Assessing the implementation of an electronic Integrated Disease Surveillance and Response System using DHIS2, 2024: Sierra Leone´s experience

Magoba Bridget¹, Joseph Sam Kanu², James Sylvester Squire², Adel Hussein Elduma^1,3, Gebrekrstos Negash Gebru^1,3,&

 

¹African Field Epidemiology Network, Freetown, Sierra Leone, ²National Disease Surveillance Program, Ministry of Health, Freetown, Sierra Leone, ³Sierra Leone Field Epidemiology Training program, Freetown, Sierra Leone

 

 

^&Corresponding author
Gebrekrstos Negash Gebru, National Public Health Agency, Wilkinson Road Freetown.

 

 

 

 

Public health surveillance systems generate information needed to assess the health status and health care system of the population [1]. In September 1998, the World Health Organization (WHO) African region member states adopted the use of Integrated Disease Surveillance and Response (IDSR) system as a regional strategy for early detection and response to priority diseases and conditions during the 48^th WHO Regional Committee for Africa meeting through resolution AFRO/RC48/R2 [2], [3]. Since then, Sierra Leone has adopted the IDSR strategy to improve data collection, reporting and analysis. The IDSR strategy is implemented by using Technical Guidelines (TGs), and the WHO African region office has developed several editions of the TGs to guide the surveillance program. The first IDSR of the technical guidelines were developed in 2001 while the second and third editions were released in 2010 and 2019, respectively [4].

 

Sierra Leone adopted the first edition of the IDSR technical guidelines in 2008 in which it prioritized to monitor 36 communicable and non-communicable diseases and conditions through the IDSR strategy [2]. These included epidemic-prone diseases, diseases targeted for eradication and elimination, and diseases of public health importance. However, implementation did not begin immediately [2]. The country adopted the 2^nd and 3^rd editions of the IDSR TGs in 2015 and 2020, respectively, and the list of priority diseases and conditions was revised with each edition.

 

Regarding the Global Health Security Agenda (GHSA) and the International Health Regulations (IHR), countries are expected to have core capacities to detect diseases, including real-time surveillance and reporting [5, 6]. Similarly, countries´ performance is assessed using the Joint External Evaluation (JEE) and State Party Annual Self-Assessment Report (SPAR) tools for achievement of the core capacities.

 

Before the Ebola Virus Disease (EVD) outbreak in 2014-15, Sierra Leone was not systematically implementing the IDSR system across the country, which contributed to the delay in detecting and reporting the first EVD case due to the weak surveillance system. The existing national disease surveillance system, which was used to collect data on priority diseases or events of public health concern at facility and community levels was paper-based [2]. The District Health Management Teams (DHMTs) would then compile the health facility reports into an Excel sheet, which was then sent to the national-level surveillance program through email for final compilation and analysis. However, the reporting rate was low at the health facilities that used paper before and during the EVD outbreak. Less than half of the health facilities submitted weekly reports that were often late [1]. Health facilities were reporting using paper reports or verbally to the district-level staff on the number of cases of disease conditions and events that had been detected. Thus, the surveillance system needed to improve to ensure rapid detection, reporting and response to priority diseases and conditions from the lower level. The first step taken to improve the surveillance system in the country was the adaptation of the 2010 second edition IDSR technical guidelines to suit the country´s health care system, standard case definitions, reporting forms and data flows. The adaptation was made in 2015, and a 3-tier training was conducted for staff at all surveillance reporting levels (health facility, district and national) in a phased approach to operationalizing the IDSR technical guidelines at these levels [1].

 

The paper-based health data recording, compilation and reporting from all health facilities at the national level continued after the adaptation of new IDSR guidelines and tools in 2015. However, this was characterized by untimely, incomplete reports, inaccurate data such as underreporting, and duplication (errors at different levels of data source and report generation). Complex report filing and record storage systems, as well as limited data access and use at all levels, were commonly observed. To resolve these challenges, it was necessary to transform the paper-based surveillance system into a digital surveillance system. The process of digitizing the surveillance system started in mid-2016, and the digital system was anchored on the existing DHIS2 for the monthly reporting of diseases [7]. Based on DHIS2 capability to manage disease surveillance data, it was important to integrate public health disease surveillance on the same platform to collect the weekly and case-based (immediately reported) data of Integrated Disease Surveillance and Response (IDSR) priority diseases adopted in the country. This paper reported the assessment of the impact in implementing an electronic disease surveillance system in Sierra Leone.

 

 

Study Period, Design, and Setting

 

In June 2024, we conducted a retrospective analysis of surveillance data collected in Sierra Leone between January 2016 and June 2024. The country is located on the West Coast of Africa, covering an area of approximately 71,740 km[1]. It shares borders with Guinea to the northeast and Liberia to the southeast. As of 2020, the country has a projected population of 8,100,318, with 1,798,271 women of childbearing age[1,2]. Sierra Leone is divided into five administrative regions comprising 16 districts (Figure 1). The health infrastructure is tied to tertiary hospitals, secondary (district) hospitals, and peripheral health units (PHUs)[2]. Sierra Leone implements a public health surveillance system in all its 16 districts and in over 1500 health facilities. Data fr the surveillance system flows from the health facility to the district and national levels.

 

Data collection and analysis

 

The weekly electronic surveillance reporting tool in the eIDSR was used to collect data from all the health facilities. The collected data was then downloaded from the eIDSR database and analyzed for key performance indicators of the surveillance system as stipulated in the IDSR 3rd edition [8]. We also conducted desk reviews on crucial documents such as outbreak technical reports, the International Health Regulations State Party Annual Self-Assessment Report (SPAR), Joint External Evaluation (JEE) surveillance indicators including: D2.1, Early Warning Surveillance, D2.2, Event Verification and Investigation and Indicator D2.3, Analysis and Information Sharing.

 

Key indicators assessed were completeness and timeliness of the health facility reporting, data submission methods, case notification and response timeliness, and IHR capacity scores. Completeness is calculated as the proportion of the actual reports received in the system with the expected reports from all the health facilities. In contrast, timeliness is calculated as the proportion of actual reports received on time (by 12 noon every Monday) with the actual reports received.

 

Data submission from the health facility to the district level is done through different forms based on the circumstances, including ordinary phone calls, paper forms, ordinary short message service (SMS), also known as text message, automated short message service from the eIDSR system also known as mobile SMS under poor or no network or internet connectivity and mobile internet where internet bundles are used to submit the data through the system. The district staff then captures the data submitted through phone calls, paper-based, and SMS forms in the system. Mobile SMS and mobile internet submissions are electronic submissions where data is submitted directly into the system, therefore only awaiting district-level staff approval.

 

Ethical considerations

 

The assessment did not require ethical clearance since it considered a part of routine surveillance activities. However, permission was obtained from both the Ministry of Health and the National Public Health Agency, who are the custodians of the data. Data security and patient confidentiality were upheld throughout the data collection and analysis process. No personally identifiable information was collected, and all data were anonymized before analysis.

 

 

Establishing the weekly electronic surveillance reporting tool

 

Since 2015, Sierra Leone´s Ministry of Health (MoH), in collaboration with partners - U.S. Centers for Disease Control and Prevention (US CDC), World Health Organization (WHO), Focus 1000, and Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), developed the electronic Integrated Disease Surveillance and Response (eIDSR) weekly reporting tool. The eIDSR tool was designed by MoH with support from eHealth Africa (eHA) as a customized web form built on DHIS2 and a custom mobile application called DHIS2 eHealth data capture, which is compatible with the national health system. The tool is configured with validation rules and a mechanism of data approval at the district level to minimize reporting errors. Through this tool, the reporting channels are Short Message Service (SMS) submission, mobile internet submission and web-based submission.

 

The tool´s implementation began at the district level, where DHMT staff captured data reported from health facilities using the web application. Two months into implementation at the district level, an evaluation showed that DHMT staff were overwhelmed with the amount of data to capture on behalf of their health facilities [1]. A mobile version of the tool was conceived to be used at the health facility level as there are limited or no computers at that level [1].

 

By the end of 2016, the mobile application was piloted in six health facilities in Port Loko District for six months. After registering success, the tool was rolled out in 1,300 public health facilities by June 2019. With support from implementing partners, each trained health facility with trained staff was given a Samsung or Techno tablet with a DHIS2 eHealth data capture application installed [1]. Additionally, more than 2,300 health facility staff were trained on using the mobile application for weekly IDSR data collection and reporting across the country. Similarly, Mobile Device Management (MDM) software was installed on user devices at the health facility level to limit misuse, enhance data security, and enable remote control on application upgrades to minimize travel expenses for the technical team. However, the high costs of maintaining the MDM software and high staff attrition rate of trained staff have proved to be challenging during this implementation.

 

The implementation of eIDSR has been monitored through daily reviews of the data in the system, weekly data review at the national level during Emergency Preparedness Resilient Response Group (EPRRG) meetings [9], and through monthly in-charge conferences at the district level to review each facility´s data over the month. Additionally, weekly eIDSR technical working group meetings are held to discuss the system´s technical functionalities. Monthly meetings with the district implementation teams are held for feedback and technical challenge resolution. There are also WhatsApp groups to communicate and resolve technical challenges users face across the country as well as give feedback.

 

Infrastructure

 

Implementing the electronic integrated disease surveillance and response system resulted in an improvement of the surveillance system in the country through the display of IDSR indicators from the weekly reports on the dashboard for real time monitoring of disease trends and outbreaks. The dashboard (Figure 2) shows different outputs, including trends of completeness and timeliness, monitoring weekly submission type, and monitoring disease trends. Similarly, over 200 new health facilities that were established after June 2019, were provided with android mobile tablets for reporting. Also, damaged, lost and stolen android mobile tablets were replaced to ease health facility staff reporting through the recommended mobile SMS and interment methods though there is no plan and strategy for device replacements.

 

Completeness and timeliness of reporting

 

Similarly, the implementation of the mobile application increased the weekly completeness from <40% in 2016 to >98% in 2023.

 

The graph in Figure 3 shows the national completeness and timeliness of reporting over eight years, i.e., from 2016 to 2023, as extracted from eIDSR/DHIS2. Before the implementation of the eIDSR, the completeness and timeliness were as low as 18.2% and 18.1%, respectively, as in Figure 3. Following eIDSR implementation, there was an improvement, as shown in 2017, and a drop in timeliness in 2018, which was consistent until 2023, where both attributes exceeded both the national and WHO targets.

 

Electronic data submission rates

 

Submission of reports at the health facility level has shifted from paper-based to electronic submissions via the eIDSR application for the past 2 years. Electronic submissions are done via mobile SMS and mobile internet. There has been improved mobile internet submissions over 50 epidemiological weeks (Epi-week) shown in Figure 4, from <40% in epi-week 26, 2023 to >80% in Epi-week 23, 2024. Similarly, the rate of mobile submissions has increased over time with a maximum rate of 87% in Epi-week 22, 2024 and a minimum of 47% in Epi-week 26, 2023. However, there are continued challenges of advance in technology, fear of technology by the health facility staff, network limitations and high expenses on data bundles and SMS costs needed for data submission.

 

Data analysis and use

 

There is increased data analysis and use at all levels, including the production of weekly epidemiological bulletins at the national and district levels. In 2024, thirteen out of the sixteen (81.3%) districts consistently produced and disseminated weekly epidemiological bulletins within national communication platforms with the exception of Bo, Kailahun and Moyamba districts (Figure 5). The percentage of districts with current trend analysis for selected priority diseases/events is at 81.3%, (13/16) exceeding the WHO target of 80%. Through the routine data analysis, district and national level have detected cluster of measles cases reported from 12 districts that triggered response through mass vaccinations across the country. Similarly, the increased number of snake bite cases and deaths reported from all districts as shown in a map in (Figure 6) triggered involvement of the Directorate of Neglected Tropical Diseases for the introduction of the anti-venom treatment in the country.

 

IHR surveillance score

 

The International Health Regulations (IHR) monitoring and evaluation framework assesses countries' capacity using two quantitative tools developed by the World Health Organization: The State Party Self-Assessment Annual Reporting tool (SPAR), which is mandatory and conducted annually, and the Joint External Evaluation (JEE), which is voluntary and conducted every 4-5 years.

 

The surveillance SPAR score for the country improved from 70% in 2018 to 80% in 2023 [10]. The JEE tool has three indicators for surveillance, and the overall country´s JEE score for surveillance was 67% in 2023. The three indicators scored as follows in 2023: indicator D2.1, Early Warning Surveillance Function scored 3 out of 5, Indicator D2.2, Event Verification and Investigation scored 4 out of 5, and Indicator D2.3, Analysis and Information Sharing scored 3 out of 5 as well [11]. Countries are required to have a minimum score of 3 for each indicator, and therefore, the country has met the minimum requirement. Due to a change in the JEE tool from the earlier years, direct comparison was not possible with the 2016 evaluation [11]. For example, in 2016, the country scored 2/5 in the indicator D2.2 Interoperable, interconnected electronic real-time reporting system. However, this indicator has since been changed although the country would now score at least 4/5.

 

Digitization of the surveillance systems has greatly contributed to the improvement in overall surveillance scores for the country as indicated above. The eIDSR system contributed to the strengths highlighted in the 3 indicators including availability of a functioning indicator-based system reporting through DHIS2.

 

Notification and Response timelines

 

The eIDSR system has improved the notification timelines for timely response to public health emergencies. The national target is for all notifiable diseases to be reported by the health facilities to the district level within 24 hours of detection. The district level is then expected to investigate and respond within 24 - 48 hours. As of June 2024, the average annual score of 83% of the immediately reportable priority diseases were reported to the next level within 24 hours meeting the WHO target of 80% while 52% of the immediately reportable priority diseases were investigated and responded to within 24 hours as compared to 8% and 3% of 2018. There was no electronic data records for 2016 and 2017 on case notifications and investigations as the electronic case-based disease surveillance system was introduced in 2018 (Figure 7).

 

 

This article details the implementation of an electronic surveillance system in Sierra Leone since 2016. By January 2024, the country had implemented the electronic system across over 1500 public health facilities in all 16 Districts. There is improved completeness and timeliness of reporting for the priority diseases, conditions, and events from the health facility to the district and national levels. This has resulted in better quality data that is timely, and hence enabling the surveillance system to detect and respond to outbreaks on time. The proportion of monthly surveillance reports submitted from the districts to the national level has been on time in the last three months, increasing from 86.6% in 2021 to 96% in 2024, exceeding the WHO target of 80% [8]. Also, the proportion of cases of diseases targeted for elimination, eradication, and any other disease selected for case-based surveillance reported with case-based forms is at 83%, exceeding the WHO target of 80%. High rates of completeness and timeliness in the evaluation of the weekly aggregate disease reporting in Guinea indicated sufficient capacity at the district level for the use of DHIS2 [10].

 

The use of DHIS2 in surveillance in other countries such as Lebanon and Kenya improved timeliness, completeness and quality of data and also reduced the bureaucratic delays associated with paper-based reporting [11,12]. Sierra Leone´s experience on improving surveillance reporting is similar to Lebanon´s.

 

The weekly IDSR submission type rates has improved as a result of interventions, including replacing obsolete tablets, conducting refresher training, support supervisions, and data quality assessments at the health facility level, There is also a notable reduction in the paper-based submissions from Epi-week 1 2024.

 

Before the inception of the electronic surveillance systems in Sierra Leone, stakeholder engagement was highly considered and executed for consensus as well as agreement on implementation. The stakeholder engagement increased awareness, fostering trust, confidence, and buy-in to the system [13]. The eIDSR involves several programs and directorates from the priority diseases reported. Therefore, it´s imperative to engage all relevant stakeholders from inception to avoid conflict and improve compliance with reporting.

 

The country surveillance system was assessed before the conception of the electronic systems, and this ensured alignment with the existing manual surveillance system. Following the IDSR technical guidelines at that time, the electronic data collection tools were aligned with the already existing tools used in the field to avoid confusing the surveillance field staff. This promoted synergy between the electronic and the manual systems. Similarly, in Guinea, during the EVD outbreak in 2021, the existing data collection forms were examined and revised to be configured in the DHIS2 tracker module for collecting outbreak data [13].

 

The sustainability of electronic surveillance systems is attributed to in-country capacity to maintain them technically, operationally and financially. Sierra Leone has therefore built capacity of staff at national, district and facility level to manage and use the system effectively. Emphasis on continuous training is paramount to the sustainability of the systems as well as increasing exposure and buy-in [14].

 

Routine follow-up with system users regarding data entry and use increased exposure and familiarity with the system. Follow-ups, done after trainings and beyond, kept users and implementers in touch, thus giving technical support where needed, this encouraged users on the system utilization.

 

Sharing experiences through conferences for learning has promoted the work in Sierra Leone. Experiences shared through DHIS2 conferences, Health Informatics forums, public health forums like TEPHINET have given an opportunity for other countries to learn from Sierra Leone. Similarly, through these forums, Sierra Leone learns how to improve on its implementation based on experiences shared by other countries.

 

The periodic data analysis increases data use at different levels of data generation. Surveillance data use promoted wider dissemination, thus providing the basis for evidence-based public health decision-making. According to Elaine and Johan, findings from DHIS2 data-informed action-oriented decisions were reported in Ghana in addition to the actions taken to promote the use of DHIS2 [15]. During the COVID-19 pandemic, data collected was used across all relevant pillars, including case management, operations and logistics, laboratory, and surveillance, among others, to reallocate resources and set restrictions to manage the spread of the disease.

 

Despite the achievements and successes in implementing digital surveillance tools and systems, challenges are faced, including issues with developing, setting up, implementing, and maintaining a surveillance electronic system. Maintaining an electronic system requires stable infrastructure, internet, and electronic devices, which are vital and resource intensive. These resources have financial implications for the implementing stakeholders, including the government of Sierra Leone and its partners.

 

There is fear of change from paper-based to electronic by the users. According to Joel and Ejane [15] managing change means managing people´s fears. The reaction of people to change is unpredictable and irrational but can be managed if done right. However, a gradual process of change was adopted to ensure that surveillance reporters conveniently use the electronic system slowly.

 

The overarching change in technology affects the implementation of electronic systems through outdated infrastructure, including obsolete devices, technology, applications, and systems. This has greatly affected the devices used for reporting by users at the health facility level, with outdated operating systems no longer supported by the application, resulting in difficulties in reporting.

 

Maintenance of electronic systems is resource-intensive, especially for infrastructure, internet facilities, network connectivity, devices, and human resources. This is a challenge in Sierra Leone, and hence, there is more reliance on funding partners in the country to support the systems. This is, therefore, a major threat to the government's ability to sustain the system.

 

Rapid response teams (RRTs) at the DHMTs have the capacity to respond to any threats in their districts at the community or health facility level. A routine emergency preparedness and response technical working group has been set up at the national level, responsible for reviewing data and making public health decisions. However, gaps in the surveillance system need to be addressed, including staff attrition, which leads to gaps in trained personnel at the health facility level.

 

The main limitation of this paper included unavailability of electronic data records of submission types from health facility level for the period 2016 - 2019 as the data collection process had not started by then. However, we analyzed available data and made a comparison over the epi-weeks. Also, the case-based data for the periods of 2016 - 2017 was not available as the electronic case-based system was not introduced by then, the paper-based records could not give us an indication of the turnaround time to case detection and investigation. This was analyzed over the period 2018 - 2024 for comparison.

 

 

The successful migration from paper-based to electronic surveillance in Sierra Leone indicates simple innovations can work even in low-resource settings. Electronic transmission of IDSR data can improve the completeness and timeliness of reporting, thus improving the detection of outbreaks and other events of public health importance. Continuous use of the system by trained personnel, routine supportive supervision, and data quality assessments contribute to the sustainability and quality of the system.

 

We, therefore, recommend that the country develop a device replacement plan and strategy to ensure the continuity and sustainability of the system. Similarly, consistent monitoring of the system through routine checks at the lower levels, giving feedback to users, routine data analysis and use for improved data quality.

 

Also, to minimize then on mobile data submission types including calls, paper-based and ordinary text messages, recommend collaboration between the Ministry of Health and the telecom companies to increase network coverage across the country but also, enable access to the system with subsided internet bundle rates. Finally, the Government of Sierra Leone is encouraged to cater for information systems strengthening in future financial budgets, including monitoring, evaluation, and information systems personnel cadre on payroll across districts for system sustainability.

 

 

The authors declare no competing interests.

 

 

Conceptualization and design: Magoba Bridget, Gebrekrstos Negash Gebru. Data Collection: Magoba Bridget. Analysis, and Interpretation: Magoba Bridget, Gebrekrstos Negash Gebru, Adel Hussein Elduma. Drafting and Review of Manuscript: Magoba Bridget, Joseph Sam Kanu, James Sylvester Squire, Adel Hussein Elduma, Ian Njeru, Stephen Abdul Regis Sesay, Calle Hedberg, Charles Njuguna, Robert Musoke, Victor Caulker, Gebrekrstos Negash Gebru, Monique A Foster. The final approval was made by all authors.

 

 

We want to acknowledge the staff of the MoH, Sierra Leone. We also acknowledge the technical support from US CDC, AFENET, and other partners during the writing of this work. Our special thanks go to Monique A. Foster, US CDC Country Office Deputy Country Director for Programs, for reviewing and providing technical support during the write-up process of this manuscript.

 

 

Figure 1: Map of Sierra Leone showing the district boundaries

Figure 2: Sample eIDSR dashboard

Figure 3: Completeness and timeliness over eight years across all the 16 districts

Figure 4: Health facility eIDSR submission type from Epi-week 29. 2023 to Epi-week 23, 2024 across all the 16 districts

Figure 5: Sample weekly epidemiological bulletin produced by one of the districts

Figure 6: Map showing cumulative number of snake bite cases and deaths reported across the country in Epi-week 35, 2024

Figure 7: Line graph showing the proportion of case notification and investigation of priority diseases over 2016 - 2024 in Sierra Leone

 

 

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