Profiling border health surveillance at selected points of entry in Uganda

Mitima Jean-Marie Limenyande^1,&, Michael Muhoozi², Joyce Owens Kobusingye¹, Sulaiman Ssebadduka³, Silvestre Herbert Gwanyi⁴, Harriet Mayinja⁴

 

¹Makerere University School of Public Health, Uganda, ²Baylor College of Medicine Children's Foundation, Uganda, ³Health Information Systems Program (HISP), Kampala, Uganda, ⁴Ministry of Health, Kampala, Uganda

 

 

^&Corresponding author
Mitima Jean-Marie Limenyande, Makerere University School of Public Health, Kampala, Uganda.

 

 

 

 

Global health security is not just a health priority but a concern that if not paid attention to can devastate lives, health sectors, and economies which in the end keeps countries from developing [1]. Outbreak mitigation and response remains then a necessary component for global stability and also needed for free movement of travelers and goods. To achieve this, the International Health Regulations (IHR, 2005) gives a binding ground to allow collaboration of nations to ensure that diseases are contained within territories where they have emerged. That collaboration is important because some emerging diseases cannot be managed with available drugs or vaccines, and their containment can only be achieved through other public health actions [2].

 

Good surveillance systems are therefore needed to help in early detection of epidemic prone diseases before their outbreaks go out of control as stated in the global health security agenda [3]. Member states that are signatories of the IHR 2005 are required to have surveillance systems with good performance in reporting, and a holistic approach from detection to response [4]. In that regard, countries should build capacities at their Points of Entry (PoE) to be able to detect and report events that may constitute potential public health emergencies of international concern (PHEIC) [5]. Screening of travelers remains very relevant and a turning point during major outbreaks since movement of travelers can lead to the spread of a disease outside the country of its origin and cause a threat worldwide [6].

 

Some good surveillance reporting practices have been noted. Among the incentives for good reporting performance, was the sender receiving feedback on submissions which elicits the feeling that the reported data is relevant to support outbreak preparedness and response is critical for the personnel involved in surveillance activities. In the same way, it is important to have a surveillance focal person responsible for data reporting and a mechanism to remind the responsible person to submit the data on time [7]. On top of that, the availability of the required infrastructure and tools like reporting forms improves critically the quality of the data and positively influences the ability to report - though electronic reporting systems are believed to be more efficient. On the other hand, it is important to note that the use of multiple reporting systems can be challenging and can reduce the performance of the person reporting. Additionally, a high workload leads to poor quality of the data, which means that an adequate number of staff is needed to fulfill this role [4, 7]. Similarly, high turnover of staff negatively impacts on data reporting since it may lead to the lack of continuity of knowledge and creates a gap in the system which needs to be filled every time a new staff comes on board [8].

 

At crossing border points with high volume of movement, it is important to screen all travelers despite the fact that it can increase the time spent at the border. Efforts are therefore needed to fast track the screening process since delays at high volume POE can lead to the spread of the disease among to travelers and even beyond [9, 10].

 

In the Africa region, countries like Uganda are vulnerable to epidemic prone conditions and commitment to enforcing border control measures is therefore needed. Uganda´s location in the great lakes region makes it vulnerable to infectious epidemiological diseases like Ebola Virus Disease, Rift Valley Fever, Measles, Yellow fever, Anthrax, and the porousness of some unofficial PoE creates more susceptibility to importation and exportation of these diseases [11]. However, Uganda is mitigating these risks through the implementation of the Integrated Disease Surveillance and Response (IDSR) strategy since 2001 just after its adoption in late 1990´s as a new strategy for disease surveillance for the WHO Africa region. The adoption of IDSR as a regional strategy for disease surveillance and outbreak response has certainly helped African countries in outbreaks mitigation [7, 12].

 

In the wake of the COVID-19 pandemic, most countries found it beneficial to enforce enhanced border surveillance and in the case of Uganda, PoE surveillance was an import part of the pandemic response. Capitalizing on the strides achieved during the pandemic, and as the country transitioned its focus to other notifiable diseases at PoE, it was important to keep the reporting trends active. This study aimed therefore at profiling border health surveillance at selected points of entry and identify best practices that can be promoted in the country to strengthen border health surveillance.

 

 

This was a cross-sectional study and used both secondary and primary data. Secondary data was obtained from the electronic Integrated Diseases Surveillance and Response (e-IDSR) system which is based on the District Health Information Software 2 (DHIS2) technology; the national surveillance repository and reporting system for all the PoE. A total of 92 PoE were registered in the eIDSR system but during the COVID-19 pandemic 53 POE were activated–meaning they were given the required capacity to screen travelers, and a daily and weekly aggregate report from the collected data was generated for analysis to inform strategic actions in the response. The 53 PoE were categorized using the total number of travelers crossing the border point - as recorded in the eIDSR; into 10 high volume, 17 medium volume, and 26 were low volume PoE. In this study, monthly aggregated data of screened travelers was used to determine the PoE which were constantly reporting for a six-month period, starting from September 2021 to February 2022. The time interval was chosen since during the period, the number of COVID-19 cases detected at different PoE had reduced sensibly and efforts were being engaged to sustain surveillance for other notifiable diseases. The data was extracted from the system in a Microsoft Excel format and analysis was limited to only the 53 POE that were activated at the time of the study. Only the PoE that reported the number of screened travelers per month for the entire six-month period (September 2021-February 2022) were considered as constantly reporting. The presence of an empty cell for any of the six months in the monthly aggregate data was considered as not reporting. Apart from the reporting trend for the secondary data, focus was also given to the volume of travelers crossing the PoE, and the region where the PoE is located.

 

To understand the drivers of reporting performance, all the PoE were subjected to an online survey to assess some of the factors that could explain differences in reporting performance. The data was collected from 1 March 2022 for a period of 4 weeks using an online questionnaire that was shared with the PoE in-charge on their emails and other online platforms used for quick communication. Follow-up calls were made and email reminders were sent to targeted respondents to increase the participant response rate. Descriptive data analysis was done to compare PoE that had reported constantly over the six months period and those that did not. All the questions considered for analysis were close ended, and analysis was done in STATA version 14. Consent was obtained from the online survey respondents. The consent form was attached to the online tool used for data collection and permission to access the POE surveillance data was granted by the National Border Health Unit of the Ministry of Health of Uganda.

 

Availability of data

 

Data used for this study is accessible through the eIDSR system, and permission to access the data is granted by the Ministry of Health, Uganda.

 

Ethical considerations

 

This study was approved by the Border health unit, Ministry of health and respondents consented to respond to online questionnaire.

 

 

Characteristics of Points of Entry based on Secondary data from DHIS2

 

Out of the 53 operational PoE, 14 (26.5%) had consistently submitted their reports in the e-IDSR system for the six months study period. Of the 14, 8 (57.1%) were high volume PoE, 3(21.4%) were medium volume and 3 (21.4%) were low volume PoE. One PoE was located in the Central region, 3 (21.4%) in the Eastern region, 5 (35.7%) in the Western region, and 4 (28.5%) in the Northern region. One PoE had constantly reported zero as the number of travelers screened over the six months. Twenty-five (47.2%) PoE had consistently submitted their reports for five of the six months cut-off that was considered.

 

Characteristics of Point of Entry from the online survey

 

Sixteen (30.2%) of the 53 PoE responded to the online questionnaire (Figure 1). Of the 16 who responded, 9 (56.3%) were among those that reported constantly; 8 PoE (50%) were high volume PoE, and 4 (25%) were functional before the COVID-19 pandemic. Nine (56.3%) had 2 or more staff that knew how to report in the e-IDSR system and 11 (68.8%) were reporting directly in the e-ISDR system. On the other hand, 5 (31.3%) PoE were sending their report to another surveillance officer who had to enter the data into the system, and that was either the District surveillance Focal person or a National Border Unit surveillance officer. Lastly, 5 (31.3%) PoE were reporting using a staff personal gadget, a telephone or a tablet (Table 1).

 

Health surveillance and reporting at PoE

 

The data from the online survey showed that 9 of the 16 (56.3%) PoE that responded were among the 14 PoE that constantly reported over the six months. Among these 9 POE that constantly reported: 5 (55.6%) were high volume PoE, 7 (77.8%) reported that they received feedback on their performance, 8 (88.9%) reported that they were able to submit their report directly in the e-IDSR system, 7 (77.8%) had internet connection available at the PoE and 8(88.9 %) had a gadget belonging to the PoE that was used for reporting (Table 2). When we compared the 9 POE that consistently reported with the 7 that did not, a statistically significant difference was only noted between those facilities that had only 1 reporting tool compared to those that used two or more reporting tools (p=0.04). The following variables had borderline statistical significance: type of report submission platform - other platforms vs eIDSR (p=0.05), internet availability-no vs yes (p=0.05) and use of personal gadget vs POE gadget for reporting (p=0.05).

 

 

Reporting is important for surveillance and informs timely decision-making in the prevention, detection, and response to Public Health Emergencies. In this paper, we present the factors that influenced reporting tendencies at different PoE in Uganda in the post-COVID-19 era and we analyze efforts made by the country to build and sustain surveillance for cross-border movement using tools like the eIDSR. In recent decades, global threats like COVID-19 have prompted countries to develop their capacity to detect and report public health threats in line with the International Health Regulations (IHR, 2005) [4]. Our research findings indicate that both staff members who reported regularly and those reported occasionally, had received feedback on their performance. Meanwhile, feedback on performance is known as a motivator for the staff on ground in charge of reporting [7] and this should be promoted as best practice. This is because it has a positive impact on the productivity, self-evaluation and engagement of staff members to keep improving their performance. Additionally, the study showed that good reporting rates was not different for staff who received regular support supervision and those who did not. However, support supervision directly affects motivation to learn, to perform and to deliver better results [13].

 

It is important to ensure that there is regular support supervision for PoE where reporting rates are consistently low. Furthermore, PoE with a larger number of individuals knowledgeable about the reporting system were at a better advantage. Certainly, the challenge arises when only one staff member is able to report and they are not available at the time for reporting [7, 10, 14]. This can be improved if the number of people able to report in the system is not limited to allow any PoE staff to focus on this essential task, while sharing the responsibility with other colleagues.

 

Having more than one reporting tool was found to be a challenge in our study and this has been reported as a hindrance elsewhere and is generally a challenge for teams doing surveillance work in the field [7, 15]. Many surveillance systems are specific to targeted conditions, leading to competing interests among those who have to report using multiples surveillance tools. In our context, the eIDSR was found to be more efficient and led to better reporting tendency when used as a unique space for reporting rather than being combined with several other reporting systems. This highlights an important point to consider for the eIDSR to be fully implemented as a strategy with an impact on surveillance and response [12, 16].

 

Meanwhile, other factors identified in the study were also found to be important for sustaining the reporting tendency. These factors included the availability of internet and devices for reporting. This means that the rollout of an online reporting platform like eIDSR, although an important milestone in improving reporting, generally requires enabling factors [16]. Therefore, it is necessary to consider the reporting systems and all the requirements needed for their implementation. In our case, the eIDSR, being an online platform, would need to be accompanied by devices such as tablets and internet access to function effectively.

 

Besides the factors affecting reporting, there was a PoE that constantly reported zero, to mean travelers were not using that specific crossing points. Zero reporting is key in surveillance - not only does it show an active system, but one can assess and monitor why no data regarding the screening of travelers is being submitted [15]. Meanwhile, the figure zero was questionable since the period that was considered had the movement of goods and people coming back to normal around the country. This could be an indication of poor reporting practices in abide of avoidance of consequences of non-reporting from different levels of authority. Meanwhile, on a general point of view, zero reporting remains better than not reporting because it can allow further discussion and investigation of which challenges are the reason for the figures if they do not reflect the reality on ground. This may lead to the support in terms of training, equipment, and logistics which are key factors that influence reporting [14].

 

Lastly, only two PoE in the western region reported being functional before the COVID-19 pandemic though only one reported constantly with active screening of travelers coming from the Democratic Republic of Congo. This is where the Ebola outbreak was present in 2018 near the Ugandan border, and the presence of that threat in that region was the main cause of enhanced activities. With the susceptibility of these PoE to receive a high-risk traveler and the fact that border communities have regular movements from one side to another, continuous screening was necessary [17]. However, the current results reflect the determination to sustain good practices countrywide and certainly this will have a positive impact on detection and containment of infectious diseases at different PoE in Uganda.

 

The limitation noted in this study was the low response rate to the online survey despite several attempts to motivate the PoE staff to answer the questionnaire. The strength of this study, on the other hand, was the consideration of a countrywide secondary dataset that allowed to perform an unbiased comparison of different regions´ performance. In addition, the follow-up step to collect primary data provided a better understanding of the drivers of PoE reporting performance.

 

 

The COVID-19 pandemic has clearly boosted the capacity at different PoE in Uganda than it was before. For the next level in this process of building sustainability in surveillance at different PoE, the best practice for good reporting should be used as a way to improve the quality of the reporting system. Reporting is important for surveillance and informs timely decision-making in the prevention, detection, and response to Public Health Emergencies. This study showed varying capacity in effective reporting which is pivotal in prevention, detection, and early response to public health threats at PoE. Limiting the number of reporting tools and the support received by PoE staff in terms equipment, and logistics remain key factors that influence reporting.

 

 

The authors declare no competing interests.

 

 

MJML: Conception, Design, Conduct, Analysis, Read and approved the final report. MM: Conception, Design, Conduct, Analysis, Read and approved the final report. JOK: Conception, Design, Conduct, Analysis, Read and approved the final report. SS: Review data, Analysis, Read and approved the final report. SHG: Data collection, Review results, Read and approved the final report. HM: Data collection, Review results, Read and approved the final report.

 

 

Table 1: Characteristics of the Points of Entry that responded to the Online survey, N=16

Table 2: Characteristics of the 16 Points of Entry the Responded to the Online Survey (N=16)

Figure 1: Uganda map showing the geographic distribution of POE that responded to the online tool and number of months they constantly reported

 

 

1. Wolicki SB, Nuzzo JB, Blazes DL, Pitts DL, Iskander JK, Tappero JW.Public health surveillance: at the core of the global health security agenda. Health Security [Internet]. 2016 Jun 17 [cited 2024 Jul 15];14(3):185-8. https://doi.org/10.1089/hs.2016.0002 Subscription or purchase required to view full article. PubMed | Google Scholar


2. De Bengy Puyvallée A, Kittelsen S. “Disease Knows No Borders”: Pandemics and the Politics of Global Health Security. In: Bjørkdahl K, Carlsen B, editors. Pandemics, Publics, and Politics: Staging Responses to Public Health Crises [Internet]. Jakarta (Singapore): Palgrave Pivot; 2018 Nov 4 [cited 2024 Jul 15]. p. 59-73. https://doi.org/10.1007/978-981-13-2802-2_5 Chapter PDF available for download. PubMed | Google Scholar


3. Quinn SC, Kumar S.Health inequalities and infectious disease epidemics: a challenge for global health security. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science [Internet]. 2014 Sep 25 [cited 2024 Jul 15];12(5):263-7. https://doi.org/10.1089/bsp.2014.0032 Subscription or purchase required to view full article. PubMed | Google Scholar


4. Andrus J, Aguilera X, Oliva O, Aldighieri S.Global health security and the International Health Regulations. BMC Public Health [Internet]. 2010 Dec 3 [cited 2024 Jul 15];10(Suppl 1):S2. https://doi.org/10.1186/1471-2458-10-s1-s2 PubMed | Google Scholar


5. Kluge H, Martín-Moreno JM, Emiroglu N, Rodier G, Kelley E, Vujnovic M, Permanand G.Strengthening global health security by embedding the International Health Regulations requirements into national health systems . BMJ Glob Health [Internet]. 2018 Jan 20 [cited 2024 Jul 15];3(Suppl 1):e000656. https://doi.org/10.1136/bmjgh-2017-000656 PubMed | Google Scholar


6. Cohen NJ, Brown CM, Alvarado-Ramy F, Bair-Brake H, Benenson GA, Chen TH, Demma AJ, Holton NK, Kohl KS, Lee AW, McAdam D, Pesik N, Roohi S, Smith CL, Waterman SH, Cetron MS.Travel and Border Health Measures to Prevent the International Spread of Ebola . MMWR Suppl [Internet]. 2016 Jul 8 [last reviewed 2017 Jul 17; cited 2024 Jul 15];65(3):57-67. https://doi.org/10.15585/mmwr.su6503a9 Google Scholar


7. Mwatondo AJ, Ng´ang´a Z, Maina C, Makayotto L, Mwangi M, Njeru I, Arvelo W. Factors associated with adequate weekly reporting for disease surveillance data among health facilities in Nairobi County, Kenya, 2013 . Pan Afr Med J [Internet]. 2016 Apr 6 [cited 2024 Jul 15];23:165. https://doi.org/10.11604/pamj.2016.23.165.8758 PubMed | Google Scholar


8. Hardhantyo M, Djasri H, Nursetyo AA, Yulianti A, Adipradipta BR, Hawley W, Mika J, Praptiningsih CY, Mangiri A, Prasetyowati EB, Brye L.Quality of National Disease Surveillance Reporting before and during COVID-19: A Mixed-Method Study in Indonesia . IJERPH [Internet]. 2022 Feb 26 [cited 2024 Jul 15];19(5):2728. https://doi.org/10.3390/ijerph19052728 PubMed | Google Scholar


9. Keller M, Blench M, Tolentino H, Freifeld CC, Mandl KD, Mawudeku A, Eysenbach G, Brownstein JS.Use of unstructured event-based reports for global infectious disease surveillance . Emerg Infect Dis [Internet]. 2009 May [cited 2024 Jul 15];15(5):689-95. https://doi.org/10.3201/eid1505.081114 PubMed | Google Scholar


10. Bastos LS, Economou T, Gomes MFC, Villela DAM, Coelho FC, Cruz OG, Stoner O, Bailey T, Codeço CT.A modelling approach for correcting reporting delays in disease surveillance data. Stat Med [Internet]. 2019 Jul 10 [cited 2024 Jul 15];38(22):4363-77. https://doi.org/10.1002/sim.8303 PubMed | Google Scholar


11. Nakiire L, Mwanja H, Pillai SK, Gasanani J, Ntungire D, Nsabiyumva S, Mafigiri R, MID, Muneza N, Ward SE, Daffe Z, Ahabwe PB, Kyazze S, MBAIT, Ojwang J, Homsy J, Mclntyre E, Lamorde M, Walwema R, Makumbi I, Muruta A, Merrill RD.Population Movement Patterns Among the Democratic Republic of the Congo, Rwanda, and Uganda During an Outbreak of Ebola Virus Disease: Results from Community Engagement in Two Districts - Uganda, March 2019. MMWR Morb Mortal Wkly Rep [Internet]. 2020 Jan 10 [cited 2024 Jul 15];69(1):10-3. https://doi.org/10.15585/mmwr.mm6901a3 PubMed | Google Scholar


12. Lukwago L, Nanyunja M, Ndayimirije N, Wamala J, Malimbo M, Mbabazi W, Gasasira A, Nabukenya IN, Musenero M, Alemu W, Perry H, Nsubuga P, Talisuna A.The implementation of Integrated Disease Surveillance and Response in Uganda: a review of progress and challenges between 2001 and 2007 . Health Policy and Planning [Internet]. 2012 Jun 4 [cited 2024 Jul 15];28(1):30-40. https://doi.org/10.1093/heapol/czs022 PubMed | Google Scholar


13. Park S, Kang HS (Theresa), Kim EJ.The role of supervisor support on employees´ training and job performance: an empirical study. EJTD [Internet]. 2018 Feb 19 [cited 2024 Jul 15];42(1/2):57-74. https://doi.org/10.1108/EJTD-06-2017-0054 Subscription or purchase required to view full article. Google Scholar


14. Bawa S, Olumide E.The effect of training on the reporting of notifiable diseases among health workers in Yobe State, Nigeria . Niger Postgrad Med J [Internet]. 2005 Jan-Mar[cited 2024 Jul 15];12(1):1-5. Abstract only. Google Scholar


15. Rahi M, Das P, Sharma A.Malaria elimination in India requires additional surveillance mechanisms. Journal of Public Health [Internet]. 2021 Apr 5 [cited 2024 Jul 15];44(3):527-31. https://doi.org/10.1093/pubmed/fdab106 Google Scholar


16. Fall IS, Rajatonirina S, Yahaya AA, Zabulon Y, Nsubuga P, Nanyunja M, Wamala J, Njuguna C, Lukoya CO, Alemu W, Kasolo FC, Talisuna AO.Integrated Disease Surveillance and Response (IDSR) strategy: current status, challenges and perspectives for the future in Africa . BMJ Glob Health [Internet]. 2019 Jul 3 [cited 2024 Jul 15];4(4):e001427. https://doi.org/10.1136/bmjgh-2019-001427 PubMed | Google Scholar


17. Mensah EA, Kisakye A, Gyasi SO.Ebola virus disease surveillance in the absence of a confirmed case; the case of the Rwenzori region of Uganda . Pan Afr Med J [Internet]. 2020 Oct 8 [cited 2024 Jul 15];37:137. https://doi.org/10.11604/pamj.2020.37.137.22957 PubMed | Google Scholar