Copy of Discovering the Real Costs of Vaccine Preventable Disease Surveillance in SSA- Ngozi Erondu

• Bacterial meningitis is an inflammation of the brain and spinal tissues

• Group A meningococcus – 85% of cases in SSA

• Since 2002 enhanced epidemic meningitis surveillance was used

• Laboratory confirmation only required for first few cases

• Polysaccharide meningococcal vaccine

• Did not decrease carriage rates

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Map of African meningitis

belt countries and populations

MenAfriVac

• New meningococcal A conjugate vaccine

• Developed to eliminate serogroup A epidemics

• Offers long-term protection

• Decreases carriage rates in vaccinated communities providing herd immunity

• Being introduced in Africa through country-wide campaigns

Meningitis

• Reached 107 million children

• 2 to 3 million deaths per year averted

• 22.4 million infants not immunized

38% SSA

40% Asia

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05

The aim of this PhD is to implement an evaluation framework that analyzes vaccine-preventable disease surveillance at sub national levels

• National immunization programs established to ensure that all children in all countries benefited from life-saving vaccines

• Routine Immunization

• Disease Surveillance

• Supplemental Immunization Activites

• Many successes and improvements in immunization services in the past 30 years

• Still, a large number children are

Vaccines

Unreached

Unvaccinated

Under vaccinated

• 1.5 million deaths among children under 5 (WHO, 2008)

• 17% of global mortality

CHAD

• More than 70% of deaths occur in just 10 countries

Meningitis and Chad

Slide (or table) showing VPD burden in Africa as vs. globally

Lack of Cost Studies

Was alarming, especially for poorer countries

EPI Challenges

EPI Successes

Need to know how much it will cost to set up that meet regional and global standards (e.g. IHR (2005)

Face extreme constraints and need to prioritize health and other activities

• Competing health priorities

• 130 countries have reached at least 90% coverage of DTP3 (WHO, 2011)

All countries need evidence to convince policy makers of the economic and health benefits of an effective surveillance and response system

• Poor management of health systems

Surveillance

• Introduction of new vaccines

• Inadequate monitoring and supervision

Perceived Problem

• Rising costs of vaccines

• Supplemental immunization activities and campaigns

During my STOP field assignment, I noticed:

• Monitors and assesses trends of disease over time

• Routine Immunization Monitoring

• Non-availability of sustainable resources

• There were very basic and practical impediments to VPD surveillance resulting in poor or incomplete data

• 12.6 million people

• Lack of community engagement

• Act as an early warning to detect communicable disease outbreaks

Conversations with field surveillance health staff

• Serious disconnect between national and sub-national

• Instructed to do things without the means to do it

• Essential for planning, implementation, and evaluation of public health practice. 

• Many times requests were not answered or not sustained

The Greater Issue

Some Identified Factors

Affecting Surveillance

What they didn’t find...

Example: Polio Progress

Place holder

• 4th least developed country

Contextual factors from health worker of what affects their job duties

More about surveillance, maybe some scattered around previous slides text?

Consequences

of Poor Surveillance

Missed Cases

WHO Conceptual Framework

of Surveillance and Response Systems

for CDSS

predict or detect disease outbreaks with a view to investigation and containment;

Identify high risk populations and areas requiring special attention

Monitor impact and progress towards disease eradicationelimination and control

identify areas in which system performance is poor, so that corrective measures can be taken

Determine the frequency of occurrence of a disease in a community and the burden of disease;

monitor programme effectiveness by documenting short- and long-term effects of immunization on disease burden and epidemiology

Identify circulating strains including serotypes genotypes and subtypes

• Historically politically unstable

Evaluation of Communicable Disease Surveillance Systems (CDSS)

All studies used at least one of two approaches

Core Activities and Support Functions (McNabb et al., 2002)

Evaluation Attributes (Updated guidelines for evaluating public health systems, German, 2001)

Few studies directly assessed the sub-national levels

There is a need!

Studies in SSA evaluated CDSS within the context of IDSR

No studies conducted a detailed assessment of cost of CDSS

To illuminate the contextual and process factors that impact surveillance

For better planning and management of surveillance programs to assist health

workers and improve

surveillance performance

Surveillance Issues

especially in SSA

Surveillance

• Poor quality of immunisation data

• Inconsistent reported data

• Weak data monitoring

• Vertical disease programs

• Outbreaks of cholera, measles, and polio high burden of malaria and malnutrition

• Lack of standardization

“The ongoing 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..”

• Burden on health workers

• Outdated systems

• Regional IDSR Strategy adopted in 1998, guidelines and training modules revised in 2010

• Strategy includes:

• Multiple surveillance systems at district levels

PhD Timeline

• Optimal use of available resources

• Harmonization of surveillance tools

• Feeds into IHR

Adapted from: Mwenda, WHO AFRO, Brazzaville, 2011

Surveillance Types

Surveillance of VPDs

• Passive

• Provides the critical intelligence to guide EPI

• priority setting

• Active

• mobilization and allocation of resources

• Sentinel

• Monitors progress towards disease control targets

• Can provide estimates of vaccine efficacy

Meningitis in Chad

• Major epidemics of serogroup A meningococcal disease

WHO conceptual framework of surveillance and response systems for CDSS

Why Modify the current framework?

• Good for high level assessment of surveillance systems

• More than 1000 cases reported each year between 2005-2002

Acknowledgments

• Does not provide relationship between activities and objectives

• Performance measures too broad

• Not enough information for program decision-making

• In 2012, 3, 874 cases and 163 deaths reported

• Meningococcal A was prominent bacteria in most outbreaks

• Heidi Larson

• MenAfriVac introduced in 2011

• Ulla Griffiths

Work Process Analysis

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Rationale:

• Immunization campaigns for all 1-29 year olds

• Scott McNabb (USA)

This work would not be possible without the valuable contributions of a number of individuals:

• Paul Fine

• No cases of meningococcal A meningitis since i

• George Ploubidis

WPA for

Public Health Surveillance

Business concept that focuses on work processes to improve system productivity

Adapted by Public Health Practice, LLC (Atlanta, USA)

Components

• Heather Meeks (USA)

Logic Models (LM)

Work Process Tree

Performance Indicators

• James Stewart

Step 1:Develop Logic Models

Step 3. Assess Performance

• Centre de Support en Santé International, Chad

Estimation of Cost of Meningitis Surveillance in Chad and Niger

Methods

Step 2: Develop Data Collection Tools

Objective 1:

Conduct a systematic evaluation and costing of the Chad MSS

Direct countries to most appropriate surveillance strategy that will ultimately provide adequate information to assess the impact of new Nm A conjugate vaccine

Specific Objectives

Research Questions

• What is the description of MSS in Chad?
• What is the MSS performance of selected health facilities in Chad?
• How much does surveillance costs? How does cost impact MSS performance?

• Assess identified surveillance system attributes
• Assess core activities and support functions
• Measure performance of current system using indicators
• Explore relationships between performance and cost

Estimate costs by...

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Objective 2:

Apply evaluation framework to assess operational and financial gaps in a VPD surveillance system

Specific Objectives

Research Questions

Ethics

• Collect information on what is needed to achieve OOS of Chad MMS
• Map workflow processes into logic model and process tree framework
• Assess areas for program integration opportunities

• What are the activities and costs to achieve OOS for MSS in Chad?
• What is the difference between the OOS and the current MSS in Chad, by cost, and performance?
• Where are the opportunities to strengthen integrated work processes with other VPD surveillance?
•  What are the incremental costs of improving the current system to the OOS?

Objective 3:

Examine the factors that influence surveillance performance

Ethics approval has been granted by the LSHTM Institutional Review Board (IRB) and an administrative authorization has been granted by the Chad MOH

Research Questions

Specific Objectives

• Document factors observed at health facilities and attained through health staff interviews
• Compare funding factors across health facility

• What are the factors associated with low, medium, and high surveillance performance?
• What factors impact surveillance and how?
• How does funding affect surveillance performance?

Ngozi Erondu

Department of Infectious Disease Epidemiology

Faculty of Epidemiology and Population Health