ETHIOPIAN PUBLIC HEALTH ASSOCIATION

LEADERSHIP IN STRATEGIC INFORMATION

TRAINING PROGRAM

MODULE 3

(MONITORING, EVALUATION, SURVEILLANCE AND EPIDEMIC MANAGEMENT)

PARTICIPANT MANUAL

June, 2014
Addis Ababa, Ethiopia
Approval of the Training Material

The Federal Ministry of health of Ethiopia has been working towards standardization and
institutionalization of in-service (IST) trainings at national level. As part of this initiative the ministry
developed a national in-service training directive and implementation guide for the health sector. The
directive requires all in-service training materials fulfill the standards set in the implementation Guide.
Accordingly, the ministry reviews and approves existing training materials based on the IST
standardization checklist annexed on the IST implementation guide.
All in-service training materials shall to be reviewed and approved by the ministry accordingly; as part
of the national IST standardization process, this Leadership in Strategic Information IST material has
been reviewed based on the standardization checklist and approved by the ministry in January 2014.

Dr Wendemagegn Enbiale Yeshaneh

Human Resources Development & Administration Directorate
Federal Ministry of Health, Ethiopia

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 Acknowledgment

The Ethiopian Public Health Association would like to acknowledge and pass its deep appreciation to

the following professional contributors for developing LSI training Participant module.

Contributors

Addis Ababa University, School of Public Health Staff

Dr. Fikre E/Silassie, Dr. Mesfin Adisse and Dr. Ababi Zergaw, Prof. Misganaw Fantahun,

Dr. Negussie Deyessa and Dr. Alemayehu Worku

Gondar University, Institute of Public Health Staff

Dr. Gashaw Andarge, Dr. Berihun Megabiw, Prof. Yigzaw Kebede, Mr. Tadess Awoke,

Dr. Abebaw Gebeyehu and Mr. Solomon Meseret

Jimma University, Institute of Health Science Research Staff

Dr. Fesehaye Alemseged, Mr. Fasil Tesema, Mr. Yibeltal Kiflie, Mr. Negalign Berhanu and

Dr. Mirkuzie Woldie

EPHA Staff

Mr. Bekele Belayihun

Independent Consultant

Dr. Hailu Yeneneh

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 Module 3: Monitoring, Evaluation, Surveillance and Epidemic Management

Overview

Program monitoring is the systematic documentation of aspects of program performance that are
indicative of whether the program is functioning as intended or according to some appropriate
standard. Program evaluation is the application of social research methods to systematically investigate
the effectiveness of social intervention programs in ways that are adapted to their political and
organizational environments and are designed to inform social action in ways that improve social
conditions. The last four decades represent a period of rapid growth in the depth of the monitoring and
evaluation body of knowledge hallmarking the professionalization of the field. For monitoring and
evaluation purpose, public health managers at different levels need reliable information about the
magnitude of different diseases and their risk factors. In this regard knowledge and skill on running the
different types of surveillance would help public health managers to effectively prevent and control
diseases. Monitoring and evaluation are important at local and international levels. At higher levels,
information generated through monitoring, evaluation, and surveillance can inform the management of
public health programmers and the direction of public health policy. Surveillance serves as an early
warning system which provides timely information needed for action. If there is no good surveillance
system in a specific locality or country, disease epidemics can affect a lot of people before actions are
taken.
Since communicable diseases are prevalent in developing countries including Ethiopia, this whole
module gives emphasis on monitoring and evaluation and, communicable diseases mainly HIV/AIDS.
Goal of the Module
This module aims to build capacity of health professionals in order to control communicable diseases
in Ethiopia

Objectives of the Module

At the end of this module, the participant will:
 Plan and implement monitoring and evaluation of health programs
 Apple to conduct health surveillance on important health problems
 Describe how outbreaks should be investigate and mange

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Contents of the Module

The Module is organized in two parts. The first part deals with monitoring and evaluation and the second
part deals with surveillance and epidemic management. The two parts are given for a given period of
two weeks, each lasting one week.

Part 1: Monitoring and Evaluation

1. Basic Concepts and Definitions

2. Components of Monitoring and Evaluation Plan

3. Program Frameworks

4. Indicators for Monitoring and Evaluation

5. Monitoring and Evaluation in the Ethiopian Health Sector

Part 2: Surveillance and Epidemic Management

1. Introduction to Public Health Surveillance

2. Burden of HIV/AIDS

3. HIV/AIDS surveillance

4. Ethical Considerations in HIV/AIDS Surveillance

5. Outbreak investigation and management

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 Acronym/Abbreviation

AIS AIDS Indicator Surveys

ART Antiretroviral Therapy
BPR Business Process Reengineering
BSS Behavioral Surveillance Surveys

CDC Center for Disease Control

DBS data base system
DHS Demographic and Health Surveys
FHI Family Health International
FMoH Federal Ministry of Health
GAR Global Alert and Response
GOARN Global Outbreak Alert and Response Network
HDSS Health and Demographic Surveillance Systems
HEW Health Extension Worker
HIV Human Immunodeficiency Virus
HMIS Health Management Information System
HSDP Health sector Development Program
IDSR Integrated Disease Surveillance and Response
IDUs Injection Drug Users
ISS Integrated Supportive Supervision
M&E monitoring and evaluation
MDG millennium development goal
MNCH Maternal Neonatal and Child Health
MSM Men Who Have Sex with Men
NGOs non-governmental organization
OR odd ratio
OVC Orphans and Vulnerable Children
PLHIV people living with Human Immunodeficiency Virus
PMTCT prevent mother to child transmission
RDS Respondent-Driven Sampling
RF results framework
RHBs regional health bureau
RR relative risk
SMART specific, measurable, achievable, reliable and timelines
SPA Service Provision Assessments
STI sexual transmitted illness
SWs Sex Workers
TB Tuberculosis
TLS time-location sampling
UAT Unlinked Anonymous Testing
VCT voluntary concling test

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 Part 1:

Monitoring and Evaluation

1. Basic Concepts and Definitions

2. Components of Monitoring and Evaluation Plan

3. Program Frameworks

4. Indicators for Monitoring and Evaluation

5. Monitoring and Evaluation in the Ethiopian Health Sector

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Session 1: Basic Concepts and Definitions

Session Overview

The last four decades represent a period of rapid growth in the depth of the monitoring and evaluation
body of knowledge hallmarking the professionalization of the field. Theorists in the field have
forwarded definitions and described contents of different concepts commonly used by monitoring and
evaluation practitioners. This section will provide definitions and brief descriptions for most
commonly discussed concepts in the field of monitoring and evaluation.

Learning Objectives

At the end of this section, trainees are expected to be able to:

 Define monitoring and evaluation

 Discuss the relationships and differences between monitoring and evaluation

 Describe the different types of monitoring and evaluation activities

Brain storming

1. Differentiating monitoring and evaluation

2. Classifying monitoring and evaluation activities

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Monitoring and Evaluation: Definitions

Discussion Points

 What is monitoring?
 What is evaluation?
 How are monitoring and evaluation related and different?

Group Exercise

Be in groups of five

Construct a hypothetical public health intervention implemented by a Woreda Health Office.

Identify two monitoring activities and two evaluation activities.

Discuss why each of the activities is classified as monitoring or evaluation.

Take a note on disagreements for further discussion.

Present your work to the group during general discussion.

Different authors and organizations have defined program monitoring and program evaluation in
various ways. Some definitions from widely referred scholars and organizations are presented below.

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 Program monitoring is the systematic documentation of aspects of program performance
that are indicative of whether the program is functioning as intended or according to some
appropriate standard. It may be related to program processes, program outcomes or both.

Program evaluation is the application of social research methods to systematically

investigate the effectiveness of social intervention programs in ways that are adapted to
their political and organizational environments and are designed to inform social action in
ways that improve social conditions.

Rossi, et al., 2004

There are also many more definitions related to the above mentioned ones. The key concepts included
in these definitions include:

Monitoring continuously tracks performance against what was planned by collecting and
analyzing data on the indicators established for monitoring and evaluation purposes. It
provides continuous information on whether progress is being made toward achieving
results (outputs, outcomes, and goals) through record keeping and regular reporting
systems. Monitoring looks at both program processes and changes in conditions of target
groups and institutions brought about by program activities.

Program evaluation is a time-bound exercise that attempts to assess systematically and

objectively the relevance, performance and success of ongoing and completed programs
and projects. Evaluation is undertaken selectively to answer specific questions to guide
decision-makers and/or program managers, and to provide information on whether
underlying theories and assumptions used in program development were valid, what worked
and what did not work and why.

UNFPA

Monitoring

 Monitoring is a systematic process

 Monitoring is a continuous process
 Monitoring involves collection, analysis, interpretation and use of data
 Monitoring involves the comparison of performance with a set of expectations

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  Monitoring can be applied to different components of an intervention including inputs,
activities, outputs, outcomes and impacts
 The purpose of monitoring is to inform decision making

Evaluation

 Evaluation is a systematic process

 Evaluation is a need based episodic endeavor
 Evaluation involves answering evaluation questions by providing explanations to observed
levels of program functionality
 Evaluation can be conducted on processes of an intervention and/or outcomes and impacts of
an intervention
 The purpose of evaluation is to inform decision making

Working Definitions

Monitoring is a systematic and continual collection, analysis, interpretation and use of

data on key aspects of an intervention and/or its expected results to inform decision
making. Program evaluation is an episodic systematic process of data collection and
analysis, about activities and/or effects of a program, looking to provide explanations for
observed levels of program implementation or changes in social conditions under
intervention with the purpose of informing decisions.

Relationships between monitoring and evaluation

Despite the very close relationship that exists between the concepts of monitoring and evaluation, the
two activities represent distinct sets of procedures serving different categories of information needs for
decision makers. The relationship between monitoring and evaluation lays in their interdependence,
overall purpose and general methods.

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Interdependence: Program monitoring is a primarily descriptive activity that provides information
what a program is doing and how the social problem targeted by the program is changing over time.
However it is limited in terms of providing explanations for observed degree of program
implementation and why social conditions are changing or not among the target beneficiaries. What
gets described in monitoring gets adequate explanations through program evaluations? In addition,
data collected for monitoring purposes also served in program evaluation.

Purpose: The purpose of both monitoring and evaluation is to furnish information for decision making
at different levels of program designing and implementation.

Methods: Collection, analysis, interpretation and use of program related data is a common feature of
both monitoring and evaluation.

Table 1. 1. Summary differences between monitoring and evaluation

Attributes Monitoring Evaluation

Frequency Continuous Episodic

Answers the ―What is going on?‖ ―Why do we have the results indicated
question by the monitoring data?‖
Method Follows trends, compares actual Compares achievements with
performance with targets counterfactual

Performed by Internal Internal and External

Uses Alerts when to take action Provides detailed information on

what types of actions to take
Focus in general Tracking performance Judgment, learning, merit

Why Monitoring and Evaluation?

Monitoring and evaluation in general serves information for decision making. This general purpose
could be through three more specific uses:

1. Program improvement
2. Accountability

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3. Generating Knowledge

Figure 1. Feature of monitoring and Evaluation

Program Improvement

Program improvement constitutes the major purpose of monitoring and evaluation activities. In most
instances findings from monitoring and evaluation are used to fine-tune program components during
planning and implementation of interventions. Managers use M&E as the basis for their routine and
basic decisions.

Accountability

Social programs including public health use public resources. Program implementers are therefore
required to demonstrate accountability to appropriate representatives of the source of resources.

- What activities are accomplished by using allocated resources?

- What results are achieved because of the program/intervention?

Generating Knowledge

Sometimes, monitoring and evaluation activities particularly program evaluations could be conducted
just with a purpose of generating knowledge for consumption by the scientific community. Findings
from such evaluation studies are usually shared through publications rather than commonly used
stakeholder forums.

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Types of Monitoring and Evaluation Activities

In the previous sub-section, it is mentioned that both monitoring and evaluation can be applied on the
different components of a program including inputs, activities, outputs, outcomes and impacts. The
application of the concepts of monitoring and evaluation into these different components produces the
different types of monitoring and evaluation activities to be discussed in this sub-section.

Table 1. 2. Summary of monitoring and evaluation program components

Categories of program Program

Monitoring Evaluation
components components
Routine program
Inputs
monitoring (also Process
Program Implementation
Activities called input/output Evaluation
Outputs monitoring)
Outcome
Outcome Outcome monitoring
evaluation
Expected Program Effects
Impact
Impact Impact monitoring
evaluation

i. Routine Program Monitoring

Routine program monitoring is the type of monitoring and evaluation involving routine tracking of
information about resources utilized and program activities implemented. It primarily uses data
routinely collected by program implementers, service providers and/or managers while executing
program processes. Routine program monitoring is also called input/output monitoring as it primarily
measures the volume and quality of resources being used and outputs produced.

ii. Process Evaluation

Routine monitoring of inputs and outputs provides descriptive information about the implementation
of program processes. Sometimes, program implementers require more explanatory information about
the level of program implementation and factors that hinder or facilitate the implementation of

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program activities. The type of evaluation conducted with a focus on answering such questions is
known as process evaluation. Implementation evaluation and implementation analysis are also used to
refer to this type of monitoring and evaluation.

Process evaluations answer questions like:

- What was the degree of implementation of a program?

- What user/program/context related factors explain observed levels of program implementation?
- Are there barriers hindering access to program?

By answering these questions, process evaluation helps program implementers to document best
practices and investigate causes of under achievement.

iii. Outcome Monitoring

Outcomes are intermediate level changes expected among beneficiaries targeted by a program.
Follow-up of these characteristics among target beneficiaries in order to understand if changes are
occurring and the direction of change is referred as outcome monitoring. In health programs, outcome
monitoring involves repeated measurement of knowledge, attitude and practice of people targeted by
different health programs. In outcome monitoring, there is no attempt to attribute observed changes in
outcomes to a specific program.

iv. Outcome Evaluation

Like outcome monitoring, outcome evaluation also measures intermediate level changes among
beneficiaries of programs. Outcome evaluation however, gives emphasis to building cause effect
relationship between observed changes in outcomes with programs being evaluated. Rigorous
evaluation designs are required to understand if there is any change in outcome and assess the
contribution of the program for observed changes. This assessment of program net effect lays the
ground to make judgments about adequacy of program effect.

v. Impact Monitoring
Impact monitoring is a type of outcome monitoring that focuses on changes agreed by major
stakeholders as ultimate results of the program. Like outcome monitoring, impact monitoring simply

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follows how the social problem targeted by the program is changing over time without any intention of
attributing observed changes to a particular program.

vi. Impact Evaluation

Impact evaluation is a type of evaluation focusing on the assessment of the worth of a program in
terms of its contributions for changes in a social problem targeted by the program. Methodologically,
impact evaluation is similar to that of outcome evaluation; however, the number of contributors to an
impact level change is expected to be much more than those contributing to outcome level changes
making impact evaluation more difficult and expensive.

Exercise

Refer back to your previous exercise

Classify the different M&E activities as routine program monitoring, process evaluation, outcome
monitoring, outcome evaluation, and impact monitoring or impact evaluation.

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Figure 1.2. Illustration of Outcome Monitoring and Outcome Evaluation

Session 2: Monitoring and Evaluation Work Plan

Session overview

As a planning document, monitoring and evaluation plan helps you, as an implementer, to think
systematically through each of the program components. A well-designed plan helps the implementer
to keep track of the program‘s progress and make adjustments if necessary. It is also a valuable tool
for demonstrating the effectiveness and impact of a program, generating credible and useful
information for both the implementer and other stakeholders. When a program has proven results, the
monitoring and evaluation plan is a useful method for showing the program‘s success. If the program
is less than successful, the monitoring and evaluation plan can help to identify specific weaknesses. In
general the monitoring and evaluation plan is useful for informing all stakeholders the actual progress
and impact of a program against the proposed activities and objectives and contributes to learning,
improved performance, and accountability. This section will help you understand what a monitoring
and evaluation plan is, how it can best be used and also provide a guide for how to write one.

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Learning Objectives

At the end of this section, trainees are expected to be able to:

 Define monitoring and evaluation plan
 Explain purpose of a monitoring and evaluation plan
 Explain goals of a monitoring and evaluation plan
 Identify who should be involved in monitoring and evaluation plan
 Describe when monitoring and evaluation plan be used
 Discuss key elements of a monitoring and evaluation plan

Discussion points
 What is a monitoring and evaluation plan?

 What are monitoring and evaluation plans used for? Purpose / function

 What are the goals of a monitoring and evaluation plan?

1. What is a Monitoring and Evaluation plan?

A monitoring and evaluation plan is a systematic and objective approach or process for monitoring
project performance toward its objectives over time. Development of a monitoring and evaluation plan
must be integral to the planning of a program design as the monitoring and evaluation plan document
helps the project team to manage all monitoring and evaluation activities throughout a particular
project cycle. It keeps track of what you should monitor, when you should monitor, who should
monitor, and why you should monitor. A monitoring and evaluation plan should be shared and utilized
by all stakeholders and sent to donors. The monitoring and evaluation plan should have flexibility.
Monitoring and evaluation plan has to be well thought out and planned but also flexible to account for
changes that can improve or identify better monitoring and evaluation practices. This is especially
important in the ever-changing and fast-moving environment
Note that almost all donors require that all l program proposals for funding must include a
comprehensive monitoring and evaluation plan. Because monitoring and evaluation plan is highly
considered as one of the key criteria in determining the competitiveness of a program proposal.

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Purpose / function of a Monitoring and Evaluation plan: What are Monitoring and Evaluation
Plans used for?
The monitoring and evaluation plan allows all staff involved with the project to have a reference sheet
of all the monitoring and evaluation activities during the progress of the project and highlights data. It
helps to identify ―who is supposed to do what to collect which data and when it is collected‖ and how
that data has changed over the course of a certain period.
Well developed monitoring and evaluation work plan helps to:
 Show how goals/objectives are related to results
 Describe how objectives will be achieved/measured
 Identify data needs
 Define how the data will be collected and analyzed
 Describe how results will be used
 Anticipate resources needed for monitoring and evaluation
 Show stakeholders how program will be accountable
The content and organization of monitoring and evaluation work plan are flexible. They should be
appropriate for the Level (e.g., country, region, district, community, or organization) and the program
areas

Goals of a monitoring and evaluation plan

A monitoring and evaluation plan focuses on the performance of a project or program and examines its
implementation plan, inputs, outputs and outcomes/results. A project is defined as an individually
planned undertaking designed to achieve specific objectives within a given budget and time frame.
A well developed monitoring and evaluation plan should address the following questions:
 Did the project take off as planned?
 What problems and challenges, if any, did it face?
 Is it being effectively managed?
 Is it providing planned activities and other outputs in a timely fashion?
 If not, why?
 Will the project be able to meet its targets?
 What are its intermediary effects and impacts?

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  What can be done to improve its performance and impacts?

Who should be involved in monitoring and evaluation planning?

The monitoring and evaluation plan is intended for the use of the organization. Therefore, the
monitoring and evaluation plan should be designed by those who are involved in the program,
including strategic partners. This allows the creators of the monitoring and evaluation plan to also be
the users. This participatory approach ensures project team support and learning, which can increase
effectiveness of the monitoring and evaluation and organizational capacity.

When should the monitoring and evaluation plan be used?

The monitoring and evaluation Plan should be used as a reference throughout the length of the
program cycle, tracking all programs and updated to include all monitoring and evaluation data and
results. It should be constantly updated to include up-to-date information of monitoring and evaluation
progress. This includes indicator results after each activity or intervention, data collection methods and
sources, and who will be collecting data. If they occur, It should also be used and to track changes and
updates to monitoring and evaluation activities.

Key Elements of a Monitoring and Evaluation Plan

1. Description of the program

2. Purpose of monitoring and evaluation activities and objectives
3. monitoring and evaluation questions
4. Description of what data will be collected
5. Methods for collecting, managing, and sharing data
6. Descriptions of who will implement various aspects of the plan
7. Resources needed to implement the plan
8. Timeline for completing monitoring and evaluation

1. Description of the program

Program narrative:
 Problem or situation that the program seeks to address
 Program goals and objectives as part of their overall description of their program

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  How the program plans to improve the problem or situation (inputs and activities)
 The expected changes that would occur as a result of the program (outputs and outcomes)
Description of program components:
 Specific, detailed description of problem statement, inputs, activities, outputs, outcomes, and
impacts
Program logic model
 Graphic display of the functional relationships between the components using a logic model
2. Purpose of monitoring and evaluation activities and objectives:
 How and to what extent the program will achieve its objectives
 Anticipated outcomes of the program‘s efforts
 How outcomes will inform decision-making
3. Monitoring and Evaluation questions
List of monitoring and evaluation questions
 Consider program‘s and stakeholder‘s needs/wants
 Prioritize based on resources and capacity to answer questions
 Make sure they are measurable
4. Description of what data will be collected
Prioritize measures and indicators:
 Describe the data needed to answer the monitoring and evaluation questions
 Describe the relevant measures and indicators
 Outline potential sources for the data
5. Methods for collecting, managing, and sharing data
Description of data collection methods:
 Data collection tools already available
 Data collection tools that will need to be developed or obtained
 The method that each tool supports
Description of data management process:
 Who, what, when, and where data will be processed
 Data storage systems
 Data quality assurance processes

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  Data flow (diagram)
Description of data dissemination plans:
 What data will be shared
 Who will data be shared with
 Reasons for sharing
 Timelines and formats
6. Descriptions of who will implement various aspects of the plan
Description of the roles and responsibilities of persons involved in implementation of
monitoring and evaluation Activities:
 Who will be involved in implementing each activity (may include program staff, organizational
administrative staff, stakeholders, consultants)?
7. Resources needed to implement the plan
Summary of resources needed and associated cost:
 Budget for each monitoring and evaluation task taking into consideration administrative costs,
program staff compensation (e.g. salary, benefits, etc.), consultants, travel, communication,
printing and duplication, materials, training
8. Timeline for completing monitoring and evaluation
Summary of resources needed and associated cost:
9. Budget for each monitoring and evaluation task taking into consideration administrative costs,
program staff compensation (e.g. salary, benefits, etc.), consultants, travel, communication,
printing and duplication, materials, training

2. Goals, objectives and Program Frameworks

a. Developing Goals and SMART Objectives

i. Section Introduction
The unit distinguishes between program goals and objectives of monitoring and evaluation. It maps
out activities contribute to higher level objectives and how meeting these objectives leads to the
achievement of the overall purpose or goal of a project or programme. Developing a clear logical
objective hierarchy is fundamental to good programme and project design and essential for monitoring

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 and evaluation. If the program goals and objectives are written in such a way that they can be easily
distinguished from each other and measured, the job of monitoring and evaluation will be much easier.
Unfortunately, many times, this is not the case. In this section, we will learn how to write program
goals and objectives so that they are easily monitored and evaluated.

ii. Learning Objectives

At the end of this section, trainees are expected to be able to:

• Design goals and objectives for specific intervention programs.

• Describe the four basic types of frameworks.
• Design frameworks for specific intervention program
• Use frameworks for developing Monitoring and Evaluation plans.

iii. Section content

1. Definition of goals and objectives
2. Types of objectives
3. Why goals and objectives
4. Types of frameworks
5. Why frameworks
6. Exercises
• Identify goals and objectives
• Rewrite objectives so they are SMART
• Develop your own frameworks for your own program

iv. Goals and Objectives: Definition

Discussion points
 What is Goal?
 What is an objective?
 What is the difference between Goal and objectives?

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Group Exercise
 Be in group of five,

 Construct a hypothetical public health intervention implemented by a Woreda Health

Office which you have mentioned in the related to pervious examples.

 Ask participants to write about Goals and objectives.

 Take a note on disagreements for further discussion.

 Ask them to write their responses on the flip charts and to hang them on the wall.

 Present your work to the group during general discussion.

Goal:
• A broad and general statement about desired program intentions that generally reflects wider
community concerns and interest.
• Establishes a program‘s direction without specifying how the direction will be accomplished.
• Must be concrete enough to provide direction for establishing measurable objectives.

Example:
• To equip participants with an understanding of monitoring and evaluation and the knowledge
and skills needed to incorporate monitoring and evaluation activities into everyday program
work.
• The enhancement of food security in single parent households in certain localities.
• Eradication of protein-energy malnutrition among risky target populations.

Objective:
 Objectives are also statements of intent which specify in concise, measurable terms how goals
will be achieved. Unlike goals, objectives are time-bound and achievable.
 Is more specific than a goal

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Examples:

 To increase the caloric intake among infants by 30% in Gondar Zuria District by
year three of the programme.
 To reduce prevalence of anemia in pregnant women by 30% in Ethiopia by 2015.
 To improve the quality of HIV counseling services at ANC clinics in Gondar
Referral Hospital for pregnant mothers by 2014.

Process and Outcome Objectives

• Remember process evaluation:

– Focuses on how a program was implemented

– Identifies steps taken and the decisions made in developing and implementing a
program

– Answers the question: Is the program providing the activities or services intended?

• Process objectives measure the implementation process of a program

• Remember outcome evaluation:

– Focuses on the results of a program's effort

– Answers the question: What difference did the program make?

– Provides information about program effects after a specified period of time

– Measures the health, knowledge, or behavioral change for the target population

• Outcome objectives measure the specific outcomes achieved as a result of program efforts over
a period of time

Examples of process and outcome objectives for the VCT Program

• Process Objective

– For the output: Clients receive results and HIV counseling services.

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 – Objective: By the end of the first program year, 98% of clients receiving their test
results will also receive HIV counseling.

• Outcome Objective

– For the outcome: HIV care and treatment increased

– Objective: By the end of the first program year, 50% of clients receiving positive test
results will begin a treatment regimen.

Example 1: The program will provide home-based care services to elderly members of the community
• Not specific:

 What do home-based services include?

 Who is the target population?

 How is elderly being defined?

• Does not specify how many people the program aims to reach (measurable):

– Is it every elderly member of the community?

• Does not indicate a timeframe:

– Does the program plan to achieve these results within the span of 6 months, 2 years?

– The results will be different depending on the timeframe.

Example 2: 150 health workers will be trained to deliver ART services according to national and/or
international standards.
• This is objective is better but the time element is missing:

– It is specific and measurable:

 Defines who and how many people the program aims to train

 Specifies what the target population will learn

– It does not provide a timeframe:

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 – When does the program expect to achieve this objective? In 3 months? 1 year?

– The timeframe will affect how activities are implemented and the results we would
expect to see

Example 3: By the end of the first program year, 1000 clients will be tested for HIV.

• This is a SMART objective:

– The objective is specific and measurable:

 The objective defines who and how large the target audience is

 It tells what services the program will provide to these clients

– The objective also provides a timeframe. ―By the end of the first program year‖

Activity: Write SMART Objectives for Your Program

• Directions:
– Work individually or as a small group
– Review your program logic model you developed earlier
– If you already have program process and outcome objectives, write them in the flip
chart, then use this flip chart to present general group and ensure that they are
SMART.
– If your existing objectives are not SMART, revise them again and then write them in
another flip chart.

b. Frameworks
i. Section Introduction

Four types of frameworks are introduced in this module: conceptual frameworks, logical frameworks,
logic models and Result frameworks. Different organizations tend to prefer a selected type of
framework. It is not important to convince participants to use any particular type. The gist of this
session, however, is the importance of designing a useful framework for a specific project in a specific
context, not the titles or particular appearance of any designated kind of framework.

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 ii. Why Are Frameworks Useful?

• Frameworks are best understood as useful tools for understanding and analyzing a program.
• Designing frameworks is one way to develop a clearer understanding of the goals and objectives at
the heart of a project, with emphasis on measurable objectives.
• Developing frameworks also helps to clearly define the relationships among factors key to the
implementation and success of a project.
• These factors may be internal or external to the program context.
• The framework design process is crucial for developing sound implementation and monitoring and
evaluation plans and serves as the foundation for selecting appropriate and useful monitoring and
evaluation indicators.
• The process of designing frameworks also helps to clarify many of the concepts and assumptions
underlying basic project activities.
• While frameworks are obviously useful after their completion, providing a clear structure of the
indicators at the heart of monitoring and evaluation plans, one of most useful qualities is that
discussing and determining their design serves to clarify many of the concepts and assumptions
underlying basic project activities.
• A monitoring and evaluation plan that does not identify appropriate, useful monitoring and
evaluation indicators, metrics, and data systems is a monitoring and evaluation plan that will not
contribute to good program management or to an intervention‘s success.

iii. Learning Activities

• In groups, ask participants to identify who should be a member of the monitoring and evaluation
team and what skills the members need.
• Ask them to write their responses on the cards and to hang them on the wall.
• Remind participants that at the planning stage of a program, it is necessary to include plans for
monitoring and evaluation. This can be done by developing a conceptual framework of the
program, a tool which is simple and readily applicable in the monitoring and evaluation of any
integrated development program.

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• Explain that developing a conceptual framework for a program allows staff to articulate how they
anticipate program inputs and activities will achieve the desired effects, reach consensus on the
details of the program, and clarify the terminology that will be used.
• Remind participants that the process in the conceptual framework starts by understanding the
problem/need the program is addressing. What is the problem, how big; who does it affect, what
are the cause(s) of the problem? If the program defines the problem wrongly, everything thereafter
is all wrong.
• Provide handout after discussing slides then explain to participants that the framework indicates
what elements need to be monitored and/or evaluated. These elements can later be translated into
indicators. Inform the participants that they will learn more about indicators in the next session.
Also point out that the framework makes it easier to identify specific constraints to program
effectiveness as the program evolves.
• Dividing a program into various components makes it easier to create the necessary indicators to
assess the program and identify the specific constraints to program effectiveness as the program is
being implemented. The program conceptual framework is a dynamic instrument.
• Further point out that in this particular framework there are four principal elements: inputs,
outputs, outcomes, and impacts that can be translated into indicators and are particularly useful in
monitoring and evaluating programs. Point out that we make assumptions about the relationships
between these elements when creating this diagram.
• Distribute the handout at the end of the exercise because they will complete the same log frame as
part of group work then explain that the elements of the conceptual framework can be rearranged
into a logical framework to organize the elements of the conceptual framework in tabular form.

iv. Types of Frameworks

1. Conceptual Frameworks (Research or Theoretical Frameworks)

 Conceptual frameworks are sometimes called ―research‖ or ―theoretical‖ frameworks.
 A conceptual framework is a useful tool for identifying and illustrating a wide variety of factors
and relationships that may affect program success.
 Conceptual frameworks take a broad view of the program itself in order to clarify the
relationship of its activities and its main goals to the context in which it operates.

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 The design of the conceptual framework should show the interrelationships between all factors
that are relevant to achieving the program‘s goals.
 These factors can be systems, organizations, government or institutional policies, infrastructure,
population characteristics, or other features of the operational landscape that may help or hinder
the program‘s success. Constructing a conceptual framework thus clarifies the complete context
affecting the outcome of a program or intervention.
 Constructing a conceptual framework also clarifies your assumptions about the causal
relationships between significant features of the program context, clarifying aspects that your
planned intervention may affect as well as other factors beyond your control.
 Identifying the variables that factor into program performance, and organizing the explicit ways
they interact with each other sets the stage for outlining the objective results you can reasonably
expect from your program activities.
 Clarifying all of these issues is a critical step toward designing valid measures for analyzing, or
evaluating, the success of those interventions.
 Another type of framework, proximate determinants, highlights the factors directly affecting the
health outcome.
 Sometimes the proximate determinants are labeled as such within a conceptual framework.
 In addition Conceptual frameworks are used in the sciences to select key variables for analysis.
 By constructing this kind of analytical framework as the foundation within which your program
will design, plan, and implement the Monitoring and Evaluation of program performance, real
possibilities and limitations become clearer to everyone involved.

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Figure 3. Conceptual frameworks on causes of malnutrition in the society

v. What is a Logic Model?

 Mainly a logic model is a systematic and visual way to present and share your understanding of
the relationships among the resources you have to operate your program, the activities you plan
to do, and the changes or results you hope to achieve.
 The term logic model is frequently used interchangeably with the term program theory in the
evaluation field.
 Logic models can alternatively be referred to as theory because they describe how a program
works and to what end.

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Table 4. Logical Model terms and definitions

vi. Why Develop a Logic Model?

A way to promote monitoring and evaluation by:

– Involving stakeholders
– Providing a reference point and promoting communication
– Illustrating the internal consistency of the program
– Helping planners identify gaps or unrealistic expectations
– Identifying potential obstacles to program operation
– Helping monitor progress
– Identifying appropriate evaluation questions and relevant data needs
– Improving program staff‘s expertise in planning, implementation, and evaluation

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 vii. How is a Logic Model used?

• Describe the main components of a program

• Show how program activities are related to intended effects
• Make assumptions about how a program will address a particular problem
• There is no ―right‖ way to begin a logic model.
• Design construction is based on stage of the program, identified ―logic,‖ information available
concerning resources, etc. However, you should have a clear definition of the problem before
starting construction of your logic model.
• The two approaches described in this module are the Forward Logic approach and the Reverse
Logic approach.
Example on Left to Right or “Forward Logic”: Developing your logic model from left to right
starts with articulating the program inputs and activities and requires you to work forward towards
distal outcomes. This approach is often used when you need to evaluate a program in the
implementation or maintenance stage but do not already have a logic model in place. You will ask the
question ―But Why?‖ as you move from left to right in your logic model.

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You can also think of this left to right movement as an IF … THEN ….Progression.
Right to Left or ―Reverse Logic‖
Developing your logic model from right to left starts with desired outcomes and requires you to work
backwards to develop activities and inputs.
Usually used in the planning stage, this approach ensures that program activities will logically lead to
the specified outcomes if your arrow bridges are solid (sound logic).
You will ask the question ―But How?‖ as you move to the left in your logic model.
This approach is also helpful for a program in the implementation stage that still has some flexibility
in its choice of program activities.

Example on Right to Left or ―Reverse Logic‖ Model

viii. Developing a Logic Model

When developing a logic model for a planned program, describe:
– How the program should function
– What results you expect
- To do this you will need:
– Information from meetings wit8h stakeholders
– Knowledge of theory

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– Experience or lessons learned
• For a program already underway, describe:
– Actual inputs
– Activities completed
– Outcomes and impacts (impacts for completed program) that resulted from program
implementation

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 Figure 5: logic model

Example: Developing a Logic Model for a VCT Program

Problem Statement: People who do not know they are sero-negative might not be as motivated to
remain disease-free, whereas those who are HIV infected might not use critical interventions to reduce
HIV transmission to their children and others or other care, treatment, and support services

Logic Model Components in a VCT Program

In small groups assign one of these five elements to each group. Ask participants to explain the
meaning of the element they have been assigned. Allow 10 minutes for this activity.

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At the end of the small group session, synthesize the group‘s reports and relate to slides the following
points should come out:
Inputs - all those resources that go into the program at the onset or start-up phase or during the
implementation to help the program achieve its objectives.

The inputs (the number and qualifications of personnel, the financial resources, the institutional set-up,
timing, etc.) must be designed as to meet the problem. The inputs should be distributed to meet all
needy groups and be accessible financially, socially and technically. If this does not happen the inputs
are useless and the outputs may not be met.
Outputs - all the goods and services delivered to the target population by the programme. Programme
inputs have to be transformed into outputs. The quantity and quality of the outputs is very important.

For instance, if one programme input were the training of CHWs, the outputs are the number of trained
CHWs. The quality of the training should also be ―adequate,‖ otherwise just training them would not
help in effectively meeting the needs of the community.
Also explain that having very well-trained staff or people does not necessarily generate programme
delivery nor impact. Success and impact are created by making sure that the trained personnel are
enabled to do the work that they were trained for.
Outcomes - changes in behaviors/practices as a result of program activities.

The outputs, if of the right quantity and quality, should produce an outcome. The skills of the CHWs
should change, and if they do their tasks well, the detrimental behavior /practices of the mothers
should change for the better of their children‘s health. The change in skills of the CHWs and/or the
change in behavior/practices of the mothers are the outcome of the programme. The outcome is
expected to influence the problem, as defined initially.
Impacts - the effect of the program on the beneficiaries. The change in the problem is the impact of
the program on the beneficiaries/clients.

Assumptions - the external factors, influences, situations or conditions which are necessary for project
success. They are important for the success of the programme but are largely or completely beyond the
control of programme management. For example, in nutrition education, we may assume that
community workers who are trained will understand the training and be motivated to do what they
have been trained to do. However, we cannot be sure that this actually will happen. Accordingly, it is

37
necessary to make assumptions explicit and list them in the framework as elements to be monitored or
evaluated. Again, walk participants through the process of transferring the conceptual framework into
a logical framework.

Divide participants into four groups, and provide each group with a set of cards on which the various
elements of a hypothetical nutrition programme are written (each group receives a different
programme. Ask participants to arrange the cards to create a conceptual framework and copy their
framework onto a flipchart. Allow about 15 minutes for this activity. Share one or two examples in
plenary sections. Ask participants to complete a conceptual framework and logical framework for their
own programme during the evening. They should be prepared to share this in plenary the following
day.

ix. Logic framework

A log frame is a tool for improving the planning, implementation, management, monitoring and
evaluation of projects. The log frame is a way of structuring the main elements in a project and
highlighting the logical linkages between them. It consists of a matrix with four columns and several
rows, which summarise the key elements of a project plan, namely:
• The project‘s hierarchy of objectives (Project description)
• How the project‘s achievements will be monitored and evaluated (Indicators and Sources of
Verification)
• The key external factors to the project‘s success (Assumptions)
• What will the activity do and what will it produce? (activity description)
• The activities hierarchy of objectives and planned results (also activity description)
• The key assumptions being made (assumptions)
• The vertical logic (reading up and down columns 1 and 4 of the matrix) clarifies the causal
relationships between different levels of objectives (column 1) and specifies the important
assumptions and uncertainties beyond the activity managers control (column 4).
• The horizontal logic: How the activity‘s achievement will be measured, monitored and
evaluated (Indicators and means of verification)
• The horizontal logic (reading across the rows of the matrix) defines how the activity objectives
specified in column 1 of the logical frameworks (Goal, Objectives, and Outputs) will be
measured (column 2) and the means by which the measurements will be verified (column 3).
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 This provides a framework for activity monitoring and evaluation. This provides a framework
for activity monitoring and evaluation.

Table 1. Log framework matrix applied for different program activities

Project structures Indicator of achievement Means of verification Important risks

& assumptions
Goal: What are the wider What are the quantitative What sources of information What external
objectives which the measures or qualitative exist or can be provided to factors are
activity will help to judgments whether these broad allow the goal to be measured? necessary to
achieve? objectives have been achieved? sustain the
Longer-term programme objectives in the
impact long run?
Purpose: What are the What are the quantitative What sources of information What external
intended immediate measures or qualitative exist or can be provided to factors are
effects of the programme judgments by which allow the achievement of the necessary if the
or project? achievements of the purpose purpose to be measured? purpose is to
What are the benefits, to can be Judged? contribute to the
whom? What achievement of the
improvements or changes goal?
will the program or
project bring about?
The essential motivation
for undertaking the
programme or project
Outputs: what outputs What kind and quality of What are the sources of What are the
(deliverables) are to be outputs and by when will they information to verify the factors not in the
produced in order to be produced? achievement of the outputs? control of the
achieve the purpose? project which are
liable to restrict
the outputs

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 achieving the
Purpose?
Activities What kind and quality of What are the sources of What factors will
What activities must be activities and by when will they information to verify the restrict the
achieved to accomplish be produced? achievement of the activities? activities from
the outputs? creating the
outputs?

x. What is a Results Framework? (Strategic Framework)

• A results framework (RF) presents an operating unit‘s strategy for achieving a specific objective.
Typically, it is laid out in graphic form supplemented by narrative.
• A result framework includes the objective and the intermediate results necessary to achieve it.
• The framework also conveys the development hypothesis implicit in the strategy and the cause-
and-effect linkages between the intermediate results and the objective.
• It includes any critical assumptions that must hold for the development hypothesis to lead to
achieving the relevant objective.
• In short, a person looking at a results framework should be able both to understand the premises
underlying the strategy and to see within the framework those intermediate results critical to
achieving the objective.
• Key elements of an RF include the strategic objective, intermediate results, hypothesized cause-
and-effect linkages, and critical assumptions. The process for identifying these elements is outlined
below as a series of steps. These steps need not be followed sequentially:
• Developing a result framework is and should be an iterative process. Operating units may use a
variety of approaches to develop their respective results frameworks. Whichever process is
followed, it is important to involve partners.

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 xi. What Functions Does a Results Framework Serve?

• A results framework is both a planning and a management tool.

• The result framework is central to the strategic plan and provides a program-level framework
for managers to gauge progress toward the achievement of results and to adjust relevant
programs and activities accordingly.
• In addition, the design of a results framework provides an important opportunity for an
operating unit to work with its development partners and customers to build consensus and
ownership around shared objectives and approaches to meeting those objectives.
• Result frameworks also function as effective communication tools because they succinctly
capture the key elements of a strategy for achieving an objective (i.e., program intent and
content).
• Finally, as ―living‖ management tools, result frameworks are the foundation for several critical
programmatic events and processes
• Reaching agreement both within the operating units on expected results and required resources
• Identifying and designing results packages
• Selecting appropriate indicators for each program result and developing the operating unit‘s
performance monitoring and evaluation systems
• Using performance information to inform program management decisions (i.e. adjusting
specific program activities)
• Analyzing and reporting on performance through the R4 process
A results framework should be kept current; that is, result frameworks should be revisited or revised
when:

1. Results are not achieved as expected

2. Critical assumptions prove invalid
3. The underlying development theory is wrong
4. Critical policy, operational, or resource problems were not adequately recognized

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 xii. Steps in Designing a Results Framework
Key elements of a result framework include:
1. Strategic objective,
2. intermediate results,
3. hypothesized cause-and-effect linkages,
4. Critical assumptions.

Figure 6 . Results Framework (strategic Framework)

The process for identifying these elements is outlined below as a series of steps. These steps need not
be followed sequentially: developing a result framework is and should be an iterative process.
Operating units may use a variety of approaches to develop their respective results frameworks.
Whichever process is followed, it is important to involve partners (i.e., NGOs, other donors, and host
government organizations sharing the objective). Although this takes time, the results framework will
be more complete and representative with their participation. Moreover, broader ownership of the
result framework among partners may promote greater harmonization of program activities aimed at a
shared objective.

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 Figure 7: Results Frameworks: Tuberculosis (TB) Control Programs

Table Summary of Frameworks

Type of Brief Description Program Management Basis for Monitoring and

Framework Evaluation

Conceptual Interaction of various factors Determine which factors the No. Can help to explain results
program will influence

Results Logically linked program Shows the causal relationship Yes – at the objective level
objectives between program objectives

Logical Logically linked program Shows the causal relationship Yes – at the output and
objectives, outputs, and between activities and objectives objective level
activities

Logic Logically links inputs, Shows the causal relationship Yes – at all stages of the
model processes, outputs, and between inputs and the objectives program from inputs to process
outcomes, to outputs to outcomes/
objectives

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Session 3: Monitoring and Evaluation Indicators
Session overview

This unit helps participants to identify the components of different programs. It also explains what
indicators are and how to identify and select appropriate indicators for programs monitoring and
evaluation.

Learning Objectives
By the end of this unit, participants should be able to:
 Define indicators
 Describe the characteristics of good indicators
 Identify indicators that can be used to monitor a program
 Identify indicators that can be used to evaluate a program
 Able to develop appropriate indicators with their respective activities
 Identify criteria for selection of sound indicators
 Know how indicators are linked to the frameworks covered in the Frameworks Module
Develop an indicator matrix and complete an indicator reference sheet (group activity)

Discussion points
- What is an indicator?
- Mention types of indicators
- List characteristic of good indicators
- Develop good indictors in your respective groups

Group exercises

- Be in groups of five

- Construct a hypothetical public health intervention implemented by a Woreda Health

Office.

- Start this session by discussing the objectives of the unit and then give a brief overview of
the unit.

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 - Brainstorm on what an indicator is.
- List their responses on the flipchart.
- List characteristics of a good indicator.
- Explain why it is necessary to identify or develop appropriate indicators for monitoring and
evaluation.
- Complete conceptual framework for child Health program
- Finally, identify and select appropriate input, output, outcome, and impact indicators for
this program by answering the following questions:
 what information is needed to monitor the program to evaluate the program

 Who will collect this information?

 Where is this information to be found?

 Who will use the information?

 For what purposes will it be used?

Definition of Indicators

• An indicator is a variable that measures one aspect of a program or project.

• Fundamentally, an indicator provides a sign or a signal that something exists or is true.
• It is used to show the presence or state of a situation or condition.
• In the context of monitoring and evaluation, an indicator is a quantitative metric that provides
information to monitor performance, measure achievement and determine accountability.
• It is important to note that a quantitative metric can be used to provide data on the quality of an
activity, project or programme.

Types of indicators

• What are the different types of indicators?

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• Indicators can be categorized in a number of different ways, depending on why they are being
categorized.
• However, there are two general approaches to defining types of indicators that are particularly
useful in monitoring the response to HIV.
• The first is based on thematic similarities among indicators; the second is based on the relative role
and/or effect that an indicator has in/on the response to the epidemic.
• The most important point about the types of indicators is how crucial it is to use a range of
different types in a given set in order to get a balanced perspective.
• Only using one or two types of indicators will result in a much narrower point of view, which may
provide an inaccurate picture of the situation. For example, the UNGASS set of indicators uses
many different types of indicators, including behavioral outcome, disease impact, infrastructure,
policy and programme/service delivery, to provide a strategic overview of the global epidemic and
response.

Why are indicators useful?

• The purpose of indicators typically is to show that program activities are carried out as planned
or that a program activity has caused a change or difference in something else.
• Its value will change from a given or baseline level at the time the program begins, to another
value after the program and its activities have had time to make their impact felt, when the
variable, or indicator, is calculated again.
• Indicator is a measurement. It measures the value of the change in meaningful units for
program management: a measurement that can be compared to past and future units and values.
• A metric is the calculation or formula that the indicator is based on. Calculation of the metric
establishes the indicator‘s objective value at a point in time. Even if the factor itself is
subjective, like attitudes of a target population, the indicator metric calculates its value
objectively at a given time.
• Indicator focuses on a single aspect of a program or project. It may be an input, an output, or
an overarching objective, but its related metric will be narrowly defined in a way that captures
that aspect as precisely as possible.

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 • A full, complete, and appropriate set of indicators for a given project or program in a given
context with given goals and objectives will include at least one indicator for each significant
aspect of program activities.
• In general very simply, indicators are standardized measures that allow for comparisons over
time, over different geographic areas and/or across programs. The ability to compare
temporally and spatially differentiates indicators from raw data, as does the ability to aggregate
data for higher-level interpretation and application.

Characteristics of a Good Indicator

• Good indicators should be useful in the establishment of ―trigger points‖ for action.
• They should provide information useful enough to merit the cost of collecting it.
• In addition, they should have the following characteristics:
Simple: - Indicators should be simple without compromising the essence of the variable.
Selecting a simple indicator is not always an easy task. It may require finding a balance between the
ideal (which may be complex and/or impossible to collect) and the practical.
Additionally, it is important to collect only what is needed rather than what is possible or interesting.
Clearly and precisely defined: Each term of an indicator should be clearly and precisely defined. It is
not sufficient, for instance, to use ―percent of underweight children‖ as an indicator. What does
―underweight‖ mean? Which children are being measured?
Moreover, presenting indicators as proportions permits an understanding of the population which the
indicator reflects (the denominator). A better indicator would be: number of underweight (WAZ < -2)
children aged 6-24 months total number of children aged 6-24 months who were weighed
Measurable: - Both quantitative and qualitative indicators should be measurable. Some indicators can
be directly measurable, e.g., height and weight, while other indicators need to be defined. Clearly and
precisely defining indicator terms makes indicators measurable. For example, access to piped water,
can be measured simply by observation once ―access‖ is defined (e.g., available inside the household;
available within 250 yards). Sometimes, a scale or index needs to be created to measure a qualitative
variable in quantitative terms. Knowledge of correct breast feeding practices, for example, might be
measured by a respondent‘s ability to give the correct answers to a set of objective questions.

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Valid: - A valid indicator accurately reflects the situation it is intended to measure. A valid indicator
in one area may be less so in another, therefore it may be inappropriate to transfer indicators from
region to region or program to program. For Vitamin A status, for example, dietary intake may be a
valid proxy indicator in an area with adequate intake of fat but an invalid indicator in another area
where fat intakes limit Vitamin A absorption.
Reliable: - A reliable indicator will produce the same results every time it is measured, regardless of
who collects the data. Reliability is not the same as validity. A reliable indicator may provide an
invalid result.
Variable: - To be useful, indicators must show variation between subjects and over time. If the
indicator does not vary, it will not discriminate between those who have benefited from the program
and those who have not. Height is a variable indicator for young children, and we can expect well-
nourished preschoolers to show more rapid growth in height than malnourished ones. Among adults,
height does not vary greatly over time or with nutritional status, therefore, it not of interest for tracking
program impact.
Sensitive: - To be useful, indicators must be sensitive to change over time. Some indicators vary in
one setting but not in another. For example, the materials used in house construction may be a good
indicator of economic status in rural areas, where houses may be made of mud, sticks, or cement, but
not urban areas where the poorest households live in cement structures. In another example, in order to
monitor or evaluate trends (changes) over time, an indicator must be able to measure (capture) the
desired changes in (during) the time intervals planned for monitoring or evaluation activities.

Essential components of an indicator

What are the essential components of an indicator?

The following series of questions is used in the Indicator Standards & Tools to confirm that the
essential components are included in an indicator.
• Does the indicator have a clearly stated title and definition?
• Does the indicator have a clearly stated purpose and rationale?
• Is the method of measurement for the indicator clearly defined, including the description of the
numerator, denominator and calculation, where applicable?
• Are the data collection methodology and data collection tools for the indicator data clearly stated?

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 • Is the data collection frequency clearly defined?
• Is any relevant data disaggregation clearly defined?
• Are there guidelines to interpret and use data from this indicator?
• What are the strengths and weaknesses of the indicator and the challenges in its use?
• Are relevant sources of additional information on the indicator cited?

Indicator components

• When new indicators are being developed, they must be fully defined.
• No indicator should be deployed without a full definition.
• In other words, the essential components of the indicator must be clear and concrete.
• To ensure meaningful responses to the questions in the Indicator Standards & Tools listed above,
it is critical to understand the terms used to define the components of an indicator.
• Title. A brief heading that captures the focus of the indicator.
• Definition. A clear and concise description of the indicator.
• Purpose. The reason that the indicator exists; i.e. what it is for.
• Rationale. The underlying principle(s) that justify the development and deployment of the
indicator; i.e. why the indicator is needed and useful.
• Method of measurement. The logical and specific sequence of operations used to measure the
indicator; e.g. data collection tools, sampling frame and quality assurance.
• Numerator. The top number of a common fraction, which indicates the number of parts from the
whole that are included in the calculation.
• Denominator. The bottom number of a common fraction, which indicates the number of parts in
the whole.
• Calculation. The specific steps in the process to determine the indicator value.
• Data collection method. The general approaches (e.g. surveys, records, models, estimates) used to
collect data.
• Data collection tools. The specific tools (e.g. AIDS Indicator Surveys (AIS), Demographic and
Health Surveys (DHS), Service Provision Assessments (SPA), patient registers, antenatal clinic
surveillance) used to collect data.

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• Data collection frequency. The intervals at which data are collected; e.g. quarterly, annually, bi-
annually. It is important that frequency is consistent with the data collection methodology. (The
frequency of data collection should not be confused with the frequency of reporting, which is
commonly associated with external organizations and agencies, particularly funding partners.)
• Data disaggregation. The relevant subgroups that collected data can be separated into in order to
more precisely understand and analyze the findings. Common subgroups include sex, age and risk
population.
• Guidelines to interpret and use data. Recommendations on how best to evaluate and apply the
findings; e.g. outlining what it means if the indicator shows an increase or a decrease in a
particular measure.
• Strengths and weaknesses. A brief summary of what the indicator does well and not so well.
• Challenges. Potential obstacles or problems that may have an impact on the use of an indicator or
on the accuracy/validity of its findings.
• Relevant sources of additional information. References to information/ materials that relate to
the indicator, including background information on the development of the indicator, comparisons
with previous versions of the indicator and lessons learned from the use of the indicator or similar
indicators in various settings.

How to select indicators

• Indicators should be selected carefully and systematically.

• It is important to consider the context or the environment in which they will be deployed.
• It is equally important to take into account any existing or applicable indicator frameworks that are
relevant to the context.
• In addition, all potential indicators should be evaluated using the international indicator standards
to ensure that they can and will provide useful data.
• They should be drawn from harmonized and/ or widely used indicator sets that have a successful
track record.
• When selecting indicators, it is essential to understand the context in which they will be used in
order to select the most appropriate ones.
Indicator frameworks : Most countries as well as most projects have developed indicator
frameworks.

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• In general, these frameworks correlate key objectives, project activities and/or work plans and
results with specific indicators and the methods for collecting data for those indicators.
• Many of these frameworks use the structure of the ‗logic model‘ or ‗logical framework‘ (i.e. log
frame), which has been widely used at the project level in development work.
• In effect, the aggregated list of individual indicators in a framework constitutes an indicator set,
whether the framework is for a specific project (e.g. a prevention project with only prevention
indicators) or a national framework that includes a range of different indicators relevant to the
country‘s epidemic and response

Session 4: Monitoring and Evaluation in Ethiopian Context

Session overview

At national level monitoring and evaluation is a vital management tool because it informs planners,
managers, and implementers to what extent the programs or project are operating effectively and
according to expectations. Monitoring and evaluation helps to make informed decisions about
implementation of Health sector Development Program (HSDP) and about various program operations
and enhances the most effective and efficient use of resources. For FMoH monitoring and evaluation
helps to know whether HSDP and other programs are right on track or not. This section is intended to
provide you brief information on the status of monitoring and evaluation in Ethiopian health system
and important concepts and indicators in Ethiopian setting.

Learning objectives
 Explain status of monitoring and evaluation in Ethiopian health system
 Identify the objectives of FMoH‘s monitoring and evaluation activities
 Explain types of evaluations used by FMoH
 Explain performance monitoring and quality improvement process
 Describe the terms: Routine administrative report ,integrated supportive supervision , and
inspection
 Describe the monitoring and evaluation principles : Standardization, integration and
simplification
 Identify the key monitoring and evaluation indicators at national level

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Overview of monitoring and evaluation work plan

According to FMoH monitoring and evaluation is an action-oriented and preplanned management tool
that operates on adequate, relevant, reliable and timely collected, compiled and analyzed information
on programme/project objectives, targets and activities. The objectives of FMoH‘s key monitoring and
evaluation component are to improve the management and optimum use of resources of programme
and to make timely decisions to resolve constraints and/or problems of implementation. FMoH
outlined that the key elements for a successful programme management and implementation are the
designing of a programme built on a hierarchy of objectives, targets, activities and measurable
indicators. The agreed indicators are the most important management tools for monitoring, review and
evaluation purposes. Indicators are always directly linked to the objective setting of a programme.

Health Sector Development Programme is monitored and evaluated on the basis of the detailed
arrangements outlined.. Quarterly, semi-annual and annual monitoring and reporting cycles are
followed. To facilitate the use of information in decision-making, all reports are presented
cumulative information for the six months and the full year. The monitoring and evaluation reports
are expected to be summarized comparison of planned activities and achieved outputs and utilization
of resources including information on actual expenditure (both capital and recurrent) during the
reporting period. The preparation of the quarterly report and monitoring is the responsibility of the
implementing and supervising institutions at different levels (FMOH, RHBs, Woreda Health Offices
and HFs). It is important to note that Federal and Regional bureaus can‘t be effective without getting
the necessary reports from Woreda health Offices and health facilities including from health
extension workers through the respective woreda health offices. Monitoring and evaluation provides
an opportunity for stakeholders to take stock of programme implementation, exchange views and
experiences, to facilitate problem-solving and possible reorientation of the programme.

Types of evaluations used by FMoH

HSDP evaluations that are carried out to assess programme implementation can be formative and
summative. While formative evaluation helps to improve progress during implementation, summative
evaluations are usually conducted at the end of the programme and aim at the overall assessment of
achieved outputs and impacts vis-à-vis the programme objectives.

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Important Issues for Data Collection and Utilization
Routine Administrative report

Patient cards and registers are designed to capture all patient related data, reports are based on the 107
sector wide indicators . Allocating resources to put in place the human resources, tools and the
equipment needed for the proper documentation, compilation, analysis, use and timely reporting of
routine facility data as per the standard. All stakeholders operating in the health sector should support
and use HMIS for programme monitoring. In Ethiopia each health facility and administrative level has
to put in place the necessary institutional mechanisms as per the standard indicated of HMIS. Data is
collected from health facilities from client-patient records. The data will be aggregated and analyzed to
compare plan versus performance for the facility‘s own consumption. Facilities must supply data to the
relevant administrative levels through the routine reporting mechanism as per the HMIS reporting
calendar. Validation of the data is done through performance monitoring, integrated supportive
supervision, surveys and regular inspections.

Performance Monitoring and Quality Improvement

Performance monitoring: is the continuous tracking of priority information on conducted activities and
the indicators of success in order to identify achievement gaps and lessons learnt as an input for
subsequent leading to the planning and implementation of corrective measures.
Quality improvement process is a performance monitoring activity by which health facilities
(Hospitals, Health centers and Health posts) themselves use the opportunity of using locally available
data generated during provision of health service to improve quality of health care through a
continuous process of measurement and improvement. This aspect of monitoring and evaluation
conducted based on Performance monitoring and quality improvement standard operating procedure
endorsed as part of PPME core process that clearly outlines the fundamental building blocks of
performance monitoring and quality improvement i.e. Quality planning, quality performance
measurement, quality improvement activities, staff involvement, evaluation of quality program, and
clinical information system.

Evaluation/Operational Research

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Evaluation is a well thought systematic approach which may be designed to determine the value or
worth of a specific program, intervention or project or any of its components to be able to link a
particular output or outcome directly to a particular intervention. Program evaluation requires a
systematic process of data collection, analysis and interpretation about interventions and their effects
about a program or any of its components in pursuit of looking answers to evaluation questions. It
fundamentally consists of making a value judgment regarding an intervention, a service or regarding
any one of their components, purposing to help in evidence-based decision making. In such evolution
processes, some issues may require further detailed investigation to get clear picture of the ―whys‖ of
program performances or achievements. Such evaluation questions will be addressed by program
evaluation. It is technically impossible to obtain all health and health related data exclusively through
HMIS. Hence, regular demand side and supply side surveys have to be conducted to capture selected
set of data and triangulate various sources in order to improve the accuracy of outcomes and impacts
of health interventions.

Integrated Supportive Supervision (ISS)

Integrated Supportive Supervision can be defined as a process of guiding, helping, training, and
encouraging staff to improve their performance in order to provide high-quality health services
through the use of integrated tools for all priority programs and empowering of health service
providers at all levels. A guideline and tools for ISS have been finalized as part of the BPR and it is
started to be used for HSDP IV.
Inspection
In the process of monitoring and evaluation, issues which are related with performance based financing
and other most priority and emergency situations need a mechanism for verification of routine reports
attached with accountability. It is being addressed by inspection which is established at all levels in the
health sector. Unlike ISS which focuses on onsite support provision, inspection is primarily to prove
activities and make institutions accountable for their level of compliance with agreed upon levels of
performance. Manuals and tools for implementation of inspection are being used and implemented
during HSDP IV.

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 Important Monitoring and Evaluation Principles for Establishing and
Utilizing Indicators in Ethiopian Health System

It is essential to address the following three overarching principles. A combined application of these
principles supports the implementation of an effective and efficient HMIS/M&E in accord with the
objectives of Business Process Reengineering (BPR).
Standardization - Common definitions of indicators, data collection instruments, and data processing and
analysis procedures form the foundation for effective HMIS/M&E. Without consistent principles and
definitions performance cannot be systematically measured and improved across locations or over time.
Integration - A single HMIS/M&E plan, shared by all partners, is a cornerstone of HSDP Implementation
of this principle requires integrating data from different programs into a shared channel from which all
derive their information.
Simplification - Collecting, analyzing, and interpreting only the information that is immediately relevant
to performance improvement makes best use of scarce resources, especially human resources.
5.6. Selected Key Monitoring and Evaluation Indicators for Result Framework at National Level
The following are selected, not comprehensive, list of indicators put in place to monitor programmatic
areas in HSDP IV. This list of indicators that should be made available on at least annual basis (or more
frequently).

Maternal Neonatal and Child Health (MNCH)

1. Contraceptive acceptance rate

2. Focused ANC 1+

3. Proportion of deliveries attended by skilled health attendants

4. Proportion of deliveries attended by HEW

5. Post natal care coverage

6. Proportion of pregnant women who receive ANC at PMTCT site who received testing for HIV

7. Proportion of deliveries of HIV+ women that receive full course of ARV prophylaxis

8. Immunization coverage; Pentavalent 3, Rotavirus, Pneumococcal, measles and fully Immunized

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9. Protection at birth against neonatal tetanus

10. Health facility with services like PMTCT, BEmONC, CEmONC, IMNCI, Youth friendly services
Disease Prevention and Control
1. PIHCT testing rate

2. VCT testing rate

3. Cumulative number of PLHIV ever enrolled in HIV care

4. Cumulative number of PLHIV ever started on ART

5. Proportion of patients who are currently on ART

6. TB case detection rate

7. TB cure rate

8. TB treatment success rate

9. Proportion households in malarious areas posses at least one LLIN

10. Proportion of households in IRS targeted areas that were sprayed in the last twelve months
Nutrition
1. Children 6-59 months given vitamin A every 6 months

2. Children 2-5 years dewormed every 6 months

Hygiene and Environmental Health
1. Proportion of households using household water treatment and safe storage practice

2. Proportion of households utilizing latrine

Health Infrastructure
1. Number of new Health Facilities constructed (by type)

2. Number of Health Facilities upgraded (by type)

3. Proportion of health facilities with latrine and with functioning water supply

4. Proportion of Health facilities with water supply

5. Number of hospitals implementing EMR

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6. Number of hospitals implementing tele-medicine
Human Resources
1. Health Staff to population ratio by category
2. Proportion of institutions staffed as per standards
Pharmaceutical supply and services
1. Average stock out duration Essential drug availability
2. Percentage of stock wasted due to expiry
Community Ownership
1. Proportion of model households graduated
2. Proportion of health facilities with boards where communities are represented
Quality Health services
1. Inpatient mortality rate
2. Customer satisfaction index
3. Outpatient (OPD) attendance per capita
4. Bed occupancy rate
5. Average length of stay
Public Health Emergency preparedness and Response
1. Proportion of epidemics averted (AWD, malaria and meningitis)
2. Proportion of epidemics controlled with zero mortality
Evidence based Decision Making
1. Proportion of partners implementing ―one-plan‖
2. Proportion of partners providing funds as DBS or MDG PF
3. Facilities implementing the new HMIS/M&E System (by type of facility)
4. Completeness and timely submission of routine health and administrative reports
5. Review meetings conducted by level
Resource Mobilization and Utilization
1. Percentage of government budget allocated for health
2. Facilities retaining and utilizing revenue (by type)
3. The ratio of health budget utilization to allocation

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 Part 2:
SURVEILLANCE AND EPIDEMIC INVESTIGATION
1. Introduction to Public Health Surveillance

2. Burden of HIV/AIDS

3. HIV/AIDS surveillance

4. Ethical Considerations in HIV/AIDS Surveillance

5. Outbreak investigation and management

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Session 1: Introduction to Public Health Surveillance
Session over view
This session gives overview of the public health surveillance, described different types of surveillance,
information generation through surveillance for evidence based practice. This session will enable you
to answer the questions: how to analyze surveillance data?

Learning objectives
At the end of this session, the participant will be able to:
• Define public health surveillance and list some of the usess

• Describe different types of surveillance

• Describe the features/attributes of good surveillance and running public health surveillance

 Conceptualize the quality parameters of public health surveillance

 Have skills of analyzing surveillance data and avail information through survilance for
evidence based practice

1. Definition of Public Health Surveillance

Public Health Surveillance is an on-going systematic collection, analysis, interpretation and

dissemination of health-related data essential to the planning, implementation, and evaluation of public
health practice

2. Purposes of Public Health Surveillance

Surveillance has the following purposes:

• Assess public health status

• Trigger public health action

• Define public health priorities

• Evaluate programs

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 • Generally, it informs the management of public health programs and direction of public health
policy

Information obtained by surveillance is important for Action. The major reason for collecting,
analyzing and disseminating information on a disease is to control that disease. Collection and analysis
should not be allowed to consume resources if action does not follow.

3. Process of Public Health Surveillance

Surveillance consists of the following interconnected activities:
• Data collection

• Data analysis

• Data interpretation

• Information dissemination

• Link to action

4. Data Sources for surveillance

Data for surveillance purpose can be obtained from:
• Records of notifiable diseases

• Routine records of health facilities

• Laboratories

• Vital records

• Registries

• Surveys

• Other data sources

5. Selection of diseases for surveillance

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All diseases may not be included in surveillance because it is too expensive to include all the diseases.
Therefore, there is a need of having criteria to include diseases in surveillance. The importance of a
health event to be included in surveillance system should be assessed using the following criteria:
1. The current impact of the health event
 Having high incidence/ prevalence

 Severity (case fatality rate, hospitalization)

2. The disease should be of epidemic potential

(eg. Measles, cholera, meningitis)

3. Surveillance required internationally

(eg plague, yellow fever, cholera)

4. Availability of effective prevention and control interventions

(eg EPI, IMCI)

5. Can easily be identified using simple case definitions

Integrated Disease Surveillance and Response (IDSR)

Integrated disease surveillance and response envisages all surveillance activities in a country as a
common public health service that carry out many functions using similar structures, processes and
personnel. The surveillance activities that are well developed in one area may act as driving forces for
strengthening other surveillance activities, offering possible synergies and common resources.
Surveillance is based on collecting only the information that is required to achieve objectives for
disease control. Even though there is integration, data requested may differ from disease to disease and
some diseases may have specific information needs, requiring specialized systems.

Features of Integrated Disease Surveillance and Response

Integrated Disease Surveillance and Response looks at surveillance as a "common" service; Seeks to
maintain surveillance and control functions close to one another; Recognizes that different diseases

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may have specialized surveillance needs; Uses a functional approach to communicable disease
surveillance
Integrated Disease Surveillance and Response exploits opportunities for synergy in carrying out:
 core functions: data collection, data reporting, data analysis, and response

 surveillance support functions: training and supervision, laboratory strengthening,

communications, and resource management

Goal of Integrated Disease Surveillance and Response Programme

The goal of Integrated Disease Surveillance and Response is to ensure that each Member State has the
capacity to define, detect and respond to communicable public health threats. To this end, an
integrated disease surveillance programme aims to provide:
 timely, complete, regular and high quality information

 early detection and prediction of epidemics (early warning systems)

 objective assessment of interventions during epidemics; and

 efficient monitoring of intervention programmes

List of Priority Diseases in Ethiopian IDSR

Epidemic-prone diseases Diseases targeted for eradication

1. Cholera 12. Acute flaccid paralysis (Polio)
2. Diarrhea with blood 13. Dracunculiasis (Guinea worm)
(Shigellosis)
14. Leprosy
3. Measles
15. Neonatal Tetanus
4. Meningitis
Other diseases of public health importance
5. Plague 16. Pneumonia in children
6. Viral hemorrhagic fever 17. Diarrhea in children
7. Yellow fever 18. New AIDS cases
8. Typhoid fever 19. Onchocerciasis

9. Relapsing fever 20. Sexually transmitted diseases

10. Epidemic typhus 21. Tuberculosis
11. Malaria 22. Rabies

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6. Types of Data on Surveillance Case Report Forms

Case report forms of surveillance may consist of the following information

 Identifying information

 Demographic information

 Clinical information

 Exposure / risk factor information

 Reporter information

 (Information on contacts)

7. Elements of Surveillance System

Once diseases for surveillance are selected, the following should be done
1. Case definition of diseases included in the surveillance. (Confirmed, probable and possible)

2. Determining and updating population under surveillance

3. Time period of collected data reporting

(Immediately, weekly, and monthly)

4. Sources of data, who would report etc.

5. How data are handled (confidentiality)

7.1 Case definition of diseases

Case definition
A case definition is a set of criteria used to decide whether a person has a particular disease.
Case definition may include:
 Criteria: Signs and symptoms with or without a laboratory test

 Restriction by time, place and person can be done depending on the nature of the disease

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Classification of cases:
1. Confirmed: a case with appropriate lab. Test confirmation

2. Probable: a case with typical clinical features of the disease without laboratory confirmation

3. Possible/ Suspect: a case with few of the typical clinical features.

Example of case definition for malaria

Confirmed Probable malaria Possible/Suspected malaria
malaria
Confirmed by Presence of chills, fever, headache, Presence of fever and headache of
laboratory test arthralgia, back pain etc, of sudden onset, sudden onset without laboratory
but without laboratory confirmation confirmation

Major advantages of case definition

• It facilitates early detection and prompt management of cases

• It is useful in areas where there is no laboratory

• It facilitates observation of trends within specified geographic areas

• It facilitates comparison accurately between different areas.

It is important to use case definition consistently because if different case definitions are used,
comparison will be difficult

7.2. Determine the population under surveillance

Different population groups can be targeted for surveillance. Target population can be individuals at
specific institutions, residents of a community, residents of a nation, etc. A surveillance system
remains effective when it is continuously assessed. Periodically updating information about the
catchment area is also necessary.

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7.3 Time period of data collection

It is useful to identify problems and solve timely. For this reason it is important to decide the data
collection and reporting time for different health problems.
There are three periods of reporting
1. Immediate reporting:

A. For diseases considering presence of a single case to result to a suspicion for an

epidemic.
B. Suspected epidemic when a threshold is crossed

2. On weekly basis:

For epidemic prone diseases. eg Malaria, meningitis

3. On monthly basis:

For Routine surveillance eg Tuberculosis, Leprosy, AIDS cases

7.2 . Confidentiality

Personal identifying information is necessary to identify duplicate reports, obtain follow-up

information when necessary, provide services to individuals, and use surveillance as the basis for
detailed investigations. One should be very careful to maintain the confidentiality of the information
provided by people included in the surveillance. Protecting the confidentiality of surveillance records
is both an ethical responsibility and a requirement for maintaining the trust of participants.
The following mechanisms can be applied to maintain the confidentiality of data:
• limiting access of personnel to sensitive data

• adequate locks for rooms and files where data are stored

• use of passwords and other security measures in computer systems

• personal identifying information should not be kept when it is not needed

While personal identifying information may be needed at the local level, it is generally not necessary
for that information to be forwarded to more central agencies. In such cases codes can be used

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8. Types of surveillance
There are three major types of surveillance. These are Passive Surveillance, Active Surveillance, and
Sentinel Surveillance
A. Passive surveillance
It is a mechanism for routine survey based on passive case detection and on the routine recording and
reporting system. The information provider comes to the health institutions for help, be it medical or
other. It involves collection of data as part of routine provision of health services.
Advantages of passive surveillance
• covers a wide range of problems

• does not require special arrangement

• it is relatively cheap

• covers a wider area

Disadvantages of passive surveillance

• Information generated is to a large extent unreliable, incomplete and inaccurate

• Most of the time, data from passive surveillance is not available on time

• Most of the time, you may not get the kind of information you desire

• It lacks representativeness as it is mainly from health institutions

• There is no feed back system

B. Active surveillance
Active surveillance is a method of data collection usually on a specific disease, for relatively limited
period of time. It involves collection of data from communities such as house-to-house surveys or
mobilizing communities to some central point where data can be collected. This can be arranged by
assigning health personnel to collect information on presence or absence of new cases of a particular
disease at regular intervals.
Example: investigation of out-breaks
The techniques employed to collect information for active surveillance are:
 Sending out a letter describing the situation and asking for reports,

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  making a telephone call

 visit the facilities to collect information on cases

 Alerting the public directly, usually through local media, to visit a health facility if they have
symptoms compatible with the disease in question.

 Asking patients of the particular disease if they know anyone else with the same condition.

 Conducting a survey of the entire population

Advantages of active surveillance

 the collected data is complete and accurate

 information collected is timely

Disadvantages of active surveillance

 it requires good organization

 it is expensive

 requires skilled human power

 it is for short period of time (not a continuous process)

 it is directed towards specific disease conditions

Conditions in which active surveillance is appropriate

• For periodic evaluation of an ongoing program

• For programs with limited time of operation such as eradication program.

• In unusual situations such as:

– New disease discovery

– New mode of transmission

– When a high-risk season/year is recognized.

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 – When a disease is found to affect a new subgroup of the population.

– When a previously eradicated disease reappears.

C. Sentinel Surveillance

Sentinel Surveillance uses a pre-arranged sample of reporting sources to report all cases of one or
more conditions. Usually the sample sources are selected to be those most likely to see cases of the
specified condition. Sentinel Surveillance provides a practical alternative to population-based
surveillance in developing countries. During the establishment of Sentinel Surveillance, health
officials define homogenous population subgroups and the regions to be sampled. They then identify
institutions that serve the population subgroups of interest, and that can and will obtain data regarding
the condition of interest.
Main Purposes of Sentinel Surveillance
 To detect changes

 To direct and focus control efforts

 To develop intervention strategies

 To promote further investigations

 Provide the basis for evaluating preventive strategies and activities

Advantages of sentinel surveillance

• relatively inexpensive

• provides a practical alternative to population-based surveillance

• can make productive use of data collected for other purposes

Disadvantages of sentinel surveillance

• the selected population may not be representative of the whole population

• use of secondary data may lead to data of lesser quality and timeliness

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8. Analysis of Surveillance Data

There is a need to analyze the data after receiving data about each individual included in the
surveillance. Usually descriptive analysis by time, place and person is conducted. Additionally, it is
also possible to conduct advanced statistical analysis like Time-series analyses to detect deviations,
Time-space clustering etc…

What can account for an apparent increase in cases?

The increase in the number of reported cases may not necessarily indicate the increase in the extent of
disease. Reports should be carefully interpreted.
The increase in the number of reported cases may due to:
• True increase in incidence

• Change in reporting procedures / change in surveillance system

• Change in case definition

• Improvements in diagnostic procedures

• Increased awareness

• Increased access to health care

• New physician, ICU, or clinic – may see more referred cases, may make diagnosis more often,
or report more consistently

• Laboratory or diagnostic error

• Change in denominator

9. Dissemination of Surveillance Data

When planning to disseminate surveillance information, it is necessary to decide to whom the

information shall be disseminated and how it can be disseminated.

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To Whom?
• Public health officials

• Governmental officials

• Clinicians / labs (reporters)

• Public

How?
• Internal briefs

• Health agency newsletters

• Press releases

• Surveillance summaries / reports

• Medical / epidemiologic journal articles

11. Features of good surveillance System

A good surveillance system:
• Uses a combination of passive and active mechanisms

• Collects the minimum data in a simplest possible way

• Collects data in a manner useful for the workers who collect the data

• Has timely reporting system

• Provide timely and comprehensive response/action

• Incorporate strong laboratory services for accurate diagnosis

Attributes of surveillance
Surveillance systems can be judged using a list of attributes (CDC 1988). This list can be used to
evaluate an existing system or to conceptualize a proposed system. Because the attributes may be
conflicting, it is necessary to determine which ones are the most important for a given system.

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The attributes of surveillance include sensitivity, timeliness, representativeness, predictive value,
Accuracy and completeness of descriptive information, simplicity, flexibility, and acceptability.
a) Sensitivity

Sensitivity answers the question - to what extent the system identify all of the events in the target
population?
b) Timeliness
It refers to timeliness of the entire cycle of information flow, ranging from information collection to
dissemination
C) Representativeness
Representativeness answers the question- To what extent do events detected through the surveillance
system represent persons with the condition of interest in the target population? A lack of
representativeness may lead to misallocation of health resources.
d) Predictive value
Predictive value answers the questions
 To what extent are reported cases really cares?

 To what extent are measured changes in trends truly reflective of events in the community

e) Accuracy and completeness of descriptive information

Forms of reporting health events often include descriptive personal information, such as demographic
characteristics, clinical pattern of disease, or potential exposures. This attribute answers the questions:
 To what extent are these sections of forms completed?

 Is the information sufficiently reliable?

f) Simplicity
This attribute answers the questions:
• Are forms easy to complete?

• Are procedures difficult?

• Is data collection kept to a necessary minimum?

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g) Flexibility
It is related to issues like:
• Can the system change to address new questions?

• Can it adapt to evolving standards of diagnosis or medical care?

h) Acceptability
This attribute answers the questions:
• To what extent are the participants in a surveillance system enthusiastic about the system?

• Does the effort they invest yield useful information?

Small group work

Different Health and Demographic Surveillance Systems (HDSS) are established in Ethiopia by
different universities. These HDSS sites are
1. Butajira Rural Health Program, Addis Ababa University

2. Dabat Research Center, University of Gondar

3. Gilgel Gibe Field Research Center, Jimma University

4. Kersa Demographic Surveillance and Health Research Center, Haramaya University

5. ArbaMinch Zuria Demographic and Health Development Program-ArbaMinch University

6. Kilte Awlaelo Demographic and Health Development Program- Mekele University

These HDSS sites are collecting data related to birth, death, migration, causes of death etc..There
is an intention to include some diseases in the already established surveillance system.
Discussion points
1) Which diseases do you recommend to include in the surveillance system? Why? Discuss from
the perspective of attributes of surveillance
2) What are the possible problems when the diseases you suggested are included in the
surveillance?

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References
• Rothman KJ & Greenland S. Modern Epidemiology (2 nd edn). Philadelphia: Lippincott-Raven
Publishers,1998

• http://www.who.int. Public Health Surveillance. Accessed on 18/7/2013

• CDC. CDC‘s Vision for Public Health Surveillance in the 21 st Century. Morbidity and
Mortality Weekly Report. July 27, 2012

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Session 2: Burden of HIV/AIDS
Session overview
This session gives overview of the burden of HIV/ADIS globally, nationally and regional, the
common programmatic areas of HIV intervention. This session will enable you to know tend and
impact of HIV/ADIS in sub-Saharan Africa and Ethiopia.
Learning Objectives

At the end of this session, participants will be able to:

 Describe the stages of HIV/AIDS epidemic

 Understand the global burden of HIV/AIDS

 Discuss on the burden, trend and impact of HIV/AIDS in Sub-Saharan Africa and
Ethiopia

 Discuss key Programmatic areas of HIV/AIDS interventions

1. Stages of the HIV/AIDS Epidemic

There are 3 stages of HIV/AIDS epidemic. These are low-level, concentrated, and generalized.
A) Low-level

– confined to persons with high-risk behavior

– not above 5% in any sub-population

– E.g Madagascar, Seychelles

B) Concentrated

– above 5% in one or more risk populations

– not above 1% in ANCs or pregnant women in urban areas

– E.g Mauritania, Senegal

C) Generalized

– well established in general population

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 – consistently above 1% in ANCs or pregnant women in urban areas

– E.g most of sub-Saharan Africa

2. Global burden

People living with HIV

In 2011, there were 34 million people living with HIV globally. Sub-Saharan Africa is the region most
affected, with nearly 1 in every 20 adults living with HIV. Sub-Saharan Africa accounts for 69% of all
people living with HIV.

New HIV infections

Worldwide, about 2.5 million people became newly infected with HIV in 2011. Twenty five countries
have seen a 50% or greater drop in new HIV infections since 2001. There has been 42% reduction in
new HIV infections in the Caribbean (the second most affected region in the world after sub-Saharan
Africa). Half of all reductions in new HIV infections in the last two years have been among newborn
children. In 2011, new infections in children were 43% lower than in 2003, and 24% lower than 2009.
However progress was uneven. Since 2001, the number of people newly infected in the Middle East
and North Africa increased by more than 35%. In Eastern Europe and Central Asia, there has also been
an increase in new HIV infections in recent years.

AIDS-related deaths

In 2011, 1.7 million people died from AIDS-related causes worldwide. Globally there were more than
half a million fewer deaths in 2011 than in 2005. The numbers of AIDS-related deaths had declined
by nearly one-third in sub-Saharan Africa between 2005 and 2011. The Caribbean experienced
declines in AIDS-related deaths of 48% between 2005 and 2011 and Oceania 41%. However two
regions experienced significant increases in AIDS-related deaths; Eastern Europe and Central Asia
(21%) and the Middle East and North Africa (17%).

Antiretroviral therapy

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In 2011, more than 8 million people living with HIV had access to antiretroviral therapy. The number
of people accessing HIV treatment had increased by 63% from 2009 to 2011. In 10 low- and middle-
income countries, more than 80% of those eligible are receiving antiretroviral therapy. However, 7
million people eligible for HIV treatment still do not have access. Seventy two percent of children
living with HIV who are eligible for treatment do not have access to the service.

HIV/TB
TB-related deaths in people living with HIV have fallen by 25% since 2004. However, TB remains the
leading cause of death among people living with HIV. All people living with both TB and HIV should
start antiretroviral therapy. However in 2011, fewer than half (48%) of people with TB who had a
documented HIV positive test result obtained antiretroviral therapy.

3. Sub- Saharan Africa

Sub-Saharan Africa remains the most heavily affected region in the global HIV epidemic. In 2011, an
estimated 23.5 million people lived with HIV resided in sub-Saharan Africa, representing 69% of the
global HIV burden. In the same year, 92% of pregnant women living with HIV resided in sub-Saharan
Africa. More than 90% of children who acquired HIV in 2011 live in sub-Saharan Africa. Women in
sub-Saharan Africa remain disproportionately impacted by the HIV epidemic, accounting for 58% of
all people living with HIV in the region in 2011.

In 2011, there were an estimated 1.8 million new HIV infections in sub-Saharan Africa compared to
2.4 million new infections in 2001 which showed a 25% decline. Between 2005 and 2011, the number
of people dying from AIDS-related causes in sub-Saharan Africa declined by 32%, from 1.8 million to
1.2 million. Since 2004, the number of TB related deaths among people living with HIV has fallen by
28% in sub-Saharan Africa. Between 2009 and 2011, the number of children newly infected with HIV
fell in sub-Saharan Africa by 24%. In six countries of sub-Saharan Africa (Burundi, Kenya, Namibia,
South Africa, Togo and Zambia), the number of children newly infected with HIV declined by 40%–
59% between 2009 and 2011. Fourteen additional countries in the region reported declines of 20-39%.
However, 11 countries in the region saw more modest declines of 1–19%. In four countries (Angola,
Congo, Equatorial Guinea, Guinea-Bissau), the number of new HIV infections among children
increased. In 2011, coverage of services to prevent mother-to-child transmission (PMTCT) of HIV in

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sub-Saharan Africa reached 59%. Six countries in the region achieved PMTCT coverage of more than
75%: Botswana, Ghana, Namibia, South Africa, Swaziland and Zambia. Seven countries reported
PMTCT coverage of less than 25%: Angola, Chad, Congo, Eritrea, Ethiopia, Nigeria and South Sudan.

Surveys conducted between 2004 and 2011 in 14 countries in sub-Saharan Africa found significant
increases in the percentage of adults who had taken an HIV test in the previous 12 months and
received their results. In Lesotho, for example, an estimated 42% of adult women reported that they
had been tested for HIV in 2009 compared to about 6% in 2004. In Rwanda, nearly 39% of adult
women were tested for HIV in 2010 compared to about 12% in 2005. In Ethiopia, an estimated 21% of
adult men were tested for HIV in 2011 compared to approximately 2% in 2005. Approximately 23%
of adult men in Kenya were tested for HIV between 2008/9 compared to about 8% of men in 2003.
Among countries surveyed, HIV testing rates tended to be higher among women than men; this may
be due, in part, to increased availability of HIV testing in antenatal settings. Increases in HIV testing
coverage can be linked to the scale up of antiretroviral therapy programmes and investment in a broad
array of HIV testing strategies, such as provider-initiated testing and counseling, rapid testing
technologies and home-based testing campaigns.

In 2011, an estimated 56% of people eligible for HIV treatment in sub-Saharan Africa were receiving
it compared to a global average of 54%. Five countries in the region have achieved more than 80%
coverage of HIV treatment namely Botswana, Namibia, Rwanda, Swaziland and Zambia. Benin,
Kenya, Malawi, South Africa and Zimbabwe achieved more than 60% coverage of HIV treatment.
Coverage of antiretroviral therapy in three countries in the region—Madagascar, Somalia and South
Sudan was is less than 20%. Wider access to treatment is saving lives. Since 1995, antiretroviral
therapy has added approximately 9 million life-years in sub-Saharan Africa. Available evidence
continues to highlight the urgent need to improve retention rates for people enrolled in HIV treatment
and care.

4. Ethiopia
HIV AND AIDS ESTIMATES (2011)
• Number of people living with HIV -790,000

• Prevalence rate among adults 15 to 49 years - 1.40%

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• Adults aged 15 years and up living with HIV - 6 10,000

• Women aged 15 and up living with HIV - 390,000

• Children aged 0 to 14 years living with HIV - 180,000

• Deaths due to AIDS - 54,000

• Orphans due to AIDS aged 0 to 17 years- 950,000

• Reported number of people receiving ART in 2012 - 288 137

• Estimated number of people eligible for ART in 2012 - 480 000

• Estimated ART coverage in 2012 - 60%

• Number of pregnant women living with HIV receiving antiretroviral medicines for PMTCT in
2012 - 15 828

• Estimated number of pregnant women living with HIV needing antiretroviral medicines for
PMTCT in 2012 - 38 000

• Antiretroviral coverage among pregnant women living with HIV, 2012 - 41%

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Goals: Global (MDG)
The following HIV/AIDS related goals were set
a) Millennium Development Goal 6: Combat HIV/AIDS, malaria and other diseases

– Target 7: Have halted by 2015 and begun to reverse the spread of HIV/AIDS

b) WHO 3 by 5 Goal: Universal access to antiretroviral therapy for all living with HIV/AIDS

– Target: Treating 3 million people by 2005

c) US Presidents Emergency Plan

• Prevention of 7 million new infections

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 • Treat 2 million HIV-infected people

• Care for 10 million HIV-infected individuals and AIDS orphans

6. Key HIV/AIDS Programmatic Areas

A) Prevention
1. Behavior Change Communication
– e.g. sexual behavior, condom use, injectable drug use (IDU) behaviors

– Most organizations are engaged.

2. Medical Interventions

– e.g. PMTCT, VCT, blood safety, universal precautions, STI treatment etc.

B) Care and Treatment

3. Care and support to PLWHA and their families.

4. Prophylaxis and treatment of opportunistic infections (including tuberculosis).

5. Treatment with antiretroviral therapy (ART).

C) Impact Mitigation
6. Support to Orphans and Vulnerable Children (OVC)

7. Reduction of stigma and discrimination

8. Addressing gender disparities

Small group work

In some Sub-Saharan African countries the prevalence of HIV/AIDS remained high. What are the
possible reasons?

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References
• UNAIDS. Global Fact Sheet. World AIDS Day 2012

• UNAIDS. Regional Fact Sheet 2012

• WHO Report (June 2013). Global Update on HIV Treatment 2013: Results, Impact and
Opportunities

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Session 3: HIV/AIDS surveillance
Session overview:
This session gives overview of the purposes HIV/ADIS surveillance to know the types of different the
types of surveillance. This session will enable you to know the surveillance sampling method and
methods of surveillance data collection. Why is HIV/ADIS surveillance needed? How do they work
and what are their types?
Learning Objectives
At the end of this session, participants will be able to:
• Describe the purposes of HIV/AIDS surveillance

• Describe core elements of HIV/AIDS surveillance

• describe the different surveillance systems

• Understand the components of Second-Generation HIV Surveillance

• Describe basic data collection methods

• Discuss the surveillance sampling methods

• Describe the indicators used in surveillance

1. Purposes of HIV and AIDS Surveillance

HIV and AIDS Surveillance have the following purposes:
• Provide an accurate assessment of the distribution of disease by person, place and time

• Provide information on trends in disease distribution by geographic, socio-demographic or

exposure parameters

• Identify groups or geographical areas for interventions

• Provide information to evaluate effectiveness of interventions

• Provide data for prevention programme management

• Provide data for development and implementation of research efforts

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2. Core Elements of HIV/AIDS Surveillance
a) AIDS case reporting
It is routine reporting of AIDS cases in all or selected health facilities in a country. The purpose of
such reporting is to monitor AIDS morbidity in the general population
b) HIV sero-surveillance

The purpose of this form of surveillance is to estimate the prevalence of HIV infection in selected
populations. Sero-prevalence surveys are conducted on selected populations on an ongoing basis

3. Common Surveillance Systems

Surveillance Description Advantages

system
Universal Minimum data collected from all health It provides data that can be
case facilities in the country where cases are generalised to the entire population of
reporting seen. a nation.

Sentinel More complete data are obtained from It provides detailed, high-quality data
surveillance all patients seen at a small number of about more specific population by
facilities, which are known to using a smaller, more reliable system.
consistently report cases.

Considerations in Selecting Sentinel Populations

The local epidemiology of HIV and major risk factors and the state of the epidemic shall be considered
in selecting the sentinel populations
In low-level epidemics, sentinel surveillance should focus on high-risk groups. For example,
commercial sex workers

In concentrated epidemics, sentinel surveillance should include both persons from high-risk groups
and women in ANCs.

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In generalised epidemics, sentinel surveillance should focus primarily on women in ANCs. Since
most sub-Saharan African countries have generalised epidemics, surveillance should focus on women
attending ANCs.

Advantages of ANC Attendees as Sentinel Populations

• ANCs include sexually active women aged 15 to 49.

• ANCs are attended by a large proportion of the adult female population in many countries.

• HIV testing can be done on an anonymous basis since blood specimens are taken for other
purposes.

• HIV prevalence among pregnant women can be used to estimate the potential for mother-to-
child transmission of HIV.

• ANCs are most common sentinel surveillance sites in sub-Saharan Africa and developing
world.

• Provide a basis to compare districts, countries and regions.

Disadvantages of ANC Attendees as Sentinel Populations

• ANCs do not include infertile women, women who have abortions and women on
contraceptives.

• HIV may decrease fertility and women‘s desire for children, so HIV+ women will be under-
represented.

• ANCs may underestimate HIV prevalence in older age groups as HIV-positive women are less
likely to:

• get pregnant

• to attend ANCs if they are pregnant

• ANC attendance may vary by gravidity and quality of care provided.

• ANC-based sentinel surveillance does not directly measure HIV prevalence in men.

• ANCs may not include or be able to identify women at highest risk for infection (for example,
sex workers).

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Selecting ANC Attendees for HIV Surveillance
• Selection criteria must be standardised.

• Clear inclusion and exclusion criteria to ensure integrity of results, e.g.

– Minimise multiple sampling of the same women attending an ANC

– Include only women who are attending the ANC for the current pregnancy for the first
time

– Only sample ANC clients screened for syphilis (syphilis screening only once)

STI Clinics for HIV Sentinel Surveillance

STI clinic patients are an easily identifiable and readily accessible group at high risk for acquiring HIV
infection through sexual intercourse.
Advantages of STI Clinic Patients for HIV Sentinel Surveillance
• HIV testing can be done anonymously with unlinked results if blood is drawn for serologic
testing for syphilis.

• STI clinics include large numbers of both men and women.

Disadvantages of STI Clinic Patients for HIV Sentinel Surveillance

• May not be representative of the population of all persons with STIs. Many persons self-treat
STIs or seek treatment outside of government-run STI clinics.

• Only patients with STI symptoms will seek care.

• Some STIs do not cause symptoms, especially in women.

Additional Sentinel Populations

Patients in other health care facilities can potentially be used as sentinel populations.
For example:
 Tuberculosis (TB) clinics

 Hospital wards and clinics providing health care to refugees or other high-risk groups

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  Workplace-based clinics: factory workers, miners or plantation workers

Members of other high risk populations may not be seen at a particular clinic. In such cases, special
community-based sero-surveys may be needed. Such populations include truck drivers, sex workers in
brothels or streets, migrant workers etc..

Recommendations for Sentinel Populations in Sub-Saharan Africa

• First Priority: Pregnant women attending ANCs

• Second Priority: STI clinic attendees

• Third priority: Other populations, for example sex workers, long-distance truck drivers or
male occupational groups

Criteria for Site Selection

Selection of sites for HIV sentinel surveillance is a balance between:
 including as much of the selected population as possible; and

 logistical necessities

One may consider the following criteria during selection of sites

1) Population served: Sites provide services for selected sentinel populations.

2) Blood samples available: Blood is drawn from patients as part of routine care.

3) Laboratory access:

 A reliable laboratory is available on-site or nearby to perform routine laboratory tests

 Alternatively, reliable transport options exist to send specimens to reference laboratory

4) Accessibility: Sites are readily accessible to surveillance staff for data collection or
supervision.

5) Size of client base: Sites provide services to a large enough number of persons to reach target
sample size within sampling period.

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 6) Geographic diversity: Sites are located in different geographic areas, both in cities and rural
areas.

7) Resources: Needed resources (human, laboratory, transport) can be mobilised.

8) Staff acceptance: On-site staff

 understand need for HIV sentinel surveillance

 willing to implement activities

 open to training and supervision

Number and Distribution of Sentinel Sites

Number and distribution of sites is usually decided on a national level. Ideally, sentinel sites Shall:
 Represent each district

 Reflect the country-wide epidemic

 Include both urban and rural areas

Setting Priorities
• First priority: Include at least one site per district so that all regions or provinces are included
in the national system

• Second priority: Include additional sites in particular districts because sexual behaviour and
determinants for HIV transmission may not be uniformly distributed

Surveillance with Limited Resources

• Aim for broad geographic coverage

• Don‘t over-stretch resources

• Quality over quantity

4. Second-Generation HIV Surveillance

Second-Generation HIV Surveillance is developed by the WHO and UNAIDS as a response to the
increasing complexity of the HIV epidemic. Second-Generation HIV Surveillance:

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 • Outlines more sophisticated surveillance activities

• Provides a more comprehensive understanding of epidemic trends

• Improves effectiveness of control and prevention efforts

Goals of Second-Generation HIV Surveillance

• Better understanding of trends over time

• Better understanding of behaviors driving the epidemic in a country

• Increased focus on sub-populations at highest risk for infection

• Flexible to change with the stage of epidemic

Indicators of Second-Generation HIV/AIDS Surveillance

• Biological indicators
• Behavioral indicators
• Socio- demographic indicators

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Biological Indicators
• HIV prevalence

• STI incidence and prevalence

• TB prevalence

• number of adult AIDS cases

• number of pediatric AIDS cases

Behavioral Indicators
• sex with a non-regular partner in last 12 months

• condom use at last sex with non-regular partner

• age at first sex for youth

• use of unclean injection equipment by drug injectors

• reported number of clients in the last week by sex workers

Socio-demographic Indicators
• Age, sex

• socio-economic and educational status

• residency or migration status

• parity (for antenatal sites)

• marital status

5. Basic Data Collection Methods

• Sentinel surveillance in defined sub-populations (such as antenatal clinic attendees, STI clinic
patients, sex workers)

• Serial cross-sectional behavioral surveys in high-risk sub-populations

• Regular HIV screening of donated blood

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 • AIDS case surveillance

Additional Data Collection Methods

• Regular screening of occupational cohorts or other sub-populations (such as factory workers,
military recruits)

• HIV screening of specimens taken in general population surveys

• Serial cross-sectional behavioral surveys in the general population

• HIV case surveillance

• Death registration and mortality surveillance

• STI and TB surveillance

• Data from VCT and treatment programmes

6. Surveillance of Populations at High Risk for HIV Transmission

Populations at increased risk are the most likely to get HIV infection first in a new epidemic. They are
infected at higher prevalence than the general population. In other words, a population at increased
risk will become infected at a faster rate than people who are not members of a population at increased
risk.
Populations at High Risk for HIV Transmission Includes:
• Sex Workers (SWs)

• Men Who Have Sex with Men (MSM)

• Mobile Populations and Migrants

• Injection Drug Users (IDUs)

• Out-of-School Youth

• Prisoners

• Uniformed Personnel

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Populations at increased risk play a central role in the spread of HIV infection. At the beginning of an
HIV epidemic, the first infections appear in these groups, because they have higher-risk behaviours.
These behaviours, for instance, include:
• having sex without using a condom (unprotected sex) with multiple partners and/or having a
high number of new partners

• injecting drugs with shared needles

Populations at increased risk also serve as bridges to other groups and the general population, since
they can introduce HIV into these groups. For example, a client of an HIV-infected sex worker may
get HIV infection. He may then have unprotected sex with his wife, infecting her. In this scenario, he
has acted as a bridge, from which HIV infection has passed from the sex worker to his wife.

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 Uses of HIV surveillance data in populations at increased risk at different states of the epidemic
Epidemic Situation Uses
State
Low-level HIV has not reached significant levels in high- Early warning of a possible epidemic
risk groups Triggers interventions to prevent HIV
HIV is largely confined to people within high-risk in populations at increased risk
groups who exhibit higher-risk behaviours
Concentrated HIV has spread rapidly in one or more high-risk Monitor infection in populations at
groups increased risk
Epidemic is not well-established in the general Monitor effects of intervention
population programmes on HIV prevalence and
behaviours
Generalised Epidemic has matured to a level where Monitor for initial decreases in HIV
transmission occurs in the general population (not prevalence in populations at
dependent on populations at increased risk) increased risk
With effective prevention, in general, prevalence Monitor effects of intervention
will drop in populations at increased risk before programmes on HIV prevalence and
they drop in the general population. behaviours
For example, following a prevention campaign
targeted at sex workers, surveillance should first
find a decrease in STIs in the sex workers, then in
male sentinel populations, and then in antenatal
clinics

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7. Behavioral Surveillance Surveys (BSS)

Behavioral surveillance involves regular, repeated cross-sectional surveys collecting data on HIV risk
behaviors and other relevant issues that can be compared over time.

Use of BSS
1) It serves as an early warning system
Not everyone in the population is at the same risk for HIV. Behavioural data can indicate which
populations are at risk locally, and can suggest the pathways the virus might follow if nothing is done
to brake its spread. It can indicate levels of risk in the general population too, and can identify sexual
links or ―bridges‖ between groups in the population with especially high risk of infection, and groups
with lower risk.

2) BSS informs program design

Without information on HIV related risk behaviour, public health officials and others are unlikely to
be able to prioritize their interventions. Behavioural data can pinpoint specific behaviours which need
to be changed, and can also highlight those that are not changing over time in response to program
efforts. This information should lead to a rethinking of prevention approaches, and the design of new,
more effective interventions.

3) BSS helps evaluate programs

A good behavioural data collection system will give a picture of changes in sexual and drug-taking
behaviour over time, both in the general population and in groups of people whose behaviour puts
them at high risk of infection. These changes should give an indication of the success of a package of
activities aimed at promoting safe behaviour and reducing the spread of HIV, both in the general
population and in groups with high risk behaviour.

4) Changes in behaviour help explain changes in HIV prevalence

Changing behaviour and a consequent reduction in new infections are possible reason for changes in
HIV prevalence

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Designing a Behavioural Surveillance System
When designing a behavioural surveillance system, you should consider:

• whom to include in surveillance

• where to access the surveillance populations

• how to link biological and behavioural surveillance data

• how to ensure that surveillance is appropriate for the context.

Whom to include in surveillance by epidemic state

State of the Biological surveillance Behavioural surveillance

epidemic (annually if feasible)

Low-level High-risk groups High-risk groups annually,

general population every 3-5 years
Concentrated High-risk groups, High-risk groups annually,
general population general population every 3-5 years
Generalised High-risk groups, High-risk groups annually,
general population general population annually

Essential Indicators for Behavioural Surveillance

General population IDUs CSWs

 proportion who had  proportion who  last time and
commercial sex in past year shared needles consistent
last time condom use
 frequency of commercial
with clients
sex in past year  proportion who
did not use  proportion
 proportion who had non-
clean needles who injected
regular/casual partners in
consistently in drugs in past

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 past year past week (or year
other time
 frequency of non-regular/
reference
casual partners in past year
period)
 last time and consistent
condom use by partner type

 proportion who injected

drugs in past year

Content of surveys useful for behavioural surveillance

Survey Content

Demographic and health  Knowledge and source of knowledge of AIDS and other
STIs
surveys (DHS),
AIDS Indicator Survey  Knowledge of how to avoid HIV/AIDS

(AIS), MACRO  Condom use at last and penultimate sex

International  Relationship to last and penultimate sexual partner
 Length of time known last and penultimate sexual
partner
 Age at first sex
Internet link: http://www.measuredhs.com/
Multiple Indicator Cluster  Knowledge and source of knowledge of AIDS
Survey (MICS), UNICEF  Knowledge of how to avoid HIV/AIDS
 Knowledge of testing sites and if ever tested
Internet link: http://www.childinfo.org/index2.htm
Behavioural surveillance  Surveys for CSW, MSM, IDUs, Youth, Adults on HIV-
related risk behaviours
surveys (BSS), FHI
Internet link: http://www.fhi.org/en/topics/bss.htm

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Working with hard-to-reach populations

High-risk groups that are included in surveillance are often hard to reach because:
• They engage in illegal/clandestine behaviours.

• They often do not want to be identified because of high levels of stigmatisation and
discrimination.

• Their existence is denied by the general population and government.

• There are restrictions on who may approach the group and how the group can be approached
(gatekeepers such as brothel owners may not want sex workers interviewed, the government
may not want non-military personnel interviewing military, etc.).

• Group members have little time to talk.

• Groups do not want to be found for surveillance because they fear authorities or do not want
outsiders entering the group.

8. Sampling Methods
Two broad methods
1) Non-probability sampling methods

2) Probability sampling methods

Non-probability sampling methods

These methods do not claim to be representative of the entire population
E.gs Convenience sampling, quota sampling

1) Convenience sampling
For convenience sake the study units that happen to be available at the time of data collection
are selected

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2) Quota sampling
It ensures that a certain number of sample units from different categories with specific characteristics
are represented. The investigator interviews as many people in each category of study unit as he can
find until he has filled his quota
Probability sampling methods
Probability sampling methods Involves random selection procedure. All units of the population should
have an equal or at least a known chance of being included in the sample. Generalization is possible in
probability sampling methods.
Probability sampling methods include:
1) Simple random sampling
2) systematic sampling
3) stratified sampling
4) Cluster sampling
5) Multistage sampling

Sampling issues in behavioral surveillance

1. Consistent sampling is required across survey rounds:

If sampling changes between rounds, we don‘t know if any observed changes are real or a result of
changes in methodology.
2. General populations can rarely be used to access high-risk groups:
• Group members may not be found in households in sufficient numbers and may not want to talk in
household settings.

• Instead, the locations where group members congregate can be defined as clusters.

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Examples of possible clusters for high-risk groups
High-risk group Possible cluster
Brothel-based sex workers Brothels
Non-brothel-based sex workers Streets, bars, hotels, guesthouses
Men who have sex with men Cruising sites
Intravenous drug users Shooting galleries, injecting sites
Truckers Loading/unloading/halting points
Migrants Households, workplaces

3. Cluster sampling is difficult when clusters are not stable.

 A measure of cluster size is needed for cluster sampling.

 It is difficult to estimate cluster size when we use locations like sex worker sites as clusters,
because the people in each cluster are rarely fixed.

 The risk behavior in a cluster may also vary by time of day.

 This makes it difficult to select a sample that is representative of the entire target population
using conventional cluster sampling.

4. Members of high-risk groups may be difficult to identify and access.

5. Cluster sampling is impossible if group members do not congregate.
• Some groups do not congregate at all.

• In others, only some members of the population congregate and important sections of the group
may be missed.

Conventional cluster sampling

It is appropriate for the general population, youth and a few high-risk groups, such as prisoners.

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Newer Sampling Methods
Two new sampling methods combine the methods of probability and non-probability sampling to
identify with relative ease samples that are representative and from which results can be generalised.
These are:
 respondent-driven sampling (RDS)

 time-location sampling (TLS).

RDS and TLS are ideally suited for surveys of high-risk groups, especially those that are harder to
find.

Respondent-Driven Sampling
RDS combines the methods of snowball sampling with a mathematical model in a way that weighs the
sample to compensate for the non-random way it was collected. This method does not require a
sampling frame. It is especially useful for finding hard-to-reach groups, which do not congregate
Steps in RDS:
1. Start with initial contacts or ‗seeds,‘ who are surveyed and then become recruiters.

2. Each recruiter invites up to three people they know in the high-risk group to be interviewed.

3. The new recruits become the recruiters.

4. Five to six recruitment waves occur.

Time-location sampling
Time location sampling is used when high-risk groups congregate, but their clusters are not stable. It
allows locations to be included as clusters more than once (e.g., at different times of the day or on
different days of the week). Clusters are defined by both location and time.
For example:
Cluster 1= Site 1 weekday afternoon
Cluster 2= Site 2 weekday evening
Cluster 3= Site 1 weekend
Cluster 4= Site 2 weekday afternoon

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 Cluster 5= Site 1 weekday evening
Cluster 6= Site 2 weekend
Time location sampling is like conventional cluster sampling, but addresses the problem of everyone
not being in the same place at the same time. It requires extensive ethnographic mapping to prepare a
sampling frame that captures the variability in the time and location of behaviours and the number of
group members

8. Indicators
Behavioural surveillance indicators should measure behaviours that are key to the spread of HIV and
that are targeted by HIV prevention programmes.
These are:
 behaviours that increase the chance that an uninfected person will come into contact with an
infected person

 behaviours that increase the chance that HIV will be transmitted if contact with an HIV-
infected person occurs

 determined by the country‘s data needs

Family Health International (FHI) publishes guidelines for repeated behavioural surveys in
populations at risk of HIV, including indicators that are key to the spread of HIV among FSWs. These
guidelines are available online at: http://www.fhi.org. The HIV/AIDS Survey Indicators Database of
MEASURES DHS includes applicable health indicators that are used to evaluate attitudes and
behaviours relative to the health risks measured by HIV and STI prevalence surveys. These indicators
are available online at: http://www.measuredhs.com/hivdata/ind_tbl.cfm

Small group work

• Discuss the HIV/AIDS surveillance systems being applied in Ethiopia.

• Suppose polygamy is acceptable in one of the districts of Ethiopia. It is also acceptable for a
man to have extramarital sex. There are many commercial sex workers in the capital city of the
district

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 • Which group of people should be targeted for surveillance? Commercial sex workers or
pregnant women attending ANC clinics? Why?

References
• FHI, Impact, USAID, DFID. Behavioral Surveillance Surveys. Guidelines for repeated
behavioral surveys in populations at risk of HIV. 2000

• UNAIDS. GLOBAL AIDS RESPONSE PROGRESS REPORTING 2013. Construction of

Core Indicators for monitoring the 2011 UN Political Declaration on HIV/AIDS. 2013

Session 4: Ethical Considerations in HIV/AIDS Surveillance

Session overview:
This session gives highlight the major ethical issues of HIV/ADIS surveillance. How to conduct
surveillance in vulnerable group of people. This session will described the major ethical priceples
when conducting HIV/ADIS surveillance.

Learning Objectives
By the end of this unit, the participant will be able to:
 Describe the basic ethical principles

 Describe the major ethical issues in HIV/AIDS surveillance

 Discuss the mechanisms of respecting the ethical principles when conducting HIV/AIDS
surveillance

 Describe how to deal with vulnerable group of people when conducting HIV/AIDS
surveillance

1. Major ethical issues in HIV-AIDS related surveillance

 elevated risk of harm for people in high-risk populations, especially if their behaviour is illegal

 stigma

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  confidentiality

 informed consent

 access to prevention and care services

2. Basic Ethical Principles

 Respect for persons – study subjects are persons whose rights and welfare must be protected,
not just passive sources of data

 Beneficence – researchers should balance benefits and risks (physical and psychological harm)
to individuals

 Justice – risks and benefits from studies should be distributed fairly and evenly in populations

These principles are considered universal regardless of geographic, economic, legal and political
boundaries. Researchers are obliged to assure that these principles are followed while conducting
research involving human participants.

2.1. Respect for persons

Respect for persons addresses two main ethical considerations

a) Respect for autonomy, and
b) Protection of persons with diminished or impaired autonomy.
An autonomous person is one who is capable of deliberation about personal goals and of acting under
the direction of such deliberation. To respect autonomy is to give weight to the considered opinions
and choices of the individual, while refraining from obstructing his/her actions
Not every individual is capable of decision-making.
Lack of maturity, mental disability, or circumstances that severely restrict liberty (as in the case of
prisoners), may all decrease the capacity for decision-making. Respect for those with diminished or
impaired autonomy may require protecting them.
Respect for persons demands the voluntary participation of the research participant with adequate
information. According to this principle, the study participants have the right to be well informed and
give consent. This process is known as informed consent

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Voluntary participation
An agreement to participate in research constitutes a valid consent only if voluntarily given. This
requires freedom from coercion and undue influence. Coercion occurs when an overt threat of harm is
intentionally presented by one person to another to obtain compliance. On the contrary, undue
influence occurs through an offer of an excessive, unwarranted, inappropriate or improper reward to
obtain compliance. It is impossible to state precisely where justifiable persuasion ends and undue
influence begins. Undue influence includes actions like manipulating a person‘s choice through the
controlling influence of a close relative and threatening to withdraw health services to which an
individual would otherwise be entitled.
Unique issues of consent with minors and the role of parents in the consent process
Protection of vulnerable individuals who may not have the psychological or legal capacity to choose is
necessary. Parents are required to consent to their children‘s participation. Depending on the nature of
the research and the age of the child, the child‘s consent is also required. This set of basic premises
raises significant problems in second generation surveillance, where interviewing adolescents about
their sexual behaviour may clearly be critically important. Parents may not want their children to
participate, and parents who are informed that their children have chosen to participate may view such
a decision as indicative of disapproved behaviour involving either sex or drugs. Without parental
involvement, adolescents may be included in studies involving sex and drugs under the following
circumstances:
1) Studies involving investigation of adolescents‘ beliefs and behaviour regarding sexuality or use of
recreational drugs;
2) Researches that address domestic violence or child abuse.
For studies on these topics, ethical review committees may waive parental permission if, for example,
parental knowledge of the subject matter may place the adolescents at some risk of questioning or
even intimidation by their parents.

Impact of the social context on the capacity to consent

People receiving clinical care who are recruited to studies may believe that they have no alternative
but to agree to participate. They may feel that their treatment will be compromised or interrupted if
they choose not to participate or if they choose to withdraw from studies that they have agreed to join.

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Even when they do not feel that their treatment is threatened, they may believe that they have a duty to
their caregivers to agree to participate. Review committees should include people who can ensure that
the approach to patients avoids coercive elements. For example, they may determine that the consent
process be undertaken by people who are not directly involved in patient care.

Prisons may provide a unique environment for second generation surveillance. Prisoners are at
increased risk for believing that their failure to cooperate with research studies will result in punitive
responses. In addition, relatively small benefits that may accrue as a result of participation may cause
undue inducements.

In poor populations, small offers or payments to potential subjects of surveillance may be hard to
refuse. In relatively wealthy countries, this is an issue that affects impoverished and marginalized
minorities. In countries in which poverty is widespread, offers by external sponsoring researchers with
access to resources may produce pressure to participate in surveillance. Payments should not be so
large or the medical services so extensive as to induce prospective subjects to consent to participate in
research against their better judgement.
Issues of consent unique to women
In many societies the father, husband or family head is expected to make all decisions regarding
sensitive family issues. Women and other family members who fail to submit to male authority are
subject to domestic violence, divorce or social ostracism. Refusing to involve women in studies
because of such cultural constraints could affect investigations crucial to women‘s interests. A
woman‘s informed consent may be supplemented by consent from a man under the following
conditions:
a) it would be impossible to conduct the research without obtaining such supplemental
permission; and

b) failure to conduct this research could deny its potential benefits to women in the host country;
and

c) measures to respect the woman‘s autonomy to consent to research are undertaken to the
greatest extent possible

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A husband, father or head of household may not provide the sole consent for a woman to participate in
surveillance. Although there may be circumstances in which a woman may need to consult with and
get the approval of her husband or father, her individual informed consent remains imperative before
she is enrolled in behavioural surveillance studies

Informed Consent
Researchers must present information to help the subject decide whether to participate, including:
 the nature of the surveillance system

 the procedures the project will entail

 potential risks and benefits

 assurance that participation is voluntary and confidential

Whenever informed consent is obtained, participation bias is an important issue and should be
considered in the analysis. When HIV test results are to be given to individual subjects, confirmatory
testing is required for positive specimens

Written Consent Forms

Written consent forms are required to document that the process of informed consent has occurred. In
some situations, verbal consent documented by the investigator may be adequate. When individuals
cannot give informed consent, surrogate consent should be obtained
2.2 Beneficence

Two general rules have been formulated as complementary expressions of beneficence:

a) Do not harm, and
b) Maximize possible benefits and minimize possible harms.
One should not injure study participants regardless of the benefits that might come to others.

Potential Benefits of HIV Surveillance

 guiding HIV prevention and care programmes

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  guiding STI and other services

 raising public awareness of and sympathy for burden of disease in the population

 reducing stigma and effecting social change, especially around HIV infection

 special benefits for certain high-risk populations, such as STI clinics specifically for sex
workers

 HIV treatment services for prisoners

Potential Harms Caused by HIV/AIDS Surveillance

Harm Result
Physical public attack, spouse/partner abuse, domestic violence
Legal arrest, prosecution, especially with high-risk populations
Social workplace discrimination, loss of employment, isolation, loss
of healthcare services

Common terminologies related to the principle of Beneficence

Stigma – a mark of disgrace or shame
Confidentiality – keeping the identity of a participant and their test results secret
Unlinked anonymous testing – when a sample of blood is tested for HIV after all information that
could identify the source of the blood is eliminated from the sample
Linked anonymous testing – when the HIV result is linked to a patient‘s other clinical data after all
information that could identify the source of the blood is eliminated from the sample

Confidentiality
Confidentiality protects subjects from adverse consequences that may arise if their personal
information is known. If confidentiality about HIV infection is violated, subjects may suffer
discrimination. Public health officers must maintain the confidentiality of individuals‘ records to guard
against accidental disclosure. In general, behavioural surveillance studies do not require that data be
recorded in a manner that links them to identifiable individuals. Research should be conducted in a
way that makes sensitive records anonymous when this can be done without compromising the

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investigation. However, identifiable records may be required in some circumstances, such as in
longitudinal studies, which seek to track changes in behaviour over time, or if linkage to other data
sources is essential for the investigation. Under these circumstances, every effort must be made to
protect the confidentiality of research records. For example, coded identifiers could be appended to
each research record and the link between that code and a given individual kept in a highly secure file.
Although researchers are obligated to report their findings in a way that protects the anonymity of their
research subjects, a very different problem arises when studies conducted in small communities would
clearly identify individuals despite the effort to make research records anonymous. Thus, anonymous
records cannot be regarded as strictly confidential in all circumstances. Researchers and ethical review
committees are obligated to protect the confidentiality of people recruited to behavioural studies. Such
an obligation may be met by recording the data anonymously. If this is not possible, every effort must
be made to secure records to prevent unwarranted disclosure. Legal or ethical limits on confidentiality
should be disclosed to research participants as part of the informed consent process. While maintaining
confidentiality, the minimum identifiable information necessary to conduct a study should be
collected.

Unlinked Anonymous Testing (UAT)

UAT without informed consent is conducted only in clinical settings. A specimen of blood originally
collected for other purposes is used as follows:
 All personally identifying information is removed from the specimen.

 The blood is tested for HIV.

UAT has been deemed ethical if:

 No interaction takes place with the survey participant solely for the purpose of the surveys

 Information that may inadvertently identify a person is not kept

Communities should be broadly notified that blood collected for one purpose may be anonymously
tested for HIV. Although fully informed consent is not required for unlinked anonymous surveillance,
the wishes of individuals wishing to opt out of such surveillance should be respected where possible. If
the numbers of individuals opting out or spontaneously refusing to participate threaten the validity of

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surveillance efforts, ethics review committees will have to determine whether the public health
significance of the studies warrants overriding the right to refuse to participate.

Advantages and disadvantages of UAT

Advantages
 Privacy of the individual is maintained.

 Participation bias is minimised.

Disadvantages
Tested individuals are not aware that they are being tested and cannot receive their test results or
counselling. This can be overcome by offering voluntary counselling and testing (VCT) at the sentinel
site

Small group work

These days many adolescents in high schools are engaged in risky sexual behavior. You want to
establish a surveillance system in high schools so that you can follow the HIV infection rate and
behavior of adolescents in the high schools
1) Describe how you will be maintaining the ethical principles when you are establishing the
surveillance
2) What are the challenges of such surveillance?

References
Ann Aschengrau, George R. Seage III. Essentials of Epidemiology in public health. Jones and Bartlett
Publishers. 2008
http://www.who.int. Ethical issues to be considered in second generation surveillance. Accessed
on 18/7/2013.
Robert B. Wallace, Nearl Kohatsu, Brownson, Schetcer, Scutchfield, Zaza. Public health and
preventive Medicine.
Thomas M. Garrett, Harold W. Baillie, Rosellen M. Garrett. Health Care Ethics. Principles and
Problems (4th edition). Upper Saddle River, New Jersey, 2001.

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Tom L. Beauchamp, James F. Childress. Principles of biomedical Ethcs, 5 th Edition, Oxford
University Press, 2001.

Session 5: Outbreak investigation and management

Session overview
Outbreak investigations, an important and challenging component of epidemiology and public health,
can help identify the source of ongoing outbreaks and prevent additional cases. Even when an
outbreak is over, a thorough epidemiologic and environmental investigation often can increase our
knowledge of a given disease and prevent future outbreaks. Finally, outbreak investigations provide
epidemiologic training and foster cooperation between the clinical and public health communities.
This session gives highlight the major steps of outbreak investigation.

Learning objectives
At the end of this session, participants will be able to:
• Understand the definition of outbreak/epidemic

• Describe the levels of disease occurrence

• Describe the types of outbreak/epidemics

• Describe the steps to be following during outbreak investigation

• Describe the different approaches /strategies of outbreak management

1. Definitions

A disease outbreak is the occurrence of cases of disease in excess of what would normally be expected
in a defined community, geographical area or season. An outbreak may occur in a restricted
geographical area, or may extend over several countries. It may last for a few days or weeks, or for
several years. A single case of a communicable disease long absent from a population, or caused by an
agent (e.g. bacterium or virus) not previously recognized in that community or area, or the emergence
of a previously unknown disease, may also constitute an outbreak and should be reported and
investigated.

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2. Levels of Disease Occurrence
Diseases can occur in a community at different levels. The occurrence can be at predictable levels or
in excess of what is expected.
The expected predictable levels can be:
 Endemic: the usual presence of disease from low to moderate level

 Hyper or Hypo endemic: a persistently high or lower level of disease

On the other hand there can be sporadic occurrence of disease where the disease normally does not
occur, but occasional cases can be seen at irregular intervals

Epidemic/ Outbreak:

Epidemic refers to an excess occurrence of disease above expected level (or threshold) at certain time.
A threshold of a specific disease is determined by taking average incidence of consecutive 3 to 5 years
duration for that month of the disease
Pandemic: is an epidemic that affects several countries or continents (a sudden increase of affected
population).

2. Types of Epidemics

A. Common Source Epidemic.

In Common Source Epidemic, disease occurs as a result of exposure of a group of susceptible persons
to a common source of a pathogen, often at the same time or within a brief time period. When the
exposure is simultaneous, the resulting cases develop within one incubation period and this is called a
point source epidemic. The epidemic curve in a point source epidemic will commonly show a sharp
rise and fall. E.g Food borne epidemic following an event where the food was served to many people.

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If the exposure to a common source continues over time it will result in a continuous common source
epidemic. E.g A water borne outbreak that is spread through a contaminated community water supply,
The epidemic curve may have a wide peak because of the range of exposures and the range of
incubation periods.

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B. Propagated or progressive epidemic:
Infectious agent is transferred from one host to another. It can occur through direct and indirect
transmissions. Propagative spread usually results in an epidemic curve with a relatively gentle upslope
and somewhat steeper tail. E.g outbreak of malaria.
When it is difficult to differentiate the two types of epidemics by the curve, spot map can help. In the
propagated epidemics there will be successive generations of cases.

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 C.
Mixed Epidemics.
The epidemic begins with a single, common source of an infectious agent with subsequent
propagative spread. Many food borne pathogens result in mixed epidemics.

4. Investigation
Investigation refers to the process of identifying the cause of the epidemic, the source of the cause, the
mode of transmission, and taking preventive/control measures
of an epidemic

4.1 Source of information for an outbreak

One of the uses of public health surveillance is detecting an outbreak. Outbreak is detected when a
routine surveillance data reveals an increase in reported cases of a disease. It can also be detected
when the outbreak come to attention of health providers. Members of affected group are other
important sources for both infectious and non-infectious diseases

4.2 Reason for investigation

1. To institute control and prevention measures

2. A good opportunity for research and training.

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 3. Useful for program consideration

4. Political concern and legal obligation

1. To Institute control/ prevention measures

It is the primary public health reason to investigate an outbreak. Before we do a control strategy, we
should identify where the outbreak is in its natural course.

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Choosing between control measures versus further investigation depends on how much is known about
the cause, the source of the outbreak, and the mode of transmission of the agent. If we know only little
about the outbreak, further investigation is needed. In contrast, if we know well about the outbreak,
control measures should be instituted immediately.
Decision regarding how extensively to investigate an outbreak is influenced by severity of the illness,
knowledge of the source or mode of transmission, and availability of preventive and control measures.
It is particularly urgent to investigate an outbreak when the disease is a severe (serious illness with
high risk of hospitalization, complication or death)
2. Research and Training opportunity
Each outbreak should be viewed as an experiment waiting to be analyzed. It presents a unique
opportunity to study the natural history of the disease in question. It could be a good opportunity to
gain additional knowledge by assessing the impact of control measures and the usefulness of new
epidemiology and laboratory techniques. It is considered as on-job-training for public health
professionals.

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3. Public, political, or legal concerns
Politicians and leaders are usually concerned with control of the epidemic. They may sometimes
override scientific concerns. The public are more concerned in cluster of disease and potentials of
getting medication.

4. Program considerations
Occurrence of an outbreak notifies presence of a program weakness. This could help program directors
to change or strengthen the program‘s effort. That means it can improve future directions

4.3 Steps in an outbreak investigation

There is no hard and fast rule but verification of the diagnosis and establishment of the existence of an
epidemic always deserves early attention. The following steps can be considered:
Step 1. Prepare for field work
Step 2. Verify the existence of an outbreak
Step 3. Verifying the diagnosis
Step 4. Establishing case definition
Step 5. Case finding
Step 6. Performing descriptive analysis
Step 7. Developing hypothesis
Step 8. Evaluating the hypothesis
Step 9: Conduct additional environmental studies
Step 10. Implementing control and prevention measures
Step 11. Communicating the findings

Step 1. Prepare for field work

Before leaving for the field an investigator must be well prepared to undertake the investigation.
Identify outbreak investigation team. Outbreak investigation is usually a team work. It is not only
health professionals but also it may need involvement of others. Composition of a team could include
a team of health workers, representative of community, politicians, concerned sectors etc.

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Preparations can be categorized into three:
A. Investigation related:
Investigator must have the appropriate scientific knowledge, supplies, and equipment to carry out the
investigation. Discuss the situation with knowledgeable people, review applicable literature, and
collect sample questionnaire.
B. Administration related:
This includes arrangement of transportation and organizing personnel matters.
C. Consultation related:
You need to clarify your and your team role in the field. Identify local contacts at the site where the
outbreak is reported and arrange where and when to meet them.

Step 2. Verify the existence of an outbreak

An outbreak/epidemic is the occurrence of more cases of disease than expected. Be cautious and rule
out the following misleading phenomena:
 Change in population size

 Change in diagnosis

 Change in case definition

 Increase in interest due to new in-service training

Step 3. Verifying the diagnosis

Goals of verifying the diagnosis include:
 To ensure that the problem has been properly diagnosed.

 To rule out laboratory error as a basis for the increase in diagnosed cases.

 To ensure the diagnosed disease is possibly endemic

We should visit several patients with the disease. Involving a qualified clinician and using possible
diagnostic equipment is essential.

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Step 4. Establishing case definition
A case definition is a standard set of criteria for deciding whether an individual should be classified as
having disease of interest or not. It includes clinical criteria but (restricted by time, place and person).
The clinical criteria should be simple having objective measures. Case definition can be narrow or
broad (confirmed, probable, suspected case). Use "loose" case definition early to capture all potential
cases.

Step 5. Case finding

Conduct systematic search based on case definition. Direct the case finding to take place both in health
institutions and outreach sites. If it is a localized form of epidemic, case finding should go to the
epidemic area. Finally, you can ask case patients if they know anyone else with the same condition.
Once the cases are found, the following information should be collected:
 Identification information

 Demographic information

 Time of onset

 Clinical information

 Possible risk factor information

 Place and distance from possible risk factor

 Reporter‘s information

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Step 6. Performing Descriptive Analysis
Once data is collected, it should be analyzed by time, place and person (Descriptive epidemiology).
Analysis by Person includes age, marital status, sex, occupation, behavior (e.g alcohol drinking) etc.

Analysis by time (time of onset) can be supplemented by using epidemic curve. One can distinguish
several types of epidemics according to the mode of transmission and duration. The epidemic curve
can help to identify the type of epidemic.

Analysis by place can be done using spot map. Spot map may ascertain localized epidemic by place
(Clustered epidemic). Use area map if large area is affected. Areas affected are identified by
intensity of shading corresponding to incidence of disease.

Step 7. Developing Hypothesis

Hypotheses can be generated by:
1. Using subject-matter knowledge

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 2. Using the information from descriptive epidemiology

3. Talking with patients

4. Talking with local officials

1. Subject-Matter Knowledge

Ask yourself:
• What kind of agents causes this clinical presentation?

• What are the agent‘s usual reservoirs?

• How the agent is usually transmitted?

• What vehicles are commonly identified?

• What are the known risk factors?

Brainstorming about the above questions with knowledgeable professionals may be important
Read also books, journal articles, reports of previous outbreak investigations. Browse websites like
www.who.int, www.cdc.gov etc…

2. Descriptive Epidemiology
Time (Epidemic curve)
 Does shape hint at mode of transmission?

 Does narrow peak point to a particular time of exposure?

Place
 Is attack rate high in one place?

Person
 Which group/s ( by age, sex, occupation, etc.) have highest rates?

3. Talking with Patients

 Open-ended conversation

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  What do they think about the source?

 For food-borne outbreak, ask about foods. sometimes, look at kitchen

 Bring some patients together to chat and see whether they have any common exposures

4. Talking with Local Authorities

 What do they think about the cause?

 Ask about any unusual events like, holidays, festivals, sporting events, gatherings?

 Ask also about any new products, local produce, etc.?

Compare hypotheses with reality at local level

 Does all the evidence point in the same direction?

 What evidence is the strongest?

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Collect laboratory data
 Environmental samples

 Clinical samples

Step 8. Evaluating the Hypothesis

Here doing analytic studies is useful. Association between the postulated exposure factor and the
disease is tested using analytic design like Case control and Cohort. Test for statistical significance
by using appropriate tests (E.g Chi-square test). Also compute appropriate measure of association
(OR for case control, RR for cohort design).

Step 9: Conduct additional environmental studies

Collect food, water, and other environmental samples. Determine what happened with the implicated
source or food

Step 10. Implementing control and prevention measures

In outbreak investigation, the primary goal is to control and prevent the outbreak. Implementing
control measure should be done as soon as possible. It should go in parallel to investigating the
outbreak.
Control measure should be aimed at the weak link in the chain of infection.
It may be aimed at:
 the specific agent,

 source or reservoir

 Interrupting the transmission or exposure

 Instructing (educating) people to reduce their risk of contacting possible exposure

 Reduce susceptibility by immunizing individuals

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Step 11. Communicating the findings

Findings can be communicated in two forms

1. An oral briefing for local authorities and implementers of control and prevention.

a) What is done,

b) what is found,

c) what should be done in the future

2. A written report

It is a blueprint having formal scientific format with [introduction, objectives, methods,

results, discussion and recommendations]

5. Global Alert and Response (GAR)

Core functions
• Support Member States for the implementation of national capacities for epidemic
preparedness and response in the context of the IHR(2005), including laboratory capacities and
early warning alert and response systems;

• Support national and international training programmes for epidemic preparedness and
response;

• Coordinate and support Member States for pandemic and seasonal influenza preparedness and
response;

• Develop standardized approaches for readiness and response to major epidemic-prone diseases
(e.g. meningitis, yellow fever, plague);

• Strengthen biosafety, biosecurity and readiness for outbreaks of dangerous and emerging
pathogens outbreaks (e.g. SARS, viral haemorrhagic fevers); Maintain and further develop a
global operational platform to support outbreak response and support regional offices in
implementation at regional level.

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Global Outbreak Alert & Response Network

The Global Outbreak Alert and Response Network (GOARN) is a technical collaboration of existing
institutions and networks that pool human and technical resources for the rapid identification,
confirmation and response to outbreaks of international importance. The Network provides an
operational framework to link this expertise and skill to keep the international community constantly
alert to the threat of outbreaks and ready to respond.

Group work exercise

• Suppose you are head of the district health office in one of the districts

• One of the health extension workers reported that there is outbreak of malaria in the kebele
where she is assigned to work. This kebele is under your jurisdiction

• What will you do in such circumstance?

References
• Fletcher M. Principles and practice of Epidemiology. 1992

• Goodman RA, Buehler JW, Koplan JP. The epidemiologic field investigation: science and
judgment in public health practice. Am J Epidemiol 1990;132:9-16.

• MacKenzie WR, Goodman RA. The public health response to an outbreak. Current Issues in
Public Health1996;2:1-4.

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 Sample Schedule on Leadership in Strategic information (LSI) training program on the third module, Surveillance, Monitoring and
Evaluation of HIV/AIDS

Week 1 Monday Tuesday Wednesday Thursday Friday

08:30 – 10:00 am Definition of basic Information sources Indicators M&E of HIV/AIDS Preparing an M&E
monitoring and Evaluation design programs Plan
evaluation terms
10:00 – 10:30 am Tea/Coffee B r e a k
10:30 – 12:30 pm Monitoring & Information sources Indicators M&E of HIV/AIDS Preparing an M&E
Evaluation Evaluation design programs Plan
frameworks
12:30 – 02:00 pm L u n c h
02:00 – 03:30 pm Monitoring & Information sources Indicators M&E of HIV/AIDS Preparing an M&E
Evaluation Evaluation design programs Plan
frameworks
03:30 – 04:00 am Tea/Coffee B r e a k
04:00 – 05:00 pm Project analysis Project analysis Project analysis Project analysis Presentation of research
work
(Mentors) (Mentor) (Mentor) (Mentor)

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Week 2 Monday Tuesday Wednesday Thursday Friday

08:30 – 09:00 am Introduction to HIV/AIDS Sero- Introduction to Introduction to STI Project analysis
Public Health surveillance Surveillance of Surveillance in and the Presentation
09:00 – 10:00 am Surveillance populations at High Risk Relationship between STIs
for HIV Transmission: and HIV:
BSS
10:00 – 10:30 am Tea/Coffee B r e a k
10:30 – 12:30 pm ANC Senitnnel Core Elements Introduction to Surveillance of Universal Case Project analysis
surveillance of HIV Populations at High Risk for HIV Reporting and Presentation
Surveillance Transmission: BSS Sentinel
Surveillance for
STIs
12:30 – 02:00 pm Lunch
02:00 – 03:30 pm Second Generation Demographic Most at Risk Populations (MARPS): Universal Case Project analysis
HIV Surveillance and Health Ethical issues in HIV surveillance Reporting and
Surveys Plus Sentinel Presentation
and its relevance Surveillance for
(Behavioral STIs
combined with
HIV test)
03:30 – 04:00 am

04:00 – 05:00 pm Project analysis Project analysis Project analysis Project analysis Project analysis
Exercise Exercise Exercise Exercise Presentation

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