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Preface Background

I was seconded to conduct an evaluation of the Nigerian Emergency Response Units (NERU) surveillance system in June 2016. The public health unit at MSF-OCA, were conducting a review of their surveillance activities with the intent on strengthening surveillance within the MSF Emergency Response Units (ERUs).

Having had limited experience in the practical implementation of disease surveillance I was excited to be given the opportunity to evaluate the NERU surveillance system, considered a flagship surveillance system in a difficult working context.

This chapter is structured around the final report I constructed for the NERU project team and MSF-OCA public health unit on the outcomes of the evaluation of the NERU surveillance system. The appendices in this chapter contain the guiding questions used in stakeholder consultations. An important caveat to make with respect to this evaluation and the interpretation of the results is that raw data is collected by the Nigerian Ministry of Health (MoH).

Due to political sensitivities it was not possible for me to evaluate the quality of the raw data or interview many of the MoH stakeholders. This is a major limitation; however given that in many of the contexts in which MSF works they are faced with similar sensitivities it is felt that this evaluation can still inform the replication of the surveillance system in other projects.

My role

I was the primary investigator in the evaluation of the NERU surveillance system. I developed the evaluation plan, conducted a desk review, liaised with the project team and the epidemiology advisor for MSF-OCA, developed the stakeholder interview guide and carried out the interviews, analysed the data, discussed recommendations with the team and prepared the final report that is presented in this chapter.

I was asked to identify the strengths and weaknesses of the surveillance system while making recommendations that could serve two purposes; firstly to inform NERU on areas for improvement and secondly to inform other ERUs within MSF.

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Lessons learnt

- This evaluation provided me with the opportunity to understand the workings of a successful surveillance system in a challenging context, the difficulties faced by the team and the prioritization of problems faced.

- I gained technical skills in using surveillance databases, and critically appraising their strengths, weaknesses and usefulness. I learnt that a very simple system is highly effective in facilitating early detection and response to epidemic prone diseases with high mortality.

- I was also reminded that a little capacity building can go a long way. The investment NERU has made in building the capacity of the MoH staff has strengthened the cooperation between MoH and NERU staff, facilitating communication and early detection of outbreaks.

- This evaluation also provided me with yet another opportunity to meet a unique and diverse group of people and experience the beauty of Nigeria and its culture.

Public health impact

This evaluation highlights the effectiveness of an integrated surveillance system where partnerships between the MoH and an NGO can be used to mitigate the effects of a slow to respond national system, ensuring rapid response to diseases that cause high mortality and morbidity.

The evaluation provides recommendations for both NERU and other MSF ERUs looking at setting up or improving disease surveillance systems.

Acknowledgements

I would like to express gratitude to Dr Jane Grieg, MSF Epidemiologist at the Manson Unit in London who offered me this opportunity and provided guidance for the evaluation and constructive feedback on the final report.

I would like to thank Dr Kerri Viney, my ANU supervisor, who also provided guidance and constructive feedback on the final report.

I would like to also express my appreciation to Valentinos Silvestros, MSF epidemiologist in Nigeria for sharing his EPIET (European Program for Intervention Epidemiology Training) experience and knowledge.

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Most of all I wish to thank the NERU team and MSF team in Nigeria for their fantastic hospitality, sense of humour, patience in answering all my questions and requests for documents; a dynamic team doing a fantastic job in a difficult context.

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Abstract

Background: Médecins Sans Frontières established the Nigerian Emergency Response Unit (NERU) in 2008. In 2011 the current surveillance system was established to facilitate a timely response to emergencies, with the aim of decreasing morbidity and mortality within the four North Western states of Nigeria; Sokoto, Kebbi, Zamfara and Niger. The objective of this study was to evaluate the attributes of the NERUs surveillance system, identifying strengths and weaknesses and to formulate recommendations for improvement.

Methodology: This was a formative observational study that used multiple forms of data collection in order to assess system attributes including; a desk review of relevant documentation, stakeholder interviews and surveillance data were analysed for the period January 2011 - June 2016. The evaluation was conducted in June 2016 using the conceptual framework and performance criteria for the surveillance system drawn from the Centers for Disease Control and Prevention (CDC) Guidelines for Evaluating Public Health Surveillance Systems.

Results: The NERU surveillance system has identified multiple outbreaks of measles, cholera and cerebrospinal meningitis since its inception. The strengths of the system included high acceptability among both MSF and Ministry of Health (MoH) staff, its simplicity, flexibility and stability and the sensitivity of the surveillance system to detect clusters and outbreaks. Areas for focussed improvement were timeliness and feedback to those collecting the data.

Conclusions: The NERU surveillance system is a strong example of an effective and efficient integrated surveillance system for monitoring epidemic prone diseases. The model could be applied in other contexts where the local MoH has an established disease surveillance system but limited capacity to respond in a timely manner.

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List of Abbreviations

AR Attack Rate

CDC Centre for Disease Control CFR Case Fatality Rate

CSF Cerebrospinal Fluid CSM Cerebrospinal Meningitis

DSNO Disease Surveillance Notification Officer

EPREP Emergency Preparedness and Response in Emergencies Plan LGA Local Government Area

MedCo Medical Coordinator MoH Ministry of Health

MOU Memorandum of Understanding MSF Médecins Sans Frontières

MSF-OCA Médecins Sans Frontières - Operational Centre Amsterdam MTL Medical Team Leader

NEMA National Emergency Management Agency NERU Nigerian Emergency Response Unit NmA Neisseria Meningitides serogroup A NmC Neisseria Meningitides serogroup c PC Project Coordinator

PCR Polymerase Chain Reaction RDT Rapid Diagnostic Test

SEMA State Emergency Management Agency WHO World Health Organization

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Internal Report:

Evaluation of the Nigerian Emergency Response Unit surveillance system: Médecins Sans Frontières, Nigeria

Author: Tambri Housen (Epidemiologist: MSF-India, MAE Scholar: Australian National University)

Summary of recommendations

 In order to assess whether NERU is meeting its specific objectives the NERU team needs to ensure it is collecting the appropriate indicators on which to measure the stated targets of success, as defined in the combined progress and proposal 2016.(1)

For example, one of the stated targets for Specific Objective 1 is that >80%

of outbreak alerts are investigated at the source, yet NERU does not keep a record of responses to alerts therefore this target is not measurable.

Likewise another target under the same objective is that >50% of Local Government Areas (LGAs) with consistent underreporting will be visited; I found no record of visits to LGAs for this purpose.

 An annual review of targets in view of data collected and reported would provide regular direction to the team on areas for improvement.

 Sensitivity to identify clusters and outbreaks could be improved by aggregating alerts at ward level. The passive surveillance data tool would benefit from an automated notification when a ward exceeds the alert threshold for a specific disease. Weekly reports should also reflect ward level data including population data, attack rates and case fatality rates.

 A mapping tool linked to the current NERU data tools will be an asset to reporting and facilitate following trends at ward level. Mapping completeness of reporting could also be used to monitor and motivate DSNOs to report.

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 The measles alert threshold should be revised to improve spatial sensitivity.

Presently the alert threshold is defined as ‘when 150 cases have been reported across all four states NERU will initiate active surveillance and assess the need for an intervention’.

NERU could consider an alert threshold defined by a spatial and temporal marker such as ‘double the weekly average number of cases seen in the previous 3 weeks for a specific location¹’. This would increase the sensitivity of outbreak detection and the capacity for a timely response.

 There is a need to further strengthen relationships between NERU and District Surveillance Notification Officers (DSNOs) in order to improve data quality, completeness and timeliness to achieve NERUs stated targets.

Specifically, investment in MoH and DSNO collaboration in the states of Niger and Zamfara should be prioritised. DSNOs expressed a desire for more interaction with NERU in the form of training and capacity building and feedback on what NERU does with the data they provide.

 Data management can be simplified by ensuring a consistent format across all data tools. The current Cholera active surveillance data tool is in a different format to the Cerebrospinal Meningitis (CSM) and Measles data tools.

 An organised filing system would be an asset to NERU. Documentation is important to monitor a project over time in order to observe lessons learnt and the continual moving forward.

1 The revision of the weekly report including location and follow-up reporting, as suggested in this report would facilitate following weekly patterns in specific LGAs and Wards.

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Introduction Context

Médecins Sans Frontières (MSF) shares an intimate history with Nigeria. The organisation was founded during the Biafran conflict in the Southern region of the country in 1971 (Figure 4.0).(2) With the exception of a response for the 1985/86 yellow fever outbreak, MSF did not return to Nigeria until 1996 when two large outbreaks of cerebrospinal meningitis (CSM) and cholera led to large scale interventions.(2, 3) Since 1996 MSF has been present in Nigeria in varying capacities, primarily responding to humanitarian emergencies due to outbreaks of communicable diseases and population displacement as a result of natural and man-made disasters.(3)

Figure 4.0 Political Map of Nigeria2

2 http://www.mapsofworld.com/nigeria/maps/nigeria-political-map.jpg NERU passive and

active surveillance activities

Region previously known as Biafra NERU to respond to

alerts, no passive surveillance

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The Northern region of Nigeria is situated in the meningitis belt of Africa and has a history of repeated large outbreaks of measles, cholera and CSM and population displacement due to both natural and man-made disasters. NERU works in close collaboration with the state Ministries of Health (MoH) in Sokoto, Kebbi, Zamfara and Niger (Figure 4.0). This partnership facilitates the timely detection and response of sudden increases in cases of endemic diseases and public health events that can have disastrous consequences on the affected population.

Diseases under surveillance Measles

Despite an effective inexpensive vaccine being introduced in the 1960s, measles remains a significant cause of mortality in the under 5 year old population in developing countries with low vaccine coverage and the presence of chronic under nutrition. In 2015 there were 386 354 reported cases of measles in the World Health Organization (WHO) member states.(4) This figure is thought to reflect a small proportion of true cases with many individuals not presenting to a health care centre. Poor reporting mechanisms in health care centres further bias the estimate of the true burden of disease.(4)

Measles is one of the most highly communicable infectious diseases, which is transmitted via airborne droplets or direct contact with nasal or throat secretions of an infected person. It is caused by a paramyxovirus (morbillivirus) which has only one reservoir, humans.(5) The incubation period ranges from 7-18 days from exposure to onset of fever.(6) The period of infectivity occurs 3-4 days prior to onset of rash and continues for up to five days after the rash begins.

(5) Infection with the measles virus is characterised by prodromal fever, conjunctivitis, coryza, cough and a rash which appears on the 3-7^th day starting on the face and progressing to become more generalised usually lasting 4-7 days.(6) Children under 5 years of age and adults experience a more severe disease; complications include otitis media, pneumonia, diarrhoea and encephalitis.(6) In children with poor nutritional status measles often precipitates acute kwashiorkor and exacerbates vitamin A deficiency which can result in blindness.(6)

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The case fatality rates in developing countries can range from 3% to 15% but can increase to over 20% in vulnerable populations, e.g. those suffering from malnutrition.(5, 6) Case confirmation occurs with laboratory identification of measles specific IgM antibodies.(6) In regions with low vaccination coverage (below 50%) and where measles is endemic, outbreaks can be expected every 1-2 years.(5)

Management involves the administration of Vitamin A, testing and treatment for malaria and other comorbidities.(5) Reactive vaccination is recommended early in the outbreak response.(7, 8)

Cholera

Cholera is one of the oldest and best understood endemic diseases, an acute highly communicable bacterial enteric disease responsible for six pandemics between 1817 and 1923.(6, 9) Cholera was also the disease responsible for the development of the first epidemiological principles in modern medicine and the move away from Miasma theory of disease causation.(10) Humans are the main reservoir for Vibrio cholera, outbreaks and pandemics have been epidemiologically linked to the consumption of contaminated water, poor hygiene and sanitation and overcrowding.(6) Cholera is transmitted via the faecal-oral route with an incubation period from a few hours to five days.(6)

Diagnosis is confirmed with the isolation of Vibrio cholerae of serogroup O1 or O139 from faeces.(6, 9) Severe illness is characterised by the sudden onset of profuse painless rice-water stools, nausea and vomiting which rapidly progresses causing severe dehydration, acidosis, hypovolemia, renal failure and death.(6) Mild infection may be asymptomatic or cause mild diarrhoea. In large outbreaks of severe disease the case fatality rate may exceed 50% if timely rehydration is unavailable, on the contrary it can be as low as 1-2% with timely intervention and adequate treatment.(6, 9) During an outbreak an individual cannot be infected more than once with the same strain, however immunity wains within 3-6 months, rendering the individual susceptible to re-infection with re-exposure.(9) Cholera is one of three diseases for which case reporting is required by the International Health Regulations Act.(11)

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Management is through active case finding, rapid rehydration of cases, identification of the source and chlorination of water sources, health promotion (hygiene and sanitation) and provision of clean drinking water.(9) Reactive vaccination during outbreaks is recommended in recent scientific literature.

(12-14)

Cerebrospinal Meningitis

Meningococcal meningitis, caused by Neisseria meningitidis (Nm), is a gram-negative bacterial disease transmitted via direct contact with respiratory droplets from the nose and throat of infected people, humans are the only reservoir.(6, 15) Outbreaks commonly occur in the sub-Saharan region of Africa in an area known as the ‘meningitis belt’, affecting areas of Sudan, Chad, Niger, the Central African Republic, Nigeria, Cameroon, Benin, Burkino Faso, Guinea and Mali, Figure 4.1.(15) The epidemic season of 1996-97 was the largest outbreak of NmA recorded with 250 000 cases and 25 000 deaths (CFR 10%).

Figure 4.1: The meningitis belt of sub-Saharan Africa (3)

In an endemic area, during outbreaks, the disease typically affects children over the age of 6 months of age, adolescents and young adults.(15) The incubation period for meningitis is between 2-10 days. Infection with Neisseria meningitides is characterised by a sudden onset of fever, severe headache,

3 http://content.healthaffairs.org/content/30/6/1049/F1.large.jpg

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nausea and vomiting, stiff neck and photophobia. (6) A petechial rash is often observed in Caucasian patients but rarely in Africans.(16) Invasive disease is further characterised by bacteraemia, sepsis and meningitis which in 10-20%

of survivors results in long term sequelae including hearing loss, loss of limbs and mental retardation.(6) Confirmation of diagnosis is traditionally by laboratory identification of meningococci from cerebrospinal fluid (CSF) or blood, polymerase chain reaction (PCR) is increasingly used when available.(16) Case fatality rates are dependent on the timeliness of an intervention and quality of treatment provided. Left untreated meningococcal meningitis will lead to death in 50-80% of cases.(15)

Management involves active case finding, antibiotic therapy, testing and treatment for malaria and other comorbidities.(15) Vaccination of close contacts is recommended. Reactive vaccination is recommended early in the outbreak response.(15)

The epidemiology of meningitis in Africa was drastically altered in 2010 with the widespread vaccination of four countries in the meningitis belt with MenAfriVac^TM, a conjugate vaccine against NmA.(16) The last significant outbreak of NmA occurred in Nigeria in 2009. In 2013 a new hyper virulent strain of NmC was isolated, this new strain was the cause of a large outbreak in Niger and Nigeria in 2015.(17, 18) There is concern that the high communicability of the new strain could potentially cause outbreaks on the scale of that previously seen with NmA.(16)

Risk in context

Risk factors for large outbreaks identified in the literature include immunological susceptibility due to loss of herd immunity or low vaccination rates, climatic conditions (dry or wet season, dust storms), pathogen virulence and other factors that increase susceptibility such as widespread chronic malnutrition, poor hygiene and sanitation practices, high density population and comorbidities that weaken the immune system.(5, 9, 15, 19, 20)

The North Western region of Nigeria is characterized by a Sahel climate Kebbi Close proximity to the Sahara deserts exposes the northern states to the dry, dust-laden Harmattan winds from December to May, damaging mucous

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membranes of the respiratory system and increasing susceptibility to communicable diseases transmitted by droplets.(17) People in the northern states rely heavily on uncovered hand dug wells as a primary water source.(12) Annual heavy rains occurring between June-September, combined with poor sanitation practices, increase the risk of faecal contamination of these water sources, increasing risk of exposure to pathogens such as Vibrio cholera.(21)

The population of each state is represented in Table 4.0. Population figures are taken from the 2006 Population and Housing Census (the most recent available) with a 2.4% annual growth rate as recommended by the National Population Commission of Nigeria⁴.

Administratively, the health system in Nigeria is based on a fee for service model divided at three levels with separate funding mechanisms. Primary health care is under the jurisdiction of the local government area (LGA) and consists of basic maternal-child healthcare and health education.(22) Secondary health care is under the jurisdiction of, and funded by the state.

Tertiary health care is funded by the federal government and focusses on the care and treatment of complex health problems. The organisational hierarchy and separate funding models at each level restricts the capacity of the MoH to mount an effective and coordinated emergency response to significant public health events.(22)

Timely identification of an outbreak and rapid response can have a significant impact on the number of cases and the case fatality rates of infectious

Timely identification of an outbreak and rapid response can have a significant impact on the number of cases and the case fatality rates of infectious