Field Epidemiology & Laboratory Training Programme (FELTP) Pakistan

Evaluation of Acute respiratory infections Surveillance System in Gilgit-Baltistan 2011

Submitted by: Dr Zakir Hussain District Health Officer, Health Department Gilgit-Baltistan FELTP 4th Cohort

Supervised by:

INTRODUCTION
Public health surveillance is the ongoing, systematic collection, analysis, interpretation, and dissemination of data about a health-related event for use in public health action to reduce morbidity and mortality and to improve health 1 Surveillance serves at least eight public health functions. These include supporting case detection and public health interventions, estimating the impact of a disease or injury, portraying the natural history of a health condition, determining the distribution and spread of illness, generating hypotheses and stimulating research, evaluating prevention and control measures, and facilitating planning 2 The new International Health Regulations, which came into force in June 2007, require World Health Organization member states to assess their core capacity for surveillance and response within two years from this date 3 Acute respiratory infections (ARIs) are classified as upper respiratory tract infections or lower respiratory tract infections. The upper respiratory tract consists of the airways from the nostrils to the vocal cords in the larynx, paranasal sinuses and the middle ear. The lower respiratory tract infections from the trachea and bronchi, bronchioles and the alveoli. Acute respiratory infections are mainly Pneumonia, Brochiolitis among children 4 Globally Acute respiratory infections are the leading cause of childhood mortality. WHO estimated that the annual number of ARI related deaths in this age group (excluding those caused by measles and pertussis and neonatal deaths) was 2.1 million, accounting for about 20% of all childhood deaths 5 Although ARI is the third most common cause of death overall, in children it is the major cause of death outside the neonatal period; an estimated 2 million deaths occur in children <5 years of age, predominantly in developing countries 6 Acute respiratory infections (ARI) are the leading cause of death in young children in Pakistan, responsible for 20-30% of all child deaths under age 5 years, appropriate monitoring and evaluation of the impact of the ARI control programme is lacking. Lack of funding for programmatic activities, lack of coordination with other child survival programs, inadequate training for community health workers and general practitioners in the private sector, lack of public awareness about seeking timely and appropriate care, and insufficient planning and support for ARI programmatic activities at provincial and district levels are major hindrances in decreasing the burden of ARI in the country 7 2

The incidence of pneumonia and severe pneumonia combined is higher than the children at lower altitude. Possible explanations for this high rate could include indoor air pollution by wood fires, harsh winters (which necessitate greater time indoors in overcrowded homes), over-diagnosis because of increased baseline respiratory rates at high altitudes, and a true increased risk of disease associated with altitude. Pneumonia incidence rates in the Northern Areas of Pakistan are much higher than rates reported at lower altitudes in the country and are similar to those in highaltitude settings in other developing countries 8 Diagnosis of ARI and assessment of its severity can made by using World Health Organization standard protocol for ARI based on the presence of cough, tachypnea, chest indrawing, and wheezing for <7 days. Severe disease is defined in children with a respiratory rate >60/minute and chest in-drawing 9 The acute respiratory infections reporting system of the Czech Republic is a modern and efficient surveillance system based on the collection of high quality data. The whole ARI / ILI reporting system is essential for pandemic planning in the Czech Republic. It can be linked with the system for crisis management to enable reporting and analysis on a daily basis. For efficient information at all levels, high quality local and national surveillance is necessary. Since using an internet-based platform, the reporting system in the Czech Republic as well as the EISS are easily accessible and provide timely information 10 14 percent of children under five years age had symptoms of an acute respiratory infection (ARI) and 31 percent had a fever. Among these children, about two-thirds were taken to a health provider and half were given an antibiotic 11

Rationale
Acute respiratory tract infections are the leading cause of death in that age group; ARI have a major impact on health services and household income, accounting for up to 50% of visits by children to health facilities in developing countries. In Gilgit-Baltistan 84% children under five years age reported at health facilities for medical care 12

Objectives of Evaluation
Objective of this evaluation to examine strengths and weakness of existing reporting system for acute respiratory infection in Gilgit-Baltistan and to formulate recommendations to improve surveillance system by identifying gaps.

Methodology of evaluation
A descriptive study will be conducted at Health department Gilgit-Baltistan from 21-29 March 2011. A Structured questionnaire developed using CDC guidelines will be used to collect data 1 Following stakeholders will be interviewed at District and Provincial level who are engaged with HMIS/LHWs at different levels Health mangers of Health department/Provincial Coordinator HMIS /LHWs MIS Coordinator at Provincial and District Pediatric physicians First level care facility incharges and reporters Lady Health workers

Using CDC Guidelines for Evaluating Public Health Surveillance Systems variables following variables will be examined 1 Simplicity, Flexibility, Data quality, Acceptability, Sensitivity Predictive value positive, Representativeness, Timeliness and Stability

Acute respiratory Infections (ARI) Reporting Systems in Gilgit-Baltistan

Acute respiratory infections are being reported through 1. Health management information system and 2. Management information system of National program for family planning and primary health care

Description of the System

a. Objectives of the system b. Operational arrangements c. System resources

REFERENCES
1. CDC. Updated guidelines for evaluating public health surveillance systems: recommendations from the guidelines working group. MMWR 2001;50(No. RR-13). 2. Teutsch SM, Churchill RE. Principles and practice of public health surveillance. 2nd ed. Oxford, New York: Oxford University Press, 2000 3. World Health Assembly: Revision of the International Health Regulations, WHA58.3 2005 [http://www.who.int/gb/ebwha/pdf_files/WHA58/ WHA58_3-en.pdf]. 4. Eric A. F. Simoes, Thomas Cherian, Jeffrey Chow, Sonbol Shahid- Salles, Ramanan Laxminarayan, and T. Jacob John,Acute respiratory infections in Children,chapter 25 5. Murray CJL, Lopez AD, Mathers CD, Stein C. The global burden of disease 2000 project: aims, methods and data sources. Geneva: World Health Organization; 2001. Global Programme on Evidence for Health Policy, Discussion Paper No. 36 6. Bryce J, Boschi-Pinto C, Shibua K. Black RE and the WHO Child Health Epidemiology Reference Group. WHO estimation of the causes of death in children. Lancet. 2005;365:114752 7. Khan TA, Madni SA, Zaidi AK. Acute respiratory infection in Pakistan: have we made any progress? J Coll Physicians Surg Pak 2004; 14: 440-8 8. Khan AJ.et al, High incidence of childhood pneumonia at high altitudes in Pakistan: a longitudinal cohort study, Department of International Health, School of Public Health, Baltimore, MD, United States of America. Bull World Health Organ 2009; 87:193199 9. Pio A. Standard case management of pneumonia in children in developing countries: the cornerstone of the acute respiratory infection programme. Bull World Health Organ. 2003;81:298300. 10. Kyncl J, Paget WJ, Havlickova M, Kriz B.Harmonization of the acute respiratory infection reporting system in the Czech Republic with the European community networks, Euro surveillance, Volume 10, Issue 3, 01 March 2005 11. Pakistan Demographic and Health Survey 2007, National institute of Population studies Islamabad Pakistan 2008. 12. Gilgit-Baltistan Demographic and Health survey 2008, National institute of Population studies Islamabad Pakistan 2008.