Developing Disease Surveillance Systems
Developing Disease Surveillance Systems: CDC Haiti has played a central role supporting the Haitian Ministry of Health (MOH) to develop disease surveillance systems for identifying outbreaks, monitoring disease trends, and collecting and analyzing epidemiological data. Haiti’s surveillance capacity has grown substantially with CDC’s support leading to increased site-level surveillance coverage, timely outbreak investigations, improved data quality, and enhanced health security.
- Epidemiologic Surveillance Network: Prior to the 2010 earthquake, Haiti’s surveillance system operated in a limited capacity providing only monthly data and covering a narrow range of disease conditions. Immediately following the earthquake, CDC supported the MOH to establish a National Sentinel Site Surveillance system (NSSS) in 51 sites to monitor disease trends and to detect potential outbreaks. Since 2010, NSSS (now NESN, National Epidemiologic Surveillance Network) has expanded to 652 sites (out of approximately 1048 health facilities across the country) and produces weekly reports on the number of cases for 41 conditions (See Figures 1 & 2). NESN data are registered through a web-based platform (MESI) allowing direct reporting to the departmental and national level. Data are reviewed, validated, and analyzed at the departmental level before being sent to the national level for further analysis and review, allowing for more real-time decision-making. The NESN also exhibits flexibility by adapting to changing information needs such as new health-related events and changes in case definitions. Haiti’s MOH integrated Zika surveillance into the NESN shortly after the outbreak occurred in 2016 and instituted a broader case definition for cholera during the 2016 Hurricane Matthew response.
- Laboratory-Enhanced Surveillance: To complement the NESN and address the limited capacity of NESN sites to carry out laboratory testing of patients, CDC developed a laboratory-enhanced surveillance system to better characterize pathogens causing the syndromes under surveillance. The laboratory-enhanced surveillance system, known by its French acronym PRESEPI, collects information on and samples from a subset of cases of diarrhea, acute febrile illness, Severe Acute Respiratory Infection, and meningitis in sentinel hospitals. Specimens are tested at the National Public Health Laboratory and reports are shared monthly with stakeholders. PRESEPI began at four sites and has since expanded to 15 sites. This system has served to support vaccine introduction and is being used for vaccine effectiveness and impact (including rotavirus vaccine and PCV13).
- National Cholera Surveillance System: Cholera surveillance focuses on timely notification of cases and a multisectoral response to case clusters or “hot spots”. In 2011, CDC Haiti worked with MOH to build the National Cholera Surveillance System (NCSS), a platform that produces daily reports from cholera treatment facilities of new and hospitalized cases and deaths aggregated by age groups. The NCSS facilitates timely reporting of surveillance data allowing the MOH to identify cholera outbreaks in real time. CDC continues to provide data management and analysis support to the NCSS. After Hurricane Matthew disrupted the NCSS in October 2016, CDC staff worked to re-establish the surveillance network and identify diarrheal disease outbreaks in the hurricane-affected communes. While suspected cholera cases surged in Grand’Anse and Sud Departments in the immediate weeks following the hurricane, timely cholera case investigations led by CDC trained FETP residents quickly contained the outbreak.
- HIV/AIDS Surveillance: CDC Haiti has been providing support to the MOH since 2004 for the development and maintenance of a named-base case notification system for HIV that tracks vital events for patients from diagnosis to death. SALVH (Suivi Actif Longitudinal du VIH en Haïti) is a patient monitoring system that links patient-level data, taken at the time of HIV diagnosis, with corresponding data from electronic medical records (EMRs). A notification platform captures new cases from three EMR systems that cover more than 96% of patients on anti-retroviral treatment (ART) and transfers the data to SALVH. Deduplication of patients in the system was previously accomplished through the use of an algorithm; the system has recently been improved by the introduction of biometric coding (fingerprinting), for over 60% of patients on treatment.
- Malaria Surveillance: CDC has helped the MOH to develop standards for malaria surveillance and a new module for a malaria case-based reporting system using the DHIS2 software. The pilot phase started in January 2018 in 108 institutions in all ten departments. The result of the assessment will be used to augment surveillance in all institutions in Haiti. Surveillance officers supported by CDC and trained through the Field Epidemiology Training Program are responsible for the case investigations for malaria.
- Tuberculosis (TB) Surveillance and Case Detection: CDC Haiti works closely with the Haitian National TB Control Program, the MOH, and other partners to implement key interventions for effective TB control. CDC Haiti helped roll out rapid diagnostics (LED fluorescent microscopy and GeneXpert), implement active case finding and TB infection control measures, and revised treatment guidelines in order to strengthen TB control in Haiti. Currently, GeneXpert has been installed in 25 high-volume TB facilities across Haiti’s ten geographic departments, affording coverage to an estimated 80% of patients with a suspicion of TB. In 2017, nearly 33,000 GeneXpert tests were performed for 31,100 individual patients, resulting in over 6,000 (21.4%) cases of drug-sensitive TB and over 300 (1.0%) rifampin-resistant cases being picked up. These interventions have contributed to increased case notification by 15-20% since 2010.
- Vaccine Preventable Disease (VPD) Surveillance: CDC provides VPD surveillance support across multiple programs ensuring the timely detection and notification of VPD outbreaks and the careful monitoring of vaccination efforts. CDC conducts meningitis surveillance in four sites across Haiti and provides technical assistance to rotavirus surveillance program staff at the Haitian Directorate of Epidemiology, Laboratory, and Research (DELR) and at the National Public Health Laboratory (LNSP) through evaluating vaccine impact and effectiveness. CDC also continues to support the Stop Transmission of Polio (STOP) program in Haiti and has carried out over 50 field assignments since 2001 including four current assignments. Through the STOP program CDC supports acute flaccid paralysis and other VPD surveillance and case investigations, vaccination coverage surveys and evaluations, and provides emergency and outbreak response.