Ebola 1

How Uganda contained Ebola outbreak using District Health Information Software 2

Gulu I In September 2022, an outbreak of the Ebola Virus Diseases (EVD) was declared in central Uganda.

EVD is contagious and deadly, with an average case fatality rate of 50%, so containing the outbreak quickly was a matter of urgency.

Uganda had already experienced previous EVD outbreaks in 2012 and 2019, and national health authorities, together with local and international partners were able to draw on lessons learned from these outbreaks.

Therefore, HISP Uganda supported the national Integrated Disease Surveillance and Response (IDSR) program in deploying systems for alert management, EVD outbreak monitoring, case management and discharge, and more.

According to WHO Director-General, Tedros Ghebreyesus, Uganda has shown that Ebola can be defeated when the whole system works together, from having an alert system in place to finding and caring for people affected and their contacts, to gaining the full participation of affected communities in the response.

Supporting Uganda’s Ebola Virus Disease response with eIDSR and other tools

Ebola Virus Disease (EVD) or (Sudan Variant) has no specific treatment and vaccines are still being developed.

As such, management of the highly infectious disease involves palliative treatment of symptoms when detected early.

Also, given that the early symptoms of EVD can be indistinguishable from diseases like malaria, which are endemic to the Sub-Saharan region, the need for an effective surveillance and case notification system was essential to halting the outbreak.

Uganda’s national disease surveillance and response organization is made up of several pillars that work together in response to prevent and control disease outbreaks.

HISP Uganda supports the Strategic Information Research and Innovation (SIRI) pillar, which is responsible for innovation, data sharing and data use during the response. Other pillars include case management, surveillance (including Port of Entry and School-Based Surveillance), and lab (responsible for sample collection, testing and results).

As part of the SIRI pillar, HISP Uganda works with other partners to make sure that people in all pillars have the information they need and can make use of it at any time.

Uganda takes advantage of routine monitoring by District Health Teams (DHTs) composed of a Bio-statistician, a District Health Officer, District Surveillance Focal Persons (DSFPs), Health Sub-District Surveillance Focal Persons (HSDSFPs) and staff of health facilities and community engagements to track and report outbreaks.

Disease surveillance data is aggregated and monitored at the district level by DHTs, who are also responsible for coordinating response activities within their respective districts such as case notification and investigation, monitoring and reporting in conjunction with the Regional and National Response Teams.

Following the country’s adoption of the revised guidelines on Integrated Disease Surveillance and Response (IDSR) in 2019, DHIS2 has been customized as a national eIDSR system, which meant that the system was already in place when the COVID-19 pandemic started.

HISP Uganda supported the customization, implementation and maintenance of the national eIDSR system. During the COVID-19 pandemic, virtual training for DHTs was conducted for more than 90% of the districts within the country, helping build their capacity to use the eIDSR to respond to COVID-19 and other notifiable diseases for early detection.

The eIDSR system provides DHTs with a single platform for alert management, case notification and investigation and case management to avoid duplicate data entry and streamline the response.

The Ministry of Health Uganda leveraged this DHIS2-based eIDSR system to respond to the 2022 EVD outbreak, and with technical and capacity-building support from HISP Uganda-further refined the system for improved signal alert management, case notification and follow-up, outbreak monitoring, and travellers screening.

Signal alert management: SMS notification, triage and dispatch in DHIS2

One of the requirements of Uganda’s eIDSR is to have immediate notification from community members at the district and national levels.

In addition, there is a need to triage these alerts/signals to the districts so they are aware of what is happening within the districts, but ideally, after the signal has been isolated from the noise.

A diagram of the eIDSR alert, triage and response workflow in Uganda.

The eIDSR system in Uganda is based on DHIS2 version 2.35, which supports SMS functionality. The DHIS2 SMS Module implemented as part of the eIDSR enables immediate reporting of alerts/signals to national-level teams directly (and anonymously) from officials, community members, or health facilities at the community level.

Each SMS is registered in DHIS2 (eIDSR) as an alert/signal event. Incoming alerts undergo a triage process, where they are reviewed in DHIS2 (eIDSR) at the national level, and the relevant ones are forwarded to the districts for follow-up.

SMS alert event management in DHIS2.

These centres needed to manage and record any suspected cases that came through and to evacuate any that fit the EVD case definition.

The SMS management app was modified by HISP Uganda to meet the needs of the response team. Within DHIS2 (eIDSR), call centre workers could create a new Signal Event for an SMS or call, which would be verified by a separate team at the call centre that could then send an ambulance in the case of a living patient displaying possible symptoms of EVD, or a dignified burial team for deceased cases.

In the event of an evacuation, an individual case would then be created in the Tracker program. In the end, most of the EVD alerts during the 2022 outbreak were logged via the call centres through this process.

The SMS management dashboard in Uganda’s eIDSR.

Case notification, investigations, admission and management in Tracker

The workflow for notification of a suspected case starts with the alert process above. As soon as an ambulance is dispatched by the call centre to evacuate the individual, the district response team begins filling out the paper surveillance form, which needs to be completed in triplicate.

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One copy goes with the blood sample to the lab for testing, one with the patient to the designated health facility (Ebola Treatment Unit), and one is kept by the district health team.

The last copy is used to enter the data into DHIS2 (eIDSR), where it is used to create an individual record for the patient in the eCase Notification and Investigation Tracker program, which includes modules for case notification, lab request and results, hospital admission and case management.

Case registration in Uganda’s EVD Tracker program.

Ideally, by the time the lab results are ready, the case notification details have already been entered into the eIDSR by the DHT, so that the EVD treatment unit team at the health facility only needs to update the admission and case monitoring details for the case, followed by subsequent case management and monitoring information during the treatment period (this typically lasts 21-42 days for EVD cases), which they can do directly in the Tracker module.

This help saves time for health workers and makes data available more quickly to DHTs and national-level stakeholders.

The EVD Tracker also includes a module for lab results, and case outcomes-such as cured, transferred to another facility, deceased, and repatriated are also recorded.

Patients who have successfully recovered from EVD can be issued an electronic discharge certificate through DHIS2 (eIDSR) using a custom Discharge App developed by HISP Uganda (using a similar approach to the digital certificates developed by the HISP network during the COVID-19 pandemic).

The goal of these printed certificates which contain the patient’s name, ID number, discharging facility, and a scannable QR code is to help people who have recovered from EVD to reintegrate into their communities by providing them with verifiable evidence of recovery, hopefully eliminating the stigma associated with EVD that has affected some survivors of previous outbreaks.

An example of an electronic EVD discharge certificate generated in DHIS2.

DHIS2 core and custom dashboards for monitoring EVD response

To support alert management, case monitoring and follow-up, HISP Uganda configured a custom dashboard app for monitoring the overall outbreak status.

The dashboard keeps track of signals/alerts from SMS notifications as well as logs from the call centre.

It facilitates immediate notification to national-level teams and provides information necessary for triage, investigation, case management and contact tracing.

Uganda’s custom EVD monitoring dashboard designed by HISP Uganda.

Meanwhile, the custom dashboard allows a variety of users and stakeholders to visualize cumulative data from the overall response in one place in a user-friendly format.

This dashboard includes a map showing the geographic distribution of notified suspected cases; charts showing signals and alerts verified over time; and key indicators that reflect the full IDSR cascade, from the number of signals triaged and verified, to cases notified, cases presenting with symptoms, samples collected, confirmed cases, and deaths.

Each pillar in the EVD response has access to these dashboards and is responsible for updating the eIDSR system with data from their pillar of responsibility.

Port of entry screening and traveller self-reporting

During COVID-19, Uganda implemented a Port of Entry (PoE) Tracker system to scan incoming travellers for infection. However, this system required significant resources, as the officials at the border needed to be equipped with mobile devices to scan and update individual traveller records.

Further, the high-volume ports required a significant boost in staffing (for example, a PoE with more than 1,000 entries per day required around 20 staff members to handle individual traveller screening). This eventually proved to be unsustainable

For the EVD outbreak, HISP Uganda updated this self-declaration form to include new questions to help determine if travellers had recently been in an outbreak-affected area, which was intended to be filled in both on arrival and departure.

The updated design of the form allows it to be used for surveillance of notifiable diseases beyond EVD so that the response teams can respond accordingly depending on the symptoms that travellers report.

Some advantages to managing these records in the eIDSR2 can then be used to notify travellers of test results by SMS and email, and results can also be shared automatically with the respective pillars supporting the EVD response for follow-up.

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