Evaluation of Hepatitis A SurveillanceIn Mafraq Health directorate

Jordan, 2010

Presented by Dr Ghazi Sharkas

Jordan FETP

with

Dr Sultan Abdalla

Dr Sami Sheikh Ali

The number of cases had dramatically decreased 1612 cases (35/100,000) in 1997 492 cases (8.2/100,000) in 2009.

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Series1 1612 1083 969 947 754 506 552 342 266 482 387 464 492

0

200

400

600

800

1000

1200

1400

1600

1800

Number of cases

Years

Trend of Hepatitis A cases, Jordan 1997-2009 by year

Series1 Linear Trend

Descriptive epidemiological analysis for hepatitis A reporting in Jordan from 2004-2008, revealed that cases

were clustered at the northern region9.4

7.9

9.4

12.2

13.2

5.1

3.8

8.9

4.7 5.0

6.6

3.3

4.0

4.5

6.3

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

2004 2005 2006 2007 2008

Reporting rate

Year

Hepatitis A reporting rate by regions Jordan (2004-2008) per 100,000

North region Middle region South region

Incidence rate/100000 of Hepatitis A Mafraq, 2004-2009

14.0

3.1

20.1

10.4

26.7

43.7

05

101520253035404550

2004 2005 2006 2007 2008 2009

Incidence Rate

)Mafraq) was the 2nd reporting site with high incidence rate in 2009 43.7/100000(

Incidence Rate Hepatitis A /100000, by reporting sites, Jordan 2009

Mafraq• Al Mafraq governorate is located in the

north-east of Jordan.• Divided into four administrative areas

• Mafraq Al-Qasaba, • North East Badia, • North West Badia • Rweished .

• Area : 26541 KM2 • 29.9% of the total area of Jordan.

• population : 281100 • population density: 10.6 /km2.

• Mafraq Health Directorate is one of the twelve health directorates.

• Includes Alqasaba and North West Badia. • (77%) of population lives in these two

administrative areas. • 26 reporting Health centers in addition to two

hospitals.

Study Rationale • It was deemed important to determine

whether the increase in reporting of hepatitis A in Mafraq is related to a public health issue or is a result of a relatively good surveillance system.

• In this study the authors attempted to obtain better information about hepatitis A surveillance in Mafraq.

Objectives

• General Objective To evaluate Hepatitis A surveillance in Mafraq

health directorate

Specific Objectives

• To assess the sensitivity of hepatitis A reporting from Mafraq health directorate at all three levels (health center, health directorate and communicable diseases directorate).

• To assess health workers knowledge about surveillance system, particularly for hepatitis A surveillance.

• To assess the commitment of health centers on the ongoing weekly reporting system and to assess accuracy of the number of sites which actually reported.

Methodology

• Ten health centers and one hospital were randomly selected

• Thirteen weeks from 2009 were selected randomly

• The specific notification forms from each health center and the comprehensive reporting forms from all health centers in the health directorate were reviewed for the number of reported cases of hepatitis A.

• Review for the number of reported cases of hepatitis A.

• Review the specific notification forms at selected health centers .

• Review the comprehensive reporting sheet in the health directorate.

• Verify the completeness of reporting in the selected weeks.

• Review the number of sites which reported in the health directorate files to those that actually reported to the communicable diseases directorate.

• An interview questionnaire was designed and completed through direct interview by FETP residents to assess: – knowledge, – attitude –practices

about surveillance system in general and hepatitis A surveillance in particular.

Results• The specific notification forms were found for only 15%

of reported hepatitis A cases form Health Directorate

• There was commitment in reporting Hepatitis A cases at all 26 reporting sites.

• The sensitivity of reporting from health centers to health directorate was 96%; nevertheless 38% of the reporting sites reported zero cases.

• The sensitivity of reporting from health directorate to communicable diseases directorate was 100%.

Discrepancies were observed in the numbers of reported hepatitis A cases:

• seven percent in excess was found in the health center registry in comparison with the original health center specific notification forms.

• Six percent less was observed between the numbers of reported hepatitis A cases in health directorate registry in comparison with health center registry.

)88%( of interviewed health workers are not trained in surveillance

Work Trained % of trained

Not trained

% of not trained Total

Physician 1 8.3 11 44 12

Medical staff 2 9.0 9 36 11

Dentist 0 0 1 4 1

Public health technician 0 0 1 4 1

Total 3 12.0 22 88 25

Training percentage in different health workers Mafraq 2009

Notifiable diseases list available in all health centers, 92% of health centers reported that they used it

Percentage of usage of notifiable diseases list Mafraq 2009

Surveillance Guidelines are avialable in 96% of health centers; only 76% had used it

Percentage of usage of surveillance guidelines Mafraq 2009

• 72% of the reporting process in the health centers was done by nurses.

• 32% of health workers were aware about the zero reporting; nurses were about two times more aware than physicians.

• 70% of health workers know about the contents of Notifiable diseases list and the proper reporting procedure.

• Only 42% of physicians know surveillance hepatitis A case definition; while other health workers do not know about it.

• 92% of health workers reported that the diagnosis of hepatitis A is clinically based.

• 16% of health workers reported that there was an increase in hepatitis A cases in 2009, 75% of them were physicians.

• The over all health workers turnover (newly working for less than one year) was 42%; – 56% among physicians a– 25% among nurses.

Discussion

• Absence of the majority of specific notification forms in the health directorate could be due to storage difficulties.

• There is good commitment in reporting infectious diseases at Mafraq health centers, but the reporting is with inadequate documentation, and is mostly by phone calls.

• No Filled investigation forms for hepatitis A were found in health directorate despite of the instructions for hepatitis A investigation.

• The discrepancies of reported cases that were observed at the health center level and health directorate level could be related to non adherence to the reporting protocol as the reporting is mostly done by telephone.

• There is lack in disease surveillance training for health workers who are involved in the surveillance process.

• Despite the fact that training in surveillance is focusing on public health doctors, the health workers who are directly involved in surveillance did not receive training.

• Although Mafraq directorate reported the highest number of hepatitis A cases in 2009 , health workers did not recognize that, this could reflect that Hepatitis A is endemic in Mafraq and the cases are within expected numbers.

Application of CDC Surveillance Evaluation Criteria on Hepatitis A surveillance in Mafraq directorate

Simplicity

• The case definition is simple. • The diagnosis does not depend on lab test• Surveillance does not require complex training

, equipments, or full time working personnel.• Reporting procedure is telephone based and

"regular mail" based which is affordable in all reporting centers.

Flexibility

• The surveillance system for hepatitis A is not only laboratory based, it includes also suspect and probable cases, the reporting is according to available facilities.

• Case definition could be easily modified to cope with any addition.

Acceptability

• Almost 38% of the reporting sites did not report any case in 2009.

• 23% of the reporting sites reported three cases or less.

This could reflect that the surveillance for hepatitis A is not well accepted.

 

Sensitivity

The percentage of reported cases to the truly existing cases (sensitivity) was 96% in average.

Representativeness

• Hepatitis A surveillance is considered representative as monthly reports from all over the country give detailed data for frequency of cases occurrence by time, and the distribution by age groups, sex and geographical areas.

Data Quality• The documentation of specific notification forms were

found for only 15% of reported hepatitis A cases from Health Directorate in 2009.

• None of hepatitis A cases were investigated.• Discrepancies were observed in the numbers of

reported hepatitis A cases in the health center registry in comparison with the original health center specific notification forms & between the health directorate registry in comparison with health center registry as mentioned previously.

Timeliness

• Almost all health centers reports to the health directorate on time by telephone.

• About 90% of the reporting from health directorate to the Communicable Diseases Directorate was done on time.

Conclusion and recommendations

• The increased number of reported hepatitis A cases in Mafraq is not related to a public health issue; it could be a result of relatively reasonable surveillance system.

• There is a big problem in the space for storing the specific notification forms, to overcome storing difficulty, health workers should fill-in the notification forms contents in a line list, and then computerize the data, while the original specific notification forms will be discarded.

• The reporting protocol is not well implemented, it is mostly phone based, this will weaken the sensitivity, accuracy and completeness of surveillance system, therefore to improve surveillance, paper based reporting should be enhanced.

• All cases of hepatitis A must be investigated.• The health workers actually involved in the

surveillance process should receive ongoing training; the training process should include nurses and physicians in health centers in addition to public health officers.

• Poor Knowledge was found among health workers in the following aspects:– Case definition of hepatitis A, which could be an

indicator for other infectious diseases case definitions. – Contents of notifiable diseases list with its two groups,

and the proper way of reporting. – Concept of zero reporting and its importance.– Awareness about surveillance guidelines; as only two

thirds of health workers reported that they use the guidelines.

• Therefore all previously mentioned issues should be stressed on future training workshops.

• High turnover was observed in Mafraq directorate mainly among physicians, while nurses turnover was about half of that found among physicians.

• The majority of reporting process in the health centers was done by nurses, therefore future training should be focused on nurses as well as physicians.