IDCAP Surveillance System

Accordias Integrated Infectious Disease Capacity-Building Evaluation (IDCAP) is evaluating the impact of a novel set of capacity-building activities on the management of infectious disease in Uganda, at three distinct levels: Individual Clinician Competence, Facility-level Performance, and Patient Health Outcomes. The evaluation of Facility-Level Performance is enabled by a comprehensive Surveillance System among all thirty-six Ugandan health facilities included in the study. Once our evaluation is complete, IDCAPs Surveillance System could be of enormous utility to others engaged in operational research and impact evaluation in resource-limited settings. Accordia desires for this surveillance infrastructure to continue to answer the most pressing questions in global health: as new strategies and technologies are developed and introduced, the IDCAP Surveillance System could be an invaluable source of evidence to evaluate their effectiveness.

The IDCAP Surveillance System is comprised of 3 components: Infrastructure 36 mid-sized government health facilities Computer hardware and software Reliable power sources Transmission capability Data storage provision Surveillance Infrastructure IDCAP operates in 36 government health facilities around Uganda, classified by the Ugandan Ministry of Health as Health Centers IV. All IDCAP sites offer general outpatient services, and most also have maternity wards and other limited inpatient services too. IDCAP sites also offer HIV services and ART programs. Collectively, these sites see 48,000 outpatients monthly. Many IDCAP sites are remote rural sites that previously had unreliable or insufficient infrastructure to support research activity. A comprehensive needs assessment process determined minimum provisions required for each IDCAP site to reliably collect, store and transmit data on a daily basis. IDCAP provided each health facility with: Alternative power sources including solar power systems, backup inverters and/or generators Computers and printers for IDCAP and general records management purposes Modem or smart phone depending on network availability Appropriate software including Microsoft Office Suites, Epi-Info and anti-virus programs Desks and chairs for the dedicated IDCAP staff and site records management staff Secure provisions for the storage of hardware and data Specifically designed tools to collect and extract data Provisional supply of key government reporting forms Personnel Full time data entry clerks at each facility Advanced data management specialists Statistical and epidemiological analysts Systems Ministry of Health collaboration Data collection instruments Protocol for routine quality assurance

Surveillance Personnel IDCAP relies on the quality and completeness of data collected from study sites. As such, a thoughtful staffing plan was developed to ensure optimal data management support for the duration of the evaluation. A dedicated Data Entry Assistant (DEA) is stationed at each IDCAP health facility throughout Uganda. The DEA role is to ensure consistent use by all clinic staff of existing HMIS components as well as the enhanced reporting instruments developed by IDCAP. DEA collect, verify and enter data daily. DEA hold university degrees and were recruited locally at each IDCAP site to minimize cost and risk of attrition.

The DEA are supported by a Central Data Team based in Kampala. The Central Data Team includes 8 Data Technicians (DT) who provide ongoing support to IDCAP sites for data auditing and quality assurance. SDT visit each IDCAP site monthly to troubleshoot, verify, and oversee the extraction of key data from HMIS registers using IDCAP-developed instruments for that purpose. They conduct regular audits of accumulated data, and assist with sorting, coding and follow-up. They also supervise ongoing training of DEA and other site staff. DEA and DT received intensive training prior to their deployment, focused on individual data collection instruments and reporting tools, general data management skills, Good Clinical Practice, quality assurance techniques, Epi-Info use, and monitoring and evaluation practices. The Central Data Team also includes more advanced data managers, biostatisticians and an epidemiologist. In addition, the Team has regular access to accomplished experts in these and related fields of study within the Infectious Diseases Institutes Research Program, and among Makerere University faculty and postgraduate students. Surveillance Systems IDCAP pulls from several data sources for its ongoing surveillance and evaluation needs. The surveillance system includes components of permanent MOH systems, other instruments enhanced to replace tools were inadequate for research purposes, and some new reporting tools designed specifically for IDCAP purposes. Outpatient Visit Data Recording A main source of data in support of IDCAP indicators is the modified Medical Form 5 (MF5). IDCAP worked closely with the Infectious Diseases Research Collaboration (IDRC) to modify the existing MOH outpatient record form to improve and standardize outpatient data collection and reporting. The MF5 was modified from a blank sheet to a coded form documenting patient history, physical and laboratory examinations, diagnosis, treatment, referral and drug supplies. The modified MF5 has been very well received by local authorities and the central government, which has recommended that it be adopted by all national health facilities. Specialty Clinic Data Mining IDCAP designed data extraction tools to collect data from existing national HMIS tools including the Ante Natal Clinic, Post Natal Clinic and Maternity Ward registers, the National TB and Leprosy Program (NTLP) register, Pre-ART and ART registers, inpatient registers and others. Extraction tools are accompanied by protocols for their use. Cohort Management System Some of IDCAPs facility performance indicators will be measured with data from enrolled cohorts of tuberculosis and HIV patients. The purpose of the IDCAP patient cohorts is to ensure complete information about long-term and chronic care among patients known for loss to follow up. DEA have been trained in informed consent and enrollment procedures, monthly monitoring, and appropriate follow-up of patients missing routine or scheduled visits. Data Transmission Records do not leave IDCAP sites. Data collected from each IDCAP site are sent electronically on a weekly basis to the Central Data Teams remote server in Kampala using internet or smart phone. If transmission problems occur, a DT is deployed to troubleshoot or collect the data physically. 3

Data Cleaning and Analysis Data transmitted by sites is received centrally by the Central Data Team at IDCAP offices in Kampala, and checked for completeness and accuracy. Routine tests are conducted to identify gaps or errors in data entry. Data is cleaned and analyzed, and on a targeted basis are reviewed by a range of consultants and investigators available to IDCAP through Accordias networks in Uganda and the rest of world. IDCAP Performance Indicators IDCAPs Surveillance System collects data in support of 54 key performance indicators identified for the purpose of the IDCAP evaluation. These indicators measure the quality of care related to HIV/AIDS, malaria, and tuberculosis, as well as each facilitys performance in supporting functions like emergency triage, inventory management, and laboratory services. Below is a sample of IDCAPs performance indicators. Others are available upon request. Proportion of HIV positive pregnant women who receive ART either as chronic care or PMTCT Proportion of HIV exposed infants who get timely and appropriate ART to PMTCT Number of outpatients 12 years or more with known HIV status Number of outpatients 18 months to 12 years with known HIV status Proportion of TB suspects less than 12 years sent for a 1st AFB smear Proportion people with AFB smear positive tests who are started on initial TB treatment phase Proportion of malaria suspects less than 5 years with malaria test (BS or RDT) Proportion of patients 5 year or more with a negative malaria test treated with any anti-malarial(s) Proportion of malaria suspects less than 5 years treated with an appropriate anti-malarial(s) Proportion of outpatients with emergency status who are managed according g to ETAT standards

Non-IDCAP Uses of Surveillance Data The Surveillance System collects data not directly employed for IDCAPs performance indicators. Inquiries are very welcome regarding other information collected routinely, and how it could support investigations around burden of disease, impact of diagnostics and other technologies on quality of care and health outcomes, and management of chronic conditions. Also see the Outpatient Reporting Form on the next page.

MEDICAL FORM 5
Name of Health Facility:__________________________________________________________
Date OPD Number Patients Surname Age
Fever or history of fever? Yes Yes Yes No No No Yes Yes No Yes No No

Pink (E) Other Names Yellow (P) Green (Q) New Attendance Re-attendance Female
Yes

Yrs

Mths

days

Sex

Male

Weight
No Not Eligible

kg

If Child, Recent Contact with someone who has TB? Night Sweats? Yes Yes No No Known Status

Bs for Malaria

Pos

Neg

RCT PMTCT

TB Exam

New Case

RDT for Malaria Pos Malaria Lab Number

Neg

CTRR

CTR

HIV Lab number

Stool ordered Lab Number

Urinalysis ordered Lab Number

HB Lab No.

g/dL

VDRL tests

Pos

Neg

Other Lab Tests + Results (specify).......................................................................

Reportable Diseases

HIV / AIDS Cough or cold (no pneumonia) Diarrhea - Acute Diarrhea - Persistent Intestinal worms Leprosy Brucellosis
Drug Anti Malarial

Infectious Diseases

New Case - No prior TB treatment New Case - Previous TB treatment Known TB case - Med Refill Alcohol and drug abuse Anaemia
Non Infectious Diseases

Tuberculosis

Maternal and Perinatal Diseases

Abortions Haemorrhage during pregnancy High BP during pregnancy Obstructed Labour Perinatal conditions in newborns
OS

Dispensary
DA

Artmemther / Lumefantrine Artesunate Amodiaquine Chloroquine Quinine SP (Fansidar)

Others (specify)

Others specify Antihelminths

Antimicrobials Amoxilicilin Benzyl Penicilin Chloramphenical Ciprofloxacin Cloxacillin Cotrimoxazole Doxyxycline Erythromycin Gentamicin Metronidazole PPf Tetracycline

RHZE

RHZES RHE

RHZ RH