University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES, UNIVERSITY OF GHANA LEGON ASSESSMENT OF THE CHOLERA SURVEILLANCE SYSTEM IN THE LEDZOKUKU-KROWOR MUNICIPALITY IN THE GREATER ACCRA REGION OF GHANA BY KODOM KWAME ACHEMPEM (10334022) A DISSERTATION SUBMITTED TO THE SCHOOL OF PUBLIC HEALTH, UNIVERSITY OF GHANA IN PARTIAL FULFILLMENT FOR THE AWARD OF THE MASTER OF PUBLIC HEALTH (MPH) DEGREE JULY, 2017 University of Ghana http://ugspace.ug.edu.gh DECLARATION I Kodom Kwame Achempem confirm that this work submitted for review is my own words. Any uses made within the works of other authors in any form are properly acknowledged at the point of their use. A full list of the references employed has been included. ………………………………….. ……………………………. KODOM KWAME ACHEMPEM DATE (STUDENT) ………………………………….. ……………………………. MR CHRIS BAMBEY GUURE DATE (SUPERVISOR) i University of Ghana http://ugspace.ug.edu.gh DEDICATION I dedicate this work to Almighty God, my wife, Mrs Christina Kodom-Achempem and my lovely daughter Nana Abena Kodom Achempem who encouraged and gave me the moral and financial support to pursue this programme Also to my dear sister, Mrs Afia Seiwaa Yegbe (Deputy Director Nursing Services, KATH/Director, Premier Nursing School, Kumasi) for her financial assistance Lastly to my late mother, Mrs Comfort Adwoa Akyaa Achempem for her love and support ii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT My heartfelt gratitude goes to Mr. Chris Bambey Guure, my academic supervisor, for his guidance, support and encouragement throughout my study. I also express my profound appreciation to Ms. Jacqueline Sfarijlani, the District Director of Health Services for the Ledzokuku-Krowor municipal for her support and inputs during my data collection. I also wish to thank the Regional Disease Surveillance officer for Greater Accra region and the deputy director and head, Disease Surveillance Department of the Ghana Health services, for their assistance and cooperation during my data collection in their respective facilities. I owe special gratitude to Mr. Jerry Adu, Mrs. Catherine Teye and Ms Comfort Ameyaw for helping me with my data collection. Finally, my heartfelt appreciation goes to my dear friend Mr Gideon Kwarteng Acheampong for his invaluable contribution and support during the course of my study. I say God richly bless you. iii University of Ghana http://ugspace.ug.edu.gh ABSTRACT Cholera outbreaks in recent time happens in between epidemic phases of dissimilar lengths in Ghana. The endemic nature of cholera in Ghana makes it prudent for the disease to be managed effectively to enhance rapid detection of likely outbreaks. The surveillance system for cholera is vital for the early detection of cases and outbreaks that will facilitate a swift control of likely epidemics. This study assesses the cholera surveillance system of the Ledzokuku-Krowor municipality of Ghana, a highly cholera endemic area to determine whether the system is performing effectively. Specifically, this study describes the public health importance of cholera in the Ledzokuku-Krowor municipality as well as the significance of the surveillance system. It also describes the purpose and operation of the surveillance system in place at Ledzokuku-Krowor municipality and suggest measures to improve cholera surveillance in the municipality. An assessment of the surveillance system was done using the Centres for Disease Control and Prevention (CDC) Guidelines for Surveillance System Evaluation. The study reviewed documents of the surveillance system at various levels in the Ledzokuku-krowor municipality. Semi structured questionnaires were used in interviews with surveillance staff at the municipal and health facilities The research revealed that the Cholera surveillance system in place in the Ledzokuku- krowor municipal is considered suitable by the surveillance and health information staff as it can detect any suspected case of cholera and other disease outbreaks. It was also found that the system is acceptable (83%), flexible and representative. Personnel from the Municipal Health Directorate confirmed there is an efficient technique to verify data quality, a development that positively affects the process of disease surveillance. iv University of Ghana http://ugspace.ug.edu.gh The research concluded that the cholera surveillance system is meeting its objectives. The Cholera surveillance system is useful and can detect cases. The municipal and the facility staff indicated indepth knowledge on case detection, notification and reporting for cholera. The system could perform better with continuous capacity building being effected at all the levels. The data collected, could also be much better and more meaningful if the system has additional specialized health information staff within all the levels to analyze data which could produce more valuable results for planning and policy. v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS DECLARATION ................................................................................................................... i DEDICATION ...................................................................................................................... ii ACKNOWLEDGEMENT .................................................................................................. iii ABSTRACT ......................................................................................................................... iv LIST OF TABLES ............................................................................................................ viii LIST OF FIGURES ............................................................................................................. ix LIST OF ABREVIATIONS .................................................................................................. x CHAPTER ONE ................................................................................................................... 1 INTRODUCTION ................................................................................................................ 1 1.0 Background ................................................................................................................. 1 1.1 Problem Statement ...................................................................................................... 3 1.2 Rationale of the study .................................................................................................. 4 1.3 Research questions ...................................................................................................... 5 1.4 Justification ................................................................................................................. 5 1.5 General objective ......................................................................................................... 6 1.5.1 Specific objectives ................................................................................................ 6 CHAPTER TWO .................................................................................................................. 7 LITERATURE REVIEW...................................................................................................... 7 2.1 Introduction ................................................................................................................. 7 2.3 Epidemiology of cholera ............................................................................................. 7 2.3 The concept of disease surveillance ............................................................................ 8 2.3.1 Some functions of surveillance system ................................................................. 9 2.4 Integrated Disease Surveillance and Response (IDSR)............................................... 9 2.5 Cholera surveillance systems in some African countries .......................................... 10 2.5 The IDSR and DHIMS II .......................................................................................... 11 2.8 CDC and WHO Guidelines for Evaluating Public health surveillance systems ....... 12 2.9 Studies conducted on the evaluation of surveillance systems ................................... 14 CHAPTER THREE ............................................................................................................. 16 METHODOLOGY .............................................................................................................. 16 3.1 Introduction ............................................................................................................... 16 3.2 Study Design ............................................................................................................. 16 3.2.1 Study Methodology............................................................................................. 16 3.3 Study Site .................................................................................................................. 18 3.4 Sampling .................................................................................................................... 21 3.5 Data collection ........................................................................................................... 21 3.6 Data Management ...................................................................................................... 22 3.7 Data analysis .............................................................................................................. 22 3.8 Quality assurance ...................................................................................................... 22 3.9 Ethical Considerations ............................................................................................... 23 Potential Policy Impact ................................................................................................... 23 vi University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR ............................................................................................................... 24 RESULTS ........................................................................................................................... 24 4.1 Description of the public health significance of cholera in the Ledzokuku-Krowor municipality ..................................................................................................................... 24 4.2 Administrative data results ........................................................................................ 25 4.3 Description of the cholera surveillance system ..................................................... 26 4.3.1 Purpose and objective of the cholera surveillance system of Ledzokuku-Krowor ..................................................................................................................................... 26 4.3.2 Case definitions................................................................................................... 26 4.3.3 Residence of a system for cholera surveillance within the municipal health system .......................................................................................................................... 27 4.3.4 Flow chart of the surveillance system................................................................. 30 4.3.5 Components of the health system ....................................................................... 30 4.3.6 Specific reinforcements and resources used to operate the surveillance system of Ledzokuku-Krowor ...................................................................................................... 33 4.4 Description of the performance and attributes of the system .................................... 33 4.4.1 Simplicity ............................................................................................................ 39 4.4.2 Flexibility ............................................................................................................ 40 4.4.3 Data quality ......................................................................................................... 40 4.4.4 Acceptability ....................................................................................................... 40 4.4.5 Sensitivity ........................................................................................................... 41 4.4.6 Positive Predictive Value .................................................................................... 41 4.4.7 Representativeness .............................................................................................. 41 4.4.8 Timeliness ........................................................................................................... 42 4.4.9 Stability ............................................................................................................... 42 CHAPTER FIVE ................................................................................................................. 43 DISCUSSION ..................................................................................................................... 43 5.1 Description of the public health significance of cholera in LKM ............................. 43 5.2 Description of the cholera surveillance system ......................................................... 44 5.3 Description of the performance and attributes of the system .................................... 45 CHAPTER SIX ................................................................................................................... 47 CONCLUSION & RECOMMENDATIONS ..................................................................... 47 REFERENCES .................................................................................................................... 49 APPENDICES .................................................................................................................... 52 APPENDIX I: CONSENT FORM .................................................................................. 52 APPENDIX II: QUESTIONNAIRE ............................................................................... 56 APPENDIX III: QUESTIONNAIRE FOR STAKEHOLDERS ..................................... 61 APPENDIX IV: STANDARD PROCEDURE FOR CHOLERA SURVEILLANCE SYSTEM ......................................................................................................................... 66 APPENDIX V: EVALUATION ATTRIBUTES OF A SURVEILLANCE SYSTEM .. 70 vii University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 3.1: Population Distribution by Zones in Ledzokuku-Krowor, 2016 ....................... 20 Table 4.1: Percentage of population with diarrheal disease from 2016-2012 .................... 25 Table 4.2: Results of Stakeholder Sessions at Municipal Health Directorate .................... 35 Table 4.3: Results of Stakeholder Sessions at Selected Health Facilities .......................... 35 viii University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 3.1: Map of Ledzokuku-Krowor Municipality ........................................................ 19 Figure 4.1: Trends in diarrheal diseases recorded in the Ledzokuku-Krowor Municipality between 2012-2016 ........................................................................................... 24 Figure 4.2: Flow chart of the Ledzokuku-Krowor cholera surveillance system ................. 30 ix University of Ghana http://ugspace.ug.edu.gh LIST OF ABREVIATIONS AWD Acute Watery Diarrhoea CDC Centre for Diseases Control CDD Control of Diarrheal Diseases CFR Case Fatality Rate CHIM Centre for Health Information Management DHD District Health Directorate DHIMS District Health Information Management System ESD Epidemiology and Surveillance Division HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome IDSR Integrated Disease Surveillance and Response LKM Ledzokuku-Krowor Municipal MOH Ministry of Health STD Sexually Transmitted Diseases TB Tuberculosis WHO World Health Organisation x University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.0 Background Cholera is an epidemic-prone disease of global significance and has over the years played a prominent role in the history of public health. Much has been studied about the causative organism, the mode of transmission, and methods of preventing the spread of cholera since th the 19 century (Cowman, 2015). This infectious disease has been virtually eliminated from developed countries due to improved water and sanitation infrastructure, but deadly cholera outbreaks still occur in many low-income countries (Lamond and Kinyanjui, 2012). In recent years, there has been intense increase in the number of reported cholera cases and virtually all developing countries are facing either a cholera outbreak or the risk of an epidemic of which Ghana is no exception (Kuma et al., 2014) . Global reports suggest that over 3.5 million people are affected annually with between 100,000-130,000 deaths per year (Kanungo et al., 2010). Cholera is endemic in Ghana with outbreaks occurring within epidemic periods of varying lengths. Epidemics have been known to typically occur every five years in Ghana, following heavy rains and flooding or acute water shortage (Miners, 2012). In the last few years however, both sporadic and epidemic cases of cholera have been reported in Ghana with onsets following no seasonality. Cholera is a severe intestinal disease caused by the bacteria, Vibrio cholerae. The bacterium is typically found in water environments such as freshwater lakes and rivers. Cholera is usually transmitted to people or animals through contaminated water sources. Contamination comes from fecal material from infected individuals. Cholera can affect people and some animals and causes severe diarrhea, vomiting, dehydration, and shock. If untreated, death can occur within hours (Cholera; Fast facts, 2006). 1 University of Ghana http://ugspace.ug.edu.gh Human exposure to the cholera bacteria most commonly occurs from ingesting (oral) fecal contaminated water or eating undercooked food. Most cases occur when a person travels to a developing country usually characterized by poor sanitary conditions or eats contaminated food. When infection occurs in humans, signs develop quickly (as short as 5 hours) and include profuse, watery diarrhea and vomiting. The disease may be so severe that the individual loses all body fluids, becomes severely dehydrated and can die (Cholera Epidemiology and Response Factsheet - Cameroon, 2013; Cholera; Fast facts, 2006). The Integrated Disease Surveillance and Response (IDSR) is a strategy developed by the World Health Organization Regional Office for Africa (WHO/AFRO) in 1998. It is intended to assist health workers to detect and respond to diseases of epidemic potential, diseases of public health importance, and diseases targeted for eradication and/or elimination (Gueye et al., 2005). Cholera features on the list of priority diseases in Ghana under the Integrated Disease Surveillance and Response program due to its endemic nature and occurrence of periodic outbreaks especially in the wet season (Adokiya et al., 2015). A national surveillance system for cholera is essential for an early detection of cases and outbreaks that will facilitate a swift control of the epidemic. A functioning surveillance system cholera permits the constant and systematic collection, analysis, elucidation and dissemination of data regarding the disease in the country. These statistics can inform health personnel in decision making required to implement strategies for disease control and prevention of future occurrence .(Sanchez-padilla et al., 2009; Adokiya et al., 2015). Most communicable disease evaluation systems set out to describe the relevance of the surveillance system of a named disease, define the purpose and operation of the system and identify items to be enhanced within the system (World 2 University of Ghana http://ugspace.ug.edu.gh Health Organization, 1947). With cholera epidemics now frequently occurring in recent time notably in 2011, 2012 and 2014 in Ghana (Kuma et al., 2014) , it is prudent to review the various aspects of cholera disease control and prevention of which the cholera surveillance system is no exception and hence necessitating this study. 1.1 Problem Statement The Ledzokuku-Krowor municipal assembly has been bedeviled with frequent cholera outbreaks in recent times (Ghana Statistical Service (GSS) 2014; Ghana National Action Plan For Cholera 2015; Dzotsi,2014). In the most recent outbreak of cholera that occurred in Ghana, the Ledzokuku-Krowor municipality recorded one of the highest attack rates in the Greater Accra Region; 190 per 100,000 cases and a 12.6% fatality rate. (Dzotsi, 2014), Notwithstanding the compulsory adherence to standardized protocols in disease surveillance reporting in reference to technical guidelines, the surveillance system the Ledzokuku-Krowor municipality with specific reference cholera is not robust enough to detect, notify and initiate control measures. During the recent cholera outbreak in 2014, the reasons that culminated in the municipality being overwhelmed was a weak diarrhoea surveillance, non-adherence to standard protocols in cholera surveillance, inadequate technical expertise in management of cholera and insufficient resources (human and material)(Dzotsi, 2014). Timeliness of notification being a key surveillance attribute, incompleteness of data collected for cholera surveillance at the various levels of the health system in the municipality and under reporting of cases in general is a problem. The high levels of cholera cases that have been recorded in the district over the years prompted health officials over the years to strengthen the health systems in Ledzokuku- Krowor and these measures included the call for improvement of cholera surveillance 3 University of Ghana http://ugspace.ug.edu.gh (Ghana National Action Plan For Cholera, 2015). In light of the current issue with cholera prevention and control in the Ledzokuku-Krowor municipality and the call for improvement of the cholera disease surveillance, this study is set out to assess the cholera surveillance improvement exercise in a bit to improve upon the ailing cholera situation in Ledzokuku-Krowor. 1.2 Rationale of the study In the background, the endemic nature of cholera in Ghana makes it prudent for the disease to be managed effectively to enhance rapid detection of likely outbreaks (Sanchez- padilla et al., 2009). According to a report on the prevention and control of cholera in Ghana,2015, all the regions in Ghana except Upper West were involved in waves of protracted Cholera outbreaks that started in December 2010 through to 2014 and posed public health security threat and national concern (Ghana National Action Plan For Cholera, 2015). The disease has subsequently become endemic in most coastal regions of Ghana: Greater-Accra, Central and Western Regions in recent time. The report more importantly mentioned strengthening of the cholera surveillance unit as one of the strategies to curb the occurrence of frequent outbreaks by orienting of health personnel on surveillance in terms of data collection, analysis and interpretation for decision making and strengthening competencies for forecasting and use of early warning systems for early detection of epidemics/outbreaks. As a mechanism to assess the success of the implementation of this strategy mentioned by the report (Ghana National Action Plan For Cholera, 2015) and to improve cholera disease surveillance on the phase of recent outbreaks, it is important to carry out a study as such to assess the entire cholera surveillance system. 4 University of Ghana http://ugspace.ug.edu.gh 1.3 Research questions The issues discussed in the problem statement highlighted challenges in cholera surveillance and management in the Ledzokuku-Krowor municipality. This study seeks to investigate the following;  What is the importance of cholera surveillance in the municipality  What are the standard procedures in cholera surveillance?  Does the district follow these standard procedures?  Has the Cholera surveillance system been effective?  What are the attributes of the surveillance system in the municipality? 1.4 Justification Assessment of a public health surveillance system emphasizes the functionality of it and how it operates to meet its purpose and objectives, and it may advance the evidence provided to guarantee that cholera is being observed resourcefully and effectively (Sanchez-padilla et al., 2009). The purpose of evaluating the cholera surveillance system of Ghana is to ensure that this disease, of public health importance, is being monitored efficiently and effectively. Ghana sets targets for reducing rates of cholera nationally, or for reducing the number of areas with endemic cholera, surveillance is needed to determine if these targets are being met (Cholera Surveillance : Detecting and Reporting Cases, 2015).To ensure whether these targets are being met at the district, regional and national levels, it is prudent for the cholera surveillance program to be evaluated. 5 University of Ghana http://ugspace.ug.edu.gh 1.5 General objective The objective of this study is to assess the cholera surveillance system to determine whether it‟s performing effectively with respect to the Ledzokuku-Krowor municipality. 1.5.1 Specific objectives Specifically, this study sets out to;  To determine whether the surveillance system is meeting its objectives  To assess the attributes of the surveillance system  To determine the usefulness of the surveillance system in the municipality 6 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Introduction The literature review profiles of cholera disease and its epidemiology followed by an overview of the concept of disease surveillance. The focus of the review is specifically on cholera surveillance systems. Pertinent subject areas such as; The Integrated Disease Surveillance and Response(IDSR), The CDC and WHO Guidelines for Evaluating Public health surveillance systems are all explored. The final sections of this chapter looks at the cholera issue in the Ledzokuku-Krowor municipality as well as similar studies that have been conducted with regards to this study. 2.3 Epidemiology of cholera Cholera is a major public health problem that is becoming increasingly important as the number of countries affected continues to increase. In 2014, there were 58 public health events within the World Health Organization (WHO) African Region and out of these, infectious diseases formed 95% of all these events with Cholera being the most frequently reported (31%), ahead of Ebola (13%) which has seen its biggest epidemic in history recently (World Health Organization, 2015).According to the WHO in 2015, new major outbreaks of cholera are continuing to occur, especially in the wake of climate changes. There were 101,987 cholera cases of which 1,881 resulted in deaths giving rise to a Case Fatality Rate (CFR) of 1.8% within the African Sub region (World Health Organization, 2015). These reported cases were more than double that of the previous years 2013 and 2014. In total, 16 countries reported cholera cases of which Ghana was the second most affected country only topped by Nigeria. Ghana, Nigeria plus DR Congo accounted for 85% of all cases reported in 2014. 7 University of Ghana http://ugspace.ug.edu.gh Cholera has now become endemic in parts of Ghana and the country has been experiencing outbreaks of the disease about every five years since 1970 (Dziedzom, 2015). In June 2014, the country reported its first 6 cases of the disease in the Greater Accra region. Within two weeks the number of reported cases had risen above 250 and began spreading to other regions (Issa et al., 2014; Kuma et al., 2014; Ghana National Action Plan For Cholera 2015). By the close of 2014, a cumulative total of 28,955 cases with 243 deaths and a CFR of 0.8% were recorded. All ten regions in Ghana reported cases with 70% of all the cases from the Greater Accra region alone, (Dzotsi, 2014). The economics surrounding Cholera have always shown poverty, social amenities like portable water and poor sanitation plus personal hygiene nexus (Dziedzom, 2015). There have been many advances in methods and development of new drugs and vaccines before the turn of the 20th century, despite this, there has been an apparent increase prevalence and incidence in the emergence of many infectious diseases throughout the world of which cholera is one 2.3 The concept of disease surveillance Surveillance is defined as the ongoing and systematic collection, analysis, interpretation of health data in the process of describing and monitoring a health event” with the objective of supporting the planning, implementation and evaluation of public health interventions and programs (Hashim, 2011). More specifically, communicable disease surveillance in this context is the continuous monitoring of the frequency and the distribution of disease and deaths due to infections that can be transmitted from human to human or from animals, food, water or the environment to humans, and the monitoring of risk factors for those infections (Cowman 2015; Bashorun et al., 2013; Hashim 2011; Aagaard-Hansen et al., 2009). This definition means information for a real action. Surveillance systems are 8 University of Ghana http://ugspace.ug.edu.gh networks maintaining their operation at different levels and providing information for disease prevention and control. Effective communicable disease control needs effective response systems, which basically depend on effective disease surveillance. An effective surveillance system is a corner stone in providing information for action on priority communicable diseases and plays a major role in public health decision-making. Surveillance provides data, which can be used for priority setting, policy decisions, planning, implementation, resource mobilization and allocation, prediction and early detection of epidemics 2.3.1 Some functions of surveillance system  The surveillance system is established to guide immediate action for cases of public health importance and thereby measure the burden of a disease including changes in related factors, the identification of populations at high risk, and the identification of new or emerging health concerns. The system also monitor trends in the burden of a disease, including the detection of epidemics (outbreaks) and pandemics and guide the planning, implementation, evaluation of activities to prevent and control disease, injury, or adverse exposure which will ultimately provide a basis for epidemiologic research. (Guerra et al., 2012; European Centre for Disease Prevention and Control 2014; Hashim 2011) 2.4 Integrated Disease Surveillance and Response (IDSR) Integrated disease surveillance activities are an effective, efficient and sustainable approach to improve national capacities; integrated disease surveillance visualizes all surveillance activities in a country as a common public service that carries out many functions using similar structures, processes and personnel (Adokiya et al., 2015; World 9 University of Ghana http://ugspace.ug.edu.gh Health Organization, 2010). By strengthening IDSR skills and resources, improved health and well-being for district communities can result. To that end, integrated disease surveillance seeks to:  Strengthen the capacity of health systems to conduct effective surveillance activities  Integrate multiple surveillance systems so that forms, personnel and resources can be used more efficiently and effectively  Improve the use of information for decision-making  Improve the flow of surveillance information between and within levels of the health system  Improve laboratory capacity and involvement in confirmation of pathogens and monitoring of drug sensitivity  Strengthen the involvement of laboratory personnel in epidemiological surveillance Increase the involvement of clinicians in the surveillance system  Emphasize community participation in detection and response to public health problems (World Health Organization, 2010) 2.5 Cholera surveillance systems in some African countries Diarrheal diseases including cholera are among the leading causes of morbidity in a number of African countries including Kenya, Ghana, Nigeria, Uganda and Togo (CDC 2014; Cowman 2015; Bwire et al., 2013; Essoya et al., 2013). In Uganda for example, cholera surveillance has become part of the Integrated Disease Surveillance and Response (IDSR) strategy, which was adopted from the WHO. Cholera surveillance is coordinated at the national level by the Uganda Ministry of Health (MOH) 10 University of Ghana http://ugspace.ug.edu.gh and overseen by the Epidemiology and Surveillance Division (ESD) and the Control of Diarrheal Diseases Unit (CDD). Weekly aggregate data are reported by the districts to the national level through IDSR, and active case reporting may be carried out during epidemic periods. In 2011, the country introduced enhanced cholera surveillance in 5 districts of Eastern Uganda through the support of the African Cholera Surveillance Network (Bwire et al., 2013). In the case of Togo, The Epidemiology Division of the Ministry of Health within the National Institute of Hygiene conducts cholera surveillance with support from the National Reference Laboratory. Each week, health district personnel compile data on cholera collected by peripheral health centers, using a standard data collection form, which is then transmitted to the district health center. On a weekly basis, the district health officer compiles data and forwards summary statistics to the regional health center, which are then further summarized and then forwarded to the National Division of Epidemiology. At the national level, only summary statistics are available (Essoya et al., 2013). 2.5 The IDSR and DHIMS II The IDSR is focused on diseases and events of national and international concern of which cholera is a major part. To date, the IDSR system still depends on paper-based data production from the peripheral health facilities (World Health Organization, 2010). However, the District Health Information Management Systems II (DHIMS II) is internet- based and the health system requires disease surveillance data to be transmitted only through the DHIMS II network from the district, to regional and national levels. Health information data collection starts with the registers and tally sheets at the health facility level. There are various registers ranging from out-patient, in- patient, consulting room 11 University of Ghana http://ugspace.ug.edu.gh and laboratory registers. At the district and regional hospitals, some of these registers have already been computerized. At the end of each week, month or quarter, summary reports are prepared at the health facility level and submitted to next higher level. Data from health facilities are normally summarized into sub-district reports. A sub-district is described as a health implementation center/unit within the district which serves a maximum population of 30,000. It provides basic curative care, prevention, maternity and primary health care services (Adokiya et al., 2015). From the sub-district, the health facility reports and its own reports are sent to the District Health Directorate (DHD). At the DHD, data from the paper-based forms are entered into the DHIMS II network by district health information officers. Data sent from the DHD to the regional health directorate on the DHIMS II network are merged into a regional database. At the regional level, changes to the data submitted by the districts are not possible. Therefore, if inconsistencies are discovered, corrections are made at the DHD after consultations with the specific health facility and the data re-sent to the region. From the region, the data is then sent to the Centre for Health Information Management (CHIM) office at the national level through the DHIMS II network (Adokiya et al., 2015) 2.8 CDC and WHO Guidelines for Evaluating Public health surveillance systems In 1988, Centres for Diseases Control(CDC) circulated Guidelines for Appraising Surveillance Systems to encourage the optimum use of public health resources through the progress of resourceful and effective public health surveillance system, CDC‟s guidelines for assessing Surveillance Structures were updated in 2001(CDC, 2001; CDC, 2013; CDC, 2014) to address the need for the integration of surveillance and health information systems, the establishment of data standards, the electronic exchange of health data, and 12 University of Ghana http://ugspace.ug.edu.gh changes in the objectives of public health surveillance to facilitate the response of public health to emerging health threats. The standard protocol developed by the CDC is summarized below. TASK A. Engage the stakeholders in the evaluation TASK B. Describe the surveillance system to be evaluated B1. Describe the public health importance of the health-related event under surveillance B2. Describe the purpose and operation of the surveillance system B3. Describe the resources used to operate the system TASK C. Focus the evaluation design TASK D. Gather credible evidence regarding the performance of the surveillance system Describe each of the following system attributes:  Simplicity  Flexibility  Data quality  Acceptability  Sensitivity  Predictive value positive  Representativeness  Timeliness  Stability D1. Indicate level of usefulness D2. Describe each system attribute TASK E. Justify and state conclusions, and make recommendations TASK F. Ensure use and share lessons learned (CDC, 2001) 13 University of Ghana http://ugspace.ug.edu.gh 2.9 Studies conducted on the evaluation of surveillance systems In Ghana, studies that set out to evaluate various surveillance systems have been limited, however in Africa number of studies have been conducted in this respect. For example, in a study on the appraisal and use of surveillance system data towards the identification of high-risk areas for potential cholera vaccination: a case study from Niger; it was established that the reporting sensitivity of the surveillance structure is sufficient, to appropriately classify the region as cholera endemic (Guerra et al., 2012). Subsequently, two high risk neighborhoods in the regional capital were identified as candidates for preventive cholera vaccination. This case study showed that evaluation of surveillance systems and the use of its data, when reliable, can be an efficient approach for the identification of high-risk areas for cholera in low- and middle-income settings (Guerra et al., 2012). Another study on the assessment of the surveillance system for cholera in Guinea-Bissau conducted in 2009 made the following recommendations; 1. To strengthen the surveillance on cholera in areas continually affected by outbreaks through implementation of sentinel survey systems and the use of quick diagnostic tests, precise transport of positive specimen to national laboratories in order to verify diagnosis. 2. To spread out the surveillance on cholera in geographically isolated regions, especially with areas that have repeated cholera outbreaks. 3. To perform healthcare seeking behavior studies to help identify areas that have inadequate health facilities and subsequently offer health promotion and education to individuals of the identified areas 4. To strengthen epidemiological training of health officials 14 University of Ghana http://ugspace.ug.edu.gh 5. To create a nationwide database for cholera cases to be effected at all levels; regional, district, sub district and community. It is worth noting that innovative surveillance methods might be increasingly helpful in the detection and monitoring of outbreaks, an equilibrium is needed between firming proven approaches (e.g., diagnosis of infectious disease and strengthening the link between clinical-care providers and health sectors) and evaluation of new approaches. Many technologies are needed in appreciation of systems and outbreak characteristics to improve performance metrics (Buehler et al., 2004). In conclusion, the appraisal should be summed up to convey the strengths and flaws of the system under study. Reporting appraisal findings should enable the comparison of systems for decision makers about new and prevailing surveillance procedures. These deductions should be corroborated among stakeholders of the system and reformed accordingly. Recommendations should aim at addressing acceptance, continuation, or variation of the surveillance structures so that it can well accomplish its projected purposes. Recommendations should be circulated extensively and interpreted for all suitable audiences (Buehler et al., 2004) 15 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.1 Introduction The following chapter discusses the approach and methodology used for the study. The chapter starts with the research design employed for the study and provides reasons for the choice of the research design. It also details the research processes, data collection techniques and tools, the sources and methods of collection of data are also discussed. The chapter ends by presenting the techniques used to analyze the data. The rationalization and analysis as well as data presentation and reporting of the study has also been highlighted. 3.2 Study Design A single case study was adopted by choosing the cholera surveillance system of the Ledzokuku-Krowor municipality. This study is a descriptive study and consists of both qualitative aspects and quantitative descriptive components of the cholera surveillance system of the Ledzokuku-Krowor municipality. The study population includes the entire cholera surveillance machinery of Ledzokuku-Krowor, stake holders at various health facilities in the Ledzokuku-Krowor municipality as well as stake holders from the central municipal health directorate of Ledzokuku-Krowor Krowor. 3.2.1 Study Methodology The study methodology was divided into 3 main stages a. A description of the public health significance of cholera in the Ledzokuku- Krowor municipality and the significance of the system for surveillance b. A depiction of the system for cholera surveillance at the district/municipal level. The objective and activities of the following items belonging to the cholera 16 University of Ghana http://ugspace.ug.edu.gh surveillance system of Ledzokuku-Krowor municipality was described; the purpose and objective of the cholera surveillance system of Ledzokuku-Krowor, case identification, residence of the cholera surveillance system within the municipal health system, level of integration with the municipal health system, the flow chart of the surveillance system as well as the components of the health system (case identification, data collection, data reportage, data management and analysis, results dissemination, privacy/confidentiality and systems security), specific reinforcements and resources used to operate the surveillance system of Ledzokuku-Krowor. These items are well defined in appendix iv of this document. c. An assessment of the Ledzokuku-Krowor municipality cholera surveillance system using the Centers for Disease Control and Prevention updated Guidelines for Evaluating Public Health Surveillance Systems (CDC, 2001). The entire assessment process was carried out using the following tasks;  Stakeholders at the district level of the health system of Ledzokuku-Krowor were interviewed using semi-structured questionnaires to get their inputs and ensure that findings from the study would be accepted and used.  Secondary data was obtained from The Disease Surveillance Department (DSD) and Public Health and Reference Laboratory from 2011 to 2015. Case-based forms were reviewed and health facility records at Ledzokuku- Krowor, these data analyzed using Excel and Stata to generate frequencies, proportions and charts.  The attributes of the system as recommended by the Centers for Disease Control and Prevention updated Guidelines for Evaluating Public Health Surveillance Systems (CDC 2001) were studied, these qualities include: the simplicity of the cholera surveillance system, flexibility, data quality, 17 University of Ghana http://ugspace.ug.edu.gh acceptability, sensitivity, positive predictive value, representativeness, timeliness and stability as explained in appendix v. 3.3 Study Site The Ledzokuku-Krowor Municipality is one of the districts of the Greater Accra region carved out of Kpeshie sub-metro(Ghana Statistical Service (GSS), 2014). It is bounded by the La-Dade Kotopon, Adentan and Tema Metropolis to the West, North and East respectively. The Southern boundary of the Municipality is the Gulf of Guinea. The Municipality has an estimated population of 273,743 (projection from 2010 census). It forms about a fifth of the total population in the region and grows at an estimated 4.4% annual growth rate. 18 University of Ghana http://ugspace.ug.edu.gh Figure 3.1: Map of Ledzokuku-Krowor Municipality (Source: Ghana Statistical Service (GSS) 2014) 19 University of Ghana http://ugspace.ug.edu.gh Ledzokuku-Krowor Municipality is one of the districts of the Greater Accra region that was carved out of Kpeshie sub-metro(Ghana Statistical Service (GSS), 2014). This municipality is a merger of the Teshie and Nungua sub metros. The need to break the Accra metropolis into smaller sectors to facilitate good governance and promote efficiency in the administrative machinery and also meet the ever pressing demands for amenities and essential services, led to the merge up of Teshie and Nungua Sub Metros into a Municipality status (Ghana Statistical Service (GSS), 2014). It is bounded by the La- Dadekotopon, Adentan and Tema Metropolis to the West, North and East respectively. The Southern boundary of the Municipality is the Gulf of Guinea. The Municipality has an estimated projected population of 273,743 (projection from 2010 census). It forms about a fifth of the total population in the region and grows at an estimated 4.4% annual growth rate. There is a mixture of artisans, traders, farmers (poultry) and civil servants. Most of the indigenes are fishermen (Ghana Statistical Service (GSS), 2014). Table 3.1: Population Distribution by Zones in Ledzokuku-Krowor, 2016 2016 SUB-MUNICIPAL & MUNICIPAL POPULATION SUB-MUNICIPALS Total Pop Less than 1year Women in Fertile Age NUNGUA 109497 4380 26279 TESHIE NORTH 93620 3745 22469 TESHIE SOUTH 70626 2825 16950 MUNICIPAL POPULATION 273743 10950 65698 (Source: Ghana Statistical Service (GSS) 2014) Approximately 43% of the population between 16 and 45 years constitute the active labour force. (Ghana Statistical Service (GSS) 2014). The urban environment of the municipality is linked with changing grades of social, financial, and psychological pressures. These 20 University of Ghana http://ugspace.ug.edu.gh comprises poor housing with congestion, teenage pregnancy, and high school drop-out rate. These are more evident in Teshie South zone. There is early sexual activity that culminates in early motherhood. Disease problems related to these characteristics include Malaria, Hypertension, STDs, and TB/HIV/AIDS. Additional problems include malaria, malnutrition, diarrhea diseases, and skin infections among others in the slum areas. 3.4 Sampling All persons that are directly involved in the entire cholera surveillance system of the Ledzokuku-Krowor municipality were included in the study. These persons were classified into the following categories for the purpose of this study as; Stake holders at various health care facilities in the Ledzokuku-Krowor municipality as well as stake holders at the municipal health directorate of the municipality that are directly involved in cholera surveillance. 3.5 Data collection The sources of information used for the study were from the following sources;  Administrative data: district guidelines, paper and electronic forms, other documentation regarding cholera surveillance from the Ledzokuku-Krowor municipality  Primary data collection from semi-structured interviews of stake holders at various health facilities in the Ledzokuku-Krowor municipality as well as stake holders from the municipal health directorate of Ledzokuku-Krowor Krowor. The data collected included; variables associated with disease notification such as; compliance with disease notification, availability of case based forms, contact with district communicable disease control coordinators, knowledge; knowledge of 21 University of Ghana http://ugspace.ug.edu.gh notifiable diseases availability of guidelines on statutory disease reporting and means of dissemination of information.  Secondary data from previous cholera outbreaks and other reports regarding cholera in Ledzokuku-Krowor municipality 3.6 Data Management Results of all qualitative data that is the information gathered through questionnaire administration were presented as narratives. All quantitative data obtained through the gathering of secondary data on various cholera outbreaks in Ledzokuku-Krowor was double entered into the Microsoft Excel software. 3.7 Data analysis Qualitative data gathered through interviews were compared to policy documents, published reports and evidence gathered from reporting databases. Results were presented as narrative and positive predictive values evaluated. Stata Statistical Software was subsequently used for all univariate descriptive analysis of cholera cases recorded in the Ledzokuku-Krowor municipality between 2011 and 2015 (generation of frequencies, drawing of charts etc.) 3.8 Quality assurance Interviews with stakeholders were conducted; asking the level of their involvement in the system and according to a semi-structured questionnaire. In the measurement of data quality sensitivity and positive predictive value, quality controls included checks on data based forms and manual reviews for consistency of data. The data collection instrument was as well pretested on administrative, medical and non-medical staff who were not 22 University of Ghana http://ugspace.ug.edu.gh selected as part of the study. The data was reviewed to check for consistency. District notification data was perused for duplication based on patient names, age and residence details. 3.9 Ethical Considerations Ethical approval was obtained from Ethical Review Committee of the Ghana Health Services. Letters of notification were written to the Regional Health Directorate, Greater Accra and Municipal Health Directorate of the Ledzokuku-Krowor Municipality. The ethical considerations for this research included the following; 1. The measurement of certain components of the surveillance system required tracking of specific cholera patient records with patients‟ names and demographic details. All data was anonymized in the databases with no data sharing. Each patient‟s records in the study was assigned a unique study identification number which prevented patients from being identified to protect patients‟ privacy. 2. The questionnaire survey of the stakeholders within the cholera surveillance system was kept confidential 3. All study respondents (stake holders) were assured that the study will not lead to any punitive measures for failure to comply with system requirements such as failure to report notifiable health events. Potential Policy Impact This study is projected to offer a platform for policy direction with regards to the standards for cholera surveillance at the district/municipal level 23 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.1 Description of the public health significance of cholera in the Ledzokuku-Krowor municipality The Ledzokuku-Krowor municipality is endemic to cholera with outbreaks occurring periodically and this is attributable to the poor water and sanitation structure within the municipality. According to administrative data obtained, a total four outbreaks have been recorded in the Ledzokuku-Krowor municipality between 2011-2015. These outbreaks were part of large scale epidemics recorded in the Greater Accra Region of Ghana between the said periods. The number of cases recorded for the documented high-profile outbreak that occurred in 2014 recorded a total of 190 per 100,000 cases and a 12.6% case fatality rate. The following year (2015), a less severe cholera outbreak was detected in the municipality with 18 suspected and 4 confirmed cases recorded, no deaths occurred. DIARHEAL DISEASES RECORDED IN THE LEDZOKUKU-KROWOR MUNICIPALITY BETWEEN 2012-2016 8000 7000 6000 5000 4000 3000 2000 1000 0 2012 2013 2014 2015 2016 YEAR Figure 4.1: Trends in diarrheal diseases recorded in the Ledzokuku-Krowor Municipality between 2012-2016 24 NUMBER OF CASES University of Ghana http://ugspace.ug.edu.gh An introspective analysis of available data of diarrheal diseases recorded in the Ledzokuku-Krowor municipality shows that there has been consistently increasing cases of diarrhea in the municipality, as observed in Figure 4.1. A situation which leaves much to be desired with regards to disease surveillance and the effectiveness of control and preventive measures that have been instituted over the years. Another trend analysis was carried out to specifically determine the percentage of populations with diarrheal disease from 2016 -2012. The results are presented in Table 4.1 below. It is observed that between the years in review, the number of diarrheal cases expressed as a percentage of the population decreased marginally from year to year (2012-2016) even though the number of cases independently was observed to increase over the years. Table 4.1: Percentage of population with diarrheal disease from 2012-2016 YEAR POPULATION NUMBER OF CASES PERCENTAGE OF DIARRHEAL CASES PER DISESASES POPULATION (%) 2016 273,743 6,951 2.99 2015 262,793 6,794 2.81 2014 252,281 6,221 2.47 2013 242,189 4,661 1.77 2012 232,501 4,073 1.49 4.2 Administrative data results As part of the study, administrative data was obtained from the Ledzokuku-Krowor municipality. The data included; district guidelines, paper and electronic forms, other documentation regarding cholera surveillance from the Ledzokuku-Krowor municipality. The results obtained from this data is outlined in the following description of the cholera surveillance system 25 University of Ghana http://ugspace.ug.edu.gh 4.3 Description of the cholera surveillance system 4.3.1 Purpose and objective of the cholera surveillance system of Ledzokuku-Krowor The objectives of the system for cholera surveillance of Ledzokuku-Krowor municipality is in line with that of all standard operating procedures for cholera prevention and control in Ghana. The general objective is to early detect, confirm, and appropriately respond to Cholera epidemics/outbreaks in the municipality. 1. To carefully collect and analyze both epidemiological and laboratory information on suspected cholera cases 2. To conduct quick laboratory verification of suspected cases and early identification of causative pathogens 3. To use this data for public health control processes and monitor its occurrence throughout the year 4.3.2 Case definitions Cholera is an immediate (within 24 hours) notifiable disease. The following standard case definitions are used: a) Suspected Cholera Case A case of cholera should be suspected when: 1. In an area where epidemic is not known to be occurring, any patient 5 years of age or older, presenting with acute watery diarrhoea and severe dehydration or dies from acute watery diarrhoea (AWD). 2. In areas where cholera is endemic, any patient aged 5 years or more presenting with acute watery diarrhoea, 3. In an area where an epidemic/outbreak is occurring, a patient develops AWD, with or without vomiting. 26 University of Ghana http://ugspace.ug.edu.gh Note: In children under 5 years a number of disease causing organisms can produce symptoms similar to those of Cholera. Children under 5 years are therefore not included in the case definition of Cholera to maintain specificity. However, if cholera outbreak is established all age groups should be included. b) Probable cholera case 1. A suspected case testing positive for Vibrio cholerae O1 or O139 by cholera Rapid Diagnostic Test (RDT). 2. A suspected case that is epidemiologically linked to a confirmed Cholera case. Note: Epidemiological linkage refers to the suspected case coming from the same area as a confirmed case within the same specified period. c) Confirmed cholera case A patient of any age with AWD and from whom V. cholerae (O1 or O139) was isolated from a fecal sample during the illness by culture or PCR. 4.3.3 Residence of a system for cholera surveillance within the municipal health system The surveillance machinery is designed in a decentralized system that embraces the following levels; facility, sub-district, district/municipal, regional and national. The Ledzokuku-Krowor municipality in this respect occurs at the municipal level. At the regional and municipal levels, Public Health Emergency Management Committees coordinate preparedness and response activities at the regional and district levels. The Committee meets at least once quarterly when there is no outbreak but more frequently during outbreaks to: 1. Review trends of cholera cases and deaths and updates on preparedness 27 University of Ghana http://ugspace.ug.edu.gh 2. Disseminate conclusions and recommendations of such meetings with key stakeholders 3. Organize mockup exercises to check the operational plans 4. Present conclusions and recommendations from studies or researches to include evidence and risk analysis into planning. a) Operating system The surveillance system operates in all the levels. In order to ascertain the functionality of it, respondents were asked certain question that elicited responses on how the system was operating in line with case reporting from the community to the health facility. One of such question was; is it difficult to detect cholera cases when there is no epidemic or an epidemic is evolving and by what means? This was the response from the users; Yes, health volunteers in the community reports cases of cholera by any means especially telephone This response affirmed the routine reporting procedure as required of the guideline in case reporting for any health condition or event. The volunteers also report to disease control officers at a known health facility and then to the medical officer in charge at the health facility or a zonal coordinator. On the frequency of sending reports to the next level as mentioned in the surveillance flow chart, this was the question posed to the users. Is it you who sends report to the next level, that is the municipal health directorate, if yes what is the periodicity of the submission of the reports? The user provided this answer; We do send our report to the next level on daily, weekly and monthly basis and for cholera its submitted daily. During outbreaks, cases and deaths due cholera are reported on a daily basis. The line list is completed at the health facility level, aggregated at district level and copies sent to the regional and national levels, on a daily basis. 28 University of Ghana http://ugspace.ug.edu.gh In confirming or otherwise of a suspected case of cholera during non-epidemic periods the user was asked how the system carries out that process. How do you diagnose cholera in the health facility? It is the work of the laboratory personnel who does the rapid diagnostic test(RDT) as initial probable investigation before doing the culture and sensitivity as confirmatory test. The results is then indicated on the case investigation form The laboratory system serves as a support function of the entire surveillance structure where information provided on the cases informs the appropriate intervention. The district surveillance officer aggregates the total number of cases, deaths, type of isolates obtained and forwards to the regional level on a weekly basis. Cholera being a disease that causes widespread outbreaks, the users were asked how additional cases are tracked during outbreaks. How do you ascertain the burden of the disease during outbreaks? This was the response; We use contact address of patients to visit the communities where cases are being reported to look for cases that have not been reported is away to ascertain the extent of the outbreak This activity forms part of the approach to case finding in disease control interventions. b) Feedback Information from the DSD is sent to the regions through the district level via email in weekly and monthly bulletins. When immediate response is required, communication is by telephone. Copies of the bulletins are sent to the Public Health Directorate and the WHO. In an outbreak situation, feedback is communicated to district disease control officer much earlier and further dissemination done by the district. Feedback is sent to the disease control officer in the sub district in hardcopy and further dissemination to the health 29 University of Ghana http://ugspace.ug.edu.gh centers by telephone. Health centers in various sub districts organize health education campaigns at health centers on radio and at community durbars in a bid to curb the outbreak. 4.3.4 Flow chart of the surveillance system DISTRICT/MUNICIPAL LEVEL HEALTH FACILITY/ SUB DISTRICT LEVEL COMMUNITY LEVEL Figure 4.2: Flow chart of the Ledzokuku-Krowor cholera surveillance system 4.3.5 Components of the health system a) Case identification When a suspected, probable or confirmed cholera case is first detected, the Rapid Response Team (RRT) in this context at the district/municipal level is activated. The RRT is made up of the following personnel; 1. Clinician/physician to verify clinical symptoms and train health workers in good case management 30 University of Ghana http://ugspace.ug.edu.gh 2. Microbiologist/Laboratory personnel to take patient and environmental samples for laboratory confirmation and train health worker on correct sampling procedures 3. Information, communication and education experts to assess community reactions to cholera, define and disseminate health education messages 4. Epidemiologist/Disease Control Officer to assess data collection and surveillance procedures 5. Water quality expert to investigate the possible sources of contamination and start appropriate treatment of these sources 6. Environmental Health Officer/sanitation expert to conduct WASH interventions. All contacts are identified. The contacts are identified by the following procedures: 1. Direct interviewing (asking probing questions) of the case if alive or family in the case of death 2. Conduction of verbal autopsy if the case is dead 3. Visitation of households and communities of the cases 4. Filling out Contact Listing Form b) Data collection For all suspected/confirmed cases of cholera, simple patient information is collected using the cholera case-based investigation form and summarized on the line listing form. All the contacts to the cholera cases are captured using the cholera contact listing form and cholera contact follow-up forms. Some of data captured include; the patient‟s name, age, gender, occupation, residential address, type of residence (rural/urban), clinical signs and symptoms, laboratory results, date patient reported at health facility, date of onset of disease and the health facility the patient reported. 31 University of Ghana http://ugspace.ug.edu.gh c) Data reportage All health facilities record a summary of suspected cases and deaths and transmit weekly to the District Surveillance Officer who will intend submit to the Region for onward transmission to National level (Disease Surveillance Department). Weekly notification is carried out throughout the year. Facilities and districts report weekly, even when no cases are recorded. During outbreaks, cases reporting is done on a daily basis. The line list is completed at the health facility level, compiled at district level and a copy sent to the regional and national levels, on a daily basis. For each suspected case of cholera with stool specimen, the cholera case-based investigation form is filled. A unique identifier is provided to match the laboratory results with the patient clinical and epidemiological records. A copy of the cholera case-based Investigation form at the facility is kept at district level and a copy is sent to the region and Disease Surveillance Department (national level) and the other copy together with the specimen sent to the referral laboratory (Regional Hospital Laboratory, Zonal Public Health Laboratory or National Public Health and Reference Laboratory. This „Epid. Number‟ is given by district level Surveillance Officer. d) Data management and analysis The line listing of Cholera cases is transmitted by health facilities to the district which is entered into a computer programme , Microsoft Excel or Epi-Info by the district surveillance officers. They will also enter the laboratory data and tests results in the same database. The completed data base is then sent to the regional level every weekly. The Disease Surveillance Officers analyzes the data by person (affected age, sex, calculate Attack Rate and Case Fatality Rate), place (affected communities, districts) and time (weekly trends of cases and deaths), illustrating with tables, spot maps and graphs (epidemic curves) every week. The supervisors at regional and national levels ensures that 32 University of Ghana http://ugspace.ug.edu.gh all districts keep an updated weekly trend (epidemic curve) of cholera cases and deaths. On weekly basis, the Data Manager of the Disease Surveillance Department make a map showing the distribution of cases, as well as the laboratory results by districts. e) Results dissemination Privacy/confidentiality As previously mentioned, in an outbreak situation, feedback is communicated to district disease control officer much earlier and further dissemination done by the municipality. Feedback is sent to the disease control officer in the sub district in hardcopy and further dissemination to the health centers by telephone. Health centers in various sub districts organize health education campaigns on radio and at community durbars in a bid to curb the outbreak. Access to data at the district or municipal level is restricted. Data is only released after approval has been given following an application of request has been submitted. Furthermore, there is a security code known to only limited number of staff to enhance privacy and confidentiality. 4.3.6 Specific reinforcements and resources used to operate the surveillance system of Ledzokuku-Krowor The source of funding for cholera surveillance is mainly from the government through the Ministry of Health. Other stakeholders, especially WHO provide logistics and personnel assistance when required. It could not be ascertained how much is dedicated to this system alone because it is integrated with other systems. 4.4 Description of the performance and attributes of the system Stakeholders at the district level of the health system of Ledzokuku-Krowor municipality were interviewed using semi-structured questionnaires to get their inputs. A total of 13 33 University of Ghana http://ugspace.ug.edu.gh individuals from the Municipal Health Directorate of Ledzokuku-Krowor and 38 officials from various health facilities in the same municipality were interviewed. The results of these interviews conducted were presented in Tables 4.2 and 4.3. These results coupled with some of the results from the administrative data obtained were used to describe the performance and attributes of the Ledzokuku-Krowor cholera surveillance system. 34 University of Ghana http://ugspace.ug.edu.gh Table 4.2: Results of Stakeholder Sessions at Municipal Health Directorate [N=13] VARIABLE CATEGORY FREQUENCY (n) 1. Objectives of cholera surveillance system To prevent cholera spread 5 To ensure clean environment 6 2. Knowledge of cholera case definition Yes 1 used at reporting sites No 10 3. Knowledge of processes concerning the Yes 7 surveillance of cholera at local level No 2 i. What are the procedures if yes? proper hand washing 4 in-patient and out-patient, 3 community reports. 4. Knowledge of processes concerning the Yes 5 surveillance of cholera at regional level No 6 i. What are the procedures if yes? public education 4 support district and health 1 facilities to review suspect of outbreak. 5. Is the period for information being sent Yes 1 by the regions the best? No 3 i. If not, what do you think is the ideal it should be done in everyday 1 6. Is there any procedure to validate the Yes 0 value of the data (as double-checking with another source –NGOs,)? If yes, what? No 2 7. Do you foresee some outbreaks are being Yes 1 missed, or declared late? No 1 8. Do you foresee cholera cases not being Yes 3 noticed when there is an epidemic No 0 i. If yes, what do you think are the reasons ? And how could it be enhanced? 9. How would cholera case detection be Educating them everyday 1 improved a during non-epidemic period? i What are some of the measures to Ensuring personal hygiene 1 implement to improve the control of a cholera outbreak? Table 4.3: Results of Stakeholder Sessions at Selected Health Facilities[N=38] 35 University of Ghana http://ugspace.ug.edu.gh VARIABLE CATEGORY FREQUENCY (n) 1. Is it required to report Yes 21 cases of cholera in Ledzokuku-Krowor No 12 Don‟t know 2 i. Is there a technical Yes 23 guideline for the surveillance of cholera in No 4 Ledzokuku-Krowor? Don‟t know 9 ii. If yes, do you have a hard copy Yes 16 here? No 14 Don‟t know 4 2.What is case definition for cholera signs and symptoms 8 in use? WHO 1 Any person 5 years of age or more 3 passes 3 or more watery stool or dies from acute watery diarrhea i. Does definition differ in Yes 11 non-epidemic and epidemic periods? No 18 3.Do you agree with the definition Yes 23 for a cholera for non- epidemic periods? No 10 i. Do you agree with the Yes 23 definition for cholera for epidemic periods No 6 ii. Is it a challenge to Yes 10 identify a case of cholera when there is no epidemic? No 20 4. Have you had challenges of right Bottles Yes 9 means to acquire, prepare and transport the specimen during the No 22 last 6 months? Medium Yes 12 No 19 CATEGORY FREQUENCY (n) Cartons Yes 11 36 University of Ghana http://ugspace.ug.edu.gh No 19 Stamps Yes 10 No 22 Gloves Yes 7 No 25 5. How long does it take to 3-4 days 9 receive the results from the lab 1-2 days 1 <1 day 8 6. Have you lacked Paper Yes 9 appropriate resources for filling in the forms at any No 23 time during the last 6 months? Pen Yes 4 No 29 7. Do you find it difficult to Yes 19 collect all the information? No 13 ii. If yes, which one is Language barrier 1 the most challenging? Laboratory confirmation 2 When patient is unconscious 4 8. Does it take a long to 5-30 minutes 6 collect all the information from a suspected case Entire day 7 9. Have you given special Yes 12 training for this activity No 18 10. i How would you improve Suspected cases must be sent for 7 the detection of cholera laboratory confirmation cases during non-epidemic periods? Public education 2 Not give antibiotics 1 VARIABLE CATEGORY FREQUENCY (n) ii. During epidemic Suspected cases must be sent for 4 37 University of Ghana http://ugspace.ug.edu.gh periods? laboratory confirmation Public education 4 11. How do you notify the Telephone 17 region of the cases Email 3 12. Do you have challenges in Yes 10 sending the data before the deadline? No 16 13. How would you enhance Weekly reporting 7 the way the reporting of the cholera case is done during non-epidemic Monthly reporting 1 periods? Cash reward for personnel 1 i. How would you Daily reporting 9 enhance the reporting of the cholera cases during epidemic periods? Cash reward for personnel 1 14. Do you take delivery of reports Yes 17 with the detected cholera cases in your health facility? No 12 i. If yes, with what 1 week 1 duration? 2-3 days 3 ii. If you don’t receive Yes 18 them, would you like to accept it? No 11 VARIABLE CATEGORY FREQUENCY (n) 15.Are you pleased with Yes 23 the way you report to the next level? No 9 16. Do you think there Yes 19 might be patients that 38 University of Ghana http://ugspace.ug.edu.gh should be tested for No 12 cholera during non- epidemic periods and No human resource 12 are not for any of these reasons Workload 15 4.4.1 Simplicity According to majority of the stakeholders interviewed (61%), the information required to detect suspected cholera case is not difficult to obtain and ascertain, since the variables to be collected is considered appropriate (example: stool sample) as noticed in Table 4.3. To a large extent, the stakeholders again could specifically tell the number of days that it would take to obtain information relevant for cholera detection and as such majority could provide answers to the question in subject. The users also mentioned that it was not difficult to send the case based forms before the stipulated deadline (62%). In terms of the flow of information, the users did not have much of a problem, they mentioned the telephone and the email modes of communication as good, this is observed in question 11 of Table 4.3 The users mentioned that the flow of information and reporting even though done weekly and monthly can be improved and that rewarding the reporters in cash can be a way of improving reporting and information flow. Officials at the Municipal Health directorate mentioned that the periodicity with which data is submitted do serve the process of data analysis well enough and it can be observed in Table 4.2. In most cases, health facilities are able to meet deadlines and therefore the process of data analysis is discrete. In a further development, the users mentioned there was enough technique to verify the quality of data that is submitted. 39 University of Ghana http://ugspace.ug.edu.gh 4.4.2 Flexibility The recently reviewed national protocol for the integrated disease surveillance and response has permitted the system of surveillance for cholera to adapt to other needs of public health. The users described the national guidelines as very easy to use. Most of the users were not keen on introducing any changes to the current national guidelines. 4.4.3 Data quality The value of data gathered from paper forms and database for cholera is largely satisfactory especially with regards to completeness. Personnel from the Municipal Health Directorate confirmed there is enough technique used to verify the quality data, a development that positively affects the process of disease surveillance. To add with, they further mentioned there was even a defined technique they use to update missing information in the dataset. 4.4.4 Acceptability The users (83%) were contented with the cholera case definition for especially during the epidemic periods. However, the users were split on whether the definition differed during epidemic and non-epidemic periods. At the Municipal Health Directorate, personnel agreed they could tell the case definition that was used at health centers and hospitals. In terms of reporting, the users at the district level mentioned they were satisfied with the periodicity and timeliness of reporting to the facility level, they mentioned health facilities reported cases within 1-3 days of detection, and that it aided the entire surveillance process. Users at the Ledzokuku-Krowor Municipal Health Directorate mentioned they were satisfied with the timeliness of information they received on the cholera situation of 40 University of Ghana http://ugspace.ug.edu.gh in their area from the Regional level. The stakeholders were at large satisfied with the mode of reporting (telephone and emails) throughout all levels. 4.4.5 Sensitivity The system is sensitive because it was able to detect an outbreak of the disease in the district in the first 4 weeks in 2014 and in 2015. The cases that were detected during the period of the aforementioned outbreaks were detected and investigated and subsequently well managed to stop it from spreading. 4.4.6 Positive Predictive Value The predictive value positive of the surveillance system was predicted using data from the 2015 cholera outbreak in Ledzokuku-Krowor Municipality, the data was obtained from the Municipal Health Directorate. All cases were analyzed in laboratory facilities in the municipality by both culture and serological techniques. The confirmed cases were documented and used to compute the Positive Predictive value as follows. Number of confirmed cases for 2015 = 4 Total number of suspected cases recorded in the Municipality = 18 Positive Predictive Value (PPV) = (No. of confirmed cases/Total no. of suspected cases) × 100 (4/18) ×100 = 22% 4.4.7 Representativeness The surveillance system of Ledzokuku-Krowor is representative since it obtains data from all health facilities in the Municipality. All individuals categorized by sex, age, socio- 41 University of Ghana http://ugspace.ug.edu.gh economic status, type of residence (rural/urban) are included in the dataset and used for all statistical and epidemiological analysis. Various health facilities and cases within the Municipality are identified and reported to give a good representation of the disease under surveillance at the community level. 4.4.8 Timeliness The issue of timeliness of cases reporting to a health facility or community health volunteer when disease signs and symptoms are observed was satisfactory. Individuals report within 1-3 days of experiencing symptoms of a disease, likewise health facilities report to the districts when patients present symptoms of cholera during epidemic periods. It was however clear from the stakeholder sessions that personnel were not satisfied with the irregular reporting from health facilities during non-epidemic periods. They suggested weekly reporting of cases during such periods go a long way to help the process of disease surveillance by promoting early detection of cases. 4.4.9 Stability A reliable source of funding is required to ensure that the system collects, analyses and disseminates information form the data and make it available for public health actions to be undertaken. As previously mentioned, the funding source for cholera surveillance is mainly from the government through the Ministry of Health. Other stakeholders, especially WHO provide logistics and personnel assistance when required. The users (Municipal Health Directorate) mentioned that the WHO consistently helps with funding the activities of the surveillance system and thus contributes immensely to the stability of the system 42 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.1 Description of the public health significance of cholera in LKM The Ledzokuku-Krowor municipality has been plagued with incessant cholera outbreaks in recent time (Ghana Statistical Service (GSS) 2014; Ghana National Action Plan For Cholera 2015; Dzotsi,2014). The surveillance system employed by the Ledzokuku-Krowor municipality with specific reference to cholera is efficient enough to detect, notify and initiate control measures with strict adherence to standardized protocols in disease surveillance reporting in reference to technical guidelines. A functioning surveillance system for cholera in Ledzokuku-Krowor is germane because of the area‟s high endemicity to cholera, likely epidemics expected due to poor water and sanitation.(Highlights, 2016; Lamond and Kinyanjui, 2012; Lee, 2001; Nsagha et al., 2015; Rebaudet et al., 2013). In the most recent outbreak of cholera that occurred in Ghana, the Ledzokuku-Krowor municipality recorded one of the highest attack rates in the Greater Accra Region; 190 per 100,000 cases and a 12.6% fatality rate. (Dzotsi, 2014). The reasons that contributed to the municipality being overwhelmed with the disease was the magnitude of the outbreak. The municipality has a strong surveillance system, adherence to standard protocols in cholera surveillance by all stakeholders, adequate technical expertise in management of cholera and resources (human and material) to manage the outbreak. 43 University of Ghana http://ugspace.ug.edu.gh 5.2 Description of the cholera surveillance system The overall surveillance system of LKM is structured and well organized. The system has a properly defined purpose and specific objectives and targeting all areas that pertain to cholera surveillance in the municipality. Case definitions are all well laid out with specific definitions for probable, suspected and confirmed cases. When a suspected, probable or confirmed cholera case is first detected, the Rapid Response Team (RRT) at the district/municipal level is activated to carry out investigations and institute control measures. For all suspected/confirmed cholera cases, patient‟s basic information is collected using the cholera case-based investigation forms and summarized on the line listing form. All the contacts to the cholera cases are captured using the cholera contact listing form and cholera contact follow-up forms. Stool specimen of suspected cases are then obtained and sent to the referral laboratory (Regional Hospital Laboratory, Zonal Public Health Laboratory or The National Public Health and Reference Laboratory) for further investigations. Disease Surveillance Officers analyzes the data every week. The supervisors at regional and national levels ensure that all districts keep an up-to-date weekly trend (epidemic curve) of cholera cases and deaths. Feedback is given to district disease control officer and further dissemination done by the municipality. Feedback is sent to the disease control officer in the sub district in hardcopy and further dissemination to the health centers by telephone. Health centers in various sub districts organize health education campaigns on radio and at community durbars in a bid to curb any likely outbreak. 44 University of Ghana http://ugspace.ug.edu.gh It can be deduced that the cholera surveillance system of LKM is useful in detecting cases at the community and health facility level and is well engineered to be able to trace suspected cases in a bid to control and mitigate the effects of any potential outbreak. 5.3 Description of the performance and attributes of the system It can be deduced from the users that the system was to some extent simple to use. Items such as the flow of information across all levels of the surveillance system and the timeliness of submitting case based forms was not a problem. Issues such as information required to detect suspected cholera cases is easy to obtain and ascertain. Majority of health facilities are able to meet deadlines and therefore the process of data analysis is optimal. In a further development, the users mentioned there was adequate technique to verify the quality of data that is submitted. In a nutshell, the simplicity of the system is worth it. Users unanimously agreed that the system was very flexible and that national guidelines were easy to use and understand, this is one of the positive aspects of the LKM surveillance machinery, it is essential for other districts and municipalities to train and educate personnel on the technical guidelines/protocol for cholera surveillance in a bid to better the process. Data quality is an important role in the efficient operations of a system of surveillance. It is crucial such that; it helps to detect the extent of an outbreak thereby ensuring that the response towards the outbreak is target specific and comprehensive in certain respects (Adokiya et al., 2015; Essoya et al., 2013). Routine reporting is always crucial in disease surveillance, data collected through routine reporting from health facilities must be representative of the actual situation in the 45 University of Ghana http://ugspace.ug.edu.gh community (Adokiya et al., 2015; Guerra et al., 2012; Sanchez-padilla et al., 2009). The users were satisfied with the mode of reporting and the case definition for cholera especially during the epidemic periods. Users at the Ledzokuku-Krowor Municipal Health Directorate mentioned they were satisfied with the timeliness of information they received on the situation of cholera in their area from the regional level. Overall, the appraisal of the system for surveillance suggests that it is reasonably sensitive and that collected data during the recent outbreak are representative of the spread of cases cholera in the region. The systematic realization of practices such as stool cultures in suspected cholera cluster of cases and the high transmissibility of the disease made it unlikely that an epidemic of cholera would evade the system for surveillance. Timeliness of reporting in the Municipality though satisfactory in some respect, is somewhat challenging. It was clear from the stakeholder sessions that personnel had challenges in reporting from health facilities during non-epidemic periods. This was one of the major loopholes in the system and hence needs to be effectively dealt with. Users as previously mentioned suggested weekly reporting of cases during such periods go a long way to help the process of disease surveillance by promoting early detection of cases. 46 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION & RECOMMENDATIONS An effective system for surveillance on cholera is relevant because of the area‟s high endemicity to cholera. The overall surveillance system of Ledzokuku-krowor municipal is structured and well organized. The system has a properly defined purpose and specific objectives and targeting all areas that pertain to cholera surveillance in the municipality. It can be deduced that the cholera surveillance system of Ledzokuku-krowor municipal is useful in detecting cases at the community and health facility level and is well engineered to be able to trace suspected cases in a bid to control and mitigate the effects of any potential outbreak. The workforces in the notification system appear to be devoted, knowledgeable and diligent; though the values of pecuniary motivations for motivation to work is widely communal. This assessment has also exposed some flaws in the Cholera surveillance system in the Ledzokuku-Krowor municipality. Data transmission from the private health facilities appeared to be a challenge in the cholera surveillance system in the municipality, issues such as data completeness needs to be addressed in the immediately. It was clear from the stakeholder sessions that personnel were satisfied with the regular reporting from the public health facilities during non-epidemic periods. Users as previously mentioned suggested weekly reporting of cases during such periods go a long way to help the process of disease surveillance by promoting early detection of cases. This assessment is intended to inform policy makers on the present state of the Cholera surveillance system in the municipality. It underlined areas in which developments can be made as well as emphasize successful practices. The Cholera surveillance system forms an integral part of the health system and public health planning and implementation. 47 University of Ghana http://ugspace.ug.edu.gh An enormous investment over a period of time is essential to make the system operate ideally and remove constraints towards achievement of a vigorous surveillance and laboratory capability. Since the aim of the surveillance system is to guide policy makers the following recommendations have been made; The Municipal Health Management Team should carry out periodic assessment of their cholera surveillance system and the result of this work could be used as a baseline for such assessment. The Disease surveillance department in the country must continue to train and build capacity of existing health personnel in the Ledzokuku-Krowor municipality. The Surveillance system should train personnel in the private health sector their capacity building programmes in order to facilitate early case detection and prompt response thereof. The users (Municipal Health Directorate) mentioned that the WHO consistently helps with funding the activities of the surveillance system and thus contributes immensely to the stability of the system. It is recommended that more funding is provided by central government in the advent of inadequate funding from the International organizations like the WHO. STUDY LIMITATIONS A challenge that was encountered was that pertaining to the differential non-response from study subjects. This changed the sample size of some of the variables that were used to draw conclusions from the analysis. The assessment was conducted outside the epidemic period, hence information concerning the performance of the system for surveillance depended on evidence solely on the users of the system. 48 University of Ghana http://ugspace.ug.edu.gh REFERENCES Aagaard-Hansen, J., Sørensen, B. H., & Chaignat, C.-L. (2009). A comprehensive approach to risk assessment and surveillance guiding public health interventions. Tropical Medicine & International Health : TM & IH, 14(9), 1034–9. https://doi.org/10.1111/j.1365-3156.2009.02330.x Adokiya, M. N., Awoonor-Williams, J. K., Barau, I. Y., Beiersmann, C., & Mueller, O. (2015). Evaluation of the integrated disease surveillance and response system for infectious diseases control in northern Ghana. BMC Public Health, 15(1), 75. https://doi.org/10.1186/s12889-015-1397-y Bashorun, A. T., Ahumibe, A., Olugbon, S., Nguku, P., & Sabitu, K. (2013). Evaluation of Cholera and Other Diarrheal Disease Surveillance System , Niger State , Nigeria- 2012. Online Journal of Public Health Informatics, 50(1), 2579. Buehler, J. W., Hopkins, R. S., Overhage, J. M., Sosin, D. M., & Tong, V. (2004). Framework for evaluating public health surveillance systems for early detection of outbreaks: recommendations from the CDC Working Group. MMWR.Recommendations and Reports : Morbidity and Mortality Weekly report.Recommendations and Reports / Centers for Disease Control, 53(5), 1. https://doi.org/rr5305a1 [pii] Bwire, G., Malimbo, M., Makumbi, I., Kagirita, A., Wamala, J. F., Kalyebi, P., … Dahlke, M. (2013). Cholera surveillance in Uganda: An analysis of notifications for the years 2007-2011. Journal of Infectious Diseases, 208(SUPPL. 1). https://doi.org/10.1093/infdis/jit203 CDC. (2001). Inside : Continuing Education Examination Inside : Continuing Continuing Medical Education for U . S . U . S . Physicians and and Nurses Nurses Inside : Medical Education for for Evaluating Public Health Surveillance Systems Recommendations from the Guide, 50(Cdc). CDC. (2013). Overview of Evaluating Surveillance Systems. CDC. (2014). Fundamental Concepts of Public Health Surveillance and Foodborne Disease. Fundamental Concepts of Public Health Surveillance and Foodborne Disease, 58–84. Cholera; Fast facts. (2006). Cholera; Fast facts. Cholera Surveillance : Detecting and Reporting Cases. (2015). Cholera Surveillance : Detecting and Reporting Cases. Cowman, G. A. (2015). Cholera prevention and control in Kenya. ProQuest Dissertations and Theses, 174. https://doi.org/10.1017/CBO9781107415324.004 Dziedzom. (2015). Cholera Outbreaks in Greater Accra Region , Ghana : the Economic Costs To the Health Facility and Affected Households This Thesis Is Sumitted To the University of Ghana , Legon in Partial Filfilment of the Requirement for the Award of Mphil Economics Degr, (10444083). Dzotsi. (2014). Addressing the Cholera Epidemic. 49 University of Ghana http://ugspace.ug.edu.gh Essoya, L. D., Gessner, B. D., Kossi, B., Tsidi, T., Ibrahim, N. D., Anoumou, D., … Abiba, B. K. (2013). National surveillance data on the epidemiology of cholera in Togo. Journal of Infectious Diseases, 208(SUPPL. 1), 115–119. https://doi.org/10.1093/infdis/jit244 European Centre for Disease Prevention and Control. (2014). Data quality monitoring and surveillance system evaluation - A handbook of methods and applications. ECDC Techical Document. Retrieved from http://ecdc.europa.eu/en/publications/_layouts/forms/Publication_DispForm.aspx? List=4f55ad51-4aed-4d32-b960-af70113dbb90&ID=1171 Ghana National Action Plan For Cholera. (2015). Ghana National Action Plan For Cholera. Accra. Ghana Statistical Service (GSS). (2014). LEDZOKUKU-KROWOR. Guerra, J., Mayana, B., Djibo, A., Manzo, M. L., Llosa, A. E., & Grais, R. F. (2012). Evaluation and use of surveillance system data toward the identification of high- risk areas for potential cholera vaccination : a case study from Niger. Gueye, D., Senkoro, K. P., & Rumisha, S. F. (2005). Baseline Monitoring and Evaluation of Integrated Disease Surveillance and Response in Tanzania Prepared by : Appropriate Technology. Hashim, N. S. (2011). Assessment of Communicable Diseases Surveillance System in Khartoum State, Sudan: 2005 - 2007. Highlights, I. K. (2016). Country Office Ghana Situation Report on Cholera Outbreak in Ghana, (November), 1–4. Issa, Z., Coordinator, H., Society, C., East, A., West, A., Central, G., … Accra, G. (2014). Emergency Plan of Action ( EPoA ) Ghana : Cholera A . Situation analysis, (August). J.K.L OPARE1, 2, C.OHUABUNWO1, 3, E. AFARI1, F. WURAPA1, S.O SACKEY1, J. DER1, 2, K. AFAKYE1, and E. O. (2012). OUTBREAK OF CHOLERA IN THE EAST AKIM MUNICIPALITY OF GHANA FOLLOWING UNHYGIENIC PRACTICES BY SMALL-SCALE, (September 2010). Kanungo, S., Sah, B. K., Lopez, A. L., Sung, J. S., Paisley, A. M., Sur, D., … Balakrish Nair, G. (2010). Cholera in India: An analysis of reports, 1997-2006. Bulletin of the World Health Organization, 88(3), 185–191. https://doi.org/10.2471/BLT.09.073460 Kuma, G. K., Opintan, J. A., Sackey, S., Nyarko, K. M., Opare, D., Aryee, E., … Asmah, R. H. (2014). Antibiotic resistance patterns amongst clinical Vibrio cholerae O1 isolates from Accra , Ghana, 3–9. https://doi.org/10.3396/IJIC.v10i3.023.14 Lamond, E., & Kinyanjui, J. (2012). Cholera Outbreak Guidelines Preparedness , Prevention and Control, (June). Lee, K. (2001). The global dimensions of cholera, 2(1), 6–17. Nsagha, D. S., Atashili, J., Fon, P. N., Tanue, E. A., Ayima, C. W., & Kibu, O. D. (2015). Assessing the risk factors of cholera epidemic in the Buea Health District of Cameroon. BMC Public Health, 1–7. https://doi.org/10.1186/s12889-015-2485-8 Rebaudet, S., Sudre, B., Faucher, B., & Piarroux, R. (2013). Environmental Determinants of Cholera Outbreaks in Inland Africa : A Systematic Review of Main 50 University of Ghana http://ugspace.ug.edu.gh Transmission Foci and Propagation Routes, 208(Suppl 1). https://doi.org/10.1093/infdis/jit195 Sanchez-padilla, E., Carrillo-santisteve, P., & Luquero, F. J. (2009). Evaluation of the cholera surveillance system in Guinea Bissau, 33(December). UNICEF. (2013). Cholera Epidemiology and Response Factsheet - Cameroon. World Health Organization. (2010). Technical Guidelines for Integrated Disease Surveillannce and Response in the African Region, 1–416. Retrieved from http://www.cdc.gov/globalhealth/healthprotection/idsr/pdf/technicalguidelines/idsr -technical-guidelines-2nd-edition_2010_english.pdf World Health Organization. (1947). World Health Organization. Food, Drug, Cosmetic Law Quarterly, 2(3), 373–381. https://doi.org/10.1016/B0-12-227055-X/01300-6 World Health Organization. (2015). World Health Organization. https://doi.org/http://dx.doi.org/10.1016/B978-012373960-5.00326-9 51 University of Ghana http://ugspace.ug.edu.gh APPENDICES APPENDIX I: CONSENT FORM Informed Consent Form Project Title: ASSESSMENT OF THE CHOLERA SURVEILLANCE SYSTEM IN THE LEDZOKUKU-KROWOR MUNICIPALITY IN THE GREATER ACCRA REGION OF GHANA Background My name is Kodom Kwame Achempem, a student from the University Of Ghana School of Public Health. I am conducting a study on the cholera surveillance system in the Ledzokuku-Krowor municipality Procedures The study will utilize; administrative data: district guidelines, paper and electronic forms, other documentation regarding cholera surveillance, primary data collection from semi- structured interviews of stake holders and secondary data from previous cholera outbreaks and other reports regarding cholera in Ledzokuku-Krowor municipality. No coercion will be used to obtain response from participants. It will be appreciated if you could take part in this study. This is purely academic research which forms part of my work for the award of a Master‟s Degree in Public Health. Risks and Benefits Both the study population and the society stand to benefit from this study. Results obtained from this study will be used to make recommendations to improve the cholera surveillance of the Ledzokuku-Krowor municipality. This research will pose no potential risk to study subjects or the society. Confidentiality All data will be de-identified and will be kept private. Your identifiable data such as name or date of birth will not be used in documents, reports, or publications related to this research. I will keep all documents secured and under lock. When typing your survey responses into the computer, all data will be entered without any information that will make it possible for your identity to be known. The information you provide will be kept strictly confidential and will be available only to persons related to the study (myself and 52 University of Ghana http://ugspace.ug.edu.gh my supervisors). Your responses will not be shown to other study subjects. The original paper survey forms will be destroyed once data entry and all analysis is complete. Voluntariness and Withdrawal Your participation in the study is completely voluntary and you reserve the right not to participate, even after you have taken part, to withdraw. This is your right and the decision you take will not be disclosed to anyone. You are at liberty to withdraw from the study at any time. There will be no negative consequences if you choose not to participate in the study. Please note however, that some of the information that may have been obtained from you without identifiers, before you chose to withdraw, may be used in analysis reports and publications. You can opt not to have me use it. Cost/Compensation Your participation in this study will not lead to you incurring any monetary cost during or after the study. Who to contact This study has been approved by the Ethics Committee Review Board of the Ghana Health Service. If you have any concern about the conduct of this study, your welfare or your rights as a research participant or if you wish to ask questions, or need further explanations later, you may contact me, Kodom Kwame Achempem (024 4746311) of the University of Ghana School of Public health or my supervisor ………………………………………………………….. Mr. Chris M. Guure Department of Biostatistics School of Public Health University of Ghana Hannah Frimpong Nana Abena Kwaa GHS-ERC Administrator Assistant GHS-ERC Administrator Mob. 233(0) 243235225, 0507041223 0244 712919 Hannah.Frimpong@ghsmail.org nanaTuesday@yahoo.com 53 University of Ghana http://ugspace.ug.edu.gh Dissemination of Results A possible presentation at the Ledzokuku-Krowor Municipal health directorate, including hospital staff, patients and other stakeholders of the Ledzokuku-Krowor Municipal health directorate will be made to disseminate the findings of the study. A copy of the study will be kept at the health directorate as reference. Before taking Consent Do you have any questions you wish to ask about the study? Yes/No If yes, please, indicate the questions below ……………………………………………………………………………………………… ……………………………………………………………………………………………… ……………………………………………………………………………………………… …………………...................………………………… Voluntary Consent I have read the information given above, or the information above has been read to me and I understand. I have been given a chance to ask questions concerning this study; questions have been answered to my satisfaction. I now voluntarily agree knowing that I have the right to withdraw from this study at any time without affecting future health care services. …………………….... …………………. ……………… ……………….. Name of participant Signature Thumbprint Date ……………………………. ………………….. ……………… 54 University of Ghana http://ugspace.ug.edu.gh ……………… Name of witness Signature Thumbprint Date ……………………………. ………………… ………….. ……………….. Name of researcher Signature Thumbprint Date Interviewers Statement I, the undersigned, have explained this consent to the subject in English language/ Twi/ Ewe, and that she/he understands the purpose of the study, procedures to be followed, as well as the risks and benefits of the study. The participant has fully agreed to participate in the study. Signature of Interviewer ……………………………………… Date ………………………………… Address ………………………………………………………. 55 University of Ghana http://ugspace.ug.edu.gh APPENDIX II: QUESTIONNAIRE UNIVERSITY OF GHANA SCHOOL OF PUBLIC HEALTH MASTER OF PUBLIC HEALTH PROGRAM ASSESSMENT OF THE CHOLERA SURVEILLANCE SYSTEM IN THE LEDZOKUKU-KROWOR MUNICIPALITY QUESTIONNAIRE FOR STAKE HOLDERS AT VARIOUS HEALTH FACILITIES AT THE LEDZOKUKU-KROWOR MUNICIPALITY This questionnaire is strictly for academic purposes. No respondent or the organization he/she represents will be identified by name in the report without his/her consent. Your input to the following questions will help improve the cholera surveillance system in the Ledzokuku-Krowor municipality 1. Is it required to report cases of cholera in Ledzokuku-Krowor? YES NO UNKNOWN 2. Is there a technical guideline for the surveillance of cholera in Ledzokuku- Krowor? YES NO UNKNOWN 3. If yes, do you have a hard copy here? YES NO UNKNOWN 4. What is the case definition cholera in you use (type & number of variables)? - ---------------------------------------------------------------------------------------------------- ----------------- a. Does the definition differ in non-epidemic and epidemic periods? YES NO b. If yes, describe each: - Non-epidemic period: ---------------------------------------------------------------- ---------------- - During outbreaks: ---------------------------------------------------------------- ----------------- 5. Do you agree with the definition for a cholera : a. For non- epidemic periods? YES NO b. For epidemic periods YES NO 6. Is it a challenge to identify a case of cholera epidemic period? YES NO 7. Is it a challenge to identify a case of cholera there is no epidemic? YES NO 8. When there is not an epidemic, based on what do you test a patient for cholera? - ---------------------------------------------------------------------------------------------------- -------- 9. How do you collect the sample? ------------------------------------------------------- ------------------- 56 University of Ghana http://ugspace.ug.edu.gh 10. How do you prepare the sample? ------------------------------------------------------- ----------------- 11. How do you transport the sample? ------------------------------------------------------- ------------------------ 12. During the cholera outbreak, when would you take a sample from a patient to be tested? ------------------------------------------------------------------------------------------- ---------- 13. Have you lacked appropriate resources to obtain, prepare and transport the samples at any time during the last 6 months? - Containers: YES NO - Medium: YES NO - Boxes: YES NO - Stamps YES NO - Gloves YES NO - Others: ------------------------------------------------------------------------- -------------------------------- 14. How long does it take to receive the results from the lab? ---------------------------- ------------- 15. Have you lacked appropriate resources for filling in the forms at any time during the last 6 months? - Paper forms: YES NO - Pens: YES NO - Others: ------------------------------------------------------------------------- ------------------- 16. Do you collect the information through directly interview with the cases, or copied from the clinical forms? ---------------------------------------------------------------- ------------------------------------ 17. Do you find it difficult to collect all the information? YES NO 18. If yes, what aspect is the most difficult / complex? ------------------------------------- ----- 19. How long does it take to collect all the information from the case? ------------------- ------------ 20. Did you receive specific training for this activity (detecting a case & filling the form, collect the sample)? YES NO 21. If yes, a. When? ------------------------------------------------------------------------------------------- -------------- b. Where? -------------------------------------------------------------------- c. By whom? ------------------------------------------------------------ d. For how long? ---------------------------------------------------------------------------------- ---------------- 22. Do you have any type of supervision on the work you do? YES NO 57 University of Ghana http://ugspace.ug.edu.gh 23. If yes, who provides this supervision? ---------------------------------------------- ---------------------- 24. How is the supervision done? ---------------------------------------------------------------- --------------- 25. How would you improve the way a cholera case is detected: a. During non-epidemic periods? ------------------------------------------------------- ----------------- b. During epidemic periods? ------------------------------------------------------- ------------------------------ 26. Is it you who reports the data to the next level? YES NO 27. If no, who is it? ------------------------------------------------------------------------- ------------------ 28. How do you report the cases to the region? Telephone mail email fax 29. If in paper for, may I see it? YES NO - Check variables included: ------------------------------------------------------- ------------------------------------------------------------------------------------------- ----------------------------- 30. Do you find it hard to send the form before the deadline? YES NO 31. If yes, why? What is the deadline? ------------------------------------------------------------------------------------------- ------------ 32. Have you lacked appropriate forms at any time during the last 6 months have enough resources for filling and sending the forms? - Paper forms - Pens - Envelopes - Stamps - Others: ---------------------------------------------------------------------------------- -------------------- 33. How would you improve the way the reporting of the cholera case is done: a. During non-epidemic periods: ------------------------------------------------------- ----------------- b. During epidemic periods? ------------------------------------------------------- -------------------------- 34. Do you know what the reporting is for (objective of reporting a cholera case)? YES NO 35. If yes, what is its objective? ---------------------------------------------------------------- -------- (if no, please explain) ---------------------------------------------------------------- ---------------------------------- 36. Do you think this is useful for the detection and control of a cholera outbreak YES NO 37. Do you receive reports with the cholera cases detected in your health facility? YES NO 58 University of Ghana http://ugspace.ug.edu.gh 38. If yes, with what periodicity? ---------------------------------------------------------------- ------------- 39. If you don‟t receive them, would you like to receive it? YES NO 40. If yes, what would you use it for? ------------------------------------------------------- ----------------- 41. Could you tell me how many meeting per year do you have? ------------------- -- 42. What are the objectives of these meetings? ---------------------------------------------- --------- 43. If the new “Technical guidelines” made changes, how difficult would you find the following changes? a. To diagnose cholera during non-epidemics in the health facility through a diagnosis rapid test? Very difficult. Difficult. Easy. Very easy. b. To diagnose cholera during epidemics in the health facility through a diagnosis rapid test? Very difficult. Difficult. Easy. Very easy. c. To change the paper forms from the patient? Very difficult. Difficult. Easy. Very easy. 44. If the new “Technical guidelines” made changes, how difficult would you find the following changes? ------------------------------------------------------------------------- ---------------------- 45. Are you satisfied with the way you report to the district? YES NO 46. If no, why? ------------------------------------------------------------------------------ 47. Are you familiar with the way the population covered by your health facility (age, sex, population by village, total population …….)? YES NO 48. If yes, who provided this information? ---------------------------------------------- ---------------------------- 49. Do you think there are patients that might not seek care in case of severe diarrhea or cholera? YES NO 50. Do you think this might change during a cholera outbreak? YES NO 51. Do you think there might be patients that should be tested for cholera during non- epidemic periods and are not for any of this reasons? i. No resources (container, medium …)? YES NO ii. No human resources? YES NO iii. Work load? YES NO 52. Do you think that during an outbreak there are patients who receive treatment but are not included in the registration books for any of these reasons? i. Workload (very busy!)? YES NO ii. No resources (pen...)? YES NO iii. No book (completed and there is not a new one)? YES NO iv. Others: ------------------------------------------------------------------------- ----------- 59 University of Ghana http://ugspace.ug.edu.gh 53. What do you normally do when there is a suspected cholera case? ------------------- ---------------------------------------------------------------------------------------------------- ---------------------- 60 University of Ghana http://ugspace.ug.edu.gh APPENDIX III: QUESTIONNAIRE FOR STAKEHOLDERS UNIVERSITY OF GHANA SCHOOL OF PUBLIC HEALTH MASTER OF PUBLIC HEALTH PROGRAM ASSESSMENT OF THE PERFORMANCE OF THE CHOLERA SURVEILLANCE SYSTEM IN THE LEDZOKUKU-KROWOR MUNICIPALITY QUESTIONNAIRE FOR STAKE HOLDERS AT LEDZOKUKU-KROWOR MUNICIPAL HEALTH DIRECTORATE This questionnaire is strictly for academic purposes. No respondent or the organization he/she represents will be identified by name in the report without his/her consent. Your input to the following questions will help improve the cholera surveillance system in the Ledzokuku-Krowor municipality 1. What is your main activity within the cholera surveillance system? - -------------------------------------------------------------------------------------- ---------------------------------- 2. Did you receive specific training for this activity (detecting a case & filling the form, collect the sample)? YES NO 3. If yes, a. When? ------------------------------------------------------------------------- ---------------- b. Where? ---------------------------------------------------------------- ----------------------- c. By whom? ---------------------------------------------------------------- -------------- d. For how long? ---------------------------------------------------------------- -------------- 4. What do you think the main objectives of a cholera surveillance system are? ------------------------------------------------------------------------- ------------------------------------------------- 5. Do you know what the case definition for cholera used in the reporting sites is (health centers and hospitals)? YES NO 6. If yes, could you tell me what it is? ------------------------------------- -------------------- a. Does it differ in non-epidemic and epidemic periods? YES NO b. If yes, describe each: - Non-epidemic period: ---------------------------------------------------------------- ------------ 61 University of Ghana http://ugspace.ug.edu.gh - During outbreaks: ---------------------------------------------------------------- ------------ 7. Do you know what the procedures regarding cholera surveillance at local level (health facility) are? YES NO 8. If yes, could you tell me what they are? ------------------------------------- -------------- 9. Do you know what the procedures regarding cholera at regional level are? YES NO 10. If yes, could you tell me what they are? ------------------------------------- ---------------- 11. Could you please describe the procedures at the district level with regards to cholera ---------------------------------------------------------------- -----? 12. How many people are involved in the data management, analysis, report writing? ---------------------------------------------------------------- --------------------------- 13. How would you describe the role of the WHO regarding cholera surveillance in Ledzokuku-Krowor? ------------------------------------- --------------------------------------- 14. How difficult is it to finish the reports on time? ---------------------------- ---------- 15. Do you think the periodicity of the information sent by the regions is the best one? YES NO 16. If not, what do you think it should be? ------------------------------------- ----------- 17. Do you use any technique to verify the quality of the data (as cross- checking with another source –NGOs,)? If yes, what? ------------------- ---------------------------- 18. Do you think the cholera cases declared by the district are representative of the global “real” total number of cases? ---------- ---------------------------------------------- 19. If not, how do you think this could be improved? ------------------- ---------------------- 20. Do you find the cholera surveillance system in Ledzokuku-Krowor useful to detect outbreaks (cholera cases in inter-epidemic periods)? YES NO a. If not, why & how would you improve it? ---------------------------- ---------------------------------------------------------------------------------- -------------------------------- 21. Do you think some outbreaks are being missed, or declared late? - -------------------- 62 University of Ghana http://ugspace.ug.edu.gh 22. Do you think there might be patients that should be tested for cholera during non-epidemic periods but are not for any of this reasons? a. No resources (container, medium)? YES NO b. No human resources? YES NO c. They have cholera but they don‟t meet the definition to be tested? YES NO 23. Do you think that during an outbreak there are patients who received treatment but are not included in the registration books for any of these reasons? a. Workload (very busy)? YES NO b. No resources (pen…)? YES NO c. No book (completed and there is not a new one)? YES NO 24. Do you think there are cholera cases not being detected when there is an epidemic (no health-care seeking, no information regarding cholera, stigma…)? YES NO 25. If yes, what do you think the reasons are? And how could it be improved? ------------------------------------------------------------------------- ---------------------------------------------- 26. In general, a. How would you improve the way a cholera case is detected during non-epidemic periods ------------------------------------------------------- ----- b. What measures would you implement to improve the control of a cholera outbreak? ------------------------------------------------------- --------------- 27. What do you think about the quality of the data declared by the regions? ---------------------------------------------------------------------------------- ------------------- 28. Do you think it could be improved, and if yes, how? ------------------- -------------------------------------------------------------------------------------- -------------------------------------------- 29. Do you use any technique to complete the missing information? - -------------------------------------------------------------------------------------- --- 30. Who does the reporting to the WHO in Ledzokuku-Krowor (what department of the MoH)? ------------------------------------------------------- ------------------------- 31. Do you think that during a cholera outbreak, there might be non-cholera cases that are registered as cholera? YES NO 32. How do you think this could be improved? ---------------------------- ------------------------- 33. Could you tell me how many meetings per year you have on cholera? - -------------------------------------------------------------------------------------- 63 University of Ghana http://ugspace.ug.edu.gh 34. When was the last one? ------------------------------------------------------- -- 35. What are the objectives of these meetings? ---------------------------- ------------------------ 36. Could you tell me how many meeting per year do you have with the nurses from various health facilities ------------------------------------- ----------------------------------------- 37. When was the last one? ------------------------------------------------------- -------------- 38. What are the objectives of these meetings? ---------------------------- -------------------------------------------------------------------------------------- -------------------------------------------------- 39. Do you think you have enough resources to run the cholera surveillance system? YES NO 40. If not, what do you miss? ------------------------------------------------------- ------------- 41. How do you think the problems with the salaries may affect the cholera surveillance system? ------------------------------------------------------- ----------------------------------------- 42. How good do you think the cholera surveillance system from Ledzokuku-Krowor is? ------------------------------------------------------- --------------------------------------- 43. How do you think it could be improved? ------------------------------------- ------------- 44. Do you consider that the adaption of the “technical guidelines” has been a difficult process? YES NO 45. If yes, why? ---------------------------------------------------------------- --------------------------- 46. If the new “Technical guidelines” made changes, how difficult would you find the following changes? a. To change the paper forms for collecting information from the patient? Difficult ---------- very difficult -------- easy ---------- very easy----------- -- b. To change the paper forms used to report the information from the cholera cases? Difficult---------- very difficult--------- easy ------------- ----------- very easy-------------- c. To send the forms to a different organization (i.e. MoH)? very Difficult- ----------- difficult ---------- easy--------- very easy--------------- d. To diagnose cholera during non-epidemics in the health facility through a diagnosis rapid test? Very difficult? Difficult Easy Very easy e. To diagnose cholera during epidemics in the health facility through a diagnosis rapid test? Very difficult------- difficult ---------- easy -------- - very easy------------- 64 University of Ghana http://ugspace.ug.edu.gh f. On your opinion, what would be the hardest change to implement? - -------------------------------------------------------------------------------------- --------------------------------------------- 47. How easy do you think it would be to implement a parallel surveillance system (as a sentinel system) in the country, and why? ------------------- -------------------------------------------------------------------------------------- -------------------------------------------------------------------------------------- ------ 65 University of Ghana http://ugspace.ug.edu.gh APPENDIX IV: STANDARD PROCEDURE FOR CHOLERA SURVEILLANCE SYSTEM THE OBJECTIVE AND ACTIVITIES OF ITEMS BELONGING TO THE CHOLERA SURVEILLANCE SYSTEM 1. Purpose and objective of surveillance system;  Objective-To identify the intended goals of the cholera surveillance system in Ledzokuku-Krowor  Activity-Listing the objective of the system per the district guidelines 2. Case definition  Objective- i. Case definition as specified in the district guidelines ii. Case definition for cholera used by the system‟s users  Activity-i. Description of cholera case definition per district guidelines ii. Description of cholera case definition used at the reporting sites; health centers and hospitals 3. Residence of the cholera surveillance system within the national health system  Objective-To describe the context in which the cholera surveillance system resides  Activity-Description of the position of the cholera surveillance system within the national health system as explained in the national guidelines 4. Level of integration with other systems in the national health system  Objective-To describe the existence of other healthcare programs or parallel surveillance systems in the country and the ability of the cholera surveillance system to combine with them  Activity- i. Description of existing parallel surveillance systems implemented ii. Description of existing healthcare programs outside the national healthcare system 5. Flow chart of the surveillance system  Objective-To describe the participating agencies and the way in which the information is transmitted through the different levels of the system  Activity- 66 University of Ghana http://ugspace.ug.edu.gh i. List of all participating agencies as explained in the national guidelines ii. Description of flow of information within the surveillance system iii. Description of the characteristics of the information transmitted and the time needed to diffuse the information between the different levels of the system 6. Components of the cholera surveillance system; a. Population under surveillance  Objective-To describe the population in which cholera is expected to be detected in terms of demographic, socioeconomic and geographic characteristics as well as healthcare availability  Activity- i. Description of population covered by surveillance system ii. Description of geographical distribution of population covered iii. Description of population covered by the national healthcare system b. Case identification  Objective-To describe the methodology used for the identification of cholera cases in epidemic and non-epidemic situation  Activity- i. Description of the sites where the cases are identified ii. Description of people in charge of case definition iii. Description of the criteria used for the identification of cases c. Data collection  Objective- i. To describe the methodology used for case definition ii. To identify barriers and gaps in data collection iii. To identify the people in charge of data collection and its level of training  Activity- i. Description of the type of data collected in epidemic and non- epidemic situation ii.Description of tools used for data collection ii.Description of the responsibility of the staff in charge of collecting the data and specific training received d. Data reporting  Objective-To describe how the data is reported to the next level of the surveillance system  Activity- i. Description of the type of data reported in epidemic and non- epidemic situation 67 University of Ghana http://ugspace.ug.edu.gh ii.Description of tools used for data reporting iii.Description of difficulties in reporting the data iv.Description of the responsibility of staff in charge of reporting data and the specific training received e. Data management  Objective- i. To describe how the data in the surveillance system is managed and to identify the barriers in data management  Activity- i. Description of the format of data and method used for data coding ii.Description of the number of people implicated in the data management and their level of training iii.Description of software used; flexibility of usage iv.Description of method used to ensure accuracy of records. f. Data analysis  Objective- To describe how the data is analyzed and the barriers that occur in data analysis  Activity- i. Description of the number of people implicated in the data analysis and their level of training ii.Description of the statistical methods used, the indicators obtained and the periodicity of analysis g. Results dissemination  Objective-To assess the adequacy of epidemiological information, reported in terms of presentation, quantity and relevance  Activity- i. Description of reports included in cholera reports and cholera outbreaks ii.Description of quality of information reported iii Identification of missing information in reports iv.Description of periodicity of reports v. Identification of agencies/levels to whom the results are disseminated h. Privacy/confidentiality and systems security  Objective- To assess the adherence of cholera surveillance system to confidentiality and security standards  Activity- i. Description of the method used to safeguard against the privacy of individuals, both soft and hard copies ii.Description of method used to ensure the security of the surveillance system. 7. Specific reinforcements of cholera activities 68 University of Ghana http://ugspace.ug.edu.gh  Objective- To identify seasonality of reinforcement of cholera surveillance activities  Activity-Description of planned and implemented means to reinforce the cholera surveillance system during cholera outbreaks 8. Resources used to operate the surveillance system; a. Funding resources  Objective-To document the funding sources of the surveillance system  Activity- i. Description of the partner agencies providing funds to the cholera surveillance system b. Human resource requirements  Objective-To document the human resource requirements to run the cholera surveillance system  Activity- Description of the staff involved in cholera surveillance activity at each level c. Other resources  Objective- To document other resources required to run the cholera surveillance system  Activity- Description of resources required to operate the system; computers, softwares, travel expenses, training expenses, internet connection and laboratory support 69 University of Ghana http://ugspace.ug.edu.gh APPENDIX V: EVALUATION ATTRIBUTES OF A SURVEILLANCE SYSTEM EVALUATION ATTRIBUTES a. Simplicity (Ease of use for the cholera surveillance system users);  A description of the level of easiness for the detection of cases; a grade of complexity in the collection of data necessary for identification of cholera cases  Description of the level of easiness for data management; human resources necessary, time and difficulty in editing and entering data, time and difficulty in checking data quality  Description of the level of easiness of data analysis; subjective difficulty in calculation of various indicators  A description of the level of easiness of data dissemination; human resources requirements, time and difficulty in report writing and dissemination b. Flexibility (Capacity to adapt to changing information needs);  Description of the level of difficulty in the development of new IDSR  Description of the level of difficulty in the implementation of new IDSR c. Data quality (Completeness and validity of data recorded in paper form and in database);  Comparison of data in database and data in paper form  Review of the data recorded in the database and method used to create database backups to ensure quality of data  Description of the proportion of missing data aggregated variables and description of the coding used d. Acceptability (Satisfaction of the users with the different elements of the surveillance system);  Description of the level of satisfaction of the users with; the case definition, the way of reporting to the upper level, timeliness, information produced 70 University of Ghana http://ugspace.ug.edu.gh  Revision of the reports on the completeness and delay of reporting by sanitary area and region e. Sensitivity (Proportion of cholera cases detected by the surveillance system);  Description of the factors that affect the ability of the surveillance system in the detection of cholera cases outside the epidemic period f. Positive predictive value (Proportion of reported cholera cases that are confirmed cases);  Description of factors that affect the probability that a case identified outside the epidemic period is a real case  Description of factors that affect the probability that a case identified during the epidemic period is a real case g. Representativeness (Accurate description of cholera cases over time and its distribution in the population by place and person);  Description of the geographic origin of samples sent to the lab in the inter-epidemic period  Number of health centers by region, number of people covered by each health center  Characteristics of cases covered by each region; age, sex, socio- economic status and geographic location  Description of the clinical course of disease (latent period, mode of transmission, outcome) by region (indicator of delay in seeking healthcare); between reported cases and “normal” course, among regions and over time h. Timeliness (Speed between steps in reporting within the surveillance system);  Review of dates of diagnosis and reporting  Review of procedure for reporting the beginning of the outbreak  Delays in the transmission of information and reasons for delay i. Stability (Reliability-ability to collect, manage and provide data properly and Availability- ability to be operational/effective/active when needed of the surveillance system);  Measure of dedicated resources 71 University of Ghana http://ugspace.ug.edu.gh  Review of alternative measures  Description of technical support regarding information systems 72