, WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR AFRICA
ORGANIZAÇAO MUNDIAL DE SAUnE SEDE REGIONAL EM ÂFRICA
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ORGANISATION MONDIALE DELA SANIE BUREAU REGIONAL DE L'AFRIQUE
REGIONAL COMMTITEE FOR AFRICA Forty-eighth session Harare Zimbabwe 31 Au2Yst - 4 Sellternber 1998 Provisional agenda item 8.2 INTEGRATED DISEASE SURVEILLANCE IN AFRICA: A REGIONAL STRATEGY (1999-2003) Report of the Regional Director EXECUTIVE SUMMARY
AFRJRC48/8 13 May 1998 ORIGINAL: ENGLISH
1. In September 1993, through resolution AFRlRC431R7, the Regional Committee approved the proposed steps for strengthening epidemiological surveillance at various levels of the health system, including organization of training activities at district level. Further, the Committee declared the next five years as a period for preventing and combatting epidemics of communicable diseases in Member States, through improved epidemiological surveillance at district level.
2. Despite the increasingJy important role of disease surveillance in planning, resource allocation and mobilization, and for early detection of and response to epidemic outbreaks as weil as for quantifying the impact of disease prevention and control programmes, the existing system in many Member States is not producing the required relevant information. 3. CUITently, the dysfunction in disease surveillance systems in most Member States is causing failure to detect epidemic outbreaks, resulting in diseases spreading, human suffering and loss of lives. Among other things, weaknesses in data collection, analysis, and use of information for action at ail levels, Jack ofresources and lack of awareness on the usefulness of the system are sorne of the reasons for the weak surveillance system. 4. Consequently, the Regional Director proposes that each Member State should strengthen its disease surveillance system following an integrated approach, the details ofwhich are presented in this document. 5. The Regional Committee is invited to review the document entitled "lntegrated Disease Surveillance in Africa: A Regional Strategy (1999-2003)", and give orientations for the strengthening of surveillance systems, using an integrated approach.
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CONTENTS Paragraphs INTRODUCTION ............ ........ ........ .... ..... ...... .. . . . . . . . . . . . . . . . . . .. 1- 4
JUSTIFICATION AND POLICY BASIS .. .... . . ... . " . ...... .......... . ....... .. ...... 5-11 THE REGIONAL INTEGRATED DISEASE SURVEILLANCE STRATEGY ................ 12-14
STRATEGIe FRAMEWORK ............................... . .............. ..... . .... 15-16 MAJOR THRUSTS . ........................................ . .... . . ..... . .. . ..... . 17-28 STRATEGIC ORIENTATIONS .............................. . ..... .. ..... ... ..... .. 29-31 IMPLEMENTATION FRAMEWORK ............ . ............................... ... . 32-37 INTERCOUNTRY AND REGIONAL LEVELS ............... .. .... ... ...... . .. . .. . ... 38·39 PARTNERSlllPS ................ ......•. ....... . .. . ... ............... ......... ...... 40 MANAGERIAL FRAMEWORK .................................................... 41-46 CONCLU<;ION ................. ....• ........... .. . . ....... ..... ....... . ......... 47-48
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INTRODUCTION 1. Commwticable diseases remain the major health problem in Africa. The cornrnonest causes of death and illness in the Region are acute respiratory infections, diarrhoeal diseases, malaria, tuberculosis, . HIV/AIDS/STIs, and vaccine preventable infections. Epidemie-prone diseases such as meningococcal meningitis, cholera, yellow fever and viral haemorrhagic diseases, especially Lassa fever and Ebola virus fever, are also dominant health threats in the continent. 2. A functional disease surveillance system is useful for priority setting, planning, resource mobilization and allocation, prediction and early detection of epidemics and monitoring and evaluation of disease prevention and control programmes. The CUITent disease surveillance systems are neither working effectively to measure the health impact of dominant diseases nor adequately evaluating current disease control programmes, not to mention detecting outbreaks for early intervention. 3. Because of the above, the Regional Office proposes to strengthen national disease surveillance systems using an integrated approach. This approach aims to coordinate and streamline ail surveillance activities and ensure timely provision of surveillance data to ail disease prevention and control programmes. As part of the strengthening process, the Regional Office plans to develop guidelines for a comprehensive, integrated surveillance system for the cornrnunity level, health facility level, the district and nationallevels, and at the Regional Office itself. 4. This strategy describes the need for strengthening the disease surveillance system and suggests the approach that Member States may adopt in the strengthening process for the next five years (19992003).
JUSTIFICATION AND POLICY BASIS 5. The policy basis for strengthening the surveillance system of commwticable diseases has emanated from the following resolutions of the World Health Assembly and Regional Committee meetings: (i) Resolution WHA22.47, July 1969, requesting the Director-General to assist Member States in utilizing their existing services to perfonn epidemiological surveillance as effectively as possible. (ii) Resolution WHA4J.28, May 1988, declaring the commitrnent of WHO to the global eradication of poliomyelitis by the year 2000 and urging al! Member States to intensify surveillance to ensure identification, investigation and accurate and timely case reporting at national and intemationallevels. (iii) Resolution WHA 48. J 3, 12 May 1995, urging Member States to strengthen national and local programmes of active surveillance for infectious diseases, ensuring that efforts are directed to early detection of outbreaks and prompt identification of new, emerging, and re-emerging infectious diseases. Il also requested the Director-General to draw up plans for improved national, regional, and international surveillance of infectious diseases and their causative agents as well as plans for accurate laboratory diagnosis and prompt dissemination of case dofmition and surveillance information, and to coordinate the implementation of these plans by Member States, agencies and other groups. (iv) Resolution AFRlRC38/R9, of September 1988, urging Member States to strengthen the epidemiological surveillance of HIV lAIDS and to report regularly to the Organization on the situation.
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page 2 :Cvl Resolution AFRlRC38/R34. of September 1988, requesting the Regional Director ta collabQrate with Member States in evaluating the potential capabilities ofMember States for surveillance, prevention and control of diseases in general and of epidemics in particular and ta support Memher States in the formulation of simple and effective measures for the surveillance and control of communicable diseases. Resolution AFRlRC38/R13, of September 1988, calling on ail affected Member countries to intensifY national surveillance of dracunculiasis and report regularly to WHO, and urging the Regional Director to intensifY regional surveillance of trends. Resolution AFRlRC43/R 7, of September 1993, approving the proposed steps for strengthening epidemiological surveillance at various levels of the national health systems, including the organization of training activities at district level and declaring the next five years as a period for preventing and combatting epidemics of communicable diseases in Member States, through improved district-Ievel epidemiological surveillance.
(vi)
(vii)
Major problems
6. A review of national survei1lance systems in selected Member States helped ta identifY the following problems: Ci) Vertical surveillance systems established as a component of different disease control programmes have resulted in duplication of efforts and resources, with different programmes approaching the same agency for funding for surveilJance activity. (ii) Health workers fail to report on time the first cases of epidemic-prone diseases that fit standard case definitions. This delay in reporting the earliest suspected cases significantly retards the identification of outbreaks and impedes the effectiveness of response. (iii) Collection, analysis and dissemination of surveillance data at the district level have heen inadequate. For the most part, surveillance data are passed without adequate analysis from the district level to the national level. Feedback has also generally heen inadequate at every leveJ. (iv) Little attention has been given to seeking opportunities to integrate survemance activities and increase efficiency. As a result, each programme organizes programme-specific training courses (including courses on surveillance) for the same health personnel, especially at the district and health facility levels. (v) The system does not include pneumonia and diarrhoeal diseases which are the number one and two causes of childhood death in Africa. Surveillance of malaria is also deficient. Information collected is inadequate for diseases with highly effective intervention or large outbreak potential and whose case load is relatively low.
(vi) Inadequate attention has been given ta evaluating programmes using surveillance data. Large quantities of resources are being put into inadequately evaluated interventions. (vii) Laboratory involvement in the surveillance system is inadequate. Neither national nor intercountry laboratory networks have been established to carry out important public health functions including the confirmation of cases and outbreaks when clinical diagnoses cannat be specific. (viii) Supervisory support, completeness and timeliness ofreporting are generally inadequate.
AFRlRC48/8 page 3 Strengthening disease snrveillance systems: An integrated approach 7. Currently, different intervention programmes have their own disease surveillance systems and are making efforts to strengthen them in order to get regular and timely surveillance data. 8. The WHO Regional Office for Africa proposes to ail Member States 10 adopt the inlegrated approach for strengthening surveillance systems. 1hls approach envisages integration of ail surveillance activities (collection, analysis, interpretation and dissemination of surveillance data) at district level. Ali the support for implementing the integrated disease surveillance system, including training, supervision, resources (financial and material) from al! programmes and donors, will be assigned ta the districts. 9. At the central leve\, ail support for the implementation of integrated disease surveillance systems will be coordinated by the surveillance unit. Data management for routine surveillance will also be perforrned by the same unit white specialized analysis could be left to the concemed intervention programmes.
10. As pan of the implementation of the strategy, the Regional Office is suggesting the following to Member States for consideration: (i) a Iist of priority diseases for the integrated disease surveillance system; (ii) minimum data (total case and death counts) for reporting to enable the monitoring of epidemioJogical trends and early detection of epidemics as well as the monitoring and evaluation of intervention programmes; (iii) introduction of two sets of case definitions to facilitate case detection by health facilities and the community respectively. Development of Integrated dlsease surveillance systems II. The need to strengthen the surveillance system using the integrated approach stems from the fol!owing common actions which should be undertaken in a coordinated manner: (i) Building awareness among clinicians (physicians and nurses attending patients) regarding the use of case defmitions and actions, specimen collection and timeliness of reporting.
(ii) Initiating case-based surveillance for selected diseases, including neonatal tetanus, haemorrhagic fever, yellow fever, and for diseases with higWy effective intervention or large outbreak potential whose case load is relatively low. (iii) Strengthening health personnel skills and practices regarding ail components of surveillance (particularly analysis and dissemination of surveillance data) at the district, interrnediate and nationallevels through integrated in-service training and supervisory support. (iv) Establishing or strengthening feedback 100ps at al!levels. (v) Building the capacity of the laboratories and strengthening their involvement in supporting the disease surveillance system. (vi) Monitoring of surveillance activities including timeliness and completeness of reporting.
AFRlRC48/8 page 4 THE REGIONAL INTEGRATED DISEASE SURVEILLANCE STRATEGY Long-term vision 12. Witrun ten years, ail Member States will have established a functional integrated disease surveillance system that ensures continuous and timely provision of infonnation to ail national programmes for disease prevention and control as weil as to health services at ail levels. With adequate surveillance data, there will he improved prediction and control of epidemics, enhanced quality of planning, rational allocation of resources and improvement in monitoring and evaluating the feedback loop. This will result in a reduction in disability, morbidity and mortality attributable to major communicable diseases. Guldlng prlnciples 13. The basis for the integrated disease surveillance system is "data collection for action" implying that only data necessary for taking action is col\ected and processed. This will he achieved and sustained by complying with the overall guiding principles of usefulness, slmplicity and flexiblIIty of the system, action-specifie orientation and integration. (i)
Usefulness refers to the applicability of the data to programme management (monitoring disease trends, detecting or predicting epidemics, quantifYing the impact of intervention programmes, etc.). The current system ensures that only data that aid public health decision making and action will be collected.
(ii) Simplicity is the ease of putting the system into operation. The watch words of integrated disease surveillance are "keep the system as simple as possible" (case definition, types of data to be reported, reporting tools and procedures, etc.). The simpler the system the more Iikely the compiling of the reporting fonns by clinicians and health workers and their timely transmission to the next higher level. (iii) Flexibility of the system refers to adaptability to changes in infonnation needs and operations (revision of Iists of priority diseases, case definitions, and reporting) with Iittle additional personnel , time and financial resources. The CUlTent approach is designed to be as flexible as possible. (iv) Action-specijic orientation in the context ofintegrated disease surveillance refers to making infonnation available to specific intervention programmes for action. (v) Integration refers to the coordination of ail surveillance activities common to ail control programmes (data collection, processing and dissemination, training, supervision, monitoring and evaluation of the surveillance system, etc.). Specific follow-up action is left to the different intervention programmes. 14. Other attributes of the surveillance system include acceptabüity and reliability of data, timeliness and completeness of reporting, sensitivity and specijicity. (i) Acceptability reflects the willingness of individuals and organizations to participate in a surveillance system. Reliability of data refers to the accuracy and quality of data made available through the system. (ii) Completeness of reporting means lhat ail reporting requirements have been met, including reporting on diseases selected for surveillance from ail reporting units, while timeliness refers to the receipt of data on or before the due date. Indeed. failure to make information available on time retards public health action.
AFR/RC48/8 page 5 (iii) Specijicity refers to the ability of the system to be specific in detecting those cases without obvious symptoms. Il refers to the proportion of persons without visible disease conditions who are correctly identified through a case definition as having the disease. (iv) Sensitivity refers to the ability of the system to detect a disease or an outbreak, be it epidemic or other changes in disease occurrence. It refers to the proportion of persons with disease correctly identified through case definition as having the disease.
STRATEGIe FRAMEWORK Strategie objectives 15. The strategic objectives of the integrated disease surveillance system are: (i) To design an integrated disease surveillance system that includes: (a) an index of the principal causes of disability, morbidity and mortality in Aftica, (b) case-based reporting on selected diseases and, (c) the enhanced use of standard case defmitions for notification.
(ii) To integrate al! surveillance activities including transportation of specimens, training ofhealth personnel on surveillance and provision of supervisory support to the districts and health facilities. (iii) Ta strengthen surveillance data management (collection, analysis, interpretation and dissemination) and the use of surveillance data and outcomes for decision making and the monitoring and evaluation of intervention programmes. (iv) Ta strengthen the capacity and involvement oflaboratories in surveillance activitie,s. Targets 16. The country targets for the integrated disease surveillance system are: (i) By the end of 1999: (a) (b) (c) 80% of the Member States will have assessed their national surveillance system as part of the implementation of the regional strategy; 80% of the Member States will have formed a central body ta coordinate ail surveillance activities; a surveillance unit will have developed at the WHO Regional Office level to coordinate ail disease surveillance activities.
(ii) By the end of2003: (a) (b) (c) ail Member States will have assessed their national surveillance systems as part of the implementation of the regional strategy; ail Member States will have formed central bodies to coordinate ail surveillance activities; ail Member States will have had functional and integrated disease surveillance systems.
MAJOR THRUSTS
Priority diseases or syndromes for integrated disease surveillance 17. The Regional Office bas suggested 18 (eighteen) communicable diseases or syndromes for integrated disease surveillance. Member States are expected ta adapt the Iist ta suit their local epiderniological profiles, taking into consideration national, regional and international perspectives.
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page 6 18. The suggested list of diseases or syndromes and their grouping inc\udes:
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Epidemie-prone diseases Cholera, Bacillary dysentery, Plague, Measles, Yellow fever, Meningococcal meningitis, Viral haemorrhagic fever
(Ii)
Diseases targeted for eradlcation Dracunculiasis, Poliomyelitis
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(Ui) Diseases targeted for elimination
Neonatal tetanus, Leprosy
(iv) Other diseases of public health importance Diarrhoea (in children under 5), Pneumonia (in children under five), HIV/ AlDS, STIs, Malaria, Trypanosomiasis, Tuberculosis
Involvement of laboratories in surveillance 19. In resolution AFR/RC431R7, Member States were urged to develop well-staffed and equipped laboratory services as a step toward the strengthening of their disease surveillance systems. The major role of a laboratory in the integrated surveillance system is to provide on time and reliably the confumation of suspected cases. The laboratory will a1so essentially monitor drug resistance and changes in the strains of disease agents. This calls for a thorough assessment of the current diagnostic capacity of each country at allievels, the supply of recommended basic laboratory equipment for specifie levels and spheres of activities and the fostering of in-service training of laboratory personnel in relevant laboratory techniques. In addition, strengthening existing laboratory facilities, concentrating on simple, cost-effective techniques for rapid diagnosis and establishing a referrallaboratory network by defining the appropriate laboratory activity for different levels, are the key steps in strengthening the process. It is envisaged that viable referral channels for samples and results and the safe handling of specimens during storage and transportation will be assured.
An/imicrobial resis/ance 20. An increase in antimicrobial resistance in the last few years has affected the treatrnent and control of important diseases, leading to prolonged illnesses and epidemics and increased case fatality. Therefore, data will be collected from sentinel laboratories in order to document resistance patterns relating to malaria, tuberculosis, S. dysentriae, chancroid, gonorrhea, pneumonia (S. pneumoniae, H. influenzae).
Data Management 21. Surveillance data management includes the collection, collation, analysis and Interpretation of surveillance data and the dissemination of information to those who take action or prepare the report.
Data collection 22. Only basic information on selected priority diseases is collected for routine programme monitoring and evaluation at ail levels. However, health facilities are expected to record al1 necessary information regarding individual cases, for future use. For routine surveillance, monthly records of the total number of cases and deaths, (including "zero reporting") for ail the selected diseases is recommended, using an appropriately designed reporting format. However, each Member State will determine the minimum surveillance data required for nationallevel use. Table 1 shows sources of surveillance data by disease and periodicity of reporting.
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page 7 23 . For epidemic-prone diseases, there is need to maintain immediate notification upon suspicion or diagnosis followed by weekly reporting during the epidemic period. In addition, the normal functions of the other supplemental surveillance systems such as laboratory-based surveillance for antimicrobial resistance, case-based or sentinel-based surveillance for other selected diseases will continue unchanged. 24. The district health office compiles ail reports from health facilities and sends them to the national level. The national level compiles ail reports and sends them to the WHO country Office which will eventually send them to the Regional Office.
TABLE 1: SOURCES OF SURVEILLANCE DATA BY DISEASE AND PERIODICITY OF REPORTING Sources of surveillauce data Routine reports Epidemic reports AlI diseases cholera, cerebrospinal meningitis, yellow fever, plague, malaria, viral haemorrhagic fever, measles, neonatal tetanus, poliomyelitis, dracunculiasis malaria (drug resistance), HIV sero-prevalence Monthly Immediately, then weekly as it occurs, immediately monthly/quarterly/ annually Disease Periodiclty
Case-based reports Sentinel site reports
Data analysis and Interpretation 25. Data analysis and interpretation are critical at ail levels, especially at the health facility and district levels. At the district level, a continuous and systematic collation and analysis of ail data derived from the lower level should help to keep track of the disease situation in the area. Data interpretation is equally emphasized in the integrated approach and should be practised at alllevels, particularly al the health facility and district levels. Dissemination of information 26. Distribution of information to those who are responsible for taking action (programme managers) or using the information for managing intervention programmes (programme staff) is an important, but often neglected, component. Community leaders (at community level), administrators, police, staff of other sectoral and nongovernmental agencies (at district and national levels) are important players. Feedback to those who generate the information (health care providers) and those who transmit the reports to the next higher level (intermediate health agencies) will be strengthened. Decisions for action 27. A decision to take action follows data analysis and interpretation. The specific action will depend on the causes of the problem, types of diseases and level of structures. Health facility and district health team personnel are expected to take immediate action without necessarily waiting for approval from the higher level. The approach is to identifY possible solutions for each problem identified during data analysis and interpretation and to take necessary action as promptly as possible, at each level. Communication Network 28. Communication of surveillance data from the health facility level right to the national and intemationallevels and back to the community level, (in the form offeedback loops) is important. In this connection, the means of communication used to transmit the information plays a vital role. In order to ensure timely receipt of surveillance data, the fastest means of communication should be used as appropriate, including e-mail, telephone, fax and radio communication. The recommendation is that
, AFR/RC48/8 page 8 transmission of surveillance data: (a) from the health facility to the district health office (DHO) could be by telephone or radio; (b) from the DHO to the nationallevel could be by telephone, radio, fax or e-mail; (c) from the nationallevel to the WHO country Office could be bye-mail or diskettes; and (d) from the WHO country Office to WHO Epidemiological Block and the Regional Office could be by e-mail. Consequently, il is planned that every WHO country Office will have e-mail. STRATEGIC ORIENTATIONS Capacity Building 29. Strengthening disease surveillance systems, using the integrated approach, involves: (i) orientating and re-orientating intensified in-service training at ail levels, using appropriate training materials, and targeting in particular the district health team and attending physicians and nurses;
(ii) establishing a focal point or organ for coordinating the integrated disease surveillance activities at allievels, particularly al the nationallevel; (iii) placing systems for computerised data management at central and intermediate levels and simple data presentation tools (tables and graphs) at district level; (iv) establishing inter country collaboration and networking to exchange information on diseases of interest at internationallevel; (v) establishing efficient communication networks within the country for prompt reporting; and (vi) building the capacity oflaboratories, inciuding that ofnetworks at national and regionallevels. Promotion of integrated surveillance systems 30. Integrated surveillance systems will be promoted at allieveis (community, health care providers, health authorities inc1uding decision and policy makers ) in order to create weil informed groups with an enhancedsense of responsibility, urgency and ownership regarding the activity and to ensure maximum cooperation. This could be done through sensitization meetings, training workshops on integrated disease surveillance, advocacy campaigns using different media channels and surveillance activity or programmatic interventions. Promotion of operational research 31. Surveillance promotes research by identifying research issues and generating hypotheses which are picked up by researchers as research issues. The findings of these research efforts could be used to modify and fine-tune control programmes. IMPLEMENTATION FRAMEWORK At country level 32. The community, health care providers, and health care agencies (at district, provincial and national ievels) are key players in integrated disease surveillance. Activities and tasks for each level are outlined below. Those Member States with provincial or regional structures could adapt the activities to those levels since the functions are essentially the same.
AFRlRC48/8 page 9 33. At the community level, community leaders or health workers with instructions on how to recognize certain disease conditions could be used as contact persons in the community for the purpose of detecting and reporting suspected cases to the health facility. Tasks at community level comprise: (i) notif'ying the nearest health facility of the occurrence of the cases selected for community-based surveillance;
(ii) supporting health workers during case or outbreak investigation; (iii) using feedback from health workers to take action, including action for health education, and (0 coordinate community participation.
At healtb facility level 34. The tirs( opportunity for disease surveillance occurs at tbis level when the clinician at the health facility sees the patient. At this level clinicians will identif'y priority diseases, using case detinition. Tasks at health facility level comprise: (i) diagnosing and managing cases;
(ii) responding promptly to any epidemic alert by community leaders; (iii) submitting monthly summary reports and weekly reports during outbreaks; (iv) collecting specimens (if needed) and sending them to the district health office (DHO); (v) preparing tables and graphs and displaying derived data for monitoring the trends of diseases; and (vi) using available data to initiate action at the locallevel.
District level 35. At this leve\, continuous analysis of surveillance data from the health facility is carried out in order to recognize outbreaks or changes in disease trends. This analysis is linked to responses from the investigations; the required interventions could also be assessed using the same data sources . Tasks at district level comprise: (i) analysing surveillance data from the peripherallevel in order to identif'y epidemiologicallinks and trends, and to achieve control targets;
(ii) providing support for specimen transportation to the laboratory network for diagnosis or confirmation of suspected cases; (iii) initiating investigation of suspected outbreaks; (iv) providing feedback to the health facility level; and (v) sending to the centrallevel monthly summary reports on selected diseases and outbreaks.
At centrallevel 36. By supporting the district level, the centrallevel plays a key raIe in ensuring the proper functioning of the system. Analysis of overall disease trends is carried out continuously. The centrallevelliaises with countries and international agencies to exchange information and mobilize resources. Tasks at central level comprise:
AFRlRC48/8 page 12 Human resources
42. The staff required to implement the strategy will be mobilized by the governments. WHO will provide technical support ta the ministries of health to build national expertise for ensuring sustainable system development.
Coordination 43. Coordination mechanisms will be set up under the leadership of the ministries ofhealth to support the implementation of the integrated disease surveillance strategy. Coordination of activities instead of structures will be the focus of the strategy.
. At district level 44. District health management committees could be entrusted with the responsibility of coordinating the integrated disease surveillance system. District health managers are expected to assume leadership as secretariats of the committees, and ta coordinate the partners at the district level (inc1uding community representatives). Technical advisory conunittees, chaired by district health managers, could be established to provide support on technical matters.
At country level 45. Ali potential partners (other sectoral structures such as ministries of agriculture, universities, agencies of the United Nations system, bilateral and non-governmental agencies) need to be approached to form a centrallevel committee to support the ministries ofhealth in the coordination and streamlining of inputs for the surveillance system. Those Member States with task forces for the control of emerging and other communicable diseases could be given the additional task of coordinating the integrated disease surveillance system. Furthermore, a technical advisory committee could be set up to advise the coordinating committee on technical matters and to ensure linkage to public health action.
Monitoring and evalnatlon 46. Monitoring the process and the outcome of the integrated disease surveillance strategy will be developed ta ensure the quality of the surveillance system. This will be done through supportive supervision and regular review meetings. Relevant indicators will be developed as part of the Integrated Surveillance Guidelines.
CONCLUSION 47. A strong disease surveillance system is the foundation of effective disease prevention and control programmes. Strengthening of the surveillance system through an integrated approach is therefore the preferred strategy for Africa. 48. The success oflhis strategy will depend on the willingness ofhealth care providers ta report ail cases and deaths at their facilities. Il will also depend on the diligence of health officiaIs and personnel al ail levels to analyse and distribute information to aIl those responsible for taking action and to provide feedback ta the peripherallevel. Without doubt, commitment both by policy makers in terms of resource allocation and by aIl partners in terms oftechnical and financial support will contribute significantly to the success of the strategy.