By Chinedu Anarado
Nigeria is the only country in Africa where polio is still endemic, however, the continent is still at risk of polio returning due to low immunity levels and weak surveillance systems. Since 2016, the AVADAR project has been implemented in 8 countries across West and Central Africa to improve the quality and sensitivity of Acute Flaccid Paralysis (AFP) surveillance by health workers and key informants within health facilities and local communities, using mobile phones and an SMS based software application. eHealth Africa trained a total of 7,847 community informants to identify and report suspected cases of AFP, which is the defining symptom of Polio.
The AVADAR mobile application
The project increased the rate of AFP detection and reporting and put the implementing countries in a better position to meet the World Health Organization’s targets for AFP surveillance. In the Democratic Republic of Congo (DRC), for example, a total of 499 true AFP cases have been reported by community informants through AVADAR, a significant improvement over traditional paper-based surveillance systems which yielded 38 cases in the same period.
The Challenge
Our goal was to model a system that would enable health systems in the implementing countries to find, report and investigate AFP cases, and that would be sustainable in the long run. It became imperative for the health systems in these countries to take ownership of and lead the implementation and expansion of the AVADAR model, and possibly replicate it for the surveillance, reporting, and investigation of other diseases of public health concern. However, without the requisite skills, most countries will fail at effectively managing the system including reporting and managing the investigation of cases, and tracking and resolving technical issues.
The Strategy
Relying on our experience with the execution of AVADAR, where some informants were groomed to take on more roles on the project, we worked with the WHO to identify champion informants who had distinguished themselves through their timeliness on the system and technical aptitude with the AVADAR devices. Some of these informants were trained to serve as investigators—who track and review reported AFP cases to confirm if they are true or not—or as technical officers, who resolve technical issues and ensure that their fellow informants are able to continue reporting suspected AFP cases.
The technical officers were grouped into two categories: first-level and second-level technical support officers. The first-level technical officers serve as the first point of contact when an informant has technical challenges with his/her device. When they are unable to resolve these issues, they escalate the challenge to the second-level technical support officers, who are usually WHO staff or investigators within the country ministries of health, with superior technical skills. The second level support officers ensure that all issues are resolved and the AVADAR system can continue to work as expected.
The Success
So far, a total of 217 first level and 57 second-level informants have been trained across all the six countries eHA supported in 2019, as well as Liberia. eHA has now ended operations in four of these six countries— Chad, the Democratic Republic of Congo, Sierra Leone, and South Sudan and the trainees are now managing the network. The technical officers were trained using a two-step approach: theory-based training that took place in a classroom setting, and field practical sessions, giving trainees the opportunity to investigate and resolve real-life technical issues in the field. eHA continues to provide support in Cameroon and Niger, leading refresher training sessions for technical support officers, and resolving advanced technical issues in the two countries.
Some AVADAR informants are also going beyond polio to detect and report other priority diseases such as Measles, Yellow Fever, and Diarrhea in their communities using AVADAR. The flexibility of the AVADAR system and its potential to be used for reporting and detecting other priority diseases leaves no doubt that these countries are better equipped to prevent future outbreaks and protect their populations.