OutREACH: eHealth Africa, Clinic Collaborate to Tackle Non-Communicable Diseases

by Moshood Isah

Hypertension is a major public health problem in Nigeria, with prevalence of 37.5%. This means that nearly 4 out of 10 Nigerian adults have hypertension. Similarly the prevalence of diabetes is increasing worldwide, and Nigeria is no exception; an estimated 7% of adults in Nigeria have diabetes, making it among the most common cardiovascular diseases in the country.

Unfortunately,  lack of access to quality and affordable hypertension and diabetes services in rural communities and primary health care is a major concern. This is largely due to  disparity in access to quality healthcare, especially between rural and urban areas in Nigeria as a result of  economic, social, geographic, and health workforce factors. For instance, the secondary health facilities where the few drugs are, with the facility for testing and the medical professionals are far from the rural communities, making access difficult. This is exacerbated by the high cost of medications, making it difficult for some clients to afford the treatment they need, resulting in low treatment outcomes.

Thus, adapting and digitizing  the World Health Organisation Package of Essential Noncommunicable (PEN) disease interventions for primary health care, eHealth Africa is collaborating with the EHA Clinic Reaching Everyone with Accessible Community Healthcare (REACH) program to reach out to marginalized communities with healthcare interventions. This, according to the Project Manager Lucy Okoye, is aimed at improving access to quality care and affordable services for persons with hypertension and diabetes and others at risk. 

She said, “Social mobilization activities will increase rural communities' knowledge of hypertension and diabetes”, saying  the identification of risk factors and the signs of hypertension and diabetes will likely result in the adoption of a preventive healthy lifestyle and prompt seeking of treatment. Another potential impact of the intervention according to her is to reduce the prevalence of hypertension and diabetes and improve the health and well-being of the target communities, helping people to live longer and lead healthier lives. 

In February, eHealth Africa supported the free medical outreach conducted in the Kuje community of the Federal Capital Territory and Gyadi-Gyadi community of Kano state. According to Adawiya, Mahmud Ila, Product and Quality Assurance Coordinator at the EHA REACH clinic said the outreach is an opportunity to reach the people accessible and  to provide free healthcare within the community. 

“We are having an outreach where we see hypertension and diabetic patients,we measure the blood pressure and fasten blood sugar.”  If there is a need for us to give hypertensive and glycine medication we give them which is going to be free for 6 months”, she said.

She said, the economic realities in developing countries like Nigeria limits citizens especially the older generation from accessing good medical care.  She said, “You know how the economy is in Nigeria; economically it's hard for them to go to the hospital so we are just trying to make an impact in the community”.

Speaking on community acceptance and mobilization strategy for the outreach, Adawiya said, the partners leveraged on its Community Health Extension Workers (CHEW) to discuss the impact of the intervention  with traditional leaders and community influencers. 

Community Feedback

Zainab Abdullahi is  a resident of Kasuwan Dare area of Gyadi-Gyadi community of Kano state. She heard of the REACH Clinic Outreach through community influencers. “Now they checked our BP,Blood sugar level and from here we will proceed to see the doctor”, she said. 

Zainab lauded the outreach initiative saying the community is receptive to ideas like this. “the hospital environment is clean and welcoming and this is why you can see close to 100 people coming for this outreach”.  “If they can spread their tentacles and establish  this kind of hospital in all areas, we will be happy so that everyone will visit the nearest hospital rather than going far from home to access healthcare”, she said.  There is also a need to have additional doctors to attend to a growing number of patients in a bid to reduce waiting time, she said.

Ahmed Salisu Musa has spent 45 years in the community.  He expressed his excitement saying the outreach has brought good healthcare delivery to his doorstep. “They took my blood samples, gave me some medications and I was told, I am not diabetic”, he said

He said, “as a community leader myself, I am glad to  have witnessed what is happening and will pull  in more people to come and get checked.” Musa called for increased mobilization of citizens and more importantly expansion of the intervention to reach other communities.

Nasarawa SPHCDB set to Sustain Vaccination Progress with User-Friendly EMID Mobile App

by Moshood Isah

The race to  ensure accessibility to  COVID-19 Vaccine and  intensive campaigns to promote the uptake of the vaccines led to its routinization especially in developing countries.   To further ensure the successful implementation of its COVID-19 vaccine deployment plan and address existing challenges of data management, Nigeria developed the Electronic Management of Immunization Data (EMID) system in 2021. By the end of the year,  the National Primary Health Care Development Agency (NPHCDA) revealed that Nasarawa state, located in North Central part of Nigeria has again overtaken other states in the COVID-19 mass vaccination campaign in Nigeria.

However, recent experience has also revealed that manual data collection remains vulnerable to damage or manipulation. Digital solutions remain mostly more recommended as it enables more accurate data capturing and better storage process.  However, the potential challenges that could hamper the progress of development and utilization of digital solutions for management of immunization data are likely technical glitches and capacity limitations of health officials, especially in underserved communities. 

 To Address these challenges, eHealth Africa in partnership with National Primary Health Care Development Agency supported by GAVI developed an optimized version of the EMID mobile application, incorporating routine immunization to further standardize and harmonize data collection and storage. Thus, eHA successfully completed the training of healthcare personnel across the country, in the use of the EMID Native App.

Speaking during the training session for healthcare personnel and immunization recorders across over 300 Primary Health facilities in Nasarawa state, key stakeholders highlighted how the optimum utilization of the EMID application will sustain vaccination progress in the state.

LGA EMID Focal Persons in Nasarawa state after a Training of Trainers on optimised EMID application

Abubakar Alilu Awei, State Primary Healthcare Development Board, (SPHCDB) Immunization Officer (SIO) said the presence of EMID Focal persons at the LGAs ensuring that all recorders upload information of clients on the national server was indeed instrumental in the state progress during the COVID 19 vaccination.  He said, “You may recall that Nasarawa state emerged as the overall best performing state in Nigeria in terms of COVID-19 vaccination and also the best performing state in the North central zone. This may not be unconnected to the good use of our EMID application that we adopted during the COVID 19 vaccination.”

Awei further lauded the incorporation of routine immunization into the application saying, the training is timely as it  will enable the state to have  data on the server to enable adequate tracking of client information. He said, “with the optimized EMID app,  at a glance we can  check on the client that has been vaccinated with the first antigens. So when they come back to the health facilities for the next antigen it's just for the recorder at the health facility to go to the server and update the current antigens that they have received”. It reinforces the prospects for effective management of immunization data.

In a similar vein, Beatrice Samuel, NPHCDA, Zonal technical officer,  Nasarawa state said, “one of the things we really enjoyed is that we could see the accessibility, the user friendly and not much challenge”. While describing the optimization of the EMID app as a milestone for the agency and eHealth Africa, she called for its sustainability. 

“I  want to believe that the excitement we have now would not just go away. It should be something that will not give us challenges when we go to the field.  There should be a sustainable native app for us to enjoy more and more”.

Immunization Recorder in Doma LGA of Nasarawa State

In his words, Ahmed Ibrahim, EMID State Focal Person for Nasarawa State lauded eHealth Africa for leading the optimization of the application saying, “ our recorders at the health facility will now know the value and importance of keeping record”. He said the application guarantees the safety of data in its electronic form saying,  “even if the facility is burnt you can still go to the database and search for the record of any person”, he concluded. 

ehealth Africa Commits to promoting early detection of Vaccine Derived Polio Virus through Lab Support

by Moshood Isah

Nigeria may have been declared a polio free nation but the Variant Poliovirus Type 2 strain transmission still lingers. Nigeria reported 168 cases in 2022. This  has made further interventions crucial particularly  around early detection. The growing cases in a  number of African countries require a focused effort to strengthen polio laboratories that can effectively help the affected countries to quickly confirm cVDPV2 cases and launch outbreak responses, including the introduction of novel OPV2.  

In 2018, the World Health Organisation (WHO) introduced a Global Polio Surveillance Action Plan (GPSAP 2018-2020) to support endemic, outbreak, and high-risk countries in evaluating and increasing the sensitivity of their surveillance systems against Polio. The plan also initiated supplemental strategies that may help in closing gaps in detecting polioviruses, including strategies for immunodeficiency-associated vaccine-derived polioviruses (iVDPVs) while also strengthening coordination across surveillance field teams to foster a more effective programme and document zero cases worldwide. 

The new Global Polio Surveillance Action Plan (GPSAP) for 2022-2024. also focuses on increasing the speed of poliovirus detection, improving surveillance quality at the subnational level, fostering the integration of polio surveillance with surveillance for other epidemic-prone vaccine preventable diseases (VPDs), and mainstreaming gender equality in surveillance activities and programming as a key enabling factor.

To achieve parts of the Global Polio Surveillance Action Plan (GPSAP) 2022-2024, ehealth Africa worked with World Health Organisation (WHO)  supported by the Bill and Melinda Gates Foundation (BMGF) to  renovate and upgrade the   Sequencing Laboratory in the Virology department, University College Hospital (UCH) Ibadan, Oyo State. The laboratory was commissioned by Kazadi Walter, Country Representative and Head of Mission; World Health Organisation to Nigeria. This is part of the effort to improve surveillance, rapid detection and response against the spread of Vaccine Derived Polio Virus and other vaccine preventable diseases.  

Speaking during the official commissioning of the Laboratory, Dr. Kazadi Walter reiterated the commitment of WHO towards eradicating polio virus through the provision of facilities and rendering of technical support to Nigeria’s health care. He stated that WHO in collaboration with the government established the Global Polio Laboratory Network of which 16 are currently in Africa, with two located in Nigeria; Ibadan and Maiduguri. According to Walter, the primary objective is to work with WHO in the African Region (AFRO) to equip the global polio laboratory network labs for robust and rapid sample analysis for polio and to provide support in equipping these labs with sequencing capabilities.

Prof. Kayode Adebowale, the university vice chancellor, commended the initiative saying “this laboratory will not only provide vital information for the eradication of polio but also contribute to our university infrastructure, helping us to fulfill our vision and mission in addressing social needs.” The VC said: “The department has played a crucial role in Nigeria’s polio eradication programmes by contributing significantly to the country’s achievements of being declared wild polio-free in 2021.

Speaking on the role of eHealth Africa in the support for Laboratory Supplies across selected countries in Africa, the Project Manager, Tolulope Oginni said, to ensure optimum utility of the laboratory supplies, eHealth Africa leverages previous and current experience in setting up and managing Emergency Operation Centers to strengthen the staff capacity at the Laboratories in operating the installed equipment.

“These interventions  for  the support for laboratory supply and installation with consumables currently ongoing in at least 12 African countries are expected to improve the labs functionality for faster outbreak detection”, he said. With the support of other stakeholders in the region, this intervention will support labs in the African region that are targeted for expansion of sequencing capacity, support to improve existing sequencing capacity, or labs that require support for virus isolation and identification. This intervention has a huge opportunity to explore collaboration with WHO and other global stakeholders to transform the laboratory infrastructure in Africa into world class facilities which in turn will significantly strengthen their capacity and preparedness for disease outbreaks.

World Tuberculosis Day: Investing in diagnosis to save lives

By Juliana Jacob

Tuberculosis (TB) is one of the world’s most significant causes of mortality, and it is also the first from a single infectious agent. 1.7 million people died from tuberculosis (TB) in 2016, with Africa accounting for over 25% of the total deaths. Tuberculosis is not incurable, but timely diagnosis is necessary to get proper treatment. However, lack of access to health facilities that provide diagnostic and treatment services is an obstacle for people in low-resource settings.

Why is TB diagnosis a challenge in Sub-Saharan Africa? Here are some facts you need to know about diagnosing and treating TB in Africa.

1. Ten million lives were saved in the African Region between 2000 and 2014 through TB diagnosis and treatment. When suspected patients of TB receive timely and accurate diagnoses, they are empowered to seek treatment which increases their chances of curing non-drug-resistant strains of TB.

2. Nigeria accounted for about 12% of the enormous gap between the number of new cases reported (7.0 million) and the estimated 10.0 million (9.0–11.1 million) incident cases in 2018. This gap was due to underreporting of detected cases and underdiagnosis.

3. In 2017, 10 million patients fell ill with tuberculosis; 36% were undiagnosed or detected and not reported. In many countries across Africa, the number goes higher. In Tanzania, it is as high as 55%.

4. Funding for TB diagnosis and treatment has doubled since 2006 but still falls far short of what is needed. When the funds required are not available, there will be a significant reduction in the number of people diagnosed with TB.

Diagnosis of TB remains a challenge in developing countries, and innovative interventions can help bridge the gap in TB diagnosis and treatment. One of such interventions is  Health Telematics Infrastructure (HTI). eHealth Africa worked with the Charité University of Medicine to design HTI, a digital solution to improve, analyze, and evaluate the diagnosis and treatment of TB and HIV. We implemented HTI in St. Francis Referral Hospital (SFRH), Ifakara Health Institute (IHI) in Ifakara, and Kilombero District (central Tanzania). 

HTI is an SMS-based solution that allows patients to get their TB and HIV test results faster through text messages. Before the implementation of HTI, patients would travel long distances to Ifakara to get tested and return at a later date to get their results. Many patients did not return to Ifakara to collect their results due to the cost of transportation and other factors. Without their diagnoses, patients did not seek treatment and potentially infected more people.

Some benefits of the HTI system include; accurate and timely diagnosis of suspected patients of tuberculosis, patients having access to cutting-edge diagnostic methods, and a treatment process that is structured and monitored to ensure that patients follow through with their entire treatment process. 

The system sends reminders to patients to inform them about the next step in their treatment plan. This method of getting test results via SMS saves time. It removes barriers to TB treatment clinics that were previously inaccessible to the people of these communities due to long distances. We gathered information from patients using a tablet and open-source software ‘open data kit (ODK) collect.’ We used Aether and Gather to analyze the data from the ODK collect app. As a security measure, we also installed data protection so that we can retrieve data in the event of a loss. We have successfully routed 79.9% of SMS correctly to the patients.

To end tuberculosis, we must coordinate and implement approaches that will help us scale the hurdles associated with TB diagnosis, especially in low-income countries and communities. Communicating test results to patients on time and effective communication on TB diagnosis will decrease the number of people who die from the disease because they better understand their condition and can start appropriate treatment regimens. 

The centrality of data in outbreak detection and response: the Data for Action intervention in Kano and Kebbi states

By Chinedu Anarado and Tope Falodun

The world is recovering from the disruptions and losses caused by COVID-19. Nigeria was heavily affected and worked hard to manage the fallout from the outbreak. Using quality data and information was central to these efforts. Daily, the Nigeria Centre for Disease Control (NCDC) published data on those infected and the attendant mortalities. It harvested information from various sources as it worked to control the outbreak. But what if Nigeria had access to quality data at all levels on disease outbreaks? Could it have done better with the COVID-19 outbreak, despite its global dimensions? Perhaps it will have enough information to plan outbreak response and keep people safe.

One of the critical challenges confronting public health management officials is access to quality data to identify, prepare, and respond promptly to potential public health events. This challenge manifests in data illiteracy among relevant officials, inability to aggregate and analyze data, and leveraging analyzed information to take action. There are also data quality issues and the political will to act on the information.  

Participants reviewing data during the Disease Identification USSD training session in Kebbi State

There are many challenges that prevent the regular use of data In Nigeria’s public health sector. For instance, data sources are stored in silos, especially at the generation points. There is no upward information flow where decision-makers can understand what is happening and prepare a response strategy for such an outbreak. For instance, the NCDC has set up Public Health Emergency Operation Centers (PHEOCs) in 23 states. But they are not staffed with the right personnel and tools to analyze information, detect and flag disease outbreaks early enough. They are also not integrated in a manner that gives the NCDC some visibility into what is happening, allowing for easy monitoring and timely response. There aren't enough skills at the generation and perhaps usage points at the local level to clean up, analyze and interpret the data at the primary source.  

Fortunately, eHealth Africa is implementing the Data for Action project to address these issues. The Data for Action effort is a component of the Subnational Emergency Preparedness and Response Capacity Building (SERCB) program, an initiative of the NCDC. The SERCB effort provides an overall emergency preparedness capacity at the state level. Its Data for Action component provides data and information for prompt response action that underpins emergency preparedness. Resolve to Save Lives (RTSL) funds this intervention, which involves delivering solutions for the benefit of the NCDC and state-based Public Health Emergency Operations Center (PHEOCs). Successfully implementing Data for Action will provide data that will support an early warning system, allowing stakeholders to detect and respond to potential disease outbreaks before they assume challenging proportions. The states will also have the critical capacity and resources to sustain the use of data for decision making at the local and sub-national levels. 

eHA has conceived an early warning system that should involve the aggregation and analysis of data. This will cause periodic reporting of identified diseases from the ward unit up to the state level, with a mechanism that shows the reported disease and the frequency of occurrence. It should also define what level of spread and actions to be taken if an outbreak is imminent. 

To arrive at these solutions, we implemented a bottleneck assessment in Kano and Kebbi states that helped us identify the critical challenges preventing the seamless flow of data from the various ward units right up to the state and the center. eHA’s findings from the assessment were addressed by investing in creating data products, building the capacity of disease surveillance and notification officers on data clean up, analysis and presentation. We also trained community informants on disease identification to help improve the sensitivity of surveillance systems. If they can accurately identify diseases, we can report more and ensure that relevant public health actors do not miss potential outbreaks. 

eHA also provided infrastructure and equipment support to ensure the conducive functioning of the PHEOCs. For instance, we operationalized a power generating set in Kano and provided a six-month diesel supply and internet connectivity to support data analysis. In Kebbi state, we provided additional equipment to support communication and visualization, including projectors and screens, public address systems, internet connectivity, air conditioners and water dispensers. Kebbi PHEOC, still at its nascent stage, requires these pieces of equipment to improve their work, and we are glad they are being put to good use.  

In the coming days, we will implement additional training on data use and ensure beneficiaries can produce data products or reports that give insights on the prevalence rate of six priority infections. These include Cholera, COVID-19, Lassa Fever, Measles, Meningitis and Yellow Fever. These diseases are the most prevalent in Kano and Kebbi states. Hence, tracking them will help reduce the prevalence of these outbreaks and the safety of Children. We will back up this effort with periodic supportive supervision to ensure that valuable data is available to ensure decision-makers keep their citizens safe and prevent more disease outbreaks.

Building Local Capacity and Infrastructure for Disease Surveillance in Africa

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.

Lessons from the eHealth Africa-Emory University Schistosomiasis Study

By Tolulope Oginni and Emerald Awa-Agwu

Schistosomiasis and nineteen other diseases are classified by the World Health Organization as Neglected Tropical Diseases. It is an acute and chronic parasitic disease caused by blood flukes called schistosoma. People become infected when larval forms of the parasite (worms) penetrate their skin during contact with infested water. 

The disease can present in two main forms: intestinal and urogenital schistosomiasis. Intestinal schistosomiasis can result in abdominal pain, diarrhea,  blood in the stool, and liver and spleen enlargement in advanced cases. The most distinguishing symptom of urogenital schistosomiasis is haematuria (blood in urine). Fibrosis of the bladder and ureter, kidney damage, genital lesions and vaginal bleeding in women, and pathology of the seminal vesicles, prostate and other organs in men. In later stages, urogenital schistosomiasis may lead to bladder cancer and infertility.

The disease is endemic to Nigeria and existing data places Nigeria as home to the highest number of recorded cases in the world. While there are insufficient research data and medical records to paint a true picture of the disease burden in Nigeria, it is estimated that 29 million Nigerians are infected with the disease and almost half of this number are children.

In June and July, eHealth Africa partnered with Emory University on a study to compare three diagnostic methods to determine their effectiveness in detecting acute and chronic schistosomiasis in low-resource settings. Accurate diagnostics are crucial to yield more information about the disease and ultimately, to achieve the goal of eliminating the disease. One of the major challenges facing the elimination of schistosomiasis is that very few infected people present at the health facilities for treatment. This can be attributed to a myriad of reasons including stigma, insufficient medical services, affordability of medical services, low knowledge of the signs and symptoms of the infection, and local perceptions and myths about the disease. The wider effect of this passive case finding (that is, cases are discovered only when infected persons visit the health facilities for treatment) and poor health-seeking behavior is that there is inadequate data to support the prioritization of schistosomiasis control by decision-makers and health program planners. In addition, medical laboratory scientists and researchers are unable to make improvements to diagnostic procedures for schistosomiasis because very few patients visit health facilities to access treatment.

During this study, eHealth Africa and two Emory University MPH students also trained 10 community health workers to administer questionnaires aimed at assessing the knowledge, attitudes, and perceptions about Schistosoma haematobium infection(urinary schistosomiasis) among communities in five Local Government Areas in Kano State.

Training of Community Health Workers

The responses from the survey yielded astounding local interpretations of the symptoms of urinary schistosomiasis. Community members saw red urine (haematuria or blood in the urine) as a normal and rather harmless phenomenon, a rite of passage or a sign of manhood for young boys. It was also linked to the menstrual cycle for girls or women. Yet another misconception was that it could be caused by staying long hours under the sun. Among women especially, underreporting of the disease was exacerbated by socio-cultural norms and beliefs that prevent them from handling urine samples in public.

Administering questionnaires at Sani Marshal Government Arabic Secondary School, Kura LGA, Kano State

With this understanding and the results of the study, eHA and Emory University hope to influence policies, strategies and plans around the diagnosis and control of Schistosomiasis in Nigeria.

Going digital improves Disease Surveillance in Sierra Leone

By Sahr Ngaujah and Nelson Clemens

According to WHO, Sierra Leone is the first country in the Africa region to fully transform its national disease surveillance system from a paper-based system to a  web-based electronic platform. This is due to the introduction of the electronic Integrated Disease Surveillance and Response solution.

Sierra Leone was one of the hardest-hit countries during the 2014 EVD outbreak in West Africa. The country’s poor disease surveillance infrastructure highlighted the need for a robust disease surveillance mechanism. Introducing an electronic method for disease surveillance reporting became one identified remedy for improving disease surveillance in a country that was still trying to catch up with the rest of the world in terms of digital technology. 

Paper-based health data recording and reporting from across Sierra Leone’s 1300 health facilities became increasingly inadequate and inaccurate and was also characterized by late reporting, incomplete district-level reports, multiple data entry errors, and difficulty storing and retrieving data.

With an expertise in health informatics, eHealth Africa (eHA) designed the electronic Integrated Disease Surveillance and Response (eIDSR) solution and has been implementing the solution in collaboration with Sierra Leone’s Ministry of Health and Sanitation (MoHS), the U.S. Centers for Disease Control and Prevention (CDC), the World Health Organization, Focus 1000, and GIZ since 2016, with  the objective to enhance disease prevention and control through the digital capture and submission of data on epidemiologically-important diseases. The eIDSR project was funded by the CDC. 

eHA customized an open source health information tool from DHIS2 for the purpose-built digital data collection and reporting. The eIDSR tool is integrated into the national health system through its compatibility with the health information systemDHIS2, which is used in over 45 countries, especially those with vulnerable health systems like Sierra Leone. eHA developed the web form and custom mobile application, piloted both, and created a Short Message Service (SMS) submission solution for health workers to submit their weekly surveillance reports in locations where internet access is weak.

Nwanyibuife Obiako, Senior Programs Manager, eHA Sierra Leone, making a statement during the eIDSR rollout closing ceremony

As of June 2019, 2758 health care workers at the health facility and district level were trained by eHA on the use of eIDSR across Sierra Leone. These health care workers now monitor 26 disease categories digitally. Digitizing health-related data has yielded positive outcomes in Sierra Leone. eHA has supported the rollout of eIDSR to all 14 administrative districts in Sierra Leone and a ceremony was held on June 6th in Tonkolili district, with participants from the MoHS and other implementing partners, to celebrate the milestone achieved.

“Thanks to eIDSR, we have seen an improvement of multiple surveillance indicators, such as reporting completeness and timeliness. It’s evident that a critical part of this success is partnership and collaboration.”

— Nwanyibuife Obiako, Senior Programs Manager, eHA Sierra Leone

Nelson Clemens, eHA’s eIDSR Project Coordinator presenting during the eIDSR rollout closing event

The eIDSR system has also enhanced:

•  Reduced data entry errors

•  Reporting completeness, timeliness, and efficiency

Reducing data entry error

Optimal data management and quality are crucial to the delivery of high-quality healthcare services. Accurate data is essential to informed decision making and appropriate public health action. In the past, when health care workers submitted their reports, there was no opportunity for their superiors to perform data quality assurance. This sometimes resulted in erroneous data being sent to the national level, reducing the quality of data used for disease surveillance in Sierra Leone. With eIDSR, digital data is now managed in an efficient manner at District and National levels and made available to all relevant parties in the quickest way possible.

“The electronic system has reduced the number of data entry errors in half, and is capturing and verifying data 60% faster than the paper-based IDSR system.”

— CDC

Reporting completeness, timeliness, and efficiency 

The eIDSR tool was created to improve the speed of the flow of information within health systems. Through the electronic Integrated Disease Surveillance Response (eIDSR) solution, disease prevention, and control is enhanced through timely electronic capture and submission of data on epidemiologically-important diseases as data can now be submitted, reviewed and acted upon near real-time.

“...My colleague Surveillance Officers would agree with me that eIDSR has relieved our stress. eIDSR roll-out commenced in the Kambia district in November 2018. A week following the roll-out, we achieved 98% of timeliness of reporting and has not gone below 90% since.”

— Usman Barrie, District Surveillance Officer, MoHS, Kambia district.

Disease surveillance plays an important role in disease prevention, control and elimination. 

eHA continues to work with its partners to ensure eIDSR is sustainable in Sierra Leone.

Modelling Disease Surveillance Systems that work in Chad and Niger

By Tope Falodun and Emerald Awa-Agwu

Participants in Maradi, Niger after the training

Functional disease surveillance systems provide data that can be analyzed to yield insight for planning, project execution, monitoring, and evaluation of public health interventions. For a priority disease like Polio, surveillance systems are important because they monitor the burden of the disease and alert health systems of any increase in the occurrence of the disease in any location of implementation, ahead of time.

A key element that is often missing in disease surveillance systems is intersectoral action. In the past, the responsibility of finding, investigating, reporting and monitoring AFP cases rested solely on the disease surveillance officers (DSOs). This resulted in incomplete data because the DSOs could not cover every single community, and also manual errors as DSOs had to enter reports using paper-based tools.  Recognizing this, eHealth Africa (eHA) partnered with the World Health Organization (WHO), Novel-T, the Bill & Melinda Gates Foundation (BMGF) and the Ministries of Health in eight countries including Chad and Niger to develop the Auto- Visual AFP Detection and Reporting (AVADAR) system for improving AFP case identification and reporting. The goal of the project was to support health systems in polio-endemic and high-risk countries to find, report and investigate AFP cases using available, context-appropriate resources, in this case, community members. 

By partnering with local communities and enlisting members to serve as informants and investigators, some of the pressure on disease surveillance officers who performed all three functions of finding, investigating, reporting and monitoring suspected AFP cases were relieved. In addition, AVADAR infused digital data management and reporting innovations through the mobile application. With this, community informants report cases of suspected AFP via the AVADAR  mobile application. The investigators receive alerts of these reports on their mobile devices, locate the cases, investigate and collect stool samples for further laboratory tests in cases of true AFPs.  

In 2017, AVADAR was launched in 6 pilot districts in Chad and three pilot districts in Niger. By 2018, the project expanded to an additional three districts in both Chad and Niger. In total, eHA trained 849 and 509 community informants in Chad and Niger respectively. eHA also supported the training of 177 investigators by the WHO in Chad and 178 investigators in Niger. Within these periods, eHA supervised the activities of the informants, investigators, and technical officers, and also resolved technical issues relating to the mobile application, telecommunication, and network access on Android phones.

Chad 1st level supports going through pre-test during the transition training in Bokoro, Chad

“AVADAR has had a great impact on AFP surveillance, directly and disease surveillance as a whole by improving communication and information transfer.”

— Mbaielde Felix, Head of Abirebi Health Area, Bokoro District, Chad

After almost three years of supporting the health systems in Chad and Niger through AVADAR, it was evident that the model worked. eHA successfully handed over the continuation of the project in the pilot districts to the Ministries of Health and the World Health Organization in Chad and Niger. A total of 109 first and second line technical support officers in the two countries, were trained to continue to handle and resolve any technical issues that may arise. 

At eHA, we support health systems to effectively monitor and eradicate communicable diseases like polio by developing and supporting the development of creative surveillance methods and innovative data management solutions.

“AVADAR has allowed us to communicate with the informants, the district management team and the health delegation on the report of other diseases other than the AFP.”

— Abakar Mahamat Kalbassou, Head of Abgode Health Area, Bokoro District, Chad

Strengthening Routine Immunization using Lessons learned from Polio Emergency Support

By Joshua Ozugbakun & Emerald Awa-Agwu

In July 2016, after over two years of being polio-free, two wild poliovirus cases were discovered in Borno State, Nigeria. This launched fresh efforts to strengthen the four pillars of polio eradication including Routine Immunization (RI), Supplementary immunization activities (SIAs) (including national Immunization Plus Days (IPDs)), Surveillance and targeted mop-up campaigns.

A health worker vaccinates a child with the Oral Polio Vaccine

Partners, both local and international, collaborated with the Nigerian government at state and national level, through various interventions and projects to increase the coverage and effectiveness of IPDs and mop-up campaigns in order to increase herd immunity and stop polio transmission, especially in high-risk states like Adamawa, Borno and Yobe states. These interventions were coordinated by the State Emergency Routine Immunization Coordination Centers (SERICCs). Each SERICC is led by individual state governments and help to improve information sharing, joint programming of public health emergency management activities (planning, implementation, monitoring, and evaluation) with partners. The National Emergency Routine Immunization Coordination Center (NERICC) is responsible for strategy development and oversees the activities of all the SERICCs. With this coordination mechanism in place, the menace of polio is being tackled collaboratively and Nigeria is well underway to being declared ‘Polio Free’, a major milestone in its vaccine-preventable disease management efforts.
A major takeaway for Nigerian polio eradication stakeholders after years of battling polio is the need for data collection, management and storage systems to be upgraded. As the need to halt poliovirus transmission increased, it became increasingly obvious that paper-based data management systems were incapable of providing decision makers with the reliable, actionable data which they needed for effective programming. eHealth Africa responded to this challenge by supporting states across Nigeria to develop comprehensive, digital maps using our expertise in Geographic Information Systems (GIS). The accuracy of these maps improves the microplanning process and guarantees a greater coverage of settlements during campaigns.

Our GIS technology has improved the quality of maps used for polio campaign planning

In addition, through our Vaccinator Tracking Systems (VTS) project, GIS-encoded Android phones are used to record and store passive tracks of vaccinators as they conduct their house-to-house visits; allowing decision-makers to have an accurate picture of the settlements that have been covered during IPDS and mop-up campaigns. This data can easily be accessed through dashboards for a more detailed analysis and breakdown of coverage information.

Supporting polio emergency response activities also highlighted the need for the Nigerian health system to move from an emphasis on SIAs and campaigns to strengthening the RI and disease surveillance systems. Sound routine immunization and disease surveillance systems are necessary to sustain the herd immunity built through polio campaigns.

In Kano state, the LoMIS Stock solution helps the State Primary Health Care Management Board to ensure that the vaccine supply chain is maintained. Health workers at the facility level use the LoMIS Stock application to send reports on a variety of vaccine stock indicators including vaccine utilization, vaccine potency, stock levels, wastage rates, and cold chain equipment status. Supervisors access the reports through the LoMIS Stock dashboard and are able to respond appropriately. This ensures that the RI system is maintained and that health facilities are never out of stock.

In the past, Acute Flaccid Paralysis (AFP) surveillance in health systems across Africa was passive. This meant that disease surveillance and notification officers (DSNOs) only reported or investigated suspected AFP cases that were presented at the health facility. According to the U.S Centers for Disease Control and Prevention (CDC)1, over 72% of polio cases are asymptomatic and as such, will not present at the health facility. In addition, DSNOs are unable to visit every single community to actively search for AFP cases due to logistics and security challenges. Relying on data from passive AFP surveillance causes programs to be designed based on data that excludes the asymptomatic polio cases. Auto-Visual AFP Detection and Reporting (AVADAR) reduces the burden on the DSNOs by enlisting members of the community to actively find AFP cases and report using a mobile application on a weekly basis; thus, providing accurate real-time surveillance data that can be used for program planning and implementation.

An often overlooked factor that promoted the transmission of the poliovirus was the rejection of the polio vaccine by mothers and households due to various myths and socio-cultural barriers. By engaging traditional and religious leaders as ambassadors of vaccination, more mothers and households are accepting the polio virus.

The central lesson in Nigeria’s journey so far towards polio eradication is the importance of collaboration and engagement at all levels including communities. eHealth Africa is proud to be supporting governments and health systems across Africa to respond to the polio emergency.

Fighting Cholera with the Power of Geospatial Mapping

By Ayodele Adeyemo & Hawa Kombian

The Cholera Threat

According to the World Health Organization (WHO), cholera (an infectious disease which causes acute watery diarrhea) remains a global threat to public health with an annual average of 82,000 deaths. In Nigeria, the cholera burden has been an average of 10,000 cases annually with over 70% of the cases coming from Bauchi, Yobe, and Zamfara states.

Following the review and recent publication of WHO guidelines on cholera control, the Nigeria Centre for Disease Control (NCDC) has begun the implementation of innovative approaches to tackle cholera via:

• Strengthening disease surveillance for early detection and quick response through innovative use of technology and data.

• Improving coordination for technical support, resource mobilization, and partnership.

• Adopting a multi-sectoral approach to meet the 2030 cholera elimination by working with the environment and Water and Sanitary Hygiene sectors to ensure that communities have good water and sanitary facilities which will prevent further outbreaks

The Digital Health Advantage

What does an innovative model for cholera prevention and control look like?

In 1854, John Snow mapped out the cholera deaths during an outbreak and observed that they all occurred within short distances and were clustered around the Broad Street pump. He went ahead to carry out statistical tests to illustrate the connection between the source of water and the cholera cases.

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Source: Netcentric Advocacy

In synergistic partnership, NCDC and eHealth Africa (eHA) used advanced geographic information systems (GIS) technologies to build on John Snow’s ideas of mapping. eHA uses data-driven solutions and tools to improve community health, with specific expertise in the design, development, validation, and deployment of predictive models for diseases like cholera.

GIS allow experts to explore different aspects of a geographical point. The identification of patterns can drive insights and enable health stakeholders to make informed decisions about how to best plan public health interventions. Due to computational and technological advancement, GIS has been used in public health for epidemiology, resource planning, and surveillance among others.  

NCDC and eHA were able to utilize GIS capabilities to enhance the data management within the NCDC National Incident Coordination Centre (ICC). The ICC serves as a the emergency operations center for coordinating disease outbreaks at the national level.

eHA’s GIS and Data Analytics team works with the NCDC to map cholera hotspots (areas where cholera persists) across Nigeria’s Local Government Areas (LGAs). At the start of the outbreak, hotspot analysis helps determine where to vaccinate and what quantity of vaccines are required per LGA. This exercise ensures the effectiveness of the oral cholera vaccine immunization campaigns which are rolled out to stop the spread of disease.

In planning, data from 2012-17 displays the spread of cholera outbreaks and also shows the relative risks of the various LGAs which have reported an outbreak during the five year period.

The Big Picture Data Source: Nigeria Centre for Disease Control

Data Source: Nigeria Centre for Disease Control

We layered the 2018 outbreak data with the historical hotspot analysis to identify specific trends and possible overlaps. The result of the hotspot analysis identified 83 LGAs as hotspots, with 87% reporting at least one case with over 70% of the burden from Bauchi, Kano, and Zamfara states. The LGAs identified as hotspots have enabled the government to make informed decisions about where to request vaccines to ensure that the most vulnerable areas are supported.

Data Source: Nigeria Centre for Disease Control

We continue to collaborate with the NCDC to strengthen cholera surveillance in Nigeria. The partnership ensures that data management and analysis expertise contribute to faster response and informed decision making before, during and after outbreaks.

This work was done in collaboration with the following partners:

• Yennan Sebastian- NCDC

• Adesola Ogunleye - NCDC

• Heloise Lucaccioni - UNICEF

• Helen Adamu - UMB

• Kobi Ampah- WHO Geneva              
  

How eHealth Africa supports Universal Health Coverage across Africa

By Emerald Awa- Agwu

April 7 is World Health Day and this year, the World Health Organization (WHO) is focusing on Universal Health Coverage (UHC).

WHO: Universal Health Coverage - What does it mean?

Good health is crucial for developing economies and reducing poverty. Governments and decision-makers need to strengthen health systems so that people can get the healthcare and services that they need to maintain and improve their health, and stay productive.  However, improving access to health services is incomplete if people plunge further into poverty because of the cost of health care. WHO estimates that over 800 million people spend at least 10% of their household budget on health care which is indicative of catastrophic health expenditure (CHE).  CHE can mean that households have to cut down on or forfeit necessities such as food and clothing, education for their children or even sell household goods.

One of the targets of Sustainable Development Goal 3—Ensure healthy lives and promote wellbeing for all at all ages— is to achieve universal health coverage by 2030. Therefore, achieving UHC has become a major goal for health system reforms in many countries, especially in Africa.

Through our projects and solutions, eHealth Africa supports countries across Africa to strengthen the six pillars of universal health coverage.

1. Health Financing for Universal Health Coverage

WHO recommends that no less than 15% of national budgets should be allocated to health. We believe that accurate and up to date data, can ensure that available health funds are better allocated. In Nigeria,  we worked with several partners to map and collect geospatial data through the Geo-Referenced Infrastructure and Demographic Data for Development (GRID3) program. Data relating to over 22 points of interest categories including health facilities, was collected across 25 states and the Federal Capital Territory in Nigeria. This data helps decision-makers to distribute resources and plan interventions that target the people who need it most.

2. Essential Medicines and Health products

Vaccines are some of the most essential health commodities

Countries decide what medicines and health commodities are essential based on the illnesses suffered by the majority or significant sections of their population. They must also ensure that quality, safe and effective medicines, vaccines, diagnostics, and other medical devices are readily available and affordable.

When essential medicines and health products are procured, it is important to maintain proper records and to ensure that health facilities do not run out of stock. eHealth Africa created Logistics Management Information System (LoMIS), a suite of mobile and web applications, LoMIS Stock and LoMIS Deliver that address challenges in the supply of essential medicines and health products such as vaccines and drugs. In Kano State, health workers at the facility level use the LoMIS Stock mobile application to send weekly reports on the vaccine stock levels, essential drug stock levels and the status of cold chain equipment. Supervisors can view the reports in near real-time through the LoMIS Stock Dashboard and plan deliveries of medicines and health products to prevent stockouts of vaccines and essential drugs, using LoMIS Deliver. LoMIS Deliver reduces errors by automating the process of ledger entry to capture the number of vaccines on-hand at the facility and the quantity delivered.

3. Health systems governance

Health system governance according to the WHO is governance undertaken with the aim of protecting and promoting the health of the people. It involves ensuring that a strategic policy framework exists and providing oversight to ensure its implementation. Relevant policies, regulations, and laws must be put in place to ensure accountability across the health system as a whole (public and private health sector actors alike).  Effective health systems governance can only be achieved with the collaboration of stakeholders and partners who will support the government by providing reliable information to inform policy formulation and amendments. Over the years, we have worked with several partners to provide this support.

4. Health workforce

Health systems can only deliver care through the health workforce

The attainment of UHC is dependent on the availability, accessibility, acceptability, and quality of health workers1. They must not only be equitably distributed and accessible by the population, but they must also possess the required knowledge and skills to deliver quality health care that marries contextual appropriateness with best practices.

Recognizing this, eHA supports the Kano State Primary Health Care Management Board (KSPHCMB) to improve health service delivery by providing health workers in Kano State with access to texts, audio courses, and training modules through an eLearning solution. Through the eLearning web and mobile-enabled platform, health workers can gain useful skills and knowledge on a wide range of topics. Read about the pilot of the eLearning solution here.

In Sierra Leone, we work with the Ministry of Health and Sanitation (MoHS), U.S. Centers for Disease Control and Prevention (CDC) and the African Field Epidemiology Network (AFENET) to implement the Field Epidemiology Training Program (FETP). Through FETP, public health workers at the district and national level gain knowledge about important epidemiological principles and are equipped with skills in case/ outbreak investigations, data analysis, and surveillance. This positions Sierra Leone to meet the Global Health Security Agenda target of having 1 epidemiologist per 200,000 population. In addition, we support Sierra Leone’s MoHS to build additional capacity in frontline Community Health Officers (CHOs), who are based at the Chiefdom level through the management and leadership training program. CHOs are often the first point of contact for primary care for the local population and the MLTP program equips them to provide better health services and improve health outcomes at their facilities.

5. Health Statistics and Information Systems

In line with our strategy, we create tools and solutions that help health systems across Africa to curate and exchange data and information for informed decision making and future planning.  The Electronic Integrated Disease Surveillance and Response (eIDSR) solution has been used in Sierra Leone and Liberia to transform data collection, reporting, analysis, and storage for a more efficient response and surveillance of priority diseases. Its integration with DHIS2, a health information system used in over 45 countries, makes it easy for health system decision makers to visualize data and gain insight into the state of public health. Read more about our other solutions Aether and VaxTrac. In addition, we also support the Nigeria Center for Disease Control and Prevention (NCDC) by creation and maintenance of a data portal which serves as a repository for all datasets that are relevant to detecting, responding and preventing disease outbreaks in Nigeria.

6. Service delivery and safety

Staff at the Kano Lab

The Service delivery and safety pillar encompasses a large spectrum of issues including patient safety and risk management, quality systems and control, Infection prevention and control, and innovations in service delivery. With our experience working to respond to polio and ebola virus emergencies across Africa, we support health systems to mount prevention and control programs at the national and facility level. We are also committed to creating new technologies and solutions that can help health providers to develop better models of healthcare. We also construct health facilities ranging from clinics to laboratory and diagnostic facilities that utilize state of the art technology to correctly diagnose diseases such as Sickle Cell Disease, Meningitis, and Malaria.

Our Sokoto Meningitis Lab has been at the forefront of meningitis testing and surveillance in Northern Nigeria, offering reliable and prompt diagnoses to support the prevention of future outbreaks.

eHealth Africa continues to work with governments, communities and health workers so that everyone can obtain the quality health care, in a prompt manner and from health workers and facilities within their communities, thus achieving universal health coverage.

eHealth Africa supports Sierra Leone’s Public Health Services for better response to public health emergencies

By Uche Ajene

The first-documented most widespread and deadly outbreak of the Ebola Virus Disease (EVD) in West Africa devastated three countries: Guinea, Liberia, and Sierra Leone. The outbreak started in May 2014 and by November 2014, during the height of the outbreak, Sierra Leone recorded over 500 new cases of Ebola a week. By October 2015, a total of 8,704 EVD cases had been diagnosed, and 3,589 people had died of Ebola in Sierra Leone.

This disease caught the country’s Ministry of Health and Sanitation (MoHS) by surprise. The outbreak could not be effectively managed because the country did not have the requisite capacity (structure and staff) and systems -Standard Operating Procedures (SOPs), policies and plans, to effectively manage and mitigate the risks posed by the disease.

Ebola’s destruction on the peoples of Sierra Leone and the absence of appropriate structures to deal with future outbreaks, prompted the establishment of Public Health National Emergency Operations Center (PHNEOC) in  June 2015, as a coordination structure charged with the responsibility of providing public health emergency preparedness leadership, scientific and technical situational awareness and advice at a national level.

As Sierra Leoneans reflect on the atrocities of Ebola and other emergencies, this question becomes inevitable: Is Sierra Leone better prepared to address any future public health emergencies?

To better prepare for future outbreaks, the U.S. Centers for Disease Control and Prevention (CDC), in collaboration with the Ministry of Health and Sanitation and eHealth Africa, conducted successful trainings for health workers and other stakeholders on Public Health Emergency Management, Risk Communication,Threat and Hazard Identification and Risk Assessment (THIRA), Incident Management Systems and Public Health Operations and Management. These training sessions were done in Bo, Bombali districts and Western Area Urban with the involvement of health workers, district councillors, the national security agency and members of the agricultural sector. These trainings are geared towards improving the PHNEOC’s capacity to better prepare for health-related emergencies.

The PHNEOC/MoHS as beneficiaries have acquired increased knowledge on the method of approach in risk mitigation, analysis, preparedness, response, and recovery. For instance, EOC Focal Persons have been trained in all districts in Sierra Leone to decentralize command and control approach which has provided the necessary pace, efficiency, and structure for response efforts and foster real-time reporting and bridged the gap in communication from the districts EOC’s to the national EOC. eHA, with support from CDC, has embarked on introducing tools that seek to improve the coordination strategy of the PHNEOC such as the Virtual  Emergency Operations Center (EOC) communication platform tool. eHA has partnered with MoHS with support from CDC to train about 200 PHNEOC/MoHS staff on various public health emergency topics such as tabletop simulation exercises on Cholera and Lassa Fever; Executive Management training and Virtual EOC training.

“I have participated in several trainings, I must confess that knowledge gained in this training is exceptional and can contribute meaningfully in any future outbreak and also benefit my District Health Management Team (DHMT) with management skills.”

— Sahr Amara Moiba

Virtual EOC training participants

Sahr Amara Moiba, District Surveillance Officer and EOC focal person in Kono district, is one of the 200 beneficiaries of the EMP training.

In 2018, there was a Measles outbreak in Pujehun and Kambia district. The EOC focal persons in these districts sent in a daily situational report to the national EOC which was presented to partners during the daily briefing meetings held at the EOC.

As part of the effort to strengthen the PHNEOC preparedness and response capacity, and also improve on the country’s Joint External Evaluation scores, eHA in collaboration with MoHS with support from CDC, developed SOPs for public health response. These SOPs will help improve on the response strategy of the PHNEOC in a coordinated way.

“These SOPs will help foster a coordinated response in an event of any public health emergency.”

— Mukeh Fambulleh, Program Manager of the PHNEOC

eHealth Africa and partners boost Sierra Leone’s surveillance capacity through 117 Call Center

By Uche Ajene

Photo caption: Alexander Taylor, 117 Call Center Manager conducted a tour of the upgraded facility

Between 2018 and 2019, eHealth Africa (eHA) and the Ministry of Health and Sanitation (MoHS) worked together to ensure that Sierra Leone’s surveillance efforts were strengthened through the use of 117 Call Center.

The 117 Call Center is a Sierra Leone Ministry of Health and Sanitation initiative that was set up in 2012 as part of a wider support system to improve maternal and child health. In 2014, eHA partnered with the Ministries of Health (MOH) in Guinea, Liberia, and Sierra Leone to scale up existing universal toll-free numbers to become Ebola focused call centers. The 117 Call Center was scaled-up in response to the Ebola Virus Disease (EVD) outbreak - to serve as a tool to document, track and provide follow-up on suspected EVD cases and deaths. The 117 Call Center provides an early warning mortality and syndromic surveillance system tool that can detect, prevent and respond to disease outbreaks. Communities are sensitized to call the 117  line and report all deaths, suspicious illnesses, and events. In Sierra Leone, the 117 Call Center has helped to solve many issues like improving community death reporting through mortality surveillance; real-time alert reporting for infectious death, increasing alert and data support to the maternal & perinatal disease surveillance.

Recently, the 117 Call Center has seen major transformation-from extending the facility and giving it a facelift, to upgrading software for a more efficient system that the peoples of Sierra Leone can trust and utilize.

“We have upgraded the call center software for a more accurate and precise data collection. Our community health workers play a very vital role in reporting cases to 117. We have added a new caller category of Community Health Workers. We also provided internet services for all the districts for real-time reporting and data collection for 117. We have also improved on our SMS software service that now provides a single text code to a caller to receive the burial code which confirms that they have indeed called 117.”

— Sally Williams, 117 Project Manager, eHA.

In an effort to get the districts more engaged, 117 is not just centralized in Freetown. Alert desks have been set up in all 14 districts with District and Data coordinators there to manage the calls in real time.

“The 117 Call Center is making positive strides in the country and the upgrade has taken it to international standard. 117 is easier to rebrand, given its popularity across the country.”

— Dr. A.J. Moosa, Deputy Director - Health Security and Emergency.

Strengthening the surveillance system in Sierra Leone through the 117 Call Center is an unending quest.

“We are planning on re-branding 117 and utilizing the social mobilization officers especially in the districts so that we can reach a greater number of our communities and encourage people to call 117 for any and all emergencies!”

— Sally Williams

The 117 Call Center actively participates in the Surveillance Technical working group of the government of Sierra Leone’s One Health Approach Initiative, where the most updated information is shared as received via our call centers to guide interventions. Every day, the 117 Call Center is striving to produce better quality data to drive the evidence-based approach when handling public health issues in the country.

eHealth Africa renovates Njala University research center with CDC funding

By Sahr Ngaujah

eHealth Africa (eHA) in partnership with U.S. Centers for Disease Control and Prevention (CDC), has renovated the  Njala University research center at Tiwai Island, in a drive to support one-health surveillance activities in Sierra Leone. The project was funded by CDC, with the objective of improving knowledge and infrastructure capacity at Njala University research center to perform routine Ebola and infectious disease surveillance.

Research began on Tiwai Island in the early 1980s, with studies on primates, other mammals, forest dynamics etc. This research was vital for disease and one-health surveillance activities as Sierra Leone, ebola virus disease outbreak was traced to bats and primates. However, over the years, the facility had fallen into disrepair and was unusable. Renovation of the Tiwai Island research center commenced in November 2018. eHA has now completed renovations on the entire campus including storage room; kitchen, meeting areas, and dormitories. The facilities were equipped with solar power, which now provides uninterrupted power on a daily basis, solar powered water supply in order to ensure adequate water supply during the dry season.

“Those who had visited the Tiwai Research Center before now, would agree with me that there is much difference after the renovation. We are happy that this facility is now ready for use. Communities and stakeholders associated with Tiwai are very grateful. This was made possible through funding from the CDC and renovations by eHealth Africa.”

— Dr. Lebbie, Head of Department of Biological Science, Njala University- Head of the Njala Research Center

“CDC has been working with Njala since the Ebola outbreak. CDC has a strong relationship with the Njala team and helping them to have more capacity to do testing to look for viruses, including the Ebola virus that caused the outbreak here. We are looking for other viruses that are in the environment so that we can know more about our environment, learn to live safely with it, and prevent outbreaks from happening. We want to prevent disease outbreaks, and we’re doing that by helping the people of Sierra Leone find those viruses themselves – to study them here so that they don’t rely on outside help. We have seen great success with Njala University and their team doing this work here. CDC is eager to continue to support that effort because we’re so impressed by what’s been done already.”

— Dr. Brigette Gleason, Surveillance and Program Lead CDC Sierra Leone Country Office

These renovated structures go to benefit not only Njala University students and faculty and  Sierra Leone’s Ministry of Health and Sanitation (MoHS), but also international researchers.

“We will be inviting international auditors who will be resident here to do research; and through that, job opportunities would be opened to the community.’”

— Dr Lebbie

The Importance of High-Quality AFP Surveillance Data in the Fight to Eradicate Polio

Polio is targeted for eradication because the presence of the virus anywhere means that children everywhere are at risk. The Global Polio Eradication Initiative (GPEI) focuses on strengthening Acute Flaccid Paralysis (AFP) surveillance worldwide to detect and respond to the poliovirus, to build herd immunity to protect the population and to halt the transmission of the virus. The data on the spread of AFP is invaluable especially for polio-endemic countries like Afghanistan, Pakistan, and Nigeria because it helps in determining whether they can finally be certified polio-free.

There are four steps involved in AFP surveillance and the Auto- Visual AFP Detection and Reporting (AVADAR) project responds to the first step—finding and reporting children with AFP—in eight priority countries in Africa. In many of these countries, disease surveillance and notification officers (DSNOs) at the health facilities are unable to actively find AFP cases for reasons ranging from difficulty in accessing settlements to security challenges. AVADAR trains community informants to search for and report the presence and/or absence of children with AFP in their community, using a mobile application. The application also has an embedded video that shows a child with AFP so that community informants can better recognize an AFP case. This reduces the burden on the DSNOs and allows them to focus on confirming if the case is truly AFP or not.

How AVADAR works

To ensure that AFP surveillance is conducted impactfully and that the AFP surveillance data collected is accurate, timely and of high quality, the GPEI defined five global indicators: Completeness of reporting, Completeness of case investigation, Completeness of follow-up, Sensitivity of surveillance and Laboratory performance.

Global Polio Eradication Initiative: AFP Surveillance indicators

AVADAR was designed by eHealth Africa, Novel-T, the World Health Organization (WHO) and other partners, to contribute to the achievement of the above targets. Below are the measures that have been put in place to ensure the collection and use of high-quality data to track and reports suspected AFP cases, and to inform decision making for polio eradication.

• Coverage: To decide where to site an AVADAR system, WHO carries out an assessment of the target country/districts to identify rural, hard-to-reach and underserved communities which are typically more predisposed to poliomyelitis. The AVADAR system, equipped with geospatial tracking capabilities is then deployed to community informants/ AFP reporters. This unique feature of the application helps to validate the location of the suspected AFP case, independent of the reporter.  

• Reporting: The AVADAR application allows informants to deliver reports anywhere and anytime in order to prevent data loss and to ensure near real-time, accurate reporting.  The app is designed to be used by people with basic literacy levels and is available in eighteen local African languages for ease of understanding. A report is better able to provide insight and enhance planning or decision making when it is timely. One of the key weekly metrics captured on the AVADAR dashboard is the number of complete results that were submitted as at when due, thus ensuring that all informants are actively engaged. Informants are expected to look out for and report cases of children aged 15 years and below, who have any form of physical deformity on the limbs or arms. In the event that no AFP case has been sighted within a week, the informant must send a ‘no report’, to validate his presence on the system.  

  AVADAR has improved the rate of AFP reporting compared to the traditional system of AFP reporting. For example, between June 2017 and June 2018 in the Lake Chad Basin countries(Chad, Niger, Nigeria, and Cameroon), the AVADAR system recorded 589 supsected cases against the 213 cases recorded by the traditional AFP Surveillance system.

• Verification: Paralysis in children can be caused by several agents including the Poliovirus. After the community informants submit their reports of suspected AFP cases, trained health workers carry out further investigations to confirm if they are true AFP cases. The WHO has designated laboratories all over target countries that are certified to test fecal samples and isolate the poliovirus. AVADAR weekly reports show how many suspected AFP cases were reported, how many were tested and the number of cases confirmed to be true AFP cases. This sort of data measures the cost of a single confirmed AFP case, the prevalence and incidence of AFP in target areas, thus enhancing the quality of AFP surveillance data for decision making.

AVADAR dashboard

Having data on the spread of AFP in a geographic location helps with planning towards its containment. Since Poliomyelitis is mainly oral-fecally transmitted, sanitization and sensitization of the environment and inhabitants respectively can help reduce the spread of polio.  AFP data gathered across different locations has been used in making an informed decision on determining the number of health workers that can effectively manage its spread to neighboring communities. On the contrary, no data or false data could lead to health workers focusing their energy in wrong locations thereby risking the spread of polio and the extension of its existence.

Without reliable and accurate AFP surveillance data, true progress towards polio eradication cannot be measured. AVADAR’s impact in high-risk countries across Africa demonstrates how context-appropriate interventions and solutions can transform disease surveillance and emergency management systems.

“One of the most important features of the AVADAR system is the engagement of over a hundred community informants per county. They are trained and equipped for the first time to provide timely reports that can be accessed at all levels from the county to the national level and beyond, thereby allowing suspected cases to be investigated in an accurate and efficient way.”

— Dr Sylvester Maleghemi, WHO Polio Eradication Initiative Team Lead, South Sudan

International Translation Day Spotlight: AVADAR

By Adaeze Obiako

“If you talk to a man in a language he understands, that goes to his head. If you talk to him in his language, that goes to his heart.”

— Nelson Mandela

This year, the United Nations is celebrating “International Translation Day” for the first time. The celebration is an opportunity to pay tribute to language professionals, whose work plays an important role in bringing nations together, facilitating dialogue, fostering understanding and cooperation, and contributing to the development and strengthening of world peace and security.

For eHealth Africa (eHA), translation has been instrumental to the success of several projects, particularly the Auto-Visual AFP Detection and Reporting (AVADAR) project.

When AVADAR commenced in 2016, we knew it was a worthwhile intervention towards the eradication of polio in Nigeria; however, we could not have anticipated just how much of a positive impact it would end up having on the Acute Flaccid Paralysis (AFP) surveillance system across Africa. Between 2016 and 2018, AVADAR grew from a small pilot in two states in Nigeria to a full-fledged project across 8 West and Central African nations. Several factors contributed to the success and scale of the project, one of which was the educational AFP video embedded in the AVADAR mobile app used to train community informants on proper detection (and subsequent reporting to health authorities) of AFP cases within their communities.

This is where language came in.

The project management team, made up of the World Health Organization (WHO), country Ministries of Health, the Bill and Melinda Gates Foundation, Novel-T, and eHA, knew early on that the key to ensuring accurate AFP detection and proper use of the AVADAR app for case reporting lay with developing a sense of connectedness and trust between all stakeholders (from project implementers to health workers to community informants) through the breakdown of language barriers.

Part of the pre-implementation phase in each country included research into what languages were spoken by indigenes using the AVADAR app and the AFP video, and the entire app was translated into each applicable language. Below is an example of the AFP video translated into Hausa, a local language commonly spoken in northern Nigeria, Niger, Chad, Cameroon and the Central African Republic.

In addition to the AFP video and app being translated into multiple languages, the training facilitators (who train informants on how to use the app) and field officers (who provide weekly phone troubleshooting support to informants) were all indigenes of the implementing regions and fluent in the local languages to ensure ease of communication and understanding for the AVADAR informants.

As AVADAR continues operation across Africa, it is clear that we have the power of translation to thank for bridging the gap and allowing thousands of community members and health workers across different African nations to support the fight against polio. At this rate, it won't be too long before polio, like smallpox, is considered a public health issue of the "past".