Simplifying the reporting systems and designating peripheral staff for surveillance can improve Case Based Surveillance for Diphtheria at Kozhikode district, Kerala, 2018

  • Public health surveillance
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Background:
Kerala State in South India had established case-based diphtheria surveillance in 2015. In 2016, incidence of diphtheria recorded high after 10 years. Analysis of case-based diphtheria surveillance data from Kozhikode district of the State indicated shift in age to 5-14 years, increase in case fatality and low case confirmation. We evaluated the case-based surveillance system in Kozhikode in terms of key surveillance attributes.

Methods:
We interviewed surveillance staff (n=35) at the district and sub district levels using a semi-structured questionnaire. We reviewed the case-based surveillance records, forms and reports for 2016-18. We adapted the guidelines on surveillance evaluation from Centers for Disease Control and Prevention, USA and European Center for Disease Prevention and Control to collect data on selected attributes. The attributes were representativeness (distribution), timeliness (reporting on time), completeness (of data), positive predictive value (proportion of reported cases, actually having diphtheria), simplicity (Structure &Ease of operation), acceptability (willingness to participate) and usefulness (contribution to prevention and control, effect on policies and programs) and were defined as in CDC 2001. Academic ethics committee of ICMR-National Institute of Epidemiology approved the protocol.

Results:
According to the stakeholders, the system was simple (10 of 33; 31%) and acceptable (19 of 33; 58%), however, pointed to lack of dedicated permanent staff for surveillance at peripheral level. Positive predictive value was 42% (28 positives of 66 samples tested) in 2016 and 6% (7 of 119 tested) in 2017. The system was representative since all the 33 public and 67 private sector reporting units were submitting reports and maintained timeliness. The system was useful in detecting cases, analysis and response. However, overall completeness of the reports by its variables (n=26), was almost 85% in both 2016 (n=207 records) and 2017 (n=127 records) and was 35% in 2018 (n=36 records).

Conclusion:
We documented that case-based surveillance system for diphtheria in Kozhikode district was representative, useful and timely. However, progressively declining positive predictive value and completeness needed immediate attention. The acceptability, despite being not simple, owes to the compulsive reporting. We recommended simplifying the reporting systems and augmenting the surveillance through training and designating peripheral (permanent) staff for surveillance.

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