Attributes, Supportive and Core Functions of Public Health Emergency Surveillance leadership, and Implementation for Tropical Diseases Control

Background Public health surveillance (PHS) is the continuing organized gathering, investigation, elucidation, and well-timed distribution of health-related information for activities and program evaluation. Conducting a surveillance system evaluation is crucial for monitoring the ecacy and effectiveness of intervention programs in health care systems. Evaluate the Status of Attributes, Supportive and Core Functions implementation of Public Health Emergency Surveillance (PHES) in the case of Awi Zone, Amhara Regional State, Ethiopia, 2020 was the main aim of the study. Methods A descriptive prevalence study design was used to evaluate the surveillance system of the Awi zone selected woreda. 25 study sources are used in the study (5 District Health Oces (5HOs), 10 Health Centers (10HCs), and 10 Health Posts (10HPs)). Purposive sampling techniques were utilized. Data were obtained by communicable diseases control the standard format of systematic evaluation of four surveillance units from January to August 2020 through observation, document review, and interviewing surveillance ocers and focal persons using a semi-structured survey.


Background
Public health surveillance (PHS) is the continuing organized gathering, investigation, elucidation, and well-timed distribution of health-related information for activities and program evaluation. Sustain the decrease of the trouble of immediately reportable diseases (IRDs), eradicate the disease, and prevent its restitution is the main aim (1).
Surveillance of immediately reportable diseases is recognized as the keystone of Public Health (PH) decision-making and practice. PHS information is critical for monitoring the health status of the community, detecting infectious diseases, and trigger actions to prevent further complications, illness and ensure that these diseases are monitored e ciently and effectively (2).
Information disseminated by a PHS structure could be used for urgent PH accomplishment, program planning, and assessment, and to formulate research suggestions. The PHS system has been developed to take in the hand of many PH needs. They comprise a diversity of information source vital to PH battle (3) The evaluation of PHS systems should encourage the top to utilize PH assets by ensuring with the aim of only vital di culty are under PHS and that the PHS system operates pro ciently. In so far as likely, the assessment of the PHS system ought to embrace the recommendation for civilizing excellence and competence, e.g., removing pointless repetition. Notably, an assessment must evaluate whether a scheme has served a helpful PH purpose and achieve the system aims (4).
Conducting PHS is key for monitoring the e cacy and effectiveness of interventional programs in the health care system. Effective PHS systems are one of the basic strategies of national disease prevention and control programs. A PHS scheme serves 2 relevant roles; (i) untimely caution of likely threats to PH and (ii) program monitoring of the PHE, which could be emerging-de nite or multiple-emergency in life (5). Therefore, the purpose of this study was to evaluate the status of Attributes, Supportive and Core Functions implementation of Public Health Emergency Surveillance in the case of Awi Zone, Amhara Regional State, Ethiopia, 2020.

Study plan and time
The prevalence lessons plan was used based on an "overview of evaluating PHS systems CDCs updated in the 2012 guideline for evaluating PHS system" as a framework for the evaluation to achieve the stated objective of the study from June 2020 to August 2020.

Study unit
The study units were woreda Health O ce (HOs) and health facilities (HF). 25 study sites were included in the study, including HO= 5, HC= 10, and HP= 10.

Sample size and techniques
A Zone is one of the Zone in the Amhara Region that reported the highest number of malaria cases in the region this year. We purposely selected to conduct the PHS system evaluation in this zone. 25 sites were selected for the study. About 5(50%) woredas are selected by a convenient sampling method based on their malaria weekly report caseload and surveillance performances. For each selected Woredas, in each selected HO: 10 HC and each selected HC: 10 HP was selected by purposive.

Selection of health facilities
Health facilities were selected by discussing with district PHEM o cers, two HCs and two HP from each woreda were included in the evaluation, similarly, HC was included based on the 2019/2020 PHEM performance by taking HCs that had better performance and least performance. HPs were selected by purposive.

Data collection and Data source
Data collection would be done by face to face interviews using questionnaires/checklists. Answers from respondents (HO head and/or PHEM o cers) and observation of tools for surveillance and secondary data review. Based on the WHO structure for monitoring and assessing PHS and response systems for malaria infection, which were used to assess the core activities, supportive functions, and quality components in the Awi zone, Amhara Regional state 2020.

Study variables
The Supportive function of the PHS system: Training, Supervision, Resource, and Feedback The Core function of the PHS system: Reporting, Data Analysis & Interpretation, and Epidemic preparedness Attributes of PHS scheme: Flexibility, Usefulness, Simplicity, Acceptability, Timeliness, Completeness, Predictive value, Stability, and Data quality

Statistics administration and investigations
The records were coded and transferred using Epi info 7 and exported to SPSS version 20. Then the mean prevalence, variability, and linear regression were executed by using SPSS statistical software version 20. The variances between groups were handled by analysis of variance (ANOVA).

Data Quality assurance
Data was reviewed by PH experts who have worked in the PHS system. Some data was de-duplicated, especially data from monitoring charts, weekly PHEM reports, and year reports. We cleaned and analyzed the data using Microsoft O ce Excel 2016 and epi-data to show report completeness, timeliness, and other variables.

Results
Population under Surveillance: Public Health Emergency Management (PHEM) targets all populations to be under surveillance for all 21 diseases nationally and 22 diseases (including Lehimaniasis) in the Awi zone, Amhara Region ( Table 1).  Community case de nition: The case de nition is used to be aware of the community to notify any suspected cases and to make them aware of the early diagnosis of the priority diseases under surveillance. These are sensitive (loose) case de nitions that increase the case detection rate. And Malaria: Any person with fever or fever with a headache, back pain, chills, rigor, sweating, muscle pain, nausea, and vomiting or suspected case con rmed by RDT Data Reporting: No lack of reporting forms in the past six months in every visited HFs and HOs except for four HPs. The weekly reporting rate of the visited HFs over the past 26 weeks(week 27-52/2020) before assessments were 90% (9/10) or HPs, 100%(10/10) for HCs, and 100% (5/5) for woreda. The overall reporting rate of the visited districts for the zonal health department in 2012 EFY for the same week period before the assessment was 96% of Ankesha Guasgusa District, 97% Banja, 100% Changi, 95% Guasgusa, and 95% for Zigem District, whereas the reporting rate of the zonal health department to the regional health bureau was 98%. Among the assessed HFs, 12 (60%) of them reported the highest level of hard copy because close to their receiving. For reporting of any PHS related rumors, the woreda used the phone call to the highest-level body (Zonal). There was a shortage of rumors logbooks and case-based reporting formats.
Data Analysis: In visited Woredas and health institutions, data is not described by person, place, and time.
The reason for the respondents failing to analyze the PHS data by place, person, and time was due to they had no awareness regarding the analysis and its use. None of the visited health facilities analyzed the data collected from PHS at their ability. In the majority of 12 (48%) of the assessed HFs, there was a Malaria Monitoring Chart (MMC) to follow the trends of malaria cases in their catchment area.
Epidemic preparedness and management: There were a written epidemic preparedness and response plan for all visited woredas, including some HF level but not secured budget. Current Covid-19 emergency preparedness plan and response plan available at woredas 5 (100%) and 6 (50%) HCs during data collection. All visited HFs responded as there was no scarcity of urgent situation antimicrobials and provisions in the past six months, despite that there were no separately secured contingency drugs and budgets for emergency cases. Regarding the existence and activities of the epidemic management committee, there was established a committee at the woreda and visited facilities. During this assessment, it was identi ed that the established committee at those levels was working regularly and formulated on all necessary disciplines, especially on Covid-19.

Supporting Functions of the PHS System
Supportive Supervision: During the past six months, the Awi zonal department did not conduct supportive supervision because of time constraints and security issues in the region. Among the 10 visited HCs, 4 (40%) had not been supervised during the past 6 months at higher levels. All HCs were not regularly supervising the HPs under their catchment area. The reasons they responded were due to transportation and budget problems. Many Woredas have conducted integrated supportive supervision for HFs with a limited number of PHS indicators last year. However, during the last six months, this is not performed.
Reporting system, active case searches, and other PHS activities were reviewed in supervised Woredas Resource: All visited HFs and districts compile weekly PHS reports manually. Data were aggregated by computer only at the zonal level. Although there is a computer for PHEM in the district and 100% of the visited HCs lack skill in data management and computer application, that is why they aggregate it manually. All HFs and districts have motorcycles. However, there is not using for PHS activities.
Laboratory Diagnosis: The Amhara National Regional State has two regional investigation laboratories at Dessie and Bahir Dar, which implements con rmatory tests for most of the weekly reportable diseases. Currently, the Bahir Dar regional laboratory starts con rmatory tests for measles. The measured HFs have RDT for the diagnosis of malaria. Blood lm was done in all visited HCs. The most serious problem that faced feedback from the national laboratory is delayed and not used for intervention most of the time it takes at least one month.
Attributes of the PHS system Usefulness: The PHS serves a total population of the Awi zone. From this population, a total of 43131 cases and 1 death of malaria were reported. All gaps in reporting timeliness and completeness as well as documentation malaria PHS system were found useful to measure the burden of the disease on some level. 25 (100%) of the respondents were accepted as the PHS system and its data was helpful to detect cases early, to evaluate the extent of diseases.
Flexibility: All visited Woreda HOs, HCs and HPs responded as the PHEM system ready the reporting pads lithe to inform further new events under immediately reportable case-based conditions. Acceptability: The suitability of the PHS scheme was determined based on the involvement of the reporting bodies. All reporting bodies allow and are ne involved in the PHS activities, The report completeness status of reporting agents is 100% for HCs and 92 % for HPs. It consists of the readiness of human on whom the PHS is based to supply precise, steady, inclusive, and well-timed information.
Representativeness: A PHS scheme is represented exactly explains the happening of a wellbeingassociated occasion over the moment and its allocation in the human by geography, person, and time. It is determined by contrasting the distinctiveness of reported dealings to all such de nite dealings. The primary health care coverage of the zone was 90% and 80% for HCs and HPs respectively.
Simplicity: Within the nding of cases, all respondents (100%) concurred that the case de nitions of these need infections of recognizable proof of suspected cases, are simple to get, and can be connected by all levels of wellbeing experts. The respondents at the woreda and wellbeing o ce levels concurred that the report took approximately 10-15 minutes to spread week after week reports through the phone although it depends on the accessibility of networking. Regarding malaria, it takes 15 minutes if it is diagnosed using microscopy and 15 minutes if the diagnosis is with RDT.
Predictive value positive (PVP): The essential center be put on diseases veri cation and proceedings can be of assessing provoked by evidence got from the scheme.
Data quality: Sixty (60%) HPs reported incomplete PHS reports. 10 (100%) of them reported clear records to read and understand. 8(80%) of the HCs sent a complete and recorded report to the woreda HOs. 5(100%) of the woreda HOs sent complete and clear data reports to the zonal health o ce. Reporting formats of weekly and immediately reportable diseases are well understood at the HC levels and HP, but there is a shortage of report formats. Lack of training some health extension workers was observed to be confused with this format.
Stability: In recent times district-level PHEM o cers were assigned to perform surveillance activities in the Awi zone. The availability of PHEM focal persons at the district HO and HFs level is a good opportunity for running a PHS system even with limited resources. However, budget constraints are affecting the stability of the system, and advances modify in this system and the workforce will create the system more unsteady and supply-exhaustive.
Completeness and Timeliness: The overall report completeness and timeliness rate was above the World Health Organization minimum target (80%) in the last ve years (Fig. 1). This might be due to increasing awareness of the community and acceptance of the community, health extension workers, and other health providers on of the PHS.
In general, health care providers (HCPs) and health extension workers (HEWs) have a good understanding of the case de nitions of malaria, other priority diseases, and surveillance. Report completeness and timeliness were good which above the national target both for the woreda and HFs. Laboratory diagnosis of malaria was available at all levels of the district and HFs were satisfactory. They only prepared a plan, there is no ready budget and resources to respond to any PHE. Data analysis is only done at the zonal level, there was a lack of skill and resources for data analysis at the district and facility level. Outbreak investigation and response activities were done in a good manner. Supervision activities were poor at the zonal and district level, there were no program-speci c supervision activities other than integrated supportive supervision which were conducted in each quarter. This might be because of the bad direction of all parties, insu cient helpful supervision, and feedback, little or no lawful enforcement to the PHS activities, lack of incentives, appropriate training, sense of ownership, and logistics.

Discussion
This study intended for the evaluation system of the Awi zone in 2020 by seeing the attributes, core and supportive function implementation of the PHS system and PHS attributes in the district on the whole presentation and using the means of veri cation to be familiar with gaps or areas that could be strengthened Systematic assessment ought to address aspects of PH's signi cance of the health-related events under PHS, purpose, and functionally of the PHS scheme, tools used to functioning the PHS scheme, and the degree of utility. PHS is the methodological, continuing gathering, organization, analysis, and evaluation of information accompanied by the distribution of this information to PH programs to promote PH intervention (6).
In short, PHS is the groundwork for decision-making in PH and empowers decision-makers to provide timely useful evidence. Inlined with the study conducted in Nigeria, 2013-2016, HFs were the primary sources of information. Overall, 65.0% of funding came from partner organizations, and the timeliness of reporting was under the target (approximately 80%), except for 82% in 2012 (7).
Study conduct in Ethiopia in 2019, all required PHS strategy, records, and reporting pads have been properly distributed to HFs. Only the district HO has Emergency Preparedness and Response Plan (EPRP), but the budget needed to respond in the event of an emergency is not funded in terms of time, location, and human, There was no routine information analysis and interpretations. The completeness and timeliness of the weekly information were 100 and 94.6% respectively. Its users found the information collected to be important for detecting outbreaks. The scheme is clear, easy to understand, representative, and could accommodate changes of all stakeholders agreed. In all HFs Written feedbacks were not received. To analyze PHS behaviors in-depth, the supervision checklist obtained in the district was not satisfactory. The positive PV calculated for malaria was 11 percent (8).
Timeliness is the momentum within the ladder in a PHS system. The majority important determines of timeliness is whether the information is submitted in rst-rate time to begin investigations and apply interventions. Reporting timeliness should be calculated against criteria established by each country, in compliance with the deadlines set by the WHO Regional O ce for Africa. In a PHS framework, critical aspects of reporting timelines include the timeliness of instantaneous noti cation, i.e., within 24 hours timeliness of posting weekly and monthly. Start, diagnosis, study, data entry, review, interpretation, and intervention of the PHS scheme have been documented (9).
The completeness of PHS can have varying dimensions and may include reporting sites submitting PHS, case reporting, and PHS data. The completeness of reporting sites, irrespective of the time the report was submitted, refers to the proportion of reporting sites that have submitted a PHS report. For each of the PHS posts, computing completeness of reporting location, which implies pattern analysis and triggers further investigation (10).
Completeness of the case detailing alludes to the coordinate within the prevalence of diseases detailed and the genuine prevalence of diseases. This will be gotten by differentiating the number of noti able conditions detailed to the following level (over a few times), with the prevalence of diseases recorded within the quiet enrollment over a similar time. Completeness of PHS information is the coordinate within the anticipated information prerequisite and what is detailed, every speci c factor collected, enlisted, and validated, if a distinguished variable is not collected routinely (11).
A PHS framework, though still meetings its targets, should be as basic as possible. Acceptance and timeliness are closely linked to simplicity. The amount necessary to enable the program is also in uenced by simplicity (12).
With a little extra time, personnel, or allocated funds, an elastic PHS scheme may adjust to evolving information needs or operating conditions, including new events to follow-up, new case de nition, new data about an event, and new sources of information. Besides, schemes using common reporting pads (e.g., in electronic information exchange) could simply be incorporated with another scheme and thus might be considered versatile (13).
Most PHS schemes rely on more than easy disease counts. Information commonly collected includes the demographic characteristics of affected persons, details about the health-related event, and the presence or absence of potential risk factors. Re ects the completeness and validity of the information recorded in the PHS system, which includes completeness of records (e.g., blanks -missing or unknown), errors when computing information, in uenced by the simplicity of the PHS form, clarity of electronic forms, training, and validation (14).
Acceptability refers to the willingness of individuals who enable the scheme and individuals outside the supporting organization, e.g., individuals who are asked to report information to use schemes. Points of contact between the scheme and its users, including people with health-related incidents and those reporting an emergency, were examined to determine adequacy, knowledge, noti cation conditions, and simplicity (13,14).
The sensitivity of a PHS scheme could assess by surveying its ability to exactly distinguish those with the infection or features of interest. As long as the sensitivity remains relatively stable over time, a PHS framework that does not have high sensitivity can still help watch patterns. Sensitivity can also refer to the capacity to detect outbreaks, and the ability to track changes in the number of diseases over time in requires, to verify the information gathered, and to gather information outside of the scheme to determine the frequency of the condition within the community (13).
Sensitivity and PV determination offers multiple views of points on how well the scheme operates. The proportion of recorded diseases that have health-related occurrence under PHS depends on the population vulnerability, speci city, and prevalence of the diseases. The impact of low PV reported using repeated false-positive ndings, insu cient follow-up of non-diseases, improper detection of outbreaks (artifacts), wastage of resources, and excessive public concern (1, 14).
A PHS framework that's spoken to precisely depicts the event of a health-related occasion over time and its distribution in the population by place and person. The information from a PHS scheme should accurately represent the features of the health-related cases under PHS to generalize results from PHS information to the population at large (5,14).
Unwavering quality (i.e., the capacity to gather, oversee, and give information legitimately without disappointment), accessibility (i.e., the capacity to be operational when it is required) of the PHS framework. A need for committed assets might in uence the solidness of a PHS. For illustration, workforce de ciencies can determine reliability and accessibility. However, the stable output is critical to the viability of the PHS scheme in any case of the health-related incident being tracked. An unreliable and unavailable monitoring scheme can delay or discourage the required PH action (12,14).

Conclusions
The structure of the PHS information ow from Keble to Zone was well organized. However, coordination and supervision of the PHS activities were not frequent. From those supervised HFs, most of them are not receiving feedback. There was no budget line, written feedback, epidemic and preparedness, and response plan regular based on supportive supervision at all visited HFs. Therefore, this nding suggests the importance of PHS training for focal persons and strict follow-up of the implementation of the acceptable PHS system might improve PHEM capacity. Besides, minimizing the irrational case de nition of diseases could also help to improve PHEM capacity.

Declarations
Consent to Participate: The support letter was taken from Debre Tabor University, College of Health Science, and then formal consent was taken from the selected zones. The purpose of the study was informed to the concerned body.