For EBS, the existing organizational structure and information flow from CHS to DHC to PPMC and to Regional Institutes was maintained with some enhancements (Figure 1), including 1) inclusion of VHWs at the CHS to identify and report signals; 2) addition of a triage step (the CHS decided which signals were "true" signals [rather than a spurious situation or non-threatening rumor] before reporting these as events to DHCs); 3) training of DHCs and PPMCs in event verification and risk assessment; 4) distribution of logbooks for recording signals and events; 5) establishment of a requirement to immediately report events by phone call, in-person meeting, or email; and 6) training of healthcare providers to detect and immediately report signals to the correct public health unit.
As of July 1, 2017, we received 2,105 acceptability/ sustainability surveys from 5 PPMC staff, 39 DHCs, 428 CHS, and 1,633 VHWs. Twenty-four (56%) of 43 districts returned the timeliness data extraction forms.
The most frequent EBS reporters were VHWs, teachers, community members, traditional healers, veterinarians, and representatives from industrial complexes (Figure 7).
Key motivating factors for participation expressed by the VHWs were a sense of service to the community, opportunities to increase community ties, and improvement in community trust.
The pilot initiative trained an existing network of VHWs and health collaborators to increase their awareness to look for and report signals as they appear in the community and to improve their understanding of patterns of disease that could signal the start of an outbreak.
Specifically, for some signals, wording needed to be simplified for VHWs, and the signal list itself needed to be more concise.
Thus, only a relatively small proportion (25%) of VHWs respondents were able to complete the survey, which might have limited the representativeness of some of the survey findings.
In addition to external funding for training, each province received a one-time start-up grant for infrastructural improvements, including purchase of a limited number of computers for reporting, a one-time allowance for VHW cellular phone minutes, and the printing and distribution of logbooks and communication materials.
A trained VHW learned that diarrhea and vomiting developed in 2 persons who had attended a wedding party meal on September 25, 2016, at [approximately equal to] 13:00 hrs.
A total of 82%-88% of VHW, CHS, and district respondents reported that EBS is very important in detecting public health events and helps to detect public health events earlier than before (Table 5).
CHS, commune health station; EBS, event-based surveillance; FGD, focus group discussion; FP, focal point; KII, key informant interview; POC, point of contact; PPMC, Provincial Preventive Medicine Center; VHW, village health worker.
CHS, Commune Health Station; DHC, District Health Center; DPMC, District Preventive Medicine Center; EBS, event-based surveillance; PPMC, Provincial Preventive Medicine Center; VHW, village health worker.