional level, on certain diseases of epidemiological importance or other health conditions.

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Constraints

1. Shortage of qualified personnel at different levels in the field of epidemiology and biostatistics.

2. Inconsistencies in reporting as a result of the use of different case-definitions and guidelines.

3. Underreporting. 4. Lack of financial resources in the current difficult

situation.

Future trends

1. Planning for the development of computerized health information system at regional and other levels.

2. Motivating private sector health services and practitioners to improve the notification system.

3. Wide dissemination of standard case-definition and guidelines on notifiable diseases to all health facilities.

4. Training of health personnel in epidemiological surveillance. 5. Collaboration with international agencies in further

developing the epidemiological surveillance.

4.5 Jordan

Foundations for the epidemiological surveillance system in Jordan were laid during the second half of this century. Interest at the beginning was focused on quarantinable diseases, epidemics and certain endemic diseases, such as tuberculosis and malaria, which posed a major public health problem at that time.

During the 1970s more diseases were added to the surveillance list, according to their epidemiological impact on the population. However, the reporting system was deficient.

Since launching EPI in Jordan in 1979, the surveillance system was intensified for the EPI target diseases and primary health centres became the basic units for routine notification. This greatly improved the surveillance system and more communicable and noncommunicable diseases have now been brought under surveillance.

The list of reportable diseases is updated according to the epidemiological situation of these diseases. Notification of diseases is done on daily, weekly or monthly basis depending on the type of disease, while outbreaks are reported immediately. The notification is considered to be an obligation on the part of all physicians (public and private) according to the public health law.

Most of the data collected at the regional and district levels undergo limited analysis and are summarized, and forwarded to the Ministry where further analysis and interpretation of these data are done centrally and the notifying facilities provided with feedback.

Levels of reporting in Jordan

1. Local level (Primary health centres) 2. Regional level (Health Directorates)

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3. Central level (Ministry of Health) 4. International level (WHO, UNICEF, etc.)

Types of surveillance activities used in Jordan

a) Routine reporting system (mainly) b) Case investigation reports c) Epidemic investigation reports d) Surveys e) Sentinel surveillance (this approach has been introduced

recently for certain noncommunicable diseases).

Monitoring of the surveillance system is now done through the use of surveillance indicators that can monitor completeness, timeliness and reliability of reporting.

Constraints

a) Underreporting, especially by the private sector; b) Inconsistencies in reports, due to the use of different

case-definitions and guidelines; c) Lack of computerized health information system, especially at

the regional level; d) Shortage of qualified personnel, particularly epidemiologists

and biostatisticians, at the regional level; e) Surveillance of mortality lags far behind morbidity

surveillance; f) Shortage of finances.

Present and future views

1. A one-year training course in community medicine has been conducted, in collaboration with WHO, with emphasis on epidemiology. The first group of 20 physicians have graduated two months earlier and have been assigned to different districts. It is planned to establish a network of such personnel in the coming few years.

2. Copies of case-definitions of some notifiable diseases and some surveillance indicators have already been distributed and it is proposed to distribute them widely to all health facilities and health practitioners.

3. Baseline data for important noncommunicable diseases are being developed.

4. Motivation and raising the awareness of private practitioners are being given priority in the planning process and this could be tackled through national health committees, seminars, workshops and dialogue.

5. It is planned, in the short term, to improve and develop a central computerized health information system and later extend it to regional and district levels.

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4.6 Kuwait

The country used to have a well-run epidemiological surveillance system. Following the Iraqi invasion on 2 August 1990 that lasted seven months the country had suffered a national disaster disrupting the health services. Since the liberation on 26 February 1991, good progress has been made in reestablishing the epidemiological surveillance system.

The first referral centres are called polyclinic health centres and include preventive health centres. These preventive health centres receive all the notification forms on communicable diseases, in accordance with public health law. The diseases are classified into five groups according to their nature and mode of notification. Surveillance activities are carried out by preventive health centres. Complete information is collected about the patient and the contacts. This information is conveyed to a senior epidemiologist in the area for analysis and action. Feedback information is sent to the preventive health centres as well as to the Preventive Health Division at the central level. The country is determined to achieve the previous level of health services and improve upon it.

4.7 Lebanon

Fifteen years of conflict and civil strife have left the health services severely disrupted. The old system of health information gathering has almost collapsed. The different departments of the Ministry of Health barely function. Another feature of health services in Lebanon is that a large proportion of health services is provided by the private sector. Thus, the health information that is available to the public health sector is limited since it is not easy to obtain health information from the private sector without a special effort.

In Lebanon, 27 infectious diseases are designated as notifiable. For the purpose of complete reporting, copies of the list of the designated diseases are distributed to all health facilities, both public and private. Depending on their nature and epidemiological importance, some of the diseases have to be notified immediately, but within 24 hours, while others are reported on weekly basis.

Deficient organizational structure of the Ministry of Health, shortage of health personnel and scarce resources do not allow, for the present, the implementation of an efficient epidemiological surveillance.

4.8 Oman -

Proper use of surveillance and epidemiology is the most important element in planning for sound and equitable comprehensive health services. In Oman, especially since 1990, epidemiology is used routinely for forecasting epidemics, planning for their control and also for planning of resources allocation for noncommunicable diseases, particularly, diabetes, cardiovascular diseases, cancer, nephrology services, etc. A modified national communicable diseases surveillance system was launched in March 1991, after a pilot study in September- October 1990 and a national training workshop in February 1991. This

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system aims at decreasing the number of forms to be filled by health facilities from 10 to 4 in an attempt to avoid duplication of reporting, to allow smooth flow of information and to initiate immediate containment action. This system divides the communicable diseases into 3 groups, A, B and C, depending on the local disease situation, potential early spread of a disease, availability of control measures and international surveillance requirements. A disease can be shifted from one group to another according to the local epidemiology and whether the disease is to be eradicated, eliminated or controlled.

Data are collected from reporting units (health centres, hospitals, etc.) and sent to regional surveillance units and then to the national surveillance system at the central level. Data are compiled using different database softwares, including EPI INFO 5. Analysis and interpretation of data lead to action against a particular disease. Group A diseases are notified within 24 hours by faxltelephone, Group B diseases within a week and Group C diseases on a monthly basis.

Diseases of both Groups A and B are individually notified, while Group C diseases are reported only in numbers. Feedback is very important and is provided either as day-to-day discussions or in the form of an epidemiological newsletter, published quarterly since January 1992. The newsletter is widely distributed to all levels and provides a feedback on disease incidence in the whole proceeding year, and by month and by region. It also shows the diseases situation in the previous quarter and a comparison with the same quarter of the previous year.

Specific indicators of surveillance, for example, low birth weight, maternal mortality, anaemia, still birth, etc. are collected, analysed and necessary actions taken. Evaluation of the system is in accordance with the programme objectives.

At present the surveillance of noncommunicable diseases, particularly diabetes, cardiovascular diseases, accidents, cancer, nutrition, etc. are mainly hospital-based, because these generally need inpatient services. Annual diabetes surveys in 1990-91 have resulted in setting up a national diabetes registry with satellite regional registration. A central cancer registry exists at the national level. Efforts are being made for these registries to be more harmonized and coordinated within the Department of Diseases Surveillance and Control, Non-Communicable Diseases Section, which will shortly start surveillance of other health problems, e.g. neonatal congenital abnormalities.

4.9 Pakistan

Pakistan, with a population of 117.3 million, is divided into provinces for administrative purposes. Each province comprises several districts which, in turn, are divided into tehsils. Health care delivery is the responsibility of the provincial government with the Federal Government providing policy guidelines and finances.

The grassroot level health facility is the basic health unit (BHu) with a single resident doctor caring for a population of 5000 to 10 000. The next higher echelon is the rural health centre (RHC), with

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2-3 doctors and up to 10 beds catering for about 20 000 people. In the next tier, health care is provided by medium-sized tehsil and district hospitals which have up to 10 specialists and 20 to 200 beds for inpatients besides outpatient clinics. These hospitals may serve a population of up to one million. In addition, many districts have maternal and child health centres and tuherculosis hospitals.

BHUs and RHCs send monthly statistics relating to 21 notifiable communicable diseases to district health officers. The data are forwarded to the Provincial Directorates for analysis and then to the Epidemiological Unit in the Federal Ministry of Health, on a quarterly basis. The national health services statistics are compiled and analysed and distributed on biannual or annual basis. The data show that malaria, diarrhoea1 diseases and respiratory tuberculosis are some of the leading causes of morbidity/mortality.

The nationwide Expanded Programme on Immunization against diphtheria, whooping cough, tetanus, poliomyelitis, measles and tuberculosis, started in 1979, has markedly reduced, during the last thirteen years, the morbidity rates for the six target diseases. Epidemiological data collection suffers from serious constraints. The coverage is limited to hospitalized patients in government health care facilities. The figures reported pertain to notifiable communicable diseases only and there is no means of ascertaining the causes of death.

4.10 Qatar -

The Ministry of Public Health has given high priority for developing an efficient surveillance system to reduce morbidity and mortality due to EPI target diseases and other major communicable diseases, such as AIDS, hepatitis B, pulmonary tuberculosis, etc. Data are collected for appropriate action, e.g. for planning and evaluation of health services, establishing priorities for communicable diseases control, identifying at-risk groups, early detection of epidemics and observing disease trends.

Health information is obtained from different sources:

- Routine reporting where health staff collect information about cases that occur in their health centres or admitted into the main clinics and notify the Preventive Health Department (PHD) daily; at the end of every month they report the total number of cases. This kind of reporting gives a fairly representative picture of disease trends.

- Case investigation refers to the actions taken by health centres or PHD to establish the circumstances surrounding the occurrence of a case.

- Outbreak investigations are conducted by staff epidemiologists working at the Communicable Disease Control Section in PHD. The major purpose of an outbreak investigation is to prevent similar outbreaks, to indicate the most appropriate control measures, to identify where and to whom to apply these measures, and to determine why the outbreak occurred.

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Information on diseases under surveillance is collected on standardized forms in order to have comparable information from the reporting units.

There are a number of health teams with responsibilities for screening for, and surveillance of, communicable diseases.

The Preventive Health Department. The Communicable Disease Control Section receives all notifications and data about the different kinds of communicable diseases from all the health areas all over the country and carries out survey of cases and contacts.

The Medical Commission is responsible for screening and surveying for AIDS, pulmonary tuberculosis, hepatitis B, syphilis and leprosy among the expatriates who are allowed to be residents, only after being declared free from these major communicable diseases. The Medical Commission is the only agency responsible for issuing medical certificates (fit or unfit) to all expatriates.

The Environmental Health Section is responsible for the surveillance of pollution or contamination of water through sanitary inspection of the water distribution system, whether public or private. Samples are regularly analysed physically, chemically and bacteriologically and supervision is done of chlorination of water, food sanitation, prevention and control of parasitic infestation, housing conditions and vector control.

The Hamad Medical Corporation (HMC) collects information from Hamad General Hospital, Rumaillah Hospital and the Women's Hospital.

The Primary Health Care Department collects information from 22 health centres distributed all over the country.

The Central Laboratories of the HMC are well equipped and can diagnose all the common communicable diseases. HIV infection can also be diagnosed there.

Lastly, the data collected from different health facilities are analysed at PHD to monitor disease trends and causation of diseases.

4.11 Saudi Arabia

In Saudi Arabia, there are 19 regions with more than 1600 primary health care (PHC) units that are expected to report on the incidence of 30 communicable diseases which are under epidemiological surveillance. These PHC units submit weekly reports to the regions, which, in turn, report to the central level on a monthly basis.

Reports on epidemics (real or potential) are sent immediately by phone or fax, regardless whether or not the disease that is included in the 30 listed diseases is causing, or likely to cause an epidemic.

Health teams are established at peripheral, regional and central levels. These teams keep a watch on the epidemiological situation at their respective levels. The teams investigate reported cases of diseases under surveillance, institute appropriate control measures and

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prepare reports on the activities carried out. The expertise required and the complexity of the investigations to be carried out increase from the periphery to the central level.

4.12 Sudan - Routine health information system is handled by the Central

Department of Health Statistics where the information received from the states is aggregated and compiled and an annual report is produced. At the provincial level, health information is received from rural health statistical units.

The communicable diseases surveillance system consists of immediate notification of Class A diseases (cholera, typhus, plague, yellow fever and haemorrhagic fevers) by the quickest means of communication, and weekly reporting of Class B diseases (malaria, measles, diphtheria, tetanus, influenza, rabies, cerebrospinal meningitis, typhoid, pertussis, polio, mumps, neonatal tetanus, chickenpox, viral hepatitis and both visceral and cutaneous leishmaniasis).

Information is received at the Central Epidemiology Department where it is computer-analysed and necessary action taken. The surveillance systems for the various vertical programmes, such as the EPI, CDD, MCH, NUT, etc., gather similar information, and is more reliable than that obtained through routine health services reporting.

Constraints

- Large country with poor communications, instability and weak economic base.

- Low reporting from health units (20% only report). - Inadequate management within the Central Epidemiology

Department. - Shortage of personnel trained in epidemiology and biostatistics.

4.13 Syrian Arab Republic

The instructions of the Ministry of Health about notification of communicable diseases are:

- Diseases that requiring immediate notification should be reported by phone or cable, within 24 hours of the date of diagnosis or suspicion, to be followed by a written notification report on the prescribed form to the Health Directorate of the province. These diseases are: cholera, plague, yellow fever, relapsing fever, typhus, poliomyelitis, meningococcal meningitis, tetanus neonatorum, malaria.

- Other communicable diseases are to be notified routinely by all medical officers who are obliged by law to do so.

- Reports are sent for action to the Division of Epidemiological Services at the Ministry of Health; the Epidemiological Services Department in the Region, and lastly the Statistics Branch of the Planning and Statistics Directorate in the Ministry of Health. A copy of the report is kept in the reporting unit.

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Recently, a regional system was introduced in the health sector, so that all health centres (specialized and general) submit general reports on activities, diseases, MCH, family planning-related services, health education, vaccinations, etc. Hospitals also send in reports on inpatients, operations, X-rays, laboratory reports, etc. The reports from the centres and hospitals are sent to the statistics departments in the governorates and from there to the Central Planning and Statistics Directorate in the Ministry of Health, where the data are analysed and feedback sent to the reporting units, through monthly bulletins, and quarterly and annual reports.

4.14 Tunisia

Epidemiological surveillance is integrated into the Primary Health Care (PHC) Department. The major system of epidemiological surveillance is based on obligatory notification, prescribed by law, of listed diseases. Notification forms are distributed to all physicians who have to notify all diseases listed therein. The completed forms are sent to regional and national levels for investigation and action. At the national level, this information is introduced into a database and copies of the resulting weekly epidemiological statement are distributed to all the regions and other relevant agencies. A quarterly epidemiological bulletin, containing an analysis of the epidemiological situation and often other useful information, is published and distributed, free of charge, to all physicians.

Complementary information on diseases is collected from sanitary public centres. This surveillance system is due for revision and improvement. The PHC Department which manages 14 national programmes is engaged in developing a surveillance system that will permit the generation of useful information.

4.15 United Arab Emirates

Strategies for the prevention and control of diseases in the United Arab Emirates relate directly to their significance as causes of much morbidity, mortality and economic loss.

The prevention and control strategies highlight the following:

- Measurement of the extent and distribution of disease problems, using reliable and pertinent epidemiological methodologies.

- Defining and specifying diseases to be included in the prevention and control programmes according to their magnitude and importance.

- Resource generation and ensuring the provision of resources for the action plans adopted.

- Development and regulation of evaluation techniques to measure the progress of intervention and its impact on the occurrence of diseases targeted in the programmes.

The pattern of diseases in the United Arab Emirates has changed considerably in recent years where noncommunicable and chronic diseases

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have now become the leading causes of mortality. Plans are underway to develop a comprehensive strategy for the control of noncommunicable diseases. The strategy will emphasize the importance of continuous monitoring and registration of chronic diseases as a prerequisite to evolving suitable prospective intervention plans.

The notification and reporting of communicable diseases are regulated by Law No. 27 of 1981, concerning the prevention and control of such diseases. A list of notifiable diseases has been developed based on the legislation and is revised regularly, according to changing trends in disease occurrence and requirements of the control programmes.

Communicable diseases are categorized into three groups according to locally relevant criteria.

- Childhood diseases of infectious origin, with special emphasis on EPI target diseases, i.e. poliomyelitis, measles, tetanus, pertussis, diphtheria, mumps, rubella, tuberculosis and hepatitis B.

- Endemic communicable diseases, according to their importance in the United Arab Emirates and as per the law on communicable diseases e.g. meningitis, salmonella infections and malaria.

- Imported communicable diseases, especially HIV infections, tuberculosis, leprosy and intestinal parasites.

A workable system has been developed for epidemiological surveillance, based on routine reporting of notifiable diseases. The system is revised and improved periodically, according to available facilities and new developments; the routine reporting system is supplemented by other surveillance procedures such as periodic surveys and other researches, according to needs and situation.

All notifiable communicable diseases are routinely reported every month from the medical districts to the central Department of Preventive Medicine; active case detection is carried out in all medical districts for imported communicable diseases. All new entrants to the country are screened at Communicable Diseases Control Centres of the Departments of Preventive Medicine (detected cases are dealt with as per the Communicable Diseases Control Law, No. 23).

Surveillance of infectious childhood diseases, especially EPI target diseases, is also conducted at the district level, according to the action plans for the elimination of their local transmission. Surveillance activities for the EPI target diseases can be used for demonstration purposes.

4.16 Republic of Yemen

Training in epidemiology and biostatistics has been lacking in Yemen for a long time. Because of this, the collection and use of health information has not been an important feature of the national health services.

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However, there is now a growing recognition of the importance of reliable information for the planning and management of national health services. The Government, in collaboration with WHO and USAID, has recently launched an initiative to institute epidemiological surveillance of diseases and a health information system. Forms for data collection have already been designed and health personnel trained in their use. Also pilot areas for pretesting data collection have been selected and computer-based data processing introduced. Some returns have already been received and the data are being checked for timeliness, flexibility and reliability. It is intended, in the light of the experience gained, to extend progressively data collection to other parts of the country. The objective is to establish a viable epidemiological surveillance and health information system that will serve the needs of the country.

4.17 United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA)

The disease surveillance system of UNRWA covers health problems designated as priorities: infectious diseases, nutrition, diabetes and maternal and child health are some examples. UNRWA has two levels of surveillance - one based on routine data collection and the other on ad hoc surveys, and the two complement each other. It is not rare, in fact, to have an ad hoc study to clarify issues for which the routine surveillance system has proved inadequate. Ad hoc surveys are also carried out to identify new policies, set baseline data and justify policy decisions.

The UNRWA surveillance system uses multiple sources of information, e.g. laboratory and environmental data. Informal sources are also considered appropriate for monitoring the health status of the refugee population.

Some points for improvement are: streamlining of the infectious diseases routine surveillance system, decentralization of data processing and analysis, and a better two-way communication between different levels of data transmission.

Training of key staff should also be based on a realistic assessment of the learning needs through problem-solving workshops.

5. ROUTINE HEALTH SERVICES STATISTICS: WAYS OF IMPROVING TAEIR USEFULNESS

5.1 Introduction

When discussing a national surveillance system, the first thing to be considered is its objectives: unless the purposes of a routine reporting system are clear and well understood, the demands made on peripheral level health staff and the substantial financial and human resources invested in the collation and analysis of data will be wasted. As part of the overall epidemiological services within a national public health system, routine reporting must contribute to guiding the formulation of the public health policy and to the management of specific public health programmes.

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To accomplish this goal, routine reporting systems should be able to measure accurately and monitor levels and trends of at least three distinct kinds of information: the health status of the population (morbidity and mortality), exposures to risk factors associated with the diseases being reported, and access to, and utilization of, the health services offered to prevent or manage these diseases. In other words, does the population know that children at risk must be immunized, whether high levels of immunization coverage have been attained and, if so, whether there has been a measurable reduction in the incidence of vaccine-preventable diseases? Or, if chronic diseases are the subject of routine reporting, as should become increasingly the case in many countries of the Region which are undergoing the "epidemiological transition" (a shift in the profile from predominantly childhood infectious diseases to primarily chronic and environmental diseases of adults and the elderly), routine reporting systems might ask, using cancer of the lung as an example, whether an increasing proportion of the population is aware of the dangers of tobacco use, whether this knowledge has resulted in a decreasing prevalence of tobacco users, and finally, whether, in the long term, a policy of discouraging tobacco use has resulted in fewer cases of lung cancer.

In other words, routine reporting systems should be able not only to count health events, but also to assist policy-makers to detect emerging health problems and to monitor and to evaluate the strategies developed to combat them. In order to be able to do so, data derived from routine reporting must be taken into consideration together with other sources of epidemiological data (surveys, special studies, etc.) and, most importantly, must be "packaged" in a way that is understandable to its intended recipients, who frequently have at best a cursory understanding of the meaning of scientific data. Stated differently, the epidemiological data must be transformed into information which can be used by non-epidemiologists. For this to happen, the presentation of the analysis of data derived from routine reporting system must be done in such a way that it effectively communicates the findings and allows for prompt action to be taken.

Users of routine reporting systems should be able to:

- measure and monitor levels and trends of health status; - measure and monitor levels and trends of risk exposure; - measure and monitor health service access and use; - detect emerging problems; - monitor and evaluate policies and programmes; and - communicate effectively with non-epidemiologists.

5.2 Routine Reporting

There are many definitions of epidemiological surveillance. The one that will be used at present is: epidemiological surveillance is the on-going systematic collection, analysis, and interpretation of health data essential to the planning, implementation, and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know. The final link in the surveillance chain is the application of these data to

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prevention and control.' This definition has the advantage of being action-oriented, and it attempts to move surveillance into the mainstream of public health practice by insisting that its product be regularly applied to all activities in the public health sector. Effective public health programmes follow a logical sequence of events, with planning followed by implementation and, at a pre-determined time, evaluation of the impact of the strategies selected. This evaluation should lead to a modification of the plans and improved programme implementation, and so on. Surveillance must enter into this cycle at all of its stages and, as programmes are dynamic and ever-changing, surveillance should be able to point the way in indicating which strategies are working, which need to be discarded, etc. Epidemiological surveillance is not the equivalent of medical statistics.

In order to serve its function well, an epidemiological surveillance system must adhere to a series of well-defined criteria, many of which have been previously discussed at this meeting. A brief review of these follow.

The primary criterion for the inclusion of an item for routine reporting is that it be relevant to the needs of the public health system which the reports are meant to serve. What determines whether or not it is relevant is spelled out in the definition of surveillance mentioned earlier: it must be applicable to prevention and control activities. In other words, anything which is not used should not be collected. In addition, its collection, analysis, and interpretation must be simple and within the competence of local health staff. The data yielded should be representative of the population reported on. Hospital-derived data should be representative of all hospitals and conclusions drawn from this data should be applied only to those hospitals which it is known to fairly represent. In order to assist in achieving this, the data should be complete: if there are fifty reporting sites selected, data should be regularly received from all the fifty, and in a timely fashion, in accordance with set deadlines.

The data, of course, must be accurate, and by this two distinct things are meant: first, disease data reported must be an accurate reflection of the problems existing in the population. Case- definitions, of varying sensitivity and specificity according to the stage of the pertinent public health programme, must be developed and disseminated to ensure both accuracy of diagnosis and consistency of reporting - a case report of measles must not only mean that a patient had measles, but 'measles' must be the same thing throughout the reporting system. In addition, accuracy of reporting must be assured; that is, what is seen must be reported - all too frequently, facility reports are not consistent with facility registers - cases are either poorly transcribed or not transcribed at all, to the detriment of the accuracy of the overall system. Finally, routine reporting systems must be flexible enough to be able to incorporate new conditions and to

' Centers for Disease Control. Comprehensive plan for epidemiological surveillance, Atlanta, GA, U.S.A., August 1986

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allow for the dropping of ones which have become irrelevant. The public health scene is a changing one and surveillance should at best try to stay ahead of the changes. At the very least, it should be able to respond rapidly to emerging needs.

It is at times difficult to serve the needs of many different levels of the health care system through a single reporting system. In these instances, local and national concerns should take precedence over international reporting, unless the latter is the subject of agreed regulations and conventions. In preparation for this meeting, Member States were requested to submit a list of the first twenty conditions registered in 1991 in their countries, with a view to aggregate and analyse these data to provide a sort of regional "epidemiological profile". Interestingly, this cannot be done: conditions reported upon seem to be different, standardized case-definitions do not exist, levels of completeness vary widely, and some conditions which are relevant in some Member States are not reported in others.

For example, the ways of reporting acute diarrhoea vary widely - one country reports, in its top twenty conditions, typhoid fever, paratyphoid fever, other salmonella infections, shigellosis, and anoebiasis; another reports diseases of the digestive system and intestinal infectious diseases; yet another distinguishes between diarrhoea 0-3 years, diarrhoea >3 years, and dysentery (in addition to typhoid and paratyphoid fevers, which are not really acute diarrhoea1 illnesses at all). Another country reports simply "diarrhoea", but distinguishes it, nevertheless, from amoebic dysentery and shigellosis. Some countries report "hepatitis"; others report "hepatitis A" and "hepatitis B"; others "infectious hepatitis". Some report "tuberculosis"; others distinguish between pulmonary and extrapulmonary manifestations. In many cases, because of difficulty in confirmation of diagnosis, descriptive nonspecific terminology is used, which makes classification of a particular disease/condition difficult. In all cases, the accuracy of reporting must remain suspect. Therefore, the use of national data for regional purposes is severely compromised - it can only be hoped that national use of national data is both simpler and more frequent.

The second part of the presentation concerned with making data more useful for the planning and management of public health programmes. In other words, assuming that a perfect routine reporting system has been developed and that the routine data are appropriately complemented by data derived from periodic surveys and by special studies (it is known from experience that even if this were to be the case), it is very likely that this data will not be reflected in the formulation of a health policy or in the managerial decision-making process. Why is this? Because technicians, both practitioners who are responsible for the collection of the data, and "epidemiologists" or "statisticians", who are responsible for their analysis, interpretation, and dissemination, have a very different approach to problems from many people who are in policy-making or managerial positions. The former, with essentially scientific backgrounds, tend to make decisions on a rational basis: when a problem is identified various options for resolving it are developed, appropriate strategies are implemented, and the outcome is evaluated. Policy-makers, however, tend more to place

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problems in a political, rather than a scientific, context. As opposed to data analysis and careful evaluation, these people, for various reasons, some good and some not so, decide more on the basis of judgment and assess the outcome more on the basis of public reaction than on the basis of pre-determined outcome criteria. This different way of approaching problems is one of the primary reasons that data do not become applied in the decision-making process and it is the responsibility of public health technicians to understand that this difference exists and to find ways to overcome it.

In summary, policy-makers and other political elements in the public health system may simply not understand the value of data in the decision-making process. They may not know what data they need, whether or not relevant data are available, from whom they might get them, what their significance is or who can explain the data to them. For their part, technicians may not have the time, nor the resources to collect, analyse, or interpret data appropriately. But, most importantly, technicians are frequently unable to communicate effectively with the end-users of their data, whether these be the policy-makers within government or the public itself.

5.3 Conclusions

What conclusions can be drawn from the above? First, much is lost in aggregating data from diverse sources to 'higher' levels of the system. The best and most immediate use of routine reporting may very well be at the more peripheral levels, and the surveillance chain referred to above may be most effectively applied if planning, implementation, and programme evaluation all take place at the point where the data are collected. Local data for local decision-making are a goal to be strived for.

Second, technicians should be trained in all aspects of surveillance, in accordance with the definition of surveillance presented, and this includes training in the ability to transform epidemiological data into useful information to communicate effectively with public health decision-makers and with the public. Third, epidemiologists must be responsible for the training of non-epidemiologists (managers) in the interpretation and use of epidemiological data - the user must become more aware of the value of the data, where to get them and how to use them. Finally, surveillance is a tool, not an end in itself. It is something to be used to achieve a set of fixed objectives.

The development of a well-functioning surveillance system is an accomplishment of which one can be proud of, but the achievement is hollow unless it is put to maximum use. To do this, reporting systems must be placed at the disposal of other support strategies: health educators must take advantage of reporting to target their activities, trainers should use routine reports to identify target areas, researchers should be able to better identify problem areas on the basis of surveillance, and so on. The widespread dissemination and promotion of surveillance data to appropriate public health personnel should bring about a more general appreciation of what surveillance has to offer and, in turn, may attract the resources necessary for the further improvement of the surveillance systems.

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6. ESSENTIAL COMFONENTS OF A NATIONAL EPIDMIOLOGICAI, SURVEILLANCE SYSTEM FOR DISEASE PREVENTION AND CONTROL

6.1 Introduction

Epidemiological surveillance is essentially information for action. It is the systematic collection, analysis, interpretation and timely dissemination of data for the planning, implementation and evaluation of public health programmes. The application of this definition to disease prevention and control would mean the routine observation and analysis of the occurrence and distribution of diseases and the factors pertinent to their control that permit timely action. For actions of prevention and control to be timely and effective, it is important that epidemiological surveillance be made an essential component of the disease control programme, and be carried out at all levels of the health service delivery, i.e. local, regional and central.

Disease surveillance should be carried out by an effective and efficient system which at the same time is simple, flexible, acceptable and adequate for the purpose. Simple systems are easy to understand and implement, less expensive and more flexible. Flexibility of the system would make it easy for new notifiable diseases to be added, or to extend the system to include more population groups or to cover more geographical areas.

The surveillance system should be acceptable to data handlers, as well as to data providers. Individuals working at each level in the surveillance should be willing to collect and process the required data in a prescribed manner. As new diseases are added or additional data are desired, the burden on data handlers should be considered and the system should be modified or strengthened accordingly. Sdrveillance methods must also be acceptable to data providers. This can be ensured by taking into account factors such as confidentiality and cultural sensitivities.

Surveillance systems can be costly, particularly when establishing new systems or improving the existing ones. It is the tendency in many countries to have several specific surveillance systems operating at the same time, such as those for EPI, CDD, ARI and several others. Much of the information collected through these systems is similar in nature to the type of information collected through routine surveillance, although the former is more reliable. The resources needed to operate such specific systems are more than any developing country can afford. Such systems are usually supported by foreign aid, and although they may show some success at the beginning, they usually collapse as soon as the external assistance is withdrawn. The alternative is to have a cost-beneficial surveillance system that covers priority diseases and flexible enough to be easily adapted to new reporting needs in response to changes in priorities of health events.

6.2 Objectives of Surveillance

National surveillance systems should have clear objectives as to why epidemiological surveillance is carried out. The general objectives

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of routine surveillance systems can be summarized as follows:

- To identify diseases of public health importance, especially those that can be prevented by specific measures;

To detect early changes in the occurrence of specific diseases so as to identify outbreaks or epidemics early enough to prevent further spread, and to institute prevention and control activities;

- To identify high-risk areas and population groups where additional activities may be needed;

- To identify factors involved in disease occurrence; and

- To assess the effectiveness of specific interventions in reducing morbidity and mortality.

6.3 Components of a Surveillance System

Surveillance is a continuous and systematic process consisting of four major components: data collection and reporting; consolidation and presentation; analysis and interpretation; and dissemination of data.

6.3.1 Data collection and reporting

The first step in epidemiological surveillance is to gather information on specific diseases to initiate certain actions. The specific diseases which are subject to surveillance should be carefully selected. Such diseases should be those of priority and public health importance in terms of magnitude of morbidity and mortality, and particularly those for which prevention and control measures can be applied.

Standard case-definitions should be introduced for diseases selected for surveillance. The aim is to ensure consistency of reporting over time in the same health units and between units. As the level of accuracy of diagnosis may differ between different categories of health personnel, because of either differences in educational background or the availability of laboratory facilities in the vicinity to confirm diagnosis, two types of case-definition should be introduced, viz., medical definition and lay definition. In such a case, medical and lay reporting should be differentiated, and the data obtained should be analysed and interpreted separately.

The data to be collected should be clearly defined, and should basically include the name, age, sex, address, date of onset, symptoms and signs, diagnosis, and action taken. Superfluous data and data for which no specific use is foreseen should not be collected.

The service units and persons who will provide data on diseases under surveillance should be identified, and simple instruments for data collection in their respective units should be organized. The system should cater for the needs of various programmes such as EPI, CDD, ARI, etc., to avoid introduction of additional forms, with subsequent increase of workload of data handlers, and which will

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adversely affect the accuracy and completeness of data collection and timely reporting.

The routine collection of information from health facilities throughout a country is the most widely used method. However, this system has its own limitations such as misdiagnosis, under- or over-reporting and delays in reporting. To overcome such difficulties it is desirable to select a group of hospitals and/or clinics that will act as "sentinel sites" to gather reliable information, and additional data on disease incidence that cannot be obtained through the routine surveillance system. The sentinel sites are usually selected on the basis of their representativeness, among other considerations, and willingness and capability of their staff to cooperate and to report accurately and regularly. This sentinel reporting is not meant to replace the routine surveillance system but to supplement it.

Reporting provides, at specified periods, reliable data on trends and pattern of diseases under surveillance. The reporting system should be backed, as appropriate, by some legislation enacted by health ministries and followed by both public and private health sectors.

Morbidity reporting legislation should specify:

- the diseases that are reportable; - those who are responsible for reporting; - the information that is required; - the manner in which reporting is needed; - to whom the information is reported; and - the control measures to be taken in the event of the occurrence

of specified diseases.

6.3.2 Consolidation and presentation

Consolidation and presentation is the grouping of data into tables, graphs and charts that facilitate analysis and interpretation. To compile data, they should be transferred from registers to well- designed summary forms. Compilation should be made at each level of the health service delivery, the first consolidated report being at the local level where peripheral health centres are located. At this level, the responsibility for compilation and analysis should be that of the person responsible for disease surveillance and for taking the necessary action. At each of the subsequent levels compilation of data reported from different sources should be made separately, e.g. data reported from hospitals should be compiled separately from data reported from health centres.

6.3.3 Analysis and interpretation

This is an activity that involves a process of data comparison in terms of person, place and time with the following objectives:

- To monitor the trend of the disease in order to detect variations in its occurrence;

- To identify the factors associated with these variations, and - To determine the most vulnerable points for applying specific

containment measures.

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Like compilation, analysis of data should be made at each level of health service delivery, i.e., local, regional and central. At the local level, the medical or health officer in charge is the person responsible for analysing the surveillance data, taking appropriate action, and reporting to the next level within the required period of time. At regional and central levels, analysis of data should be made by the medical officer responsible for surveillance and for initiating special investigations and control measures.

Where applicable, computers are recommended as important tools for quick collation and analysis of surveillance data. The recent development and use of telecommunication network has decreased the time lag in data turnover and enabled more complete analysis of reports.

6.3.4 Dissemination of information

One of the crucial stages of epidemiological surveillance is the dissemination of information obtained as a result of analysis and interpretation of data collected on individual cases, outbreaks and epidemics. Health workers who notify the occurrence of cases and deaths should be informed of the entire situation in order to maintain their enthusiasm and to let them feel the importance of their contribution to the whole process.

The feedback mechanism can be achieved by several ways, such as publishing and distributing a newsletter, through conferences and seminars or during regularly scheduled staff meetings.

6.4 Elements of Surveillance

The data used for epidemiological surveillance are related mainly to the following elements.

(a) Morbidity and mortality data. Data obtained from the study of cases and deaths constitute the core element of epidemiological surveillance. In addition to the total number of cases and deaths, the date and place of occurrence, the characteristics of patients, such as age and sex, should also be noted and recorded.

(b) Demographic data. These refer to data on the size of the population, its composition by age and sex, its geographic distribution, migration patterns, its susceptibility and resistance to certain diseases.

( c ) Laboratory results. Data obtained from laboratories constitute a very important element of epidemiological surveillance. Routine or specific tests are often required to confirm cases by serology or isolation of organisms; to detect bacterial resistance to antibiotics and chemotherapeutic agents; to determine the level of immunity in the population by serological and skin tests; and to determine the level of environmental contamination.

(d) Prevention and control measures. Data on prevention and control measures obtained from specific programmes can be of great help to . - - those responsible for epidemiological surveillance. ~xam~les of such information are vaccination coverage; distribution and use of

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oral rehydration salts; number of patients treated; number of dwellings sprayed, etc.

(e) Data on environment. Information on environment is also of importance, especially in case of outbreaks and epidemics, such as the quality of water; proportion of population supplied with safe water; excreta and garbage disposal; level of air pollution, etc.

(f) Information on vectors and reservoirs. Other information of interest is the type of vectors existing in the area, their geographic distribution and behavioural pattern, their level of resistance and susceptibility to insecticides; also the type of human carriers and the type and distribution of animal reservoirs.

(g) Special Surveys. An important element of an effective disease surveillance system is the result of surveys conducted to collect more reliable and complete information which cannot be obtained through the routine surveillance system. Examples of such surveys are hospital admission and outpatients surveys; serologic surveys; vaccination coverage surveys; CDD morbidity and mortality surveys, tuberculin surveys, etc.

6.5 Monitoring and Evaluation

The surveillance system should be reviewed regularly in terms of its sensitivity, specificity and timeliness. The sensitivity of the system, often referred to as completeness of reporting, is the ability of the system to detect true health events. Quantitatively, it is the ratio of the total number of health events detected by the system to the total number of true health events as determined by independent and more complete means of ascertainment; for example, comparison of data obtained from routine surveillance system with data obtained from sentinel sites located in the same area, or with the results of surveys.

Specificity is a measure of how infrequently the system detects false positive cases. The best way to measure specificity - the failure of the system to correctly identify cases of diseases under surveillance - is to determine the number of misclassified cases or false positives. Reporting of diseases that do not meet the case-definition, i.e. false positives, will result in overreporting and in resources being wasted in unnecessary investigation of these false positives.

Timeliness involves not only the interval between the occurrence of the event and the receipt of the report, but also the time delay between the identification of cases and outbreaks and the initiation of control measures. Timeliness is particularly important for acute diseases that may spread rapidly, resulting in outbreaks or epidemics. In such cases if timeliness is not observed the outbreak or epidemic may get established before effective control measures can be applied. To assess timely reporting, the number of weekly or monthly reports, as specified by the period of reporting, received at a particular level should be compared with the number of health facilities expected to report; reporting defaulters should be followed up.

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Regular monitoring of the system should be made at regional and central levels. Supervisory visits should be made by the regional staff to local health units to check on reporting accuracy in terms of completeness of reporting and to ensure that the diseases reported coincide with the corresponding case-definitions. The number of cases and deaths recorded should be checked with the number of cases and deaths reported and discrepancies should be investigated. The central level staff should visit the regions to check on the accuracy and completeness of consolidated reports, as well as the timeliness of reporting. The supervisory visits should also serve as means of identifying needs for relevant training.

7. USES OF EPIDEMIOLOGY FOR DISEASE CONTROL

7.1 Introduction

Epidemiology is essentially a methodology for controlling diseases. After all, the science which describes the patterns of occurrence of a disease and which can define the determinants, or risk factors for the disease, should have no other more important purpose. Traditionally, epidemiology has been focused on the study of infectious diseases. But it is - other, non-infectious disease-related, applications which have stimulated professionals to apply standard epidemiological concepts to the description and control of an array of contemporary public health problems. And it is the utilization of epidemiological approaches to new issues and challenges that makes applied epidemiology such a powerful and exciting tool for defining priorities, setting objectives and evaluating modern disease control initiatives.

Over the 1990s, there will remain approximately 30-40 countries in which health problems will continue to be dominated by childhood infectious diseases. Simultaneously, a larger group of countries emerging into middle-income levels will confront a new set of health problems related to urbanization and industrialization, primarily injuries, occupational diseases and a variety of chronic diseases. Such a growing epidemiological diversity among developing countries will require a flexible approach to the use of epidemiological methods. Thus, epidemiological methods can be considered to have demonstrated the utility in monitoring the continuing evolution of disease control priorities generated from social and economic transformations which accompany demographic and epidemiological transitions.

In most developing countries, both pre- and post-epidemiological transition problems will coexist for many years. Since the increasing burden of chronic diseases initially affects the relatively more affluent and politically-established older populations, governments need to take great care to ensure that infectious diseases predominantly affecting children and the disadvantaged sectors of the population are not neglected in the face of resource demands placed in large measures by the more affluent.

7.2 Malaria Control in Zaire

An examination of the diversity of epidemiological methods applied to the control of malaria in this Central African nation offers an

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instructive approach. Improvements in routine reporting during the mid-1980s indicated an increasing trend in the number of hospitalized children under five years of age with fever, largely presumed to be malaria, if no other diagnosis was given. In addition, hospitalized case fatality rates for malaria cases in this age-group were also on the increase. Utilization of a modified WHO protocol for assessing in vivo drug sensitivity in the same age-group demonstrated increasing Plasmodium falciparum resistance to chloroquine at various sites throughout the country.

As a result of this information, the staff of the national malaria control programme and Combating Childhood Communicable Diseases (CCCD) Project identified a set of critical programme issues and reviewed a wide variety of available sources of relevant data. A number of analyses were performed in order to address the relevant issues and to prepare presentations for decision-makers. As a result, treatment guidelines were modified to adjust chloroquine dosage, clarification of the indications for the use of second and third line drugs was agreed upon, and a follow-up study on prophylaxis in pregnancy was designed and implemented. Improvements in the surveillance system were introduced, appropriate educational materials were prepared for health staff, health education materials were developed for informing mothers about prompt attention to children with fever, a malaria newsletter for distribution to zonal medical chiefs was initiated and data collection systems were implemented to compare alternative strategies for malaria control in Zaire. Based on this data, the National Plan of Action for Malaria Control was subsequently revised and disseminated widely. In addition, the use of a variety of available data sources has created a scientifically-inquisitive environment in which programme activities are being eagerly monitored, essential questions are being asked and the information made available is being used to make modifications in

-0 ramme. policies and implementation of the national malaria control p, g

7.3 Injury Control in Indonesia

In both developed and developing countries, injuries have now been widely recognized to have a substantial effect on public health and on the quality of life. Studies in Egypt and Indonesia have indicated that injuries are the leading cause of hospitalizations in those countries. In Indonesia, the recognition that injuries represented an emerging public health priority surfaced during the last decade. A review of available data from 1984 to 1989 indicated that hospitalizations for injuries increased by 42X, including a 21% increase for fractures and a 35% increase for head injuries. All injuries combined represented the leading cause of hospitalization in tertiary referral hospitals and the third leading cause of hospitalizations at lower levels. At least 11% of all hospitalizations were related to injuries.

Because of the complex nature of injury causation, injury prevention activities require coordination from multiple governmental, nongovernmental, public and private organizations. In Indonesia, it was recognized that an intersectoral Committee on Injury Prevention in Indonesia needed to be established within the Ministry of Health. As one of its first activities, the committee developed a comprehensive situation analysis of injuries. It was acknowledged that a small number of injury control projects would be helpful in institutionalizing

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injury prevention activities within the government. One of the major projects included was the effort to increase the use of motorcycle helmets in Jogjakarta. A study on compliance with the motorcycle helmet regulation was conducted in Jogjakarta, a district capital of almost 500 000 population in Central Java. The use of helmets use was observed at five heavily-travelled main road locations in various sections of the town from 6 a.m. to 8 p.m. on a designated Saturday, when government staff work during the morning only. Research teams of 3-5 observers, stationed at a traffic light counted helmet usage by motorcyclists who stopped at that light during observation periods of ten minutes in each direction every two hours. In addition, 150 interviews were conducted, two weeks after the initial data collection, of motorcyclists in parking areas near the observation locations in order to describe ta them the concepts involved in the usage of helmets.

As a direct result of these studies, a comprehensive initiative was implemented for increased helmet use. Police enforcement was increased and public education efforts were developed through the mass media and licensing offices. Special efforts were made to emphasize that passengers also should wear helmets. Industrial safety standards for helmet design were promulgated so that at least a minimal level of protecbion was ensured. Further studies were planned to assess the impact of these efforts and to explore additional alternatives. As it has turned out, the law relating to the use of helmets and these studies represented a solid foundation for the development of a national injury control programme. In association with the Ministry of Health's Field Epidemiology Training Programme, additional studies were conducted and presentations to decision-makers have contributed to forming an agency for injury control within the government and to establishing mechanisms for collaboration between governmental and nongovernmental organizations.

7.4 Conclusions

Public health practice should be based on scientifically sound strategies for improving the quality of life and reducing morbidity and premature mortality. In order to provide public health officials and policy-makers with a framework for assessing priorities, selecting disease control strategies and allocating resources, staff at the Centers for Disease Control (CDC) in Atlanta, GA, U.S.A., have developed a Framework for Assessing the Effectiveness of Disease and Injury Prevention. The Framework offers two complementary approaches to conceptualizing prevention programmes and suggests a range of process and outcome measures that might be assessed.

In another recent development, the World bank has commissioned a series of analytical studies to assess the effectiveness and costs of potential health interventions for both children and adults. Epidemiological and economic methods were used to evaluate the relative significance and cost-effectiveness of more than two dozen potential interventions. A standard methodology was adopted to rank diseases and estimate the dollar costs per discounted health life-year gained from each intervention.

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The convening of the present meeting may represent a milestone in the progress that countries of this Region are making towards addressing the anticipated needs in capacity-building.

8. FIELD TRAINING IN EPIDWIOLOGY FOR DISTRICT EEALTB lUWAGEBS

8.1 The Epidemiological Process

The earlier deliberations that have focused on the importance of epidemiology not only in disease surveillance and control, but also in the planning of health care, provided an excellent backdrop against which field training in epidemiology for effective district health management was discussed. The underlying assumption of the meeting was that appreciation, understanding and use of epidemiology can lead to improved population health by making management decision-making more effective.

The skills of epidemiology involve a subtle repeated process between observation, interpretation and action. An observation is made, a question asked and information gathered based on which a conclusion is drawn and action is taken. At some point in the process, data or facts are transformed into information on which to base decisions. Epidemiology becomes an integral part of management with communication as a key to its success. The quality of the decisions made depends on how epidemiological activities are allocated, i.e. who requests, who collects, who interprets and who takes action. Fulfilment of these activities requires teamwork since even the professional epidemiologist must usually depend on others to collect data and to implement her/his recommendations.

The tasks of requesting, collecting, compiling, manipulating, presenting, interpreting and taking action are commonly and easily allocated vertically within the district. Staff are resigned to responding to requests for information, but the quality of information will reflect their appreciation of its value. There is a danger that the epidemiological process, while being implemented, becomes so fragmented that each task becomes an end in itself and its purpose is forgotten. Even within the district, the responsibilities of the health management team can be so allocated that statistical staff are requested and they respond without any communication with the rest of the team.

For successful implementation of epidemiology, health staff at all levels and members of the community need to appreciate the process and to request, respond, interpret and make decisions on the basis of the information available to them. This requires education and communication.

8.2 The Training Process

It is tempting to think of training in terms of training, that is workshops, seminars, courses attended by participants who are taught and/or who learn. These activities are an integral, but minor part of the training process and often serve as a convenient distraction. Also, they conveniently avoid the key issues of relevance and implementation

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of the skills communicated. Success is measured in terms of numbers attending and the frequency with which the course is repeated.

The training process begins with an assessment of the need for the particular training activity and continues with curriculum development, establishment of the mechanism for delivery of the training and proceeds to the supervision and evaluation of the implementation of the skills imparted. The process is continuous, with constant updating of the curriculum as the evaluation and needs assessment indicate. By the time the delivery of the course becomes stereotyped it may have become redundant.

The decision to initiate a training programme in epidemiology is likely to be a policy-decision based on recommendations made by experts such as those attending this meeting. The justification as to why training in field epidemiology is required will usually be made on the premise that good epidemiology can lead to improved health and a general recognition that the knowledge, attitude and practice of epidemiology are currently very inadequate. Once the programme has been agreed to, the needs assessment investigates the category of persons to be trained and the minimum skills which are required and implementable.

Epidemiological skills are primarily empirical, using powers of observation and interpretation which are intuitive to most people. Members of the community observe health events. Their interpretation may not always be appreciated by health workers, but two-way communication and education will result in good epidemiology at the grassroots level.

Unfortunately, empirical skills are often overshadowed by the mechanical skills which, although essential, preoccupy the heavily burdened health staff. They evaluate the activities of compilation and tabulation in terms of quantity of output, rather than in terms of quality of input. It is, therefore, fruitless to teach mechanical skills without relating them to appropriate empirical skills.

It is the fault of professional epidemiologists that lay people are daunted by the theoretical skills of epidemiology. Theoretical analysis extends, rather than replaces, empirical analysis. If all professional epidemiologists had to understand the mathematics of multivariate analysis or disease modelling there would be few around. There is a point at which an appreciation of the technique is enough for the general practitioner of epidemiology. In the same way, it is possible to delineate the theoretical knowledge required of district medical officers, health centre staff and village health workers.

A vital component of the needs assessment is consideration of the way in which the training in epidemiology can be integrated into other essential training. It may be more efficient and productive to combine training in epidemiology with other inservice training programmes.

A comprehensive needs assessment will simplify the development of the curriculum. Against the background of the needs assessment, educational objectives can be set for different target groups and the minimum syllabus drawn up. The training methodology should be as

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imaginative as possible within the pedagogic approach of the country. The emphasis should be on relevance with time being spent on the preparation of good examples and case-studies based on data from the district. No course can be complete without field work. A procedure for course evaluation should be prepared in parallel with the educational objectives and the course content.

The mechanism for delivery is the point at which, erroneously, many programmes start. It involves decisions about course length and structure, the training of trainers, the choice of venue, the language of delivery and the materials required. The structural design should consider the need for regular revision, support and updating, possibly in the form of workshops and refresher training. The delivery mechanism will have to take into account resource constraints and the requirements of other teaching programmes.

The most important part of the training programme starts once the course has been conducted. The course evaluation may be excellent, but unless the skills imparted are actually implemented the training programme has failed. This relates once again to the needs assessment which should have given consideration to the feasibility of implementing the skills identified. It is a waste of the limited time available, for example, to train health workers in computing unless they will have access to a computer on which their skills can be used. At the other extreme, it may be difficult for enthusiastic trainees to convince their colleagues of the value of what they have learned and therefore to implement the new ideas. This is an argument for training teams rather than individuals, but, in any case, it will be necessary to provide long-term support from within the district for implementation both on an individual and a district level.

The final component of the training process is monitoring and evaluation. It would be naive and impractical to suggest that it is possible to evaluate a training programme in terms of changes in health indicators. The evaluation should confine itself to the relationship between the training and the practice of epidemiology, on the belief that good epidemiology will, in the long run, lead to improved health. The question to answer is whether or not the training has led to better practice of epidemiology and, if not, which component of the training programme has failed. The methods of such evaluations are difficult and require some development and research making use themselves of epidemiological methods.

8.3 The Liverpool Epidemiology programme

In 1988, the Forty-first World Health Assembly urged Member States to make greater use of epidemiology and appealed to schools of medicine to ensure training in modern epidemiology, particularly to meet the needs of developing countries (resolution WHA41.27). In addition to the important role of WHO, particularly of EMRO in this Region, there are a number of well-established international training programmes in epidemiology, for example, run by the Centers for Disease Control in Atlanta, U.S.A., and many countries and regions have their own programmes. In 1990, with the support of the British Overseas Development Administration, the Liverpool School of Tropical Medicine set up the Liverpool Epidemiology Programme with the objective of

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improving the health of communities by developing training programmes for health workers to assist them to implement epidemiological methods within the health programme management.

A major component of the Liverpool Programme is the provision of support for training programmes in epidemiology in developing countries. The school is currently involved in programmes in Sudan and Yemen within the Eastern Mediterranean Region (EMR), and also in India, and Ethiopia.

The first major activity was in Sudan where there was the unique opportunity of collaborating with the Ministry, the Universities of Khartoum and Gezira and EMRO in the development of a three-week training course for mid-level health managers. The objective of the course was to enable managers to respond promptly to changes in health, to identify health problems, to use routine and surveillance data and to act on the information. This experience was influential in the development of some of the ideas expressed earlier. More recently discussions were held in Yemen where the possibility of implementing the training process described here was discussed.

Another component of the work of the Liverpool Programme is the development of innovative and appropriate training material. Several case-studies were developed for the Sudan course, based on real data which the participants were able to identify. The school is developing other case-studies which can be made available to other training programmes, but it is preferable to provide guidelines for the development of local, relevant case-studies.

At the other extreme, as part of collaboration with the National Institute of Health and Family Welfare, New Delhi, India, the School has developed a game set in the imaginary state of Vindhya Pradesh. The game is based on simulated, but realistic data collected routinely to monitor maternal and child health activities at sub-centres, primary health centres and districts in India. The aim is to illustrate the methods of epidemiology relevant to handling and using such routine data. As part of this collaboration, the School is also involved in a training programme for district health management in Orissa State with the possibility of piloting some of the ideas of needs assessment and evaluation described in the presentation.

In the Liverpool School, a variety of short courses in epidemiology are conducted and are tailored to individual requirements of the participants. In addition, a number of Liverpool Epidemiology Programme Visiting Fellowships have been established. These are awarded to senior colleagues from developing countries to visit Liverpool for periods of between three and six months to share their ideas for preparing and implementing training programmes in epidemiology.

9 . PANEL DISCUSSIONS

Since practically the whole deliberations of the meeting revolved around the subject of epidemiological surveillance, the purpose of this session was to give the participants an additional opportunity to air freely their views and concerns about different aspects of

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epidemiological surveillance. It was also an attempt to obtain the essentials of the discussions of the previous days.

Four topics that summarized the meeting's programme were presented for panel discussion or brainstorming. The panel opened the discussions and then the rest of the participants joined in. What follows is a rgsum6 of the discussions on the individual topics.

(1) Presenting epidemiology in a user-friendly manner

It was generally accepted that epidemiology needs to be demystified and introduced to the uninitiated, such as undergraduate students, in an interesting and more easily understandable form. It was thought that the earlier health workers were exposed to epidemiology and its uses while they were still under training, when they are more likely to get used to this discipline and appreciate its significance and its utilization. The feeling was that teaching epidemiology should not be encumbered with unnecessary jargon, and the commonly used terminology should be clearly explained in simple language. Without sacrificing its scientific basis, epidemiology could be presented in lively and practical manner, by using everyday experiences and examples that the trainee could relate to. In this way the concept that epidemiology was there to 'serve its user' could be fostered.

(2) Population-based surveillance versus sentinel surveillance

From the start, the consensus among the participants was that each country should strive to establish a viable population-based surveillance system for disease prevention and control. It was, however, observed that even what was described as population-based surveillance was in reality "sentinel", since the whole population was not covered because of limited facilities. Nevertheless, the usefulness of sentinel site reporting in certain situations was recognized. It transpired that it was not unknown for some countries to have started their epidemiological surveillance with sentinel surveillance and progressively developed the system until it became nationwide (i.e. population-based). It was also mentioned that population-based and sentinel surveillance could operate side by side, although the information obtained by the different methods should be handled separately. However, in order, to obtain the maximum benefit out of sentinel site reporting, the sites should be carefully selected in respect of, among other things, locality, population density, technology available for the health problem under surveillance, and the willingness of the health personnel concerned to cooperate fully.

(3) Ad hoc surveys versus routine surveillance in information-poor countries

It was cautioned that although well executed ad hoc surveys could produce reasonably good quality information about the subject of interest, they were expensive and this increased with the degree of precision of the results required. As such, it was unlikely that such surveys would be used routinely. Routine surveillance, properly formulated and monitored, was considered essential for the planning and management of the national health services. Among the many uses of the ad hoc survey, it was pointed out that it could be used to augment

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or validate the information generated by routine surveillance. Also, this type of survey proved useful in special situations, e.g. refugees where rapid needs assessment was called for or in figuring out periodically the trend of a chronic disease, such as tuberculosis. It was implied that frequent recourse to ad hoc surveys was a reflection on the adequacy of the existing routine surveillance and thus the aim should always be the development of the latter.

(4) Criteria for placing a particular disease under surveillance

It was suggested that the diseases under the International Health Regulations should head the list of diseases under surveillance to indicate countries' obligations to international control of diseases. Otherwise, it was felt that the pattern of diseases and available resources in a given country would influence decisions on disease surveillance. It was, however, stressed that it was in situations such as this that the uses of epidemiology mattered most, in categorizing diseases and thus setting priorities. The consensus was that the criteria would include: incidence and prevalence of the disease; its severity, availability, acceptability and affordability of technology for its detection, prevention and/or control. It was stressed that the number of health problems selected for surveillance should match the resources available for the purpose. It was expected that this epidemiologically-based approach to the establishment of disease surveillance would result in gathering only the information that is required for action. This would in turn improve the routine health services statistics.

In the light of the presentations and discussions, the following recommendations were adopted.

1. The uses of epidemiology should not be confined to disease prevention and control. Participating countries may ensure that epidemiological methods are also applied to the planning, management and evaluation of public health services.

2. Departments of epidemiology should be strengthened at the central level and focal teams established at intermediate and peripheral levels.

3. The needs for training in applied epidemiology should be assessed (a) for in-service, and (b) for the basic education of all health personnel.

4. Training programmes should be developed on the basis of the needs assessment conducted.

5. Epidemiological surveillance systems should be strengthened and their flexibility ensured. Diseases or conditions should be carefully selected for surveillance, with appropriate case-definitions. Data collected routinely should be commensurate with the resources and needs of the country.

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6. Efforts should be made to establish a regional network of national epidemiologists to stimulate the active utilization of epidemiology.

7. WHO is requested to support Member States in these activities.

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Annex 1

AGENDA

1. Registration

2. Opening session

3. Election of officers

4. Announcements

5 . Elaboration on objectives of the meeting

6. EMRO's collaboration with Member States in the development of epidemiological services/surveillance

7. Country presentations on surveillance of diseases

8. Routine health services statistics: ways of improving the usefulness of this information

9. Essential components of a national epidemiological surveillance system for disease prevention and control

10. Uses of epidemiology for disease control

11. Field training in epidemiology for district health managers

12. Panel discussion

- Presenting epidemiology in a user-friendly manner - Population-based versus sentinel surveillance - Ad hoc surveys versus routine surveillance in

information-poor countries - Criteria for placing a particular disease under epidemiological

surveillance.

13. Discussions on recommendations

14. Closing session

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Annex 2

Sunday, 13 September 1992

08:30 - 09:30 Registration

09:30 - 10.00 Opening session

10:30 - 10:40 Election of officers

10:40 - 10:50 Announcements

10:50 - 11:OO Elaboration on the objectives of the meeting, by Dr A. Deria

11:OO - 11:45 EMRO's collaboration with Member States in the development of epidemiological services/ surveillance, by Dr Deria

11:45 - 12:OO Discussions

12:ZO - 14:OO Country presentations on surveillance of diseases

Monday, 14 September 1992

08:OO - 12:OO Country presentations (continued)

12:15 - 13:30 Routine health services statistics: ways of improving the usefulness of this information, by

Dr R. Waldman

13:30 - 14:OO Discussions

Tuesday, 15 September 1992

08:30 - 09:30 Essential components of a national epidemiological surveillance system for disease prevention and control, by Dr T. Guirguis

09:30 - 1O:lO Discussions

1O:lO - 11:25 Uses of epidemiology for disease control, by Dr J. Weisfeld

11:25 - 11:45 Discussions

12:OO - 13:30 Field training in epidemiology for district health managers, by Dr S. Macfarlane

13:30 - 14:OO Discussions

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Wednesday, 16 September 1992

08:OO - 1O:OO Panel discussion

- Presenting epidemiology in a user-friendly manner

- Populaticn-based versus sentinel surveillance - Ad hoc surveys versus routine surveillance

in information-poor countries - Criteria for placing a particular disease under epidemiological surveillance

11:OO - 12:30 Discussions on Recommendations

12:30 - 13:OO Closing session

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Annex 3

LIST OF PARTICIPANTS

Dr Fawzi Ameen Chief of Medical Staff Health Centers Ministry of Health Manama

DJIBOUTI

Dr Said Salah Youssouf c/o Ministere de la Sante publique et des Affaires sociales Djibouti

ISLAMIC REPUBLIC OF IRAN

Dr Mohammad Azmoudeh Director-General Communicable Diseases Ministry of Health and Medical Education Teheran

Dr Hassan Abdul Hussien Abdul Kareem Preventive Medicine and Environmental Protection Department c/o Ministry of Health Baghdad

JORDAN

Dr Saad Kharabsheh Chief of Communicable Diseases Ministry of Health Amman

Dr Rashed A1 Owaish Director, Public Health Department Ministry of Health Kuwait

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LEBANON

Dr Assaad Khoury Head, Auditing Committee ~octor/Inspector of Hospital c/o Ministry of Health and Social Affairs Beirut

OMAN

Dr Aly Jaffar Mohamed Director Department of Family and Community Health Programmes Ministry of Health Muscat

PAKISTAN

Dr Abdul Majid Rajput Joint Executive Director Pakistan Institute of Medical Sciences Medical Superintendent Federal Government Services Hospitals Islamabad

Dr Aminuddin Director, Health Services Academy Islamabad

Dr Sameen Siddiqi Physician, Department of Medicine Pakistan Institute of Medical Sciences Islamabad

QATAR

Dr Khalifa A1 Jaber Director of Preventive Medicine Ministry of Public Health Doha -

SAUDI ARABIA

Dr Amin Mishkhas Director of Infectious Diseases Ministry of Health Riyad

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SUDAN

Dr Isam El Din Galender Director, Epidemiology Department Ministry of Health Khartoum

SYRIAN ARAB REPUBLIC

Dr Jamil El Faqih Health Director Suweida Governgrate c/o Ministry of Health Damascus

TUNISIA

Dr Kame1 El Hili Deputy Director Primary Health Care Department Ministry of Public Health Tunis -

UNITED ARAB EMIRATES

Dr Awadif Abu Haliqa Ministry of Health Abu Dhabi

REPUBLIC OF YEMEN

Dr Abdel Halim Hashem Director-General of Public Health Ministry of Public Health Sana ' a

United Nations Agencies

United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA)

Dr S. Pappagallo WHO Medical Officer Chief, Health Protection and Promotion

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United Nations Children's Fund (UNICEF)

Dr J. Weisfeld Islamabad PAKISTAN

WHO Secretariat

Dr Nabil A1 Tawil Acting WHO Representative to Pakistan Islamabad

Dr A. Deria Regional Adviser Communicable Diseases EMRO

Dr R. Waldman Medical Officer Strengthening of Epidemiological and Statistical Services World Health Organization Geneva

Dr S. Macfarlane WHO Temporary Adviser Liverpool School of Tropical Medicine Liverpool, ENGLAND

Dr Talaat Guirguis WHO Temporary Adviser EMRO