Reporting Systems for Disease Surveillance in Kenya

Following the inception of IDSR strategy, the reporting system has been evolving. Before then, there was no surveillance reporting system for priority diseases. At the inception, the existing reporting challenges resulted in district reporting rates of 30% and below, with even lower health facility reporting rates. The system was largely paper-based. Health facilities reviewed records and summarized data of priority diseases on a form that was relayed to the district (currently called sub-county) offices by fax, hand delivery, courier or email by end of business every Monday. Districts likewise collated the health facility reports manually onto a summarized form and relayed it to the province and national level using fax, hand delivery, courier or email by end of business every Wednesday. The national focal offices received the data forms from districts and submitted them to data management officers for manual entry into computers for analysis.

In 2007, then Disease Outbreak Management Unit (DOMU) at MOH resolved to develop an electronic database that would meet the evolving information needs. With the support from partners, an Epi Info electronic database was established at Afya House. Facilities sent their data to districts for aggregation and onward transmission to the National. Penetration and availability of mobile phones services among health workers also offered opportunities to improve reporting. Health workers at periphery begun to use unstructured Short Message Services (SMS) messages to report to the next level in order to beat timelines and other challenges related to hard to reach areas.

A study on IDSR reporting showed that for districts that had achieved >80% reporting rate (RR), about 62% of the health facilities (HFs) used SMS based reporting while 31% had used hand delivery method. For districts that achieved <80% RR, about 63% of HFs used hand delivery method whole 28% used SMS based reporting. The study concluded the use of SMS based reporting had a positive association with surveillance RR [4] Justification to embrace an innovative mobile phone-based reporting platform was strongly building up.

In 2011 the Ministry of Health with support from partners (WHO, CLinton Health Access Initiative, Hewlette-Packard, and Strathmore University), innovated eIDSR, a web based system to overcome challenges of sending data from sub-county to the county and national level. The desired goal was to have data relayed from the facility top a central server, but due to challenges of inadequate resources this was not realized.

Currently, data from health facility is transmitted to the sub-county transmission on paper-based standardized tools. The  system transits at sub-county level into web-based eIDSR platform where the hard copy data from the facility is keyed in for onward transmission to the county and national.

While significant leaps on IDSR have been realized, bottlenecks exist that form potential areas for improvement. The web-based system (eIDSR) that rests at the sub-county, does not allow facilities on suspected outbreak cases and public health events are not availed on time as required to allow timely execution of necessary public health action. In addition, several officers manually handle data before it reaches destination, thus data is prone to high chances of errors.

To address the observed gaps in the existing eIDSR system for immediate reporting, the MOH in collaboration with the JICA_AMED SATREPS project piloted and established a mobile SMS-based disease outbreak alert system (mSOS). The pilot was conducted in Busia and Kajiado counties for six months [5,6]. A stakeholders meeting was held in June 2015 and findings and recommendations were shared. (In the meeting, salient issues were raised and recommendations were shared to improve and roll-out the system to other regions in the country [7-9]. In order to foster sustainability of the system, it was necessary to integrate the immediate and weekly reporting reporting of IDSR data and immediate disease reporting system (mSOS) into the National District health Information System (DHIS) platform [10].

mSOS/IDSR Weekly Mobile Reporting System

Mobile SMS-based disease Outbreak alert System (mSOS)/Integrated Disease Surveillance and Response (IDSR) Weekly Mobile Reporting System is designed for real-time information sharing and prompt response disease outbreaks and public health events.

The system is intended for health facility in-charges to report the following:

1. IDSR Weekly reporting (MOH 505)
2. Immediately reportable diseases, and
3. Public health events. Disease Surveillance Coordinator (DSC) and Health Records an Information Officer (HRIO) at the County and Sub-county levels validate and allow submission of the data.

The system was developed by the Ministry of Health in Kenya (Disease Surveillance and Response, Health Information System, ICT, eHealth, Zoonotic Disease Unit, Disaster Response) within the DHIS2 system, through collaborations with World Health Organization (WHO), Centres for Disease Control (CDC), Japan International Cooperation Agency (JICA) and United STates Agency for International Development (USAID).

IDSR Weekly Reporting (MOH 505)

There are 36 disease and conditions that require weekly reporting in the MOH 505 form. Existing IDSR reporting system is incapable of real time reporting from facility to higher levels for public health action. In the new mSOS/IDSR Weekly Mobile platform, health workers at facility level will be able to submit disease surveillance data using mobile phones. The mSOS/IDSR Weekly Mobile application is hosted in the DHIS2 platform for affordability and sustainability amidst competing healthcare priorities.

Disease surveilance focal person of the in-charge of the health facility have rights in the mobile pltform and is expected to report every Monday as stipulated in the IDSR national technical guidelines.

The SUb-county Disease Surveillance Coordinator (SCDSC) oversees surveillance activities within the sub-county. He/she validates, responds and submits the data into the server and gives feedback. In the event that the SCDSC does not verify data in the system by Wdnesday of every week, the system wil assume that the sub-county has not reported. County Disease Surveillance Coordinators (CDSC) have rights to view, comment and provide feedback in support for the sub-counties within their counties.

Health Records and Information Officers (HRIO) at County and Sub-county levels provide administrative and technical support for the system hosted in the DHIS platform. This includes, troubleshooting and continued training in DHIS2.

Immediate Reportable Diseases 

The mSOS/IDST Weekly Mobile system enables health workers to report immediately reportable disease on real time basis as required in the IDSR national technical guidelines. There are a number of disease and conditions requiring immediate reporting within 24 hours.

Once data is reported, the server synchronizes and raises alerts via SMS and emails of designated managers to trigger response action. Responsible disease surveillance officers are expected t respond and record the initial response measure via the web portal.

Alerts generated through the DHIS2 platform will be relayed to the Emergency Operation Centre (EOC) for analyses and further public health action. Analyses of the occurrence of events, response actions taken, time between reporting and response are availed for evaluation.

Public Health events 

The mSOS/IDSR Weekly Mobile sytej enables health workers to report public health events on real-time basis as required in IHR 2005. There are a number of conditions and events requiring immediate reporting within 24 hours.

Disease outbreak rumours, the location of the occurrence of the event, the number affected and deaths are reported in mSOS/IDSR Weekly Mobile Reporting System. Once data is reported, the server synchronizes and raises alerts via SMS and emails of designated managers to trigger response action. Responsible disease surveillance officers are expected to respond and record the initial response measure via the web portal.

Alerts generated through the DHIS2 platform will be relayed to the Emergency Operation Centre (EOC) for analyses and further public health action. Analyses of the occurrence of events, response actions taken, time between reporting and response are availed for evaluation.

Surveillance Indicators 

• Timeliness: Measures whether the report was sent by the due date
• Reporting rate/completeness: measures the rate of the reports received from the total reports from the sub-county
• Complete reports: measures the report that has all the variables expected in it
• Intra-district reporting rate: Measures the rate of health facilities that respond to the sub-county
• Intra-sub county reporting rate: Measures the rate of sub-counties that reported to the county

Surveillance Data Flow 

Weekly Data (MOH 505)

The surveillance focal person at health facility level submits surveillance data into DHIS2 via mobile phone or computer

Sub-county Disease Surveillance Coordinator does verification and validation before the data is submitted to the server. In the event that the verification is not completed by Wednesday, the system assumes that the sub-county did not report. County and National levels access the ddata after the data is submitted to the server.

Immediately Reportable Diseases

Surveillance focal person of health facility in-charge submits data for immediately reportable diseases real-time (or within 24 hours) of detection into the system. The disease and conditions are specified in Table 2.

Alert messages, surpassing thresholds, are automatically raised via SMS and email to Sub county, County, and National focal person real-time.

Public Health Events 

Surveillance focal person or health facility in-charge submits data for public health events, including rumours from community real-time (or within 24 hours). The events are specified in Table 3.

Alert messages, surpassing thresholds, are automatically raised via SMS and email to Sub county, County, and National focal person real-time.

Primary source of information

Rachel Wanjiru, Ian Njeru, mSOS/DST Weekly Mobile Reporing Stakeholders, John Gichangi, David Kareko, Annastacia Muange, Sophia Karanja, Ngina Kisangau, Boniface Waweru, Raphael Pundo, Oliver Munyao, Steve Waweru, Daniel Langat, Lyndah Makayotto, Mitsuru Toda (2016) mSOS/IDSR Weekely Mobile Reporting: Training Manual, Ministry of Health Kenya, Nairobi

References 

[1] Division of Disease Surveillance an Response (DDSR). IDSR STrategy. Available from: http://www.ddsr.or.ke/idsr/strategy.php

[2] World Health Organisation, International Health Regulations (2005), 2008.

[3] Ministry of Public Health and Sanitation, Integrated Disease Surveillance and Response in Kenya: Technical Guidelines 2012, 2012

[4] Njuguna, C., Integrated Disease Surveillance & Response (IDSR) Strategy in Kenya, 2010, WHO KEnya: Nairobi

[5] Mendoza, G., et al., mSOS: Using mHealth to strengthen real-time disease surveillance and response in Kenya, in mHealth Compedium, M.S.f.H. African Strategies for Health, Editor 2014, USAID: Arlington, VA.

[6] Minstry of Health Disease Surveillance and Response Unit. Mobile SMS Based Disease outbreak Alert System. 2015 Available from: http://ddsr.or.ke/mSOS/about

[7] Njeru, I., et al., mSOS (mobile SMS-based disease outbreak alert system) Preliminary Report, 2015, Disease Surveillance and Response Unit (DSRU) at the Ministry of Health: Nairobi, Kenya.

[8] Japan International Cooperation Agency. mSOS: A versatile Tool for Disease outbreak Alert. 2015 June 5, 2015. Available from: http://www.jica.go.jp/kenya/english/office/topics/150605.html

[9] Japan International Cooperation Agency. Meeting with Mr. James Macharia, cabinet Secretary, Ministry of Health. 2015. Available from: http://www.jica.go.jp/project/english/kenya/006/news/general/150708.html

[10] Ministry of Medical Services. Ministries of Health Launch District Health Information System. 21 Feb 2012 5 July 2012. Available from: http://www.medical.go.ke/index.php?option=com_content&view=article&id=136:ministry-of-health-launch-dhis-software&catid=34:news-and-events&itemid=62