Measles surveillance system Evaluation in Benishangul Gumuz, Mandura woreda, Ethiopia in 2018

Objective The main objective of this study is to Evaluate measles surveillance system in Benishangul Gumuz, Mandura woreda, Ethiopia in 2018. Result The weekly reporting rates of the health facilities over the past 52 weeks of 2018 were >80% timeliness and completeness as show below by line graph for health posts. All the weekly surveillance reports were sent to the next level via report format and telephone. Mandura Woreda administration has made major progress in tackling the spread of measles. The overall structural set up of the surveillance system in creation of responsible unit /focal person of Public Health Emergency Management at each district and health facility level is good.


Introduction
Measles is a viral disease transmitted through the respiratory route and illness begins with fever, cough, and conjunctivitis followed by a characteristic rash.Most organ systems, with pneumonia accounting for most measles-associated morbidity and mortality due to its complications.The management of patients with measles includes provision of vitamin A (1). Measles can be prevented through vaccination.The only natural host of measles virus is human.
Measles can be occurred in all age groups.However, children younger than 5 years of age and adults older than 20 years of age are more likely to suffer from measles complications (2).
Measles is still commonly transmitted (endemic or large outbreaks) worldwide, including some countries in Europe, Asia, the Paci c, and Africa (2) In Africa before the introduction of measles vaccination, measles was mostly a disease affecting young children, and more than 1 million cases were reported annually (3).But its incidence rate decreased by 85%, from 841 cases in 2000 to 100 cases in 2015 per million populations in African region after the introduction of measles vaccine by WHO (4).
In Ethiopia, Measles has been one of the major causes of death and sickness of children.About 348 cases had been con rmed and 40 outbreaks reported in March 2017(5).
The surveillance system should be simple, exible, acceptable and situation speci c in response to an emergency in a given functioning system.Therefore, we want to evaluate the existing measles Surveillance system in Mandura woreda to know whether the surveillance system was well operated or not.Therefore, this evaluation addresses the following objectives: 1.To describe the best use of health resources and assure that systems operate effectively in Mandura woreda.
2. To know whether measles surveillance system is useful for community health and is achieving its objectives in the Woreda.
3. To evaluate some attributes of measles surveillance system in Mandura woreda.Different data sources such as; Mandura Woreda Measles surveillance database, annual reports, records and documents were used in addition to data gathered using in depth interview with standardized checklists and questionnaires.

Collection procedure
Standardized questionnaire was adapted from the World health Organization (WHO) Guideline based on the objectives of the evaluation.Interview was made to the surveillance o cers and focal persons in the selected o ce for this evaluation purpose.Therefore, data were obtained from two ways of routine reporting system.These are PHEM and HMIS reports that are weekly and monthly reports respectively.PHEM data has been collected at health facilities and reported to woreda health o ces weekly every Monday and on wards to the next level every next day of receiving the data.The HMIS reporting form integrated measles disease.The HMIS data are also collected at health facilities.However, these data were reported to woreda health o ce by hard copy monthly every 28 days.

Results
Any person with fever and maculopapular (non-vesicular) generalized rash and cough, coryza or conjunctivitis (red eyes) or any person in whom a clinician suspects measles in Mandura woreda were addressed under the existing Provider initiated (passive) population-based measles surveillance system.
Measles surveillance data is received from governmental health facilities, NGO health facilities missionary churches and private clinics.There was no shortage of reporting form in all health facilities and health o ce as we interview.The weekly reporting rates of the health facilities over the past 52 weeks of 2018 were >80% timeliness and completeness as show below by line graph for health posts, but it was 100% health centers 100% All the weekly surveillance reports were sent to the next level via report format and telephone.
However, reporting through telephone is limited in health posts where there were no telephone services.In case of such setups, the HEWs use their personal mobile phones for emergency, for which they were complaining for refund, the other limitations telephone is affecting report objectivity Among the 10 visited health facility, all of them have standard case de nition of measles and the understanding of the cases de nitions by the health extensions, 75% were good understanding, as they explaining us while we interviewing them at the time of the eld visit.Concerning weekly PHEM reports format was there.
In this evaluation some useful indicators (attributes) were used to evaluate measles surveillance system performance in Mandura woreda.These indicators are presented as follow 4.1.Simplicity: In Madura woreda measles Case de nition was understood at local & Facility level but community measles case de nitions were not well known due to different factors.
There was weekly report format at all health facility level.However, reporting is still paper-based at the health facility level and data reporting to the next level was by telephone calls and messages due to lack of computer & internet services that induces report subjectivity and report delay.
4.2.Flexibility: In Mandura woreda, measles surveillance system was performed with adaptable manner to any without no di culty in district.
4.3.Completeness/Data Quality: As we reviewed the annual report records, most required information was clearly recorded manually using standardized formats and log books and there were complete and valid data at the observed sites.Moreover, we checked data completeness/quality by checking the recorded and reported data (simple case counts) comparing with woreda FHEM reports.and asking the clarity of the case de nition as indirect measure of data quality.
4.4.Acceptability: As we reviewed the surveillance report records, the concerned organizations have awareness on it and have a willingness to participate in the surveillance system.This was assured by completeness of report forms and timeliness of data reporting processes.But the Woreda didn't well engage for measles surveillance due to lack of multi-sectorial, health worker turns over, community cultural factor and poor geographical coverage as we interview & identi ed by programmers.
4.5.Sensitivity: In Mandura, proportion of reported suspected measles cases in the woreda is 2(100%) as expected but Proportion of serum/ dried blood specimens arriving at lab within 3 days of being taken.
This may be due to geographical settings, poor medical care infrastructure, and population working behavior and far to get health facilities.Even though, 1(50%) blood specimen has been collected, the serological result feedback was not sent from the laboratory to the woreda.
4.6.Predictive Value Positive (PVP): digit's get cases result received from the national measles laboratory department for father conformation.As a result, we couldn't measure the effect of PPV.
4.7.Representativeness: The health service coverage of Madura woreda is 96%.The routine surveillance covers all governmental and some private health facility, and all population under surveillance in the catchment area.But the data we obtained cannot accurately re ect the characteristics of measles under surveillance in related to time, place, and person due to poor quality health care service provision i.e. one health center 57 000 population, only geographical health coverages are covered by HP and HEWs.Therefore, the representativeness of the system in the woreda is likely to be low.
4.8.Timeliness: In Mandura Woreda reporting of measles cases to a public health agency and the time required for the identi cation of cases, outbreaks, or the effect of control and prevention measures including immediate control efforts, prevention of continued exposure and program planning was encouraging.
4.9.Stability: In Mandura Woreda, the surveillance system, the desired and actual amount of time required for the system to collect or receive data was stable.

Discussion
The Ethiopian Federal Ministry of Health and partners working in health has a plan to achieve at least 90% national coverage and 80% in every district with all vaccines by 2020.The plan encompasses all components of immunization services: service delivery, vaccine supply, quality and logistics, disease surveillance and accelerated disease control, advocacy, social mobilization and communication and programme management.Therefore, we evaluate that case de nitions understanding was found to be good among Healthcare providers including the health extension workers.
The structure of data reporting ow from the lower to the upper level is well organized with unidirectional ow of data, with simple and de ned role and responsibility of each reporting entities.However, the reporting ow has a number of obstacles such as inadequate infrastructure like transport, telephone, and computers for data management and analysis.These affected the overall generation of reports by the expected health facilities and make the surveillance system to relay on very limited reports validity rather than report consumption.These can make the surveillance system less useful to meet its objectives.

Conclusion And Recommendation
Mandura Woreda administration has made progress in tackling the spread of measles.
The overall structural set up of the surveillance system in creation of responsible unit /focal person of PHEM at each district and health facility level is good.
Despite current achievements, Mandura Woreda is not on track to achieve the measles elimination goal of less than 1 case per million populations by 2020 with the current pace of elimination efforts.
Ethiopian MOH should make it a priority for resource allocation for each region to help Measles control programs and encourage Researches & developments on Measles Benishangul Gumuz RHB and Mandura Woreda health o ce should scale up the quality and implementation of all the measles elimination strategies, including the introduction of measles vaccine second dose (MCV2) in routine immunization services and should continue promoting local resource mobilization with sustained advocacy and tracking funds mobilization 7. Limitation This evaluation system is limited only in Mandura woreda that didn't evaluate measles surveillance system in throughout the country.

Figures Figure 1
Figures Mandura woreda is one of the 7th woreda's of Metekel zone which is divided in to 20 kebele administrations (17 rural and 3 urban kebeles); The Woreda has 23 health posts, one health center, Non- generalized, maculopapular rash lasting ≥3 days; temperature ≥101°F or 38.3°C; and cough, coryza, or conjunctivitis 1.3.3.Epidemiological linked/Probable measles case: In the absence of a more likely diagnosis, an illness that meets the clinical description with: no epidemiologic linkage to a laboratory-con rmed measles case; and noncontributory or no measles laboratory testing.1.3.4.Con rmed measles case: An acute febrile rash illness with: Isolation of measles virus from a clinical specimen; or Detection of measles-virus speci c nucleic acid from a clinical specimen using polymerase chain reaction; or A signi cant rise in measles immunoglobulin G antibody using any evaluated and validated method; or A positive serologic test for measles immunoglobulin M antibody 1.4.Indicators used Some useful indicators (attributes) were used to evaluate measles surveillance system performance in Mandura woreda such as: -

Table Table 1
: showing numbers of Measles case Surveillance reports in Mandura woreda in 2018